Orthopaedic Surgery

Case summary
A 70-year-old woman was brought in by ambulance to the emergency department of a large private hospital after experiencing low back and buttock pain at home. She was admitted under a geriatrician. After admission it was noted that the patient was reluctant to mobilise and there was considerable difficulty in controlling her pain. 

On day 4 of admission, she developed severe left leg pain. This was attributed to her leg being twisted while being moved to her bed. Subsequent X-rays showed a left periprosthetic femoral fracture with a transverse fracture below an old Charnley stem with surrounding osteolysis. An orthopaedic surgeon assessed the patient and recommended surgery. 

On day 7 of admission, she underwent a revision of the femoral component, whereby the fracture was stabilised with a plate, femoral allograft and cables. Prior to this femoral surgery the orthopaedic surgeon undertook a right femoral vein cutdown to allow cannulation of the vein. Presumably, this was to facilitate the use of cell saving and re-transfusion; her peripheral venous access was poor.

At the end of the femoral procedure the patient was moved from the lateral position to supine and a large haematoma in the right groin was noted. The groin was re-explored and packed, with a plan to return to theatre the following day to close the wound.

The patient spent the next four days in intensive care. On postoperative day 1 the right femoral wound was closed over a drain tube. 

However, following removal of the drain there was persistent ooze from the groin wound. The left femoral operative site had also started to ooze. Two weeks after her initial procedure she underwent debridement of both the right groin and left femoral wound. Both wounds had vacuum dressings applied.

Over the next two months there were 10 further returns to theatre to either address the draining groin or the femoral wound. Infectious disease specialists were involved, and peripheral catheter lines and peripherally inserted central lines were placed. The patient would periodically remove these due to onset of delirium. All surgeries were undertaken by the same surgeon.

At 10 weeks post-surgery both wounds were still constantly oozing, and the patient required three people to assist her to a chair. She significantly deteriorated over the next two weeks and was transitioned to palliative care. She died 14 weeks following surgery.

Discussion
There are several concerns regarding the management of this case.

The indication to undertake a femoral cut down was questionable and unlikely to have been in the scope of practice for an orthopaedic surgeon. It would be unusual that adequate peripheral access for an anaesthetist was unavailable without having to do a femoral cutdown. Autologous blood transfusion would have been a better option than a second surgery for this patient. If the orthopaedic surgeon was determined to have the femoral vein cannulated, then a vascular surgeon should have been invited to do this.

Despite the patient having a major complication—most likely a chyle leak from the femoral cutdown—the orthopaedic surgeon never sought a second opinion from a colleague more expert in this area, such as a vascular surgeon. Instead, the same repetitive process of debride and drain was undertaken for over six weeks.

Similarly, over the nearly four-month stay in hospital, apart from the initial preoperative note there was no documentation in the medical record by the orthopaedic surgeon as to his assessment of the situation and options for management. There was no record of seeking a colleague’s opinion. Having a less-invested set of eyes review the situation can be of immense help.

Notes in the medical record describe physicians becoming increasingly frustrated with the patient removing her peripheral lines and sometimes her central lines. It does not appear that a constant patient observer was employed, which may have assisted in the ability to administer intravenous antibiotics.

In the six days prior to the patient’s death she was seen by a speech therapist, who recommended a dietician be involved. This was the first documentation of concerns regarding the patient’s nutritional status, despite 14 weeks in hospital with two wounds draining copious fluids. Her albumin had dropped from 26 at admission to 16, two months later.

In summary, while the operation to manage the periprosthetic fracture was appropriate, the death of this patient may have been avoided if the surgeon had not undertaken an unnecessary procedure outside their scope of practice and had sought further opinions and assistance when complications arose.

Clinical lesson
This case exemplifies a loss of situational awareness: undertaking a procedure outside of one’s typical scope of practice (with no apparent assistance sought), then persisting with the same strategy to manage the postoperative complication. Gaining advice from a colleague would have been enormously beneficial for the effective management of this case. This was a potentially preventable death.

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Disclaimer
Please note that these cases are edited from ANZASM first- or second-line assessments that have been generated by expert surgeons in the field. Any recommendations relate to these cases as they were presented.