This case involves an elderly male patient with a history of a total left knee replacement who had a sudden onset of pain. The patient was seen by his orthopedist and a bone scan revealed that the replacement hardware was loosening, causing him pain. A repeat replacement was scheduled. During this procedure, a large bony lesion was discovered in the tibia. A pathology report read the lesion as a benign tumor which needed to be excised. The patient was advised to return for follow up xrays to evaluate the tumor’s growth. Follow up xrays noted a lobulated lucency and the doctor recommended waiting over reconstruction. The patient insisted on proceeding with the knee revision procedure because the pain was so intense. During surgery, the doctor used the same surgical instruments for the femur as he used on the tibia, and worked on the tibia first, causing an intra-operative spread. A subsequent guided needle biopsy showed bone cancer present and the patient underwent a left above the knee amputation. The patient underwent a cycle of chemotherapy, but his body did not respond to the treatment. He continued to decline and eventually developed Kahler’s disease. An expert in orthopedic oncology was sought to opine on the standard of care for a patient under these circumstances.
Question(s) For Expert Witness
- 1. How often do you treat patients like the one described in the case?
- 2. If cancer is suspected, should different instruments be used in different parts of the bone?
Expert Witness Response E-020916
I am a professor of orthopedics and division director, musculoskeletal oncology at a large university medical center in the midwest. If cancer is suspected different instruments should be used but more importantly if cancer was initially suspected, the knee revision should not have occurred. The surgeon potentially (depending on pre-op imaging + findings at the time of surgery) should have stopped the surgery once he realized that cancer was a potential issue. It is typical to use the same instruments on the femur and tibia during a total knee revision. Therefore the concern for cancer if present before surgery is a very important piece of information. There are several turning points in the patient’s treatment that cannot be determined without a thorough review of the initial imaging.