Ronni, a 75 y.o. woman, has a long history of problems with her left knee. MVA in 1988 caused L tib/fib fx requiring ORIF. In 1994 she had a left total knee replacement. In 1998 TKR was revised. On 9/28/15 she presented with c/o severe pain with significant periprosthetic ostepenia. MVA 11/10/18 causing L knee pain and likely accelerating need for TKR. On 1/8/19, Dr B. performed knee revision. Post-op doing well except lacks quite a few degrees of flexion which she claims she also had in prior TKR. By 3/11/19, pt lacks full flexion, and manipulation under anesthesia warranted. MUA on 3/12/19. immediate onset extreme pain. CT scan shows non-displaced tuberosity fx of tibia. Ronni was diagnosed with L foot drop. Second opinion ortho believes may be peroneal nerve injury from fx and MUA.
Was a decision to perform MUA within the standards of care? Could a decision to perform a MUA be a matter of clinical judgment where two different orthopedic surgeons may offer a different opinion?
Files:
No questions yet!
Do you believe there might have been medical error?
It would depend on the bone quality seen on xray.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A fracture is a known complication, peroneal n injury is not common. It depends on xray appearance pre manipulation
What makes you a good expert for this case?
This is my area of expertise. I perform these surgeries / procedures on a regular basis. I testify well.
How often do you encounter cases similar to this one in your practice?
very often. this is my specialty
Do you believe there might have been medical error?
Performing a MUA is within the standard of care for contracture after a TKA or revision TKA. If the surgeon saw the osteopenia on xrays prior to the manipulation he should have been more cautious with the MUA since there is always a risk for fracture. The operative note will be important as it may note how much effort he had to produce to manipulate. The tibial tuberosity is on the front of the knee and the nerve is lateral so I'm not sure how it could have caused a foot drop. Hopefully they performed an EMG/NCS.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The tibial tuberosity is on the front of the knee and the nerve is lateral so I'm not sure how it could have caused a foot drop. Hopefully they performed an EMG/NCS. Also, flexing a knee is unlikely to cause a peroneal nerve stretch or contusion or other injury. Most injuries to the nerve occur with varus stress or when correctly severe knee valgus during a TKA.
What makes you a good expert for this case?
I perform a lot of TKAs and manipulations
How often do you encounter cases similar to this one in your practice?
I have never seen a peroneal nerve palsy after a MUA but have seen it after TKAs
Do you believe there might have been medical error?
An MUA in such cases is definitely a shared decision process after a thorough discussion of the relevant risks and complications. Nerve and vessel damage and fracture are certainly risks of an MUA in the given case. Scarification in and around the multiple revision knee could expectedly tether the peroneal nerve. An MUA-related peroneal injury occurred is a bad outcome, but it is not necessarily a complication from a breach of the standard of care. A fracture of the proximal tibial tuberosity would cause local bleeding and pressure, both of which could directly affect the function of the juxtaposed peroneal nerve. Treatment options, in lieu of the peroneal nerve involvement, include watchful waiting to see if the nerve function returns with dissolution of the swelling and local noxious red cells from the bleeding. If nerve function fails to return as expected (in weeks), nerve conduction studies would be appropriate. If the surgeon felt the peroneal nerve was actually "torn" or disrupted, formal surgical acute exploration would be indicated. I would offer early exploration to decompress the nerve and evacuate the hematoma and "lay eyes" on the nerve to formally inspect for injury. I am often asked to arthroscope stiff TKR knees to perform a more gentle scar tissue removal often found within the joint. I agree that wo different orthopedic surgeons may offer a different opinion with regards to how best to manage the stiff TKR. The potential real question is with regards to how the nerve injury was managed after the injury occurred. Was it addressed appropriately to best mitigate the damage from the injury?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I do feel there is causation as the peroneal function by assumption was fully functional prior to the MUA. The real issue may be as to how the injury was managed after the occurrence.
What makes you a good expert for this case?
I am a board certified sports medicine fellowship surgeon with a large and very high volume tertiary referral practice. I manage difficult cases involving complex knee pathology on a daily basis.
How often do you encounter cases similar to this one in your practice?
I routinely am referred complex knee cases that require complex surgical planning. Stiff postoperative knees from major reconstruction or after TKR or routinely sent to me for definitive management. I have not personally seen a peroneal injury due to my own MUA, but have been sent similar patients and have treated them "aggressively", and often with early nerve decompression and exploration.
Want to open a case or submit response?
Comments from similar speciality or otherwise pertinent to the case may also be accepted.