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AAOS Now

Published 9/1/2009

AAOS Board takes professional compliance actions - Dr. Arangio

George A. Arangio, MD

Fogelsville, Pa.

Censure

The grievance against Dr. Arangio was filed on Jan. 16, 2008, alleging violations of Mandatory Standards Nos. 1, 2, and 3 of the AAOS Standards of Professionalism (SOPs) on Orthopaedic Expert Witness Testimony. The grievance arose from statements made by Dr. Arangio in a written medical record review and during his courtroom testimony as an expert witness for the defense in a medical liability case alleging that the defendant-orthopaedic surgeon failed to properly diagnose an Essex-Lopresti (E-L) injury to the right forearm, which resulted in the need for additional corrective surgery. The jury trial returned a verdict in favor of the defendant-orthopaedist.

In his report, Dr. Arangio stated that the defendant-orthopaedist correctly diagnosed the injury and performed appropriate radial head resection and removal of loose bodies. He further stated that literature would support no difference in outcome between primary and delayed radial head excision and that excision of the radial head following a displaced radial head or neck fracture often leads to a good or fair result. He opined that there is no evidence of obtaining better results from radial head replacement with a prosthesis or open reduction internal fixation (ORIF) than from radial head excision. Dr. Arangio declared that results are more correlated to the severity of the injury.

Dr. Arangio testified in court that he did not think that the patient had sustained an E-L injury at the time of the fall. He also testified that the E-L injury is a lesion and not a spectrum of injuries. “You either have it or you don’t have it…You x-ray the elbow. You x-ray the wrist. If it’s there, it’s there. If it isn’t, it isn’t.” He opined that a nondisplaced fracture of the radial head is not consistent with an E-L lesion; the radial head has to be comminuted and displaced. Additionally, he reported that the E-L injury was not present at surgery because other studies of the wrist did not show distal radioulnar joint subluxation or dislocation.

Dr. Arangio further testified that when, during surgery, the radial head was found to be comminuted with loose bodies in the joint, resection of the radial head remained within the standard of care because the findings did not warrant placement of a radial head implant. He declared that no objective evidence existed showing that the radius migrated after the surgery performed by the defendant-orthopaedist but that the radius had migrated after a subsequent surgery. Dr. Arangio also stated that silastic radial head implants had been removed from the market at the time of the surgery (1998) and that titanium implants had not yet undergone long-term study.

On Oct. 25, 2008, the Committee on Professionalism (COP) Hearing Panel conducted a grievance hearing attended by Dr. Arangio, his legal counsel, and the Grievant. Dr. Arangio was questioned by the panel about his testimony, which he said had been inaccurately portrayed.

During the hearing, Dr. Arangio continued to express his opinion that E-L has no variants and that there was no evidence of an E-L injury while the plaintiff was under the care of the defendant-orthopaedist. He further stated his belief that significant longitudinal instability of the forearm will not develop unless the distal radioulnar joint is dislocated and the radial head is fractured. The hearing panel, however, believed that a fracture of the radial head, combined with a lunate dislocation of the ipsilateral wrist and magnetic resonance imaging (MRI) evidence of an injury to the distal radioulnar joint, should lead one to consider the existence of an E-L lesion.

When questioned by the panel, Dr. Arangio reported that although he testified that no migration of the radial head occurred prior to or following the excision surgery performed by the defendant-orthopaedist, he believed his testimony had been inaccurately portrayed. He stated that “…taken as a whole, I acknowledged some migration after excision surgery, but pointed out that there was no migration prior to excision.” He explained that he recognized titanium implants existed but was unaware of any that had been studied long-term and were considered the standard of care. At the conclusion of the Grievance Hearing, Dr. Arangio referenced the Standards of Professionalism and agreed that expert witnesses should not use absolute terms, such as those he employed in his courtroom testimony.

After thorough evaluation of the facts of the case, the courtroom documents, and the oral testimonies during the hearing, the COP Hearing Panel found Dr. Arangio had violated only Mandatory Standard No. 2 of the SOPs on Orthopaedic Expert Witness Testimony. The COP Hearing Panel recommended that the Board of Directors censure Dr. Arangio. No appeal was made.

On June 20, 2009, after thorough consideration and due deliberation, the AAOS Board of Directors upheld the findings and recommendation of the COP Hearing Panel and voted to censure Dr. Arangio due to unprofessional conduct in the performance of expert witness testimony.