59-year-old male who is a diabetic has cellulitis to his right second toe from dropping something on his foot in April 2024.
First appointment with podiatrist 4/18, states PC has a skin ulcer for the past 2 weeks, is 8 mm in diameter and is full thickness to the subcutaneous tissue. Provider mentions that the PC “had not been treating it during this time”.
There is noted absence of right and left dorsalis pedis pulses and left posterior tibial pulse is also absent. He is diagnosed with cellulitis and hammer toe. X-rays were negative. A flexor tenotomy of the second toe was performed and a small debridement of the wound was also done. Was given antibiotics and told to follow up in one week.
The follow-up appointment on 4/25 states that the wound is necrotic and almost gangrenous. He recommends a referral to vascular surgery due to his vascular insufficiency. The wound was debrided again and was redressed.
He sees vascular on April 30. Vascular assesses him and says he needs a full work up, schedules it for a few weeks later, but he does have faint pulses.
May 2nd, he returns to Podiatrist again for follow-up the wound is now 20 mm x 10 mm and probes to the bone. Noted to be severely necrotic. X-rays were performed and was negative for any gas within the tissue or osteomyelitis. The doctor recommended he go immediately to the emergency room to be admitted for his toe. As at this point it looks like amputation might be necessary.
PC has a complicated few months and ended up needing toe/foot amputations.
We seek an opinion concerning treatment plan from the initial visit on 4/18 and/or if the flexor tenotomy was indicated.
I have attached the progress notes from the podiatrist’s visit on 4/18, 4/25, 5/2. As well as the tenotomy note for 4/18
I have also attached photo provided by the PC. Unfortunately, they are not timestamped, but am told they are from the first week or so after the wound appeared.
We currently do not have the vascular surgeon records.
Please let me know if you require any further info.
Thank you in advance.
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Do you believe there might have been medical error?
Diabetic ulcers require an aggressive plan of wound care, debridement, radiographs, cultures and antibiosis, and most importantly in this case, prompt referral to vascular specialists. Without good blood perfusion to the foot, any surgical procedure is destined to fail. These high risk patients require a team of specialists to maximize the potential of a favorable outcome. Infectious disease, endocrinology, vascular and orthotists are necessary. The failure to obtain vascular clearance prior to surgery did not meet the standard of medical care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Surgery should not have been performed without medical clearance to stabilize the patient.
What makes you a good expert for this case?
I have been working in a full time podiatry practice for 34 years. I have owned and operated my own surgical center, presided as chief of podiatry at our hospital, maintained board certification in foot surgery, and treated hundreds of similar patients such as this one. I have reviewed over 70 cases in the last few years when I began medical-legal consulting on a regular basis. I work quickly and efficiently and am reliable. I would enjoy learning more about this case.
How often do you encounter cases similar to this one in your practice?
Weekly. I treat diabetics on a daily basis for many different types of pathologies.
Do you believe there might have been medical error?
The patient delayed getting in to see the doctor which led to a worse infection. Also, long-standing diabetes, had already done significant damage to the patient’s Vascular status. The physician was right to order images and to try and weigh the wound.. Perhaps the patient should’ve been sent to a vascular surgeon after the initial visit and cultures should’ve been taken at the initial visit.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient already had poor sensation and poor blood flow. The lack of sensation and poor blood flow lead to poor outcomes with diabetic foot infections no matter what sort of cares rendered.
What makes you a good expert for this case?
I’m a board certified foot Angle Dr. Associate professor in the department of orthopedics at Stanford University. Previously ran a wound care center.
How often do you encounter cases similar to this one in your practice?
I see cases similar to this weekly
Do you believe there might have been medical error?
I believe that the doctor treated the wound and cellulitis appropriately with debridement and topical as well as oral antibiotics. However, the flexor tenotomy should not have been performed during an active infection. He should have waited until the infection improved.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes I do. I believe that the amputation may have been avoided
What makes you a good expert for this case?
I am highly experienced in wound care and foot surgery.
How often do you encounter cases similar to this one in your practice?
I very frequently see cases like this in my office
Do you believe there might have been medical error?
On the patient's first visit the note states that the second toe presented with cellulitis in addition to a chronic wound with a 2 week duration, and absent dorsalis pedis pulses. A flexible hammer toe was present at the tip of the second right toe. There is no mention of the patient being on any kind of antibiotic prior to the procedure being performed on the patient's initial visit. There is also no record of an informed written consent for the procedure aside from the oral okay. Based on the fact that the toe had a chronic wound, the patient pad diminished pedal pulses and the toe had cellulitis, the tenotomy should have not been performed on the day the patient initially presented. With the combination of the objective findings mention, this patient is a high risk patient. The patient's infection should have been stabilized first, he should have been instructed to be non weight bearing on the right side, oral or intravenous antibiotics should have been started prior to any tenotomy along with appropriate vascular assessment and/or intervention. In addition, efforts should have been made to get the patient into a vascular specialist sooner than a month from initial presentation. This may have involved some travel based on the patients distance from another vascular specialist that was more accessible. There was no mention of post procedure instructions given also.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I feel that the decision to perform a tenotomy, although a minimally invasive procedure, on this patient was a poor decision based on his cellulitis and compromised vascular status.
What makes you a good expert for this case?
I have practiced for over 27 years in a private practice. I am residency trained, board certified, and have treated hundreds of diabetics with foot and ankle wounds. I am extremely well respected by my patients and colleagues and I can review cases objectively and provide my subjective opinion based on the presented material. I have been the managing shareholder of a very successful small group practice located in North Central Texas and have practiced in rural Oklahoma where there is a high diabetic population. Thank you for your consideration.
How often do you encounter cases similar to this one in your practice?
I see diabetic patients every week. I see cellulitic toes every week and vascular compromised patients every week.
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