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Patients with arthritis of the knee and an extra-articular deformity present a unique technical challenge, as it becomes more difficult to restore the mechanical axis during total knee replacement (TKR). Current treatment options include a 2-stage procedure in which an extra-articular correctional osteotomy is performed several months before the primary TKR, a 1-stage procedure in which an extra-articular correctional osteotomy is performed at the time of the index TKR, or a 1-stage procedure in which TKR is performed with correction of the extra-articular deformity. One-stage TKR with intra-articular correction of the extra-articular deformity is our treatment of choice. With proper planning, appropriate bone cuts to restore alignment, and the necessary soft tissue releases to balance the knee in flexion and extension, a satisfactory TKR can be achieved. Two patients with arthritis and a severe extra-articular deformity (varus/valgus deformity >20 degrees , recurvatum and malunion of a tibial or femoral fracture) were treated with 1-stage TKR with intra-articular correction of the extra-articular deformity. The technique followed had been successfully performed in 15 previous cases. The procedure was clinically successful in both patients without complications. At 2-year follow-up, Knee Society Scores improved from 40 to 95 and there was no evidence of instability in either case.

Healthcare administrators and physicians alike are navigating an increasingly complex and highly regulated healthcare environment. Unlike in the past, institutions now require strong collaboration among physician and administrative leaders. As providers and managers are trained and work differently, new methods are needed to provide the infrastructure and resources necessary to create, nurture, and sustain alignment between them. We describe four initiatives by administrators and physicians at Hospital for Special Surgery to work together in mutually beneficial relationships that help us achieve the highest level of patient care, satisfaction and safety. These initiatives include improving management efficiency through an orthopaedic service line structure, helping individual physicians grow their practices through the demand-office-operating room initiative of the Physicians Service Department, controlling costs through the supply effectiveness policy, and promoting teamwork in innovation through the technology transfer program.

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Background: The cost of health care in the United States continues to grow faster than any other sector of the economy. A small portion of the health care costs is attributed to physician reimbursement, but orthopaedic surgeons have an abundance of costly diagnostic and therapeutic modalities for patient care. Providers must be aware of the health care costs they generate in their practice in order to become stewards of cost control. Identifying the costs associated with an ambulatory orthopaedic practice is an important foundation in understanding and controlling the costs that the practice generates. Questions: What is the average cost of an initial encounter with an orthopaedic surgeon? What are the most costly elements in a management plan? How can we financially optimize resource utilization? Methods: We conducted a retrospective review of the records of 23 orthopaedic surgeons that span the main orthopaedic subspecialties at an urban academic medical center. All physician-generated orders were obtained and valuated by their cost to the institution’s health care management organization. Results: A total patient of 822 encounters were reviewed with a total cost of $403,235 (an average of $490 per patient). The most prevalent order was an x-ray (68.1% of patients). The majority of the financial burden was from physical therapy prescriptions (43.1% of total costs). The most expensive diagnostic modalities were advanced imaging studies, particularly magnetic resonance imaging and computed tomography (20.8% of costs). Conclusion: This health care burden exposé is not designed to discourage technology utilization. The authors aim to encourage stewardship through judicious use of diagnostic and therapeutic modalities. Most common musculoskeletal conditions presenting for evaluation can be appropriately diagnosed with a thorough history and physical examination followed by initial non-operative management. Diagnostic workups are only necessary during an initial visit when the initial evaluation suggests life or limb threatening conditions that need to be identified in an expeditious fashion. Diagnostic imaging may become necessary during future visits if the patient has not responded to the initial management and the patient is ready to undergo a surgical intervention based on the imaging. Obtaining imaging to identify a surgical lesion is an unnecessary expense if the patient is not ready to undergo surgery. Understanding the cost of clinical decisions can promote adherence to evidence-based diagnostic indications to more efficiently use health care funds.