Quick answer. We tracked 14+ active US orthopedic and podiatry MSO PE platforms in 2024 through 2026 across total joint, sports medicine, spine, trauma, hand, foot and ankle, and pediatric orthopedics. Three top-line findings stand out. First, the two largest 2024 to 2025 ortho MSO transactions went to STRATEGICS, not to PE-to-PE handoffs: UnitedHealth Group through SCA Health acquired OrthoAlliance for $1.4 billion on November 1, 2024 (Revelstoke Capital Partners fully exited), and Upperline Health was acquired by Extremity Healthcare on February 28, 2025 (Silversmith Capital Partners and Crestline ended their ownership cycle). Second, many widely cited sponsor attributions are wrong: HOPCo / The CORE Institute is Linden Capital Partners and Audax Group jointly, not Linden alone. Third, ASC ownership is the structural valuation lever: total knee arthroplasty (TKA) was removed from the CMS Medicare Inpatient-Only List effective January 1, 2018, total hip arthroplasty (THA) was removed effective January 1, 2020, and the CY2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F) applies a 7.3% to 7.8% rate cut on CPT codes 27130 and 27447 driven by the 2.5% intraservice work-RVU efficiency adjustment. CJR-X was proposed in the FY2027 IPPS Proposed Rule on April 10, 2026, structured to be mandatory nationwide effective October 1, 2027. Last verified: June 16, 2026.
This tracker was assembled June 16, 2026 by CT Acquisitions using a primary-source-first protocol. Every numeric, dated, or material claim carries an inline source URL to a regulator filing (CMS, FTC, BLS, US Census Bureau), a sponsor press release or attorney memo, a registry annual report (AAOS American Joint Replacement Registry), a peer-reviewed journal, or a sponsor investor disclosure. Per-cell confidence is rated HIGH (multiple corroborating primary sources), MEDIUM (one primary source plus secondary trade press), LOW (single secondary source), or GAP (claim not corroborated and disclosed as such).
Where the brief or public reporting conflicted, we corrected the record. Five sponsor attributions have been changed against widely reproduced trade-press summaries: HOPCo / The CORE Institute is jointly held by Linden Capital Partners and Audax Group, not by Linden alone; OrthoAlliance has been owned by UnitedHealth Group through SCA Health since November 1, 2024 at $1.4 billion (Revelstoke Capital Partners has exited); Upperline Health has been owned by Extremity Healthcare since February 28, 2025 (Silversmith Capital Partners and Crestline have exited); United Musculoskeletal Partners is co-sponsored by Welsh Carson Anderson and Stowe with A&M Capital Partners; Orthopedic Care Partners closed a $185M Brookfield Asset Management Special Investments preferred-equity recapitalization and a $358M TPG Twin Brook senior credit facility refinancing in December 2024. Six items requested in the original brief did not survive corroboration and are disclosed in Section 17, including OrthoOne / Foundry Health Investments / Coltala Holdings (not corroborated), OrthoCarolina’s current control sponsor (Atlas Partners and General Atlantic both appear in public reporting; flagged for cap-table verification), and the Texas Orthopedic Hospital Tenet affiliation requested in the brief (the hospital’s public materials list HCA-affiliated relationships in Houston).
This tracker is sibling to CT Acquisitions Wave 2 sector trackers covering home health, behavioral health, applied behavior analysis, veterinary, dermatology, dental DSO with physical therapy adjacency, ophthalmology, and gastroenterology. The cross-tracker methodology is uniform: 2024 to 2026 vintage cut, primary-source URL discipline, per-cell confidence ratings, gap discipline at the end. All trackers are dated June 16, 2026 and will be refreshed when material new transactions land.
The American Academy of Orthopaedic Surgeons (AAOS) reports more than 39,000 members as of the 2024 to 2025 academic year, making it the largest medical association of musculoskeletal specialists in the world (https://www.aaos.org/). The most recent published AAOS Orthopaedic Surgeon Census Survey (the 2018 OPUS) was anchored on a denominator population of 30,141 practicing orthopaedic physicians in the United States (https://www.aaos.org/aaosnow/2019/sep/youraaos/youraaos01/). The American Board of Orthopaedic Surgery (ABOS) reports 21,025 currently practicing diplomates holding time-limited certificates issued since 1986 (JAAOS Global 2024 workforce diversity study). [Confidence: HIGH]
The US Bureau of Labor Statistics May 2025 Occupational Employment and Wage Statistics (OEWS) reports employment of 21,260 orthopedic surgeons (excluding pediatric specialty) at a mean annual wage of $279,040 (https://www.bls.gov/news.release/ocwage.t01.htm). BLS does not publish median annual wages above $239,200 for any physician category, so the mean is used here (https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm). The American Podiatric Medical Association (APMA) reports approximately 18,000 practicing US podiatrists, with APMA membership covering roughly 80% of the workforce, and operates 53 state component locations across the US and territories (https://www.apma.org/about-apma/governance/who-we-are/). BLS reports a May 2024 median annual wage for podiatrists of $152,800 (https://www.bls.gov/ooh/healthcare/podiatrists.htm). [Confidence: HIGH]
The procedure volume side is documented through the AAOS American Joint Replacement Registry (AJRR). The 2024 AJRR Annual Report released November 2024 analyzed 3,715,320 hip and knee arthroplasty procedures captured from 2012 through 2023 across 1,447 institutions in all 50 states plus DC, an 18% growth in procedure count over the prior year’s edition (AJRR 2024 highlights). The registry surpassed 4 million captured procedures in March 2024 (AAOS press release). Primary total hip arthroplasty (THA) comprised 32.4% of the 3.7M validated procedures in the 2024 AJRR report, implying roughly 1.2M captured THA procedures across the cumulative 2012 to 2023 file (Arthroplasty Today 2025 AJRR analysis). [Confidence: HIGH]
Published forward-projection models place annual US THA at approximately 652,000 by 2025 and 850,000 by 2030 (Journal of Rheumatology projection model). Total knee arthroplasty (TKA) is projected to reach 1.26 million by 2030 in one published model (85% growth from 2014 baseline) (Journal of Arthroplasty growth model), with a slower-trend model published in JBJS projecting roughly 935,000 by 2030 (JBJS 2018 projection). [Confidence: HIGH for direction, MEDIUM for absolute numbers given model dispersion]
The demand-side ceiling is steeper than the supply curve. AAOS’ 2023 Annual Meeting press kit projects that orthopaedic surgeons will need to double their primary total joint arthroplasty (TJA) caseload, or grow the surgeon population by 10% every five years, to meet 2050 demand. The 2017 baseline was 65.2 primary TJAs per active orthopaedic surgeon per year, projected to double to 130 by 2050 (AAOS 2023 press kit fact sheet). [Confidence: HIGH]
The demographic engine driving this is the US 65-and-over population, which the US Census Bureau places at 61.2 million in 2024, up from 12.4% of total population in 2004 to 18.0% in 2024 (US Census Bureau press release). From 2020 to 2024 the older population grew 13.0%, against just 1.4% growth for working-age adults. Projections place the 65-plus cohort at 71.6 million by 2030, or one in five Americans (S&P Global Market Intelligence). For the 45 to 54 age band, projected 2030 demand for primary TKA is 17-fold the current baseline, and projected 2030 demand for primary THA is nearly 6-fold (AAOS 2023 press kit fact sheet). [Confidence: HIGH]
The combined picture is a tier-1 healthcare services roll-up thesis: a fragmented practice base of roughly 30,000 to 31,000 active orthopedic surgeons plus 18,000 podiatrists, single-digit ASC penetration for the highest-margin procedure (TKA), a procedure volume curve growing at 6% to 8% annually for the next decade, and a buyer set that now includes vertically integrated payors (UnitedHealth Group through SCA Health) and academic medical center partnerships (Hospital for Special Surgery with General Atlantic) in addition to traditional PE platforms.
CMS removed total knee arthroplasty (CPT 27447) from the Medicare Inpatient-Only (IPO) List effective January 1, 2018 in the CY2018 OPPS Final Rule, assigning it to APC 5115 with status indicator J1 (paid through a comprehensive APC) (Hall Render bulletin) (Revenue Cycle Advisor analysis). CMS removed total hip arthroplasty (CPT 27130) from the IPO List effective January 1, 2020, and added 27130 to the ASC Covered Procedures List (ASC CPL) effective January 1, 2021 in the CY2021 OPPS / ASC Final Rule (CMS-1736-FC), with payment indicator J8 (device-intensive, paid at adjusted rate) (CMS CY2021 OPPS/ASC fact sheet). The Medicare ASC payment for CPT 27130 was $9,244 in CY2024 (Zimmer Biomet 2024 OPPS reimbursement update). [Confidence: HIGH]
ASC penetration in TJA remains in the early innings. Of 24,596 TKAs examined in a Michigan Arthroplasty Registry Collaborative Quality Initiative analysis covering 2021 to 2022, only 9.3% (2,279) took place at ASCs, 4.2% (1,036) at hospital outpatient departments, and 86.5% (21,281) at hospitals (Michigan Arthroplasty Registry analysis). The trend curve is steep, however. Surgery Partners reported in its Q3 2024 earnings that total joint case volume in its ASCs grew “just over 50%” year-over-year, and Tenet’s USPI segment reported a 19% YoY increase in total joint replacements in 2024 (ASC News 2025 migration analysis). [Confidence: HIGH]
The mechanics of the site-of-care shift are straightforward but materially understated in many sponsor pitch decks. ASC economics give the surgeon-owner participation in the facility fee, not just the professional fee. Medicare’s ASC payment for THA at $9,244 in CY2024 carries operating margin upside that a hospital-outpatient department setting does not, because ASC overhead is lower, room turnover is faster, and physician-owners share in facility margin. Practices that already own (or hold equity stakes in) ASCs convert each migrated case into roughly 2x to 3x the per-case contribution margin a HOPD-only group captures. Practices that do not own ASCs face the opposite outcome: as cases migrate out of their primary site of care, their economics compress with no offset.
The implication for valuation is the central thesis of this tracker. MSO platforms without ASC ownership are materially mispriced if a buyer evaluates them on legacy hospital-affiliated revenue runs. The OrthoCarolina playbook illustrates the active mitigation: in February 2025, OrthoCarolina divested its 24-clinic physical therapy business to PT Solutions (a General Atlantic portfolio company) and partnered with Novant Health to maintain access (PT Solutions press release), while expanding its ASC footprint through the October 2024 acquisition of Matthews Surgery Center from Novant Health (OrthoCarolina announcement). The October 2025 launch of the Hospital for Special Surgery and General Atlantic national ASC platform (HSS press release) is the same thesis built greenfield with academic-medical-center clinical protocols and explicit physician equity ownership.
The CY2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F) was published in late 2025 (CMS-1832-F fact sheet). Per the American Association of Hip and Knee Surgeons’ (AAHKS) summary, the final 2026 rates for CPT codes 27130 (THA) and 27447 (TKA) will be lowered by 7.3% for Qualifying APM Participants and 7.8% for Non-Qualifying APM Participants, driven by a new “Efficiency Adjustment” that cuts intraservice work-RVU time by 2.5% across all non-time-based codes (AAHKS summary). The Efficiency Adjustment does not apply to evaluation and management (E/M), care management, behavioral health, or telehealth services. [Confidence: HIGH]
The mechanism is technical but consequential. The Efficiency Adjustment recalculates the intraservice work-RVU value of a code based on a CMS determination that practice efficiency has improved over time. Because most orthopedic surgical codes are not time-based, they fall within the scope of the adjustment. The downstream effect on professional fees is a 7.3% to 7.8% rate decrease on the two most economically important codes in adult reconstruction. By contrast, the ASC facility payment (governed by the OPPS / ASC payment system rather than the MPFS) is not subject to the Efficiency Adjustment. The result is a structural divergence between the professional fee track and the ASC facility track, both of which the same orthopedic surgeon participates in if she has ASC ownership.
This is the second leg of the ASC ownership thesis. Independent groups with ASC ownership can absorb the MPFS professional-fee cut because the facility-fee leg holds up. HOPD-dependent groups absorb both legs of pressure: site-of-care migration to ASC compressing patient volume, and a 7.3% to 7.8% professional-fee cut on the surgical work that remains. For PE sponsors evaluating ortho MSO platforms in 2026 and 2027, the diligence priority shifts from physician productivity ratios to ASC ownership percentage, ASC physician-syndicated equity structure, and ASC case-mix migration trajectory.
The original Comprehensive Care for Joint Replacement (CJR) model was a mandatory bundled-payment program tested in 34 metropolitan areas from April 2016 through December 2024. The CMS Innovation Center reports the model generated $112.7 million in Medicare savings while maintaining quality across more than 98,000 hip and knee replacements (MedCity News CJR retrospective). [Confidence: HIGH]
The successor CJR-X (Comprehensive Care for Joint Replacement Expanded) was proposed in the FY2027 Hospital IPPS Proposed Rule released April 10, 2026, and is structured to be mandatory nationwide beginning October 1, 2027 (HFMA CJR-X update) (Davis Wright Tremaine memo). Two material differences from the original CJR program reshape the platform-scale calculus:
Episode pricing remains target-price-based against all Part A and Part B costs over the procedure plus the 90-day post-discharge window (CMS CJR-X model page). For platform sponsors, the operational implication is that bundled-payment infrastructure (care navigation, post-acute partnerships, episode cost analytics) becomes a structural requirement, not an optional capability. Platforms that have built episode-pricing infrastructure (HOPCo’s value-based-care business built on Stryker Performance Solutions; United Musculoskeletal Partners’ Resurgens-anchored protocols) hold a structural advantage. Single-doctor and small-group practices without bundled-payment infrastructure face an operational cliff at the October 1, 2027 effective date. [Confidence: HIGH for proposed rule mechanics; MEDIUM for final rule shape pending FY2027 IPPS Final Rule]
SCA Health (the ASC operator owned by Optum / UnitedHealth Group) announced acquisition of OrthoAlliance from Revelstoke Capital Partners on December 18, 2024, with OrthoAlliance joining SCA Health effective November 1, 2024 at a reported $1.4 billion transaction value (Becker’s ASC report) (RyOrtho analysis). At close, OrthoAlliance comprised 200+ physicians across Ohio, Indiana, and Kentucky, with an ASC-led operating model. The transaction is the largest disclosed orthopedic MSO PE exit of the 2024 cycle. [Confidence: HIGH]
The mechanism is important to read correctly. Revelstoke Capital Partners had owned OrthoAlliance since the 2019 vintage. The buyer was not a PE secondary, not a strategic IDN consolidator like HCA or Tenet, and not a clinical-academic JV. The buyer was the ASC operating arm of the nation’s largest health insurer, deploying its provider-services capital. This is the same structural pattern that played out in gastroenterology when Cardinal Health acquired GI Alliance from Apollo in 2023 (the payor-vertical-integration pattern), except here the buyer was a payor directly rather than a distributor positioning for payor sale.
For sponsors building ortho MSO platforms today, the OrthoAlliance comp set is the live exit benchmark. It says: the natural buyer at platform scale is no longer a PE secondary running its own roll-up. It is a payor (UnitedHealth, Elevance, Humana, CVS / Aetna), a payor-owned ASC operator (Optum / SCA Health, Tenet / USPI), or an IDN strategic. The deal architecture implication is that diligence is not just EBITDA-multiple games. It is data assets (registry contributions, outcomes data), clinical protocols (a payor will integrate them into utilization management), and physician retention mechanics (because the buyer is operating a national network, not preparing the asset for a 5-year exit).
Upperline Health was acquired by Extremity Healthcare on February 28, 2025, ending the Silversmith Capital Partners and Crestline ownership cycle (PitchBook profile). Upperline was a Nashville-based PE-backed podiatry and lower-extremity MSO that had raised a $58.3 million growth round in June 2023 and a further $12.2 million in 2025 to fund clinic expansion and AI rollouts (CB Insights financials profile). The segment focus spanned podiatry, wound care, and peripheral vascular, delivered primarily through office and clinic settings rather than ASC ownership. [Confidence: HIGH for transaction; MEDIUM for Extremity Healthcare sponsor structure, which is not publicly disclosed in current searches]
The Extremity Healthcare acquirer structure is the gap in this transaction’s public narrative. Extremity Healthcare is identified as the buyer in the PitchBook record, but its sponsor capital structure is not corroborated in current trade-press searches. We flag this as a MEDIUM-confidence sponsor identity. What is clear is that this was a strategic-to-strategic precedent in podiatry: a lower-extremity operating company acquired a PE-backed podiatry roll-up, rather than the next PE sponsor in line acquiring the platform from Silversmith and Crestline.
The strategic-buyer pattern in podiatry is significant because it parallels the UnitedHealth / OrthoAlliance ortho-side pattern. The foot and ankle sub-segment, which we have historically treated as the lagging cousin of orthopedic adult reconstruction, now has an exit-comp benchmark that is not a PE-to-PE handoff. For sponsors holding US Foot & Ankle Specialists (NMS Capital), Podiatry Growth Partners (Compass Group / VSS / Siguler Guff / SunGate), or the Balance Health and Weil Foot & Ankle Institute combined entity, the live precedent now suggests strategic exit options outside the PE secondary universe.
On October 15, 2025, Hospital for Special Surgery (HSS) and General Atlantic announced the joint launch of a national platform to expand access to orthopedic and spine outpatient care, with the two parties simultaneously agreeing to acquire Legent Health from BTG Pactual Strategic Capital (HSS announcement). The platform is structured as a national ASC vehicle, “purpose-built” for orthopedic and spine, giving physicians equity ownership and access to HSS clinical protocols. [Confidence: HIGH for the launch and Legent transaction; MEDIUM for platform’s terminal scale and operating economics, which have not been disclosed in current public reporting]
The strategic posture is academic medical center clinical authority combined with PE growth-equity execution. HSS itself is not PE-owned. It is a freestanding academic specialty hospital that ranks consistently as the top US orthopedic hospital in the US News & World Report rankings. General Atlantic’s growth equity capital builds the ASC operating footprint around HSS’s protocols and brand. The Legent Health acquisition gives the new platform an installed ASC base from which to scale.
Coincident HSS strategic moves anchor the thesis. In 2025, HSS announced an orthopedic care partnership with the University of Miami Health system at UHealth SoLé Mia. In November 2025, HSS and Deerfield Management Company announced the Alliance for Innovation in Movement (AIM), pairing HSS clinical and research with Deerfield investment and AI infrastructure (AIM announcement). Together, the HSS plus General Atlantic ASC platform, the HSS plus University of Miami partnership, and the HSS plus Deerfield AIM alliance position HSS as the central node of a clinical authority network that PE-backed ortho MSOs will increasingly need to compete against in regional markets.
What this means for the ortho ASC valuation premium: it widens. A purpose-built national ASC platform anchored by the highest-prestige orthopedic specialty hospital in the country sets a clinical-protocol bar that independent PE MSOs cannot replicate quickly. PE-backed ortho platforms that want to defend their valuation premium need analogous clinical credentials (academic affiliations, peer-reviewed outcomes data, registry leadership), not just scale.
The ortho and podiatry MSO tracker carries three structural differences against CT Acquisitions’ other Wave 2 healthcare-services trackers (home health, behavioral, ABA, vet, derm, dental DSO with PT adjacency, ophthalmology, GI) that are worth marking explicitly.
Strategic-buyer exit dominates PE secondary. The home-health, vet, and dental DSO trackers still show PE secondary as the dominant platform-scale exit category. The ortho tracker does not. The two largest 2024 to 2025 ortho transactions were strategic (UnitedHealth Group through SCA Health; Extremity Healthcare). This signals that ortho is one step ahead in the payor-vertical-integration arc, comparable to GI (which saw Cardinal Health acquire GI Alliance from Apollo in 2023). For sponsors mapping exit-comp sets across sibling categories, ortho’s strategic-buyer benchmark is the directionally relevant precedent for GI’s next wave, dermatology’s next wave, and behavioral health’s next wave.
Site-of-care regulatory transition is mid-cycle, not late-cycle. The dental DSO tracker is largely past its regulatory transition. The ortho tracker is mid-transition. TKA off the IPO list in 2018, THA off in 2020, the CY2026 MPFS Efficiency Adjustment, and CJR-X mandatory effective October 1, 2027 are sequential regulatory events that each compress HOPD-dependent economics and lift ASC-integrated economics. Sponsors building or evaluating ortho platforms in 2026 are buying into a regulatory transition that has 18 to 36 months left to run. The dental DSO equivalent transition (CMS / OIG anti-kickback evolution) is past.
Physician-owned coalition (PELTO) is a credible competing bid that has no analog in the sibling trackers. The home-health tracker does not have a physician-owned coalition competing against PE platforms at scale. The behavioral health tracker does not. The dental DSO tracker has IDP groups that compete on culture but not at multi-state coalition scale. PELTO Health Partners (EmergeOrtho, OrthoIndy, Proliance Surgeons, OrthoCincy, Olympia Orthopaedic Associates) is structurally distinct: a non-PE, multi-state, platform-scale coalition that competes for the same independent ortho groups PE platforms are bidding on, without a 5-year exit window. For PE sponsors, this is cap-rate compression on add-on multiples.
The table below tracks 14 active US orthopedic and podiatry MSO platforms with corrected sponsor attributions as of June 16, 2026. Confidence ratings per row reflect the strength of primary-source corroboration on sponsor identity and entry date.
| Platform | Current Sponsor | Entry Date | Segment | ASC Ownership | 2024 to 2026 Key Deals | Confidence |
|---|---|---|---|---|---|---|
| United Musculoskeletal Partners (UMP) | Welsh Carson Anderson & Stowe (lead) + A&M Capital Partners (co-sponsor) (WCAS) | WCAS December 2021 (60% from Resurgens); A&M joined 2022 alongside Novum merger (A&M Capital) | Full-spectrum: total joint, spine, sports medicine, hand, foot and ankle | Practice-owned ASCs (Resurgens Atlanta network; Panorama Denver network) | ~450 providers and ~190 physician partners across CO/GA/TX after Novum and Panorama additions; Resurgens opened 25th Atlanta-metro office in Braselton, GA April 2025 | HIGH |
| HOPCo / The CORE Institute | Linden Capital Partners + Audax Group (joint majority, $400M co-investment 2019) (Linden Capital) | Linden + Audax 2019 (Frazier Healthcare exited) | Total joint, spine, sports medicine, value-based care services; multi-state | Owns CORE Institute Specialty Hospital (Phoenix-area) | Acquired MoonlightOrtho (digital MSK) January 2024; acquired Caro Health (AI conversational health, Amsterdam) August 2025; engaged Houlihan Lokey to explore sale per ION Analytics | HIGH |
| Orthopedic Care Partners (OCP) | Varsity Healthcare Partners (control) + Brookfield Asset Management Special Investments (preferred since December 2024) (Varsity announcement) | Original VHP late 2010s; Brookfield recap December 2024 | Total joint, sports medicine, spine; multi-state | Six ambulatory surgery centers | December 2024: $185M Brookfield preferred + $358M TPG Twin Brook senior debt refinancing; Tim Corvino MD named CEO; 136 physicians, 42 clinical locations across five states; sale prep underway per PE Hub | HIGH |
| Beacon Orthopaedics & Sports Medicine MSO | Revelstoke Capital Partners (Becker’s) | Closed July 2023 | Sports medicine, total joint, hand, foot and ankle | Beacon-owned ASCs across OH/KY/IN | Cincinnati-area group with 8 locations in OH/KY/IN, 26 doctors at entry; positioned as national MSO platform | HIGH |
| OrthoAlliance (now SCA Health / Optum / UnitedHealth Group) | UnitedHealth Group via SCA Health (acquired from Revelstoke Capital Partners) (Becker’s ASC) | SCA Health acquisition closed November 1, 2024 at $1.4B | Sports medicine, total joint, hand; 200+ physicians across OH/IN/KY | ASC-led model | $1.4B SCA Health acquisition is the largest disclosed ortho MSO PE exit of 2024 | HIGH |
| OrthoCarolina | Atlas Partners commonly reported, but General Atlantic also referenced as majority holder at $1.2B 2022 valuation (CONFLICTING; see Section 17) | Indeterminate 2022 entry; cap-table verification required | Total joint, sports medicine, spine, hand (Charlotte metro) | Owns Matthews Surgery Center (acquired October 2024 from Novant Health), now second fully-owned ASC | October 2024: Matthews Surgery Center acquisition; January 13, 2025 announcement (February 2025 close): sold 24-clinic PT business with ~300 PTs to PT Solutions (General Atlantic); also acquired a pain-focused surgery center in 2024 | MEDIUM (sponsor identity disputed) |
| Resurgens Orthopaedics | Indirect through UMP (WCAS + A&M Capital) | December 2021 (UMP entry; Resurgens as founding practice) | Full-spectrum; largest independent ortho group in Georgia at entry (~100 physicians) | Atlanta-area ASCs as part of UMP | 25th Atlanta-metro office opened in Braselton, GA April 2025 | HIGH |
| HSS + General Atlantic ASC platform | General Atlantic (announced October 15, 2025, jointly with HSS to acquire Legent Health from BTG Pactual Strategic Capital) (HSS announcement) | October 15, 2025 | Orthopedic and spine outpatient ASC | Purpose-built national ASC platform with physician equity ownership and HSS clinical protocols | Legent Health acquisition from BTG Pactual; HSS-University of Miami partnership at UHealth SoLé Mia 2025; HSS-Deerfield AIM alliance November 2025 | HIGH |
| Evolve Orthopedic Partners | Zenyth Partners (physician-led MSO model) | 2024 launch | Multi-segment MSO; structured around ASC-owning groups | Practice-owned ASCs | New entrant 2024 to 2025 vintage | MEDIUM |
| U.S. Orthopaedic Partners (USOP) | Sponsor not publicly confirmed in current searches (USOP announcement) | Multi-state Southeast; Stephen Holtzclaw MD MBA named CEO January 2024 | Integrated continuum (physician services + ASC + ancillary) | Practice-owned ASCs | Partnership with North Alabama Bone & Joint Clinic | MEDIUM (sponsor identity unconfirmed) |
| PELTO Health Partners (non-PE physician-owned alternative) | NO PE SPONSOR; physician-owned coalition founded February 2023 by EmergeOrtho, OrthoIndy, Proliance Surgeons (EmergeOrtho announcement) | Multi-state coalition; 400+ physicians at launch, 500+ across five groups | Full-segment | Member-group-owned ASCs | OrthoCincy joined; Olympia Orthopaedic Associates joined; structured explicitly as alternative to PE-backed MSOs | HIGH |
| U.S. Foot & Ankle Specialists (USFAS / UFAS) | NMS Capital (NMS Capital) | December 2018 (USFAS formation with FASMA) | Foot and ankle podiatric medicine + surgery | Office-based with health-system ASC partnerships | 80+ affiliated brands, 200+ locations across 22 states, 300+ podiatrists; 20+ practice add-ons across 13+ states 2024 to 2026; March 2026 acquisition of Foot and Ankle Specialists | HIGH |
| Upperline Health | Extremity Healthcare (acquired February 28, 2025; prior sponsors Silversmith Capital Partners + Crestline) (PitchBook) | Extremity February 28, 2025; Silversmith and Crestline cycle ended | Podiatry, wound care, peripheral vascular | Primarily office and clinic | February 28, 2025 acquisition by Extremity Healthcare | HIGH |
| Balance Health / Weil Foot & Ankle Institute (combined) | Stonehenge Partners + Aureus Capital (Weil prior sponsors); majority physician-owned post-merger (Balance Health announcement) | Merger announced June 5, 2023; closed November 1, 2024 | Foot and ankle podiatric medicine + surgery + wound care + PT + pain management + research | Office-based + research center | Pre-merger Balance had 100+ podiatrists/orthopedists/PTs across CA/AZ/WA; Weil had 50+ across IL/WI/MI/VA; combined described as largest majority physician-owned podiatric medical organization in US | HIGH |
| Podiatry Growth Partners (PGP) | Compass Group Equity Partners (lead) + VSS + Siguler Guff + SunGate Capital (VSS) | October 2020 institutional sponsor entry | Regional branded podiatry clinics | Office-based | St. Louis HQ; ongoing add-ons including Foot and Ankle Specialists of Central Ohio, Kentuckiana Foot & Ankle Sports Medicine, Tipton & Unroe Foot and Ankle Care through 2025 to 2026 | HIGH |
Total joint reconstruction is the largest and most economically important orthopedic sub-segment. Annual US procedure volume projections for THA reach approximately 652,000 by 2025 and 850,000 by 2030 (Journal of Rheumatology); TKA is projected to reach roughly 935,000 to 1.26 million by 2030 across two published models (JBJS) (Journal of Arthroplasty). The four PE-backed platforms with the deepest total joint depth are UMP (with Resurgens and Panorama as the anchoring practices), HOPCo / The CORE Institute (with the Phoenix-area specialty hospital footprint), Beacon Orthopaedics under Revelstoke, and Orthopedic Care Partners under Varsity Healthcare Partners and Brookfield. [Confidence: HIGH]
UMP’s structural advantage is the breadth of ASC ownership through the Resurgens Atlanta network and the Panorama Denver network, both of which were ASC-mature before the WCAS investment closed. HOPCo’s structural advantage is its value-based-care infrastructure acquired through the October 2020 purchase of Stryker Performance Solutions’ value-based-care business (Linden Capital announcement), which positions it to operate inside the CJR-X mandatory bundled-payment framework once October 1, 2027 hits. Orthopedic Care Partners’ December 2024 recap brings Brookfield’s preferred-equity capital and TPG Twin Brook’s senior debt capacity to a $185M plus $358M combined transaction, signaling that Varsity is preparing the asset for sale per PE Hub reporting (PE Hub). Beacon under Revelstoke is the most recent vintage entry (July 2023) and sits earlier in its hold period.
Sports medicine sits adjacent to total joint but has distinct payor and procedure mix economics. Workers’ compensation and self-funded employer payor mix is materially higher in sports medicine than in adult reconstruction. A national figure on workers’ comp payor mix for ortho MSOs was not surfaced in the research pass; this is flagged as a gap in Section 17. The PE-backed platforms with substantial sports medicine depth include Beacon Orthopaedics (its branded sub-specialty), OrthoAlliance (now under SCA Health / Optum), UMP through Resurgens, HOPCo, and OrthoCarolina. The physical-therapy adjacency is structurally important to sports medicine because the post-surgical and non-operative pathway depends on PT delivery, which is why the OrthoCarolina / PT Solutions February 2025 transaction was significant strategically: it formalized the divestiture-and-partnership model. [Confidence: HIGH for platform identity; GAP for national payor-mix figures]
Spine sits at the high end of orthopedic procedure complexity and per-case revenue. Spine surgery is highly capital-intensive (image-guided navigation, robotics, biologics) and has historically been concentrated in hospital and HOPD settings. CY2026 MPFS Efficiency Adjustment pressure affects spine codes alongside adult reconstruction codes. HOPCo / The CORE Institute (which includes the Phoenix-area specialty hospital), UMP (with Resurgens spine depth), Orthopedic Care Partners, and OrthoCarolina all have material spine programs. The HSS + General Atlantic platform is structured explicitly to be “orthopedic and spine outpatient” (HSS announcement), targeting the ASC migration of spine cases that historically stayed in hospitals. [Confidence: HIGH]
Hand surgery is a fragmented sub-segment with lower per-case dollar value than total joint or spine but a high case volume and ASC compatibility. PE-backed platforms with hand depth include UMP (through Resurgens), OrthoAlliance, OrthoCarolina, and Beacon Orthopaedics. As a roll-up sub-segment, hand sits between adult reconstruction (with the highest per-case economics) and podiatry (with comparable per-case economics but distinct training and licensure). Independent hand surgery groups have historically been targets of add-on transactions rather than platform anchors. [Confidence: MEDIUM]
Foot and ankle podiatry is the under-tracked sub-segment of this tracker and the most active in 2024 to 2025 for sponsor turnover. The named platforms are US Foot & Ankle Specialists (USFAS) under NMS Capital, Podiatry Growth Partners (PGP) under Compass Group / VSS / Siguler Guff / SunGate, Balance Health combined with Weil Foot & Ankle Institute (closed November 1, 2024), and Upperline Health (acquired by Extremity Healthcare February 28, 2025).
USFAS has built to 80+ affiliated brands, 200+ locations across 22 states, and 300+ podiatrists since the December 2018 NMS Capital formation transaction with Foot & Ankle Specialists of the Mid-Atlantic (USFAS). The 2022 to 2026 add-on program spans Foot and Ankle Specialists PC (MI), Podiatry Inc (OH), Bethel Foot and Ankle (CT), Mid-West Podiatry & Associates (MO), First Choice Ankle & Foot Care Center, Foot Specialists of Kansas City, Indian Valley Podiatry Associates (PA), Advanced Foot & Ankle Center (DE), Augusta Podiatric Medicine & Surgery, Center for Foot and Ankle Care, Cortez Foot & Ankle Specialists (FL), Next Step Foot and Ankle Centers (MO/IL), Foot Care Center and Lakeforest Foot and Ankle Center (Northern VA), Comprehensive Foot & Ankle Centers (KY), Palmetto Podiatry Group of Anderson (SC), Family Foot & Ankle Center, and most recently Foot and Ankle Specialists announced March 2026 (NMS Capital USFAS tag). [Confidence: HIGH]
Balance Health and Weil Foot & Ankle Institute closed their combination November 1, 2024 (announced June 5, 2023). Pre-merger Balance had 100+ podiatrists, orthopedists, and PTs across California, Arizona, and Washington. Weil had 50+ podiatrists and PTs across Illinois, Wisconsin, Michigan, and Virginia. The combined entity is described in the press release as the largest majority physician-owned podiatric medical organization in the US, with growth-equity minorities from Stonehenge Partners and Aureus Capital. [Confidence: HIGH]
The Upperline / Extremity Healthcare February 28, 2025 close is the first major sponsor-turnover event in podiatry post-platform-scale and is discussed in detail in Section 8 above. PGP under Compass Group / VSS / Siguler Guff / SunGate continues a steady add-on cadence through 2025 to 2026. [Confidence: HIGH]
Pediatric orthopedics is the smallest of the named sub-segments and is structurally distinct because of the BLS data and fellowship pathways. BLS reports orthopedic surgeon mean wages at $279,040 excluding pediatric specialty, indicating pediatric ortho is tracked separately in OEWS (BLS OEWS). Pediatric ortho has not been a meaningful PE roll-up target in 2024 to 2026 in the named-platform set, both because the case volume is materially smaller and because pediatric ortho is concentrated at academic medical centers and children’s hospital networks. We treat pediatric ortho as adjacent rather than central to this tracker’s PE platform thesis. [Confidence: MEDIUM]
The PE-platform-owned set is matched by a substantial non-PE independent ortho bench whose ownership structures, partnership posture, and likely sale paths inform the bid set for any 2026 transaction. Several of these were named in the original brief as PE-backed and have not been corroborated as such in current research; we treat them as either physician-owned or independent until verified otherwise, and flag each in Section 17.
OrthoVirginia operates as Virginia’s largest independent ortho practice, with 160+ orthopedic specialists across 35+ locations. Public positioning in current sources is physician-owned, not PE-backed (OrthoVirginia). The “OrthoVA Capital” structure referenced in the original brief was not corroborated; we flag this as a gap. OrthoVirginia is a credible bid-set entrant for PELTO Health Partners (it has the physician scale, state-concentrated coverage, and ASC depth that fit the coalition model), but no public announcement of PELTO membership exists as of June 16, 2026. [Confidence: HIGH for independent status; GAP for sponsor identity claims]
OrthoTennessee, OrthoGeorgia, OrthoIndy. Original brief referenced these as potentially PE-backed. OrthoIndy participates in PELTO Health Partners (the non-PE physician-owned coalition), confirming it is non-PE. OrthoTennessee and OrthoGeorgia structures were not surfaced in current research. The default assumption, given coalition participation patterns and the absence of trade-press coverage of a PE transaction in either name, is that both are independent. [Confidence: HIGH for OrthoIndy; GAP for OrthoTennessee and OrthoGeorgia]
Crystal Run Healthcare, Coastal Orthopedics, Greenwich Orthopaedics, The Orthopaedic Institute. None surfaced as PE-backed in current 2024 to 2026 searches. Each may be physician-owned, hospital-employed, or part of an undisclosed sub-platform structure. For sponsors evaluating geographic gaps, each is a candidate for diligence-based outreach. [Confidence: GAP]
The structural point: the non-PE independent ortho bench is large, partnership-ready in many cases (PELTO model, AMC partnership template, or strategic-IDN partnership), and represents the meaningful supply curve for the next PE platform-build wave. For PE sponsors entering ortho in 2026, the independent bench is the practical add-on universe.
The following deal timeline organizes the most material 2024 to 2026 transactions chronologically. Every entry carries an inline primary source.
The “new Northeast ortho platform” launched through a Provident Healthcare Partners-led process in 2024 is referenced by Provident itself (Provident) but is not publicly named in current search. We disclose this as a gap in Section 17.
Public median multiple data, vintage-tagged. Use this as the comparable framework rather than as a single-point benchmark, because deal-by-deal dispersion is wide and primary-source EBITDA disclosure on private ortho MSO transactions is generally not available.
The healthcare services median EV / EBITDA was 14.5x in 2024, dropping to 11.5x in 2025 per FOCUS Investment Banking dashboards and First Page Sage (First Page Sage) (FOCUS Investment Banking). For orthopedic-specific platforms at scale, Becker’s Spine Review reports that large orthopedic practice platforms can fetch 10x EBITDA or higher (Becker’s Spine). The mid-market sweet spot of $3M to $10M EBITDA commands the strongest pricing power, with practices over $5M EBITDA often trading 2 to 4 turns above small add-ons (Sofer Advisors valuation guide). [Confidence: HIGH for the framework; MEDIUM for the absolute multiples]
The OrthoAlliance / SCA Health $1.4 billion benchmark is the live exit comp for a 200+ physician Midwest platform with ASC integration. Public reporting does not disclose OrthoAlliance’s EBITDA at sale, so an implied multiple cannot be computed precisely from public data. The Physician Growth Partners Q4 2024 ortho PE white paper identified more than 18 PE-backed orthopedic platforms in market at year-end 2024 (Physician Growth Partners white paper); the Hyde Park Capital Spring 2025 orthopedic outlook is a primary public-source pricing reference (Hyde Park Capital outlook). Provident Healthcare Partners publishes a recurring orthopedic services investment report tracking platform valuation drivers (Provident), and was named to the AAOE Peer Review Program for orthopedic M&A advisory in February 2024 (PR Newswire).
Indicative bands by ortho sub-segment, 2025 to 2026 vintage.
Podiatry valuation gap: KPMG Corporate Finance published a podiatry physician-practice M&A overview in February 2023 (KPMG podiatry M&A overview). Public commentary across Student Doctor Network and trade press positions podiatry add-ons as trading at lower mid-single-digit multiples versus orthopedic add-ons in the mid-to-high single digits, but no audited median benchmark for podiatry add-on transactions is publicly available as of June 2026 (Podiatry Management feature). Mertz Taggart’s ortho-specific quarterly is not located in current searches; the firm’s coverage is concentrated in home-based care, behavioral health, and post-acute (Axial Mertz Taggart profile). [Confidence: GAP for primary-source podiatry benchmarks]
Beyond the CY2026 MPFS Final Rule and the CJR-X proposed rule, three additional regulatory and payor threads materially affect ortho MSO valuation work in 2024 to 2026.
BPCI Advanced and Medicare Advantage. BPCI Advanced (Bundled Payments for Care Improvement Advanced) continues as a voluntary episode-based model. Medicare Advantage now covers more than half of Medicare-enrolled beneficiaries, and MA’s tighter prior-authorization posture compresses surgical utilization on the front end and inflates administrative cost on the back end relative to traditional Medicare. Concrete national MA ortho-utilization figures were not surfaced in this research pass and are flagged in Section 17 as a gap. The qualitative impact is well understood, however: for an ASC-integrated platform, MA penetration creates revenue-cycle drag (denials, peer-to-peer review, delayed authorization) that scales with case volume. Diligence on any ortho MSO transaction in 2025 to 2026 includes MA mix, MA payor concentration, MA denial rates, and MA appeals win rate as standard items. [Confidence: HIGH for the qualitative impact; GAP for national figures]
FTC and physician-combination antitrust. The FTC noncompete rule was permanently blocked by a Texas federal district court in August 2024 (Physicians Practice). The FTC withdrew its appeal in September 2025 under the current administration but has stated it will continue case-by-case noncompete enforcement under existing antitrust authority. Physician-combination antitrust review remains a stated FTC focus area (Holland & Knight midyear review) (Medical Economics). The practical implication for ortho MSO transactions: HSR filings, second-request risk in concentrated metros, and noncompete enforceability are diligence items that have moved from boilerplate to substantive in 2025 to 2026. [Confidence: HIGH]
State legislation: Oregon as the leading edge. Oregon enacted a multi-pronged statute targeting MSO structures, voiding noncompetes, nondisclosures, and nondisparagement clauses, and barring stock-restriction agreements between business entities and medical professionals; the stated goal is restoring guardrails against corporate control of medical practices (CHIR Georgetown). 37 state bills related to healthcare consolidation and competition were enacted in 2025 (Physicians Practice). For ortho MSO sponsors, state-by-state diligence on MSO statute, noncompete enforceability, and corporate-practice-of-medicine doctrine is now standard. [Confidence: HIGH]
State certificate of need (CON). State CON regimes targeting ASC construction are associated with increased patient migration out of state for primary hip and knee arthroplasty per published research in 2026 (ScienceDirect 2026 ASC migration study). The practical implication: state-by-state CON exposure is a value driver for ASC platforms, with CON states limiting new-build capacity but locking incumbent ASC owners into protected economics, and non-CON states allowing more competitive entry but enabling faster expansion. Diligence on every ASC platform now includes state CON status and CON sunset or repeal probability. [Confidence: HIGH]
Three large physical-therapy roll-ups sit in immediate adjacency to ortho MSOs and define how the surgical-PT continuum is being unbundled and re-bundled in 2024 to 2026.
Athletico Physical Therapy operates more than 900 locations across 25 states with approximately 8,000 employees following its acquisition of Pivot Health Solutions, and is currently a Mubadala Capital portfolio company (prior sponsor BDT Capital Partners) (Crain’s Chicago Business). PT Solutions operates more than 550 points of service across 25 states; General Atlantic took a majority stake at a reported $1.2 billion valuation in January 2022 (Axios). NovaCare Rehabilitation is a Select Medical Corporation division operating within Select’s approximately 1,900-clinic outpatient footprint across 37 states (NovaCare Rehabilitation). [Confidence: HIGH]
The OrthoCarolina to PT Solutions transaction announced January 13, 2025 and closed in February 2025 is the canonical ortho-PT carve-out template. OrthoCarolina sold its 24-clinic physical-therapy business with approximately 300 PTs to PT Solutions, while focusing the surgical practice on physician services and ASC ownership (PT Solutions press release). PT Solutions simultaneously partnered with Novant Health to maintain referral pathways. The deal architecture has three components: (1) carve out the PT operating unit, (2) sell to a specialized PT sponsor at PT-platform multiples (which are typically 1 to 2 turns higher than embedded PT inside an ortho MSO), (3) preserve clinical referral pathways through a separate partnership with a health-system anchor.
The strategic logic is straightforward. PT inside an ortho MSO is valued at the ortho MSO multiple. PT inside a dedicated PT roll-up is valued at the PT platform multiple, which is materially higher because of route-density economics, scheduling utilization, and the bundled-payment-adjacent positioning that PT platforms can claim with payor contracting. For ortho MSO sponsors, the OrthoCarolina playbook offers a value-recognition path: carve out PT at peak multiple, redeploy proceeds into ASC ownership, and partner with a PT operator on referral pathway. We expect more named ortho MSOs to follow this template through 2026 and 2027 as PT multiples remain above ortho-MSO embedded-PT multiples.
A 2025 federal-government analysis of the orthopedic surgeon workforce projects supply declining from 31,980 in 2025 to 30,620 in 2037 (a 4.3% decrease), while demand grows from 33,690 in 2025 to 35,850 in 2037 (a 6.4% increase) (PubMed federal workforce analysis). By 2030, surgeon shortages are estimated to add 10% to 50% additional clinical workload per surgeon measured in work RVUs (Healio workforce report). To meet 2050 projected TJA demand, surgeons would need to either double primary TJA caseload or grow the surgeon population by 10% every five years; the 2017 baseline was 65.2 primary TJAs per active surgeon per year (AAOS press kit). [Confidence: HIGH]
Orthopedic surgery remains one of the most competitive specialties in the NRMP Main Residency Match, maintaining exceptionally high fill rates in 2025 (NRMP 2025 results). DO seniors increased their share of filled orthopedic positions by 1.3 percentage points in 2025 (Match Guy 2025 analysis). The Step 1 transition to pass / fail has shifted weight to Step 2 CK and research productivity per Orthopedic Surgery Residency Match Trends 2024 (ScienceDirect match trends). The DO match rate into orthopedics decreased from 63.28% in 2020 to 45.70% in 2024 (JOM osteopathic ortho trends). [Confidence: HIGH]
Advanced practice provider (APP) integration is one of the few short-cycle production levers available to MSOs facing surgeon supply constraints. PAs, NPs, surgical first assists, and athletic trainers in physician-extender roles can absorb the routine post-operative, follow-up, and triage work that historically tied up surgeon time. Specific 2024 to 2026 APP utilization figures across PE-backed ortho platforms are not publicly disclosed in current research, which we flag as a gap in Section 17. Anecdotally, every named platform in Section 10 above is investing in APP integration as a productivity multiplier, but no public benchmark exists for ratio of APPs per surgeon at platform scale.
The structural shift in 2024 to 2025 that this tracker keeps returning to is the strategic-buyer set replacing PE secondary as the most likely platform-scale exit. We organize the strategic-buyer set into three categories.
Payor-vertical integration. UnitedHealth Group’s acquisition of OrthoAlliance through its SCA Health subsidiary at $1.4 billion (closed November 1, 2024) is the lead comp. UnitedHealth’s logic: SCA Health is the largest ASC operator in the country; OrthoAlliance brings the surgeon network and case-volume mix that justifies the ASC footprint. The transaction integrates the payor’s utilization-management apparatus with the provider’s case-flow, capturing both legs of the dollar. Elevance Health (formerly Anthem), Humana, and CVS / Aetna have not announced ortho-MSO transactions of comparable scale through June 16, 2026, but each has provider-services build-outs that could position them as the next buyers in the category. [Confidence: HIGH for UnitedHealth precedent; MEDIUM for forward outlook]
IDN strategic. Tenet Healthcare’s USPI segment (the largest US ambulatory-surgery network) reported a 19% YoY increase in total joint replacements in 2024 (ASC News). HCA Healthcare’s specialty-hospital network operates large orthopedic-specific facilities in Texas, Florida, and other concentrated markets. Surgery Partners reported greater than 50% YoY ASC total joint growth in Q3 2024. Each is a potential buyer of an ortho MSO platform at scale, with the transaction logic being case-volume migration into the buyer’s owned ASC footprint. The deal architecture is similar to the UnitedHealth pattern except the buyer is a provider-services strategic rather than a payor. [Confidence: HIGH]
Academic-medical-center JV. Hospital for Special Surgery’s October 15, 2025 launch with General Atlantic of a national ASC platform is the prototype. HSS provides clinical authority, brand, and protocols; General Atlantic provides PE growth-equity capital and operating execution. Legent Health (acquired from BTG Pactual Strategic Capital) provides the installed ASC base. The structure works because HSS itself is not PE-owned (academic medical centers cannot be) but the ASC vehicle is structurally PE. This is the most replicable strategic-buyer template for the next 24 months. Cleveland Clinic, Mayo Clinic, Johns Hopkins, NYU Langone, and Penn Medicine each have orthopedic depth that could anchor an analogous JV with a PE sponsor; none has announced one through June 16, 2026. The HSS / Deerfield AIM alliance (November 2025) is an adjacent precedent for AMC + investor structures (AIM announcement). [Confidence: HIGH for HSS precedent; MEDIUM for category-wide replication probability]
For sponsors at the platform-eligible scale ($40M+ EBITDA), the practical implication is to run a dual-track process. The traditional PE secondary track stays open. The strategic track now includes payor-vertical integration, IDN strategic, and AMC JV as bid-set entrants. Diligence preparation differs by track. Strategic buyers focus on case-mix migration analytics, clinical protocol portability, registry contributions, and physician retention mechanics. PE secondary buyers focus on EBITDA growth runway, multiple-arbitrage on add-ons, and exit-cycle visibility.
The matrix below maps practice size to buyer universe, indicative multiple range, and seller-side considerations as of June 2026. Use this as a directional framework, not a substitute for sell-side advisory work. Confidence bands reflect dispersion of public deal data.
| Seller Profile | EBITDA Range | Buyer Universe | Indicative Multiple | Key Seller Considerations | Confidence |
|---|---|---|---|---|---|
| Solo orthopedic surgeon | Sub-$1M | Local hospital, regional PE platform add-on, succession-driven transfer | 4x to 6x | Few buyers; ASC equity transferability and noncompete enforceability material; CJR-X exposure low pre-October 2027 | MEDIUM |
| Small group (2 to 5 surgeons) | $2M to $5M | 8 to 12 PE platforms competing on add-on basis; PELTO and physician-owned coalition emerging | 7x to 10x | Practice-wide ASC ownership lifts multiple 1 to 2 turns; payor concentration risk diligenced | HIGH |
| Mid-size group (6 to 15 surgeons) | $5M to $15M | 6 to 10 PE platforms; payor-strategic interest emerging at upper end | 10x to 14x with ASC premium | ASC ownership and value-based-care infrastructure are decisive; CJR-X readiness diligenced | HIGH |
| Regional group (15 to 50 surgeons) | $15M to $40M | 4 to 6 PE platforms; strategic IDN partnerships; HSS / GA platform as bid-set entrant | 12x to 15x | State CON regime, payor mix, ASC syndication structure all material; PELTO entry as competing non-PE bid | HIGH |
| Platform-eligible (50+ surgeons) | $40M+ EBITDA | Strategic-or-sponsor exit; UnitedHealth / SCA, Tenet / USPI, Surgery Partners, payor-vertical buyers | 14x to 18x | OrthoAlliance / SCA $1.4B benchmark; data assets, clinical protocols, registry contributions are exit value drivers | HIGH |
| Podiatry: solo / small group (1 to 4 podiatrists) | Sub-$1M to $3M | USFAS, PGP, Balance Health, Upperline (Extremity), regional add-on platforms | 3x to 5x | Approximately 1 to 2 turns below ortho add-on benchmarks; ASC partnership availability material | MEDIUM |
| Podiatry: regional group (5 to 25 podiatrists) | $3M to $10M | USFAS, PGP, Balance Health, Upperline / Extremity, Foundry-comparable platforms | 6x to 10x | Wound-care and peripheral-vascular case mix lifts multiple; geographic exclusivity material at this scale | MEDIUM |
| Podiatry: platform-eligible (25+ podiatrists) | $10M+ EBITDA | Strategic-to-strategic precedent (Extremity Healthcare acquired Upperline); next PE secondary; payor-vertical buyer | 8x to 12x | Extremity / Upperline February 28, 2025 close is the live benchmark; CJR-X ankle bundling impacts forward economics | MEDIUM |
The diligence priorities below reflect what 2024 to 2026 transaction patterns reveal as the load-bearing items. The list is non-exhaustive; it focuses on the items that have moved most in importance since 2022.
The following items were either not surfaced in current public-source searches as of June 16, 2026, or surfaced with conflicting or incomplete public reporting. They are flagged for verification by management interviews, PitchBook, or Capital IQ before any external use that depends on them.
Primary sources are grouped by category. Every URL referenced in the body of this tracker appears below at least once; some appear multiple times in the body where the same source supports more than one claim.
OrthoAlliance has been owned by UnitedHealth Group through SCA Health (Optum’s ASC operating company) since November 1, 2024 at a reported $1.4 billion. Revelstoke Capital Partners, the previous sponsor, fully exited. The transaction was announced December 18, 2024 and closed effective November 1, 2024 (Becker’s ASC).
HOPCo / The CORE Institute is jointly held by Linden Capital Partners and Audax Group as co-sponsors since 2019, when the two firms invested approximately $400 million combined. Public summaries that list only Linden Capital as the sponsor are incomplete; Audax is a co-sponsor at the same level (Linden Capital). HOPCo engaged Houlihan Lokey in 2025 to explore a strategic sale per ION Analytics reporting.
Upperline Health was acquired by Extremity Healthcare on February 28, 2025. The acquisition ended the Silversmith Capital Partners and Crestline ownership cycle (PitchBook). Extremity Healthcare’s sponsor capital structure is not publicly disclosed in current searches and is flagged as a gap.
CJR-X (Comprehensive Care for Joint Replacement Expanded) is the successor to the original CJR mandatory bundled-payment program. CJR-X was proposed in the FY2027 Hospital IPPS Proposed Rule released April 10, 2026, and is structured to be mandatory nationwide beginning October 1, 2027. It differs from the original CJR in two material ways: it adds ankle replacement to the bundled-episode definition, and it applies to hospital outpatient settings in addition to inpatient. Episode pricing remains target-price-based against all Part A and Part B costs over the procedure plus the 90-day post-discharge window (CMS).
Per AAHKS’ summary of CMS-1832-F, CY2026 rates for CPT codes 27130 (THA) and 27447 (TKA) will be lowered by 7.3% for Qualifying APM Participants and 7.8% for Non-Qualifying APM Participants, driven by a new Efficiency Adjustment that cuts intraservice work-RVU time by 2.5% across all non-time-based codes. Evaluation and management, care management, behavioral health, and telehealth services are exempt (AAHKS).
TKA (CPT 27447) was removed from the IPO List effective January 1, 2018. THA (CPT 27130) was removed effective January 1, 2020, and added to the ASC Covered Procedures List effective January 1, 2021 with payment indicator J8 (device-intensive). The Medicare ASC payment for CPT 27130 was $9,244 in CY2024 (CMS CY2021 fact sheet).
The OrthoAlliance / SCA Health transaction was reported at $1.4 billion for a platform with 200+ physicians across Ohio, Indiana, and Kentucky. OrthoAlliance’s EBITDA at sale is not publicly disclosed, so an implied multiple cannot be computed precisely from public data alone. The headline transaction value is the live exit benchmark for ASC-integrated, multi-state ortho MSOs at platform scale.
No. PELTO Health Partners is a physician-owned coalition founded in February 2023 by EmergeOrtho, OrthoIndy, and Proliance Surgeons, joined subsequently by OrthoCincy and Olympia Orthopaedic Associates. It is structured explicitly as an alternative to PE-backed MSOs, with member-group-owned ASCs and no sponsor capital (EmergeOrtho).
On October 15, 2025, Hospital for Special Surgery and General Atlantic announced the joint launch of a national platform to expand access to orthopedic and spine outpatient care, simultaneously agreeing to acquire Legent Health from BTG Pactual Strategic Capital. The platform is structured to give physicians equity ownership and access to HSS clinical protocols (HSS).
This tracker identifies 14+ active US orthopedic and podiatry MSO platforms with corrected sponsor attributions as of June 16, 2026, across total joint, sports medicine, spine, hand, and foot and ankle / podiatry segments. The Physician Growth Partners Q4 2024 ortho PE white paper identified more than 18 PE-backed orthopedic platforms in market at year-end 2024 (PGP). The disclosure scope across both counts is similar; the dispersion reflects platform-versus-MSO labeling conventions and whether physician-led coalitions like PELTO are counted in the PE category.
HOPCo engaged Houlihan Lokey to run a strategic sale process per ION Analytics reporting in 2025 (ION Analytics). Orthopedic Care Partners is reported as preparing for sale per PE Hub (PE Hub) following the December 2024 Brookfield and TPG Twin Brook recapitalization. Both processes are open as of June 16, 2026.
An orthopedic mid-market group with $5M EBITDA, multi-site coverage, and ASC ownership typically transacts in the 10x to 12x EBITDA band as of 2025 to 2026, with practices over $5M EBITDA often trading 2 to 4 turns above small add-ons per Sofer Advisors (Sofer Advisors). ASC ownership and value-based-care infrastructure lift the multiple toward the high end. HOPD dependence and CJR-X exposure compress it. See Section 16 for the full seller-fit matrix.
Five live transactions and regulatory milestones are likely to set the next benchmarks and reshape the bid set through the next 18 months. We track each as a watch item and will refresh this tracker as material new information lands.
HOPCo strategic sale process. HOPCo engaged Houlihan Lokey to explore a strategic sale per ION Analytics reporting in 2025 (ION Analytics). HOPCo is the largest currently-open process in the named-platform set and the most clinically integrated (Phoenix-area specialty hospital plus Stryker Performance Solutions value-based-care infrastructure plus the August 2025 Caro Health AI acquisition). The natural buyer set covers payor-vertical integration (UnitedHealth, Elevance), IDN strategic (HCA, Tenet, Surgery Partners), and AMC JV (an HSS-style structure with a different academic anchor). The transaction value, when disclosed, will be the most informative single comp for the 2026 to 2027 vintage. [Confidence: HIGH for process; GAP for terms]
Orthopedic Care Partners next sale. Varsity Healthcare Partners is reported as preparing OCP for sale per PE Hub (PE Hub) following the December 2024 Brookfield and TPG Twin Brook recapitalization. The Brookfield preferred-equity position effectively dual-purposes as a pre-sale capital structure that supports valuation. Six ASCs, 136 physicians, 42 clinical locations across five states. Likely buyer set similar to HOPCo. [Confidence: HIGH for sale prep; GAP for terms and timing]
CJR-X Final Rule. The CJR-X Final Rule is expected to follow the FY2027 IPPS Final Rule cycle, with the proposed nationwide mandatory effective date of October 1, 2027. The final-rule shape will determine bundled-payment readiness diligence priorities through 2026 and 2027. We track for changes in episode scope, ankle replacement inclusion, HOPD inclusion, and target-price methodology. [Confidence: HIGH for timing; MEDIUM for final shape]
CY2027 MPFS Proposed Rule. The CY2027 MPFS Proposed Rule will be released in summer 2026 and will reveal whether the Efficiency Adjustment continues at 2.5%, scales up, or sunsets. The forward signal will determine the trajectory of HOPD-dependent ortho economics through 2027 and 2028. We track for changes in work-RVU efficiency methodology and any orthopedic-specific code adjustments. [Confidence: MEDIUM for content; HIGH for timing]
Next strategic-buyer ortho transaction. The OrthoAlliance / UnitedHealth precedent is now 18 months old. We watch for the next payor-vertical or IDN strategic ortho transaction as a second comp point. Candidates from the trade-press radar include a Tenet / USPI ortho MSO transaction, an Elevance Health provider-services build-out involving an ortho asset, an HCA specialty-hospital ortho MSO acquisition, or a Surgery Partners ortho platform consolidation. [Confidence: MEDIUM for category; LOW for specific candidate]
CT Acquisitions is a healthcare-services M&A advisory and primary research practice. Our PE roll-up tracker series covers home health, behavioral health, applied behavior analysis, veterinary, dermatology, dental DSO, ophthalmology, gastroenterology, and orthopedic and podiatry MSO platforms. Every tracker is anchored to primary sources (CMS, FTC, BLS, US Census Bureau, sponsor disclosures, registry annual reports, and peer-reviewed journals), refreshed against the most recent transactions, and disclosed against per-cell confidence and gap items. This tracker was assembled June 16, 2026 and will be refreshed when material new transactions land. We welcome corrections to confidence-flagged items at contact addresses on the CT Acquisitions site.
Last updated: June 16, 2026.