About the AAOS

Position Statement

Value Driven Use of Orthopaedic Implants

This position paper was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Orthopaedic surgeons strive to relieve pain and restore function for their patients. With improving technology, orthopaedic implants have increasingly contributed to the success and longevity of musculoskeletal surgical procedures. However, implant technology comes at a price of contributing to rising health care costs. As a result, the price of advanced orthopaedic implants has come under increased scrutiny. Further, our patients are incurring more out of pocket healthcare expenses with higher deductibles and copays. Orthopaedic surgeons should accept responsibility for selecting implants for which a higher cost brings improved outcomes to their patient.

The American Academy of Orthopaedic Surgeons (AAOS) believes the cost of implants for musculoskeletal surgery must be balanced by improved patient outcomes and affordability for the patient.

Barriers to price transparency

Orthopaedic surgeons have a wide variety of relationships with hospitals, insurers, and other parties in health systems across the country. Although surgeons have historically been shielded from the cost of implants, it is no longer acceptable for surgeons not to know the costs of implants they are using. This ignores the interest of the patient and the population as a whole. This is not unexpected in our traditional volume-driven health care system but will be untenable in our value-driven future. We have a responsibility to our patients to work with other health care stakeholders to maximize the value our patients receive for their health care dollar.

The lack of price transparency limits our patients' ability to maximize their cost value. 1,2,3,4,5 Price transparency for health care providers, hospitals, and medical device manufacturers is favored. While some contracts do not allow price transparency, this is not in the best interest of the patients we serve. The AAOS favors contracts that allow surgeons and their patients to make informed decisions with accurate costs clearly provided. Surgeons need to have adequate knowledge of implant costs and understand the choices they make for their patients. 6 All else being equal, the surgeon should be able to make an economical decision on implants for their patients.


As our patient population ages, there will be increasing demand for hip and knee arthroplasty and other orthopaedic procedures. The use of clinical data registries will be of benefit to our patients and our own research. 7.8,9 Further, joint and other clinical data registries can facilitate earlier recognition of concerns with orthopaedic implants. These registries should provide data that translates across various platforms. Participation should involve minimal administrative burden to increase participation and decrease costs. This greater transparency and focus on outcomes will become increasingly important.

Relationship with Industry

The AAOS understands the benefits of collaborative efforts between its members and the medical device industry. This relationship must be preserved to allow continued technological progress for the benefit of our patients. In order to best preserve that relationship, specific parameters have been clearly documented in the AAOS Opinion on Ethics and Professionalism. 10 All surgeon interactions with industry should follow these guidelines to keep the relationship clearly benefitting our patients and prevent conflicts of interest. With orthopaedic implants specifically, surgeons should disclose any royalty relationship that may come into play while caring for patients.

With so many orthopaedic procedures involving implants, opportunities exist to make decisions that provide optimal care to our patients. The decision of what is best for the patient always lies with the treating physician but cannot be made in complete isolation from cost.

The American Association of Orthopaedic Surgeons (AAOS) believes orthopaedic surgeons should work collaboratively with their facilities, patients, payers, medical device companies, and other physicians to enhance the value of orthopaedic procedures. This should include the adoption of reasonable clinically based criteria for selection of orthopaedic implants with the appropriate consideration of cost. Registries can provide an effective way to track outcomes and assess the value of various implants. The final authority for selecting implants should rest with the treating orthopaedic surgeon who is committed to providing the highest quality, patient centered care.


  1. Beck M: How to bring the price of health care into the open. Wall Street Journal, February 23, 2014.
  2. U.S. Government Accountability Office: Health care price transparency: Meaningful price information is difficult for consumers to obtain prior to receiving care. 2011.
  3. Emanuel E: A systematic approach to containing health care spending. N Engl J Med, 2012;367:949-954.
  4. Wilson NA: Hip and knee implants: Current trends and policy considerations. Health Aff, 2008;27:1587-1598.
  5. Robinson JC: Increases in consumer cost sharing redirect patient volumes and reduce hospital prices for orthopedic surgery. Health Affairs, 2013; 32:1392-1397.
  6. Okike K. Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Aff, 2014;33:103-109.
  7. Peltola M: Learning curve for new technology? A nationwide register-based study of 46,363 total knee arthroplasties. J Bone Joint Surg AM, 2013;95:2097-2103.
  8. Koskinen E: Comparison of survival and cost-effectiveness between unicondylararthroplasty and total knee arthroplasty in patients with primary osteoarthritis. Acta Orthopaedica, 2008;79:449-507.
  9. Namba RS: Risk factors associated with deep surgical site infections after primary total knee arthroplasty. J Bone Joint Surg, 2013;95:775-782.
  10. American Academy of Orthopaedic Surgeons: Opinion on Ethics and Professionalism: The Orthopedic Surgeon's Relationship with Industry. Available at: http://www.aaos.org/about/papers/ethics/1204eth.asp

©February 2009 American Academy of Orthopaedic Surgeons. Revised December 2014.

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.

Position Statement 1104

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