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XXXXX Attorneys at Law xxxxxxxx Street, Suite xxx XXXX, Florida xxxxx
XXXXX VS. THE XXXX ORTHOPAEDIC GROUP, PA
1. Records of XXX
, M.D. of the XXXX Orthopaedic Group: Records from December 13, 1995,
July 10, 1996, and September 20, 2000 through December 20, 2000.
ALL PATIENT AND HEALTHCARE PROVIDER NAMES, FACILITIES AND ADDRESSES HAVE BEEN BLOCKED OUT MAINTAIN CONFIDENTIALITY.
CASE REVIEW (Patient) has been treated by her internist Xxx since July of 1999. At the time of her first visit she was a 59-year-old white female with a longstanding history of peripheral neuropathy affecting her feet. She had been on Pamelor and Zostrix for this problem. The patient also had a skin condition involving psoriasis/eczema. She had a long-standing history of gastroesophageal reflux and irritable bowel syndrome and a history of pernicious anemia and was obtaining B12 shots monthly. She also had a history of a craniotomy and had an aneurysm clipping. The patient had been left with left-sided weakness from her previous history of a mild CVA and had a history of temporal arteritis as well. The patient also has a history of being legally blind. On the patient's initial visit to Dr. Xxx, based on her examination, necessitated medication for hypertension as well as for hypercholesterolemia. She had a long-standing history of osteoarthritis and was taking Celebrex for this and was followed by Dr. Xxxxx, her rheumatologist. Her peripheral neuropathy was to be followed by Dr. XX, her neurologist and pernicious anemia and B12 shots were given by Dr. Xxxxx. The patient's followup visits from October 5, 1999 through November 2000 indicate that she was seen on a few occasions due to various mild medical conditions, including esophageal reflux, abdominal pain, as well as anxiety. In December 2000, her internist saw her again and scheduled her for a stress test and Holter monitor for a baseline with regard to her cardiovascular system. She was still having anxiety problems and was started on Paxil and Wellbutrin. The patient was a smoker and Dr. Xxx states she discussed the idea of cessation of her smoking for medical reasons. In March 2001, there is a notation by Dr. Xxx with regard to the fact that the patient was having persistent right arm pain after Dr. XXX's surgery and that she was seen by Dr. Xxxx. In June 2001, the patient followed up and another note states that she underwent surgery by Dr. Xxxx and that she occasionally gets some pain and swelling in her elbow, but overall was doing well. A followup note on July 16, 2001 states that she was doing well since Dr. Xxxx's surgery, but that she still had a great deal of burning in her feet, secondary to her neuropathy. No other notes of importance from Dr. Xxx' office records with regard to the patient's elbow problem were discussed between her visits from July 16, 2001 through October 23, 2001. Records from Dr. Xxxxx from December 18, 1998 indicate the patient was referred for evaluation of pain in her joints. The patient's records indicate that she had pain in her hands as well as in her feet and at the time, her medications included Darvocet, Adalat, Prilosec, Zocor, and Estradiol. Her past history was significant for hypertension, history of a left CVA in 1980, she was legally blind secondary to temple arteritis, and gastroesophageal reflux. She also had a previous history of a re-section of a brain aneurysm, status post hysterectomy, status post arthroscopic surgery of the right knee, status post hemorrhoidectomy, and artificial tear duct replacement. She had been a smoker for many years. His assessment at that time, was that she had generalized osteoarthritis with a peripheral neuropathy and hypertension as well as a history of cerebrovascular disease. He suggested to start her on Pamelor at night, and gave her a B12 shot. He was to obtain CBC, Sed-rate, ANA, rheumatoid factor, TSH, and B12 levels. The patient was seen again by Dr. Xxxxx in July 1999. At that time, her findings were approximately the same. He suggested she start on Celebrex and also felt that she was unable to tolerate the Pamelor, so he tried Klonopin at night and that she should continue on Zoloft 100 mg per day. He followed up with her on September 21, 1999, November 18, 1999 and January 17, 2000 all of which were similar visits with regard to treatment for osteoarthritis and she was kept on Celebrex two times per day.
When the patient was seen in July 2000 by Dr. Xxxxx, the patient was having neck pain and headaches. She was seen by a neurologist, Dr. XX as well as Dr. Xx, both who felt that this was an arthritic condition in her neck and she should continue using the Celebrex. She was also complaining of a "restless leg syndrome" which was treated with Klonopin 12.5 mg at sleep hour, as well as Lortab prn. It should be noted that she had pernicious anemia and was continuing on B12 shots by Dr. Xxxxx. The patient was seen again in August 2000 and that time, she was having hip and leg pain. She was treated with the Celebrex and Lortab. A trochanteric bursal injection was performed. She came back on August 31 and September 11 for B12 injections and during her September 11 office visit, she stated she was having a great deal of burning sensation in her hands, feet, and legs, and she was going to see Dr. XX. She was continued on Pamelor and B12 injections and was still using Lortab and Celebrex. The patient was seen again on August 31, 2000 and at that time, she started complaining of numbness and burning sensation in her fourth and fifth fingers of the right hand. She had seen Dr. XX and was to follow-up with Dr. XX concerning her hand problem. She was continued on Klonopin and Celebrex. She received B12 shots on October 20, November 17, and December 14, 2000. On December 14, 2000, she saw Dr. Xxxxx and at that time, informed him that she had undergone an operation by Dr. XXX . She was continued with Pamelor and Celebrex and was to be followed-up by Dr. XX for her "neuropathic" pain. The patient was seen again in March 2001, as well as October 2001. No other records from Dr. Xxxxx's office were reviewed (Patient) originally saw Dr. XXX in December 1995 for degenerative arthritis of her hand. He treated her conservatively for this and she returned for a second opinion for bunion surgery in July 1996, at which time Dr. XXX recommended a conservative approach for her bunions with orthotics. The patient, according to his records, returned on September 20, 2000. According to the history of present illness, the patient had a new problem with her right elbow and she was having "ulnar nerve symptoms" and had a nerve conduction study by Dr. XX that showed damage of her ulnar nerve at her elbow. Her examination revealed that she had findings with a positive Tinel's sign at the elbow joint and pain with flexion. Electrophysiological studies showed that distally, her motor function was normal, but her sensory function was absent in the ulnar nerve distribution. According to Dr. XXX, in light of her symptoms and nerve conduction study, he felt that she was a candidate for an anterior ulnar nerve transposition. She was going out of town and he gave her an injection and told her that when she returned from her trip to Texas, he would schedule her for surgery. The next note is an operative procedure done at XXXX Surgery Center on October 5, 2000. Dr. XXX was the surgeon and XXXXXX was the PA-C. The anesthesia was done with an axillary block. The preoperative diagnosis was right cubital tunnel syndrome. The postoperative diagnosis was the same. The operation performed was a right anterior ulnar nerve transposition. According to the operative report, the ulnar nerve was dissected free from surrounding tissue. After a careful dissection of the ulnar nerve, a trough was placed in the flexor pronator origin using a Z-plasty technique to lengthen the fascia. The nerve was transposed anteriorly and the fascia was then loosely closed over the nerve. There are no specific records from XXXX Surgery Center of anesthesia records or perioperative care. The patient returned to Dr. XXX four days after the surgery for a re-check of her elbow. Her dressing was changed and she was started on range of motion exercises. She was to return in one week. The patient was seen on October 16, 2000 for a re-check. Her arm was healing and her range of motion was 22-degrees to 130-degrees. According to the note, her gross motor function was within normal limits, but she still had subjective feelings of numbness. She was started on a range of motion therapy program and was to be followed-up in one month. A note from October 25, 2000 states a telephone call was made by (the patient) that was answered by X, Dr. XXX's physician's assistant, and she stated that she was having increasing pain in her pinky finger. Dr. XXX recommended Neurontin 100 mg tablets, one tablet PO every hour sleep and return to see Dr. XXX for her October 27, 2000 visit. According to this note, the patient's elbow was healing well, but at that time, she was complaining of shoulder pain and his examination was consistent with an impingement syndrome of the shoulder. She was going to be started on physical therapy for her shoulder, ROM exercises for her elbow, and modalities for pain relief. The patient followed up three weeks later on November 20, 2000. She was complaining of a burning sensation in her right ring and small fingers and that there was no change, according to her, since the surgery. Her ROM was full and according to Dr. XXX's note, the patient had a positive Tinel's sign around the wrist over the ulnar nerve. According to Dr. XXX, he felt that it was only six weeks since the surgery and that since her preoperative studies did show serious ulnar nerve compression, that it would take time for her to heal and he would follow-up with her in five to six weeks. Dr. XXX sent her for a postoperative nerve conduction study, which was performed on December 18, 2000 by the same neurologist, Dr. XX. According to the nerve study, there was minimal slowing of the right ulnar sensory conductions and otherwise a normal nerve conduction study, which indicates improvement compared to preoperatively. She was seen on December 20, 2000 by Dr. XXX who explained to her the findings of the nerve conduction study and that he felt nothing needed to be done, other than to continue and wait to see if nature would take its course and she would feel better. Dr. XXX sent the patient to Dr. x, an anesthesiologist at XXXXX Surgery Center. Between the end of January 2001 and early February 2001, the patient underwent stellate blocks to attempt to decrease her right elbow and hand pain. This was not successful with regard to decreasing her discomfort. According to further records, the patient saw Dr. Xxxx on February 12, 2001 for a second opinion. According to the intake history by Dr. Xxxx, the patient was noted to be 61 years old. Five months prior to seeing Dr. Xxxx, a local orthopaedist had done an ulnar nerve transposition decompression of the ulnar nerve, but she did not get significant improvement in the area of her right hand. She had pain that radiated into the right shoulder and also down into the right fourth and fifth fingers. According to the note, she continued to have numbness, paresthesias, and difficulty with activities of daily living. Her examination showed that she had a positive Tinel's sign in the area of the right wrist. She had some numbness over the ulnar distribution of the right hand and some slight clawing of the fourth and fifth fingers. X-rays were negative. According to Dr. Xxxx's plan, the patient was to receive another EMG and nerve conduction study. He thought she might be a candidate for a re-exploration and decompression of the ulnar nerve, both at the elbow as well as at the wrist over Guyon's canal. The patient returned to see Dr. Xxxx on March 5, 2001 and at that time, EMG studies, which had been done, did not show any change compared to the December 18, 2000 studies. They revealed slight slowing of the nerve conduction studies of the right ulnar nerve. He felt that in spite of no significant nerve study changes that she might still necessitate an ulnar nerve exploration. On March 26, 2001, the patient returned. He felt in spite of the negative EMG study that the patient would be a good candidate for a re-exploration as well as a decompression of the nerve at the wrist. On April 4, 2001 she returned to Dr. Xxxx and a history and physical was performed. The risks and benefits involved in surgical intervention were discussed. The patient on April 10, 2001 underwent an operative procedure which included an ulnar nerve transposition and decompression at the right elbow, external neurolysis of the right elbow ulnar nerve, a carpal tunnel release, and a Guyon's canal release at the right wrist. According to Dr. Xxxx's operative note, "we entered into the area of the flexor mass of the elbow and we found significant compression of the ulnar nerve. It appeared to be transposed submuscular in the region of the elbow and there was significant scar tissue around the area of the ulnar nerve and there was significant damage to the ulnar nerve at the area of the submuscular transposition." Dr. Xxxx then decompressed the nerve throughout the entire course, placed it in a subcutaneous position, and did an external neurolysis of the nerve. Dr. Xxxx then opened her wrist with a small incision made at the fourth finger position of the wrist and a carpal release and a Guyon's canal release was done to decompress the ulnar nerve and median nerves. According to the records, there was significant compression of the nerve at the wrist, there was "difficulty decompressing the ulnar nerve at the wrist and especially at the elbow, where there was significant scar tissue". Once the decompressions were completed, Dr. Xxxx stated that the ulnar nerve did not have any significant entrapment and he closed the wound and placed her in a bulky dressing and a long-arm splint. Postoperatively, the patient was seen on April 16, 2001. Dr. Xxxx stated that the stitches were removed and she was started on ROM exercises. According to the records, he did a significant decompression of the elbow in order to expose the ulnar nerve, which had been "encased" in scar tissue. Dr. Xxxx followed up with her again on May 14, 2001, June 11, 2001 and July 18, 2001. According to his note on July 18, 2001, the patient had no pain whatsoever in the area of the right hand, she was able to do most of her activities of daily living without discomfort, and she had complete resolution of her symptoms. She followed up again on August 27, 2001 and at that time, had tendonitis of the flexor tendons and he gave her a local injection around the medial epicondyle for medial epicondylitis. He did state her ulnar was doing very well and her hand resolved nicely of all paresthesias. The patient followed up for a last visit on September 24, 2001. His note states "approximately five months S/P surgery in the area of the right shoulder" (this is probably a typographical error). The patient stated that she still had tenderness over the medial epicondyle. He gave her another local injection and he started her on Toradol 10 mg b.i.d. for pain relief and she was to be followed-up in six weeks. No further records were available in regard to Dr. Xxxx's office.
CASE SUMMARY: Patient, who at the time of her surgery by Dr. XXX, was a 60-year-old white female. She had, based on her medical records, multiple medical problems including pernicious anemia, hypertension, hypercholesterolemia, gastroesophageal reflux, previous history of aneurism clipping, right CVA, temple arteritis, and also significant history of peripheral neuropathy. Her medications at the time of the surgery included Lipitor, Celebrex, Pamelor, and Prilosec. The patient had, prior to the surgery, been complaining of elbow and hand pain and had undergone an EMG and nerve conduction study, which revealed a right ulnar nerve neuropathy. It also revealed mild carpal tunnel syndrome. On October 5, 2000, the patient underwent an ulnar nerve transposition and the nerve was placed under the fascia of the flexor pronator. Postoperatively, the patient continued to have significant pain in her hand, as well as in her forearm and elbow. She was followed up routinely by Dr. XXX during her perioperative and postoperative period. She underwent a repeat nerve conduction study in December, which indicated an improvement over her preoperative studies. There was only minimal slowing down on the right ulnar sensory conductions compared to the previous study. There was a faster ulnar nerve velocity of 63.2 post-surgery versus 50 preoperatively. Since the nerve studies showed improvement, Dr. XXX decided to wait and see how the patient did prior to any further surgical intervention in spite of the patient's discomfort. Further records
indicate that she got a second opinion from Dr. Xxxx in February 2001.
At that time, Dr. Xxxx treated her conservatively for this discomfort
from December through April 2001. During this time, the patient received
another EMG and nerve conduction study which basically was unchanged
from her previous postoperative study in December 2000. It was Dr.
Xxxx's opinion that since the patient was not getting any relief of
symptoms with regard to her pain, tingling, and numbness, that a
re-exploration should be performed in spite of the fact that there were
no changes in the nerve studies. In April, the patient underwent further
surgery in which Dr. Xxxx performed an external neurolysis of the right
ulnar nerve, a carpal tunnel release, as well as Guyon's canal release.
Postoperatively, the patient improved from this surgery over a period of
six months and she had resolution of her tingling and numbness in her
hand, but continued to have elbow pain. LITERATURE REVIEW AND DISCUSSION Ulnar nerve compression at the elbow is a fairly common diagnosis when patients present with tingling and numbness from the elbow to the ulnar nerve sensory distribution into the fingers. Compression of the ulnar nerve occurs most commonly at two sites: the epicondylar groove or when the nerve passes between the two heads of the flexor muscles. Differential diagnosis for ulnar nerve compression should also include systemic metabolic disorders, one of which is pernicious anemia. Complete history and physical examination is especially important with ulnar nerve compression syndromes. There is controversy with regard to EMG and nerve conduction studies. In some articles, electrodiagnostic studies were extremely useful to determine the site of the compression, as well as to determine if the compression could have occurred at multiple levels. However, further articles indicate that there is no direct scientific correlation between nerve conduction studies and ulnar nerve compression. Many studies indicate that a patient may have a normal electrodiagnostic study, but still have compression of the ulnar nerve at the elbow and have the signs and symptoms of an ulnar nerve neuropathy. Therefore, it is still appropriate, if a patient has signs and symptoms of an ulnar nerve compression at the elbow, in spite of normal studies, to undergo surgical intervention for this problem. Further studies indicate that external neurolysis of the ulnar nerve is not always appropriate treatment in view of the fact that you can devascularize the nerve and cause more damage to it. There are numerous procedures that are acceptable in the literature with regard to ulnar nerve transposition. Transposing the nerve by removing the epicondyle is one choice. A decompression without transposition is another appropriate procedure. A decompression with transposition of the ulnar nerve is also appropriate and can be done in numerous ways, including a subcutaneous transposition, intramuscular transposition, submuscular transposition, and subfascial transposition. All of the above treatments for this specific problem are acceptable procedures for this problem. Mrs. XXXX had appropriate diagnostic and physical examination studies done by Dr. XXX prior to her surgery. His procedure for ulnar nerve transposition is an acceptable method of transposing the nerve for a compressive neuropathy. There was no indication that her pernicious anemia played a part in her upper extremity neuropathy. Furthermore, there was no indication for a carpal tunnel release at the time of the initial surgery in view of the fact that the patient did not have any median nerve distribution of pain or tingling in the hand, nor was there any definitive electrodiagnostic findings of carpal tunnel. In the notice of intent to initiate litigation that was sent to Dr. XXX, there is indication that an external neurolysis should have been performed. There is no indication in the literature that an extensive neurolysis is appropriate at the time of initial surgery with compressive neuropathies. Dr. XXX also
performed appropriate postoperative care in treating the patient
conservatively after the surgery without any indication that he would
perform a second surgical procedure early on, during her postoperative
care. His repeat of an EMG and nerve conduction study is also within the
appropriate care for this patient and in view of the fact that the ulnar
nerve velocities increased, indicates that in essence, there was
improvement from the preoperative electrodiagnostic studies. This
certainly is another indication not to progress with further surgery on
an immediate basis. It is well-documented in the literature that when a nerve is placed under the fascia of the muscle, one of the major complications is submuscular scarring. This certainly can occur after an appropriate procedure with ulnar nerve transposition. The fact that Dr. Xxxx states that there was damage to the ulnar nerve, does not indicate that the damage was done from the previous surgery, but rather could be associated with the scarring that occurred postoperatively. In view of the fact that the patient postoperatively was still having diffuse pain in the ulnar nerve distribution of her hand, it was appropriate for Dr. Xxxx to further perform a decompression of the patient's Guyon's canal and carpal tunnel at the wrist. However, there is no indication that a decompression of the carpal tunnel, involving the median nerve or Guyon's canal involving the ulnar nerve, was indicated for the first procedure that was done on this patient. The patient's preoperative findings as well as electrodiagnostic studies indicated that an ulnar nerve transposition was the appropriate treatment and that there was no indication for decompression at the wrist. Dr. Xxxx's indications for the decompression at the wrist was due to the fact that this was a secondary procedure after a known complication from the previous surgery. Dr. XXX only had the opportunity to follow the patient for approximately two and one half months after the surgery and during this time period, he did all the appropriate postoperative treatment. Dr. Xxxx had the opportunity to follow the patient for another two and one half months, or a total of five months postoperatively, and therefore, at that time, it was appropriate for Dr. Xxxx to perform the further exploration of the patient's ulnar nerve at both the elbow and wrist. In conclusion, based on my complete review of the medical records and subsequent literature search regarding compressive ulnar nerve neuropathy and its signs, symptoms, treatments, and complications, it is my opinion that Dr. XXX treated Mrs. XXXX appropriately. There is no indication that Dr. XXX's treatment was below the standard of care for this patient. I feel if the case proceeds, Dr. XXX necessitates an expert in the field of upper extremity and hand surgery to defend his position. It may also be necessary for an internist, who specializes in pernicious anemia to testify. I will be happy to help you with finding experts in these areas if the case is not dropped. Furthermore, I will be happy to sign an affidavit on behalf of Dr. XXX. Enclosed are important articles and abstracts that will help in defending Dr. XXX's position in the case. Sincerely yours,
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