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Open Access

Peer-reviewed

Research Article

Risk factors for perioperative nerve injury associated with total knee arthroplasty: Analysis of a national administrative database

  • Rahul H. Jayaram,

    Roles Conceptualization, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing

    Affiliation Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America

    ⨯
  • Lucas Kim,

    Roles Writing – original draft, Writing – review & editing

    Affiliation Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America

    ⨯
  • Wesley Day,

    Roles Writing – original draft, Writing – review & editing

    Affiliation Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America

    ⨯
  • Rushabh H. Doshi,

    Roles Writing – original draft, Writing – review & editing

    Affiliation Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America

    ⨯
  • Lee E. Rubin,

    Roles Conceptualization, Investigation, Methodology, Project administration, Supervision, Writing – review & editing

    Affiliation Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America

    ⨯
  • Jonathan N. Grauer

    Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – review & editing

    jonathan.grauer@yale.edu

    Affiliation Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, United States of America

    ⨯

Abstract

Introduction

Nerve injury related to total knee arthroplasty (TKA) is a rare but serious complication. Previous studies identifying risk factors for nerve injury related to TKA have been constrained by institutional data or small cohorts. The current study utilized a comprehensive, national, administrative database to investigate independent risk factors for nerve injury associated with TKA.

Materials and Methods

The PearlDiver M161 database was queried for adult TKA procedures performed between 2010 and 2022. Cases with postoperative nerve injury within 90 days of surgery were identified. Factors such as patient age, sex, body mass index (BMI), Elixhauser Comorbidity Index (ECI), fracture indication, and type of surgery (primary vs. revision) were evaluated for their correlation with nerve injury using multivariate analyses.

Results

Out of 1,517,637 TKA procedures, nerve injury was identified for 4,480 (0.3%). Multivariate analysis identified the following independent risk factors for nerve injury, listed in decreasing order of odds ratio (OR): revision surgery (OR: 1.68), female sex (OR: 1.31), ECI ≥ 5 (OR: 1.27), and younger age (OR: 1.02 per decreasing decade) (P < 0.05 for each). Factors not significantly associated with nerve injury included underweight BMI (<20 kg/m2) and fracture indication. A decreased risk of nerve injury was observed in individuals with a BMI ≥ 35 kg/m2 (OR: 0.80, P = 0.002).

Discussion

As expected, the incidence of nerve injury following TKA was low at 0.3%. Independent risk factors were identified for this adverse outcome, with the highest risk associated with revision surgeries. These findings, drawn from the largest cohort studied to date, offer valuable insights for risk stratification, and should inform patient discussions.

Citation: Jayaram RH, Kim L, Day W, Doshi RH, Rubin LE, Grauer JN (2025) Risk factors for perioperative nerve injury associated with total knee arthroplasty: Analysis of a national administrative database. PLoS One 20(6): e0324527. https://doi.org/10.1371/journal.pone.0324527

Editor: Osama Farouk, Assiut University Faculty of Medicine, EGYPT

Received: December 27, 2024; Accepted: April 27, 2025; Published: June 2, 2025

Copyright: © 2025 Jayaram et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying the results presented in the current study are owned by the third party vendor PearlDiver (https://pearldiverinc.com/). Data can be queried using Bellwether software, which is part of the PearlDiver database. The authors did not have special permission or privileges outside of those granted via payment to the vendor.

Funding: The author(s) received no specific funding for this work.

Competing interests: Financial Disclosures and Conflicts of Interest: Rahul Jayaram: None Lucas Kim: None Wesley Day: Medical/Orthopaedic publications editorial/governing board – Associate editor at the North American Spine Society Journal Rushabh Doshi: None Lee Rubin: Paid consultant - DePuy Synthes, Innovative Medical Products, Thompson Surgical Instruments; Royalties, financial or material support - SLACK, Inc., Johns Hopkins University Press, Inc., Wolters Kluwer; Medical/Orthopaedic publications editorial/governing board - Journal of Arthroplasty, Arthroplasty Today. Jonathan Grauer: Medical/Orthopaedic publications editorial/governing board – North America Spine Society Journal, Editor-in-Chief; Board member/committee appointments - North American Spine Society, Board

Introduction

Total knee arthroplasty (TKA) is a prevalent orthopaedic procedure that is projected to grow in utilization over the years [1–3]. While TKA is generally regarded as a successful procedure with high satisfaction rates [4–7], significant adverse events, including nerve injuries, have been reported [8–13]. These nerve injuries can be debilitating and have a severe impact on patient outcomes, possibly resulting in lawsuit [8,14]. Recovery from these injuries can differ [9–11], as motor nerve injuries tend have a greater functional impact than sensory deficits [9]. Consequentially, it is essential to identify factors of TKA patients that increase susceptibility to nerve damage.

Prior analysis has found a low incidence of TKA-related nerve injury. One systematic review by Carender et al. found that in eleven studies including 47,585 TKAs, the incidence of postoperative peroneal nerve palsy was 0.4% [10]. A retrospective analysis of 383,000 TKAs from a New York State database found the incidence of nerve injury to be 0.12% [12], and another study from this database found the incidence in revision TKA to be higher at 0.56% [13]. Injuries to the peroneal nerve are most described in the literature [8,10,15]. However, injury has also been identified to other nerves of the lower extremity, including the sciatic and femoral nerves [12,16].

There have been numerous previous investigations to ascertain risk factors for nerve injury following TKA, with inconsistent results. In a retrospective review of 65 nerve injuries in 39,990 TKAs, Shetty et al identified female sex and a history of lumbar pathology as risk factors for nerve injury [16]. A different single-institution retrospective study found that patients with peroneal nerve palsy following TKA were younger and had higher BMI [17]. Moreover, female sex, younger age, in-hospital postoperative complications, valgus disorder, and previous spinal disorder were identified as risk factors in a statewide database study [12]. Nevertheless, these prior investigations were limited by either sample size or geographic distribution.

The purpose of the current study was to leverage a national, administrative claims database to produce a large sample to better determine the frequency and risk factors for nerve injury related to TKA.

Materials and methods

Study population

A retrospective analysis was performed using the M161 PearlDiver Ortho Mariner Patient Claims Database (PearlDiver Technologies, Colorado Springs, CO, USA) from 2010 to Q1 2022. This commercially available database contains an extensive collection of over 161 million patient records in the United States. With its vast repository of Health Insurance Portability and Accountability Act-compliant patient data, the PearlDiver database has gained increasing prominence in orthopaedic outcomes-based research [18–27]. As data from this database is in a de-identified and aggregated format, our Institutional Review Board (IRB) determined that studies utilizing this database are exempt from review. The authors did not have access to information that could identify individual participants during or after data collection.

The data used in this study are owned by the third-party vendor PearlDiver (URL: https://pearldiverinc.com/). The data can be queried using the Bellwether software, which is part of the PearlDiver database. The authors did not receive any special permissions or privileges beyond those granted through payment to the vendor.

TKA cases were queried using Current Procedural Terminology (CPT) code 27447 for primary procedures and CPT codes 27486, 27487, and 27488 for revision surgeries. The following exclusion criteria were then applied: age < 18 years; cases of infection or neoplasm; and missing 90-day follow-up healthcare data. Patient age, sex, body mass index (BMI), Elixhauser comorbidity index (ECI, a commonly used comorbidity index) [28], and indication for fracture were extracted from the dataset.

International Classification of Diseases (ICD)-9 and ICD-10 codes for nerve injury (refer to Table in S1 Table) were employed to find patients with nerve injuries within 90 days after TKA. Initial analyses indicated that the most frequent type of nerve injury involved unspecified codes. Given the challenge in clearly categorizing different nerve injuries and to increase study power, all nerve injury codes were collectively analyzed.

Statistical analysis

Variables such as patient demographics, comorbidities, surgical indications, and types of surgery were compared between patients in the nerve injury and no-nerve injury cohorts. Univariable analyses using Pearson’s chi-squared test were conducted. Subsequently, multivariable logistic regression was performed for each variable to obtain odds ratios (ORs) and 95% confidence intervals (95% CIs).

PearlDiver’s internal software was used for statistical tests, with an alpha value set at 0.05. Figures were made using Microsoft Excel (Microsoft Corporation, Redmond, WA) and Graph-Pad Prism 9 (GraphPad Software, San Diego, CA).

Results

The base cohort comprised of 1,517,637 patients who underwent TKA. Of these, nerve injury within 90 days of surgery was found for 4,480 (0.3%). Age, female sex, BMI status, ECI, and revision surgery were associated with nerve injury upon univariable analysis (Table 1).

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Table 1. Univariate and Multivariate analysis of risk factors for nerve injury 90-days after TKA.

https://doi.org/10.1371/journal.pone.0324527.t001

Multivariable analyses found younger age (OR 1.02 for each decade decrease, P < 0.001), female sex (OR 1.31, P < 0.001), an ECI of 5 or higher (OR 1.27, P < 0.001), and revision procedure (OR 1.68, P < 0.001) to be significantly associated with nerve injury (Table 1, Fig 1).

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Fig 1. Forest Plot of Multivariate Odds Ratios for Risk Factors Associated with Nerve Injury 90 Days After Total Knee Arthroplasty.

https://doi.org/10.1371/journal.pone.0324527.g001

Multivariable analysis also revealed significant non-associations with nerve injury, including underweight BMI (<20 kg/m2) and an indication of fracture. Conversely, a morbidly obese BMI (≥35 kg/m2) was associated with a reduced likelihood of nerve injury (OR 0.80, P = 0.002)

Discussion

While TKA is regarded as a safe procedure, there is potential for nerve injury, which can have devastating consequences for patients, resulting in medical and legal ramifications [8,9]. The present study is the most extensive to date in evaluating the incidence and independent risk factors for nerve injury following TKA, drawing from 1,517,637 surgeries. From this population, nerve injuries were identified for 4,480 (0.3%), which is in the scope (0.12 to 1.3%) from previous literature [9,10,16,17,29,30]. While this is a low percentage of the overall cases, it represents a significant number of patients.

Numerous significant risk factors for nerve injury related to TKA were found. Of all variables examined, revision TKA (OR 1.68) carried the highest odds. This finding is expected, as revision surgeries typically present with a higher degree of scarring and anatomical variation. Comparative studies using prior statewide databases have highlighted this risk: Christ et al. reported a nerve injury incidence of 0.12% following primary arthroplasty [12], whereas Chen et al. found a higher incidence of 0.56% after revision TKA [13].

Age was another significant risk factor, with younger age carrying a higher odds (OR 1.02 per decade decrease) of nerve injury. While the specific reasons why younger patients are at higher risk for nerve injury after TKA cannot be defined here, this finding is consistent with prior literature [12,31]. Females were at higher odds of sustaining nerve injury after TKA than males (OR 1.31), which is also in line with prior literature [12,16]. Finally, an ECI score of greater than or equal to five indicated high patient comorbidity, was associated with greater odds of nerve injury (OR 1.27). This finding is supported by prior studies, which have found that patients with diabetes, tobacco use, and hypertension are at an increased risk of nerve injury following surgery [32].

Morbidly obese BMI status (≥35 kg/m2) was linked to decreased odds of post-operative nerve injury (OR 0.80), whereas underweight BMI status showed no relation. This finding conflicts with prior literature, which does not show an association between nerve injury and BMI range [11,16]. Given this, it is possible that the substantial patient population of this current study revealed an underlying association that would not be seen in smaller sample sizes. Obesity might be associated with greater soft tissue envelopes around structures that provides protection. Furthermore, the indication of fracture for TKA showed no association with nerve injury. To our knowledge, this relationship has not been previously evaluated, but it is encouraging to find that neither the fracture nor the surgical intervention appeared to increase the risk of nerve injury.

The current study is subject to limitations. Given its utilization of an administrative database, it depends on the accuracy of coding in administrative records. Additionally, specific details about patient anatomy and pathology are not accessible in this study, including the extent and volume of knee deformity being treated, the presence of soft tissue changes and contractures at the surgical site, and the type of neurologic deficit that occurs (partial vs. complete/motor vs. sensory). Furthermore, we were unable to assess the influence of surgical technique on post-operative neurological outcomes. Nevertheless, the large patient cohorts examined in this investigation have not been obtainable in previous research, significantly enhancing its statistical power.

Overall, the present study, involving over 1.5 million patients, is the largest investigation to date to analyze risk factors for nerve injury within 90 days of TKA. The incidence of nerve injury after TKA was low at 0.3%. Revision surgery, female sex, and ECI score of five or more were found to be associated with the greatest odds of nerve damage. Comprehending these risk factors can help future TKA patients by facilitating risk assessment, enhancing patient communication, and developing strategies to reduce risks during surgical planning.

Supporting information

S1 Table. International Classifications of Disease Codes and Descriptions of Nerve Injuries.

https://doi.org/10.1371/journal.pone.0324527.s001

(DOCX)

Acknowledgments

No funding or additional support was received for this study.

References

  1. 1. Gao J, Xing D, Dong S, Lin J. The primary total knee arthroplasty: a global analysis. J Orthop Surg Res. 2020;15(1).
  2. 2. Steinhaus ME, Christ AB, Cross MB. Total Knee Arthroplasty for Knee Osteoarthritis: Support for a Foregone Conclusion?. HSS J. 2017;13(2):207–10. pmid:28690473
  3. 3. Sloan M, Premkumar A, Sheth NP. Projected Volume of Primary Total Joint Arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am. 2018;100(17):1455–60. pmid:30180053
  4. 4. Kahlenberg CA, Nwachukwu BU, McLawhorn AS, Cross MB, Cornell CN, Padgett DE. Patient satisfaction after total knee replacement: a systematic review. HSS J. 2018;14(2):192–201.
  5. 5. Haynes MS, Alder KD, Bellamkonda K, Kuzomunhu L, Grauer JN. Incidence, predictors, and timing of post-operative stroke following elective total hip arthroplasty and total knee arthroplasty. PLoS One. 2020;15(9):e0239239. pmid:32941539
  6. 6. Choi YJ, Ra HJ. Patient satisfaction after total knee arthroplasty. Knee Surg Relat Res. 2016;28(1):1–15.
  7. 7. Bovonratwet P, Ondeck N, Nelson S, Cui J, Webb M, Grauer J. Comparison of outpatient vs inpatient total knee arthroplasty: an ACS-NSQIP analysis. J Arthroplasty. 2017;32(6):1773–8.
  8. 8. Zywiel MG, Mont MA, McGrath MS, Ulrich SD, Bonutti PM, Bhave A. Peroneal nerve dysfunction after total knee arthroplasty: characterization and treatment. J Arthroplasty. 2011;26(3):379–85. pmid:20570090
  9. 9. Cohen D, Backstein D. Nerve Injuries in Total Knee Arthroplasty. Orthop Clin North Am. 2022;53(2):123–7. pmid:35365256
  10. 10. Weynandt CL, Kowski A, Perka C, Rakow A. Iatrogene nervenläsionen in der hüft- und knieendoprothetik. Z Orthop Unfall. 2020;158(05):535–55.
  11. 11. Jacob AK, Mantilla CB, Sviggum HP, Schroeder DR, Pagnano MW, Hebl JR. Perioperative nerve injury after total knee arthroplasty: regional anesthesia risk during a 20-year cohort study. Anesthesiology. 2011;114(2):311–7. pmid:21239974
  12. 12. Christ AB, Chiu YF, Joseph A, Westrich GH, Lyman S. Incidence and risk factors for peripheral nerve injury after 383000 total knee arthroplasties using a New York state database (SPARCS). J Arthroplasty. 2019;34(10):2473–8.
  13. 13. Chen XT, Korber SS, Gettleman BS, Liu KC, Palmer R, Shahrestani S, et al. Risk Factors for Peripheral Nerve Injury Following Revision Total Knee Arthroplasty in 132,960 Patients. The Journal of Arthroplasty. 2023 Oct 21;39(4):1031–5.e2.
  14. 14. Upadhyay A, York S, Macaulay W, McGrory B, Robbennolt J, Bal B. Medical malpractice in hip and knee arthroplasty. J Arthroplasty. 2007;22(6 Suppl 2):2–7.
  15. 15. Asp L, Rand JA. Peroneal nerve palsy after total knee arthroplasty. Clin Orthop Relat Res. 1990;261(NA):233–7.
  16. 16. Shetty T, Nguyen J, Sasaki M, Wu A, Bogner E, Burge A, et al. Risk factors for acute nerve injury after total knee arthroplasty. Muscle Nerve. 2018;57(6):946–50.
  17. 17. Park J, Restrepo C, Norton R, Mandel S, Sharkey P, Parvizi J. Common peroneal nerve palsy following total knee arthroplasty: prognostic factors and course of recovery. J Arthroplasty. 2013;28(9):1538–42.
  18. 18. Day W, Jayaram RH, Rubin LE, Grauer JN. Total Hip Arthroplasty in Patients Who Have Marfan Syndrome: Adverse Events and 5-Year Revision Rates. J Arthroplasty. 2024;39(9S2):S275–8. pmid:37952742
  19. 19. Halperin SJ, Dhodapkar MM, Radford ZJ, Li M, Rubin LE, Grauer JN, et al. Total Knee Arthroplasty: Variables Affecting 90-day Overall Reimbursement. J Arthroplasty. 2023;38(11):2259–63. pmid:37279847
  20. 20. Joo PY, Jayaram RH, McLaughlin WM, Ameri B, Kammien AJ, Arnold PM, et al. Four-level anterior versus posterior cervical fusions: Perioperative outcomes and five-year reoperation rates: Outcomes after four-level anterior versus posterior cervical procedures. N Am Spine Soc J. 2022;10:100115. pmid:35392022
  21. 21. Gillinov SM, Kim DN, Islam W, Lee MS, Moran J, Fong S. Medicaid insurance is associated with more complications and emergency department visits but equivalent 5-year secondary surgery rate after primary hip arthroscopy. Arthroscopy. 2023;39(8):1234–42.
  22. 22. Dhodapkar M, Halperin S, Joo P, Maloy G, Jeong S, Rubio D. Weight loss makes the difference: perioperative outcomes following posterior lumbar fusion in patients with and without weight loss following bariatric surgery. Spine J. 2023;23(10):1506–11.
  23. 23. Ratnasamy PP, Halperin SJ, Dhodapkar MM, Rubin LE, Grauer JN. Emergency department visits following patellofemoral arthroplasty. JAAOS Glob Res Rev. 2023;7(11).
  24. 24. Jayaram R, Joo P, Gouzoulis M, Ratnasamy P, Caruana D, Moore H. Single-level anterior cervical discectomy and fusion has lower five-year revisions than posterior cervical foraminotomy in a large national cohort. Spine. 2023.
  25. 25. Dhodapkar MM, Modrak M, Halperin SJ, Joo P, Luo X, Grauer JN. Trends in and factors associated with surgical management for closed clavicle fractures. JAAOS Glob Res Rev. 2023;7(12).
  26. 26. Jayaram RH, Gillinov SM, Caruana DL, Kammien AJ, Joo PY, Rubin LE, et al. Total hip arthroplasty imageless navigation does not reduce 90-day adverse events or five-year revisions in a large national cohort. J Arthroplasty. 2022;37(12):1–7.
  27. 27. Halperin SJ, Dhodapkar MM, Radford Z, Frumberg DB, Rubin LE, Grauer JN, et al. Patients With Down Syndrome and Total Hip and Total Knee Arthroplasty: Outcome Measures Show Increased Risk of Perioperative Complications. J Am Acad Orthop Surg Glob Res Rev. 2023;7(12):e23.00108. pmid:38054749
  28. 28. Ondeck NT, Bohl DD, Bovonratwet P, McLynn RP, Cui JJ, Grauer JN, et al. Discriminative Ability of Elixhauser’s Comorbidity Measure is Superior to Other Comorbidity Scores for Inpatient Adverse Outcomes After Total Hip Arthroplasty. J Arthroplasty. 2018;33(1):250–7. pmid:28927567
  29. 29. Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA. Nerve injury after primary total knee arthroplasty. J Arthroplasty. 2001;16(8):1048–54. pmid:11740762
  30. 30. Ward J, Yang L, Urquhart A. Surgical decompression improves symptoms of late peroneal nerve dysfunction after TKA. Orthopedics. 2013;36(4).
  31. 31. Horlocker TT, Hebl JR, Gali B, Jankowski CJ, Burkle CM, Berry DJ, et al. Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg. 2006;102(3):950–5. pmid:16492857
  32. 32. Welch MB, Brummett CM, Welch TD, Tremper KK, Shanks AM, Guglani P, et al. Perioperative peripheral nerve injuries. Anesthesiology. 2009;111(3):490–7.