Knee Osteotomies and the Importance of the Post-Operative Availability of the Surgeon
What is a Knee Tibial Osteotomy?
Patients who suffer from osteoarthritis of the knee experience excessive wearing of the meniscus and articular cartilage. This is measured in grades from I-IV, from soft cartilage to cartilage worn down to the bone. This cartilage provides shock absorption and allows the bones to slide over each other. This damage can limit the ability of the knee to function properly.
A high tibial osteotomy is used to relieve pressure, realign the knee joint and prolong the life span of the joint before needing a joint replacement. These benefits can last up 10-15 years before requiring a knee replacement.
However, there are some disadvantages when compared with a partial or total knee replacement. The recovery period may be prolonged if the osteotomy does not heal. The arthritic part of the knee is not replaced in osteotomy surgery and so may gone to progress over time requiring delayed knee replacement surgery. Also, in some circumstances an osteotomy can cause a future knee replacement to be far more challenging.
It is important that appropriate care and advice is implemented throughout the course of treatment, from preoperative consultations to postoperative reviews and assessments.
The patient underwent an arthroscopy and knee tibial osteotomy to a good standard and was transferred on to the recovery bay. While recovering, the patient was in a high level of pain and his leg was examined as was found to be cold to the touch and dark in colour.
The operative surgeon reviewed the patient and reassured the patient that colour of the leg would improve, and the blood flow was slowly improving. Pain relief was appropriately administered via patient-controlled analgesia (PCA).
Due to ongoing pain, the anaesthetist reviewed the patient later and administered further pain relief. There was a concern regarding a surgical issue and the operative surgeon was contacted for further review. The operative surgeon confirmed over the phone that he had no surgical concerns and that PCA should continue.
The patient’s leg did not improve in colour and remained cool to the touch. Attempts were made to contact the operative surgeon and a voicemail was left requesting to discuss guidance for the patient’s limb.
The limb was rechecked by the nurse and was said to be slighter warmer than before with the colour seeming to improve. At the physiotherapy assessment, a day after the operation, a poor pulse was noted in the patient’s foot and the operative surgeon was contacted again for review. Unfortunately, the surgeon was in theatre scrubbed with another patient.
The patient was transferred to a local NHS hospital, where he underwent a fasciotomy for suspected compartment syndrome and a vascular injury following the original osteotomy was identified. An artery in the knee had been severed. Attempts were made to save the leg, but it was eventually decided that a below the leg amputation had to be undertaken.
It was found that an appropriate post-operative assessment was not made by the operating surgeon. While the nurse and the anaesthetist did assess the patient appropriately, the limb should have been reviewed by the surgeon following the index procedure. The operative surgeon was uncontactable and fell short of the standards required for post operative care in this instance which unfortunately led to the patient’s outcome.
Recommendations to Improve Patient Safety and Clinical Standards
• Vascular injuries are an uncommon but devastating complication from osteotomy surgery and should be actively looked for in the postoperative period as these are time sensitive complications.
• The operating surgeon should always review the patient post-operatively and make themselves available as far as they are able for urgent reviews.
• Operation notes and documentation should always be kept to a high standard.
This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact [email protected] or call +44 (0) 203 355 9796.