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


All closed malpractice claims involving primary and revision TKA performed between 1982 and 2012 were provided by the Federation of Jewish Philanthropies (FOJP) Service Corporation, an underwriter of medical professional liability insurance for a large number of hospitals and health systems across New York. All claims alleged improper TKA surgery and/or negligent postoperative care. All claims were closed between 1989–2015. An orthopaedic surgeon specializing in TKA (C.S.M.) and one orthopaedic resident (D.C.P.) collected and reviewed all medical and surgical diagnoses in the claims data. They reviewed all pertinent data the malpractice carrier provided, including data on intraoperative occurrences, in-hospital falls or medical complications, and postoperative complications. Physician and patient confidentiality was maintained according to the standard policies of the FOJP. Because these human subject data were preexisting and unidentifiable, no institutional review board approval was required.

We identified cases from the FOJP by using the International Classification of Diseases, Ninth Revision, Clinical Modification codes listed in Table 1. Demographic information for patients included age, sex, date of loss, date of opening and closing of claim, indemnity paid, expenses paid, procedural codes, admitting diagnosis, other relevant diagnoses, and detailed allegations. We grouped adverse outcomes into immediate postoperative or more distantly postoperative complications and as either intraoperative or in-hospital versus after discharge. We then further subdivided outcomes into orthopaedic or general medical concerns. Intraoperative and short-term orthopaedic complications included nerve injury, vascular injury, wound complications, leg-length discrepancy, and in-hospital falls. Orthopaedic complications occurring after or noted after discharge from the hospital included infection, malrotation, instability, loosening, contracture, chronic pain, and miscellaneous patient dissatisfaction. Medical complications included deep vein thrombosis and/or pulmonary embolism, cardiac arrest, cerebrovascular accident, medication overdose, gastrointestinal and urologic complaints, decubitus ulcers, dental injury, and death.

All cases made available for analysis were closed. The legal expenses of the suit and the indemnities paid to the plaintiff were normalized to 2015 dollars on the basis of the Consumer Price Index.[9]

DeNoble et al[10] described the method used to estimate the annual incidence of TKA malpractice claims among orthopaedic surgeons covered by the FOJP. We quantified the incidence of TKAs in New York state by using de-identified discharge data from the New York Statewide Planning and Research Cooperative System database for 2014.[11] This database included all discharge data from inpatient stays in nonfederal hospitals in New York state by year, with the most recent data available from 2014. We extracted the population of orthopaedic surgeons in New York state from the 2014 American Academy of Orthopaedic Surgeons census,[12] and the FOJP provided the number of orthopaedic surgeons they insured. We then calculated the annual incidence of TKA lawsuits on the basis of these numbers and study data from 2008 through 2012.

The FOJP distributed all de-identified data and details of claims as Excel spreadsheets (Microsoft). We reviewed all cases and defined and tabulated the primary cause of each malpractice claim. We performed univariate analysis by using Excel spreadsheets to extract the descriptive statistics (ie, mean, range) of age, overall cost, cause-specific cost, and time from surgery to closure of the case. For cost and indemnity analysis, we adjusted the variables denominated in dollars to 2015 dollars by using the all-urban Consumer Price Index.[9]