Allegation:
A number of failures by the orthopedic surgeon resulted in non-union of a patient's injured ankle.
The Case:
The patient, a 56 YOM (5’11”, 230 lbs.), injured his right ankle in a fall down steps. During his admission to the ED, x-rays showed non-displaced fractures of the medial malleolus without tilting or widening of the tibiotalar joint. On the lateral view, a questionable additional fracture with cortical disruption was noted involving the posterior malleolus. The patient was splinted, given crutches, instructed to remain non-weight bearing on the ankle, and told to follow-up with an orthopedist in four to five days.
Later that day, the defendant orthopedic surgeon saw the patient in his office, reviewed x-rays, and applied a short leg cast. The practice provided the patient with a walker and instructed him to follow up in two weeks for x-rays and evaluation for displacement. At the follow-up visit, x-rays showed a small 1-mm step-off of the medial malleolus with minimal rotation. There still appeared to be good alignment and surgery was not recommended at this time. The plan was to continue non-weight bearing on the casted leg and follow up in four weeks.
The cast was removed at the follow-up appointment. The patient had minimal ROM of his ankle. The defendant noted that x-rays revealed more of a step-off than previously seen of the medial malleolus with malrotation; decreased medial clear space with the fragment also appeared to be in a hinged position. The patient was placed in a cam walker boot. The defendant recommended open reduction internal fixation surgery (ORIF) with two cannulated screws.
One week later, the defendant orthopedic surgeon performed surgery on the patient consisting of an ORIF of the right ankle medial malleolus with ORIF of right ankle syndesmosis. A reduction of the medial malleolar fragment was performed; however, there was significant bone loss and the fragment size did not appear to match up consistently. A total of two K-wires were placed to hold the medial malleolar fragment of the proximal fragment. Given the bone loss, only one screw was able to fit, but the fracture appeared stable.
The following day, the defendant saw the patient, and indicated that a tibiotalar tilt was noticed after the fracture was fixed. The patient’s ROM was a few degrees shy of neutral, to approximately 25 degrees. The cast was set in a position as neutral as possible due to Achilles tightness that had already developed.
The patient was seen weekly for the next three weeks. The foot remained dorsiflexed and in equinus position. The patient had significant pain in the right knee and limited ROM. The defendant discussed a possible lengthening of the Achilles tendon, and planned for a recasting of the leg on the next follow up. This would be the last time the patient would visit the defendant.
The patient sought a second opinion from another orthopedic surgeon and eventually underwent additional ORIF surgery, hardware removal, and Achilles tendon lengthening. It was noted in the OR report that the previous fracture had not healed and the bone was significantly osteopenic.
The plaintiff’s expert testified the defendant orthopedic surgeon should have suspected fracture instability after seeing the 1-mm step-off, and that he should have reassessed the ankle in one to two weeks rather than four weeks later. The expert also stated the defendant placed the medial malleolus fragment too laterally, causing the fragment to invade the clear space between the tibia and talus bones, and causing the talus to push laterally. The expert explained that when syndesmotic screws were placed, the fibula was pressed more medially, further narrowing the ankle mortise. The improper placement of the medial malleolus in conjunction with the syndesmotic screws forced the ankle into a downward flexion of at least 20 degrees. The laterally-shifted talus bone caused the muscle tendon unit in the back of the ankle to contract which ultimately required an Achilles tendon release.
Defense experts testified it was appropriate to treat the ankle fracture conservatively based on the initial x-rays that showed good alignment of the talus with the fibula, tibia, and medial malleolus. They stated it was likely that the fragment shifted after surgery so that it was more lateral by the time of the second operation. The probability of this occurrence is evidenced by the surgeon describing the fragment as a non-union—meaning it had never healed and making it highly likely that it shifted. Experts also noted the patient was at considerable risk for permanent decreased ROM of the right ankle and future arthritis as a result of the severe original injury.
Verdict:
The case was eventually tried to a defense verdict.
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