The Northern Cape Court (Kimberley) has thrown out a woman's claim against the orthopaedic surgeon who performed her total hip replacement a decade ago, which left her with a drop foot, and has ordered her to pay all legal costs involved.
TimesLIVE reports that Susara van Wyk was 73 on 13 February 2015 when Dr James Duze carried out the surgery. It was performed with informed consent and the post-operative care and management were acceptable, but, the court heard, Van Wyk suffered a permanent sciatic nerve injury during or because of the surgery, leaving her with a permanent “drop foot”.
She asked the court for a finding on whether the intra-operative damage to the sciatic nerve was the result of negligence by Duze. The nature of the negligence was said to be “the incorrect and careless placement of a retractor during the THR procedure”.
Several medical experts were called and Duze testified on his own behalf. Two doctors tasked with examining and assessing Van Wyk a year after the surgery were of the opinion that due care had not been taken during the hip replacement, but that it was possible she could heal further in time.
Van Wyk was examined again in 2017 and it was agreed there had been no significant improvement, as she still had to wear a drop-foot splint and had a limp on her left side. The doctors were still of the view that Duze had not taken proper care during the procedure and that due to the damage to the sciatic nerve, Van Wyk had a claim for damages.
Retired orthopaedic/arthroplasty surgeon and emeritus member of both the South African Orthopaedic Association and the South African Arthroplasty Society Dr Jaco Naude testified for Van Wyk. He has performed about 6 000 hip replacements over his career.
Naude agreed with the report given by Duze’s neurologist Dr Liesl Smit that there was a direct relationship between Van Wyk’s sciatic nerve injury and the surgery. He agreed that the technical performance of the hip replacement was good, with no radiological evidence of complications, loosening or abnormalities.
He said the most likely cause of the injury to the sciatic nerve was due to incorrect retractor placement. He explained the retractor as “the fifth hand during surgery” when the hands of the surgeon and assistant were not enough to keep the wound open enough to gain access to the joint. Because the sciatic nerve is so close to the hip joint, incorrect placement of the retractor can cause damage to the nerve, he said.
Naude noted that the presence of the sciatic nerve was the first thing registrars are taught about – and how it had to be protected at all times during surgery.
He said he had experienced three cases of drop foot over his career and all had healed within eight weeks, with no permanent damage.
He later testified that the complications in these cases could also have been as a result of constriction or over-manipulation, and that they were not deliberate and only with hindsight could the cause have been determined.
Naude said the cause of 50% of sciatic nerve injuries associated with hip replacements is unknown and that no single risk factor has been consistently reported as being significant.
Duze testified that he qualified in 2012 and a year later qualified as a super-specialist in arthroplasty, specialising in joint replacement. He had performed 150 to 200 hip replacements and had assisted in about 500.
He said Van Wyk had come to him with extreme pain in her left hip. She had already consulted two other private surgeons, but because her medical aid benefits were limited she could not afford their rates.
Duze, as a state doctor, was allowed a certain number of hours to do private work. He agreed to help her, reduced his fee and submitted a motivation for the THR to her medical aid and performed the procedure at the MediClinic private hospital.
He said Van Wyk was lean, with more muscle than fat, which made the procedure easier. He performed the operation with due care and skill, placed the retractors himself, only requiring his assistant to hold it in place. There was no force used.
He said the retractors were used for less than 20 minutes and were rounded off at the ends to prevent serious injury to the nerve. The procedure was uncomplicated, there was no excessive manipulation or overstretching necessary, and no excessive bleeding.
He said his operating area was far from the sciatic nerve. He did not palpate for it as there was no need to fiddle with the nerve. He was satisfied that the surgery had been a success. At the post-operative exam he found the sciatic nerve in order. Van Wyk could move her left leg and there was no swelling.
However, on day two her leg swelled grossly and she could not move it. He was concerned that she had developed a deep vein thrombosis, though nothing showed up on an ultrasound.
It was later determined that Van Wyk had incurred a sciatic nerve injury, but he did not know what could have caused it. He did not believe there was a direct relationship between the symptoms and her surgery.
Duze’s expert witness Dr Koos Jordaan, head of the arthroplasty unit at Tygerberg Hospital, has performed about 3 000 hip replacements, and he agreed that thermal damage, local anaesthetic application or excessive traction were unlikely to have caused Van Wyk’s sciatic nerve damage.
He disagreed with Naude’s contention that direct retractor damage was the cause, saying he believed indirect compression was most likely.
Direct compression of the nerve would result from, for instance, a finger, a knife, a retractor or any hard object that is placed on the nerve and which then compresses it. Indirect injury could be caused for example by the rotation of the leg during the operation (a normal part of the procedure) and the nerve gets caught between different anatomical structures around the hip, such as muscles or a muscle and a bone.
He said a haematoma formation in the nerve fibres could also cause indirect compression.
There was nothing in the X-rays or surgical notes to indicate that the surgery had been anything other than an uncomplicated procedure, he said, and did not constitute unreasonable or unprofessional conduct by Duze.
Judge Cecile Williams said she accepted that while permanent sciatic nerve damage in an uncomplicated THR was rare, it was also a well-known complication and in 50% of cases, the cause cannot be determined.
She found Naude’s contention that Duze must have been negligent was not properly backed up.
“There is no factual evidence that the injury was caused by incorrect retractor placement. The explanation by Dr Jordaan of the impact of anatomical variance with regard to sciatic nerve injury is not only logical but is underpinned by the medical literature,” she said.
“The plaintiff (Van Wyk) has … failed to show on a balance of probabilities that incorrect and careless placement of a retractor had caused the injury to her sciatic nerve. As a result, the claim should be dismissed.”
She ordered Van Wyk to pay all legal costs, as well as those of the experts who testified.
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