Dr. Aprajita Nakra is a board-certified reconstructive foot and ankle surgeon. She is the president of the Arizona State Physicians Association and is also the medical director at Advanced Ankle and Foot which is located in Gilbert, Arizona. Dr. Nakra is an editor, instructor, lecturer and speaker. 

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Transcription: 

Rochelle: Good afternoon and welcome to today's presentation "Foot & Ankle Injuries, Malpractice and Medicine." The information presented by the expert is not to be used as legal advice and does not indicate a working relationship with the expert. All materials obtained from this presentation are merely for educational purposes and should not be used in a court of law, sans the expert's consent, i.e., a business relationship where she or he is hired for your particular case. In today's webinar, Dr. Nakra will discuss legality of foot and ankle pathology, personal injury, medical malpractice, workers' compensation, expectations of the expert, significance of the diabetic foot, complex regional pain syndrome.

To give you a little background about our presenter, Dr. Aprajita Nakra is a Board Certified Reconstructive Foot and Ankle Surgeon. She is the President of the Arizona State Physicians Association and is also the Medical Director at Advanced Ankle & Foot, which is located in Gilbert, Arizona. Besides practicing medicine, Dr. Nakra is a publisher, editor, instructor, lecturer, and speaker. She comes to us with extensive experience in medical-legal work involving medical malpractice, personal injury, product liability, and worker compensations cases. She has worked on federal and state and out-of-state cases. Attendees who require passcode, the word for today is "Foot."

During the Q&A session, we ask that you enter this password into the Q&A widget for CLE reporting purposes. The Q&A is located to the left of your screen. Please remember that if you are applying for CLE credit, you must log on to your computer as yourself and stay for the full 60 minutes. You are also required to complete the survey at the end of the program. Please know that CLE credit cannot be given to those watching together on a single computer. Tomorrow morning, we will send out an email with a link to the archive recording of the webinar. The slides can be downloaded from the resource list at the widget at the bottom of your screen. Thank you all for attending today, and Dr. Nakra, the presentation is now turned over to you.

Dr. Nakra: Thank you. Welcome, everybody. Can everybody see the slides?

Rochelle: I'm sorry?

Dr. Nakra: I just want to make sure, Rochelle, everybody can take a look at the slides.

Rochelle: Yes, yes. They can. I'm sorry.

Dr. Nakra: Perfect. Excellent. And I'm trying to bring this live up on my screen. Perfect. Bear with me, folks, as I maneuver through this. Perfect. Well, welcome, folks. Thank you for...depending on which part of the country you're from, thank you for joining in during your lunch or half of the week is done. So towards the latter part of Wednesday. For the next probably 45 to 50 minutes what I would like to do is share with you my experience as an expert as a reviewer, etc., in legal cases involving foot and ankle pathology. As Rochelle introduced me, I'm a Board-Certified Reconstructive Foot and Ankle Surgeon and I'm a Fellow of the American College of Foot and Ankle Surgeons.

And my specialty is of course foot and ankle medicine and surgery. What we will focus in over the next little bit is the different legal cases that I've been involved in that I've reviewed or, etc., and they encompass personal injury. They encompass workers' compensation and certainly medical malpractice. Another part of legal consulting that I do is product liability cases. And we'll briefly talk about that as we go. So starting with personal injury. For all you folks at the lawyers, CNAs, insurance companies, adjusters out there in the audience right now, the personal injury cases involving foot and ankle really involves slips, trips, and falls. So motor vehicle accidents and liability cases.

So this would include some of the recent cases, or cases in the past that I've reviewed include fall from while driving a vehicle and getting out while they're at work. And getting involved in an accident. And the cases that we've just reviewed our patients who were pedestrians and they were involved in the accident. So certainly that goes under motor vehicle accidents. And there's various pathologies that we see in there involving the foot and ankle. These can range anywhere from fractures to nerve injuries, to dislocations, to ankle sprains, to open wounds, etc. So these are the cases that I'm referring to. And I'm talking about personal injury.

Some of the other cases, interesting cases that I've seen is a patient who underwent a pedicure at a nail salon and ended up with infection in their foot. So these are the different kinds of liability cases or personal injury cases involving foot and ankle. In regards to malpractice, there are various cases or anything really frankly involving the foot and ankle, but some of the more common ones that we see, that we talk about include surgical correction of a bunion deformity. As some of you are probably, most of you are aware of bunion is that bony permanence in your foot, which leads to pain, difficulty in shoe gear, limitations of activities, etc. One of the very common cases that routinely comes across my table is the diabetic foot.

And actually, we'll go with a little bit more detail later on in the presentation about the diabetic foot source, go into more details later on about the wound care where there's so many wound care products out there. So you're essentially utilizing wound care for open wounds, alterations that patients or claimants might have. And the etiology, the cause of these wounds can be multifactorial. It could be because of diabetes, it could be because of sickle cell anemia, it could be because of obvious trauma, it could be because of smoking, it could be because of peripheral arterial disease, various, various medical conditions that cause open alterations.

The reason this is very relevant in regards to what we're talking about is anytime you have an open wound, there's a much higher propensity for an infection with subsequent complications associated with that. So it behooves not only the patient, but the treating physician to evaluate and render prompt care. We'll talk more about this in concert with the diabetic foot and I'll put all of that together when we come to those slides, just a little bit further down in this talk.

And then we'll talk about broken feet, broken ankles, different kinds of fractures. There are well over 25 bones in the foot and the ankle. So various bones that can be fractured. So we'll talk about what's the appropriate treatment protocols for these are. Then we'll talk about infection in regards to the diabetic foot. Why these need to be treated aggressively and properly, and surgical intervention and pain and we will certainly talk a little bit more about CRPS, it stands for complex regional pain syndrome, which was in the past known as RSD, or reflex sympathetic dystrophy. Some of these from my viewpoint from a legal perspective and a medical perspective. Here are some of the things that we'll talk about and during question and answer. I certainly encourage all of you to ask me any questions that you have as we proceed further to this presentation.

Under WorkComp, like I said, the three primary components of medical-legal work that I do are the personal injury, medical malpractice, and brokerage compensation. And workers compensation there is in the State of Arizona, which is where I practice. It's the same thing where folks who are at work falling from ladders, slipping and falling on the curb, stepping on something that goes to the shoe. The slips, trips, and falls can result in sprains and strains of the various joints and ligaments and tendons in the foot and the ankle. They can result in fracture of the foot and the ankle. So these are some of the things that are included in brokerage compensation and the appropriate treatment protocols for it. So moving right along under since I'm the expert and I actually do plaintiff and defendant work.

And so, as an expert, when I get a case, I review the case and I frankly give you a candid opinion in regards to what the pros and cons of the case are. And then I leave it up to the specialist, which is you folks, to decide how you want to take it. So how I prepare the expectations that you should have from an expert or presentation. Speaking for myself as the expert, I should be able to articulate my viewpoint as clearly to you, to the opposing attorney, to the jury, etc., to the judge, etc. So presentation. And presentation will come across as succinct, will come across as concise, will come across as something in simple terms where non-medical person can understand my viewpoint where I'm the advocate for the site that I'm representing only happens if I'm prepared.

And preparation is an extremely important part of what we offer to our folks. I take a lot of pride in reviewing my records in quite a fair amount of detail and the best compliment that I've ever gotten from an opposing attorney is, "I'm not used to experts like yourself who are so prepared for deposition." So preparation is key. I request that you folks provide us the records. And this is fair amount of communication so that I have a clear appreciation of what the case involves. And responsiveness. Prompt responsiveness is extremely important so all deadlines are met. In experience, I've been doing this for approximately 20 years.

Now I'm board certified. I published a textbook. I lecture. I teach residents, students, practicing physicians and surgeons all over the country, all over the world. It's a covet affair, not just of didactic, what's published in the textbook, but also the real world. Being a physician myself, being the surgeon myself, the challenges that I face when I treat these patients so I can humbly appreciate both sides of the perspective and hopefully you offer a rational and reasonable opinion on these cases. So it really to me the key is offering a candid, well-thought-out opinion as an expert that's based on published evidence, that's based on my own personal experience, and that's based on standard of care.

So these are all the thought processes. This is really a process that goes into coming up with the plan that I like to articulate to you. There's a lot from the adjuster, the insurance company, etc., a bit whether I'm on the plaintiff side or the defendant side. So what do we do as an organization? We really like to believe that we offer all services, the medical-legal community in regards to charge reviews for all the out of state referrals that come in. We certainly do IMEs in Arizona and for our WorkComp request and for personal injury, fair amount of experience in depositions and trial testimonies in state, out of state, and at the federal levels.

So hopefully over these years with a fair amount of gray hair on my head and a lot of wrinkles on my face and, of course, just scars of having done this for a long time, I think we hopefully bring a well-thought-out plan to all of you to give you an opinion of what we think of these cases. So before we go on to some two particular cases that seem to make it to my table more often than not and certainly going through some clinical scenarios and tying everything together, I just want to open up the floor to some questions that you might have anybody in the audience before we take it to the next part of this presentation. Rochelle, the floor is yours.

Rochelle: Hi, Dr. Nakra, we were still actually on slide eight. So a lot of the attendees did not see the slides that you were speaking about.

Dr. Nakra: Okay.

Rochelle: Okay.

Dr. Nakra: Can you see them now?

Rochelle: No, you have to control the slides.

Dr. Nakra: Okay.

Rochelle: But it's okay. We can do some questions now.

Dr. Nakra: Okay.

Rochelle: If all the attendees can enter in the passcode for today, the past code is "foot." And first question, "Do you prefer to receive cases in electronic or paper format?"

Dr. Nakra: So our preference is actually whatever is easiest for you folks. We are technologically quite up to date. So depending on the enormity of the record, if your preference is to put them in Dropbox and send it to us, that's not a problem at all. If you much rather send it to us in a flash drive, you just send us a flash drive. I will do it on our end or paper chart. Whatever is easier for you folks. We have an internal process in place that we utilize. So whatever is easier for you folks, we can make that work.

Rochelle: "Do you handle product liability cases regarding surgical products or devices that are involved in foot and ankle surgery?"

Dr. Nakra: Yes, we do. And I think I might have actually mentioned that at the start. Yes. As you're aware, there are so many in foot and ankle surgery is focusing on my area of specialty, there's so many different kinds of bone grafts, plates, screws, etc. And so we do product liability cases where if there's reports of multiple failures, etc., then we go and review all the white papers, etc., and tell them what potentially could have happened in the manufacturers, etc. And why this implant, for example, failed on multiple locations. Yes, we do work with different kinds of companies who are making these products and give them feedback regarding what things they should be mindful of in regards to foot and ankle products taking into account the biomechanics of the foot and the ankle taking into account physiology, anatomy, etc. So, yes, we do offer that service also.

Rochelle: "Are you familiar with impairment guidelines and calculation?"

Dr. Nakra: Yes, we are. So impairment guidelines are...as for most of you in the audience, we're probably aware of it. Impairment guidelines are commonly utilized that I'm doing a bit personal injury or work on cases. So we stay up to date with that. The IME guidelines, sixth edition is what we use and to calculate the impairment and supportive care ward, etc. So we are able to provide those services also. And we're either doing chalk reviews or doing a face to face IMEs, etc. So, yes, we are able to offer that in addition to the ODG guidelines, etc. So we keep up with all of that and can provide you input in regards to these things.

Rochelle: Next question, "With a fracture calcaneal, how often is a subtalar often with BC is necessary? And what does that do for the function?"

Dr. Nakra: Excellent. I do have some clinical cases. So I think let's talk about this because I don't have this clinical case. So this is a very good question actually. It was just recently, I was invited to a national work on lecture just a few weeks ago. And this was one of my cases that I presented was far from heights that's commonly something I see more often in Work Comp cases or fall from height can result in a calcaneal fracture. The calcaneal is the medical term for the heel bone and a fall from a height can lead to a joint depression or a compression fracture of the calcaneus. So a little anatomy 101 for all of you, calcaneus is...so if you were standing that heel bone is the calcaneus.

So in a calcaneal fracture, depending on the severity of the fracture, it more often than not will involve the joint and the joint that's involved is known as the subtalar joint. Hence, there is an associated concern of what's known as post-traumatic arthritis of the subtalar joint because the calcaneal fracture will commonly involve the subtalar joint. So depending on the severity of the fracture, we worry about post-traumatic arthritis. In the event that the post-traumatic arthritis is symptomatic for the patient or the claimant, then the recommended treatment at that time, depending on how severe varies from either fusing the joint where you essentially put screws across the joint and take away that motion. Because it's that micromotion in the joint that is arthritic, which has lost its cartilage that causes pain.

So by fusing the joint to take that micromotion away and helps alleviate the discomfort that the claimant or the patient complains about. But by fusing the joint, certainly, it comes with its own consequences that you take micro motion to joint so the surrounding joint have to compensate and then are utilized much more. So yes, joint fusion is a surgical procedure that would be recommended for post-traumatic arthritis off the subtalar joint after a calcaneal fracture depending on how severe, A, the calcaneal fracture was, B, the quality of the repair that was done. Number three, all the associated injuries associated with the calcaneal fracture, etc. So all these factors go into deciding if the patient or the claimant or the defendant or the plaintiff would be an appropriate candidate for subsequent surgeries to manage the sequela of a calcaneal fracture.

Rochelle: Thanks so much. You can continue with the presentation.

Dr. Nakra: Excellent. Thank you. And so please let me know if I'm...so that I can make sure everybody can see those slides.

Rochelle: Yeah. I'll let you...

Dr. Nakra: Perfect. Yeah, Rochelle, feel free to interrupt me. I get interrupted all day in the office and no worries at all.

Rochelle: That's fine. Thank you.

Dr. Nakra: I just want to make sure these attendees get everything that they've given up an hour of their schedule. So I want to make sure that they get everything that they would like. So case presentation. So once again, since most of you folks could not see the previous slides, we're going to primarily focus on Med Mal personal injury and workers compensation. And there's a fair amount of overlap in these cases. All our cases, as I previously stated, involve foot and the ankle. And MedMal involves essentially be it that the appropriate care wasn't rendered or more aggressive care was rendered. Being a physician myself, I battle with this day in day out. We as physicians always vary because just because the patient didn't like the color of my hair, these things become an issue.

So I think the key thing that I always tell my residents and my students is I think patient communication is extremely important. And I'm as guilty of it as anybody else. Sometimes we are rushed. Sometimes there's so many other things going on. But I think at the end of the day, if we can all kind of communicate with our patients, sit down and answer their questions. And I think that goes a long way. And frankly, these are all viewpoints that I've learned as I've gone through my own personal growth as a physician and surgeon. We talked about personal injury and workers' compensation. Like I said, fair amount of overlap the injuries that are involved personal injury, workers' compensation, more overlap. The example that was the case that I was just asked, calcaneal fracture. I routinely see that in Work Comp cases in regards to fall from heights, etc. So let's start with some of these cases.

As I previously stated, one of the most important things that I see in regards to a request for an opinion of either from an insurance company, from a lawyer, be it MedMal or Infocomm case that's not healing up and because there's underlying diabetes, etc., and the reason diabetes gets so much attention is just because the consequences truly can be drastic, the consequences truly can be as severe as it gets. So I'm just going to take you through this process how a very simple cut or a wound on a diabetic have such severe consequences. So for all the patients, approximately, one out of four patients of diabetics that I see in a day will end up with DFU stands for diabetic foot ulcer. So that's a pretty high percentage that we worry about. And the reason that's important is that we want to get these ulcers healed. That's reason so much emphasis is placed on healing of the diabetic ulcer, management of the diabetic ulcer.

Once again, DFU stands for diabetic foot ulcer is just because not only because of the personal consequences on the patient, but for consequences on the employer because the patient or their employee is out of work or that ankle fracture is not healing because they have diabetes or that diabetic ulcer is getting infected, all these reasons are these reasons diabetes gets so much attention in the media, in medical offices, in the corporations is that 50% of these diabetic foot ulcers will get infected. So one out of every two ulcers that I see, these are published statistics that I'm sharing with you, one out of two of these diabetic ulcers will get infected. So this is a pyramid and think of the pyramid upside down or think of the domino effect, that things will just continue to go downhill very rapidly in a diabetic patient if they are not very aggressively treated.

Just recently, I was the expert in a case on the East Coast, which involves a diabetic foot ulcer that, unfortunately, just wasn't treated as aggressively as we would have hoped with a subsequent patient ending up with a below-knee amputation. And it all started with a diabetic foot ulcer that persisted and that diabetic foot ulcer ended up getting infected. And if the diabetic foot ulcer gets infected and DFI stands for diabetic foot infection. So 15% to 25% of diabetic patients will end up with an ulcer, 50% of these ulcers will get infected and out of these ulcers that get infected and end up with a diabetic foot infection anywhere from 20% to 60% of these infections and end up with OM, stands for osteomyelitis or infection of the bone. So hopefully as I continue to build this pyramid, I want you to appreciate how we're just going down a very slippery slope. We've gone from an open wound, which is an ulcer to an infection.

We've gone from a skin infection to an underlying bone infection, which is what osteomyelitis is, and this is the most important point. Diabetic foot ulcers are precursors to 85% of leg amputation. So just imagine the immense amount of mortality associated with this wound on the foot and the ankle which diabetics are predisposed to could end up with a leg amputation. And that's reason in the medical-legal world, be it personal injury, be it MedMal, be it workers' compensation, there's a fair amount of emphasis and legality associated with diabetes just because of the consequences associated with this. And there's a 50% incidence of contralateral amputation within 2 to 5 years. And the reason that happens is because of the increased cardiac load, the increased stress placed on the heart and the remaining organs in the rest of the body because of an amputation that happens enhance the much higher 50% incidence of contralateral amputation within 2 to 5 years.

So hopefully all of you can appreciate why I'm spending so much time on this slide. And as we continue on this pyramid, there's a 3 to 4-year survival rate after amputation is 50% and 40% with the cardiovascular disease being the major cause of death. So once again, start with a patient who's got diabetes. They end up with a wound because they had a broken ankle or they'll screen their ankles, or the surgeon did surgery on the ulcer. These diabetic patients have a much higher propensity for these dropping diabetic foot ulcers. These ulcers can get infected. This skin infection can lead to a bone infection, bone infection can lead to an amputation. If you have an amputation on one side, 50% incidence of amputation on the other side.

Once you've had an amputation, the increased mortality because of the increased load placed on the rest of the organs, primarily cardiovascular, primarily your heart. So this is truly is very consequential and hence there's a lot of things when I'm reviewing these cases where I'm looking at various things. So when they're reviewing these cases, what I'm essentially looking for is how was this appropriately managed by the treating physicians? Was the appropriate consults taken into account? And I apologize folks, Rochelle is not letting me advance the slide bouncing. Should I be doing something else?

Rochelle: Oh, no, you could just advance them once you're done with each slide.

Dr. Nakra: Okay. Perfect. Let's just go to this. Perfect. I can just spend enough time on that. So definitely I call this navigating the diabetic foot ulcer. Why is it so important? The ulcer is a precursor to an infection. Cellulitis refers to the soft tissue infection. Osteomyelitis refers to the bone infection. The key is to heal that ulcer up as soon as possible. Because the longer that ulcer persist as I showed you in that previous slide, the longer that ulcer persists, it's going to get infected. If it gets infected, you have to worry about a bone infection. Once you get a bone infection, you have to worry about amputation.

So you want to get this ultra-healed as quickly as possible. So in the event you are going to have some loss of tissue you want to minimize that loss of tissue. So your level of amputation should be as difficult as possible so that the load that's placed on the remaining body organs is as minimal as possible. So I just I want to make that point that this clinical picture that I'm showing to you is a transmetatarsal amputation. And so we want to make sure that we're minimizing the level of amputation.

And when I'm reviewing these cases, the things that I look for is the consults that were done. The vascular consult was the appropriate specialist consulted. Diabetes is a multi-specialty disease process. So you really want to make sure that all the associated organs or systems in the body that are involved are appropriately navigated through. So you want to make sure that their blood supply is checked. Do they have what's known as diabetic neuropathy where their nerves are potentially damaged? Do they have what's known as a Charcot foot, which is the joint in the body have collapsed leading to body prominence?

All these things have to be looked at. What X-ray is done? If the patient was taken to surgery, what appropriate culture is done? Were appropriate protocols followed for doing cultures? Were the appropriate antibiotics placed...was the patient placed on appropriate antibiotics? Was appropriate blood-work done on these patients?

That's reason these cases are quite popular comprehensive and involves a fair amount of time. And myself as an expert by keeping up with all the evidence that's published out there, I can offer you an opinion that if all the appropriate standard of care, if all the appropriate evidence based medicine, if all those protocols were followed in treating the diabetic foot ulcer, there are published guidelines by American Diabetes Association regarding patients who should be tested for what's known as vascular disease because diabetic patients have compromised blood supply to their legs. If you don't have enough blood supply coming down to the leg and the patient has a wound that ulcer will take a much longer time to heal and based on our previous conversation, we know that the longer time ulcer takes to heal the greater likelihood it will get infected.

So we want to make sure that an appropriate vascular consult was done or appropriate vascular evaluation of workup was done. And talking about vascular evaluation, we want to make sure that the appropriate tests were ordered. And this is something I constantly spend a fair amount of time teaching my residents that when...not only should you be ordering these tests but you have to know the pros and cons of each one of these tests. So in a diabetic foot ulcer, you are testing for what's known as the macro versus micro. Until today, I'm baffled by how little VS physicians who are the front line for treating the diabetic foot ulcer know so little about this.

So when I'm teaching my residents, my students in lecture hall, that's one point I always make about, is the vascular workup that you have to do. So know which tests to order, know the limitations of each one of these tests, the tests that you're ordering, and certainly appreciate the pros and the cons and what the test doesn't know. So if you should know that if this test gives me, for example, what's known as ankle-brachial indices that tells me the amount of blood supply and the amount of compromise, know what the limitations of each one of these tests is regarding some of the diagnostic tests that they order MRI, CT bone scans, and this might be a good time for us to talk a little bit about this. Bone scan is one of the very commonly over utilized tests in medicine.

So for example, after I'm done with this talk, I get up and I start seeing patients and I bang my ankle against the door. It's a certain likelihood that bone scan will show up what's known as positive. And routinely you will get counsel from the hospital saying bone scan is positive. So the patient has underlying bone infection. And that's just not true. So once again, knowing which tests to order, I as a specialist have to be able to read my MRIs, bone scans, CT scans, X-rays. I do not rely on the radiologist. So anytime I'm rendering an opinion in my office as the treating physician or I am an expert in either a personal injury, MedMal, Work Comp case, one of the things that I say is just not negotiable with me being the expert is I want to look at the CDs of the tests that were done. I want to look at those MRI films myself. I want to look at the images I read it myself.

To give you an example, I recently reviewed a case in which the patient had, and I think I just shared this video, patient underwent a pedicure at a local nail salon ended up with a wound on the bottom of their foot, ended up in the hospital. Did an MRI. MRI got red as osteomyelitis bone infection. And I'm left scratching my head, this just doesn't make sense to a certain extent. I'm playing Nancy Drew. I love reading Nancy Drew in my younger days. So my job and my goal is to gather as much information as possible and then reviewing it with my strong of fundamentals and knowledge base and offering that opinion.

So I will strongly recommend that please get me the CDs of all the studies that were done and I will review them myself. So this particular case I had a hard time believing that ulcer progressed to infection in the bone and the patient ended up with an amputation. So I requested the MRI film. And I strongly disagreed with the read done by the radiologist. And I said, "This is not osteomyelitis. The patient does have bony pathology but it's not osteomyelitis." So the patient did not have a bone infection. The patient should not have had an amputation. And now the patient is walking with no foot at the end of their leg. So you can understand why for me as an expert this is just not negotiable. I absolutely want to look at the study and give you an opinion. So not only does it help me give you an opinion but it also helps me determine any pre-existing issues which becomes quite relevant in Work Comp cases, for example, or in personal injury cases and to a great extent also in MedMal.

So when I'm looking at X-rays and the patient tells me that I never had any issues with my foot and ankle prior to this ankle sprain and when I look at an X-ray and I spend amount of arthritis in that foot and ankle, well, that's something I would put in my notes and I will discuss with you with the opposing side be it the...or whoever's requested this opinion, be the nurse case manager, adjuster, insurance company, lawyer, etc. and tell you...patient may or may not have had an injury but I can tell you all these issues the claimant or the patient has these pre-existing issues. And then we take it from there and determine if there are...well, what role these pre-existing issues are playing? And I take that into account while offering an opinion and giving an overall view.

So the key is, even though the slide says navigating the diabetic foot ulcers, it's navigating the foot and ankle pathology. You want to take a look at the overall picture. Take all that information that's out there. And then I paint a picture and present to you in non-medical terms so you can take it to...so that you can essentially do what you folks have to do from a legal or case management, occupational viewpoint. And so the diagnostic studies to me is a very key part.

All the tests that are out there I would like to review them myself so I can attest to the accuracy of these tests. We have this protocol in the office, my practice is primarily second opinion and third opinions, where when I'm doing this before I offer an opinion and come up with a game plan for the patient, I will look at these films and if those aren't available I'll order a new one so I can actually look at the films. I will, depending on the circumstances, offer my opinion based on what's already been done and personally order more tests so that I have the ability to review those films myself and come up with a game plan out for these patients or in these cases.

Moving right along, let's commonly talk about a very commonly utilized surgery that we do in my profession which is bunions. Bunions is the bony prominence that you see in your feet. So if all of you who are sitting down at your desk look down on your feet. So you have the big toe which is in this towards in the center of the two big toes. And as you work your way outwards, you go to the fifth toe. So the bunion involves that big toe. So a fair amount of complications associated with this. Certainly, I'm not at all saying that every bunion has a complication. But when these things go bad just like in any surgeries, any specialties, when things go bad unfortunately things like the floodgates open. So common bunionectomy risk that we certainly educate our patients about.

I'm certainly not at all standing here or sitting here saying that all bunions end up with complications. No, all surgeries have associated risk factors. And we certainly, as a physician, as a surgeon, I try to educate my patients and determine who's an appropriate candidate so in the event that these complications do happen, which can truly happen in the best of hands, I can sincerely say these complications have happened to me. But I think the key is educating our patients. And when these complications happen, determining why these complications happen, providing the appropriate treatment and suddenly referring them out if you see this is outside your area of expertise.

But some of the complications that we see when they're doing these bunions surgeries is that you can get a recurrence of the deformity where the bunions comes back. And there could be multiple reasons for it. And that's what my job either as the expert or as a treating physician is. You can overcorrect the deformity and if you overcorrect the deformity, you end up with a worse deformity than hallux valgus, which is what a bunion deformity do.

You can end up with that slide, that clinical, that you're seeing which is the toe goes in the opposite direction. So these patients, of course, are then predisposed to that same phenomenon of post-traumatic arthritis we spoke about, or they complain of that they have difficulty walking, they're constantly falling, they have pains in the joint, they have difficulty wearing shoes. So various risks associated with bunionectomy surgery. As with any bone surgery we do, another associated risk is that the bone might not heal up in the right position. That's known as malunion, or it takes too much time to heal up, and that's known as a delayed union, or it just doesn't deal up, and that's known as non-union. And there are various reasons behind it. It can be anywhere from a technical compromise to pre-existing issues, to patient non-compliance, to, frankly, sometimes just bad things happen.

And so my job as an expert, my job as a treating physician is to make that determination. Why is this happening and what the appropriate treatment is? Other potential risks associated with bunion surgery that leads folks to knocking on doors of all the lawyers that are out there, is that they feel that they've lost motion or they have pain in that joint, and because of the Arthritis that has developed a bit in the joint or the surrounding bones, or because for various reasons you end up with what's known as avascular necrosis, that that bone just dies.

So all these issues that are addressed in front of you such as avascular necrosis, such as other associated deformity that develop, or the big toe shortened job, or it becomes floppy where the patient doesn't have control over the big toe, or they start getting pain under the big toe joint, and that's known as metatarsalgia that's listed in front of you or metatarsalgia pain in the ball of the foot. So all these are potential complications associated with bunion surgery which can lead to unhappy patients. And various and there could be for multiple reasons, and that's the reason for me as a trained physician I try my best to educate our patients as an expert when I review the chart.

That's the opinion I give to you why these things happened. If there was truly any malpractice involved or was this a patient issue, or, frankly, this is just something that an unfortunate incident happened. So the reasons for most common things that I see, and this applies not just to bunion surgery, this applies to pretty much all kinds of surgical procedures that we do in foot and ankle, that the reasons for recurrence and patients go, "Well, you have fixed my broken ankle and I feel I'm just not walking properly now." Or, "You fixed my bunion," or, "You fixed my flat foot," or, "You fixed my ankle ligaments," etc. "Why do I feel my deformity is back?" Or, "Why do I feel that I have a persistent or new issues?" And the things that I look for was the selection, the procedure choice, was that appropriate to begin with? Was there inadequate execution? Could I? And I clearly say this, I have my share of complications. I'm certainly not standing here and lecturing to anybody that I have no complication. I have my share. But suddenly, the key is you have to be critical of the work that you yourself do. And that's the reason I stand here, sit here and give this talk, is I've critically looked at my own results and made appropriate changes over the last 20 to 25 years that was there. Could I have been more aggressive in my procedure or should I have been more aggressive in my procedure? Did the patient play a role in this? Was the patient non-compliant? They walked on something when I told them, "Please don't walk on it." They got the foot and the ankle wet. They didn't take their antibiotics. They didn't get the blood work done. So what role did patient non-compliance play in an unhappy patient? Did I drop the ball on something? Did the treating physician fail to recognize something? Did the patient not disclose all the issues? So once again, it's kind of boils down to utilizing your expertise.

For us, physicians, surgeons, utilizing our expertise, keeping up with all the literature out there, going to conferences, lecturing at conferences, critically looking at your own results, publishing, etc., all this plays a big role because that widens your armamentarium that I rely on when I'm offering an opinion, either as an expert or as a treating physician. The last entity that I would like to talk about is complex regional pain syndrome. And until today I am actually working on a case right now. And so today I scratch my head because either this is completely messed or it's a commonly utilized diagnosis and nobody can figure out what's going on.

And there's some very strict criteria that I follow and this really has to be treated quite aggressively. And so to go through the slide, the most common etiology for complex regional pain syndrome, which previously was known as reflex sympathetic dystrophy is nerve injury from fractures and sprains. And 50% of CRPS, complex regional pain syndrome is secondary to a very simple injury that unfortunately just doesn't get the respect it deserves, which is ankle sprains. So I have horribly weak ankles and hence my specialty is foot and the ankle.

So I sprained my ankle so many times and...but just something that's commonly missed is an ankle sprain is just doesn't get the respect it deserves. Ankle sprains can have a...there's a percentage that does involve some nerve injury. You have to be very mindful of how we treat these patients because sometimes a simple diagnosis as an ankle sprain should be treated aggressively can end up in complex regional pain syndrome. And you know in today's day and age of Google, where I can't tell you how many times a patient walks into my office and go, "Well, I Googled this." And then my response is, "Well, what did Dr. Google tell you?" So I encourage patients taking a role in their care, but sometimes my biggest competition is Dr. Google.

And if you Google complex regional pain syndrome, it's what you read on the internet is really as bad as a cancer diagnosis. So these things, we have to be able to recognize these things and treat them very aggressively. Other things in my own practice, in foot and the ankles, and one of the more common etiologies besides fractures and sprains that I see as an etiology for complex regional pain syndrome is crush injury. So that fall from the height, which led to that heel fracture is a crush injury or a vendor case that I viewed a patient was a pedestrian didn't stop and a truck ran over the top of their foot. So that's a crush injury. So those are things I would look for, is there potential complex regional pain syndrome here? Surgery. Things that folks like myself do surgeons in the audience who might do surgery can potentially lead to complex regional pain syndrome.

So my consent talks about that. And the last slide, the last notation, 10% to 25% is a non-traumatic origin. Well, I can't explain to the lawyer, to the nurse case manager, to the insurance, to the patient why they developed complex regional pain syndrome. Our nervous system truly is like that motherboard in all our computers that we're watching this presentation on. It is you sometimes can't explain and that's reason I sometimes do find myself saying this to the patient that medicine is as much an art as it is a science. Sometimes in a year, I can't explain to you what happened. And that's the opinion I will render, that this is what's happened and this is how it should be treated. This is how it should be managed.

So suddenly, always on the lookout for complex regional pain syndrome because this takes an insignificant emotional toll on the patient and the family. The simple consequences associated with it. So in a typical allegations that I see in cases that go on to legal cases is as in...and this is my last slide and then I want to make sure that we have enough time to answer any questions, which is delay in diagnosis. When I'm reviewing kids, that's something I commonly look for, whatever kind of a case I'm doing. Was there a delay in diagnose? Should that infection have been picked up sooner than later? Was that phone call returned in time?

How sooner to the surgery did the surgeon see the patient in the office? Was the patient taking too many pain medications? Was the cast too tight? All these things are...when I put on that Nancy Drew hat and that cap and I'm trying to determine, looking for clues, that's what I'm looking for. Was there a failure to refer the station out to the appropriate specialist? So going back to the diabetic example that we use. That when I'm seeing a patient with diabetic ulcer, there has to be a vascular evaluation because of the high incidence of vascular disease.

When I see a patient with that calcaneal fracture that one of the attendees brought up, and the patient after surgery continues to complain of pain, should I be worried about underlying compartment syndrome that was missed earlier on because of the incidence of compartment syndrome with calcaneal fractures? What subluxing peroneal tendons missed at the initial time of diagnosis of calcaneal fracture? So having this breadth of knowledge which has come by keeping up with medical literature, by publishing my lecturing, etc., I know the things that I have to look for. So I know what are the things which I feel comfortable treating and if it's outside my area of specialty, where should I be referring these patients at? So I minimize the risk of failure to make a diagnosis because if we haven't made a diagnosis, they won't offer the appropriate treatment and there won't be appropriate referrals made. So on that note, I'll come to stop because I want to make sure everybody gets adequate time to ask any questions they have. Rochelle, the floor is yours.

Rochelle: Thanks, Doctor. All the attendees can enter the passcode for today which the passcode is "Foot." Our first question is, "The standard of care for continual fracture weight or non-weight bearing and for what length of time?"

Dr. Nakra: Well, that's a difficult question to answer without knowing more details, but I'll try to do the best so that you have a fair amount of...so I can give you some parameters that you can deal with. If the calcaneal fracture was surgically treated, yes, the patient should be made non-weight bearing. But then once again, there's a little caveat to this. If the patient had an external fixator placed on that foot, several surgeons including myself depending on more information such as what is the compliance of the patient? What is the weight of the patient? What's their support network? I will let them walk on that external fixator. So whether they're non-weight bearing or weight bearing, it depends a lot on the kind of a fracture it was from the social makeup of the patient, what kind of surgery that was rendered.

So those are the factors that play a role in determining whether this patient or claimant should be made non-weight bearing or should be allowed to bear weight after the surgery if surgery was undertaken. And if surgery wasn't undertaken, depending on what kind of a calcaneal fracture there is, there are various kinds of calcaneal fractures and that's truly that's one of my talks that I do, is management of calcaneal fractures and sequela. There are various kinds of calcaneal fracture. It could be a chip fracture, it could be an avulsion fracture. It could be an interior beat fracture. So without knowing more details on the kind of the calcaneal fractures, it's hard for me to offer you an exact answer. So it could range anywhere from partial weight bearing to non-weight bearing.

Rochelle: Next question, "How often do you see a diagnosis of CRPS secondary as a common trip and fall ankle fractures?"

Dr. Nakra: That's it. You know what? I wouldn't say I never see it because I do see it. I've reviewed a few cases on it. It's certainly a notch. I couldn't give you a number but I wouldn't say it's common and I wouldn't say it's uncommon. You're only going to look for it if you know that something you should be checking for. In an ankle sprains, one of the nerves that can be involved is the peroneal nerves. And if you have traction of the nerve, then you can end up with some nerve cryptology.

And then you can also end up with complex regional pain syndrome. So when I'm evaluating patients with ankle sprains, I am looking for complex regional pain syndrome so that I don't miss it. So I think that's a more accurate way of me answering that question, that you should evaluate forward to my note, hopefully, it says something to that regard that I looked for hair, skin color change. I'm thinking I'll have the patient come back and see me in a few weeks. I won't say come and see me in three months because I don't want to miss on some of these potentially very consequential diagnosis such as CRPS.

Rochelle: Next question, "Are these statistics regarding mortality after amputation true of all amputations or only after diabetes-related complications were the precursors to this eventual amputation?"

Dr. Nakra: Well, the statistics that I shared with you are...

Rochelle: Can I read this again?

Dr. Nakra: Please, yes, that's right. I actually had...please, Rochelle, go ahead.

Rochelle: "Are these statistics regarding mortality after amputation true to all amputation, or only after diabetes-related complications were the precursors to eventual amputation?"

Dr. Nakra: The statistics that I shared for you are only for the diabetic patients. And the reason why there's a much higher complication rate, morbidity and mortality rate is because of the overall metabolic process involved with diabetes. Diabetes to great extent is known as the silent killer. And that's the reason it has to be so aggressive. You have to be so aggressive in diagnosing it when any red flag goes up. And then when it's been diagnosed, it has to be very aggressively managed because the consequences are so disastrous because it involves so many organs. It involves your eyes, it involves your nerves, it involves your blood supply, it involves your heart, it involves your kidneys, it involves the skin. So there's so many organ systems involved. And that's reason it's from a legal standpoint, this is a hotly pursued entity diagnosis that comes with very high associated complication rate.

Rochelle: "What should be done to monitor for Charcot foot?"

Dr. Nakra: Excellent question. So I briefly mentioned Charcot foot. It's spelled as C-H-A-R-C-O-T for all the other attendees in the audience who might not know what that is. Charcot foot is essentially a neurological diagnosis. So all patients who've been diagnosed with Charcot foot don't have diabetes. But diabetics, because it is a medical diagnosis that comes with nerve dysfunction, can potentially lead to Charcot arthropathy. Charcot arthropathy in the foot and in the ankle, essentially what happens is your joints start to collapse.

So if all of you looked at your foot, most of you probably have an arch to your foot so that you're not walking on the inside of your foot, that instep region. In a Charcot foot, because the joints collapse rather than having a concave arch, you end up with a convex arch. So you're essentially walking on these bony prominences. So if you walk on a bony prominence, you're going to end up with an ulcer and we shared all the potentially bad things that can happen once that diabetic patient develops that ulcer. And also will go to an infection, infection will go to osteomyelitis, which is a bone infection, bone infection can lead to amputation, one amputation can lead to the contralateral amputation and then that amputation can potentially lead to death. So the key is you want to minimize any...first of all, minimize the risk of complications such as Charcot.

And if and then these complications happen, recognize them in a timely fashion and treat them aggressively. So, yes, I always worry about Charcot deformity in my patients who have diabetes, or who have any kind of neurological compromise, such as folks who are alcoholics, or prior history of alcoholics, or who have some kind of spinal cord issues, or who have some kind of neurological history such as the various diagnosis. So we look for Charcot arthropathy. Anybody who's got some kind of a neurological compromise because it puts the patient at a disadvantage in regards to potential complications such as observation, alteration in the way they walk, which leads to other issues. It's something we always want to look for not only in diabetics, but also in patients who've got some form of neurological compromise.

Rochelle: Our last question, "What percentage of your work is for plaintiff and what percentage is for defendant?"

Dr. Nakra: You know, I never done the numbers but I'm going to say I'm pretty close. I frankly look at the case. And I will offer an opinion based on the case whether if I'm going to be a strong advocate for you. If I feel I'm not going to be a strong advocate, I have a friend to tell you that. And if the merits of the case, if I feel like I can magnify the merits while having a rational, reasonable explanation for the weaknesses of the case, I give an opinion. So I really don't pick a case based on plaintiff versus defendant. I pick a case based on if I can be a strong, articulate advocate for the patient or for the plaintiff or the defendant.

Rochelle: Thank you so much. That's enough for us. In addition to being your best source for testifying and consulting experts for the past 60 years, TASA also offers e-Discovery and forensic solution, free interactive webinars, day-in-the-life videos, research reports on expert witnesses including the Challenge History Report 2.0 and Expert Profile 360. I want to take this opportunity to thank everyone for tuning and most especially Dr. Nakra for her time and effort in creating this presentation. If you would like to speak with Dr. Nakra or if you'd like to speak with a TASA representative regarding an expert witness for a case that you're currently working on, please contact us at 1-800-523-2319. One of my colleagues will be following up with you regarding your feedback on today's presentation. This concludes our program for today. Thank you all for attending.