PC is a 60-year-old male with extensive and chronic hx of bilateral Dupuytren's contracture. However, this case is in reference to the left hand. His contractures involve the thumb, ring, small fingers, and palm. He has marked benediction hand deformity. He is having difficulty with activities of daily living, grasp, reaching into a pocket, cabinet, or store shelves. PC elected to proceed with surgical management.
An excision of the palmar fascial fibromatosis from the thumb, ring and small fingers is done in August of 2023. PC was aware that because of the severity of his ring and small PIP contractures, that it was unlikely he would not achieve full extension and would be shortened due to the length of the digital arteries. He also was notified that there would possibly be a need for a skin graft for wound closure.
The PC’s contention is that a skin graft was warranted, however did not receive it during this procedure. He has had these procedures multiple times in the past and was aware of the process and felt he was shortchanged.
This operative note is attached as a screenshot.
PC began to have maturation approximately 4 days post-op and some suture separation. PC attended physical and occupational therapy for many months. The PC contends that the hand is much worse off than prior to the procedure. Pc claims the hand is basically without meaningful use.
It seemed that his disease was/is pretty advanced, however considering his lack of options and the severity of his condition, we are seeking confirmation that this particular surgery was performed appropriately and was warranted.
Please advise of any questions.
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No questions yet!
Do you believe there might have been medical error?
From the operative report it appears the surgeon appropriately released the dupuytrens fibromatosis and contractures and then assessed the feasibility of wound closure. The skin was able to be closed without tension and this was done appropriately as is the standard if care. There is no indication that a skin graft should have been used in this situation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Some patients have a propensity to form significant scar tissue post operatively, particularly patients with dupuytrens disease. The post operative course is not secondary to medical malfeasance.
What makes you a good expert for this case?
I am a board certified hand surgeon.
How often do you encounter cases similar to this one in your practice?
As a board certified orthopedic hand surgeon I see surgical as well as non-surgical patients with dupuytrens disease many times per month. I have been in practice doing hand surgery exclusively for 7 years.
Do you believe there might have been medical error?
This patient clearly had very severe Dupuytren's Disease. Dupuytren's is a disease with a nearly 100% recurrence rate following surgical treatment. It always eventually returns, because surgery treats the symptoms, not the cause (which we do not know or understand, and which we have no way currently to treat). Surgery is a battle, but the war is eventually always won by the disease. We do not have a long-term treatment strategy that cures the disease. That said, the operative report documents an appropriately-performed procedure. Skin grafting is rarely performed for Dupuytren fasciotomy, and there is even an accepted technique called the McCash technique, or "Open-Palm Technique" where the skin is left deliberately wide open to heal from secondary intention. Thus some open areas following a fasciectomy is entirely within the accepted standard of practice. There is no medical error identified here, unfortunately this is likely just yet another unsatisfied Dupuytren surgery patient, one of many who fail to understand that this disease is not curable, and that surgery is a meager attempt to get them some improvement for a short while. The surgeon likely could not have done anything further to prevent the patient's dissatisfying outcome, and it seems like they did quite a lot to try to help this patient, and properly.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Given that there is very unlikely to be medical error, there is equally unlikely to be causation.
What makes you a good expert for this case?
I am a fellowship-trained hand subspecialist who regularly sees Dupuytren Disease in my office setting. I counsel patients on a daily basis regarding this problem and we have thorough discussions regarding what we can and what we can NOT achieve with our current techniques for treatment.
How often do you encounter cases similar to this one in your practice?
At least once a month I see patients who are less than thrilled with the long-term results of their prior Dupuytren treatments, whether from myself or as a second opinion. It is exceedingly common and does not represent a complication, or a medical error, most of the time. Usually it is simply the bad luck of this unfortunate disease. Surgery can be gratifying in some cases, but often it is not, or the gratification only lasts a short while before the disease returns. The only other option to consider might have been amputation... But that can still be entertained. I always let the patient tell me when they're ready for that.
Do you believe there might have been medical error?
In severe contracture, full extension of the PIP joints is unlikely to be achieved, and certainly is not a given. When the patient has chronically stretched out extensors from contracture, there will always be a residual boutonnière contracture that is nearly impossible to correct. Skin grafting happens sometimes but is never a necessary element of standard of care - both primary closure, partial closure and “open palm” techniques are standard..
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no injury and no violation of standard of care that you have identified.
What makes you a good expert for this case?
I am an experienced medical expert, a national expert in evidence based medicine, Section Leader for Clinical Practice Guideljne development at AAOS, on the Editorial Panel for the AMA Guides to the Evaluation of Permanent Impairment and have performed several hundred Dupuytren’s surgeries. Have published on Dupuytren’s Contrscture in the Journal of Hand Surgery.
How often do you encounter cases similar to this one in your practice?
I see 10-15 Dupuys patients a week and operate on 30-40 a year in addition to extensive use of needle aponeurotomy and Xiaflex.
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