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Duty to warn

01 August 2003

In the mid 1990s, Mr L presented to hospital following a spontaneous rupture of his left Achilles tendon. Mr C, consultant orthopaedic surgeon, performed a percutaneous repair of the tendon, following which the tendon appeared to heal well.

At a follow-up consultation four months later, Mr L told Mr C that he was experiencing numbness and discomfort affecting the lateral skin of his left leg and heel. Six months after the injury, Mr L was becoming increasingly concerned by the numbness and paraesthesiae.

Mr C suspected sural nerve injury as the cause and referred Mr L to his colleague, Mr R, a consultant plastic surgeon. Mr R explored the sural nerve and found it transfixed by a suture, with an accompanying neuroma, requiring reconstructive repair.

Mr L alleged that his sural-nerve damage caused him ongoing discomfort, hampered his mobility and left him prone to neuropathic damage of his foot.

Proceedings against Mr C alleged negligence in failing to identify and isolate the sural nerve during the operation.

Expert opinion

We sought the advice of orthopaedic experts, who reported as follows: The technique of percutaneous repair of the Achilles tendon was first described in 1977 by Ma and Griffith. Previous research had shown that it carried a significantly higher risk of sural nerve damage than the more common technique of open repair (17% in one series, compared to about 2% for the open technique).

Given these research findings, the experts felt that it would be wise to warn patients of potential damage to the sural nerve using the percutaneous technique. One expert noted, ‘It is clear that, while the percutaneous technique is well established and very acceptable, the main complication … is damage to the sural nerve, and several researchers have adopted modifications specifically to avoid this … the incidence suggests that it is uncommon but not rare in most people’s hands.’

We decided to settle the claim for a moderate sum, on the basis that Mr L should have been warned of the potential risks before consenting to the procedure.

Learning points

  • Recent research – Lim J, Dalal R, Waseem M. Percutaneous vs. Open Repair Of The Ruptured Achilles Tendon: A Prospective Randomised Controlled Study. Foot Ankle Int (2001) 22(7): 559–68 – suggests that the picture is not so clear when using a modified percutaneous technique. Lim et al. reported a low rate of sural nerve damage in a small series of cases, and some distinct outcome advantages, compared to the open technique.
  • If using an alternative technique to treat a particular problem, it is important to be fully aware of how it may differ from a more common method, in terms of outcome and complications. Patients must be informed of how the risk of a certain complication differs, if it differs significantly, when compared to standard technique.