How To Minimize Legal Risks With Bunionectomy Complications

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Allen Jacobs, DPM, FACFAS

   If a deformity is nonreducible, one should document this. The presence of a nonreducible deformity argues against effective utilization of orthotics, splints or other similar device devices, which a plaintiff expert might suggest appropriate for the reversal of the deformity without the need for surgery.

   Not uncommonly, the expert witness for the plaintiff will allege that the surgeon selected an inappropriate procedure that doomed the patient. Every hallux valgus surgery is unique as a variety of factors may lead one to opt for a particular bunion procedure. Such factors may include the patient’s medical condition, ligamentous laxity, osteoporosis, the patient’s foot type and foot function, the presence of open growth plates, metatarsal width and social factors. One should document these factors to justify the procedure selection.

   For example, consider the case of a patient who was scheduled for bilateral bunion surgery on the first visit. When the patient was dissatisfied with the results of the surgery and suggested that the present symptoms were not significant, the absence of any detailed examination in his chart made the defense for surgical intervention quite difficult.

Pertinent Pearls On Effective Intraoperative Documentation

   Operative notes all too frequently contain the details of surgery but do not contain confirmatory evidence to justify intervention. Be sure to include intraoperative findings in the operative note. For example, one should document the presence of degenerative arthritis of the joint as this can help justify such procedures as resection arthroplasty, implant arthroplasty or arthrodesis. Other intraoperative findings may include confirmation of osteotomy reduction and stabilization, failure of the fixation devices to penetrate the joint, stability of the osteotomy construct on manipulation, crepitus free range of motion and adequate reduction of the deformity.

   When it comes to any abnormal findings that could compromise the surgical procedure or lead the surgeon to alter the planned procedure, one should document these findings in the operative note.

   Experienced hallux valgus surgeons understand that there is a variety of procedures and indications for these procedures. The intraoperative note should include such factors as reduction of the intermetatarsal angle with soft tissue correction, the observed proximal articular set angle and the quality of bone at the time of surgery.

   Finally, always consider confirmatory intraoperative radiographs. Intraoperative radiographs can provide evidence that one properly performed the surgery, adequately reduced a deformity and properly placed a fixation. Conversely, obtaining multiple views of intraoperative radiographs gives the surgeon the opportunity to revise the surgical procedure prior to the discovery of “surprises” in the office when he or she sees the first postoperative radiographs.

   In one case, there was a displaced/dislocated implant of the great toe joint. Staff took the X-rays in the office following surgery. In subsequent litigation, the patient alleged that the toe was dislocated from the time they had left the operating room. Unfortunately, in spite of the protestations of the surgeon to the contrary, no intraoperative X-rays were available to support the surgeon’s claim that he or she had properly performed the procedure. Of course, this made it quite difficult to defend this case.

Ensure Proper Postoperative Documentation

   Complications can occur following any surgical procedure. Not infrequently, patients and/or their attorneys allege that the surgeon failed to recognize and treat abnormal sequela or complications in a timely manner following surgery. Sadly, many competent doctors fail to properly document the postoperative status of the patient.

   Postoperative documentation should include more than “the patient is doing well.” Documentation should include local and systemic evaluation of the patient.

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