Inadequate Supervision On The O.R.

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Description

A 53-year-old female underwent a right total knee replacement which required four subsequent revision surgeries for recurrent dislocations. The patient has persistent patella problems and weakness of her right leg.

Key Lessons

  • Ensuring that appropriate equipment is available in the OR prior to surgery helps minimize the risk of causing harm by "making do."
  • If a resident is having difficulty, the supervising attendant needs to intervene to prevent patient harm.
  • Disclosing surgical complications to the patient can lead to informed decision making and prevent loss of trust.

Clinical Sequence

A 53-year-old female underwent total right knee replacement. Because the patient was large and her knee was arthritic-her bones were more dense than normal. The resident who was performing most of the procedure encountered more resistance than usual as he used a saw to cut a notch in the femur. The saw vibrated excessively, and the resident accidentally severed the patient's posterior cruciate ligament and removed an excess amount of bone from the femur. The largest available implant available in the OR was used, though a larger one would have fit better.

No explanation was given to the patient or her husband as to why the surgery took longer than expected or that unexpected complications had been encountered. In the operative note, the attending surgeon documented that the patient had no functioning posterior cruciate ligament, but did not state the reason.

One month post-op, the patient's knee dislocated. An X-ray showed that the implant was malaligned. For a revision surgery, the orthopedist used a larger implant to try to stabilize the knee and prevent dislocation. Postoperatively the patient had moderate laxity of her ligaments and the knee was unstable. The patient proceeded with physical therapy.

One year later, the patient had her other (left) knee replaced by the same orthopedic surgeon. The surgery was successful, but on the third day post-op, the patient's right knee dislocated again. A second revision was done and a still larger implant was used to attempt to stabilize the right knee.

The patient did well for about two years, then experienced another dislocation of her right knee. Because the patient's surgeon was traveling abroad, she was seen by a different orthopedic surgeon. This surgeon showed the patient on X-ray that too much bone had been removed in the original surgery of her right knee. He explained that this caused her ligaments not to function properly, leading to the dislocations. A new total replacement of the right knee was successful; however, the patient has constant pain, is unable to climb stairs, and cannot stand for long periods. The likelihood is that she will need to have her right knee fused in the future.

Allegation

The patient filed suit against the attending surgeon and the resident alleging negligent supervision, leading to negligent removal of too much bone and severing of the posterior cruciate ligament.

Disposition

The resident was dropped from the case. Following two unsupportive expert reviews, the case against the attending was settled in the high range (>$500,000).

Hyperlinks

  1. Ligament (definition)
  2. Disclosure (Forum May 2003)
  3. Resident Supervision (Forum, March 1999)

Analysis

Clinical Perspective

  1. Given the patient's size and arthritic condition, the resident was not prepared for sawing against the patient's bone density.

    Better pre-op preparation might have helped the surgeons anticipate and accommodate for the saw vibrations.

  2. Pre-op templates were not obtained to ensure that the appropriate size implant was available at the time of surgery. The use of an implant that was too small contributed to the dislocations that required several subsequent surgeries. These surgeries in turn led to stretching of the ligaments that resulted in laxity and continued joint instability.

    Better pre-op preparation might have helped the surgeons ensure the OR was adequately stocked for this procedure.

Patient Perspective

  1. The patient expected her new knee to function and no intra-operative injuries, because she understood a competent surgeon was doing the procedure. Both the density of her bones and the necessary implant size were predictable.

    Patients rightfully expect that any known atypical aspects of their condition or treatment will be understood and addressed by the clinicians to whom they entrust their care.

  2. The patient based her decisions to have the same surgeon do the revisions and replace her left knee based on her belief that her initial right knee surgery was appropriate and successful. Being informed of the surgical errors by a subsequent provider was key to this patient initiating a lawsuit.

    Openness about errors or unexpected outcomes in real time can reinforce trust, bolster the physician-patient relationship, impact future decision-making, and diffuse allegations of a cover-up.

Risk Management Perspective

  1. During the procedure, the surgeon was aware that the resident experienced extreme vibration when the saw was used on dense bone, but did not take over.

    In settings where resident staff perform most of a procedure, the attending surgeon must be prepared to recognize when a patient's risk of being harmed outweighs the value of allowing a resident to learn and gain experience.

  2. The attending surgeon dictated an operative note that mentioned a non-functioning posterior cruciate ligament without referring to the fact that it was severed during the procedure. Later on, this omission was perceived as an attempt to hide the mishap.

    All significant clinical events in the course of rendering and documenting care need to be included to avoid misunderstandings and to inform patients and subsequent providers.

Legal Defense Perspective

  1. The plaintiff attorney in this case was also a board-certified orthopedist, giving him relevant medical expertise. While deposing the insured attending physician, the plaintiff's attorney questions about the OR note led to the surgeon acknowledging that the ligament had been severed by the resident, and that too much bone had been removed from the femur.

    Withholding from the defense team critical information-no matter how troublesome-benefits none of the parties involved.

  2. The insured physician cancelled several appointments with the defense attorney and insurance claim adjustor prior to his deposition.

    Lack of cooperation with the defense team seriously hampers its ability to provide an effective defense.