Long a bastion of growth and profitability, the orthopedic service line has historically served as a reliable source of surgical volumes and attractive per case economics for hospitals and health systems. However, the rate of profitable volume growth is progressively challenged by several recent trends, including soaring implant costs, wavering reimbursement, and intensifying competition, which includes the migration of care to ambulatory centers. In addition, in the wake of the Patient Protection and Affordable Care Act (PPACA) of 2010, hospitals will increasingly be held accountable for delivering high-quality, low-cost orthopedic care. In this rapidly changing environment, the orthopedic service line will require careful management to ensure its continued success. This presentation explores the most important business and structural challenges to musculoskeletal healthcare delivery, covering topics such as the impact of healthcare reform; physician alignment tactics; and strategies for organization, staffing, and structure.