59 year old male who was seen by orthopedic for ongoing right foot pain for 3 years. There was an unknown previous procedure attempted to address this in 2020, but there is no clarity on the details of the surgery.
According to the referred surgeon, he is diagnosed with 1: Right great toe end-stage arthrosis, 2: Right Second hammer/claw toe 3: Right gastrocnemius contracture 4: Right great toe retained deep implant and is offered surgical intervention in the form of first metatarsophalangeal joint arthrodesis as well Strayer procedure and second hammer/claw toe correction with hardware removal.
This procedure is performed in late December of 2022. The operative note is attached in two pages.
He has a follow-up appointment on January 3rd. It is a standard dressing change if he is told healing is appropriate with no signs of infection. Weight-bearing limited. Second follow-up is January 10th and no complications noted. January 17th, he arrives for suture removal and it is noted that the “second toe pin is halfway out of his toe” and it was removed without complication. Told to return in 4 weeks for revaluation and x-ray (this xr was normal, no hardware or alignment issues)
February 14th, PC continues to have increased discomfort to Strayer site. No physical therapy had been ordered to this point, but it is now recommended and initiated for range of motion and strengthening exercises. Will re-evaluate in 4 weeks. Physical therapy is started and sees improvement as of June of 2023.
July of 23 PC thinks that his gait is unstable and they recommend continued physical therapy. Another XR shows no abnormality.
This pain continues through August and PC is referred to a different group for second opinion.
In September of 2023, an ordered MRI revealed a chronic Achilles tendon rupture to the right foot. The measured Gap was 8 to 10 cm. REPORT ATTACHED.
He is presented with the option of surgical intervention which he accepts. That surgery is in January 2023 and the OP note is also attached in 2 pages.
Post-operatively, PC has had some improvement, however has had an overall decrease in mobility and has been forced to go on disability. Limited working. There is concern that the original procedure in December of 2022 was done incorrectly from the beginning that may have led to the Achilles rupture, or if it possible the rupture was unrelated or could have been traumatic at any point after the procedure and is a recognized complication.
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Do you believe there might have been medical error?
According to the peer reviewed articles reviewed the chance of an achilles rupture after an appropriately performed Strayer procedure almost never occurs.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient had multiple procedures performed at the same time. Normally this procedure is performed for documented relevant gastrocnemius equinus contracture. Based on the multiple procedures and foot problems that were documented by the first surgeon is is questionable whether the patient actually had the diagnosis that required the Strayer procedure. Review Foot Ankle Surg . 2015 Jun;21(2):77-85. doi: 10.1016/j.fas.2015.02.001. Epub 2015 Feb 26. Gastrocnemius recession for foot and ankle conditions in adults: Evidence-based recommendations Chris C Cychosz 1 , Phinit Phisitkul 2 , Daniel A Belatti 1 , Mark A Glazebrook 3 , Christopher W DiGiovanni 4 Affiliations expand PMID: 25937405 DOI: 10.1016/j.fas.2015.02.001 Abstract Background: Gastrocnemius recession is a surgical technique commonly performed on individuals who suffer from symptoms related to the restricted ankle dorsiflexion that results when tight superficial posterior compartment musculature causes an equinus contracture. Numerous variations for muscle-tendon unit release along the length of the calf have been described for this procedure over the past century, although all techniques share at least partial or complete release of the gastrocnemius muscle given its role as the primary plantarflexor of the ankle. There exists strong evidence to support the use of this procedure in pediatric patients suffering from cerebral palsy, and increasingly enthusiastic support-but less science-behind its application in treating adult foot and ankle pathologies perceived to be associated with gastrocnemius tightness. The purpose of this study, therefore, was to evaluate currently available evidence for using gastrocnemius recession in three adult populations for whom it is now commonly employed: Achilles tendinopathy, midfoot-forefoot overload syndrome, and diabetic foot ulcers. The Gastrocnemius Intramuscular Aponeurotic Recession: A Simplified Method of Gastrocnemius Recession Neal M. Blitz, DPM, FACFAS,1 and Shannon M. Rush, DPM, FACFAS2 Although morbidity with gastrocnemius recession is low, associated complications are still common enough that one should carefully consider the method of recession. The senior author (S. M. R.), along with Ford and Hamilton, reported a 6% complication rate in 126 patients who under- went a high gastrocnemius recession (27). Complications included scar and nerve problems, Chronic Regional Pain Syndrome (CRPS), wound dehiscence, and superficial in- fection.
What makes you a good expert for this case?
I have seen this problem in my practice and patients do well with physical therapy and rare.y succumb to this surgery.
How often do you encounter cases similar to this one in your practice?
Sometimes. I have not performed this procedure myself but have seen patients with the problem.
Do you believe there might have been medical error?
The patient underwent a Strayer (gastrocnemius recession) procedure which is a lengthening of the gastrocsoleus muscle tendon unit. This procedure is typically performed proximally, near the musculotendinous junction. The surgeon cuts the gastrocnemius portion of the muscle tendon unit allowing for greater dorsiflexion of the ankle while maintaining the soleus portion of the Achilles unit intact. In this case, it is impossible to determine exactly when or why the remaining Achilles tendon ruptured, based on the information available. The description in the operative note of the first surgery would be in line with the accepted technique for a Strayer procedure. Thus, it is considered equally likely that there was and that there was not error, as it can really not be adequately determined based on this information.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The second operative note, which describes an FHL transfer to treat the chronic Achilles tendon rupture, does not specify exactly where the rupture happened. If the Achilles rupture happened more proximally than usual, at the typical site of a Strayer procedure, then it would be fairly likely that there was medical error in the form of inadvertently also cutting the soleus muscle tendon unit which directly caused the injury. If, however, the Achilles rupture was more distal than the surgical site for the Strayer, and it is more likely that this was just an unfortunate second injury that occurred during the rehabilitation phase of the first surgery and not a direct consequence of error. Because either of these scenarios seems equally plausible based on the available information, neither appears more likely than the other and the probability must stand at 50% for each.
What makes you a good expert for this case?
I am a board-certified fellowship trained orthopedic surgeon with several years of experience doing expert witness review and testifying for both plaintiffs and defendants.
How often do you encounter cases similar to this one in your practice?
In my clinical practice, analogous situations are not encountered very frequently, on the order of 1 every few months or so, often as second opinions. In expert witness work, however, cases such as these are more common.
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