Fasciotomy
15. 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 we consider the surgeon acted appropriately when carrying out the fasciotomy to Mr P’s left little finger.
16. Mr P tells us that his Dupuytren’s disease affecting his left little finger was too severe to be treated with a fasciotomy surgery. He states the Consultant Physiotherapist should not have recommended the fasciotomy and the surgeon should not have carried out the surgery. Mr P states he did not have good correction following the surgery and that if he had been treated with a fasciectomy in the first instance an additional surgery could have been avoided.
17. The Trust said it had no concerns that the fasciotomy was the correct procedure. It also noted that Mr P signed a consent form which documented the risks of incomplete correction or recurrence. It concluded that following the procedure, Mr P’s finger was straight with good correction.
18. Our adviser referred us to several infographics from the BSSH. One of these, called ‘Choosing the treatment for you’, documents that a fasciotomy has a quicker recovery and lower chance of permanent regrettable complications. However, it states it has quicker onset of recurrence and poorer initial contracture correction with advance cases but can still improve quality of life. The infographic compares this to a fasciectomy which has a longer recovery, higher chance of permanent regrettable complications but slower onset of recurrence and better initial contracture correction with advanced cases.
19. Our adviser explained that a fasciotomy is a well-recognised and frequently used treatment for Dupuytren’s disease, particularly in patients such as Mr P, who had a history of poor recovery from more invasive surgery. They said it is particularly effective with metacarpophalangeal joint (MCP) contractures (where a joint cannot move through its full range of motion) and simple ‘precentral Dupuytren’s cords’ (single tight band at the base of the finger), which is what Mr P had. They added that a fasciotomy can often be considered as a first step before considering more invasive surgery in a patient consenting to its risks, as Mr P did, and that it does not prevent further surgery if needed.
20. Our adviser explained that fasciotomy is not so effective with proximal interphalangeal joint (PIP) contractures, but these were not documented to be present in Mr P’s left little finger at his consultations between 2020 and 2024.
21. Our adviser confirmed that Mr P’s operation notes say a correction was made from 80 degrees flexion to -5 degrees. They explained that this is a good result on the operating table. However, it is noted that Mr P did not feel like he had good correction after the surgery, so we acknowledge that there is a difference of opinion here.
22. Given that Mr P has MCP contractures and no PIP contractures, we consider that a fasciotomy was an appropriate treatment for his Dupuytren’s disease in his left little finger, as outlined in the Infographics. This coupled with his poor recovery following surgery on his right ring finger means the fasciotomy was an appropriate first step before considering a more invasive surgery. It is, of course, unfortunate that he did not get the result he wanted and required further surgery. Regrettably, that was always a possibility with this procedure, and one that he consented to. It does not mean it was wrong to start with it, however.
23. We recognise that there is a difference of opinion between the Trust and Mr P regarding the correction of his left little finger following surgery. Our decision is based on whether a fasciotomy was appropriate given Mr P’s clinical presentation before surgery and not the result of the surgery.
24. We recognise that having multiple surgeries has been extremely distressing for Mr P. We hope that he finds our explanation for our decision helpful and offers him some reassurance.
Records
25. We have reviewed Mr P’s medical records. They do not show that he requested the fasciotomy surgery, just that he was happy to go ahead with it. They do, however, show that the surgeon felt there was a good degree of correction following surgery.
26. Mr P says the Consultant Physiotherapist told him he requested the fasciotomy surgery. Mr P states he believes from this conversation that his medical notes contained this information, which he says is untrue.
27. The medical notes from Mr P’s appointment with the Consultant Physiotherapist state Mr P is happy to go ahead and get the surgery done. They do not say or indicate that Mr P requested the surgery. We are satisfied that Mr P was happy to go ahead with the procedure as he consented to and underwent it. We do not, therefore, consider that there is a substantive complaint here and have decided not to consider it further.
28. Turning to the note about correction, the only evidence to say how well the contracture was corrected is the operation note and Mr P’s opinion, which directly conflict. However, we can see that by the time of his follow-up appointment, he was not happy with it and so the surgeon recommended splinting to try and help. We also know that by the time of his private appointment the contracture was 45 degrees, which is better than it was before the fasciotomy but worse than what the surgeon recorded in theatre. It is entirely possible that the contracture worsened over time, as, unfortunately, was always the risk with this procedure.
29. All this means that we cannot say, even on the balance of probability, whether or not there was a ‘good’ degree of correction and so we have decided not to consider this matter further.
30. We are sorry to hear of the distress Mr P has been caused regarding his medical notes. We hope our review of his notes offers him some reassurance and helps him understand why we cannot progress this to a detailed investigation. Mr P could consider obtaining his medical records himself and placing an addendum on them if there is anything he disagrees with.