Seybold v. Neu

105 Wash. App. 666
Court of Appeals of Washington·Decided February 20, 2001·No. No. 45505-2-I·Published·Cited by 77 cases

Opinion

Kennedy, J.

To decide this appeal we must determine whether a reconstructive (plastic) surgeon practicing at the Scripps Clinic in California is competent to testify that (1) an orthopedic surgeon specializing in musculoskeletal oncology in Seattle overtreated a soft-tissue malignancy that had not invaded bone by removing approximately a third of the circumference of Charles Seybold’s right lower tibia bone during the surgical removal of the tumor; (2) the standard of care applicable to orthopedic surgeons specializing in musculoskeletal oncology and treating soft-tissue malignancies in Seattle in June of 1992 required knowledge of the existence of and consultation with experts in a technique of progressive pathologic examination of tissue before its removal to determine whether tumor invasion had occurred — to the end that healthy tissue would not be removed unnecessarily; (3) the unnecessary removal of healthy bone resulted in a greater than 51 percent probability that Mr. Seybold would ultimately suffer a pathological fracture of the weakened, weight-bearing tibia; (4) the use of cadaver bone as opposed to live bone from Mr. Seybold’s own body to graft the excised bone tissue, followed by radiation treatment, greatly increased the chances that Mr. Seybold would suffer a pathologic fracture of his lower right tibia, which he ultimately did; and (5) but for the inappropriate treatment, Mr. Seybold more likely than not would never have been placed in the position, four years later, of deciding on amputation of his right leg below the knee. Because the record reflects that both orthopedic surgeons and plastic surgeons routinely treat cutaneous malignancies growing next to bone that have not invaded [670] bone, the relevant specialty here is not orthopedic oncology; it is the surgical treatment of cutaneous malignancies. Thus, the trial court erred in striking the deposition of the California plastic surgeon on the basis of incompetency in the relevant medical specialty, and in dismissing the Seybolds’ complaint on summary judgment for lack of expert testimony to support the claims. We reverse and remand for trial or such other proceedings as shall be consistent with this opinion.

FACTS1

In April 1992, Charles Seybold went to Dr. Bruce Neu, a plastic surgeon, for an examination of a lump on his lower right tibia, commonly known as the shinbone. Dr. Neu performed an excisional biopsy of the lump and pathology reports subsequently revealed that it was a malignant soft-tissue sarcoma, specifically a myxoid malignant fibrous histiocytoma, located on the distal third of the tibia. This is a rare and life-threatening condition. Dr. Neu referred Mr. Seybold to Dr. Daniel Flugstad, an orthopedic surgeon specializing in musculoskeletal oncology. Dr. Flugstad practices in Seattle.

Dr. Flugstad evaluated Mr. Seybold by physical examination and magnetic resonance imaging (MRI). The MRI showed no margin between the tumor and the periosteum, which is the thin layer of tissue that covers the tibia bone. Dr. Flugstad recommended limb-sparing surgery followed by radiation therapy. He concluded that a wide local excision of the tumor, including resection of a portion of the tibia as a deep margin, and a wide excision of the skin, was needed to eradicate the tumor. This was to be followed by an allographic transplant to repair the resulting bone loss and a skin flap to repair the resulting skin loss.2

Dr. Flugstad subsequently testified in a deposition that [671] he discussed various risks associated with the surgery with Mr. Seybold, including the risk of local recurrence of the tumor, the risk of neurovascular injury, the risk of pathologic fracture of the tibia, the risk of nonunion of the bone in the event of fracture, and the risk of eventual below-knee amputation of the right leg. But he did not discuss these risks in terms of probabilities or percentages because Mr. Seybold did not ask him those questions. Dr. Flugstad further testified that if Mr. Seybold had “cornered” him he would have stated that the risk of either a pathological fracture or a nonunion of the bone was “somewhere less than 50 percent, but I can’t narrow myself down anymore than that.” Clerk’s Papers at 46. If he had been asked about the risk of eventual amputation, Dr. Flugstad testified that he would have responded that the risk was about 10 percent. There was no discussion of the risks of taking bone versus not taking bone when the cancer is cutaneous only, and no discussion of any alternatives to taking bone to ensure eradication of the tumor.

The surgery proceeded as planned on June 17, 1992. Dr. Flugstad cut out about a third of the circumference of Mr. Seybold’s lower right tibia, creating a deep, bony margin. Fresh frozen cadaver bone was fashioned to fit the area from which bone had been removed, and then was screwed into place. A compression plate was also bent and twisted into an appropriate shape and screwed into place. A plastic surgeon then took over and performed the skin grafting to cover the wound. Radiation treatment followed.

Two years later, Mr. Seybold suffered a pathological fracture of his right tibia, which subsequently led to a painful nonunion that failed to heal. In June 1996, after considering limb-sparing options that would take considerable time to heal and were not guaranteed to produce a functional leg, Mr. Seybold elected to undergo a below-knee amputation. Dr. Flugstad performed the amputation on June 26, 1996. Mr. Seybold was then 34 years of age.

The Seybolds subsequently brought this lawsuit, alleging medical negligence and failure to obtain informed consent [672] to the initial treatment, proximately causing the amputation of Mr. Seybold’s lower right leg and physical, economic and marital consortium damages. In August 1999, Dr. Flugstad moved for summary judgment dismissing the Seybolds’ claims on the basis that they lacked the requisite testimony of a qualified medical expert to support the claims.

The Seybolds responded to the motion by presenting the deposition testimony of Dr. Gerald L. Schneider, a reconstructive (plastic) surgeon from the Scripps Clinic at La Jolla, California. Dr. Schneider testified that as a board-certified plastic surgeon he is an expert in the surgical removal of cutaneous malignancies such as that which Mr. Seybold had. He was recruited by the Scripps Clinic to do cutaneous cancer reconstruction, although he also performs cosmetic surgeries for aesthetic reasons. His previous experience includes a large amount of trauma surgery, with respect to which missing bones or bones that do not heal are frequently referred to plastic surgeons for repair. Accordingly, Dr. Schneider testified that he is also an expert in bone grafting. Although he is not an expert in orthopedic surgery as compared to reconstructive surgery, he has assisted orthopedic surgeons during surgery, has been trained in bone fixation, and could fill in for an orthopedic surgeon for that purpose, if no orthopedic surgeon were available. He has testified in court as an expert witness in a case involving lower limb reconstruction in which the patient died. He has presented lectures to other physicians on various subjects, including cutaneous malignancies, and has twice published written materials on reconstructive surgery, including one article written in conjunction with an expert on Mohs surgery, a technique that Dr. Schneider opined should have been utilized in Mr. Seybold’s case.

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Seybold v. Neu, 105 Wash. App. 666 (Wash. Ct. App. 2001).

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