Like all subspecialty areas within orthopaedic surgery, foot and ankle work carries risks, complications and the potential for litigation. Certain areas of this work have been highlighted for this article to aid the surgeon in appropriately counselling the patient, and improving understanding of major risk areas and knowledge of the outcomes of injury and surgery.
Foot and ankle litigation claims
Historically, information on litigation claims has been difficult to acquire because it involves obtaining information from a number of different bodies. There is no mechanism for compulsory reporting of complications, coding accuracy is usually found wanting, and most claims are either dismissed or settled without going to court. However, in 2014, Ring1 provided an analysis of 1214 National Health Service Litigation Authority (NHSLA) claims in England, involving foot and ankle surgery, over 17 years. These represented 12.6% of orthopaedic claims. Thirty-four per cent of claims involved the ankle, with 73% resulting from trauma. Twenty-one per cent involved the first ray, of which 98% involved elective surgery. Nineteen per cent of claims involved diagnostic errors, 19% were for alleged incompetent surgery, and a further 13% for mismanagement. The authors recognised that reducing incorrect, delayed and missed diagnoses was a key area for improvement.
Medico-legal implications:
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One in 8 orthopaedic claims involve the foot and ankle.
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Only one in 5 claims arise from incompetent surgery allegations.
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The importance of reaching a correct and timely diagnosis with a cogent management plan cannot be over-emphasised.
Nerve injury
Nerve injury is a common foot and ankle surgical complication, with the most frequent causes being inadvertent laceration, entrapment under metalwork, contusion/soft-tissue swelling and accidental injury from suture needle placement. This may result in diminished sensation, painful neuroma formation, adverse effects on mobility and problems with footwear. The sural, superficial peroneal, deep peroneal, saphenous and tibial nerves can all be injured.
Bai2 reported a 6% nerve injury rate following ankle surgery, involving sural, superficial peroneal and medial plantar nerve injury. Ferkel3 reported that 49% of complications following ankle arthroscopy were neurological.
The sural nerve is particularly at risk in Achilles tendon surgery, hindfoot posterolateral approaches and incisions of the lateral aspect of the foot. Paavola4 reported a nerve injury rate of 0.9% in surgery for chronic Achilles tendinopathy. Kirkley5 recorded a 6.0% rate in surgical repair of Achilles ruptures, although Lim6 described a 10.5% incidence of sural nerve region paraesthesia prior to Achilles rupture surgery. Similar to axillary nerve injury in shoulder dislocations, it would be helpful to document nerve health prior to intervention. Ribbans’ review7 reported an 11% injury rate in the open posterolateral approach for posterior ankle impingement syndrome. Injury during open reduction of calcaneal fractures has been reported in numerous publications, with rates as high as 55% described.8
The superficial peroneal nerve is at risk in fixation of fibular fractures, ankle ligament reconstruction and ankle arthroscopy. Redfern9 reported a 15% incidence of superficial peroneal nerve injury following open reduction and internal fixation (ORIF) of ankle fractures. This could be reduced by making a more posterolateral incision. Deng10 reported a 3.5% incidence, and Ferkel3 a 2.4% incidence, of nerve injury following ankle arthroscopy.
Medico-legal implications:
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Nerve injuries are a common potential complication of foot and ankle surgery and procedures should be planned with nerve anatomy in mind.
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Patients should be counselled pre-operatively about nerve injury and specific nerve risks according to the planned procedure.
Complex regional pain syndrome
Complex regional pain syndrome (CRPS) is a relatively rare but well-recognised complication following trauma and elective surgery to the foot and ankle.
Foot and ankle trauma is the most likely outcome with contusions, sprains, crush injuries, and fractures, including prolonged immobilisation. One small series 11 found that trauma was the most common cause (73%), of which fractures accounted for 45%. The other 27% were secondary to elective foot surgery, with neuroma excision the most common procedure. A low threshold of suspicion is required and a rapid referral to a multidisciplinary unit most likely to yield optimal outcomes.12,13 The combined incidence of CRPS following open reduction for calcaneal fractures using a variety of approaches was 7% in 139 cases.14-16
A Scottish retrospective study17 found an incidence of 4.4% in 390 patients undergoing elective foot and ankle surgery. The condition appeared to have a particular predilection for middle-aged females and those with a pre-existing history of anxiety and depression. The authors felt that such patients should be counselled pre-operatively regarding such a potential complication.
Medico-legal implications:
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With an overall risk of 1 in 23 patients, CRPS should reasonably be added to any developed patient information leaflets and consenting process.
Thromboembolic issues
While the use of anti-thrombotic prophylaxis in major hip and knee surgery is well-established, its use in foot and ankle surgery remains a contentious issue.
Griffiths18 reported upon 2627 elective foot and ankle procedures over a seven-year period, of whom 41% had aspirin and 59% no prophylaxis. There was no apparent protective effect of aspirin and the overall incidence of DVTs was 0.27%, and pulmonary emboli of 0.15% at three months. The authors concluded that the risk of clinically significant thromboembolic events in elective foot and ankle surgery was low, and chemoprophylaxis should be confined to high-risk groups for VTE. Hamilton19 reported upon a postal questionnaire to UK foot and ankle surgeons who between them undertook 33 500 elective cases per annum. The reported perceived incidence of DVTs was 0.6%, PEs 0.1%, and fatal PEs of 0.02%. Solis20 reported an ultrasound incidence of DVTs of 3.5% in 201 elective patients with no clinical symptoms of a thromboembolic event.
The incidence of thromboembolic events following trauma may be greater than elective surgery. Most work has centred on tendo Achillis ruptures. Patel21 retrospectively reported an incidence of 0.43% for DVTs and 0.32% for PEs. Nilsson-Helander22 reported colour duplex sonography findings of DVTs in 34% and PEs in 3% of 95 acute ruptures, with no difference between non-surgical and surgical patients.
Medico-legal implications:
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BOFAS guidelines23 published in 2010 considered most elective foot and ankle procedures as low-risk for a thromboembolic event.
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The decision to place patients on chemical thromboprophylaxis should be based upon patient-specific factors.
Infection in foot and ankle surgery
Infection is an ever-present risk in surgery. A major prospective survey of 1737 patients undergoing elective foot and ankle surgery described an overall 14.5% wound healing and/or infection rate – 11.6% had minor wound problems; 2.4% required antibiotics to control a post-operative infection; and 0.5% required re-admission for intravenous antibiotics and/or surgery.24 A retrospective review of 1000 patients25 undergoing foot and ankle surgery reported an overall infection rate of 4.8% but diabetic patients had a rate of 13.2% compared with non-diabetics, whose incidence was 2.8%. Further analysis demonstrated that patients with complicated diabetes, such as neuropathy, had a tenfold increased infection risk compared with non-diabetics.
Medico-legal implications:
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Up to one in seven elective foot and ankle procedures can result in wound healing problems and/or infection.
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Diabetic patients, especially those with neuropathy, have a significantly increased risk of post-operative infection.
Injecting around the foot and ankle
Various soft-tissue and articular injections for both diagnostic and therapeutic purposes are widely used in foot and ankle practice. However, the administration of such injections is not without hazard. Local complications can include skin atrophy, hypopigmentation, increased pain, steroid flare, and infection. Systemic effects can occur including skin rash, flushing and menstrual irregularities. Rarer complications including osteomyelitis have been described. A review of extra-articular steroid injections in general reported a risk of major adverse effects ranging from between 0% and 5.8%, and of minor events ranging between 0% and 81%.26 Hunter27 reported an approximate rate of septic arthritis following an intra-articular injection of steroids as 1:10 000.
Within the foot and ankle, the following should be particularly acknowledged:
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Atrophy of the plantar fat pad from injections for plantar fasciitis and Morton’s neuroma.
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Rupture of the plantar plate following injections to the lesser MTP joints or inter-metatarsal space.
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Rupture of the plantar fascia following injections for plantar fasciitis – reported to be as high as 10%.28
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Counsel patients carefully pre-injection and acquaint them with potential complications.
Total ankle arthroplasty surgery
The UK National Joint Registry has only been acquiring data about total ankle arthroplasties (TAAs) since 2010. As a result, the long-term survivorship of TAAs nationally is not as well-progressed as it is for hips and knees, particularly when the relatively low number of procedures performed is taken into account.
In 2014, 509 primary TAAs were recorded in the UK29 compared with 83 125 knee, 95 850 hip, and 4756 shoulder replacements.
Survivorship of specific TAAs has been reported. For example, Barg30 reported 94% and 84% survivorship for the Hintegra TAA at five and ten years, respectively. For the STAR TAR, five-year survivorship has been reported at 89% to 90%31,32 and 71% to 76% at ten years.31,33 The Swedish Registry recommended patients be advised that, using modern designs of TAAs, the probability of implant survival is around 80%.34 With the limited data available, the NJR estimates that the four-year cumulative revision risk for a TAA (2010-2014) was 3.28%.
Haddad35 undertook a systematic review of the literature, establishing and comparing the intermediate and long-term outcomes of TAA and ankle fusion (Table I). The analysis revealed similar results in both procedures for end-stage ankle arthritis:
Table I.
Haddad et al. (2007):35 outcomes of TAA and ankle fusion
| TAA | Ankle fusion | |
|---|---|---|
| Patients | 852 | 1262 |
| Results: | ||
| Excellent | 38.0% | 31% |
| Good | 30.5% | 37% |
| Fair | 5.5% | 13% |
| Poor | 24.0% | 13% |
| Survivorship (TAA only): | ||
| 5 years | 78% | |
| 10 years | 77% | |
| Revision surgery | 7% | 9% |
Medico-legal implications:
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Compared with hip and knee arthroplasty surgery, TAA is still undertaken in relatively small numbers.
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A reasonable estimate of TAA implant survival at ten years is about 80%.
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In experienced hands, TAA outcomes can rival those of ankle fusion.
Misdiagnosis of acute tendo Achillis rupture
Acute ruptures of the tendo Achillis can present to a variety of healthcare professionals. Frequently the patient does not appreciate the significance of the injury. The diagnosis is missed in up to 25% of patients on initial assessment36-39 but rises higher in the elderly, with a 36% misdiagnosis in the over-65-year-old group. This is felt to be due to both reduced patient awareness and lowered clinical suspicion.40
Medico-legal implications:
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A careful clinical assessment and, if necessary, a confirmatory ultrasound or MRI is important in patients of all ages presenting with suspicious Achilles injuries.
Lateral ankle ligament sprains
A considerable amount of literature is available on the epidemiology of lateral ankle ligament sprains.41,42 In the UK, it is estimated that approximately 1.8 million ankle sprains occur annually but only 300 000 present in emergency departments. Fourteen per cent of injuries are regarded as severe, and the risk of re-injury within three years is regarded as 34% in the general population and 73% in athletes. There are variable estimates of patients making a full recovery within three years ranging between 36% and 85%.
Medico-legal implications:
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Ankle sprains are among the most common conditions presenting to emergency departments.
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However, they are not always benign injuries, with a sizeable proportion experiencing re-injury and prolonged and incomplete recoveries.
Commonly missed foot and ankle fractures
From the many fractures witnessed within the foot and ankle, several have a particular reputation for being commonly missed on initial presentation, including:
Calcaneal body fractures
This injury, which has a reputation for poor outcomes, is missed in up to 10% of cases.43
Anterior process of the calcaneum fractures
This fracture represents 15% of all calcaneal fractures but is commonly misdiagnosed as an ankle sprain.44 Up to 25% of these fractures can remain symptomatic for up to 12 months after injury despite apparent radiographic union.45 Nonunions may require excision.
Lateral process of the talus (LPT) fractures
With the increasing popularity of snowboarding, the incidence of LPT fractures has increased in recent years. These injuries are now commonly referred to as ‘snowboarder’s fracture’ and are believed to be caused by an external rotation or eversion stress placed on an axial loaded dorsiflexed ankle,46 with between 33% and 41% being missed on initial presentation.44
Lisfranc injuries
Injuries to the Lisfranc midfoot complex can range from severe displaced fracture-dislocations to subtle ligamentous injuries. However, long-term deformity and disability is common, particularly if the diagnosis is delayed which occurs in 20% to 40% of cases.47
Medico-legal implications:
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Overall, 7.6% of foot fractures and 2.8% of ankle fractures were missed in the emergency department,48 with several specific fractures commonly misdiagnosed.
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