Orthopedic Surgeon Gives Improper Orders for Knee Device

Case Overview

This case involves the incorrect use and positioning of a continuous passive motion device on a patient’s leg following a total right knee replacement surgery. The medical records showed that the patient’s leg was placed into the device without a foam boot and, as a result, her leg was not maintained in a neutral position while the device was in operation. Furthermore, the patient was not given a control to stop the device, which caused the patient to receive therapy for longer periods than originally intended. The patient was discharged from the hospital with an area of redness and induration that eventually progressed to a full thickness wound. The patient had to undergo several rounds of surgical debridement and extensive, year-long treatments by a plastic surgeon to close the wound. An expert in decubitus ulcer care was considered to opine on this issue.

Questions to the Orthopedic Surgery expert and their responses

Should this problem have been noticed before discharge?

Providers working with persons at risk need to be able to recognize skin changes that might indicate an impending breakdown. This is particularly true in elderly patients or in patients who are immunocompromised because the signs of impending or fulminating infection are frequently absent in these patients.

What are the earliest signs to identify skin damage before it becomes a serious issue?

The earliest clinical evidence of damage to the skin is inflammation of the skin that blanches on application of digital pressure. This process originally presents like a hyperemic response; however, unlike hyperemia, the inflammation persists longer.

About the expert

This expert has practiced orthopedic surgery for over 40 years and has performed numerous total hip replacements. He is a Stanford trained Orthopedic Surgeon, and is currently the attending orthopedic surgeon at a major New York medical center.