• Patient had a two-year history of right hand pain and muscle spasm, with decreased grip strength and night pain, and imaging showed significant degenerative changes in the right middle finger metacarpophalangeal joint with cartilage loss, osteophyte formation, and ulnar deviation
• After a pre-operative visit in October 2024, he underwent a right middle finger metacarpophalangeal joint arthroplasty on November 7, 2024
• Within about two weeks, the finger dislocated volarly at the arthroplasty site, office reduction failed, and repeat imaging confirmed the dislocation
• He then returned for another procedure on November 21, 2024, which was originally planned as a closed reduction but was converted to an open reduction internal fixation procedure with capsular reconstruction
• The joint dislocated again, and December 3 and December 4, 2024, notes documented recurrent volar dislocation and discussion of another revision surgery
• On December 10, 2024, he underwent a third surgery involving hardware removal, irrigation and debridement, and revision of the metacarpophalangeal arthroplasty
• A wound culture later grew light Staphylococcus aureus, and he was treated with a peripherally inserted central catheter line and a planned six-week course of intravenous antibiotics
• By April 2025, he reported numbness, tingling, and cramping in the hand, and electromyography showed carpal tunnel syndrome and cubital tunnel syndrome with axonal loss, which the provider said suggested permanent nerve damage
Potential Standard-of-Care Concern Points???
• The initial arthroplasty was associated with early volar dislocation that was not maintained after attempted reduction, and the record includes operative/procedure labeling that could bear on surgical technique/management (including “closed reduction” listed for 11/21/2024 and an “open reduction internal fixation” procedure field on the 11/21/2024 form)
• Recurrent postoperative dislocation after the second intervention was documented on X-ray and examination, reflecting a persistent instability issue
• The 12/23/2024 incision discharge and swelling, along with the need for a PICC line and planned prolonged intravenous antibiotics, suggests a significant postoperative infection course after the 12/10/2024 procedure (which itself involved hardware removal and irrigation-debridement with vancomycin powder)
• The later development of carpal tunnel syndrome and cubital tunnel syndrome with axonal loss and provider assessment of “permanent damage” are significant late complaints and objective findings that may be relevant to causation/complication evaluation
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Do you believe there might have been medical error?
This is a gray area case, and the devil will be in the details. There does not appear to be much in the way or preoperative workup or nonsurgical treatment - the surgeon saw the patient once in October preoperatively and then surgery for a major arthroplasty was booked within a few weeks. Seems aggressive. That pattern holds when you see that the surgeon felt the need to go back in again and again, trying the same thing to fix a problem that clearly warranted some sort of alternative approach. The decision-making has to be questioned in a case like this, retrospectively, and that would require a careful review of all of the available documentation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It's difficult to determine causation in a case such as this as we lack important details such as timing, imaging, and the onset of these nerve symptoms. Nerve symptoms should not be directly related to an MCP arthroplasty gone wrong, especially at the elbow. But if there were certain positional habits that the patient had to adopt due to elevation requirements for the hand, that could in fact cause a secondary cubital tunnel syndrome.
What makes you a good expert for this case?
I am a board-certified, fellowship-trained hand and upper extremity orthopedic surgeon with CAQ in Hand Surgery. I have served as the Clinical Director of Hand Surgery in my hospital for over two years. I trained in multiple level-one institutions with extensive experience evaluating and treating arthritis of the hand, infections, and nerve compression syndromes and their sequelae. I have served as an expert witness in multiple cases with experience in review, deposition, and in-court testimony work, for both plaintiffs and defendants, and I am available to be retained for this case upon request.
How often do you encounter cases similar to this one in your practice?
Something akin to this exact perfect storm is uncommon. However post-operative complications occur and are encountered by every upper extremity surgeon.
Do you believe there might have been medical error?
Instability/dislocation of a silicone MP arthroplasty is not uncommon. If it were ignored or improperly treated, that would potentially be below the SOC. Here, it seems like the surgeon managed it appropriately. Infections happen and, again, it appears that appropriate precautions were taken and appropriate treatment rendered. The presence of an infection doesn't suggest a violation of SOC unless there is something glaring in the documentation. No idea how or why carpal and cubital tunnel would develop as a result of any of this and they are highly likely to be completely unrelated.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Instability/dislocation of a silicone MP arthroplasty is not uncommon. If it were ignored or improperly treated, that would potentially be below the SOC. Here, it seems like the surgeon managed it appropriately. Infections happen and, again, it appears that appropriate precautions were taken and appropriate treatment rendered. The presence of an infection doesn't suggest a violation of SOC unless there is something glaring in the documentation. No idea how or why carpal and cubital tunnel would develop as a result of any of this and they are highly likely to be completely unrelated.
What makes you a good expert for this case?
15 years of experience as a hand surgeon. Performed dozens of silicone arthroplasties. Experienced arthroplasty surgeon. Expert in evidence-based hand and upper extremity surgery, former chair of the ASSH Evidence Based Practice Committee; currently the Section Leader for Clinical Practice Guideliens for AAOS.
How often do you encounter cases similar to this one in your practice?
Weekly. I see carpal and cubital tunnel multiple times a day, same with MP joint arthritis.
Do you believe there might have been medical error?
It sounds like the indication for the initial operation of the metacarpal phalangeal joint arthroplasty, metacarpal phalangeal joint arthritis, was appropriate. Instability following surgery is a known complication. The dislocation was noted and the patient was brought back to the OR appropriately for attempted reduction. It sounds like a open reduction was performed with attempted soft tissue stabilization. Apparently this failed and this was noted on the December 3 and 4 office visits. It was appropriate to take him back for revision of the arthroplasty which he underwent on December 10. Unfortunately the patient developed a postoperative infection. This was appropriately treated with IV antibiotics. The subsequent development of EMG positive for carpal tunnel syndrome and cubital tunnel syndrome is unrelated to the index operation. Metacarpophalangeal joint arthroplasty would not directly cause carpal and cubital tunnel syndrome. The patient may have been developing this concomitantly. I do not think there was gross negligence or actions outside of the standard of care for this procedure. The complication of instability following a metacarpal phalangeal joint arthroplasty known complication, was identified and intervention was attempted appropriately. The postoperative infection is also a known complication within the standard of care and this was treated appropriately with antibiotics. I do not think there is a direct link with the development of carpal and cubital tunnel syndrome in the index operation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, I do not think a medical error led to the outcome in this case. Instability post op is a known complication as is infection. Also, the carpal and cubital tunnel syndrome is not related.
What makes you a good expert for this case?
I am a board certified orthopedic hand surgeon who frequently takes care of both finger arthritis and carpal and cubital tunnel syndrome, both with surgery and without.
How often do you encounter cases similar to this one in your practice?
I operate on carpal and cubital tunnel syndrome 10-20 times a month. I see patients with finger are arthritis 10-15 times a week.
Do you believe there might have been medical error?
Recurrent dislocation is not normal after an operative repair of volar plate and/or capsular structures.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
First attempt at relocation should have been operative instead of "closed reduction" as closed would be unexpected to fix the issues of dislocation. Axonal injury to nerves is not a normal complication of this procedure.
What makes you a good expert for this case?
Orthopedic hand surgeon, 14 years of hand surgery experience, multiple mcp arthroplasties per year in my practice.
How often do you encounter cases similar to this one in your practice?
4-6 similar cases per year normally
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