Episode 6. Douchebag Department of the Week!

Another first for this series: this story is about a department – so, it’s about collective stupidity rather than just individual incompetence.

Yesterday I saw a lovely lady in her 60’s who’s got patellofemoral arthritis in her knee. Over the last 10 months she’s had 7 episodes where her knee has locked up, with severe pain. The longest episode of locking lasted 3 days.

This lady went to the orthopaedic department in her local hospital in West London. (This place is an utter ‘Pit of Doom’! (I know: many years ago I used to work there… and it was GRIM!)

• On one occasion this lady’s knee has been manipulated in A&E, to unlock it. She was then simply given a knee brace and discharged.
• On another occasion, the team that she saw in the orthopaedic department of her local hospital offered her a manipulation of her knee under a general anaesthetic (but without an arthroscopy at the same time!).
• On one other occasion, she was offered an intra-articular injection of steroid.
• She was also sent for a CT scan of her knee (quite why, I’m not sure)… but not an MRI!

Thankfully, the lady came to see me for a proper, sensible, sane opinion.

An MRI scan confirmed evidence of the pre-existing patellofemoral arthritis, and it showed that the medial and lateral menisci and the articular cartilage in the medial and lateral compartments all looked fine. However, there was clear evidence of a roughly 1cm-diameter bony loose body sitting at the front of the joint, directly in front of the ACL tibial footprint.

I’ve offered this lady a slot on my list next week, for an arthroscopy with removal of the loose body. (This should be a quick, easy, straightforward procedure, under a brief anaesthetic, done as a day-case, and she’ll be fully-weight-bearing straightaway afterwards.)

Learning points?

1. If someone complains of recurrent temporary intermittent locking of their knee… then it’s a loose body or an unstable meniscal tear…. until proven otherwise!
2. (If someone presents with a locked knee, especially after a twisting episode), then it’s a displaced locked bucket handle tear, until proven otherwise – and this is a far more urgent issue: https://kneearthroscopy.co.uk/condition/locked-knees/.)
3. The correct imaging for this lady, right from the go, should have been an MRI scan.
4. As a surgeon, if you’re going to give someone an anaesthetic, in theatre, to manipulate a locked knee straight… then why on Earth would you not also combine this, then and there, with a quick arthroscopy too, to remove the loose body (or, potentially, to deal with an unstable meniscal tear) at the same time, in order to fix the actual problem.
5. Well done to A&E for giving this lady a brace…. as opposed to them doing absolutely nothing of any use or value whatsoever, which is so often the actual case for so many ‘orthopaedic’ patients (even if just giving her a brace was little more than just a token gesture!).
6. Simply treating a knee with recurrent intermittent locking with an intra-articular steroid injection shows a fundamental and crushing lack of understanding about what the heck was actually going on in this poor lady’s knee.

Questions

1. Would you like to know the name of the hospital in West London where this lady was mismanaged?
2. Assuming that this lady does actually go ahead with the arthroscopy that I’ve offered her next week… then would you like to see a photo of the loose body?