The state has been held liable for more than $500,000 in a bizarre medical malpractice case involving a surgeon at the state-owned Hilo Medical Center who implanted a screwdriver shaft into the spine of a 73-year-old patient.

Lawyers for Arturo Iturralde wanted the Intermediate Court of Appeals to hold the state responsible for $2.1 million as recommended by a Hawaii island jury in 2006.

But the appeals court upheld a judge’s ruling that lowered the amount to $629,250.

The appeals court added $110,000 onto the amount in the ruling but ruled that the amount must be reduced because of a $200,000 settlement with the doctor’s employer. The amount of reduction will be determined later, according to Iturralde’s attorneys.

The 36-page unanimous opinion, written by Appeals Judge Katherine Leonard and issued last week, is the latest development in the lengthy and complicated litigation that drew widespread attention.

The case involved orthopedic surgeon Dr. Robert Ricketson, who cut from a surgical, stainless steel screwdriver a piece of the shaft 1 to 2 inches long, according to the ruling by a three-judge panel of the appeals court.

He used the piece as replacement for titanium rods that were discovered missing more than two hours into the spinal fusion surgery, the appeals court said.

The next day, Iturralde fell at least once and the screwdriver shaft shattered, the court said.

A week later, Ricketson removed the shaft and put in titanium rods.

The appeals court said Iturralde was not notified by Ricketson about the screwdriver shaft but learned about it from his sister, who got the information from a nurse.

Nurse Janelle Feldmeyer was present during parts of the initial operation and immediately reported to her supervisors what Ricketson had done, the court said.

But she was told it was the surgeon’s responsibility to talk to the patient.

When Ricketson failed to tell Iturralde, Feldmeyer decided to tell the patient, but she was not able to talk to him because he didn’t speak English and the hospital reportedly posted a security guard in his room, the appeals court said.

Iturralde was a Baptist minister who spoke Spanish.

Feldmeyer arranged to "discretely" recover the screwdriver shaft, delivered it to an attorney and informed Iturralde’s sister, who told her brother, the court said.

Mark Davis, Iturralde’s lawyer, said the placement of the screwdriver shaft would never have been disclosed if whistleblower Feldmeyer had not stepped forward.

"She was the one going around telling everybody, ‘You can’t do that,’" Davis said. "She was the real heroine of this entire case."

Iturralde underwent two other surgeries when the titanium rods later became dislodged, the appeals court said.

He ended up bedridden and died in 2003.

The appeals court said Ricketson was the subject of disciplinary orders in Oklahoma, Texas and Hawaii. The orders included "falsifying medical records, violating state and federal drug laws, abusing his authority to write prescriptions, lying to licensing authorities and failing to report prior actions against this license," the court said.

"Despite these serious lapses, HMC granted Dr. Ricketson hospital credentials," the court said.

After a 2006 trial that spanned more than a month, the Hawaii island jury returned a $5.6 million verdict against Ricketson and the state.

The jury found the state negligent for allowing Ricketson to perform the surgery at the hospital.

The verdict included $3.4 million in punitive damages against the doctor, who is solely responsible for that payment.

But the jurors also found the state and the doctor liable for about $2.1 million in special and general damages for hospital bills and pain and suffering.

Circuit Judge Glenn Hara, who considered the verdict against the state to be advisory, later reduced the damages award mostly because Iturralde suffered from medical problems before the spinal fusion surgery.

The judge ruled the state and the doctor were jointly andseverally liable, which means the state would be responsible for $629,250 if Ricketson doesn’t have money.

It is questionable whether Ricketson can pay the judgment. He did not have malpractice insurance and represented himself during the trial.

He could not be reached for comment. Lawyers in the case said he was last known to be in Kansas.

The appeals court ruling also added $110,000 to the damages for the suffering by the sister, Rosalinda, but said the damages amount should be offset by the settlement with Ricketson’s employer, Hawaii Orthopaedics Inc.

Davis said they had not yet decided whether to seek a review of the ruling with the Hawaii Supreme Court.

But he said they were "very pleased" with the part of the ruling that ordered a new trial for the claims against Medtronic Sofamor Danek USA, which supplied the hospital with a kit that was supposed to have titanium rods.

The jury had cleared Medtronic of any liability in the case, but the appeals court ruled that the jury instructions on Medtronic were erroneous.

Davis said they would ask for punitive damages against Medtronic in a retrial.

Medtronic lawyer Edmund Burke would not comment because he said they were preparing a request asking the appeals court to reconsider its ruling.

George Playdon, attorney for the state, said the state faces paying just under $600,000. He said the state doesn’t intend to ask for a high court review.

Rosalinda Iturralde, who joined her brother in filing the lawsuit, died in 2008 at age 63.

Davis said the Iturraldes’ survivors would get the money from the case.