Douchebag doctor of the week: Episode 2.

 

So, here we go with Episode 2 of our newly-birthed ‘Douchebag of the week’ series…

This story (below) highlights yet another case of poor-quality shoddy patient management, with (hopefully) a few useful lessons to be learnt.

Case history.

A 59-year-old lady came to clinic complaining of a 2-year history of pain and swelling in both knees.

The patient went to see a local orthopaedic surgeon who sent her for a scan of her left knee, and he advised the patient that she had Grade 4 osteoarthritis. The patient was given an injection of hyaluronic acid into her knee (which, unsurprisingly, did nothing), and the patient was referred for physiotherapy.

The patient’s symptoms persisted. The patient therefore went to see her GP, and unfortunately the GP simply went and injected some i.m. steroid into one of her buttocks.

The patient then went to see a surgeon (who I’ve never heard of before) at an ‘internationally famous clinic’ in Central London. This surgeon arranged for some imaging, with X-rays and MRI scans of both knees. Surprisingly, the follow-up appointment was simply just via a telephone consultation, not face-to-face: the surgeon told the patient that she needed a partial knee replacement in each knee, with both knees being done together, at the same time, and he offered her a slot for this surgery for literally the following week! Thankfully, and very sensibly, the patient decided to get a second opinion, instead, and hence she came to see me.

When I saw the patient myself in clinic, she was complaining of pain and swelling in both knees, with pain when weight-bearing and when walking or exercising, plus she also had pain specifically at the front of her knees with stairs / squatting / kneeling. However, she was still able to walk decent distances and she was not actually having to take any painkillers or anti-inflammatories for her knees at all. Importantly, the patient reported that about 2 years previously, she had suffered an attack of uveitis in one of her eyes (and she was under the care of an ophthalmologist for this), plus the patient had also been getting pain in her elbows, her ankles, her toes and some of her fingers.

When I examined the patient myself, she had a fixed varus deformity in both knees, of over 5 degrees on each side; however, both knees actually had a full range of motion, and there was no actual pain on either side with knee movements or even with forced deep flexion. The knees were not hot, red or swollen, and there was no tenderness at all. The both joints felt stable, and McMurray’s test was negative on both sides; however, a Clark’s test for patellofemoral irritability was positive at the front of each knee.

When I reviewed the patient’s imaging, her MRI scans showed evidence of medial compartmental osteoarthritis in both joints, but with advanced patellofemoral degeneration as well. Importantly, however, when these scans were taken, there was a small to moderate effusion in each knee, with evidence of synovitis and with multiple intra-articular rice bodies present.

I explained to the patient that, unfortunately, she actually had clear evidence of a probable inflammatory arthropathy in both of her knees, and I emphasised to the her that what she actually needed, ahead of anything else, was a formal rheumatological opinion.

I also explained to the patient that even though she does have underlying osteoarthritis (in addition to a probable inflammatory arthropathy), I would not consider her an appropriate candidate for just a medial unicompartmental partial knee replacement in either knee as:-

• First, she clearly needs a proper diagnosis about her probable rheumatological issues.
• Next, she will need appropriate medical treatment for this, to get the inflammation to hopefully settle down.
• Next, her varus deformity in each knee is fixed, plus she also has evidence of symptomatic patellofemoral compartment, and hence even without the presence of an inflammatory arthropathy, I would not consider this lady an appropriate candidate for just a medial unicompartmental partial replacement, and instead, I explained to her that if she were to have surgery under my care, then I would specifically recommend a total knee replacement for each knee.
• Next, I explained that personally, I am not a fan of bilateral simultaneous knee replacement surgery (given that the post-op rehab for just one knee at a time is so difficult, whilst at the same time being so important, in terms of the patient being able to cope with the rehab and hence achieve a good long-term outcome).
• Next, and very importantly, partial knee replacement surgery is actually contraindicated in the presence of an inflammatory arthropathy!
• And finally… this lady’s symptoms from her osteoarthritis are not actually bad enough to justify any kind of arthroplasty type surgery at all at this stage anyway!

What lessons can we learn from this?

In my mind, the mistakes that this surgeon at the ‘internationally famous clinic’ made were:-

1. First, a post-imaging follow-up appointment, where one should go through the imaging with the patient in detail, and where one should then discuss the diagnosis, the potential treatment options, the pros and cons of those options, the possibility of surgery, the potential risks of any surgery, the likely outcomes of any surgery and the post-op rehab that would be required afterwards… is a terribly important conversation to have with a patient, and this is never something that I, personally, would ever do simply just via a phone call.
2. Next, it feels really quite inappropriate for this patient to have been offered a slot for major surgery for just 1 week later, after just a telephone consult. Personally, I do not feel that this is appropriate, in terms of giving a patient sufficient time to think things over and ask any additional questions that they might have.
3. Third, the surgeon at the ‘internationally famous clinic’ in London completely missed all of the fairly obvious red flags in the patient’s history and the fairly blatant synovitis and rice bodies that were clearly visible on the patient’s MRI scan, and hence he missed the very important issue of this patient most likely having an inflammatory arthropathy.

So, questions for the audience….

A) Should I name the surgeon?

B) Should I name the clinic?

C) Would you recommend bilateral simultaneous medial unicompartmental partial knee replacement surgery for a lady with a fixed varus deformity in both knees and with evidence of patellofemoral arthritis, and who is complaining of anterior knee pain?

D) Do you think that telephone consultation was sufficient / appropriate for this lady’s case, and would you consider that ‘gold standard’ management?

E) Would you like me to post a follow-up to this story once the patient has actually seen the rheumatologist? And finally…

F) Why are there are so many utter douchebags within my profession, and would you personally classify this surgeon as a douchebag?