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Short-sighted surgery

01 January 2013

Ms W, a 45-year-old secretary, had poliomyelitis as a child, which left her with a leg length discrepancy, the right leg being several centimetres shorter than the left.

Despite the obvious cosmetic appearance and impaired functional mobility, she had never thought of having any form of treatment. However, one day she watched a programme on TV about surgery to lengthen limbs, so she asked her GP to get her an appointment to see the surgeon involved in the programme, Mr A.

Mr A saw Ms W in clinic; soon after she had a date for her surgery. Mr A did not document any counselling of the potentially serious side-effects or the intensive physical therapy that would be required after the surgery. The possibility of subsequent surgery was not mentioned, nor the frequent development of contractures at a later stage, despite physiotherapy or bracing. Ms W was only seen once prior to the surgery and, although she was provided with an information leaflet, there was very little mention of the complications of the procedure.

Although the aim of treatment was to improve limb function Ms W had very high expectations and thought that her leg would be ‘normal’ after the operation. All the people in the TV programme had had great results. Mr A did not explain that this was not always the case, nor was the risk that she may be worse off after surgery explored. Mr A only made brief notes at the initial consultation, the operation and follow-up with no documentation about explanation of risks and complications.

Unfortunately, the postoperative progress was not good and Ms W suffered incapacitating pain. Over the course of a few months Ms W experienced progressive stiffening of the ankle and was subsequently left with an equinus contracture.

During the next few years she also developed a valgus deformity of her proximal tibia with some procurvatum. Her mobility deteriorated. The cosmetic appearance of her leg, although longer, was no better and overall her clinical condition was worse than before the operation.

Eventually Ms W made a claim against Mr A. The experts involved thought it was difficult to decide how much of her subsequent problems were due to the surgery and poor quality of follow-up, or because of post-polio syndrome. However, due to lack of adequate medical notes, to demonstrate adequate warning of risks, the case could not be defended and was settled for a substantial sum.

Learning points

  • Patients can often take away unrealistic expectations from what they see or read about in the media, and increasingly in social media. In these circumstances it is even more important to explore expectations about realistic outcomes, take proper consent and document appropriately. Remember good notes at all stages are the cornerstone of your defence.
  • It is important that the patient fully appreciates all that is involved, not just in the surgery but in the follow-up. This can sometimes influence the final outcome as much as the operation itself.
  • This case highlights the importance of a robust consent process when using innovative techniques.
  • Limb lengthening surgery is highly specialised and complex. There are numerous recognised complications and these must be made clear to the patient.
  • It can sometimes take more than one discussion before the patient is able to make a fully-informed decision to proceed with surgery.
  • It is important to make timely decisions.
  • MPS’s workshop Mastering Shared Decision Making is available via the MPS website.
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