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


We identified 77 malpractice cases in the carrier's database: 68 after primary TKA and 9 after revision TKA. One of the primary cases contained two clinically significant allegations, and two of the revision cases similarly alleged two separate etiologies of malpractice. The American Academy of Orthopaedic Surgeons 2014 census stated that there were 1,647 orthopaedic surgeons in New York state. The FOJP stated that it insured 70 orthopaedic surgeons—4.2% of orthopaedic surgeons in the state. The New York Statewide Planning and Research Cooperative System database indicated that 33,030 TKAs were performed in New York state in 2014, approximately 1,127 of which were performed by physicians insured by the FOJP. Between 2008 and 2012, there were 18 claims relating to TKA filed against physicians insured by the FOJP, or 0.27% annual incidence of malpractice claims per year in our dataset. Of the 77 claimants, 46 were women and 31, men. The mean age at the time of surgery was 64.1 years (range, 32 to 86 years). The mean time from surgery to case closure was 6.39 years (range, 0.5 to 14.58 years). In the group of patients in our study, 34 claims were opened for cases performed between 1982 and 1998 and 43 for cases between 1999 and 2012.

Chronic pain (12 claims) and allegations of negligence or improper performance of surgery were the allegations cited most frequently after TKA. Nerve palsy (footdrop) occurred in eight cases; wound complications occurred in three cases, two of which required muscular flap coverage; infection occurred in five cases, one leading to death; contracture occurred in four cases. Vascular injury occurred in three cases; only one case of vascular injury resulted in amputation, but that case consisted of bilateral TKAs that resulted in bilateral vascular injuries and amputations—one above-knee and one below-knee amputation. Deep vein thrombosis or pulmonary embolism occurred in three cases, with two resulting deaths. One patient died of cardiac arrest and one of a postoperative drug overdose. One patient had an epidural hematoma leading to paralysis after receiving spinal anesthesia, and a separate patient suffered severe brain injury following epidural anesthesia with air visualized on brain imaging. Implant failure was cited in two cases (one being an unspecified liner failure and the other a tibial post fracture); component malrotation in one case; and instability in four cases. There were five cases of in-hospital falls caused by alleged improper supervision. Two of these falls resulted in injuries that required further orthopaedic surgery, including bilateral wrist fractures, a hip fracture, and a wound dehiscence.

Medical complications were the primary cause in 14 cases, including two complications in one case. A patient with acute respiratory distress syndrome requiring prolonged and repeated intubations reported dental injuries. There were three deaths. One case of superior mesenteric artery syndrome required emergency bowel resection. Two cases involved alleged sexual assault by a male aide on a female patient. Other medical complications are described in Table 2.

In revision cases, contracture or dissatisfaction was the most common complication, occurring in three cases. Nerve injury occurred after two revisions. Loosening, wound dehiscence, and unexplained pain occurred in one case each. The wound dehiscence case required a vascular bypass and provision of a muscular flap by means of plastic surgery.

Thirty-nine cases resulted in an indemnity payment. The overall average indemnity payment was $171,478, but that increased to $325,369 when we included in the analysis only those claims that resulted in payment. The largest single indemnity payment was $2.42 million for bilateral arterial injuries after bilateral TKAs that resulted in right below-knee and left above-knee amputations. The insurers' average expenses to defend the allegations were $66,365; two cases of wounds separate from the surgical site accrued no expenses but resulted in indemnity payments, likely secondary to immediate settlement. There was little correlation between the prepayout defense costs and the eventual payouts (Table 3).

In primary TKA, the average indemnity payment for allegations of nonspecific dissatisfaction or chronic pain was $118,740, but 9 of the 12 cases did not result in payment. The mean cost to defend these claims was $60,940 (Table 3).

In revision TKA, the average indemnity payment was $204,249 (range, $0 to $550,537) for contractures and $134,328 (range, $62,210 to $206,445) for footdrop. However, no payments were made for the cases alleging ongoing unexplained pain or the occurrence of an ankle blister away from the surgical site (Table 4).