This case is based on a real scenario, with some facts altered to preserve confidentiality.
Mr A, a 36-year-old man, consulted Mr B, an orthopaedic surgeon, on a private basis with a ten-month history of right knee pain. The pain was severe enough to interfere with Mr A’s normal hobbies and activities.
On examination, Mr B identified tenderness to the medial and lateral aspects of the knee. He requested an MRI scan, which demonstrated a degenerative posterior horn of the medial meniscus and a meniscal cyst, consistent with a degenerative tear. It was reported that the hyaline cartilage was well-maintained.
Mr B recommended an arthroscopy and trimming of the meniscus. Mr A was informed of the potential benefits and risks. Other potential management options were not discussed. At the time of surgery, a bucket handle tear of the posterior horn of the medial meniscus was identified and resected.
A month after the surgery, Mr B reviewed Mr A. Ongoing pain in the knee was reported by Mr A. This did not settle, and Mr B referred Mr A for physiotherapy. As the pain continued, Mr B arranged a repeat MRI scan four months after the surgery had taken place. This showed evidence of a previous partial medial meniscectomy and significant bone marrow oedema of the medial femoral condyle including complete loss of hyaline cartilage. It was reported that there had been a significant deterioration since the original scan.
Mr B considered there was nothing further that he could do other than offer additional physiotherapy, so discharged Mr A from his care. Some months later, Mr A sought a second opinion from Mr C. The symptoms reported to Mr C included medial knee pain, with knee swelling and stiffness. On examination there was tenderness over the medial joint line.
Mr C requested a further MRI scan. This demonstrated resolution of the bone marrow oedema but identified that the medial femoral condyle lesion was larger and there was also an osteochondral cyst.
Mr C recommended a repeat arthroscopy, which was performed 11 months after the first procedure. Two areas of damage to the medial femoral condyle were identified, as well as an incompletely excised bucket handle tear of the posterior horn of the medial meniscus.
Following the surgery, Mr A reported that although his pain was slightly improved, he was still experiencing symptoms impacting on his activities. Over the next year, a further scan and repeat arthroscopy was carried out, but Mr A continued to have pain to the medial aspect of the knee, and giving way of the knee.
Mr A subsequently brought a claim against Mr B, alleging that the initial arthroscopy should not have been offered without further attempts at conservative management, and that Mr B’s surgical technique at the time of arthroscopy was negligent. He alleged that this had resulted in ongoing symptoms and a requirement for autologous chondrocyte implantation (ACI) and likely a partial knee replacement within the next 15 years. Mr A also complained that Mr B should have identified the ongoing issue was iatrogenic in origin at the time of the second MRI, and should have alerted him to this and apologised.
The case was reviewed by an expert who considered:
It was appropriate to offer an arthroscopy in the first instance, although it would have been reasonable to have also set out the likely progression of symptoms to allow Mr A to consider the option of no surgical intervention.
However, the damage seen to the medial femoral condyle at the time of the second arthroscopy had, on balance of probabilities, been negligently caused by Mr B at the time of the first arthroscopy.
Had the first arthroscopy been performed to the expected standard, then, on balance, Mr A would have made a good recovery and would not have required further procedures.
ACI would be a reasonable treatment and should provide 10 to 15 years of benefit, following which a partial knee replacement would likely be necessary.
The case was settled for a sum in excess of £200,000.
Ensure all options for management, including taking no action, are discussed.
If symptoms are ongoing following intervention, explain to the patient the possible causes and how this may be managed. Seek advice or referral to a colleague if necessary.
Review your surgical technique and complication rate to ensure you are up to date and in line with your peers. Seek further training if necessary.
If you become aware that iatrogenic damage may have been caused, ensure you comply with duty of candour, explaining and apologising to the patient, as well as outlining any potential action that could be taken to rectify the injury. It is important to note that an apology is not an admission of liability.