by Mr Nader Neil Terry Rehmatullah & Carly Cotton
Consultant Trauma & Orthopaedic Surgeon | Welsh National Clinical Lead for Knee Surgery
BSc (Hons), MBChB, MRCS, FRCS (Tr&Orth England) | Instructed by Claimant and Defendant solicitors in personal injury and clinical negligence matters
Could you tell us about your journey into trauma and orthopaedic surgery, and what led you to specialise in knee surgery and lower limb trauma?
I have wanted to be a knee surgeon since I was 18 years old. I was part of the British Athletics team at junior level and was out for a year with a knee problem. I saw the British gymnastics knee surgeon, who diagnosed me within minutes, operated, and had me back competing within two months. My orthopaedic training was focused around sports knee injuries – I completed six six-month placements in sports knees during six years of training, when most trainees complete only one or two. I then undertook two of the five leading Sports Knee fellowships in the UK before becoming a consultant, and I am now the knee surgeon for a professional football club by invitation. Lower limb trauma comes hand in hand with being a knee surgeon, and I am referred most of the complex knee trauma within my unit.
Your clinical practice spans sports injuries, ligament reconstruction, knee replacement surgery and orthopaedic trauma. What are the most common conditions and injuries you encounter in your day-to-day practice?
The conditions I see most frequently include ACL tears and reconstructions, meniscal tears and repairs, tibial plateau fractures and fixation, and multi-ligament knee injuries and reconstructions, which I perform once or twice a month. I also regularly treat patella dislocations, mal-aligned legs centred around the knee requiring osteotomy, and both partial (uni-compartmental) and total knee replacements for arthritis.
You currently serve as Welsh National Clinical Lead for Knee Surgery. What does that role involve, and what are the key challenges and priorities in knee surgery today?
The role involves analysing how patients are managed across Wales and identifying differences in treatment, clinical care and timing for the same condition, then developing new pathways to ensure parity and equity for patients regardless of where they live or are seen. The key challenge is that it is nearly impossible to change practice without financial backing, and instigating change within the NHS more broadly involves many hurdles. My priorities are improving revision knee care across Wales and improving the speed of soft tissue knee care in certain locations, where it is often treated as secondary to joint replacement due to national policy drivers.
How does your national leadership role help you maintain a broad perspective on clinical standards and best practice across orthopaedics?
The role gives me an overview of how practice differs across units and how slowly change can happen, but it would be wrong simply to accept that and not push for improvement, so I act as an advocate for patients and consultants to ensure standards of care are correct and continue to improve. It also drives me to stay up to date with research and developments across the whole of the knee syllabus, and my own clinical standards have improved considerably since taking on the role.
From a medico-legal perspective, how important is it for expert witnesses to remain actively involved in shaping and improving clinical services?
I wouldn’t say it is essential, but it is certainly very useful. From a witness perspective, it means I know the latest research and literature to reference as evidence in the cases I write. It also allows me to give a quick initial response on whether a potential instruction carries merit, which is valuable for both the client and the instructing solicitor.
Knee injuries can affect patients of all ages and activity levels. What are some of the long-term consequences if these injuries are not diagnosed or treated appropriately?
Soft tissue knee injuries in young patients can be severely problematic in the long term if left untreated. For example, an untreated ACL injury in an active 23-year-old can result in very early-onset post-traumatic arthritis and, at the worst end of the spectrum, a knee replacement – I have had to perform this surgery in a 42-year-old woman who was not treated appropriately at the time of injury. Meniscal tears and OCD lesions that are not correctly diagnosed and treated have a similar effect, and in all these situations patients’ lives are severely and negatively affected.
What developments in knee surgery and orthopaedic trauma are currently having the greatest impact on patient outcomes?
The biological side of knee treatment is developing at the most rapid rate currently, with numerous products now coming onto the market aimed at keeping people active for longer, later into life. Patients are, correctly, no longer as willing to simply accept being told to stop an activity or to have an early knee replacement. Robotics is also a significant topic in arthritis surgery at present – it is a fashionable technology, but there is not yet strong evidence of long-term patient benefit, and we still await robust results.
What prompted you to develop a medico-legal practice alongside your clinical work?
I was involved in a number of court matters unrelated to my clinical work, where I assisted various individuals, and solicitors and barristers commented that my reports and analytical approach suggested I should retrain as a barrister. I compromised – I love knee surgery, so I moved into medico-legal work instead. I thoroughly enjoy it, and from the outset solicitors have told me that my reports are very good and that they wanted to instruct me again in future.
Having completed Bond Solon Expert Witness training, what do you believe makes an effective expert witness?
Passion, knowledge, thoroughness, enthusiasm for the role, effective time management, and the ability to communicate clearly and hold your nerve under pressure.
What can solicitors expect when instructing you on a personal injury or clinical negligence matter?
Enthusiasm and thoroughness, a commitment to holding to the timescale agreed regardless of circumstances, and effective, direct two-way communication whenever it is required. I am also honest about the time a report is taking – there may be occasions when I take slightly longer than some experts, but this reflects the thoroughness that goes into the report, and I am extremely competitive on behalf of my clients. An honest, high-quality report is always guaranteed.
How does your active clinical practice help you provide balanced and up-to-date expert evidence?
I work across one NHS practice and four private practices, and as Welsh National Lead I have to remain active and current, since private patients often come with detailed questions and knowledge of their condition, and my national role requires me to keep up to date more broadly. My clinical and medico-legal work complement each other well in this respect.
What types of orthopaedic injuries most commonly arise in personal injury litigation?
In the lower limb and knee, the most common injuries are meniscal and ligament tears and tibial plateau and patella fractures. In relation to joint surgery, I also see infected knee replacements and knee replacements that have been incorrectly performed.
How important is early diagnosis and appropriate rehabilitation in determining long-term outcomes for injured patients?
Extremely important. As a sports knee specialist, I find that early diagnosis and treatment – ideally within weeks – significantly improves the outcome, by preventing further damage where the injury is caught and treated promptly.
Sports injuries frequently feature in personal injury claims. What are the key factors that influence whether an individual can return to their previous level of activity following a serious knee injury?
What types of orthopaedic clinical negligence cases do you most commonly encounter?
The most common are problematic knee replacements, whether infected or mal-positioned; delayed diagnosis, referral or treatment of sports knee injuries, especially meniscal tears; and distal femoral and proximal tibial fractures with complications arising afterwards.
Are there recurring themes you see in cases involving delayed diagnosis or treatment of knee and lower limb conditions?
Yes. Common themes include the treating clinician not considering the correct diagnosis early enough, or reaching an incorrect diagnosis with confidence and not discussing the case in an MDT despite the patient having ongoing problems, and delayed referral to the specialist who ultimately treats the underlying condition.
From an expert witness perspective, what factors are particularly important when assessing breach of duty and causation in orthopaedic claims?
The central questions are whether a clinician’s management fell below the standard expected of a reasonably competent practitioner, and, if so, whether that breach caused or materially contributed to the patient’s injury or outcome. I also take into account the usual factors: clinical history, examination findings, imaging and test results, prior medical records, and the mechanism of injury.
You balance clinical practice, national leadership responsibilities, research, teaching, football medicine and medico-legal work. What do you enjoy most about the variety of your role?
I am often asked this – work doesn’t feel like work to me, it’s something I enjoy. It does take time, of course, but I can honestly say I wake up happy to go to work. I sometimes wish I had a little more time for cycling or golf, but I still love every part of it.
What do you find most rewarding about combining clinical practice, leadership responsibilities and expert witness work?
The variety, and the ability to benefit patients in different ways. My role with the football club is different again and enjoyable in its own right – my children are able to join me in the members’ bar and clubhouse, and my son has got to know the players, which he loves. Each of my roles complements the others in similar and quite different ways – variety really is the spice of life.
Is there a particular case, patient journey or professional experience that highlights the importance of timely diagnosis, appropriate treatment and robust expert evidence?
There are many, but one that stands out involved a woman who sustained a severe hamstring injury while on honeymoon, which was completely misdiagnosed and mistreated. The outcome for her has been poor, largely due to a lack of knowledge within the treating team and a significant delay in treatment, arising mainly from a failure to recognise the injury or seek appropriate specialist input.
Looking ahead, what developments in knee surgery and orthopaedic care are you most excited about?
The UK lags behind Europe in the use of osteotomies, which can make a significant difference by delaying the need for joint replacement and reducing morbidity. Robotics remains a major current topic. And BMAC – which is close to my heart – has the potential to significantly benefit patients through the repair of damaged cartilage.
Mr Rehmatullah is instructed by both Claimant and Defendant solicitors in personal injury and clinical negligence matters.