California – Orthopedic Surgery – MRSA Bacteremia With Swelling And Erythema Of The Left Knee

On 6/11/2014, a 20-year-old male at that time presented to an emergency department with left knee pain and swelling of the left leg.  On 6/15/2014, Orthopedic Surgeon A provided an orthopedic consultation, which was requested by the admitting physician to rule out infection in the knee.  In his exam, Orthopedic Surgeon A noted swelling around the left leg area, satisfactory circulation of the left lower extremity, a mildly tender left leg, and definite tenderness over the tibia.  Diffuse tenderness over the left knee and no obvious swelling were noted.  The range of movement for the left knee was painful from full extension to beyond 90 degrees; otherwise, the knee was stable.

Orthopedic Surgeon A reviewed an x-ray of the left knee finding no obvious swelling and an essentially normal exam.  No complaint of an acute infection was found on the tibia or knee by the orthopedic surgeon. Orthopedic Surgeon A’s impression was a healed fracture of the left tibia with tibial nailing with positive blood culture for infection. Orthopedic Surgeon A’s aspiration of the left knee did not show any pus and very little serosanguinous fluid was aspirated, the fluid was sent for culture and sensitivity. Orthopedic Surgeon A did not feel the patient needed aggressive orthopedic treatment, and his plan was for the patient to be treated for infection as per the infectious disease specialist’s recommendations.

On 6/17/2014, an internal medicine physician noted that the patient had severe sepsis due to methicillin-resistant Staphylococcus aureus bacteremia.  The patient was receiving IV vancomycin; however, he continued to have persistent bacteremia, which was suspected to be secondary to the knee.  The internal medicine physician attempted to have Orthopedic Surgeon A evaluate the patient on that day; however, Orthopedic Surgeon A felt there was no needed to see the patient on 6/17/2014.  The internal medicine physician then requested a second opinion from Orthopedic Surgeon B.

On 6/17/2014, the patient was examined by Orthopedic Surgeon B.  Upon his exam, Orthopedic Surgeon B noted a circumferential anterior cellulitis type of finding on the anterior left knee and that the skin appeared to be indurated in this region.  Orthopedic Surgeon B’s impression was left knee infection, possible prepatellar bursitis.  Orthopedic Surgeon B was not convinced that the aspiration performed by Orthopedic Surgeon A was in the knee joint as he saw the location of the aspiration was directly through the red prepatellar bursa region.  Orthopedic Surgeon B found that the patient would likely need surgery for treatment of infection.  However, the treatment would depend on whether the patient had prepatellar bursitis or septic knee.  Orthopedic Surgeon B noted that he called Orthopedic Surgeon A on 6/17/2014 in an attempt to discuss his findings.  However, Orthopedic Surgeon A did not feel the need to follow up with the patient that day.

On 6/18/2014, Orthopedic Surgeon A examined the patient for the second time.  Orthopedic Surgeon A noted redness over the anterior surface of the knee.  He did not find any evidence of prepatellar bursitis except for redness and noted that there was diffuse tenderness around the left knee.  Orthopedic Surgeon A reviewed an MRI of the knee, finding synovitis with effusion.  Orthopedic Surgeon A aspirated the knee again, obtaining 2 ml of bloody fluid and finding no evidence of pus.  Based on the MRI and his evaluation, Orthopedic Surgeon A’s impression was that the patient had hypertrophic synovitis with effusion of the left knee per MRI.  Orthopedic Surgeon A’s plan was for the patient to be treated with IV antibiotics as recommended by the infectious disease specialist until the infection was under control.  Orthopedic Surgeon A did not recommend surgery of the left knee.

Orthopedic Surgeon B also reviewed the MRI of the left knee and found a large effusion with evidence of soft tissue edema.  Orthopedic Surgeon B noticed a clear abscess in subcutaneous tissue and loculated fluid in the knee joint.  Orthopedic Surgeon B’s impression was severe sepsis due to probable left septic knee and possible secondary cellulitis over the left knee.  Accordingly, on 6/18/2014, the patient underwent a left knee arthroscopy, incision and drainage with lavage of the left knee joint; left knee arthroscopy; synovectomy; left knee arthroscopy and synovial biopsy; left knee prepatellar bursa incision and drainage; and left knee proximal tibia hardware removal of one single locking bolt of tibia intramedullary nail.

Orthopedic Surgeon B’s findings included positive gross pus in the prepatellar bursa consistent with prepatellar bursa and abscess of 150 ml of gross pus; positive gross pus and left knee joint synovitis; and medial proximal locking bolt of tibia intramedullary nail exposed in the prepatellar bursa region.

The Board reprimanded Orthopedic Surgeon A and ordered him to complete 20 hours of a continuing medical education course in reading and interpreting MRI’s.

State: California

Date: January 2017

Specialty: Orthopedic Surgery, Internal Medicine

Symptom: Joint Pain, Swelling

Diagnosis: Septic Arthritis, MRSA, Sepsis

Medical Error: Diagnostic error

Significant Outcome: N/A

Case Rating: 4

Link to Original Case File: Download PDF

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