Assessing Hand Perfusion With Eulerian Video Magnification and Waveform Extraction.

PURPOSE: Timely and accurate triage of upper extremity injuries is critical, but current perfusion monitoring technologies have shortcomings. These limitations are especially pronounced in patients with darker skin tones. This pilot study evaluates a Eulerian Video Magnification (EVM) algorithm combined with color channel waveform extraction to enable video-based measurement of hand and finger perfusion. METHODS: Videos of 10 volunteer study participants with Fitzpatrick skin types III-VI were taken in a controlled environment during normal perfusion and tourniquet-induced ischemia. Videos were EVM processed, and red/green/blue color channel characteristics were extracted to produce waveforms. These videos were assessed by surgeons with a range of expertise in hand injuries. The videos were randomized and presented in 1 of 3 ways: unprocessed, EVM processed, and EVM with waveform output (EVM+waveform). Survey respondents indicated whether the video showed an ischemic or perfused hand or if they were unable to tell. We used group comparisons to evaluate response accuracy across video types, skin tones, and respondent groups. RESULTS: Of the 51 providers to whom the surveys were sent, 25 (49%) completed them. Using the Pearson χ2 test, the frequencies of correct responses were significantly higher in the EVM+waveform category than in the unprocessed or EVM videos. Additionally, the agreement was higher among responses to the EVM+waveform questions than among responses to the unprocessed or EVM processed. The accuracy and agreement from the EVM+waveform group were consistent across all skin pigmentations evaluated. CONCLUSIONS: Video-based EVM processing combined with waveform extraction from color channels improved the surgeon's ability to identify tourniquet-induced finger ischemia via video across all skin types tested. CLINICAL RELEVANCE: Eulerian Video Magnification with waveform extraction improved the assessment of perfusion in the distal upper extremity and has potential future applications, including triage, postsurgery vascular assessment, and telemedicine.

Indications for Ligament Reconstruction and Suspensionplasty in Carpometacarpal Arthroplasty.

The trapeziometacarpal joint is the site that most commonly develops arthritis in the hand. Although optimal treatment requires careful consideration of history, physical examination, radiographs, and functional goals, many patients ultimately undergo surgical intervention. Several described techniques and approaches are highlighted in this article, especially pertaining to carpometacarpal arthroplasty with ligament reconstruction and tendon interposition. The rationale, benefit, and evidence for each approach are discussed and the author's preferred technique is described.

Incidence and risk factors for perioperative death after revision total hip arthroplasty: a 20-year analysis.

INTRODUCTION: The number of revision total hip arthroplasty (THA) procedures is increasing in the US. Revision THA is associated with higher complication rates compared with primary THA. We describe patterns in incidence and risk factors for perioperative death after revision THA. METHODS: Using the National Hospital Discharge Survey, we identified nearly 700,000 cases of revision THA from 1990 through 2010. Procedure incidence, perioperative mortality rates, comorbidities, discharge disposition, and duration of hospital stay were analysed. Multivariable logistic regression was used to identify independent risk factors for perioperative death. Alpha = 0.01. RESULTS: Population-adjusted incidence of revision THA per 100,000 people increased from 9.2 cases in 1990 to 15 cases in 2010 (p < 0.001). The rate of perioperative death was 0.9% during the study period and decreased from 1.5% during the "first" period (1990-1999) to 0.5% during the "second" period (2000-2010) (p < 0.001), despite an increase in comorbidity burden over time. Factors associated with the greatest odds of perioperative death were acute myocardial infarction (odds ratio [OR], 37; 95% confidence interval [CI], 33-40; p < 0.001), pneumonia (OR, 16; 95% CI, 15-18; p < 0.001), and pulmonary embolism (OR, 13; 95% CI, 11-15; p < 0.001). CONCLUSIONS: The rate of perioperative death in patients undergoing revision THA in the US decreased from 1990 to 2010 despite an increase in comorbidities. Acute myocardial infarction, pneumonia, and pulmonary embolism were associated with the highest odds of perioperative death after revision THA.

Impact of Missing Data on Identifying Risk Factors for Postoperative Complications in Hand Surgery.

BACKGROUND: The mismanagement of missing data in large clinical databases may lead to inaccurate findings. The purpose of this study was to demonstrate the effects of missing data on hand surgery research findings using an analysis of postoperative morbidity in patients undergoing hospital-based hand surgery. METHODS: The National Surgical Quality Improvement Program database was queried for patients undergoing common hand and upper extremity surgery between 2011 and 2016. Major and minor postoperative complications were identified. Demographics, comorbidity, and preoperative laboratory values were identified, and the percentage missing of each was tabulated. To demonstrate how missing data can alter analysis results, these variables were evaluated for an association with major complications using multivariable regression on 3 separate cohorts: (1) all patients; (2) all patients after exclusion of any patient entry with >10% of missing data; and (3) after removal of any patient entry with any missing data. RESULTS: Groups 1, 2, and 3 had 48 370, 23 118, and 6280 patients, respectively. There were 14 variables associated with increased odds of major complications in group 1, yet only 10 and 9 variables for groups 2 and 3, respectively. Six variables were associated with increased major complications across all 3 groups, whereas only 1 was associated with decreased odds of major complications across all groups. CONCLUSIONS: Filtering patient cohorts according to the amount of missing patient information affected analyses of predictors for major complications associated with hospital-based hand surgery. These findings highlight the importance of considering and addressing missing data in large database studies.

Bridge Plating with Masquelet Technique for Ballistic Proximal Interphalangeal Joint Injury: A Case Report.

CASE: A 70-year-old man sustained a ballistic injury to the proximal interphalangeal (PIP) joint of his left index finger. He was treated with bridge plate osteogenesis with staged bone grafting using an antibiotic spacer to manage bone loss. The patient demonstrated union, excellent functional recovery, and the ability to make a composite fist by 6 months. CONCLUSION: Ballistic injury to the PIP joint of the finger is a challenging injury to manage. This case demonstrates that length and alignment can be maintained with good functional range of motion using a combination of bridge plate distraction osteogenesis and the Masquelet technique.

Short-Term Complications and Readmission Following Total Shoulder Arthroplasty: A National Database Study.

BACKGROUND: The incidence of total shoulder arthroplasty (anatomic and reverse) is increasing as indications expand. The purpose of this study is to identify predictors of short-term complications and readmission following total shoulder arthroplasty for patients with glenohumeral osteoarthritis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to identify 12,982 patients who underwent total shoulder arthroplasty (anatomic or reverse) from 2011-2016. Demographic data, postoperative complications, and readmission within 30 days were analyzed. Multivariable logistic regression was used to determine independent risk factors for complications and for readmission occurring within 30 days of surgery. RESULTS: The mean age of the cohort was 69.1 years, 56.1% were female. Mean American Society of Anesthesiologists (ASA) classification score was 2.6. The postoperative complication rate was 5.6% and the readmission rate was 2.8% within 30 days of surgery. Independent predictors for any complication included preoperative dependent functional status (OR 1.8, P<0.001), ASA class 3 (OR 3.6, P=0.021) and 4 (OR 8.5, P<0.001), age 70-79 (OR 1.4, P=0.019) age ≥ 80 years (OR 2.3, P<0.001, and female gender (OR 1.6, P=0.001). Independent predictors for readmission included congestive heart failure (OR 3.4, P=0.002) and ASA class 4 (OR 14, P = 0.013). Independent functional status was associated with decreased odds of readmission (OR 0.4, P<0.001). CONCLUSION: Patients with age greater than 70 years, congestive heart failure, and ASA class 3 and 4 are at increased risk for postoperative complications and readmission. Preoperative risk stratification and medical optimization are important in these patients.

High-Fidelity Wrist Fracture Phantom as a Training Tool to Develop Competency in Orthopaedic Surgical Trainees.

BACKGROUND: This article will describe the development of a low-cost 3D-printed medical phantom of the arm with a distal radius fracture (DRF) to facilitate training of reduction and splinting techniques. The phantom incorporates tactile responses and visual stimuli from fluoroscopy to assist skill acquisition in a clinical setting. This provides feedback to trainees to help them develop competency and knowledge before providing care to patients. METHODS: Phantoms were developed through advice and feedback from fellowship-trained hand surgeons and orthopaedic senior and junior residents. Phantoms were then pilot tested during a surgical skills examination, with residents having minimal previous exposure to distal radial reduction techniques. Residents were evaluated on procedure speed and accuracy by attending surgeons using the objective structured assessment of technical skills. Residents then completed a written knowledge examination about relevant requirements of DRF management and feedback on their opinion of the exercise using the Likert scale. RESULTS: Residents who passed the hands-on examination also scored higher on the written examination. All residents reported that the phantom was beneficial and motivating as part of their overall training. DISCUSSION: Real-time feedback using a phantom limb and fluoroscopic imaging, in conjunction with guidance from surgeons, allows residents to learn and practice DRF reduction and splinting techniques. These educational exercises are relatively low-cost and remove the risk of potential harm to patients during early skill acquisition. This training method may be a predictor of surgical performance in addition to providing assessment of background knowledge. Additional training sessions will be required to determine the effect of repeat exposure to residents' proficiency and comprehension.

Worsening racial disparities in patients undergoing anatomic and reverse total shoulder arthroplasty in the United States.

BACKGROUND: The most comprehensive health care policy changes aimed at reducing racial disparities were implemented in 2011 and continue today. It is unknown if these initiatives have led to a decrease in racial differences among patients undergoing total shoulder arthroplasty. The purpose of this study is to examine racial differences in procedural rates, complications, and mortality in patients undergoing total shoulder arthroplasty. METHODS: National rates of utilization of primary anatomic (TSA) and reverse total shoulder arthroplasty (RTSA) were analyzed from 2012 to 2017. Population-adjusted and gender-adjusted procedural rates were trended over time and standardized based on insurance status. Multivariable logistic regression was used to determine racial differences in complications and mortality. RESULTS: In 2012, the incidence of TSA and RTSA among white patients was 18.7/100,000 compared to 5.1/100,000 among black patients (difference: 13.6/100,000) and increased to 36.9/100,000 in white patients and 10.8/100,000 in black patients in 2017 (difference: 26.1/100,000). This equated to an increase in the race disparity by 12.5/100,000 over the study period. Blacks underwent lower rates of TSA and RTSA than whites regardless of insurance status. Black patients had a longer length of hospital stay and a higher rate of discharge to facility. Black patients had increased odds of complications, including acute myocardial infarction (odds ratio [OR] 1.43), pulmonary embolism (OR 1.97), acute renal failure (OR 1.40), sepsis (OR 1.68), and surgical site infection (OR 2.19). Black patients had increased odds of mortality compared with white patients (OR 2.88). CONCLUSION: Racial disparities in patients undergoing TSA and RTSA are worsening over time. Black patients undergo TSA and RTSA at lower rates than white patients regardless of insurance status and have increased odds of complications and mortality. Improved initiatives are needed to reduce these racial disparities and further research is warranted to understand their root causes.

Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States.

BACKGROUND: The purpose of this study was to determine the incidence of primary reverse total shoulder arthroplasty (RTSA) and anatomic total shoulder arthroplasty (TSA) in the United States and examine changes in age- and sex-based procedure rates. A secondary goal was to determine the incidence of hemiarthroplasty. METHODS: Using nationally representative data along with US Census data, we identified >508,000 cases of primary RTSA, anatomic TSA, and shoulder hemiarthroplasty from 2012 to 2017. Trends in the incidence of each procedure were analyzed, and sex- and age-adjusted procedure rates were calculated. RESULTS: From 2012 to 2017, the population-adjusted incidence of primary RTSA increased from 7.3 cases per 100,000 persons (22,835 procedures) to 19.3 cases per 100,000 (62,705 procedures); anatomic TSA increased from 9.5 cases per 100,000 (29,685 procedures) to 12.5 cases per 100,000 (40,665 procedures); and hemiarthroplasty decreased from 3.7 cases per 100,000 (11,695 procedures) to 1.5 cases per 100,000 (4930 procedures). These trends were observed among male and female patients, as well as all age groups. The greatest increase in incidence was seen in male patients as well as patients aged 50-64 years undergoing RTSA. CONCLUSION: The incidence of primary RTSA and incidence of anatomic TSA have increased substantially in the United States from 2012 to 2017 whereas the incidence of hemiarthroplasty has decreased.

The impact of chronic steroid use on early postoperative complications in shoulder surgery.

OBJECTIVES: Chronic steroid use has been associated with poor healing and worse long-term outcomes in patients undergoing orthopedic surgery, but the specific risk profile and short-term complications related to chronic steroids in patients undergoing outpatient shoulder surgery are inadequately defined. The purpose of this study is to characterize the effects of chronic steroids on 30-day post-operative complications following arthroscopic and open shoulder surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent arthroscopic and open rotator cuff repair, shoulder stabilization, and associated procedures from 2011 to 2018. Patients on chronic steroids were compared with patients not on chronic steroids. Demographic data and 30-day postoperative complications were analyzed. Multivariable logistic regression was used to isolate the effects of chronic steroid use on postoperative complications. RESULTS: We identified 99,970 patients who underwent shoulder surgery during this period, of which 1.7% (1,662 patients) were on chronic steroids. Patients on chronic steroids were older (58.3 ± 0.30vs52.1 ± 0.05 years, p < 0.01), had higher average BMI (30.6 vs 30.1, p = 0.02), and were more likely to be female (54.9%vs38.0%, p < 0.01) and white (76.2%vs73.1%, p < 0.01). Patients on steroids had a higher American Society of Anesthesiologists class, and higher rates of diabetes, CHF, COPD, hypertension, bleeding disorders, and functionally dependency (all P < 0.01). Patients on chronic steroids were less likely to smoke (P < 0.01). Multivariable logistic regression revealed that chronic steroid use was an independent risk factor for major (OR 2.20[1.51-3.21], p < 0.001), minor (OR 2.32[1.13-3.2], p < 0.001), and infectious complications (OR 1.90[1.13-3.2], p = 0.01). CONCLUSIONS: Preoperative chronic steroid use is independently associated with increased odds of major, minor, and infectious complications after open and arthroscopic rotator cuff repair, shoulder stabilization, and associated procedures. Patients on chronic steroids should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk.

The Impact of Smoking on Early Postoperative Complications in Hand Surgery.

PURPOSE: Smoking is a prevalent modifiable risk factor that has been associated with adverse postoperative outcomes across numerous surgical specialties. We examined the impact of smoking on 30-day complications in patients undergoing hand surgery procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program data sets were queried for patients who underwent common hand surgery procedures from 2011 to 2016. Cohorts were divided into smoking and nonsmoking and compared in terms of demographic characteristics, comorbidities, and postoperative complications. Multivariable logistic regression models were used to control for demographic characteristics and comorbidities in assessing the association between smoking and postoperative infections as well as other major and minor complications. RESULTS: We identified a cohort of 48,370 patients in the National Surgical Quality Improvement Program who underwent certain outpatient and inpatient hospital facility-based hand surgery procedures from 2011 to 2016. Up to 22% of these patients reported active smoking. Compared with nonsmokers, smokers were more likely to be younger and male and to have a lower body mass index. In addition, they were more likely to have a higher American Society of Anesthesiologists classification and to report dyspnea and chronic obstructive pulmonary disease. Multivariable logistic regression identified an independent association between smoking and major complications. Smoking was not significantly associated with minor complications. When regrouped by complication type, smoking was associated with infectious and wound healing complications. In subgroup analysis, smokers undergoing elective hand surgery had increased odds of wound healing complications but not major, minor, or infectious complications. CONCLUSIONS: Smokers may be at a significantly higher odds of certain complications compared with nonsmokers. For patients undergoing the elective procedures evaluated in this study, perioperative smoking may increase the risk of wound-healing complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Relative Value Unit Compensation Rates for Hospital-Based Shoulder/Elbow Surgery Versus Hand Surgery.

Upper extremity surgeons perform diverse operations, including hand surgery, microsurgery, and shoulder/elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates may encourage surgeons to adjust their case mix, favoring a shift toward procedures with higher compensation. To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder/elbow procedures than hand procedures in a hospital-based setting, relative value unit (RVU) compensation rates were compared for these 2 fields. Using Centers for Medicare & Medicaid Services-assigned work RVUs (wRVU) and National Surgical Quality Improvement Program operative time data, wRVU compensation rates per minute of operative time were determined for common shoulder/elbow surgeries. Overall nonweighted and weighted wRVU/min averages were calculated for hospital-based shoulder/elbow and hand surgery. A total of 27 shoulder/elbow procedures and 53 hand surgery procedures were analyzed. Nonweighted comparison showed shoulder/elbow surgery had a higher wRVU/min (0.19±0.03 vs 0.14±0.05, P<.0001) vs hand surgery. When weighted by procedure frequency, shoulder/elbow surgery also had higher wRVU/min (0.19±0.02 vs 0.15±0.05, P<.0001). Fourteen of the 27 shoulder/elbow procedures were compensated either the same wRVU/min or more than all hand procedures except for epicondyle debridement and flexor tendon bursectomy. Almost half of commonly performed shoulder/elbow procedures were compensated at greater rates than most hand procedures in a hospital-based setting. This disproportionate compensation may affect upper extremity surgeons' case mix and motivate providers and hand-fellowship trainees to seek additional training in shoulder arthroplasty and arthroscopy to supplement their practice. [Orthopedics. 2021;44(3):e373-e377.].

Diabetes is an independent risk factor for infection after non-arthroplasty shoulder surgery: a national database study.

OBJECTIVES: Diabetes has been associated with poor healing and prior literature has shown worse functional outcomes in diabetic patients undergoing both open and arthroscopic shoulder surgery. However, the effects of diabetes on perioperative complications for patients undergoing non-arthroplasty type shoulder procedures are not well defined. The purpose of this study was to analyze the effects of diabetes on 30-day complications following non-arthroplasty shoulder surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open and arthroscopic shoulder procedures (excluding arthroplasty) from 2011 to 2018. Diabetic patients were identified and compared to a non-diabetic cohort. Demographic data and postoperative complications within 30 days were analyzed. Multivariable regression was used to determine the effect of diabetes on shoulder surgery. RESULTS: We identified 99,970 patients who underwent shoulder surgery in our cohort and 13.9% (13,857 patients) of these patients were diabetics. Within the diabetic cohort, 4,394 (31.7%) were insulin dependent. Diabetics were more likely to be older, female, and have a higher body mass index (P < 0.01). Diabetics had a higher rate of associated medial comorbidities (P < 0.05). Diabetics were less likely to be smokers and on average had shorter surgeries (P < 0.05). Univariate analysis showed that diabetes was associated with increased risk for infectious and other major and minor complications; however, multivariate regression revealed that diabetes was only independently associated with infection (OR 1.33, P = 0.38). CONCLUSION: While diabetes is associated with increased likelihood of infection following shoulder surgery, absent commonly associated comorbidities, they are not at increased risk for other 30-day postoperative complications.

Misvaluation of Hospital-Based Upper Extremity Surgery Across Payment, Relative Value Units, and Operative Time.

Background: Many US health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. Among other factors, a major determinant of payment and wRVU assignments is operative time. Our objective was to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures. Methods: Data on wRVUs, surgeon payment, and estimated operative times were collected from CMS for 53 procedures. We used regression models to compare relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined the relative valuation of each procedure based on operative time. Results: There was a wide discrepancy between CMS and NSQIP operative times (R2=0.49), with 60% of CMS times being longer than NSQIP times. Payment correlated more strongly with CMS operative times (R2=0.55) than with NSQIP operative times (R2=0.24). Similarly, wRVUs more strongly correlated with CMS operative times (R2=0.84) than with NSQIP operative times (R2=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) had the highest valuation while any ORIF proximal to the distal radius had lower valuation in analysis of both databases. While 61% of trauma procedures were highly valued, 70% of elective procedures had a low valuation, including nearly all elective tendon procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus four corner fusion, and distal radius open versus percutaneous fixation. Conclusions: CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates. By identifying which procedures are misvalued in terms of payment and wRVU per operative time, providers and payors may be able to address these imbalances and maximize appropriate care delivery incentives.Level of Evidence: III.

Economic implications of decreased elective orthopaedic and musculoskeletal surgery volume during the coronavirus disease 2019 pandemic.

PURPOSE: In order to reduce viral spread, elective surgery was cancelled in most US hospitals for an extended period during the COVID-19 pandemic. The purpose of this study was to estimate national hospital reimbursement and net income losses due to elective orthopaedic surgery cancellation during the COVID-19 pandemic. METHODS: The National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) were used to identify all elective orthopaedic and musculoskeletal (MSK) surgery performed in the inpatient setting and in hospital owned outpatient surgery departments throughout the USA. Total cost, reimbursement, and net income were estimated for all elective orthopaedic surgery and were compared with elective operations from other specialties. RESULTS: Elective MSK surgery accounted for $65.6-$71.1 billion in reimbursement and $15.6-$21.1 billion in net income per year to the US hospital system, equivalent to $5.5-$5.9 billion in reimbursement and $1.3-$1.8 billion in net income per month. When compared with elective surgery from all other specialties, elective MSK surgery accounted for 39% of hospital reimbursement and 35% of hospital net income. Compared with all hospital encounters for all specialties, elective MSK surgery accounted for 13% of reimbursement and 23% of net income. Estimated hospital losses from cancellation of elective MSK surgery during 8 weeks of the COVID-19 pandemic were $10.9-$11.9 billion in reimbursement and $2.6-3.5 billion in net income. CONCLUSION: Cancellation of elective MSK surgery for 8 weeks during the COVID-19 pandemic has substantial economic implications on the US hospital system.

Medicare Compensation Rates for Hand and Shoulder/Elbow Surgery by Operative Time: A Comparative Analysis.

BACKGROUND: There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the perception that this exposure will improve their professional "marketability" in a subspecialty they perceive as having higher compensation. METHODS: Using Medicare data, we investigated the most common surgeries from these fields and determined which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement (payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that of hand surgery. RESULTS: Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery has a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), and reimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P<0.01). Non-weighted mean wRVUs/min were similar (0.12±0.03 vs. 0.13±0.03, P = 0.12). When weighted by procedure frequency, hand surgery had greater wRVUs/min (0.15±0.036 vs. 0.13±0.032), payments/min ($14.17±4.50 vs. $6.97±2.26), charges/min ($75.68±30.47 vs. $42.61±7.83), and reimbursement (20±5.0% vs. 17±6.0%) (all, P<0.01). CONCLUSION: According to Medicare compensation, and when weighted by procedure frequency, hand procedures are associated with greater overall mean wRVUs/min, payments/min, charges/min, and reimbursement compared with shoulder and elbow procedures. Hand-surgery fellowship applicants should be aware that subspecialty compensation is complex in nature but should seek shoulder/elbow elective experience to acquire an additional surgical skill-set as opposed to primarily monetary reason.

Smoking is an independent risk factor for complications following open rotator cuff repair.

Objectives: Smoking has been associated with poor cuff healing and worse long-term outcomes in patients undergoing rotator cuff repair. The effects of smoking on short-term complications following open rotator cuff repair are not well defined. The purpose of this study is to analyze the effects of smoking on 30-day outcomes following open rotator cuff repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open rotator cuff repair from 2011 to 2016. Patients who were current smokers (within 1 year prior to surgery) were identified and compared with nonsmokers. Demographic data and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of smoking on complications after surgery. Results: We identified 5,157 patients who underwent open rotator cuff repair, of which 18% (946 patients) were current smokers (within 1 year of surgery). Smokers were younger (54.4 years versus 61.5 years, P < 0.001) and were more likely to be male (60.8% versus 56.9%, P = 0.03). Compared with nonsmokers, smokers had a similar rate of comorbidities (P = 0.35) and similar preoperative functional status (P = 0.53), but had higher mean American Society of Anesthesiologists (ASA) class (P < 0.001). Logistic regression revealed that smoking was an independent predictor for any complication (OR 1.9, P = 0.03), any venous thromboembolic event (OR 4.6, P = 0.01), and pulmonary embolism (OR 6.4, P = 0.02). Conclusion: Patients who smoke are at increased risk for short-term complications after open rotator cuff repair. Smoking is independently associated with increased rate of postoperative venous thromboembolic events such as pulmonary embolism. This further highlights the importance of preoperative smoking cessation in patients undergoing open rotator cuff repair.

Poroid Hidradenocarcinoma of the Ankle: Case Report of a Rare Malignant Cutaneous Adnexal Neoplasm.

Soft-tissue masses on the anterior ankle result from a broad range of underlying processes, often presenting a diagnostic challenge. Appropriate treatment of these tumors can be determined by using a combination of patient history, interpretation of pathologic findings, physical examination, and radiographic appearance. We present a case of an exceptionally rare malignant cutaneous adnexal tumor, highlighting the importance of adherence to fundamental biopsy principles for diagnosing and managing musculoskeletal lesions.

Lupus and Perioperative Complications in Elective Primary Total Hip or Knee Arthroplasty.

BACKGROUND: The number of patients with systemic lupus erythematosus (herein, lupus) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) is increasing. There is disagreement about the effect of lupus on perioperative complication rates. We hypothesized that lupus would be associated with higher complication rates in patients who undergo elective primary THA or TKA. METHODS: Records of more than 6.2 million patients from the National Inpatient Sample who underwent elective primary THA or TKA from 2000 to 2009 were reviewed. Patients with lupus (n = 38,644) were compared with those without lupus (n = 6,173,826). Major complications were death, pulmonary embolism, myocardial infarction, stroke, pneumonia, and acute renal failure. Minor complications were wound infection, seroma, deep vein thrombosis, hip dislocation, wound dehiscence, and hematoma. Patient age, sex, duration of hospital stay, and number of Elixhauser comorbidities were assessed for both groups. Multivariate logistic regression models using comorbidities, age, and sex as covariates were used to assess the association of lupus with major and minor perioperative complications. The alpha level was set to 0.001. RESULTS: Among patients who underwent THA, those with lupus were younger (mean age, 56 vs. 65 years), were more likely to be women (87% vs. 56%), had longer hospital stays (mean, 4.0 vs. 3.8 days), and had more comorbidities (mean, 2.5 vs. 1.4) than those without lupus (all p < 0.001). In patients with THA, lupus was independently associated with major complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1 to 1.7) and minor complications (OR, 1.2; 95% CI, 1.0 to 1.5). Similarly, among patients who underwent TKA, those with lupus were younger (mean, 62 vs. 67 years), were more likely to be women (93% vs. 64%), had longer hospital stays (mean, 3.8 vs. 3.7 days), and had more comorbidities (mean, 2.8 vs. 1.7) than those without lupus (all p < 0.001). However, in TKA patients, lupus was not associated with greater odds of major complications (OR, 1.2; 95% CI, 0.9 to 1.4) or minor complications (OR, 1.1; 95% CI, 0.9 to 1.3). CONCLUSIONS: Lupus is an independent risk factor for major and minor perioperative complications in elective primary THA but not TKA.