Orthopedic Surgeon Expert Witness Report

To whom it may concern:

I, **************, MD, have been asked to review medical records of the above-named person.  These records pertain to the treatment of her knee arthritis and subsequent severe complications of wound dehiscence with multi-organism deep infection, wound necrosis, and multiple operations with plastic surgery.

I am a board-certified orthopedic surgeon has been in continuous active practice for 34 years. I have performed hundreds of total knee arthroplasties and revisions during this entire practice period.  I am currently an attending orthopedic surgeon at the ***** **** *****. I am involved in teaching orthopedic residents. At this medical center, we have concrete criteria for candidates for total knee arthroplasties.

In the process of review of records which are listed below, I have formed opinions which are outlined below and which are based on my education, my practice experience, and my continuing education. These opinions are based on scientific principles and evidence-based orthopedic literature.  I reserve the right to modify or supplement these opinions should additional opinions become available.  Should this case come to litigation, I have no financial interest in the outcome.

Records Reviewed

• Riddle Hospital- multiple admissions.
• Operative summaries.
• Consultation of Dr.  D.
• Office records of Dr. S.
• Pathology and microbiology reports

Facts

Ms. M was seen by Dr. S, an orthopedic surgeon, who seemed to not hesitate in scheduling her for a total knee arthroplasty.  There are no concerns listed by her surgeon for extremely high risk of complications with Ms. M going through this surgery. I find no documentation beyond the customary boilerplate consent form as to discussion with the patient about the greatly elevated risks for her with her many co-morbidities, especially morbid obesity and diabetes. I find no evidence that Dr. S paid any attention to A1C values and how well or not her diabetes was controlled.  There is no evidence that Ms. M was aware that if she experienced an infection that she could face multiple operations and possible loss of her leg. Additionally, there is no record of discussion by Dr. S of safer alternative methods of treatment as that of a program of regular injections of cortisone or viscosupplementation while she is losing weight and getting her diabetes under acceptable control.

As would definitely be expected, Ms. M within 3 weeks of her total knee arthroplasty developed wound dehiscence with tissue necrosis and frank infection.  This condition then required an operation to wash out the knee with a poly exchange. The infection persisted with additional surgery for removal of implants and plastic surgery to close wounds.  The patient required a pic line and weeks of IV antibiotics. The last notes available, seem to indicate that the knee is quite and no active infection. The consultant –Dr. D—produced an opinion that the risk of replanting her knee with permanent implants at this time would be above 50% for reviving or introducing another infection. His thoughts were to get her weight way down and optimize her diabetes before ever attempting to do a replant.

Standard of Care Deviations

1. There is no evidence in the records that Ms. M was appraised of the extreme risk of the surgery and what those risks and complications could produce for her.  We are required by the standard of care to fully inform patients of the risks vs reward of surgical procedures. I agree with Dr. Ds statement that there would be greater than a 50 % risk of infection in re-planting the knee of Ms. M.  I feel that was the same risk at the time of the initial knee surgery with the severe risk factors of morbid obesity and not well-controlled diabetes.  Therefore, it is below the standard of care for an orthopedic surgeon to perform a total knee on such a patient as Ms. M with such severe risk factors without an intense formal clear discussion of what odds they have for known complications and what would happen if these complications occurred. Dr. S deviated from the standard of care in ignoring these risk factors and not properly informing Ms. M.
2. If a patient as Ms. M persisted in demanding a knee replacement, it is the standard of care to take all precautions as possible to prevent the complications which were discussed. Precautions were taken in this case to prevent thrombo-embolic events, but there is no record of adequate infection prophylaxis. There is one comment pre-operatively of dosing of an antibiotic IV prior to surgery but the intra-op record does not note any antibiotics. The operative summary notes use of antibiotic cement, but this alone is not sufficient.  Also, there is no evidence of any antibiotics for the next 24 hrs. There is no record of any antibiotics after discharge. The orthopedic literature indicates either a single pre-op dose of antibiotics or pre-op and the 24 hrs. of additional antibiotics especially if there are risk factors for infection. Likewise, the procedure of a few days of post-op oral antibiotics is within the standard of care for high-risk patients. Dr. S breached the standard of care by only ordering one dose of an antibiotic in such a high-risk patient as Ms. M.
3. The x-rays post-operatively reveal an unstable total knee with the medial side of the knee opening up compared to the lateral side. This indicates poor tensioning of the knee and a spacer which is too thin. The knee components recommended in a patient who is well above ideal body weight is to use a stemmed tibial component to prevent failure due to severe body weight loading resulting in loosening and subsidence with severe pain.  Had Ms. M escaped a wound dehiscence and a severe infection, it is more likely than not that the knee tibial component would have failed and needed a revision. It is felt that Dr. S breached the standard of care in incorrect tensioning of the knee and incorrect tibial component.

Damages

The breaches in the standard of care and negligence in the performance of a total knee are felt to be the direct and proximate cause of injury to Ms. M consisting of a severe deep infection with multiple organisms, multiple operations, and prolonged IV antibiotics with potential renal and hearing damages. The risk of another surgery now is prohibitive in order to put permanent implants.  Even if the patient lowers her risk factors by losing lots of weight and getting her diabetes under control in order to have her replantation, she would still have a substantial risk of another serious infection with possibilities of having to have a knee fusion or an amputation.

Biomechanical Engineering report

INTRODUCTION:

On February 14, 2013, at about 6:45 PM, Mr C. was stopped in traffic in the southbound lane of Route 622 at the intersection of Broadway with Pine Grove, City of Kingston, State of New York when the van he was operating was struck on the rear drivers’ side by Mr. V.

This crash involved:
– 2012 Dodge Grand Caravan passenger van operated by
– 2012 Hyundai 4DSD operated by V

 

The purpose of my investigation was to determine if C’s injuries could have been caused by this crash.

INFORMATION AVAILABLE FOR REVIEW:

1. Arbitration submission for C
2. New York State Department of Motor Vehicles Police Accident Report No. ********* dated February 14, 2013
3. Damage Assessment and Appraisal for C Dodge by A.F. S., Inc. dated February 22, 2013
4. Transcript of the Deposition of Mr. C dated January 15, 2014
5. 8 black & white photographs of C’s Dodge
6. Medical records for Mr. C.

DESCRIPTION OF THE INCIDENT

This crash occurred at the intersection of Broadway with Pine Grove in the City of Kingston. V was operating his vehicle traveling northbound on Pine Grove and struck C’s Dodge while attempting to make a left-hand turn onto Broadway. The left-front of Vs’ Hyundai impacted C’s Dodge at the back left wheel causing damage along the left side.

ANALYSIS

What is Biomechanics? – Biomechanics is the science which studies the action of energy and forces on living bodies. Sometimes, the action of external forces generates sufficient internal force which cannot be sustained by the body’s tissues resulting in injury. The injury is the damage caused by physical trauma and the mechanism of injury is the fundamental physical process responsible for the injury.

In the context of musculoskeletal biomechanics, injury mechanisms include:

✓ Impact
✓ Dynamic overload
✓ Crushing
✓ Skeletal acceleration/deceleration
✓ Exceeding joint range-of-motion
✓ Rate & extent of tissue deformation

Each injury mechanism includes some combination of kinematic and kinetic variables. Kinematics variables are the physical factors of time, position, velocity, displacement and acceleration while kinetics variables deal with force. Forces can be developed mechanically or by mass and inertia. Forces or loads are described by magnitude, direction, location, duration, rate, variability, and frequency.

Vehicle movements and resulting occupant kinematics during side vehicle collisions

C testified he was wearing his seatbelt while making a right turn to go to the YMCA just across the street. Vs’ vehicle made a left turn without a turn signal and appeared to be going to impact his vehicle. C attempted to turn to the right to avoid the collision but was unable. His vehicle rotated counter-clockwise completely going the opposite direction (~180°). C estimated his speed was about 10 MPH while V was traveling about 35-40 MPH. This resulted in a “very heavy” impact.

Review of the Damage Assessment, the Police Accident Report and the photographs of C’s Dodge, Vs’ Hyundai impacted C’s Dodge with a primary point of impact at about 11 o’clock on his Hyundai. The primary point of impact on C’s Dodge was at the drivers’ side rear wheel with damage along the drivers’ side. Information on V’s Hyundai was not available for this analysis. Figure 1 shows the accident location.

Occupant Kinematics

Newton’s 1st Law states that a body at rest will remain at rest and a body in motion will remain in motion at a constant velocity unless acted upon by an outside force. During crashes, motor vehicles abruptly accelerate or decelerate while the vehicle occupants continue on in their current state of motion. These differences in motion often cause impacts within the vehicle interior, with passengers or with outside objects that intrude into the vehicle. If sufficient crash forces are generated, these impacts can injure or kill the vehicle occupants.

The crash cycle of experimental crashes similar to this one last about 500 milliseconds or about ½ second. During a side collision like this, the door and seat serve as the primary restraint to the side and rearward occupant movement by compressing and rotating.1 The 3-point seatbelt serves as the primary restraint to forward motion along with the steering wheel airbag if deployed. Cushioned internal compartment components along with the seat and seatbelt are understood to distribute impact energy over a larger area of the body and serves to lengthen the impact time reducing maximum force application.

At the moment of impact, C’s Dodge was abruptly accelerated linearly and rotationally. These accelerations caused the vehicle to rotate counter-clockwise and translate from left to right. Applying Newton’s 1st Law to this crash, C’s body would have remained relatively motionless with respect to the vehicle as it translated and rotated abruptly. C’s left side would have been impacted by the door and the pan support structure. He would also have moved forward with respect to the vehicle interior.2

As the crash cycle continued from initial impact by rotating counterclockwise and translating left to right, C’s body would have been caused to accelerate in the same directions. Because the human body is not considered rigid like the vehicle structure, body components accelerate at differing times during the crash cycle. It is these differing motions between body structures which, if sufficient in magnitude, cause injury. Joints exceed their acceptable ranges of motion causing stress and strain on supporting ligaments and muscles. Bone fractures can result along with soft-tissue tears.

What is Whiplash?

Orthopedist, H.E. C.  first introduced the term “whiplash” in 1928 – “lash-like effect in which the head moved suddenly to produce a sprain in the neck.”3 The term ‘Whiplash Associated Disorders’ (WAD) is a more modern term and is an appropriate term because the symptoms are not always confined to the neck. Whiplash is most often associated with a hyperextension injury following a rear impact but soft tissue injuries to the neck can also occur from frontal or side impacts. Soft tissue injuries to the cervical spine have also been described by terms such as neck sprain, neck strain, soft-tissue injury, and acceleration-deceleration injuries.

Researchers have generally agreed that the whiplash injury mechanism which results from automobile collisions, occurs is the initial phase of the event as the head and torso move in opposing directions. The cervical spine develops an unnatural posture during this event which is believed to be the mechanism of osteoligamentous injury. Common whiplash associated injuries include damage to: cervical facets, capsular ligaments, dorsal root ganglion, and the vertebral artery.4 Skeletal muscle can be injured under its own contraction and are likely to be injured during a single lengthening contraction.5 Neuropathology in both the peripheral and central nervous systems results from whiplash events causing pain and musculoskeletal dysfunction.6, 7

Common injuries from whiplash include:1, 8, 9, 10, 11, 12

1. Headache
2. Restricted head movement
3. Musculoligamentous strain/rupture
4. Intervertebral disc prolapsed/herniation
5. Abnormal spinal curvature
6. Radiculopathy
7. Myelopathy
8. Tinnitus
9. Vertigo
10. Neuropathy

Injury Analysis

As a result of the sudden evasive maneuvers and subsequent impact by Vs’ vehicle, C’s left knee and ankle struck front driver’s door and toe pan structure. His back and hips were impacted by the seat. Abnormal spinal curvatures developed resulting in cervical and lumbar injuries with muscular strain/sprain.

The two most common causes of a meniscus tear are traumatic injury (often seen in athletes) and degenerative processes (seen in elderly patients who have more brittle cartilage). Meniscus tears can occur in all age groups. Traumatic tears are most common in active people from age 10-45. The most common mechanism of a traumatic meniscus tear occurs when the knee joint is bent and the knee is then twisted. It is not uncommon for the meniscus tear to occur along with injuries to the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL)-these three problems occurring together are known as the “unhappy triad,” which is seen in sports such as football when the player is hit on the outside of the knee.

Side impacts with the vehicle interior with C’s left knee and ankle would be consistent with causing meniscal and ligamentous stress/strain.

During this crash, C’s body was abruptly rotated and translated. During similar experimental crashes, abnormal spinal curvatures resulted causing cervical musculoskeletal injury which included intervertebral disc and soft tissue damage.13, 14 A study by Chipman demonstrated up to 10% of their study sample which included about 47,500 crashes, experienced whiplash symptoms with neck/spinal injuries.15

C’s knee, ankle, and spinal injuries are consistent with his description of this crash. Experimental studies of crashes similar to this crash demonstrate occupant injuries consistent with C’s.

FINDINGS

Within a reasonable degree of biomechanical and engineering certainty, and subject to change if additional information becomes available, it is my opinion that:

1. Review of the Damage Assessment, the Police Accident Report and the photographs of C’s Dodge, Vs’ Hyundai impacted C’s Dodge with a primary point of impact at about 11 o’clock on Vs’ Hyundai.
2. The primary point of impact on C’s Dodge was at the drivers’ side rear wheel with damage along the drivers’ side.
3. Side impacts with the vehicle interior with C’s left knee and ankle would be consistent with causing meniscal and ligamentous stress/strain.
4. C’s knee, ankle, and spinal injuries are consistent with his description of this crash.
5. Experimental studies of crashes similar to this crash demonstrate occupant injuries consistent with C’s.