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Prioritizing Perioperative Quality Improvement in Orthopaedic Surgery
Peter L. Schilling, MD, MSc1; Brian R. Hallstrom, MD1; John D. Birkmeyer, MD2; James E. Carpenter, MD1
1 Department of Orthopaedic Surgery, University of Michigan, 1500 East Medical Center Drive, 2912 Taubman Center, Ann Arbor, MI 48109. E-mail address for P.L. Schilling: petschil@umich.edu
2 Department of Surgery, Michigan Surgical Collaborative for Outcomes Research and Evaluation, University of Michigan, 211 North Fourth Avenue, Suite 2A, Ann Arbor, MI 48104
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Aug 04;92(9):1884-1889. doi: 10.2106/JBJS.I.00735
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Surgical quality improvement has received increasing attention in recent years, but it is not clear where orthopaedic surgeons should focus their efforts for the greatest impact on perioperative safety and quality. We sought to guide these efforts by prioritizing orthopaedic procedures according to those that generate the greatest number of adverse events.


We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify all patients who had undergone an orthopaedic surgical procedure between 2005 and 2007 (n = 7970). Patients were assigned to forty-four unique procedure groups on the basis of the Current Procedural Terminology (CPT) codes. We first assessed the relative contribution of each procedure group to the overall number of adverse events in the first thirty postoperative days, and we followed that with a description of their relative contribution to an excess length of stay in the hospital.


Ten procedures accounted for 70% of the adverse events and 65% of the excess hospital days. Hip fracture repair accounted for the greatest share of adverse events, followed by total knee arthroplasty, total hip arthroplasty, revision total hip arthroplasty, knee arthroscopy, laminectomy, lumbar/thoracic arthrodesis, and femoral fracture repair. No other procedure group accounted for >2% of the adverse events.


Only a few procedures account for the vast majority of adverse events in the first thirty days following orthopaedic surgery. Concentrating quality-improvement efforts on these procedures may be an effective way for surgeons and other stakeholders to improve perioperative care and reduce costs in orthopaedic surgery.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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