PC had a left knee revision. (Specifically, total left knee arthroplasty, rotating hinge construct, extensor mechanism reconstruction with Marlex mesh and left knee patellectomy.) in April of 2023. She was attending physical therapy and rehabilitation. She was getting multiple follow-ups with her Orthopedic surgeon.
FOLLOW UPs Post-OP
5/11: Mild pain, incision looks good. “A win for this patient would be to have at worst a 10° extensor mechanism lag.”
5/31: “removed cast and removed steri-strips. Applied new splint until fitted with hinged knee brace locked and extension for 5 to 6 more weeks. We'll start range of motion in 5 weeks. 0 to 30° with 15° advances each week.”
6/29: limited passive range of motion. Strength is decreased. If she's able to have knee extension even with a 10 to 15° lag that is a very good outcome. However even without significant knee extensions, she is still in a good place.
8/10: L knee symptoms reported as being moderate. Complaints of pain. Abnormal extensor lag 10 to 20°. Flexion active 110. Flexion passive 110. Extension active 20. Extension passive 0. Incision is healed well and I recommend pool exercises. Continuing to do PT, she is doing well. X-rays taken today hardware intact” No vital signs taken.
8/15 10:15am: She notates in her intake that MD was very rude and dismissive about her symptoms. The surgeon's notes mention that the “symptoms occur constantly” and “her problem is unchanged”. Also states that her pain is “aching, piercing, stabbing, sharp and shooting” and pain scale “10 out of 10”. It is also noted that she does have “moderate swelling”, “abnormal extensor lag” and her “strength is limited”. The patient plan by MD states “today she's presented back due to overworking at physical therapy on Friday. She now has swelling in her knee. I do not believe the knee is infected, I believe that she does work too much. If the mesh has torn this time, does not matter because the primary reason to perform the surgery was to revise the knee. She still has the extensor lag and is only able to range 30 to 110°. She will take off from therapy today and resume back Monday. I do recommend icing and compression with an ace wrap. Otherwise follow up as scheduled.” No vital signs are taken
PC goes to ER the following day (8/16 at 1753), work up found necrotizing fasciitis to her left knee with beginning stages of sepsis. Different MD does extensive debridement, I/D, wound vac on 8/16/23. Attempted to transfer to a higher level of care to possibly save limb, unsuccessful. Note: mesh was not damaged.
August 23rd 2023, 2nd surgeon did the amputation above the left knee and PC was eventually sent to rehabilitation without further complications.
Should the visit on 8/10 been a red flag to do an immediate work up for complications? Even if the work up was complete, would necrotizing fasciitis been a differential Dx? Was the 8/15 visit a deviation of care? Was his note concerning? Why not send for immediate evaluation? PC is a known diabetic.
Looking for an orthopedic surgeon who is well-versed in total knee replacements.
We have full records from the initial operation, follow-ups and subsequent admission/AKA.
Thank you in advance.
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Do you believe there might have been medical error?
In a total knee patient especially a diabetic. Who presents with a health change. Period it is not acceptable to just apply ice. At the very minimum this. Patient should’ve had an ultrasound done. As well as bloodwork and possibly even an aspiration. If there was a fluid collection in the knee. The risk of a rapidly progressive infection is too high given a patient with her comorbidity. I’m uncertain if the outcome would have been different given the necrotizing fasciitis diagnosis. However, there was a delay in diagnosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If she was diagnosed earlier. She most likely would’ve been taken to the operating room. And debrided. I’m uncertain if this would have ultimately prevented the amputation.
What makes you a good expert for this case?
I’m in board-certified orthopedic surgeon. However, I do not do total knee replacements.
How often do you encounter cases similar to this one in your practice?
This is something that we have trained, and I’ve seen often during our training. The treatment remains the same for these infections.
Do you believe there might have been medical error?
The patient was evaluated by the surgeon on 8/10 and available notation that visit suggests the patient was making expected progress without significant sign of complications. Vital signs were not taken , however standard practice in Orthopedic Surgery offices is not to take vital signs unless there is a specific reason to do so, and there is no indicator available that there was a clinical reason for suspicion to take vital signs on 8/10. In any event, the patient would likely have been afebrile on 8/10 and likely even if vital signs were taken, it is doubtful anything would have been identified or outcome changed. The patient then seems to have called in on 8/15 with evolving symptoms of pain (it is also noted that she does have “moderate swelling”, “abnormal extensor lag” and her “strength is limited” - however these were not out of line with the patient's prior progress). On 8/15, vital signs may have been taken if there was any concern about infection (there is a quote that the surgeon states does not believe the knee is infected). It is still possible that vital signs were taken (it is not noted that they weren't) and it is also still possible that vital signs would have been normal at this stage. The patient then ultimately presented to ED the following day 8/16. Had the patient presented to ED 24 hours earlier, it is doubtful that the overall course of this complication would have changed significantly.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient seems to have had a serious prosthetic joint infection in a multiply-revised knee - and patient is a diabetic - this is a known possible outcome and complication. While earlier identification of this infection may possibly have been achieved, ultimately even if an aspiration was performed on 8/15/23, results would not have been back until 8/16 and the patient would have presented to ED within the same time frame and received the same treatment (and course gone the same). Thus, even if there was some error, which seems unlikely, the ultimate outcome was likely to occur regardless.
What makes you a good expert for this case?
I am a board-certified orthopedic surgeon who has performed hundreds of total joint arthroplasty and revision cases.
How often do you encounter cases similar to this one in your practice?
Thankfully, not very commonly. However, I have reviewed several similar cases in the past as an independent expert.
Do you believe there might have been medical error?
The swelling should have prompted labs such as cbc esr and crp to work up for infection especially with a mesh recon for the extensor mechanism. Needed to do infection work up due to the nature of the reconstruction
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Needed to do infection work up due to the nature of the reconstruction The swelling should have prompted labs such as cbc esr and crp to work up for infection especially with a mesh recon for the extensor mechanism.
What makes you a good expert for this case?
I am fellowship trained in joint replacements. My practice is 80% joints and over 50% revisions. I have performed many hinge prosthesis. I have felt with infected total joints for the past 24 years.
How often do you encounter cases similar to this one in your practice?
Monthly since I am fellowship trained in revision joint arthroplasty.
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