We have settled a claim against Imperial College Healthcare NHS Trust for negligence by an orthopaedic surgeon at St Mary’s Hospital in London. The claim concerned our client’s anterior cruciate ligament (ACL) reconstruction. The ACL is important for stability in the knee.
Our client had injured his right knee playing football some five years before he underwent the reconstruction surgery. In that accident, soft tissue known as the meniscus in his right knee was torn. This was confirmed by an MRI scan and he underwent keyhole surgery to repair this, after which he had a full range of movement in his right knee, but suffered with pain and occasional instability. Over the next few years, he worked hard on physiotherapy exercises to manage his pain and instability, but this deteriorated over time. Eventually, he had an MRI that confirmed he had by then suffered a complete tear of his ACL. He was advised to undergo ACL reconstruction.
ACL reconstruction involves drilling tunnels, one through the femur (the thigh bone) and one through the tibia (one of two bones in the lower leg). A graft is then taken from the hamstring and threaded through these two tunnels and fixed in position, to recreate the function of the ACL.
It is extremely important that the position of the tunnels is accurate for the hamstring graft to recreate the precise biomechanical effect of the patient’s ACL.
After the operation, our client was advised he needed physiotherapy and exercise, to build muscle strength, but he felt his knee was unstable. He persisted with physiotherapy, but was still concerned about his knee. He returned to his consultant, who told him that he needed to allow time to recover and should meanwhile try to build up muscle strength. Our client diligently continued with physiotherapy, adding in light exercise, but still experienced pain on twisting his knee, which occasionally gave way. His consultant advised that there was no problem with the reconstruction and he just needed to continue exercising.
Despite continuing with exercise over many months, our client felt no improvement in his pain or stability and a private physiotherapist eventually suggested he should have an MRI and seek a second opinion. The MRI and clinical consultation that followed confirmed to our client that the ACL reconstruction had not been correctly positioned. The new consultant found that the tibial tunnel had been drilled in a position that was too far back and could not provide the support our client needed. He advised that revision surgery was required.
Given our client’s experience of the earlier surgery, he was concerned to take further advice as to whether revision surgery was really necessary. Two more consultants independently agreed that the tibial tunnel was wrongly positioned and needed revising. Our client was referred to another surgeon for the revision to be performed. This was done as a two-stage procedure. During the first operation, the hamstring graft was removed and the existing tibial tunnel filled with bone graft to seal the hole. The surgeon confirmed the tunnel was positioned very far back.
It took nine months for our client to heal after the first stage before he could proceed to the second stage of surgery, to drill a new tibial tunnel and re-do the ligament graft. Unfortunately, following this operation, our client developed a severe infection at the graft site. He had to have the graft removed and repeated once the infection had settled. That further attempt to reconstruct his ACL ligament also ended in infection and further surgical options were therefore abandoned. Instead, our client was advised he will need to continue for life with exercises to maintain the strength of his quadriceps muscles to control his right knee in the absence of the ACL and will suffer long-term pain and reduced function.
We obtained expert evidence at an early stage, after reviewing our client’s medical notes and records, and then submitted to the hospital a formal letter setting out the allegations of negligence that our expert considered had occurred. Our expert was robust in his opinion that the original tibial tunnel had been drilled in such a poor position as to be negligent. By this time, that tunnel had been filled, but our expert relied on a combination of the historic MRIs and the documented findings of the four eminent surgeons whom our client had consulted for further opinions, particularly the surgeon who performed the revision and had therefore seen the position of the original tunnel that had been drilled.
Notwithstanding the weight of clinical opinions that were clearly noted, the hospital denied that there had been any negligence in our client’s care. We were therefore forced to issue legal proceedings against the hospital to progress the claim, giving rise to increased legal costs, including instructing counsel (a barrister) to advise on the prospects of the claim succeeding. Formal proceedings were served on Imperial College Healthcare NHS Trust and detailed witness evidence obtained from our client and others in relation to his claim. Our expert’s report had to be finalised and he examined our client to assess his condition and prognosis. In the meantime, we offered to settle the claim.
Following exchange of expert evidence, the hospital eventually agreed to enter into negotiations and accepted settlement of the claim for £85,000 shortly before it was due to serve its own evidence on our client’s condition and prognosis. While the settlement was a good outcome for our client, it could have been achieved at a far earlier stage had the hospital taken a more sensible approach to the evidence in the case, not least given the number of different surgeons whose clinical opinions had been that the tibial tunnel had been drilled wrongly and needed revising. The NHS could have avoided a large proportion of the legal costs that resulted from its handling of the case had it only approached settlement at an earlier stage.