Aligning physician and hospital incentives: the approach at hospital for special surgery.

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.

Meniscal root tears: diagnosis and treatment.

Meniscal tears within the body of the meniscus or at the meniscocapsular junction represent a well-understood and manageable condition encountered in clinical practice. In comparison, however, meniscal root tears (MRTs) often go unnoticed and represent a unique injury pattern with unique biomechanical consequences. Though first described decades ago, improvements in magnetic resonance imaging and arthroscopy have only recently enhanced our diagnostic and treatment capabilities with regard to MRTs. This review contains an anatomic description of the roots including their significance in meniscal function as well as the consequences of their loss. In addition, how to properly identify MRTs and when it is appropriate to surgically repair them are described. Finally, we review the surgical techniques available in the existing literature and present an illustrative case.

Analysis of single nucleotide polymorphisms in the promoter region of interleukin-10 by denaturing high-performance liquid chromatography.

Interleukin-10 (IL10), an anti-inflammatory cytokine, has been implicated in a variety of immune- and inflammatory-related diseases. We investigated the following SNPs: -1082, -819, -592 in the promoter region of IL10 in a normal (control) population and selected diseases: breast cancer (BrCa), systemic lupus erythematosus (SLE), and B-cell chronic lymphocytic leukemia (B-CLL) by denaturing high-performance liquid chromatography (DHPLC) and found distinct genotype and haplotype patterns. DHPLC was performed using the Transgenomic WAVE instrument, a mutational discovery tool that allows for high throughout analysis of SNPs. The principle of DHPLC is based on separation of homo- and heteroduplex formation of individual polymerase chain reaction products at specific melting temperatures and set gradients. The melting temperature selected for each SNP was based on size and sequence of the polymerase chain reaction product (for -1082, 57 degrees C; for -819, 58 degrees C; and for -592, 59.2 degrees C). Before fragment mutational analysis, all samples were denatured at 95 degrees C and slowly reannealed to allow for reassociation of different strands. Heteroduplex samples were easily distinguished from homoduplex samples. In order to identify wild type from homozygous mutant, two homoduplex polymerase chain reaction samples had to be mixed together, denatured at 95 degrees C and reannealed. The homozygous mutant, when combined with wild type, displayed a double peak on chromatogram. Once distinct chromatograms were established for each of the SNPs and the nucleotide changes confirmed by sequencing, genotype and haplotype frequencies were tabulated for the groups studied.

Extra-articular deformity is always correctable intra-articularly: in the affirmative.

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.