The Doctor’s Advocate | Fourth Quarter 2013
Director's Forum

An Analysis of Orthopedic Claims

by David B. Troxel, MD, Medical Director, Board of Governors

Dr. Troxel

Researchers at the University of Washington in Seattle reviewed 464 consecutive orthopedic malpractice claims from The Doctors Company that closed between January 2008 and April 2010. Their analysis, titled “Lessons Regarding the Safety of Orthopaedic Patient Care,” was published in February 2013 in the Journal of Bone and Joint Surgery.1 A few highlights from this study follow; I encourage you to read the entire paper.

Degenerative conditions accounted for 56 percent, and traumatic injuries accounted for 44 percent of total orthopedic claims. Emergency treatment was related to 29 percent of total claims. It is significant that 81 percent of these claims were related to surgical treatment. This prevalence of claims relating to intraoperative events contrasts with general surgery, where most claims result from pre- and postoperative events. The anatomic sites of the adverse events giving rise to these claims were lower extremity, 45 percent; upper extremity, 30 percent; spine, 15 percent; and hip, 10 percent.

Major allegations in the claims included:

  • Failure to protect structures in the surgical field, 15 percent.
  • Fracture management errors, 14 percent.
  • Failure to prevent, diagnose, and treat infections, 11 percent.
  • Implant malposition, 8 percent.
  • Failure to prevent, diagnose, and treat complications, 7 percent. The complications included:
    • Compartment syndrome, 28 percent (60 percent involved fracture fixation).
    • Skin ulcers, 19 percent.
    • Pulmonary embolism, 15.5 percent.
    • Reflex sympathetic dystrophy, 12.5 percent.
    • Hematoma, 12.5 percent.
  • Medication errors, 4 percent.

Nineteen percent of knee arthroplasty claims alleged implant malposition, and 16 percent were related to infection. Thirty-three percent of knee arthroscopy claims alleged failure to diagnose or treat the presenting problem, and 13 percent were related to infection.

Twenty-one percent of shoulder arthroscopy claims alleged inadequate postoperative care, 16 percent were related to medication errors, and 16 percent were related to equipment issues.

Thirty-two percent of spine procedure claims involved injury to structures in the surgical field (77 percent involved spinal cord and nerves), 15 percent alleged failure to diagnose or treat the orthopedic problem, 9 percent involved implant malposition, 9 percent involved patient dissatisfaction with the final outcome, and 6 percent involved wrong-level surgery.

Forty-nine percent of hip arthroplasty claims alleged implant malposition, 17 percent alleged failure to protect surrounding structures (50 percent involved nerves, and 50 percent involved new fractures), and 9 percent involved patient dissatisfaction with the final outcome.

The following vignettes are representative of orthopedic claims:

Clinical Presentation

Intractable back pain: an L4/5 microdiscectomy was performed using a rongeur.

Unexpected Outcome

BP at closure was 64/40; EBL 3L. Abdominal US showed iliac artery bleeding. A nicked artery was repaired with a graft. Post-op the patient developed DIC; no platelets were available. Transferred to larger hospital, where bleeding from graft was diagnosed; clotting factors depleted; cardiac arrest. Autopsy showed complete transection of iliac artery.

Clinical Presentation

Shoulder hemiarthroplasty for degenerative arthropathy.

Unexpected Outcome

Plastic reamer became lodged in humeral shaft, and implant wouldn’t fully seat. While “reaming out” the reamer and cement, the humeral shaft cortex was perforated. When implant and cement were replaced, cement leaked out and caused thermal necrosis of radial nerve.

Clinical Presentation

Total knee arthroplasty for degenerative arthropathy.

Unexpected Outcome

Post-op patient couldn’t dorsiflex foot, c/o pain, and developed foot drop. Returned to surgery and found partial laceration/crush of peroneal nerve proximal to fibular neck (possibly a saw injury). Post-op developed a MRSA wound and joint infection with prolonged recovery.

Clinical Presentation

External fixation of severe tibial plateau fracture.

Unexpected Outcome

Post-op, developed intermittent loss of pulses and sensation in toes. Four days later, ORIF performed, and, in the PACU, patient had no dorsalis pedis pulse, couldn’t move foot, and c/o pain. Foot became edematous, mottled, and tight; calf became hard. Compartment pressure not measured, and vascular consult not obtained. CT scan two days later c/w compartment syndrome. Incisions opened and found extensive muscle loss—may need BKA.

Clinical Presentation

Thirteen y/o to ER with arm pain due to wrestling injury. X-ray showed transverse fracture of proximal third of radius and ulna with a 2 mm lateral displacement of distal radial segment. Cast was applied in ER.

Unexpected Outcome

Saw orthopedist five weeks later; fracture healed and cast removed. Mother thought arm looked deformed, but orthopedist said it was fine. Obtained a second opinion because arm couldn’t be fully extended. X-ray showed alignment of radius and ulna on A-P view, but, on lateral view, there was a malunion of the radial fracture with angulation and possible rotation. Radial shaft osteotomy with internal fixation performed.

Clinical Presentation

Patient with ankle pain due to severe osteoarthropathy of talonavicular joint had arthrodesis with bone graft. Patient was diabetic with history of peripheral neuropathy, but surgeon felt sensation was intact. Blood glucose was 300 on day of surgery, but patient wanted to proceed.

Unexpected Outcome

Cryotherapy was used post-op to control pain and swelling. Instructions for its use were given by a PA two weeks before surgery; no documentation of discussion or risks; no written instructions; no informed consent. Five days post-op, frostbite injury occurred with skin necrosis requiring multiple débridements and skin grafts.

Clinical Presentation

Patient with chronic back pain had uneventful arthrodesis of posterolateral L3/4 with placement of screws and an autogenous graft from the iliac crest.,

Unexpected Outcome

X-rays taken two weeks later showed misplaced L4 screws. Right lower screw was lateral to L4 vertebral body, and the screw on the left was in the spinal canal. Surgeon did not recognize these misplacements. Patient developed L4 radicular pain and saw another surgeon, who ordered a CT scan and saw the problem. The screws and plating system were removed.

Clinical Presentation

Thirty y/o morbidly obese male fell on knee and saw surgeon four days later for pain. Leg was immobilized and elevated. MRI six days later showed dislocated patella. H&P noted family history of DVT and lupus; no lab tests were ordered. Surgery was uneventful.

Unexpected Outcome

Eight days later, the patient died suddenly. Autopsy revealed pulmonary saddle embolus and DVT in the leg with a 3" larger calf circumference. PCP’s medical records documented that he had a genetic increased risk for DVT and a diagnosis of lupus. Family claimed they told surgeon that the patient’s mother had died from a clotting disorder and that the patient had the same condition, but the surgeon replied he had “everything under control.”

Clinical Presentation

Morbidly obese diabetic with hypertension, CAD, and osteomalacia had total knee arthroplasty. During surgery, femur was fractured and repaired with bone graft. Post-op x-ray was OK. He was discharged to a SNF for rehabilitation.

Unexpected Outcome

At the SNF, patient had sudden severe pain upon standing; x-ray showed displaced fracture of femoral shaft and lateral femoral condyle. Patient had ORIF with cables and a plate. In PACU, he developed foot numbness with foot drop, but perfusion appeared to be OK, so he was again discharged to the SNF, where he developed cool foot and no leg pulses. Angiogram showed abrupt cutoff of popliteal artery at level of cable fixation. When repaired with a vascular graft, cable found looped over artery and nerve. Post-op developed muscle necrosis in posterior compartment and had AKA.

Clinical Presentation

An outpatient right knee arthroscopy for medial meniscus tear was scheduled. Patient missed pre-op appointment, and orthopedist told OR the patient was probably a no-show, but patient showed up and surgeon was called.

Unexpected Outcome

Surgeon stopped the admission process because he hadn’t done an H&P. He arrived and did a rushed H&P and informed consent for the right knee. Patient transported to OR while the assigned RN was at lunch. Admission process was incomplete before transfer, and right knee was not marked. OR nurse prepped both knees. Patient’s name and surgical procedure were not put on the grease board. Right knee x-rays were in OR but were not reviewed. Surgeon operated on left knee—a never event.

Clinical Presentation

Seventy-five y/o with hip pain due to degenerative osteoarthropathy underwent anterior total hip arthroplasty. A prosthesis with a smaller-than-usual stem was used due to surgeon’s concern about fracture.

Unexpected Outcome

Two weeks post-op, patient c/o pain on lateral aspect of hip and a limp; x-rays were unremarkable. Seen again at four weeks for persistent pain and limp; no x-rays ordered. Second opinion obtained at four months due to leg length discrepancy with external rotation deformity. X-ray showed subsidence of femoral component of hip prosthesis with fracture on posterior medial proximal femur and 2.5 cm leg shortening. Opinion: too-small stem caused subsidence and both the fracture and leg shortening.



1. Matsen FA III, Stephens L, Jette JL, Warme WJ, Posner KL. Lessons regarding the safety of orthopaedic patient care: an analysis of four hundred and sixty-four closed malpractice claims. J Bone Joint Surg Am. 2013 Feb 20;95(4):e201-8. doi: 10.2106/JBJS.K.01272.


Investigation performed at the University of Washington, Seattle, under the auspices of the Washington State Orthopaedic Association.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

The Doctor’s Advocate

Fourth Quarter 2013

Director's Forum
An Analysis of Orthopedic Claims

An Ounce of Prevention
Defective Devices

Politically Speaking
Anti-MICRA Ballot Measure Filed; Oklahoma Special Session

New On-Demand CME Activity

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