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Had a patient show up with a large hypertrophic scar over the distal tarsal tunnel and porta pedis. She previously had an apparent fasciotomy(by her history) and probable tarsal tunnel release, but do not have other physicians' records. She then had a second procedure to try a scar revision and then went to another physician and had another scar revision with no improvement in which she claims that she was nonweightbearing for 6 weeks with PT referral for mobilization. Last physician injected site with steroid and that helped for 2 days. And then discharged her and said he could do nothing more to help her.

The scar is no classic keloid as it is noninvasive to the surrounding skin, but does have multiple nucleated keratotic spots. There is a dense fibrosis that extends essentially down to the calcaneus. It was very difficult to infiltrate any steroid into this fibrotic band.

I referred patient back to primary care physician for possible referral for possible flap coverage, but the likelihood of that happening approaches zero since she is a Medicaid patient.

Any words of wisdom or options? I am exceedingly reluctant to be the final blame holder in our litigious society, especially after 3 previous failures by competent physicians. If it had been try number 2, not 4, then I might have resected it and tried to place a Graftjacket under it to reduce adhesions. This worked nicely in a redo of a fasciectomy previously.

 

My advice is to validate what your intuition is telling you. You can even aggravate her symptoms so I would stand on the banks where it is safe from the high risk of being dragged into the quicksand. Its no fun going to the office seeing patients that you did surgery on that have complications. It is draining and distracts you from giving 100% to your other patients.

Steven

 

Rick:

My advice? Don't do surgery on her unless you really have a wish to be the name at the top of her list on the malpractice lawsuit that has an excellent probability of occurring.

As you do more and more surgery, you will eventually discover that you must pick and choose your surgery patients carefully if you also want to have a happier life with fewer complications. Maybe you can send the patient to a teaching hospital where there will be plenty of surgical residents anxious to take on a difficult pathology such as you describe.

Just because you do not do surgery on the patient, does not also mean that you cannot empathize with her unfortunate circumstance and try to refer her to someone who is willing and possibly better able to treat her surgically.