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OBJECTIVE To determine if an educational intervention effects surgeon implant decision-making measured by total implant costs for temporizing knee spanning external fixation construct. DESIGN A total of 24 cases were prospectively collected following an educational intervention and matched to 24 cases prior to intervention cases using Schatzker classification and surgeon. SETTING A single level one trauma center.Patients/Participants: 48 patients with Schatzker II-VI tibial plateau fractures. INTERVENTION Education session to create transparency with component pricing and to provide 3 clinical cases of OTA/AO 41-C3 (Schatzker VI) with accompanying images and fixator construct costs. Total implant costs displayed in the session ranged from $2,354 to $11,696. OUTCOME MEASUREMENT External fixator construct cost. RESULTS The mean cost of constructs in the post-intervention group was $4,550.20 (95% CI $3,945.60 to $5,154.00), which was significantly different compared to the pre-intervention group cost of $6,046.75 (95% CI= 5,309.54 to $6,783.97, P=0.003). After one year the total implant costs of external fixation constructs were reduced by an average of almost $1,500 per patient. CONCLUSION An educational intervention created a reduction in the average total implant construction costs for temporary knee spanning external fixation in the treatment of tibial plateau fractures. Surgical implant selection and cost variance remains an ideal area to improve value for patients and hospitals. Empowering surgeons with knowledge regarding implant prices is a critical part of working towards the cost reductions of external fixation constructs. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To determine the total cost for a 30-day episode of care for high-energy tibial plateau fractures and the aspects of care associated with total cost. DESIGN Time driven activity-based costing analysis. SETTING One Level I adult trauma center. PATIENTS 121 patients with isolated, bicondylar tibial plateau fractures undergoing staged treatment were reviewed. PRIMARY OUTCOME Total cost. RESULTS A total of 85 patients were included, and most sustained Schatzker VI fractures (n = 66, 77%). All patients were treated with biplanar external fixation prior to definitive fixation. A total of 26 patients (31%) were discharged to skilled nursing facilities, and 37 patients (43%) were not discharged between procedures. Total cost for a 30-day episode of care was $22,113 ± 4056. External fixation components ($5,952, 26.9%), length of hospital stay ($5,606, 25.4%), discharge to SNF ($3,061, 13.8%), and definitive fixation implants ($2,968, 13.4%) contributed to total cost. The following were associated with total cost: Patient discharged to SNF (p

The cartilage surgeon is a comprehensive knee surgeon. A sound understanding of meniscal, ligamentous, and patellofemoral issues is required. Cartilage injuries are often a result of trauma or aberrant anatomy. Excessive pressure or shear forces on articular cartilage will decrease the longevity of its pristine surface. With limited native regeneration potential, specific techniques must be employed to restore or reconstruct the articular surface. This chapter discusses a complete evaluation of the knee including history, physical exam, and imaging. Core components will be obtained for all patients, but it is important to note that not every test or study will be employed uniformly. As with any sound evaluation, it will begin by conducting a comprehensive history.

BACKGROUND Rising health care expenditures and declining reimbursements have generated interest in providing interventions of value. The use of external fixation is a commonly used intermediate procedure for the staged treatment of unstable fractures. External fixator constructs can vary in design and costs based on selected component configuration. The objective of this study was to evaluate cost variation and relationships to injury and noninjury characteristics in temporizing external fixation of tibial plateau fractures. We hypothesize that construct costs are highly variable and present no noticeable patterns with both injury and noninjury characteristics. METHODS A retrospective review of tibial plateau fractures treated with initial temporizing external fixation between 2010 and 2016 at 2 Level I trauma centers was conducted. Fracture and patient characteristics including age, body mass index, AO/OTA classification, and Schatzker fracture classification were observed with construct cost. In addition, injury-independent characteristics of surgeon education, site of procedure, and date of procedure were evaluated with construct cost. Factors associated with cost variation were assessed using nonparametric comparative and goodness-of-fit regression tests. RESULTS Two hundred twenty-one patient cases were reviewed. The mean knee spanning fixator construct cost was $4947 (95% confidence interval = $4742-$5152). The overall range in construct costs was from $1848 to $11,568. The mean duration of use was 16.4 days. No strong correlations were noted between construct cost and patient demographics (r = 0.02), fracture characteristics (r = 0.02), or injury-independent characteristics (r = 0.10). Finally, there was no significant difference between constructs of traumatologists and other orthopaedic surgeon subspecialists (P = 0.12). CONCLUSIONS Temporizing external fixation of tibial plateau is a high-cost intervention per unit of time and exhibits massive variation in the mean cost. This presents an ideal opportunity for cost savings by reducing excessive variation in implant component selection. LEVEL OF EVIDENCE Level III. Retrospective Cohort.

Summary Time-series observations and a phytoplankton manipulation experiment were combined to test the hypothesis that phytoplankton succession effects changes in bacterial community composition. Three humic lakes were sampled weekly May–August and correlations between relative abundances of specific phytoplankton and bacterial operational taxonomic units (OTUs) in each time series were determined. To experimentally characterize the influence of phytoplankton, bacteria from each lake were incubated with phytoplankton from one of the three lakes or no phytoplankton. Following incubation, variation in bacterial community composition explained by phytoplankton treatment increased 65%, while the variation explained by bacterial source decreased 64%. Free-living bacteria explained, on average, over 60% of the difference between phytoplankton and corresponding no-phytoplankton control treatments. Fourteen out of the 101 bacterial OTUs that exhibited positively correlated patterns of abundance with specific algal populations in time-series observations were enriched in mesocosms following incubation with phytoplankton, and one out of 59 negatively correlated bacterial OTUs was depleted in phytoplankton treatments. Bacterial genera enriched in mesocosms containing specific phytoplankton assemblages included Limnohabitans (clade betI-A), Bdellovibrio and Mitsuaria. These results suggest that effects of phytoplankton on certain bacterial populations, including bacteria tracking seasonal changes in algal-derived organic matter, result in correlations between algal and bacterial community dynamics.

Time-series observations and a phytoplankton manipulation experiment were combined to test the hypothesis that phytoplankton succession effects changes in bacterial community composition. Three humic lakes were sampled weekly May-August and correlations between relative abundances of specific phytoplankton and bacterial operational taxonomic units (OTUs) in each time series were determined. To experimentally characterize the influence of phytoplankton, bacteria from each lake were incubated with phytoplankton from one of the three lakes or no phytoplankton. Following incubation, variation in bacterial community composition explained by phytoplankton treatment increased 65%, while the variation explained by bacterial source decreased 64%. Free-living bacteria explained, on average, over 60% of the difference between phytoplankton and corresponding no-phytoplankton control treatments. Fourteen out of the 101 bacterial OTUs that exhibited positively correlated patterns of abundance with specific algal populations in time-series observations were enriched in mesocosms following incubation with phytoplankton, and one out of 59 negatively correlated bacterial OTUs was depleted in phytoplankton treatments. Bacterial genera enriched in mesocosms containing specific phytoplankton assemblages included Limnohabitans (clade betI-A), Bdellovibrio and Mitsuaria. These results suggest that effects of phytoplankton on certain bacterial populations, including bacteria tracking seasonal changes in algal-derived organic matter, result in correlations between algal and bacterial community dynamics.