This case involves a male patient with an unremarkable medical history who injured his left knee during a recreational softball game. The man was taken to the hospital after his injury , where an x-ray revealed a tear in the meniscus of his left knee. His physician elected to attempt a surgical repair through arthroscopic surgery, which proceeded without major incident. Nevertheless, the patient developed redness, pain, and a fever shortly after surgery, and doctors diagnosed him with a deep tissue infection. The infection was able to progress, allegedly due to insufficient treatment, and the man’s knee suffered extensive and permanent damage as a result, which forced him to undergo a total knee replacement.
Question(s) For Expert Witness
- 1. How often do you perform arthroscopic knee surgery?
- 2. What procedures or protocols should be in place to prevent unnecessary anthroscopic knee surgery?
- 3. In a patient with this type of presentation, what would be considered the standard of care for treatment of postoperative infection?
Expert Witness Response E-017978
The standard of care for treating a postop knee infection dictates an urgent attention to the patient’s situation delivered by:
- Hands-on evaluation of the patient within a day or
- Review of initial patient complaints that something “seems wrong” including basic examination of the patient looking for clinical signs of a worsening clinical picture such as a painful effusion, drainage, wound/portal breakdown, joint stiffness out of proportion to what is expected for a basic knee arthroscopy, skin redness, erythema, increasing warmth, streaking or an elevated temperature.
A thorough evaluation of the suspected condition with appropriate workup such as blood work, Lynne joint aspiration, and analysis via culturing and gram stain for infection, as well as possible consultation with an infectious disease specialist. I have definitely seen similar cases and it is usually a failure to respond appropriately to early signs of infection that get health care providers into trouble. I perform arthroscopy of the knee, shoulder, and hip on a weekly basis with as many as 12-16 cases per week. Using appropriate indications is paramount to negating iatrogenic complications.
Expert Witness Response E-113268
I perform about 250 knee arthroscopies per year. In general horizontal meniscal tears are felt to be degenerative in nature. Treatment is usually attempted at conservative treatment to include NDAIDs, activity modification, physical therapy, and occasional steroid injection. However, when this fails and the patient is having mechanical symptoms, i.e. catching locking or localized pain, then arthroscopy and partial meniscectomy with chondroplasty is reasonable and medically necessary. The procedure is performed under sterile conditions usually in an outpatient surgery center, occasionally a hospital. The risk of deep infection and arthroscopy is about .001%. Nonetheless, it does occur. Treatment of postoperative knee infection requires early recognition. Cultures are usually taken preoperatively and intraoperatively. This is followed by four to six weeks of intravenous antibiotics. I have had this complication in my practice, albeit extremely rarely. It is within the standard of care to have an infection, however the standard of care does require early recognition and prompt appropriate treatment.