Case of the month - Not on the X-ray

BACKGROUND: Mr D – a 64-year-old man – makes an appointment at his GP surgery complaining of persistent pain in his lower back made worse by gardening. Mr D has no previous history of low back pain but just over a year before he had undergone a total left hip replacement.

One of the partners – Dr G – examines the patient and finds nothing of note. He gives Mr D guidance on proper lifting technique and advises use of over-the-counter analgesia at the maximum recommended dose.

A month later Mr D returns to Dr G with a three-week history of pain in his left hip. He also complained that his foot was lying funny when he went to bed. The GP noted "restricted hip flexion on knee extension/pain in left pelvic rami". Dr G was concerned that Mr D’s symptoms might indicate early failing of the hip replacement due either to loosening or infection. He orders an X-ray and again advises Mr D to persist with the analgesia.

Two weeks later Dr G receives the results of the X-ray: "Left hip prosthesis noted and appears satisfactory. Right hip normal." Mr D attends to discuss the result and Dr G explains there appears to be nothing amiss on the X-ray. He advises the patient to persist with the analgesia and return in two weeks if the pain has not settled. No other tests are arranged as not indicated by the X-ray results.

Three months later Mr D returns still complaining of hip pain. Dr G prescribes diclofenac and codeine and refers the patient to a physiotherapist. A month later a report from the physio comments: "Patient responding well to treatment. Pain free unless doing anything, e.g. cutting grass."

Dr G does not see Mr D again but a month later the patient is referred to hospital by an out-of-hours GP having developed an abscess on his hip. Further investigation reveals an infection around the hip replacement. Mr D remains in hospital for another six weeks and has a further hip replacement which also fails again due to infection.

Six months later Dr G is contacted by solicitors representing Mr D, investigating a claim of negligence. It is alleged that Dr G should have requested further investigations or blood tests considering Mr D’s persistent hip pain.

ANALYSIS/OUTCOME: Dr G contacts an MDDUS medical adviser and the GP is asked to provide a copy of the patient records and also to provide an account of the case. In his reply Dr G relates a full chronology of his encounters with the patient including a justification for the treatment decisions made. On the question of blood tests he writes: "In my judgement it was not necessary or helpful to order blood cultures as the X-ray did not indicate any problem. Even a raised ESR could be due to any number of causes in this age group."

MDDUS lawyers draft a robust response to the allegations and the action is subsequently dropped.

KEY POINTS

• Be aware that infection can be a possibility even with normal X-rays - vigilance is essential.
• Other complications of hip replacements include loosening of the joint, dislocation, DVT and pulmonary embolism.