Every year, hundreds of thousands of Americans undergo hip and knee replacement surgery. Surgeons can often predict how the operation itself will go.
What surgeons have historically struggled to predict is something far more important: how any individual patient will feel a year later.
Will they be satisfied? Will their pain improve? Will they regain the function they hoped for? Or will they become one of the small but significant number of patients who remain disappointed despite a technically successful operation? Nicolas Piuzzi, MD, believes that uncertainty represents one of the biggest remaining blind spots in orthopedic surgery.
The Cleveland Clinic orthopedic surgeon and adult joint reconstruction research director has spent the last decade helping build one of the nation’s most comprehensive patient-reported outcomes programs, collecting data from thousands of hip and knee replacement patients in an effort to better understand what happens before, during and after surgery.
The work earned him the 2025 Kappa Delta Young Investigator Award from the American Academy of Orthopaedic Surgeons. But for Dr. Piuzzi, the recognition reflects something much larger than a research achievement.
It reflects a shift he believes is beginning to reshape orthopedic care. For decades, surgeons have used outcomes data to understand what happened after surgery. The next frontier, he said, is using that information to predict what is likely to happen before surgery ever begins. “We need to move beyond simply collecting data,” Dr. Piuzzi said. “The question is how we use that information to personalize care and improve outcomes.”
The lesson Cleveland Clinic learned first
Long before CMS began requiring hospitals to collect and report patient-reported outcome measures, known as PROMs, for hip and knee replacement patients, Cleveland Clinic was already building its own infrastructure.
The process was not always smooth. Like many health systems entering the space, the organization initially tried to collect as much information as possible. “We were collecting way too many patient-reported outcomes. We were collecting way too many time points,” Dr. Piuzzi said. The result was a large volume of data that proved difficult to use consistently.
Over time, the team refined its approach, focusing on a smaller set of standardized measures collected at key moments throughout the patient’s journey. The experience reinforced one of the most important lessons of the past decade. Collecting data is not the goal. Using data is.
“What you cannot measure, you cannot improve,” Dr. Piuzzi said.
The X-ray doesn’t tell the whole story
As Cleveland Clinic’s database grew, researchers began noticing something that many surgeons see every day but struggle to explain. Two patients can arrive with nearly identical X-rays, undergo nearly identical operations and leave with dramatically different perceptions of success.
Traditional orthopedic evaluations focus heavily on anatomy and disease severity. But patients bring much more into surgery than a damaged joint. Pain levels. Physical function. Mental health. Overall quality of life. Expectations. Support systems. “We started to understand that there are multiple layers to every patient,” Dr. Piuzzi said. That realization became the foundation for Cleveland Clinic’s work on patient phenotypes.
Researchers began grouping patients based on combinations of pain, physical function and mental health measures, creating profiles that help identify who may be at higher risk for dissatisfaction or a more difficult recovery.
The goal is not to determine whether a patient should undergo surgery. The goal is to understand what additional support may help them succeed.
A patient with poor physical function may benefit from prehabilitation before surgery. A patient struggling with depression or anxiety may be connected with behavioral health resources. Instead of applying the same pathway to every patient, care can be tailored to the individual’s needs.
“We’re not just saying, ‘This patient seems sad, so let’s send them to behavioral health,'” Dr. Piuzzi said. “We actually have a process. We measure it.”
Moving from measurement to prediction
For Dr. Piuzzi, the most exciting work is happening now. The first decade focused on understanding outcomes. The next decade will focus on predicting them. His team is developing phenotype-based prediction tools designed to estimate a patient’s likelihood of pain relief, functional improvement, quality-of-life gains, hospital length of stay and postoperative complications before surgery occurs. The vision is not to replace clinical judgment. It is to strengthen it.
Surgeons would be able to combine their experience with predictive analytics, allowing for more informed conversations and more personalized treatment plans. The approach aligns with healthcare’s broader shift toward value-based care, but Dr. Piuzzi believes its impact could extend far beyond compliance with CMS reporting requirements.
The real opportunity is identifying risk before problems occur. “We need to use this data to identify high-risk-profile patients earlier,” he said.
The challenge ahead
The next challenge is scale. Large academic medical centers can invest heavily in data infrastructure, analytics teams and research programs. Many community hospitals cannot.
For predictive medicine to meaningfully improve orthopedic care, Dr. Piuzzi believes the tools must ultimately work everywhere. “Muskuloskeletal disease and osteoarthritis are the No. 1 burden of disease in our nation and worldwide,” he said. “This has to work everywhere.” That means creating systems that are practical, scalable and capable of supporting surgeons regardless of practice setting.
It also means convincing health systems that patient-reported outcomes are more than another regulatory requirement. Some organizations will collect the data because they have to. Others will use it to redesign care. Dr. Piuzzi believes the difference will become increasingly apparent over the next several years.
For decades, orthopedic surgery has become increasingly precise. Implants have improved. Techniques have advanced. Technology has transformed the operating room.
Yet one challenge remains: understanding how individual patients will experience their outcomes. For Dr. Piuzzi, solving that problem represents the next major evolution of the field.
“It’s mesmerizing to me,” he said. “You can walk into a bank and they’ll run countless models before deciding whether to give you a loan. Yet patients can walk into an orthopedic office and often receive major surgical recommendations without that same level of analytics.”
He believes that gap will eventually close. And when it does, the future of orthopedic surgery may be defined less by what happens in the operating room and more by what surgeons understand about a patient before the procedure ever begins.
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