Cath Lab Digest

There are proactive measures podiatric surgeons can take to minimize the risk of litigation with bunion procedures. Accordingly, this author emphasizes informed consent, proper patient and procedure selection, and thorough documentation before, during and after surgery.

   In his classic 1965 textbook, Hallux Valgus, Allied Deformities Of The Forefoot And Metatarsalgia, Kelikian listed the most common complications associated with surgery for the repair of bunion deformity (see “A Guide To Common Complications With Bunion Surgery” on page 40).¹ Over 43 years later, it is safe to say the majority of complications that Kelikian associated with the correction of bunion deformity remain problematic today.

   The reality is poor results, patient dissatisfaction and/or surgeon dissatisfaction may occur following the surgical correction of bunion deformity absent any negligence. Unfortunately, poor results, limited results or patient dissatisfaction may result in negligence litigation against the foot and ankle surgeon.

   Since hindsight and Monday morning quarterbacking are without consequence or difficulty, it is relatively easy to obtain an expert witness to testify that the operating surgeon was negligent, and that the complication or adverse sequela that the patient sustained was avoidable had the surgeon acted differently. After all, the patient is dissatisfied, has an alleged poor result and has alleged damages. Dr. Expert knows the reason why this occurred and will explain to the jury the manner in which this catastrophe could have been averted.

   From a practical standpoint, hallux valgus litigation invariably is decided by the extent of damages that have allegedly occurred as a result of the “improperly” performed surgical procedure or negligent postoperative care. Realistically, the plaintiff’s lawyer is interested in damages because that is “where the money is.”

   The critical factor in the evaluation of such alleged negligence cases are the medical records of the treating foot and ankle surgeon. When the medical records are complete and detailed, this will not infrequently negate the pursuit of litigation. All too frequently, however, medical records are lacking in detail and open the door for the allegation of damages.

What Do Patients Want From Bunionectomies?

   In regard to a bunion surgery, Steven Smith, DPM, stated that the patient wishes the postoperative foot “to look good and to feel good.”² The patient is not concerned with intermetatarsal angles, sesamoid positions or elevated first metatarsals. The patient does not care whether the surgeon reduced the hallux valgus deformity by reducing the proximal articular set angle or via a “cheater Akin.” The patient desires a straight toe that does not hurt and functions properly. As noted by Marty Pressman, DPM, “the patient wants to look down and not see a bump or a crooked toe.”³

   Patients desire correction of the bunion deformity with minimal pain and discomfort. Generally, patients desire outpatient care and a rapid return to home and a normal life. The patient wants no recurrence of the bunion deformity and minimal or no out-of-pocket expense.

   Perhaps the best description regarding the inciting factors for negligence litigation was simply stated in “Recipe for a Writ,” in which the author opined that the three major factors leading to medical litigation are poor patient-doctor rapport, unmet patient expectations and unexpected large bills.⁴ As a professor at the Pennsylvania College of Podiatric Medicine (now the Temple University School of Podiatric Medicine), James Ganley, DPM, felt that surgery for bunion correction should be aimed at gaining “limited results.”⁵