Physician Professional Fees Are Declining and Inpatient and Outpatient Facility Fees Are Increasing for Orthopaedic Procedures in the United States.

PURPOSE: To examine the trends in physician professional fees and inpatient and outpatient facility fees in orthopaedic surgery in the United States. METHODS: Physician professional fees and inpatient and outpatient facility fees were tracked from 2008 to 2021 for the most common orthopaedic procedures in each orthopaedic subspecialty. Using common procedure codes for physician and outpatient procedures and Medicare severity diagnosis related group codes for inpatient procedures, the Medicare Physician Fee Schedules were used to obtain the national payment amounts for physician professional fees and inpatient and outpatient facility fees. Trends in fees were tracked over time after adjustment for inflation. RESULTS: From 2008 to 2021, physician professional fees decreased by an average of 20%, whereas inpatient facility fees increased by 15%, and outpatient facility fees increased by 72%. The orthopaedic subspecialty with the largest decrease in physician professional fees was oncology, with an average decrease of 23.5%, followed by general orthopaedics (23.1%), and sports medicine (22.8%). The largest increase in outpatient facility fees was seen in the subspecialties of general orthopaedics (149.8%), spine (130.1%), and trauma (123.0%). CONCLUSIONS: Over the past 13 years, physician professional fees for the most common orthopaedic procedures have declined while inpatient and outpatient facility fees have increased. Understanding these changes is important to the practice of orthopaedic surgery in the United States. LEVEL OF EVIDENCE: IV, economic.

The Moderating Effect of Age on Patient-Reported Benefits From Operative Management of Intra-Articular Distal Radius Fractures: A Meta-Regression Analysis.

PURPOSE: The optimal treatment of intra-articular distal radius fractures in older adults (>65 years) remains uncertain despite numerous randomized trials. The purpose of this study was to examine the moderating effect of age on patient-reported benefits of volar locked plating versus cast immobilization for intra-articular distal radius fractures. METHODS: A meta-analysis of randomized controlled trials was conducted to compare volar locked plating and cast immobilization of intra-articular distal radius fractures. Meta-regression analyses were used to examine the moderating effect of age on improvements in patient-reported outcome measures from operative treatment of distal radius factures. Modeling results were then used to estimate improvements in Disability of the Arm, Shoulder, and Hand (DASH) scores from surgery that are associated with ages ranging from 65 to 90 years. RESULTS: Twelve randomized controlled trials including 1,806 patients were included. Age was a significant moderator of patient-reported benefits after operative treatment, with decreasing DASH score benefits from surgery associated with older ages. Model predictions show that a majority of patients aged <70 years will experience a clinically meaningful improvement in DASH scores from surgery. Patients aged 70-80 years have decreasing DASH benefits with age, but many may still experience a clinically meaningful improvement from surgery. Patients aged >80 years are unlikely to experience a clinically meaningful improvement in DASH scores with surgical management. CONCLUSIONS: Older ages are associated with decreased benefits from surgical management with volar locked plating as compared to cast immobilization. Patients aged >80 years are unlikely to experience a clinically significant improvement with surgery. Surgeons and policymakers may use these data to counsel patients, health systems, and professional organizations on the risks and benefits of operative treatment in older adults. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis 1, Meta-Analysis of Randomized Controlled Trials.

A Prospective Clinical Trial Comparing Denervation With Suspension Arthroplasty for Treatment of Carpometacarpal Arthritis of the Thumb.

PURPOSE: Trapeziectomy with suspensionplasty is the most popular treatment for thumb carpometacarpal arthritis. However, carpometacarpal denervation has recently shown promise as an alternative treatment option. This study was designed to compare functional outcomes, pain reduction, and quality of life between denervation and suspension arthroplasty in patients treated for thumb carpometacarpal osteoarthritis. METHODS: We conducted a prospective clinical trial between June 2020 and December 2021. Preoperative and postoperative evaluations were conducted on patients, including the evaluation of functional outcomes via the Michigan Hand Outcomes Questionnaire, pain with the visual analog score, quality of life with the EuroQol-5D, and the evaluation of time to return to function. Outcomes and complications were compared between patients undergoing denervation versus arthroplasty. RESULTS: Forty-eight patients were included in the study, 34 of whom underwent denervation and 14 underwent suspension arthroplasty of the thumb carpometacarpal joint. Patients in the denervation group were younger, with an average age of 59 years compared with 67 years in the arthroplasty group. All other patient characteristics were similar. Pain reduction, functional outcomes, and quality of life scores showed equal improvement in both groups. Denervation patients had a reduced time to return to function (3.3 weeks vs 4.5 months in the arthroplasty group). CONCLUSIONS: Carpometacarpal denervation appears to provide similar short-term outcomes as suspension arthroplasty for the treatment of thumb carpometacarpal arthritis. Treatment with denervation may offer a quicker return to function. The long-term outcomes of denervation remain unknown. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Development of a Risk Stratification Scoring System to Predict General Surgical Complications in Hand Surgery Patients.

PURPOSE: Avoidance of postoperative complications is important to both patients and surgeons. In an attempt to optimize postoperative outcomes, a risk stratification scoring system has been created to aid in optimizing risk factors for general surgical complications in hand surgery patients. METHODS: Patients were identified who underwent hand procedures as part of the American College of Surgeons National Surgical Quality Improvement Program. Independent risk factors associated with postoperative complications within 30 days of surgery were identified and used to develop a point-scoring system to estimate the relative risk for sustaining complications. For validation, the system was tested on a subset of patients from the database who had undergone hand surgery. RESULTS: A total of 49,272 patients were identified as having undergone hand surgery from 2005 to 2015. The incidence of postoperative complications within 30 days of hand surgery was 2.3%. Risk factors associated with postoperative complications were male sex, tobacco abuse, congestive heart failure, anemia (male hematocrit less than 42; female less than 38), elevated creatinine (greater than 1.3 mg/dL), hypoalbuminemia (less than 3.5 g/dL), and hyponatremia (less than 135 mEq/L). Point scores derived for each of these factors were: hypoalbuminemia, +5; congestive heart failure, +2; anemia, +2; elevated creatinine, +2; male sex, +1; tobacco abuse, +1; and hyponatremia, +1. In the validation cohort, patients categorized as low-risk (0-3) using the point-scoring system had a 2.4% rate of 30-day complications; patients categorized as medium risk (4-7) had a 10.4% complication rate (relative risk = 4.3; 95% confidence interval, 3.1-5.9 compared with low risk) and high risk (≥8), 28.9% (relative risk = 11.9; 95% confidence interval, 9.0-15.7). CONCLUSIONS: This point-scoring system predicts risk for general postoperative complications after hand surgery. These data may help surgeons identify areas of clinical concern with patients to reduce the risk for sustaining postoperative complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Comparison of Postoperative Complications Associated With Anesthetic Choice for Surgery of the Hand.

PURPOSE: There is a recent trend toward performing most hand surgery procedures under local and/or regional anesthesia without sedation. However, little evidence exists regarding the postoperative complications associated with local/regional anesthesia without sedation, especially compared with local/regional anesthesia with sedation or general anesthesia. METHODS: Patients who underwent hand procedures as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Thirty-day postoperative complications were compared among patients who received local/regional anesthesia without sedation, local/regional anesthesia with sedation, and general anesthesia with adjustment for patient and procedural factors. RESULTS: We identified 27,041 patients as having undergone hand surgery from 2005 to 2013. A total of 4,614 underwent local/regional anesthesia without sedation (17.1%), 3,527 underwent local/regional anesthesia with sedation (13.0%), and 18,900 underwent general anesthesia (69.9%). Overall, both local/regional anesthesia with and without sedation were associated with fewer postoperative complications compared with general anesthesia. In patients aged over 65 years, there was an additional benefit of avoiding all forms of sedation; these data showed that treatment with local/regional anesthesia without sedation decreased the odds of sustaining a postoperative complication compared with sedation and general anesthesia. CONCLUSIONS: Although the overall risk of postoperative complications remains small in hand surgery, these data suggest that avoiding general anesthesia may decrease the overall risk of sustaining postoperative complications. In addition, for patients aged over 65 years, avoiding any form of sedation may decrease the risk of postoperative complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Calculating the Cost and Risk of Comorbidities in Total Joint Arthroplasty in the United States.

BACKGROUND: With increased scrutiny regarding the cost and safety of health care delivery, there is increasing interest in judicious patient selection for total joint arthroplasty (TJA) procedures. It is unknown which comorbidities incur the greatest increase in risk to the patient and cost to the system after TJA. Therefore, this study sought to characterize the association of common preoperative comorbidities with both the risk for postoperative in-hospital complications and the total hospital cost in patients undergoing TJA. METHODS: A retrospective cohort study was conducted using the National Inpatient Sample. All elective, unilateral, primary or revision total knee or hip arthroplasty procedures in patients aged 40-95 years from 2008 to 2012 were identified. Common preoperative comorbidities were identified with use of clinical comorbidity software. Risk of complication and cost were calculated for each comorbidity. RESULTS: A total of 4,323,045 patients were identified. Patient comorbidities increased the risk of major postoperative complications, with the highest risk associated with congestive heart failure (CHF; relative risk [RR], 4.402), valvular heart disease (VHD; RR, 3.209), and chronic obstructive pulmonary disease (COPD; RR, 2.813). Likewise, comorbidities increased overall hospital costs, with the largest additional costs associated with coagulopathy (+$3787), CHF (+$3701), and electrolyte disorders (+$3179). The cumulative number of comorbidities was associated with increased risk (R2 = 0.86) and cost (R2 = 0.90). CONCLUSION: The findings of our study suggest that greater comorbidity burden is associated with increased risk and cost in TJA. Specifically, this article identifies the patient comorbidities that incur the greatest increase in postoperative complications (CHF, VHD, COPD) and cost (coagulopathy, CHF, electrolyte disorders) after TJA.

The Detrimental Effect of Decentralization in Digital Replantation in the United States: 15 Years of Evidence From the National Inpatient Sample.

PURPOSE: Recent reports suggest a decrease in success rates in digital replantation in the United States. We hypothesize that this decrease may be associated with decentralization of replants away from high-volume hospitals. METHODS: All amputation injuries and digital replants captured by the National Inpatient Sample during 1998 to 2012 were identified. Procedures were characterized as occurring at high-volume hospitals (> 20 replants/y), and as being performed by high-volume surgeons (> 5 replants/y). A successful procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Hospital and surgeon volume were tested for association with the year and the success of the procedure. RESULTS: The authors identified 101,693 amputation injuries resulting in 15,822 replants. The overall success of replants dropped from 74.5% during 2004 to 2006 to 65.7% during 2010 to 2012. The percentage of replants being performed at high-volume hospitals decreased from 15.5% during 2004 to 2006 to 8.9% during 2007 to 2009. Similarly, the percentage of replants being performed by high-volume surgeons decreased from 14.4% during 1998 to 2000 to 2.6% during 2007 to 2009. Replants performed by high-volume surgeons operating at high-volume hospitals had higher success rates than low-volume surgeons operating at low-volume hospitals (92.0% vs 72.1%). In addition, high-volume surgeons operating at high-volume hospitals attempted replantation at greater rates than low-volume surgeons operating at low-volume hospitals (21.5% vs 11.0%). Overall, an amputation injury presenting to a high-volume surgeon at a high-volume center had a 2.5 times greater likelihood of obtaining a successful replantation than an amputation injury presenting to a low-volume surgeon at a low-volume hospital. CONCLUSIONS: These data suggest that decreased success rates of digital replantation in the United States are correlated with the decentralization of digital replantation away from high-volume hospitals. CLINICAL RELEVANCE: The establishment of regional centers for replant referral may greatly increase the success of digital replantation in the United States.

Evaluating the Effect of Comorbidities on the Success, Risk, and Cost of Digital Replantation.

PURPOSE: The clinical decision to replant an amputated digit is driven primarily by surgical indication. However, the extent to which patient comorbidity should play into this decision is less well defined. This study was designed to determine the effect of patient comorbidities on the success, risk, and cost of digital replantation. METHODS: All amputation injuries and digital replantation procedures captured by the National Inpatient Sample during 2001 to 2012 were identified. A successful replantation procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Patient comorbidities were tested for association with failure of replantation, risk of postoperative complications, and overall hospital costs. RESULTS: We identified 11,788 digital replantation procedures. A total of 3,604 patients (30.6%) experienced revascularization failure associated with replantation. The risk for replant failure was highest among patients with psychotic disorders, peripheral vascular disease, and electrolyte imbalances. The risk for postoperative complications was highest among patients with electrolyte imbalances, drug abuse, or chronic obstructive pulmonary disease. Hospital costs were greatest among patients with deficiency anemias, electrolyte imbalances, or psychotic disorders. Patients with more than 3 comorbidities experienced significantly higher failure, risk of postoperative complications, and cost of digital replantation. CONCLUSIONS: These data suggest that even when surgical indications are met, patients with more than 3 comorbidities and those who have a history of alcohol abuse, deficiency anemias, electrolyte imbalances, obesity, peripheral vascular disease, or psychotic disorders are at increased risk of replantation failure and associated postoperative complications. Assessment of this risk should have a role in decision making regarding whether a digit should be replanted. Patients at high risk should be carefully counseled regarding the difficult perioperative course before undergoing digital replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

3D-FSE Isotropic MRI of the Lumbar Spine: Novel Application of an Existing Technology.

STUDY DESIGN: Retrospective diagnostic trial. OBJECTIVE: To determine the diagnostic performance of 3-dimensional isotropic fast/turbo spin-echo (3D-TSE) in routine lumbar spine magnetic resonance imaging (MRI). SUMMARY OF BACKGROUND DATA: Conventional 2-dimensional fast spin-echo (2D-FSE) MRI requires independent acquisition of each desired imaging plane. This is time consuming and potentially problematic in spine imaging, as the plane of interest varies along the vertical axis due to lordosis, kyphosis, or possible deformity. 3D-TSE provides the capability to acquire volumetric data sets that can be dynamically reformatted to create images in any desired plane. METHODS: Eighty subjects scheduled for routine lumbar MRI were included in a retrospective trial. Each subject underwent both 3D-TSE and conventional 2D-FSE axial and sagittal MRI sequences. For each subject, the 3D-TSE and 2D-FSE sequences were separately evaluated (minimum 4 wk apart) in a randomized order and read independently by 4 reviewers. Images were evaluated using specific criteria for stenosis, herniation, and degenerative changes. RESULTS: The intermethod reliability for the 4 reviewers was 85.3%. Modified intermethod reliability analysis, disregarding disagreements between the lowest 2 descriptors for appropriate criteria (equivalent to "none" and "mild"), revealed average overall agreement of 94.6%. Using the above, modified criteria, interobserver variability for 3D-TSE was 89.1% and 88.3% for 2D-FSE (P=0.05), and intraobserver variability for 3D-TSE was 87.2% and 82.0% for 2D-FSE (P<0.01). The intermethod agreement between 3D-TSE and 2D-FSE was statistically noninferior to intraobserver 2D-FSE variability (P<0.01). CONCLUSIONS: This systematic evaluation showed that there is a very high degree of agreement between diagnostic findings assessed on 3D-TSE and conventional 2D-FSE sequences. Overall, intermethod agreement was statistically noninferior to the intraobserver agreement between repeated 2D-FSE evaluations. Overall, this study shows that 3D-TSE performs equivalently, if not superiorly to 2D-FSE sequences. Reviewers found particular utility for the ability to manipulate image planes with the 3D-TSE if there was greater pathology or anatomic variation.

The controversy surrounding bone morphogenetic proteins in the spine: a review of current research.

Bone morphogenetic proteins have been in use in spinal surgery since 2002. These proteins are members of the TGF-beta superfamily and guide mesenchymal stem cells to differentiate into osteoblasts to form bone in targeted tissues. Since the first commercial BMP became available in 2002, a host of research has supported BMPs and they have been rapidly incorporated in spinal surgeries in the United States. However, recent controversy has arisen surrounding the ethical conduct of the research supporting the use of BMPs. Yale University Open Data Access (YODA) recently teamed up with Medtronic to offer a meta-analysis of the effectiveness of BMPs in spinal surgery. This review focuses on the history of BMPs and examines the YODA research to guide spine surgeons in their use of BMP in spinal surgery.

Education Forum: Restrictive Covenants (Non-competes) in Orthopaedic Fellowships: What Every Resident Should Know Before Applying to Fellowship.

Introduction: More than 90% of orthopaedic surgery residents in the United States complete a fellowship program. While there is significant oversight of the educational process and rights of residents during residency, there is little standardization in fellowships in the United States. Applicants to fellowship need to be aware that they may be required to sign restrictive covenants ("non-competes") as part of the fellowship application or acceptance process. These restrictive covenants may be designed to protect the business interests of the host institution but may affect the fellow's ability to obtain employment in a geographic region. Methods: A review of society websites designed to education fellowship applicants was reviewed. Information was gathered on whether the society provided information on restrictive covenants in fellowship programs. Results: There is little standardization of restrictive covenants in orthopedic fellowships in the United States. Only accredited fellowships prohibit restrictive covenants in orthopedic fellowships. Pediatrics is the only sub-specialty society that provides information to applicants on restrictive covenants for fellowship applicants. Conclusion: The current lack of standardization in the fellowship process means applicants need to be well versed in these restrictive covenants before applying. In turn, fellowships themselves, as well as subspecialty societies, should seek to be transparent in providing information on restrictive covenant requirements of their respective fellowships.

Surgical knee denervation for the treatment of pain due to primary osteoarthritis.

BACKGROUND: Denervation techniques have increased in popularity for treatment of primary knee osteoarthritis. However, few clinical trials have been conducted on surgical knee denervation. This study was conducted to evaluate the safety and efficacy of a surgical denervation technique for the treatment of primary knee osteoarthritis. METHODS: Patients were included in the trial if they had failed conservative management for osteoarthritis with corticosteroid injections and were not candidates for total knee arthroplasty. Patients were treated with a surgical knee denervation. Pre- and post-operative scores were assessed to examine the improvement in pain, function, and quality of life. RESULTS: Twenty-four knee denervation procedures were performed in twenty-one patients. The average follow-up time was 21 months, with a minimum follow up of 12 months. Patients experienced an improvement in pain with a decrease in VAS pain scores from 8.7 to 2.9, an improvement in function with a decrease in WOMAC scores from 69 to 32, and an improvement in quality of life with an increase in EQ-5D from 0.183 to 0.646. A clinically significant improvement in pain occurred in 92% patients, while 75% of patients had an improvement in function, and 83% an improvement in quality of life. CONCLUSIONS: The treatment of recalcitrant knee pain in non-arthroplasty candidates is a difficult issue. This trial suggests that a surgical denervation technique provides improvement in pain, function, and quality of life. Surgical denervation may be a beneficial treatment for patients with recalcitrant pain from primary knee osteoarthritis.

An Evaluation of Patient-reported Outcome Measures and Minimal Clinically Important Difference Usage in Hand Surgery.

Background: This study was designed to examine the current use of patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) calculations in the hand surgery literature in an effort to standardize their use for research purposes. Methods: A systematic review of the hand surgery literature was conducted. All nonshoulder upper extremity articles utilizing PROMs were compared between different journals, different surgical indications, and differing usage. MCID values were reported, and calculation methods assessed. Results: In total, 4677 articles were reviewed, and 410 met the inclusion criteria of containing at least one PROM. Of the 410 articles reporting PROMs, 148 also mentioned an associated MCID. Of the articles that mentioned MCIDs, 14 calculated MCID values based on their specific clinical populations, whereas the remainder referenced prior studies. An estimated 35 different PROMs were reported in the study period; 95 different MCID values were referenced from 65 unique articles. Conclusions: There are many different PROMs currently being used in hand surgery clinical reports. The reported MCIDs from their related PROMs are from multiple different sources and calculated by different methods. The lack of standardization in the hand surgery literature makes interpretation of studies utilizing PROMs difficult. There is a need for a standardized method of calculating MCID values and applying these values to established PROMs for nonshoulder upper extremity conditions.

Postanesthesia care unit imaging is unnecessary when intraoperative imaging is used during anterior cervical decompression and fusion procedures.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To characterize the clinical utility of imaging in the postanesthesia care unit (PACU) after anterior cervical decompression and fusion (ACDF) procedures. SUMMARY OF BACKGROUND DATA: Two sets of imaging are often taken at the end of ACDF procedures: one intraoperatively and the other in the PACU. The latter may have low clinical utility. MATERIALS AND METHODS: One hundred four patients who underwent ACDF procedures with anterior plate/screw constructs were identified. A panel assessed intraoperative and PACU series for adequacy of images to detect potential issues with placement of the surgical construct and for any actual visible issues with placement of the surgical construct. RESULTS: Intraoperative series were adequate to detect potential issues with construct placement for 78.8% of cases, whereas PACU series were adequate for only 58.7% of cases (significant difference, P<0.001). For both series, nearly all inadequacies were because of the shoulders obstructing the lateral view. Accordingly, cases with lower inferior operative levels were much more likely to have inadequate intraoperative and PACU series than cases with higher inferior operative levels (significant differences, P<0.001 for both). In no case was an issue with construct placement visible on a PACU series that was not also visible on an intraoperative series. CONCLUSIONS: This study demonstrates that PACU images are inferior to intraoperative images and offer little or no incremental clinical utility for detecting issues with surgical construct placement after ACDF procedures. PACU imaging after ACDF procedures might be discontinued to realize savings in time, cost, and radiation exposure.

Current advances in training orthopaedic patients to comply with partial weight-bearing instructions.

Partial weight-bearing instructions are commonly given to orthopaedic patients and are an important part of post-injury and/or post-operative care. However, the ability of patients to comply with these instructions is poorly defined. Training methods for instructing these patients vary widely among institutions. Traditional methods of training include verbal instruction and use of a bathroom scale. Recent technological advances have created biofeedback devices capable of offering feedback to partial weight-bearing patients. Biofeedback devices have shown great promise in training patients to better comply with partial weight-bearing instructions. This review examines the background and significance of partial weight bearing and offers insights into current advances in training methods for partial weight-bearing patients.

Development of a Risk Stratification Scoring System to Predict General Surgical Complications for Patients Undergoing Foot and Ankle Surgery.

Preventing postoperative complications is crucial for patients, surgeons, and health care facilities. We developed a risk stratification scoring system to optimize postoperative outcomes for patients undergoing foot and ankle surgery. A total of 35,580 patients who underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To assess the risk of a postoperative complication, we identified several independent risk factors associated with 30-day postoperative complications, then proceeded to develop a point-based risk scoring system. To validate our scoring system, we used it on a cohort of patients from the database who underwent foot and ankle surgery. Risk factors that correlated with postoperative complications included tobacco abuse, age (≥65 years), diabetes mellitus, hypertension, elevated creatinine level (≥1.3 mg/dL), hypoalbuminemia (<3.5 g/dL), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hyponatremia (<135 mEq/L), and anemia (hematocrit value, men <42%; women <38%). Point scores for each factor were: anemia, +10; hypoalbuminemia, +9; elevated creatinine level, +6; CHF, +4; diabetes mellitus, +3; hyponatremia, +3; COPD, +2; hypertension, +2; age, +1; and tobacco abuse, +1. For the validation cohort, we stratified patients according to risk as low (0-20 points), medium (21-30 points), and high (≥31 points) risk. In terms of having a postoperative complication, compared with low-risk patients, patients who were at medium risk had an odds ratio of 4.7 (95% CI, 2.8-7.9) and those at high risk had an odds ratio of 8.3 (95% CI, 4.8-14.5). [Orthopedics. 2022;45(3):139-144.].

Targeted Muscle Reinnervation Does Not Increase the Risk of Postsurgical Complication or Overall Cost.

Background: Targeted muscle reinnervation (TMR) has shown promise in reducing postsurgical limb pain in amputees. However, there has been little evidence on the increased risk of complications and cost as compared with traditional amputations. This study was designed to assess the rate of complications and healthcare costs between those treated with TMR and traditional amputations. Methods: Patients undergoing amputation were selected from the PearlDiver Mariner dataset and categorized into one of two treatment groups depending on the use of TMR versus traditional amputation. Rates of postsurgical complications and overall healthcare costs were compared between the two groups, while controlling for differences in patient demographics and comorbidities. Results: One hundred sixteen TMR procedures and 76,412 traditional amputations were included in the study. The rate of complications did not differ between groups, with a complication rate of 77% in the TMR and 87% in the traditional amputation groups. Overall healthcare costs also did not differ 1 year after surgery, with an average cost of $32,632 in the TMR group and $36,219 in the traditional amputation group. Conclusions: Amputees experience high rates of postsurgical complications, morbidity, and mortality. However, there is no increased risk of complications or cost with the use of TMR. TMR has the potential benefits of reducing overall postsurgical pain and reestablishing activities of daily living. Although TMR is more expensive up front, it may reduce the overall healthcare costs by reducing the need for subsequent care. Further work is needed in large, randomized trials to examine these findings.

The changing face of pediatric respiratory tract infections: how human metapneumovirus and human bocavirus fit into the overall etiology of respiratory tract infections in young children.

Lower respiratory tract infections are one of the leading causes of morbidity and mortality in children worldwide. Recent technological advances in the field of molecular biology have allowed virologists to detect many previously undetected viral pathogens. Two of these, human metapneumovirus (hMPV) and human bocavirus (HBoV), are of particular clinical interest to pediatric health care providers. This review discusses the most common viral respiratory infections in children, explores the role of newly discovered respiratory pathogens, and describes techniques for the diagnosis of viral respiratory infections.

Hypoalbuminemia Is Associated With Increased Postoperative Mortality and Complications in Hand Surgery.

Background: Malnutrition has been associated with increased perioperative morbidity and mortality in orthopedic surgery. This study was designed with the hypothesis that preoperative hypoalbuminemia, a marker for malnutrition, is associated with increased complications after hand surgery. Methods: A retrospective cohort study of 208 hand-specific Current Procedural Terminology codes was conducted with the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013. In all, 629 patients with low serum albumin were compared with 4079 patients with normal serum albumin. The effect of hypoalbuminemia was tested for association with 30-day postoperative mortality, and major and minor complications. Results: Hypoalbuminemia was independently associated with emergency surgery, diabetes mellitus, dependent functional status, hypertension, end-stage renal disease, current smoking status, and anemia. Patients with hypoalbuminemia had a higher rate of mortality, minor complications, and major complications. Conclusions: Hypoalbuminemia is associated with an increased risk of postoperative morbidity and mortality in patients undergoing hand surgery. As such, increased focus on perioperative nutrition optimization may lead to improved outcomes for patients undergoing hand surgery.