Lawsuits After Primary and Revision Total Knee Arthroplasty

A Malpractice Claims Analysis

Diana C. Patterson, MD; Ronald Grelsamer, MD; Michael J. Bronson, MD; Calin S. Moucha, MD


J Am Acad Orthop Surg. 2017;25(10):e235-e242. 

In This Article

Abstract and Introduction


Introduction: As the number of total knee arthroplasties (TKAs) increases, the number of associated complications will also increase. Our goal with this study was to identify common causes of and financial trends relating to malpractice claims filed after TKA.

Methods: We analyzed malpractice claims filed for alleged neglectful primary and revision TKA surgeries performed between 1982 and 2012 by orthopaedic surgeons insured by a large New York state malpractice carrier.

Results: We identified 69 primary and 8 revision TKAs in the malpractice carrier's database. All cases were performed between 1982 and 2012; all claims were closed between 1989–2015. The most frequent factor leading to lawsuits for primary TKA was chronic pain or dissatisfaction in 12 cases, followed by nerve palsy in 8, postoperative in-hospital falls in 5, and deep vein thrombosis or pulmonary embolism in 3. Medical complications included acute respiratory distress syndrome, cardiac arrest, and decubitus ulcers. Contracture was most common after revision TKA (three of eight cases). Mean indemnity was $325,369, and the largest single settlement was $2.42 million. The average expense relating to the defense of these cases was $66,365.

Conclusions: Orthopaedic surgeons should continue to focus attention on prevention of complications and on preoperative patient education. Preoperative counseling regarding the risks of incomplete pain relief could reduce substantially the number of suits relating to primary TKAs.


Total knee arthroplasty (TKA) is one of the surgical procedures most frequently performed by orthopaedic surgeons. Compared with other surgical interventions, knee replacement surgery provides substantial health gains in quality of life and in cost-effectiveness,[1–3] although it is not without known morbidity or complications. More than 600,000 TKAs were performed in 2009 in the United States, and this number continues to increase every year.[4] Large population-based studies repeatedly have shown TKA to be extremely cost effective.[3–5]

Nevertheless, with the increase in the number of primary TKAs, the number of complications and failed surgeries, reports of patient dissatisfaction, and need for revision will increase, as well. Any complication may lead to patient discontent and, as a result, spur malpractice allegations.

In general, orthopaedic surgery is a specialty prone to a high risk of malpractice allegations. One study analyzing the cases of one large professional liability insurer between 1991 and 2005 found that the proportion of orthopaedic surgeons facing a claim was approximately 15% per year, with a little less than one third of suits leading to payouts.[6] The mean payment was $233,072. However, in each year of this study, 7.4% of physicians overall had a malpractice claim, and just 1.6% had a claim leading to payment. Within the English National Health System Litigation Authority (NHSLA), more than $321,695,072 was paid in settlements related to adult orthopaedic surgery for nearly 5 million orthopaedic surgical procedures performed between 2000 and 2006; damages secondary to litigation after TKA totaled $13,509,480.[7] In a study of claims in the NHLSA arising between 1995 and 2001, consisting of 2,117 orthopaedic surgery cases across many subspecialties, Kahn et al[8] found that the most common causes of claims were postoperative complications, incorrect diagnosis, inadequate consent, and surgery performed at the incorrect site. We hypothesized that these findings would be similar to those in the TKA subcategory in New York state.

The goal of this study was to identify the most common reasons for malpractice suits filed after primary and revision TKA. Additional goals were to investigate the costs of claims, indemnities rewarded, and overall trends and associations.