PC is a 56 year old gentleman who had chronic ankle issues and began to see and orthopedic foot/ankle specialist in May of 2021 to consult about his ongoing right ankle pain. He had discomfort to the point that he had impaired gait and subsequent knee and hip issues. Was diagnosed him with bilateral ankle severe osteoarthritis, bilateral ankle valgus deformity, bilateral pes planus severe. Conservative treatment was unsuccessful, so October 2021 PC is lined up for triple arthrodesis.
PRE OP CT from August of 2021:
Significant degenerative changes a.represent. in the right ankle joint with joint space narrowing and bony reactive change. There is also some varus angulation of the ankle joint itself with widening of the lateral ankle mortise . Some of the fibular abutments suggested along the anterolateral calcaneus. marked degenerative changes are also noted in the subtalar joint with subchondral cyst formation and bony reactive change, greatest medially , Pes planus. No evidence of acute displaced fracture . Moderate
degenerative change medial compartment of the knee.
OP NOTE IS ATTACHED AS DOCUMENT
PC has continued pain despite following PT and non-weight bearing order. March 2022, same orthopedic suggests Infinity Prophecy total ankle replacement, CT ordered and the OP is performed in May of 2022.
CT SCAN RESULTS:
FINDINGS: Patient has had Interval postop changes of subtalar joint fusion with .2 partially threaded bone screws with an additional! longitudinally oriented screw seen in the talus. There is also been fusion of the calcaneal cuboid articulation with spacer
and bone staple. Significant degenerative changes are noted in the talonavicular cuneiform articulations. Advanced degenerative changes again noted in
the ankle Joints •with some valgus angulation. There is also fibular .abutment on
the lateral talus. Fixation hardware appears intact. An acute displaced fracture is not evident Moderate medial compartment joint space narrowing is noted in the knee joint.
OP NOTE IS ATTACHED AS DOCUMENT
Begins PT and has multiple follow ups, including unremarkable XR of ankle from May until November.
November of 2022. F/U XR, first mention of talar component subsidence. Ordered custom molded richie brace and modified activity. F/U in January.
January 2023, XR’s reveal talar collapse and potential loosening. Told to modify weightbearing, PT and wear boot.
Feb 2023, No change to pain. Conservative treatment not working. Ordered CT and to return in March.
CT RESULT: patient has had interval post-op changes of subtalar joint fusion with two partially threaded bone screws with an additional longitudinally oriented screw seen in the talus. There's also been fusion of the calcaneal cuboid articulation with spacer and Bone staple. Significant degenerative changes are noted in the talonavicular cuniform articulations. Advanced degenerative changes again noted in the ankle joints and some valgus in angulation. There's also fibular abutment on the lateral talus. Fixation hardware pairs intact. And acute displaced fracture is not evident. Moderate medial compartment joint space nearing is noted in the knee joint.
March 22, 2023, REAR ENDED BY CAR GOING 70MPH. No radiology done of foot at the time, had no significant injury.
March 28, 2023. Office F/U: No change from talar collapse and tibial loosening. Referred to another ortho for re-eval.
New ortho suggested to the patient that they may benefit from consideration of a right ankle hardware removal with antibiotic cement spacer placement, followed by a right total ankle revision. PC agrees
OP NOTE IS ATTACHED AS DOCUMENT
PC doing F/U and PT until pain returns in August 2023.
August 2023 XR reveals displaced Fx of the neck of talus.
F/U Hardware removal and wound clean out done 8/2023
OP NOTE IS ATTACHED AS DOCUMENT
POST OP CT SCAN:
Impression:
1. Mako protocol study for surgical planning purposes for requesting team.
2. RIGHT ankle: Wide periarticular excision with antibiotic plug suspected within the anterior jointspace. Periarticular
erosions and large joint effusion do not exclude chronic septic arthritis here.
3. Multiplanar effusions in the hindfoot and midfoot with bony incorporation. At least moderate residual OA in the
remaining intertarsal joints.
4. RIGHT knee: Mild to moderate tricompartmental OA or CPPD arthropathy (given chondrocalcinosis meniscus).
Subsequently, PC left care of this group and has had multiple follow up procedures with varying degrees of success.
Our contention is not with anything that happened prior to August of 2023.
We are seeking an Orthopedic surgeon with foot/ankle specialty/experience who can shed light on these 3 procedures. The PC informed us that he was told there may have been sizing issues with the Prophecy system.
We appreciate your review and opinions in advance.
Files:
Q: The dates are hard to follow. Did the car accident cause the talar fracture? Was there a confirmed infection? Was there an open fracture?
A: Unknown if accident was culprit. No imaging was done until much later. No confirmed infection. No open fracture.
Q: I already responded. Do I need to respond again?
A: —
Do you believe there might have been medical error?
The issue is poor outcome vs. technical difficulties.; most of these cases fall towards sloppy surgery but within the standard of care. The total ankle over a triple is common, the decision to perform a calcaneus osteotomy was commendable. A talar neck fracture is very rare after these procedures—I cannot remember seeing one in 30 years. Talar sizing sounded fine in the op note and, while the devil is in the details, the op note seems appropriate.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Complex revision surgery has its attendant outcome issues. Nothing seemed off in the op notes I saw except that I rarely use an 11 poly( usually smaller).
What makes you a good expert for this case?
I am an academic foot and ankle subspecialist who has extensive experience with triple arthrodesis and with total ankle replacement.
How often do you encounter cases similar to this one in your practice?
As above, not seen a talar neck fracture like this case. I do several triple arthrodesis and a couple of total ankle procedures each month.
Do you believe there might have been medical error?
Unfortunately without additional information to include whether the patient is a diabetic and if any labs or cultures came back positive for infection it is difficult to answer the question. Also it would be helpful to actually see the x-rays and CT scans to better and more accurately answer the questions.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
as stated above. Again in order to answer these questions appropriately one would need to see the x-rays and CT scans.
What makes you a good expert for this case?
I have been in practice for over 25 years. My fellowship is in postraumatic issues to include nonunions, malunions and infections.
How often do you encounter cases similar to this one in your practice?
Rarely but I have seen them from other physicians.
Do you believe there might have been medical error?
It's very difficult to say anything of substance regarding sizing of the implant, given that we don't have the ability to personally view the images. It sounds as though there may have been an infection, but these records are not easy to follow. The records are incomplete and do not specify when a subtalar fusion was done, etc.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above, it is not easy to say based on the limited information available.
What makes you a good expert for this case?
I am a board-certified orthopedic surgeon and I've done hundreds of quality review cases including for total ankle arthroplasty
How often do you encounter cases similar to this one in your practice?
Not that frequently, to be perfectly honest.
Do you believe there might have been medical error?
It is difficult to fully comprehend the patient's treatment course without a complete medical record. The attached operative reports are incomplete. I suspect some of your dates are off in terms of the year. It sounds like the client had a severe flatfoot deformity and that a 2-stage operation was planned by Dr. Acevedo - triple hindfoot arthrodesis followed by total ankle arthroplasty. This is an acceptable treatment plan that does not deviate from the standard of care. It is also known that talar subsidence can occur following total ankle arthroplasty. It is difficult for me to assess this without x-rays and CT scan images. Did the talar fracture occur before or after the total ankle arthroplasty? Did the talar fracture occur before or after the explant and placement of antibiotic cement spacer? Was there a confirmed infection that warranted explant and antibiotic cement spacer? Was the talar fracture open or closed? If a talar fracture resulted from the car accident and this was not diagnosed, then this would be considered failure to diagnose a fracture in a timely manner.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I believe this client was more likely than not treated appropriately for a complex orthopedic foot and ankle problem. My question would be whether or not an infection was confirmed prior to explant and antibiotic cement spacer placement. Was a revision total ankle arthroplasty performed? If the talar fracture occurred after the total ankle arthroplasty and resulted from the car accident, failure to diagnose this could cause talar subsidence. The timeline is unclear to me.
What makes you a good expert for this case?
I am an orthopedic foot and ankle surgeon who frequently performs triple arthrodesis and total ankle arthroplasty.
How often do you encounter cases similar to this one in your practice?
I perform multiple triple arthrodeses and total ankle arthroplasties per month on average.
Do you believe there might have been medical error?
the provided documents are incomplete and out of order. They appear to be partial operative notes from two different procedures, and notes in between the procedures are not provided, so we do not know if the first surgery-a fusion/arthrodesis- was successfully healed. The pts medical history is not provided and can be very important, diabetes and BMI are variables that can negatively affect healing and bone quality.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
more information is needed on the patients PMH as well as documents including the surgeons pre-op and post-op office notes, describing his thought process and more information on his reading of the xrays pre and post op. It is unclear if the pt had a triple arthrodesis, or if the fusion consolidated. Or why an ankle replacement was chosen.
What makes you a good expert for this case?
20 plus years as orthopedic surgeon, and have performed ankle fusions.
How often do you encounter cases similar to this one in your practice?
often in diabetics that are overweight and have jobs that require a lot of standing & walking distances
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