13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
14. Mrs A had a traumatic dislocation of her left thumb. She was booked in for surgery to attempt fix the dislocation. Mrs A complains about the surgery she had at the Trust on 25 September 2023. She says it inappropriately left the tightrope in her hand which caused further pain and a tingling sensation.
15. It is first helpful to explain what type of injury Mrs A had. Our adviser explained Mrs A had a traumatic isolated subluxation of the basal joint (a partial dislocation and separation of the thumb joint). They said this type of dislocation is a rare and difficult injury to treat.
16. Our adviser confirmed a recommended and suitable treatment option to fix this type of injury is to use a mini tightrope to try and stabilise the joint. The Arthrex tightrope guidelines explains this surgical technique. It says the mini tightrope supports and maintains the thumb whilst allowing healing and scar tissue to form. Importantly, it recommends keeping the device in unless it needs to be removed.
17. The records show Trust staff decided to keep the tightrope in Mrs A’s thumb following her initial surgery on 25 September. Our adviser confirmed this was an appropriate clinical decision and in line with the above guidelines. They confirmed the tightrope needs to stay in place to hold the bones together for at least several number months to allow the damaged ligaments to stabilise. Our adviser could not see any indications from the surgical notes the procedure was carried out incorrectly.
18. Section 15(b) of the GMC guidance says a clinician must promptly provide or arrange suitable advice, investigations or treatment where necessary. In this case, it appears Trust staff carried out ‘suitable treatment’ when it decided to keep Mrs A’s tightrope in place following this surgical procedure. We can see from our adviser’s comments, and the Artex tightrope guidelines this is the recommended surgical technique for this type of injury. On this basis, we did not identify any indications of failings for this part of the complaint.
19. Mrs A also complains on 16 January, she had surgery to remove the tightrope in her thumb. Following this, her thumb became ‘rigid’ and ‘barely flexible’. We are very sorry to hear this. It must be very upsetting and frustrating for Mrs A to struggle with her mobility in her left hand. We appreciate this has had a huge impact on her quality of life and we do not wish to underestimate how much distress this has caused her.
20. Our adviser said given the complexity of Mrs A’s type of injury, the tightrope surgical procedure does not have a guaranteed 100% success rate. It is possible for the tightrope to fail, and it is a known and common risk for the patient to experience stiffness after surgery. This is in line with the BSSH information guide. It says if the ligaments do not heal satisfactorily, ‘there is a risk the joint will become unstable and can cause loss of function’. The medical records indicate this is what happened in this case.
21. Section 10 of the GMC decision making standards say a clinician must give the patients information they want or need to make a decision about their treatment. Section 10(e) says clinicians should discuss the potential benefits, risks of harm, uncertainties about the likelihood of success for each option, including the option to take no action. Section 54 says a consent form can be a helpful prompt to share key information and to record decisions.
22. With this in mind, we would have expected Trust staff to have made Mrs A aware of the risks the surgery may naturally fail, and that loss of function and stiffness were a common risk of both surgeries.
23. The records show the Trust completed the consent form with Mrs A on 25 September. This consent form confirms the proposed treatment including tightrope procedure. It shows the Trust discussed the risks and complications of the proposed treatment, which includes stiffness, recurrent instability and damage to nerves, vessels and tendons. Mrs A consented to the procedure.
24. On the 2 November 2023, the Trust saw Mrs A in the clinic and discussed her surgery. It explained sadly the first surgery had not worked and the tightrope was no longer allowing her thumb to flex and abduct. It said it needed to remove the tightrope to allow her muscles to work.
25. The records show Trust staff discussed the risks of this surgery during this appointment. It documented the risks as failure to improve thumb function, and thumb base instability. On 16 January 2024, the consent form was completed with Mrs A ahead of her surgery which she signed. This form notes Trust staff discussed the risks of failure to improve thumb function and lasting instability.
26. Taking all this into account, we can see there is a known risk of the tightrope procedure failing due to the complexity of this type of injury. It is also a known risk the patient can experience stiffness and loss of thumb function. We are pleased to see Trust staff correctly made Mrs A aware of these known risks before each procedure in line with the relevant guidelines. We do not see any indications of failings here.
27. Sadly, Mrs A’s first and surgery were not successful in restoring her thumb function. Our adviser reviewed her surgical notes and confirmed each procedure was carried out appropriately and there does not appear to have been any complications during surgery which led to this being unsuccessful. We hope to reassure her the Trust’s care appears to be in line with GMC Good Medical Practice. It appears it arranged ‘suitable treatment’ for her injuries.
28. In summary, we have not found evidence of something going wrong with the Trust’s treatment of Mrs A’s dislocated thumb. We are sorry Mrs A’s surgeries did not improve the function in her hand. We have seen evidence Mrs A’s injury was complex, and there were known risks and complications to this surgery. We would like to take this opportunity to thank her for bringing this complaint to us. We are grateful for her time and effort.