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BACKGROUND: Access to high-quality care for revision total joint arthroplasty (rTJA) is poorly understood but may vary based on insurance type. This study investigated distance traveled for hip and knee rTJA based on insurance type. METHODS: A total of 317 revision hips and 431 revision knees performed between 2010 and 2020 were retrospectively reviewed. Cluster sampling was used to select primary hips and knees for comparison. Median driving distance was compared based upon procedure and insurance type. RESULTS: Revision hip and knee patients traveled 18.2 and 11.0 miles farther for surgery compared to primary hip and knee patients (P ≤ .001). For hip rTJA, Medicaid patients traveled farther than Medicare patients followed by commercially insured patients with median distances traveled of 98.4, 67.2, and 35.6 miles, respectively (P = .016). Primary hip patients traveled the same distance regardless of insurance type (P = .397). For knee rTJA, Medicaid patients traveled twice as far as Medicare and commercially insured patients (medians of 85.0, 43.5, and 42.2 miles respectively, P ≤ .046). Primary knee patients showed a similar pattern (P = .264). Age and ASA-PS classification did not indicate greater comorbidity in Medicaid patients. CONCLUSION: Insurance type may influence rTJA referrals, with disproportionate referral of Medicaid and Medicare patients to nonlocal care centers. In addition to patient burden, these patterns potentially present a financial burden to facilities accepting referrals. Strategies to improve equitable access to rTJA, while maintaining the highest and most economical standards of care for patients, providers, and hospitals, are encouraged.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Aged , Humans , United States , Medicaid , Medicare , Retrospective StudiesABSTRACT
BACKGROUND: Lymphedema can occur in patients undergoing axillary lymph node dissection (ALND) and radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed to decrease the risk of lymphedema in patients after ALND. Some patients who ultimately require ALND are candidates for attempted sentinel lymph node biopsy (SLNB) or targeted axillary excision. In those scenarios, ALND can be performed (1) immediately if frozen sections are positive or (2) as a second operation following permanent pathology. The purpose of this study is to evaluate immediate ALND/ILR following positive intraoperative frozen sections to guide surgical decision-making and operative planning. METHODS: A single-center retrospective review was performed (2019-2022) for breast cancer patients undergoing axillary node surgery with breast reconstruction. Patients were divided into two groups: immediate conversion to ALND/ILR (Group 1) and no immediate conversion to ALND (Group 2). Demographic data and operative time were recorded. RESULTS: There were 148 patients who underwent mastectomy, tissue expander (TE) reconstruction, and axillary node surgery. Group 1 included 30 patients who had mastectomy, sentinel node/targeted node biopsy, TE reconstruction, and intraoperative conversion to immediate ALND/ILR. Group 2 had 118 patients who underwent mastectomy with TE reconstruction and SLNB with no ALND or ILR. Operative time for bilateral surgery was 303.1 ± 63.2 minutes in Group 1 compared with 222.6 ± 52.2 minutes in Group 2 (p = 0.001). Operative time in Group 1 patients undergoing unilateral surgery was 252.3 ± 71.6 minutes compared with 171.3 ± 43.2 minutes in Group 2 (p = 0.001). CONCLUSION: Intraoperative frozen section of sentinel/targeted nodes extended operative time by approximately 80 minutes in patients undergoing mastectomy with breast reconstruction and conversion of SLNB to ALND/ILR. Intraoperative conversion to ALND adds unpredictability to the operation as well as additional potentially unaccounted operative time. However, staging ALND requires an additional operation.
ABSTRACT
BACKGROUND: Studies indicate aseptic revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) requires much more effort but is reimbursed less than primary procedures per minute work time. This study quantified planned and unplanned work performed by the surgeon and/or their team during the entire episode of care "reimbursement window" and compared it to allowed reimbursement times by Centers for Medicare and Medicaid Services (CMS). METHODS: Between October, 2010, and December, 2020, all unilateral aseptic rTHA and rTKA procedures performed by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated from surgery scheduling to 90 days postoperative. Impromptu patient inquiries and treatments after discharge but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. Work time was compared to CMS allowable times for rTHA (617 minutes) and rTKA (520 minutes). RESULTS: There were 292 Aseptic rTKA and 63 aseptic rTHA procedures included. Based upon CMS allowable times per patient there were a mean of 4.4 hours (267 minutes) of uncompensated care time per rTKA patient and a mean of 2.4 hours (141 minutes) of uncompensated care time per rTHA patient. CONCLUSION: Aseptic revisions are substantially more complex than primaries, requiring work effort that is not commensurate with current reimbursements. Financially disincentivizing surgeons to care for patients requiring revision surgery could reduce patient access to care when high quality care is needed the most.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , United States , Humans , Aged , Episode of Care , Medicare , Retrospective StudiesABSTRACT
BACKGROUND: Septic revision total hip (rTHA) and knee (rTKA) arthroplasty requires more effort but is reimbursed less than primary procedures per minute of intraoperative time. This study quantified planned and unplanned work performed by the surgical team for septic 2-stage revision surgeries during the entire episode-of-care "reimbursement window" and compared that time to allowable reimbursement amounts. METHODS: Between October 2010 and December 2020 all unilateral septic 2-stage rTHA and rTKA procedures performed by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. RESULTS: Sixty-eight hips and 64 knees were included. For 2-stage rTHA and rTKA the average time per patient for planned care was 1728 and 1716 minutes and for unplanned care was 339 and 237 minutes. Compared to the Centers for Medicare and Medicaid Services' allowable reimbursement times, an additional 799 and 887 minutes of uncompensated time was required to care for 2-stage rTHA and rTKA patients. CONCLUSION: Two-stage revision procedures are substantially more complex than primary procedures. Financially disincentivizing surgeons to care for these patients reduces access to care when high-quality care is most needed. These findings support increasing the allowable times for 2-stage septic revision cases.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Aged , Episode of Care , Humans , Medicare , Reoperation , Retrospective Studies , United StatesABSTRACT
Breast cancer-related lymphedema results in chronic upper limb swelling with subcutaneous deposition of fluid and fibroadipose tissue. Morbidity includes psychosocial distress, infection, and difficulty using the extremity. Operative management includes excisional procedures such as suction-assisted lipectomy to reduce abnormal subcutaneous fibroadipose tissue to improve limb volume. Patients who have had postmastectomy breast reconstruction often benefit from fat grafting. This report introduces the concept of fat grafting the breast using the lymphedematous arm as a donor site. This technique improves the volume of the limb by removing the excess subcutaneous adipose, and at the same time reconstructs the breast without adding a donor site not related to the breast cancer-related lymphedema.
ABSTRACT
Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. There is no cure for the disease. Clinically, a preventive surgical approach called immediate lymphatic reconstruction (ILR) has gained traction. Experimental gene-based therapeutic approaches (e.g., using viral vectors) have had limited translational applicability. Tissue nanotransfection (TNT) technology uses a direct, transcutaneous nonviral vector, gene delivery using a chip with nanochannel poration in response to a rapid (<100 ms) focused electric field. The purpose of this study was to experimentally prevent lymphedema using focal delivery of a specific gene Prox1 (a master regulator of lymphangiogenesis). TNT was applied to the previously optimized lymphedematous mice tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: group I (sham) was given pCMV6 (expression vector backbone alone) and group II was treated with pCMV6-Prox1. Group II mice had decreased tail volume (47.8%) compared to sham and greater lymphatic clearance on lymphangiography. Immunohistochemistry showed greater lymphatic vessel density and RNA sequencing exhibited reduced inflammatory markers in group II compared to group I. Prox1 prophylactically delivered using TNT to the surgical site on the day of injury decreased the manifestations of lymphedema in the murine tail model compared to control.
ABSTRACT
Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are used to prevent or treat neuromas in amputees. TMR for above-the-knee amputation (AKA) is most commonly performed through a posterior incision rather than the stump wound because recipient motor nerves are primarily located in the proximal third of the thigh. When preventative TMR is performed with concurrent AKA, a posterior approach requires intraoperative repositioning and an additional incision. The purpose of this study was to evaluate feasibility of TMR and operative times for nerve management performed through the wound compared to a posterior approach in AKA patients to guide surgical decision-making. Patients who underwent AKA with TMR between 2018-2023 were reviewed. Patients were divided into two groups: TMR performed through the wound (Group I) and TMR performed through a posterior approach (Group II). If a nerve was unable to undergo coaptation for TMR due to the lack of suitable donor motor nerves, RPNI was performed. Eighteen patients underwent AKA with nerve management were included from Group I (8 patients) and Group II (10 patients). TMR coaptations performed on distinct nerves was 1.5 ± 0.5 in Group I compared to 2.6 ± 0.5 in Group II (p = 0.001). Operative time for Group I was 200.7 ± 33.4 min compared to 326.5 ± 37.1 min in Group II (p = 0.001). TMR performed through the wound following AKA requires less operative time than a posterior approach. However, since recipient motor nerves are not consistently found near the stump, RPNI may be required with TMR whereas the posterior approach allows for more TMR coaptations.
Subject(s)
Amputation, Surgical , Nerve Transfer , Humans , Male , Female , Amputation, Surgical/methods , Middle Aged , Adult , Nerve Transfer/methods , Retrospective Studies , Operative Time , Amputation Stumps/innervation , Amputation Stumps/surgery , Nerve Regeneration/physiology , Feasibility Studies , Aged , Neuroma/surgery , Thigh/innervation , Thigh/surgery , Muscle, Skeletal/innervation , Muscle, Skeletal/transplantationABSTRACT
Background: Lymphedema is chronic limb swelling resulting from lymphatic dysfunction. It affects an estimated five million Americans. There is no cure for this disease. Assessing lymphatic growth is essential in developing novel therapeutics. Intravital microscopy (IVM) is a powerful imaging tool for investigating various biological processes in live animals. Tissue nanotransfection technology (TNT) facilitates a direct, transcutaneous nonviral vector gene delivery using a chip with nanochannel poration in a rapid (<100 ms) focused electric field. TNT was used in this study to deliver the genetic cargo in the murine tail lymphedema to assess the lymphangiogenesis. The purpose of this study is to experimentally evaluate the applicability of IVM to visualize and quantify lymphatics in the live mice model. Methods and Results: The murine tail model of lymphedema was utilized. TNT was applied to the murine tail (day 0) directly at the surgical site with genetic cargo loaded into the TNT reservoir: TNTpCMV6 group receives pCMV6 (expression vector backbone alone) (n = 6); TNTProx1 group receives pCMV6-Prox1 (n = 6). Lymphatic vessels (fluorescein isothiocyanate [FITC]-dextran stained) and lymphatic branch points (indicating lymphangiogenesis) were analyzed with the confocal/multiphoton microscope. The experimental group TNTProx1 exhibited reduced postsurgical tail lymphedema and increased lymphatic distribution compared to TNTpCMV6 group. More lymphatic branching points (>3-fold) were observed at the TNT site in TNTProx1 group. Conclusions: This study demonstrates a novel, powerful imaging tool for investigating lymphatic vessels in live murine tail model of lymphedema. IVM can be utilized for functional assessment of lymphatics and visualization of lymphangiogenesis following gene-based therapy.
Subject(s)
Disease Models, Animal , Intravital Microscopy , Lymphangiogenesis , Lymphatic Vessels , Lymphedema , Tail , Animals , Lymphedema/pathology , Lymphedema/diagnostic imaging , Lymphedema/metabolism , Lymphedema/genetics , Mice , Intravital Microscopy/methods , Lymphatic Vessels/diagnostic imaging , Lymphatic Vessels/pathology , Lymphatic Vessels/metabolism , Female , Gene Transfer TechniquesABSTRACT
BACKGROUND: As medical students consider residency training programs, access to comprehensive training in abortion care and the legal climate influencing abortion care provision are likely to affect their decision process. OBJECTIVE: This study aimed to determine medical students' desire to stay in a state with an abortion ban for residency. STUDY DESIGN: A cross-sectional survey was distributed to all medical students at a large allopathic medical school. Anonymous survey questions investigated the likelihood of seeking residency training in states with abortion restrictions and the likelihood of considering obstetrics and gynecology as a specialty. Qualitative responses were also captured. RESULTS: The survey was distributed to 1424 students, and 473 responses yielded a 33.2% completion rate; 66.8% of students were less likely to pursue residency training in Indiana following a proposed abortion ban. Moreover, 70.0% of students were less likely to pursue residency in a state with abortion restrictions. Approximately half of respondents (52.2%) were less likely to pursue obstetrics and gynecology as a specialty after proposed abortion restrictions. Qualitative remarks encompassed 6 themes: comprehensive health care access, frustration with the political climate, impact on health care providers, relocation, advocacy, and personal beliefs and ethical considerations. CONCLUSION: Most medical students expressed decreased likelihood of remaining in Indiana or in states with abortion restrictions for residency training. The field of obstetrics and gynecology has been negatively affected, with medical students indicating lower likelihood to pursue obstetrics and gynecology. Regardless of specialty, the physician shortage may be exacerbated in states with abortion restrictions. The overturn of Roe v Wade has the potential for significant effects on medical student plans for residency training location, thereby shaping the future of the physician workforce.
Subject(s)
Internship and Residency , Students, Medical , Pregnancy , Humans , Female , Indiana/epidemiology , Cross-Sectional Studies , Women's HealthABSTRACT
Genetic screens have been used to identify genes involved in the regulation of different biological processes. We identified growth mutants in a Flp/FRT screen using the Drosophila melanogaster eye to identify conditional regulators of cell growth and cell division. One mutant identified from this screen, B.2.16, was mapped and characterized by researchers in undergraduate genetics labs as part of the Fly-CURE. We find that B.2.16 is a non-lethal genetic modifier of the Dark82 mosaic eye phenotype.