From Knee Replacement to Amputation: Why Proper Documentation is Crucial in Medical Procedures

Case Summary

The plaintiff, a 59-year-old obese woman who was a candidate for a total knee replacement due to degenerative disease of her left knee, was admitted by an orthopedic surgeon to a community hospital. Although the surgeon had some difficulty performing the procedure, it proceeded uneventfully. However, on a postoperative day one, the plaintiff exhibited footdrop and complained of knee and calf pain despite using patient-controlled analgesia. The nurse’s notes documented she had positive pedal pulses. There were no signs of cyanosis, and her foot was not cold.

The following day, the physician’s assistant (PA) who saw her failed to record the temperature, the appearance of her foot or the presence or absence of pulses. However, the PA did document that she was unable to dorsiflex her foot.

On postoperative day three, the patient complained of pain in the bottom of her foot, as well as numbness and tingling. The footdrop had persisted, and she was unable to dorsiflex or plantar flex her foot. The practitioners from the orthopedic service who saw her concluded that her pain was due to musculoskeletal strain secondary to the surgery. The nurse’s notes continued to indicate palpable pulses in her foot. The patient was then transferred on postoperative day four to a nursing home for rehabilitation.

Four days later, the patient was brought by ambulance to the emergency department of a tertiary hospital. Her foot was cool and cyanotic with no palpable pulses. A Doppler revealed that there was no blood flow below the popliteal artery. A vascular consult was ordered and they suspected she had compartment syndrome. The patient was taken to surgery for a lateral fasciotomy. An intraoperative arteriogram demonstrated an abrupt cutoff of the popliteal artery with some reconstitution of the tibial arteries. When the popliteal artery was opened, a fresh thrombus was removed. The patient was subsequently returned to the operating room for an additional fas ciotomy. The remainder of her post-operative course was stormy, with multiple débridements and skin grafts performed. Although her limb was initially salvaged, she later fell and injured the limb, necessitating an above-the-knee amputation.

The plaintiff commenced a lawsuit based on the theory that there was a series of undiagnosed post-operative symptoms and incidents that eventually led to an amputation. She claimed that the blood clot was due to a tear of the intima of the popliteal artery. She further alleged that as blood flowed through the artery, exacerbating the intimal tear, the blood collected and clotted, blocking the blood flow in the artery to the foot. The patient’s pedal pulse became weaker as less blood flowed through the popliteal artery. As the clot expanded, the pain in her foot and calf got progressively worse. When the peroneal nerve became affected, she devel oped numbness, tingling, footdrop and was unable to dorsiflex. Because her tibial nerve was also affected, she was unable to plantar flex as well. She claimed that her post-operative signs and symptoms were clearly suggestive of a blood clot.

The plaintiff alleged that the orthopedic providers had deviated from the standard of care by failing to order a Doppler study of the popliteal artery or perform any other testing to rule out a blood clot before she was discharged. The plaintiff also claimed that a vascular surgeon should have been consulted. Finally, the plaintiff alleged that the orthopedic surgeon failed to see and examine her during her post-operative course. Instead, he relied on the PA and nurse practitioner for knowledge of the patient’s condition. This indicated a lack of communication between the surgeon and other providers, in addition to their failure to adequately diagnose and document the patient’s condition and an apparent lack of attentiveness by the surgeon to the patient post-operatively.

The defense argued that the patient had experienced an intimal tear of the artery from within, resulting in a flap of intimal tissue impeding the blood flow to the lower leg. This caused both ischemia and compartment syndrome. The defense further argued that, prospectively, there was no indication of a vascular injury to her left leg. Thus, there was no indication of an order for either vascular studies or a vascular consultation prior to her discharge. The defense claimed that the signs and symptoms observed by the PA, nurse practitioner and the nursing staff were consistent with nerve palsy from a pre-existing flexion contracture, varus deformity and full extension of the knee during surgery. Allegedly, when these tissues stretched, she developed peroneal nerve palsy. The defense further argued that footdrop and lack of dorsiflexion are fully consistent with a peroneal nerve palsy.

In contrast, if a popliteal artery blood clot had been present at the level of her knee, first the tibial nerve and then the peroneal nerve would have been affected. This is because the peroneal nerve is not directly/fully perfused by the popliteal artery. To support the defense’s argument, the nurse had documented that the patient’s foot had positive pulses, no loss of warmth, no changes in color, no loss of capil lary refill and no progression of pain.

This lawsuit was tried twice. The first trial resulted in a hung jury, which voted four to two in favor of the plaintiff. The jury commented that despite the documentation in the nurse’s notes of reasonable nursing care and attention, the orthopedic surgeon was not at all attentive to this patient. Further, although the surgeon claimed he did not document his one post-operative visit to her, the plaintiff testified he had not come to see her at all during her hospital admission.

The second jury rendered a verdict in favor of the orthopedic surgeon despite his failure to see the patient and the lack of documentation of the absence of evidence of possible vascular compromise. However, despite the defense verdict, this case was arduous to defend because of the minimal documentation by all the orthopedic providers and the surgeon’s lack of attention during the postoperative period.

Legal Analysis

This case, unfortunately, rests primarily upon the lack of adequate documentation by all providers, including the failure to document any communication between the advanced practitioners and the operating surgeon. Although it can be appropriate to delegate routine post-operative care to advanced practitioners, this patient was clearly developing symptoms of a very serious complication. It would have been in the patient’s best interests if the orthopedist had personally assessed the patient.

One of the biggest complaints by patients in both physician offices and the hospital is the lack of time spent with the patient by the doctor and/or the patient’s inability to see the doctor rather than an advanced practitioner. Although the surgeon claimed that he did visit her once during the post-operative period, because he failed to document this visit, his testimony as to that fact would be far less credible than that of the patient. The plaintiff can argue that the surgeon sees many patients daily so his memory of that visit would be suspect. However, because the patient was concerned about her increased symptoms, she would have a much more believable recollection of whether she had been visited by the surgeon.

The defendants were fortunate to win the case. However, it would have been much easier to defend if the surgeon and his employed providers had better documentation of regular communication about post-operative patients in the hospital and had properly documented their care and assessments in the medical record rather than primarily relying on the nursing documentation.

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This document is for general purposes only and should not be construed as medical or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical or professional obligations, the applicable state or federal laws or other professional questions.