OBJECTIVES: The majority of studies on centralization of elective orthopaedic surgeries focus on the association of high hospital/surgeon volume and clinical outcomes. There is a knowledge gap about other aspects of the centralization process and associations with all outcomes in the context of multiple dimensions of quality of care. The objective of this study was to assess centralization of elective orthopaedic surgeries as a complex intervention and report relationships with quality of care according to multiple dimensions.  METHODS: We searched Ovid MEDLINE, EMBASE, and CINAHL from 1950 to July 2015. Original studies that reported on any aspect of centralization of elective orthopaedic surgeries and relationships with any dimension of quality of care were included. Identified quality measures were mapped to the dimensions of the Alberta Quality Matrix for Health: accessibility, acceptability, appropriateness, effectiveness, efficiency and safety of care. Using a narrative synthesis approach we summarized frequencies and the direction of changes in quality of care associated with centralization.  RESULTS: Overall, 51 articles, representing 50 unique studies, satisfied the inclusion criteria. Six aspects of the centralization process were identified: high number of beds per hospital, high hospital procedure volume, high surgeon procedure volume, surgeon specialization, central hospital location, and specialized hospitals/units. Although all dimensions of quality were covered in the included studies, none of the studies assessed changes in every dimension. Centralization of elective orthopaedic surgeries was associated with greater appropriateness, efficiency and safety of care, mixed changes in acceptability, had no difference in effectiveness of care, and led to decreased accessibility. CONCLUSIONS: The complexity of the centralization process, and resulting trade-offs across multiple dimensions of quality must be considered when centralizing elective orthopaedic surgeries.