62yo F total right hip on August 2nd 2023.
***OP NOTE AND IMPLANTS ATTACHED AS PHOTOS***
Limited mobility and decrease range of motion to the ankle and right knee one day post-op. Very painful.
MD says good rehab potential and elects to see how she does with PT. One week later, is given an AFO brace and continues medications and PT. There is recognition of possibility of foot drop in office note. Hip x-ray was negative.
August 15th, another visit with office and now high concern for foot drop and nerve damage. Notes that the PC did refuse to wear the AFO brace due to discomfort and pain. Refilled medications and stated will continue to watch closely and consider EMG if no improvement in the "near future".
August 25th, seen by surgeon with noted zero out of 5 dorsiflexion and zero out of 5 toe extension. Significant pain. MD elects to try ankle corset and observe with PT. X-ray was performed with no evidence of fracture or hardware issues.
September 15th PT continued with the slightest improvements in sensation however still having significant pain. Numbness to foot and still no active dorsiflexion or toe extension. Noted in record "significant foot drop". Surgeon recommends continuing PT and AFO refitting. Refers to PM&R for EMG and 3 week follow-up.
September 27th, sees PM&R who does initial assessment for foot drop. They noted it's "likely a stretch injury" and unclear as to why she has not received new AFO yet.
EMG is performed on October 24th, which confirm sciatic injury.
***EMG summary attached as photo***
Next follow up is December 5th with surgeon. Still in 8 out of 10 pain and walking with a cane. X-ray was performed with no findings and he referred back to PMR. PMR recommends extensive rehab.
After 2 months, there's no improvement it still has significant right side of foot drop with difficult ambulating and daily activity.
Surgeon in February of 2024 recommends lumbar MRI. MRI was insignificant for acute injury.
Attempted electrostimulation by PMR that was ineffective.
Looking for opinion with Hip/knee experience and currently practicing/educating.
Recognized Complication? Delay in Dx? Delay in treatment? Quality of operative note?
Thank you in advance.
Files:
No questions yet!
Do you believe there might have been medical error?
Yes, the surgery comes with risks of nerve and vessel damage. It is about 1.5%. The patient had symptoms on POD #1 therefore the nerve was injured or cut during the surgery. The EMG at 6 weeks shows no function and her exam at 6 months shows no return of function of the muscles supplied by the nerve.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, as stated the nerve if retracted and protected during this surgery should not be injured. The patient thought at 6 months post surgery should have a repeat EMG to see if there is any change in the nerve.
What makes you a good expert for this case?
I have been doing partial hip replacements for fractures over 25 years. I perform the posterior incision on all my cases. In all my years I have never injured the nerve. This is a rare complication when discussed with colleagues and reviewed in the literature for partial and/or total hip repacements.
How often do you encounter cases similar to this one in your practice?
I have never encountered this issue in over 25 years of practice.
Do you believe there might have been medical error?
Failure to recognize and adddress peroneal nerve injury after joint replacement surgery
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Injury was not addressed by surgeon in post operative period - was the hip made too long or was damage done to the nerve during surgery.
What makes you a good expert for this case?
Significant experience in joint replacement surgery and extensive experience in medical legal cases but no significant history in med mal cases.
How often do you encounter cases similar to this one in your practice?
Never. Experienced a nerve injury during joint replacement surgery but extensive knowledge of how to deal with this postoperatively
Do you believe there might have been medical error?
Sciatic nerve injury is a known possible complication of total hip arthroplasty. Standard precautions to prevent sciatic nerve injury in total hip arthroplasty includes careful placement of posterior retractors. The operative report documents that this was performed. This case likely is the occurrence of a known potential complication rather than a medical error. There is no way to establish error in this case. Even the delay in diagnosis, would likely not have made a significant difference in the ultimate outcome, as if a sciatic nerve injury is recognized early, and there is no specific reason to think that the nerve was transected or lacerated, exploration is not warranted in the acute period and observation still would be the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As there is not established error, causation can similarly not be determined,
What makes you a good expert for this case?
I am a board-certified orthopedic surgeon who routinely performed hip replacements, especially utilizing the posterior approach.
How often do you encounter cases similar to this one in your practice?
On average, once to several times per year, with varying degrees of severity, and sometimes as a second opinion.
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