Orthopedics

Feature Article 

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database

Kyle H. Cichos, BS; Michael A. Ewing, MD; Evan D. Sheppard, MD; Christoph Fuchs, MD; Gerald McGwin Jr, PhD; James T. McMurtrie, MD; Shawna L. Watson, MD; Shin Xu, MD; Charles Fryberger, MD; Dustin K. Baker, MD; Reaves M. Crabtree, MD; Austin B. Murphy, MD; Loy O. Vaughan, MD; Jorge L. Perez, MD; Brandon A. Sherrod, MD; Brad W. Edmonds, Esq; Brent A. Ponce, MD

Abstract

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms “orthopaedic or orthopedic” and “malpractice.” Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260–e267.]

Abstract

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms “orthopaedic or orthopedic” and “malpractice.” Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260–e267.]

Medical malpractice claims are relatively common, with one study reporting 7.4% of physicians having a claim filed against them each year.1–3 Traditionally high-risk specialties (in terms of surgeons being sued), including surgery, have a reported 99% likelihood of physicians having a suit filed against them by the age of 65 years.3 More than 50% of orthopedic surgeons have been named as a defendant in at least 1 medical malpractice lawsuit.2,3 Despite up to 90% of medical lawsuits not going to trial, litigation has a significant impact on the cost and practice of medicine in addition to contributing to physician burnout and depression.2,4,5 Malpractice is, however, a reality in orthopedics.6–10 The payouts for plaintiff-favorable decisions are substantial, with a reported median payout of more than $130,000.2

The 3 broad categories leading to medical litigation include improper performance, negligent or inappropriate surgery, and patient dissatisfaction. Improper performance may include postoperative complications or technical errors (ie, inadequate fracture reduction). Negligent or inappropriate surgery may involve wrong, delayed, or failed diagnosis (ie, compartment syndrome or tumor diagnosis) and wrong-site surgery. Patient dissatisfaction, defined as a patient's perception of how successful a surgery was, commonly involves patients' claiming potential complications were not adequately explained or informed consent was not properly obtained.11 Success rates in defending malpractice claims vary based on the reason for litigation.11

Reports examining medical litigation in orthopedics largely focus on malpractice involving certain subspecialties or procedures.1,6,8,12 Nearly all existing studies have used private insurance data or were limited by geographic region.3,4,7 Additionally, few reports have been published in the past decade or have assessed long-term trends.4,6 The authors hypothesized that litigation against orthopedic surgeons has increased over time and varies with geographic region, procedure, and surgical subspecialty. The purpose of this study was to use a public, national, legal database to assess temporal and geographic patterns and risk factors associated with lawsuits brought against orthopedic surgeons.

Materials and Methods

Data for this retrospective cohort study were obtained from publicly available Westlaw databases (Thomson Reuters, New York, New York). Westlaw is a national legal research service composed of many databases containing court records and case descriptions.13 Databases containing medical malpractice case information were used. Westlaw databases contain only cases that were filed in court; cases that were settled before a lawsuit was filed are not included. The detailed case proceedings found within the West-law research service make its databases conducive to examining malpractice lawsuits. Westlaw has been used to examine medicolegal proceedings in neurosurgery, otolaryngology, colorectal surgery, urology, and emergency medicine.13–17

The search terms “orthopaedic or orthopedic” and “malpractice” were used to identify pertinent cases from the years 1988 to 2013. Cases in which an orthopedic surgeon was not the primary defendant were excluded. Cases were reviewed for the following details: procedure with anatomic region and subspecialty domain (eg, anterior cruciate ligament was placed under knee region and sports domain), malpractice complaint, complication(s), verdict, payment, and location by state. Subspecialty classification was determined by the nature of the operation performed. Cases in which subspecialty or anatomic region could not be determined were excluded from the analyzed data. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals for the association between case characteristics and plaintiff verdict. Linear regression was used to estimate similar associations with settlement payout amount. Given that the payout amount was highly skewed, values were log-transformed for use in the linear regression analysis. This study received institutional review board approval.

Results

This study analyzed 1562 case settlements and verdicts over 26 years of Westlaw data (1988–2013). Overall, plaintiffs won 30% (462 of 1562) of cases, with a mean payout of $1.37 million. The total number of lawsuits reported per year by Westlaw increased during the course of the study (Figure 1). The frequency and verdict of litigation varied across surgical procedures, surgical domains, and geographic regions.

Line graph showing the increase in orthopedic malpractice cases over time, representing a total of 1562 cases from the Westlaw database (Thomson Reuters, New York, New York).

Figure 1:

Line graph showing the increase in orthopedic malpractice cases over time, representing a total of 1562 cases from the Westlaw database (Thomson Reuters, New York, New York).

Fracture fixation procedures were most commonly litigated (363 cases), followed by hip and knee arthroplasty (290 cases) (Table 1). Procedures related to infection had the highest mean payout ($5.1 million), followed by failure to diagnose ($2.1 million). Fasciotomy procedures, although infrequent (21 cases), had the highest plaintiff success rate (48%), followed by procedures treating infection (43%) and carpal tunnel release (37%).

Verdicts

Table 1:

Verdicts

By subspecialty, pediatrics had the highest plaintiff success rate (49%), followed by tumor (33%) and spine (31%), whereas foot/ankle (20%) and sports (26%) had the lowest plaintiff success rates (Table 2). Pediatrics had the highest mean payout ($2.6 million) and the largest maximum payout ($32.0 million) of all subspecialties. Hand surgery had the lowest mean payout ($0.3 million).

Payout for Plaintiff Verdicts

Table 2:

Payout for Plaintiff Verdicts

When examining specific plaintiff complaints, technical/surgical errors accounted for the highest number of plaintiff verdicts (108 cases). Complaints of insufficient informed consent (82 cases) resulted in the lowest plaintiff success rate (15%). Negligent postoperative monitoring had the highest mean payout ($1.9 million), closely followed by failure to diagnose ($1.9 million). Foreign object left in body and wrongful death complaints had the lowest mean payouts ($0.9 million). Wrong-site surgery had a mean payout of $1.6 million.

When accounting for population size, the states with the highest rate of lawsuits were New York (10.9 total lawsuits/1,000,000 population) and Connecticut (10.6 total lawsuits/1,000,000 population) (Figure 2). Accordingly, the northeast was the busiest litigation region, having 8.7 cases filed per 1 million population (Table 3). The southeast and the southwest were the lowest litigation regions at 3.3 and 3.6 cases per 1 million population, respectively. The southeast region had the highest mean payout ($1.7 million). The west region had the lowest mean payout ($0.86 million) and the lowest percentage of plaintiff verdicts (24%). The midwest region had the highest plaintiff verdict rate (34%). Mean payouts for plaintiff verdicts by state are shown in Figure 3.

Values represent total malpractice cases by state per 1 million population. State rankings are arranged from #1 to #51 (District of Columbia was included as well), with #1 being the most litigious and #51 being the least litigious. Darker shading represents a higher number of cases. States with 0.0 cases recorded in the Westlaw database (Thomson Reuters, New York, New York) during the study period were ranked #46 to #51 in no particular order. Population data are based on the 2015 US Census.

Figure 2:

Values represent total malpractice cases by state per 1 million population. State rankings are arranged from #1 to #51 (District of Columbia was included as well), with #1 being the most litigious and #51 being the least litigious. Darker shading represents a higher number of cases. States with 0.0 cases recorded in the Westlaw database (Thomson Reuters, New York, New York) during the study period were ranked #46 to #51 in no particular order. Population data are based on the 2015 US Census.

Litigation by Regiona

Table 3:

Litigation by Region

Values represent mean payout for plaintiff verdicts by state, in millions of dollars (US). State rankings are arranged from #1 to #51 (District of Columbia was included as well), with #1 being the highest mean payout and #51 being the lowest mean payout. Darker shading represents higher payout. States with mean payouts of $0 did not have a plaintiff verdict recorded in the Westlaw database (Thomson Reuters, New York, New York) during the study period and were ranked #42 to #51 in no particular order.

Figure 3:

Values represent mean payout for plaintiff verdicts by state, in millions of dollars (US). State rankings are arranged from #1 to #51 (District of Columbia was included as well), with #1 being the highest mean payout and #51 being the lowest mean payout. Darker shading represents higher payout. States with mean payouts of $0 did not have a plaintiff verdict recorded in the Westlaw database (Thomson Reuters, New York, New York) during the study period and were ranked #42 to #51 in no particular order.

Comparing the first 5 years of the study period (1988–1992) and the last 5 years of the study period (2009–2013), the overall trend was an increase in the total number of lawsuits. The growth between these 2 periods was 215% (96 vs 302 cases). During this time, the monetary awards for plaintiff-favorable verdicts increased from $0.50 million to $1.9 million (280% increase).

In the multivariate analysis of factors associated with plaintiff verdicts (Table 1 and Table 3), certain specific procedures were associated with an increased odds of a plaintiff verdict compared with fracture fixation procedures. Spine procedures (OR=2.00), infection (OR=2.03), carpal tunnel release (OR=1.77), and fasciotomy (OR=2.94) were all associated with elevated odds. Arthrodesis procedures were associated with decreased odds of plaintiff verdicts (OR=0.57). Relative to the specialty of arthroplasty, pediatrics was the only domain/specialty that showed a statistically significant association with plaintiff verdicts (OR=2.52). Regarding specific complaint, relative to technical/surgical errors, wrong-site surgery (OR=4.84) showed an increased odds of plaintiff verdicts, while lack of informed consent (OR=0.30) was associated with a decreased odds of plaintiff verdicts.

Regarding payouts associated with plaintiff verdicts, compared with fracture fixation procedures, spine procedures (estimate=1.48) and procedures treating infection (estimate=1.49) were associated with higher payouts, while casting procedures (estimate=−0.99) were associated with lower payouts. Compared with the specialty of arthroplasty, spine (estimate=−0.65) and hand (estimate=−0.68) domains/specialties were associated with lower payouts. The only complaint associated with higher payouts was negligent postoperative monitoring (estimate=0.73). The southwest region (estimate=−1.20) was associated with lower plaintiff payout when compared with the northeast region.

Discussion

Medical liability is an ever-present factor in the current health care environment, with significant associated costs and psychological impact for those involved.2,5 Although most physicians will be impacted by medical liability during their careers, orthopedic surgeons are at higher risk and bear a greater medicolegal burden.3 This study sought to characterize lawsuits against orthopedic surgeons using a public, national, legal database. The principal findings of this analysis were that the frequency of litigation and the likelihood of plaintiff-favorable verdicts vary among specialties, procedures, and regions of the country.

Evidence as to the overall trends of medical malpractice during recent years has been mixed.2,3,5,11,18–20 A few studies report an increase in the number of claims filed, but a stable or increased percentage of these cases successfully defended.2,20 The current study identified a 215% increase in lawsuits between the first and the last 5-year periods of this 26-year study, and the percentage of defendant-favorable verdicts increased from 59% to 73% during this period. The total percentage of defendant-favorable verdicts, at 70% of cases, was higher than that seen in studies investigating 598 to 2117 claims of orthopedic malpractice in other countries (range, 48%–60%)11,20 as well as studies of other surgical specialties (range, 58%–70%).11,14,15,21 Payment to claimants increased 280% during the study period, which is significantly greater than other studies (range, 1%–52%).2,5

The variation among lawsuit databases, regarding types of surgical cases reported, years analyzed, geographical constraints, and limited number of reports, makes comparisons across databases difficult. This variation likely played a role in the aforementioned differences seen in this study regarding total litigation and payment claims. Despite these obstacles, the median payout in plaintiff-verdict cases in this analysis was similar to that found by DeNoble et al22 ($500,000 vs $440,000), suggesting that the Westlaw data are reasonably consistent. Unlike previous studies, the current study involved only cases that were brought to court and did not review cases that were settled out of court. Patients who wish to search their physician's lawsuit history cannot search out-of-court settlements. Therefore, this study evaluated a publicly accessible database with cases potentially found by patients.

Providing orthopedic care to pediatric patients is associated with lawsuits resulting in higher rates of plaintiff-favorable verdicts23 and higher average payouts. Compared with all other groups, the rates of plaintiff-favorable verdicts were higher (49% vs 27%), with higher indemnity payments ($2.6 million vs $1.3 million). Regarding pediatric orthopedic malpractice, past literature suggested that closed reduction of forearm fractures accounted for the highest number of claims. The same study involving 25,702 total claims over 27 years from an insurance database also showed a higher rate and amount of indemnity payments when comparing orthopedic claims in the pediatric (13% of claims) and adult populations.21

Spine surgery is commonly viewed as a high-risk subspecialty, with both high claim numbers and high average indemnity payments.3,6 This was seen in the current study as well, with both a relatively high claim total (231 cases) and the highest median payout ($0.75 million) for plaintiff victories of any subspecialty. This may be explained in part by the potential for catastrophic outcomes relatively unique to spinal surgery, such as quadriplegia.24 An existing study found 45% of spine claims to be centered around death or permanent injury.25

Regarding the 3 broad categories leading to medical litigation, improper performance involving technical error had the highest number of plaintiff verdicts at 112 (30%). This substantiates assertions that most orthopedic claims stem from intraoperative events.25 Of the 270 total lawsuits for patient dissatisfaction, 30% focused on informed consent. Traditionally, the doctrine of acceptable informed consent focuses on the risks, benefits, alternatives, and expected outcomes of a given surgery or procedure.26 However, recent case law has examined whether this doctrine sufficiently educates patients. Although most patients report being satisfied with the consent process, fewer than half may remember the potential complications of surgery.27 This number falls to less than 25% when considering trauma patients.28 Recommendations to lessen the likelihood of informed consent claims focus on adequately informing patients of potential complications and outcomes, especially considering that more than 70% of filed suits are reportedly related to poor physician communication skills.29

A high variability in the frequency of litigation between states and regions within the United States was identified in this analysis, with histories of higher malpractice rates found in Florida, Pennsylvania, Illinois, and Connecticut.30,31 A higher rate of malpractice claims, however, did not correlate with a high mean payout in this study. The variability in claim rate among states has been attributed to differences in state tort legislation.32 This is controversial, as Waters et al30 in 2007 concluded that tort law differences explain 25% or less of the variability in mean payments and an even smaller percentage of total paid claims. These varying reports highlight the difficulties in correlating the impact of tort reform and a state's medicolegal environment with claim volume and mean payout. For instance, Texas and Georgia are both states that have enacted tort reform in which each raised the standard of malpractice beyond “ordinary negligence.” However, Texas has a $250,000 cap on noneconomic damages in place for most malpractice suits, whereas Georgia's $350,000 cap was overturned in 2010, being ruled unconstitutional.33 Texas had a higher number of total cases and cases per capita, but Georgia had an average payout for plaintiff verdicts nearly 5 times ($4.2 million) that of Texas ($0.86 million). Whether this payout difference is associated with the aforementioned tort reform legislation changes cannot be concluded within the scope of this study; however, it may be an area for future investigation.

There were several limitations to this study. The first was the variable completeness of case entries in the Westlaw databases. Approximately 10% of summaries failed to provide thorough details, particularly surgical details (“knee surgery” and not specific for trauma, arthroscopy, or arthroplasty). This was also the reason for the arthroplasty domain not having the same number of cases as the arthroplasty procedure: missing variables. The same was true for spine procedures and spine domain. The Westlaw database differs from large insurance databases in that in Westlaw, only cases that were filed in a court and identified by Westlaw are recorded. That is, settlements in instances of threatened litigation, where the plaintiff never filed a lawsuit in a court, are not included in the Westlaw database. Additionally, the database is likely less complete for years preceding widespread use of the Internet for reporting, and some states' court systems might enable more complete reporting than others. Despite those limitations, this series is the largest publicly available orthopedic malpractice report and covers a longer period than do other studies in the literature. Finally, to extract information from such a large database, several authors (K.H.C., M.A.E., J.T.M., S.X., C.F., R.M.C., A.B.M., L.O.V., B.A.S.) entered case data. Although all received instruction regarding the categories of data collection with early group verification of data interpretation, some variability likely existed between authors. However, this was believed to be minimal and not to impact analysis and conclusions.

Conclusion

Malpractice liability is having a greater presence in the health care environment nationwide. Great variability exists in both the number of claims and the amount paid to plaintiffs across states, suggesting local legal environments play a major role. Investigation into orthopedic malpractice can identify areas for improvement and help alert surgeons to potential pitfalls, including fasciotomy (management of compartment syndrome), procedures for infections, and aspects involved with postoperative monitoring of patients. By better understanding the nature of medical malpractice and the information publicly available to patients, efforts can be made to avoid lawsuits while also ensuring that deserving claimants are appropriately compensated.

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Verdicts

ClassificationNo.Odds Ratio95% Confidence Interval

Total VerdictsPlaintiff Verdicts
Procedure
  Fracture fixation363102 (28%)1.00Reference
  Arthroplasty29079 (27%)1.060.55–1.99
  Arthroscopy16648 (29%)1.230.67–2.27
  Spine procedure23176 (33%)2.000.80–4.99
  Infection2310 (43%)2.030.81–5.07
  Casting5718 (32%)1.050.52–2.11
  Carpal tunnel release3513 (37%)1.770.70–4.49
  Fasciotomy2110 (48%)2.940.96–8.97
  Osteotomy377 (19%)0.830.32–2.14
  Tendon repair234 (17%)0.690.21–2.24
  Not applicable (failure to diagnose)9930 (30%)1.240.65–2.33
  Arthrodesis172 (12%)0.570.12–2.75
  Total procedures1562462 (30%)
Domain
  Arthroplasty27974 (27%)1.00Reference
  Trauma27079 (29%)1.090.56–2.11
  Sports/shoulder and elbow22659 (26%)0.970.51–2.01
  Spine22268 (31%)0.750.27–2.06
  Foot/ankle12826 (20%)0.750.36–1.56
  Hand12235 (29%)0.940.44–1.98
  Pediatrics8341 (49%)2.521.24–5.14
  Tumor217 (33%)0.900.27–3.04
Specific malpractice complaint
  Improper performance
    Technical/surgical error369112 (30%)1.000Reference
    Failure to diagnose/treat/test/medicate/refer28589 (31%)1.110.74–1.67
    Negligent postoperative monitoring10934 (31%)1.010.61–1.67
    Delayed/missed diagnosis8426 (31%)1.160.63–2.15
  Negligent or inappropriate surgery
    Negligent/unnecessary surgery34897 (28%)0.800.55–1.15
    Foreign object left in body206 (30%)0.840.26–2.74
    Wrong-site surgery108 (80%)4.840.89–26.19
  Patient dissatisfaction
    Infection10530 (29%)1.090.65–1.85
    Wrongful death8325 (30%)0.860.46–1.58
    Lack of informed consent8212 (15%)0.300.14–0.64
    Other6819 (28%)0.880.41–1.88

Payout for Plaintiff Verdicts

Classification$EstimateaP

MeanStandard DeviationMedianMinimumMaximum
Procedure
  Fracture fixation1,216,1702,876,923400,000024,870,000Reference
  Arthroplasty1,459,7202,504,184600,00068,00014,891,1230.53.21
  Arthroscopy1,093,7072,752,135449,000106517,892,4400.08.84
  Spine procedure1,991,3443,388,225750,000021,935,3691.48.00
  Infection5,128,1319,577,5171,583,000850,00032,000,0001.49.00
  Casting248,653278,309124,0980937,100−0.99.02
  Carpal tunnel release380,220390,606230,00025,0001,200,0000.35.54
  Fasciotomy519,835490,828347,97940,0001,535,0000.55.37
  Osteotomy819,5441,365,201275,00047,5003,890,0000.25.69
  Tendon repair801,000374,051880,000280,0001,164,0000.57.47
  Not applicable (failure to diagnose)2,075,3283,453,341604,500404011,831,2500.74.07
  Arthrodesis278,75040,659278,750250,000307,5001.32.24
  Total procedures1,374,6403,025,365500,000032,000,000
Domain
  Arthroplasty1,505,4142,777,984686,50021,00017,892,440Reference
  Trauma1,231,2331,865,975600,000024,870,0000.13.77
  Sports/shoulder and elbow1,278,3762,298,762535,693525014,891,123−0.11.80
  Spine1,681,9723,181,215750,000021,935,369−0.65.24
  Foot/ankle1,478,6523,284,422287,50015,00013,097,954−0.18.70
  Hand346,997321,551230,00025,0001,164,000−0.68.16
  Pediatrics2,593,0576,374,706390,000032,000,0000.18.67
  Tumor1,647,2492,182,251500,000100,0005,500,000−0.12.88
Specific malpractice complaint
  Improper performance
    Technical/surgical error1,025,3161,722,327554,320011,600,000Reference
    Failure to diagnose/treat/test/medicate/refer1,912,7204,804,330583,524032,000,0000.27.30
    Negligent postoperative monitoring1,960,7773,069,4641,071,023360114,891,1230.73.02
    Delayed/missed diagnosis1,176,2202,369,938400,000011,831,2500.08.84
  Negligent or inappropriate surgery
    Negligent/unnecessary surgery1,304,7232,923,235324,895021,935,369−0.11.66
    Foreign object left in body900,2721,698,528196,23904,341,919−0.13.86
    Wrong-site surgery1,578,3132,866,687323,75021,00010,500,0000.65.35
  Patient dissatisfaction
    Infection1,171,9161,460,094773,50050,0005,850,0000.59.09
    Wrongful death896,634931,397500,000125,0004,000,0000.07.86
    Lack of informed consent1,129,782753,474975,000350,0002,889,2840.61.25
    Other1,739,4234,385,617166,000106517,892,4400.20.70

Litigation by Regiona

RegionNo.Odds Ratio95% Confidence IntervalMean Payout, $EstimatebP

Total CasesTotal Cases per 1 Million PopulationTotal Plaintiff VerdictsPlaintiff Verdicts per 1 Million Population
Northeast4868.694140 (29%)2.5051.00Reference1,389,161
West3164.93177 (24%)1.2021.040.73–1.47857,933−0.37.10
Midwest3124.646106 (34%)1.5780.860.59–1.251,593,749−0.38.12
Southeast2793.31485 (30%)1.0101.030.72–1.491,757,079−0.36.14
Southwest1533.57038 (25%)0.8700.820.52–1.29944,032−1.20.00
Total1546446 (29%)1,378,264
Authors

The authors are from the Department of Orthopaedic Surgery (KHC, MAE, EDS, CF, JTM, SLW, SX, CF, DKB, RMC, ABM, LOV, JLP, BAS, BAP), the Department of Public Health (GM), and the Department of Epidemiology (GM), University of Alabama at Birmingham; and Regions Bank (BWE), Birmingham, Alabama.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Brent A. Ponce, MD, Department of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th St S, Ste 207, Birmingham, AL 35205 ( bponce@uabmc.edu).

Received: February 27, 2018
Accepted: September 10, 2018
Posted Online: February 14, 2019

10.3928/01477447-20190211-01

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