A previously healthy twenty-four year-old medical student saw her university-based orthopedic surgeon for a tear in a ligament in her knee. In college she had been an all-American soccer player and had considered a career in professional soccer but had decided instead to go to medical school. She had injured her knee in a pick-up soccer game. When the pain did not improve, she sought help from the orthopedic surgeon on her medical school faculty with the best reputation for complex knee surgery. An MRI showed a tear in her anterior cruciate ligament, and he scheduled her for surgery.
Unbeknown to her, the surgeon was on retainer by a medical device company to try a new instrument they had invented to aid in knee surgery. He had been instructed in its use it but had never actually used it on a patient in surgery. This was his first case with the new tool, and he looked forward to seeing how it would perform.
During the surgery, because of his unfamiliarity with the new device, he accidentally placed a screw right through her popliteal artery, the main artery supplying the leg below the knee, without realizing it. Two days later she began to complain that her lower leg was cold, blue ,and painful. The surgeon was away, so his partner’s nurse practitioner, who knew nothing of the case, suggested pain pills and leg elevation. After two more days of increasingly excruciating pain, she went to the Emergency Department and was found to have almost no blood flow below the knee.