Deviation in the Standard of Podiatric Care During Bunion Surgery

Evaluate breaches in the standard of care by asking and answering the questions herein below and analyzing as well to determine if there has been a Deviation in the Standard of Podiatric Care During Bunion Surgery

Answer the following questions to find out if the standard of care was followed for your case.

  • With which of the following symptoms did the patient present? (Choose all that apply)
    Plantar foot pain
    Outward turned first toe that may overlap the second toe
    Thickened skin over the bony protrusion at the base of the first toe (callus)
    Swelling
    Symptoms not elicited
    Answer unknown
    Why is this important?
    Symptoms of hallux valgus include poor-fitting shoes, plantar foot pain, medial first Metatarsophalangeal (MTP) joint pain, deep MTP aching pain from joint degeneration, and pain with weight bearing.
    (2014) 98 EMEDCN 2 227-232

  • With which of the following risk factors of bunion did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
The cause of hallux valgus (bunion) associated with genetic predisposition, restrictive footwear, other foot deformities such as pronation of the hindfoot and pesplanus (flatfoot),hypermobility, contracture of the Achilles tendon, and neuromuscular disorders such as cerebral palsy and stroke.

    (2014) 98 EMEDCN 2 227-232 



  • Was a medical history obtained and documented? Why is this important?
    Answer this question
    
Past Medical History (PMH) includes all past and current illness, hospitalizations, surgery, trauma, allergies, and medications. The date, location, and physician/surgeon for each hospitalization and/or surgery should also be included. Particularly important issues in the identification of manifestations of systemic disease include alcoholism, cancer, cardiovascular events, diabetes, and hepatic, renal, and psychiatric reasons for admission. Particularly important medications for oral manifestations include immunosuppressives, antibiotics, cardiac medications, and psychotropics. The PMH is also important for investigating whether the Chief Complaint (CC) is a manifestation of a previously diagnosed disorder.

    (2011) 55 EDECNA 1 15-28 



  • Was a physical examination performed? Why is this important?
    Answer this question
    
A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's evaluation and enables the clinician to make the most judicious use of additional tests. It helps determine the value of incongruent and conflicting results that can emerge during the diagnostic process, and it can obviate the need for tests that are costly or expose the patient to discomfort or risk. The deep understanding of the patient that can be obtained only through the immediacy of the history and physical examination also plays a pivotal role in treatment decisions that must be addressed at various points throughout the patient's lifetime.

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  • Was an x-ray of the affected foot obtained? Why is this important?
    Answer this question
    
Radiographs of the foot need to be taken with the patient in the weight-bearing position. The basic studies should include AP, lateral, and oblique views.

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  • Was the patient diagnosed with a bunion deformity? Why is this important?
    Answer this question
    
Hallux valgus (bunion) is readily apparent with clinical inspection of the patient. Significant findings may include a subcutaneous bony prominence or medial bump. 

    (2003) 42 JFAASU 3 112-123 



  • Were follow-up evaluations advised? Why is this important?
    Answer this question
    
Regular follow-up physical examinations, laboratory studies and diagnostic imaging evaluations are needed for effective follow-up care. 

    (2002) 16 EHOCNA 4 907-926 



  • With what severity of bunion deformity was the patient diagnosed? Why is this important?
    Answer this question
    
The severity of a bunion deformity is typically based on symptoms and radiologic assessment using weight-bearing radiographs and is described as mild, moderate, or severe. No one classification is perfect, and the numbers used to define a mild, moderate, or severe deformity are not “etched in stone”. Classification should be used only as a general guide.

    (2014) 98 EMEDCN 2 227-232 



  • Was a vascular evaluation of the affected foot performed? Why is this important?
    Answer this question
    
Vascular evaluation includes palpation of the dorsalis pedis and posterior tibial pulses, observation of capillary filling of the toes, and assessment of the skin and hair pattern. If there is any question regarding the circulatory status of the foot, a Doppler evaluation is obtained.

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  • Was a neurologic examination of the affected foot performed? Why is this important?
    Answer this question
    
The neurologic examination focuses on sensation, vibratory sense, and strength of the intrinsic and extrinsic muscles. Often, a sensory deficit may develop with reduced sensation over the medial eminence and medial hallux. 

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  • Which of the following conservative treatment options were recommended? (Choose all that apply) Why is this important?
    Answer this question
    
Conservative care in most patients with a bunion deformity is adequate to relieve symptoms. A symptomatic mild hallux valgus deformity should be periodically examined and radiographs obtained to evaluate any progression in the magnitude of the deformity.

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  • With which of the following indications for bunion surgery did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
Although cosmesis is mentioned as a possible indication for surgery, pain and discomfort should be the major considerations for surgical correction. It may be difficult on occasion to distinguish between a patient's concern for cosmesis and actual discomfort.

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  • Was bunion surgery recommended? Why is this important?
    Answer this question
    
With more than 100 surgical procedures described in the literature to correct a hallux valgus deformity, no procedure is adequate to correct all bunion deformities. An algorithm has been developed that gives the clinician a logical scheme with which to approach a patient with a hallux valgus deformity. The deformity is placed into one of three main groups according to the radiographic appearance: a congruent joint, an incongruent (subluxated) joint, or a joint with arthrosis.

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  • With which of the following contraindications for surgical intervention did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
Non-surgical care should also be considered in patients with hyperelasticity, ligamentous laxity, or neuromuscular disorders because of the high recurrence rate.

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  • Was an informed consent obtained? Why is this important?
    Answer this question
    
The laws of most states require that surgeons obtain informed consent before providing treatment.

    (2011) 23 EOMSCA 3 475-484 



  • Which of the following surgical treatment options were recommended? Why is this important?
    Answer this question
    
Not all hallux valgus deformities are equal, and many different factors must be considered when evaluating a deformity for surgical intervention. 

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  • Was a pre-operative evaluation performed? Why is this important?
    Answer this question
    
A pre-operative basic health assessment is typically performed within 30 days of planned surgery. At least a limited assessment is mandated by the Joint Commission on Accreditation of Healthcare Organizations on all patients, but a more thorough evaluation is necessary to obtain a comprehensive view of patient risk factors.

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  • Were prophylactic antibiotics administered prior to the surgery? Why is this important?
    Answer this question
    
Use of pre-operative and peri-operative prophylactic antibiotics is a key to reducing systemic infections.

    (2012) 26 EIDCNA 1 29-39 



  • Was the affected toe positioned accurately during the surgery? Why is this important?
    Answer this question
    
Accurate positioning of the hallux is essential during the procedure of bunion surgery.

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