Wrong Side Total Knee Implant Case Study
A surgeon performs a left total knee replacement and implants a right femoral component. The error is not noted until after the cement sets. The patient’s ROM and patellar tracking is felt to be reasonable. The incorrect implant is left in position. The patient has a “good” ROM, but is having ongoing pain.
The manufacturer’s representative testified that he read the contents from the box, including the type of component, the size, and the laterality, and then he held the box up so the surgeon could see. The surgeon maintains that the manufacturer’s representative confirmed the size, but did not mention laterality. Even if the representative had held the box up, the surgeon maintains he would not have been able to read the contents at a distance of ten feet.
Regardless of the determination of fault for this medical error, or the surgeon’s choice to accept the implant, this wrong side implant event is another example of the vigilance required to avoid wrong sight, wrong side, wrong patient, and wrong operation errors. While preoperative time outs are critical (see Confirm Before You Cut in AAOS Now), this case example demonstrates that intraoperative decisions require the same attention.
Jeffrey M. Nakano, MD
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I was performing a right TKA and asked for the components. The rep brought the components close enough for me to confirm they were the correct side & correct size,based in the trials used. The scrub nurse opened the sealed sterile boxes and I immediately noticed they were for a left TKA, based on the anterior flange of the femoral component . I brought this to the attention of the rep and it was obvious there was a packaging error. I was fortunate not to have begun applying cement before checking the components . This event confirmed to me "that Murphy's Law is alive and well." This established a precedent in the OR of always confirming the components are correct for the operative side. --Michael Klein, MD, FACS
Jeff Good case example. Remain vigilant at all times! A case just like this was presented at the "How to avoid a lawsuit" instructional course at the AAOS in San Diego that the medical liability committee organizes. A bit sobering, to be sure. There was an interesting discussion during the course about "now what??!" is surgeon recognized the wrong side component was implanted AFTER the cement dried and yet the knee "tracked well".
Dr. Nakano. I applaud this excellent and timely article. It proves once again that being captain of the operative team requires constant and eternal vigilance and that nothing can ever be taken for granted. Thank you again for your contribution on this important subject.