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Amputation and Transfer Malpractice Case

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CASE SYNOPSIS (AME#165444)

Posted: May 10, 2016

Mr. MT, a family man in his forties, was injured in an accident which resulted in an amputation of his right index finger just beyond the middle joint. In photos submitted in these records, the amputated –shortened finger is hardly noticeable. The patient however was self-conscious of the finger and no nail present. Mr. MT then began to search out options for his finger. The patient found Dr. UJ, a plastic surgeon well known for hand surgery. The records reveal that when evaluated by Dr. UJ, Mr. MT was thought to be an ideal candidate for a transfer of a portion of the second toe up to the index finger. 

The patient indicates another minor procedure which was discussed to give him a nail. He was told it was a minor procedure and he would be back to work in a few days. Apparently, the transfer was discussed as an alternate procedure, the patient understood that he was agreeing to and signing a consent for the minor procedure.  The review of the consent form for the first surgery only mentions amputation not microsurgical transfer of the second toe to the index finger. It does not mention that most all of the toe will be removed. It does not spell out that any alternative options had been discussed or any specifics of complications of this procedure. The patient indicates that he was never informed of the possibility of using a finger prosthesis. There is no evidence in the record of any pre-surgical testing of the status and location of arteries and nerves in the stump of the index finger. The patient’s trauma and amputation was done several years previously.

QUALIFICATIONS

I am a board certified orthopedic surgeon who had a 6 month mini- hand fellowship within my residency. I have done over 30 years of orthopedic and hand surgery which included elective hand surgery, joint replacement in the wrist and hand for arthritis, and trauma repair and reconstruction. I have done an occasional microsurgery case and have reviewed the current literature regarding second toe to index finger transfer. After review of the above named records of Mr. MT, I have formed opinions which are based on my training, my practice experience, and my continuing education.

Should additional information about this case come to light, I reserve the right to amend or alter my report. Additionally, should this case come to litigation, I have no financial interest in the outcome.

RECORDS REVIEWED

1.      Synopsis of the case resented to me along with colored photos.

2.      Radiology reports from ***** ***** Medical Center Department of Radiology

3.      Operative report of 6/12/2008.

4.      Operative report of 6/18/2008.

5.      Progress notes after both surgeries as well as nurses notes.

If the original trauma was an avulsion rather than a sharp amputation, the nerves and blood vessels would be located well proximally and not in their usual locations. The patient was known to have had atrial fibrillation for years and was taking a beta blocker—Metropolol. Several untoward events occurred either during or just after the procedure which lasted 11-12 hours. The patient was noted to have a low blood pressure during the surgery and the foot and finger were very slow to pink up. The patient had an episode of high fever and briefly according to the progress notes the finger pinked up. This did not last long and in spite of using leeches and Botox, the finger became gangrenous and the wound of the foot dehisced. A second surgery was then done in order to remove the dead transplanted toe and to close the wound on the foot. The patient has been cared for by a second hand surgeon who apparently feels that the hand and foot both have permanent scarring and hypersensitivity. Mr. MT apparently has lost his job and has become depressed.

OPINIONS

The literature review reveals that under the RIGHT circumstances, the success of this procedure noted here is a survival rate of 95% and complications are minimal in the busy microsurgery unit. The recommended conditions are those of a laborer under the age of 40 with a fresh amputation. Mr. MT was 47 and had arrhythmias and an amputation that was several years old. From records and statements it appears that Dr. UJ never discussed the actual levels of expected success vs. failure. Nor, were there any discussions regarding non-operative treatment with a custom made prosthesis such as the ones made in France. These prosthesis’s can be made to an exact color match with same skin wrinkles, hair etc. I have seen these prosthesis and they are truly life like.

I feel the process of informing this patient and the consent process is negligent on the part of Dr. UJ.

It is also felt that Dr. UJ fell below the standard of care in not adequately assessing the status of the circulation of the amputated finger and the second toe. It is also my opinion that there was failure to meet the standard of care in not completely considering the effect of the arrhythmias and the beta blocker medication on the circulation of blood into the transplanted toe.

The above noted errors and acts of negligence are felt to be more likely than not causative for producing the failed to transfer with gangrene of the toe and subsequent surgery to remove the dead toe. This resulted in more scarring and deformity in these areas with great functional deficits and painful hypersensitivity. Had the surgery been done at the proper time, with the proper assessment, and with proper discussion then it is my opinion that this report would not be necessary and Mr. MT would have a decent fingertip replacement.

 
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