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The microcirculation comprising of arterioles, capillaries and post-capillary venules is the terminal vascular network of the systemic circulation. Microvascular homeostasis, comprising of a balance between vasoconstriction, vasodilation and endothelial permeability in healthy states, regulates tissue perfusion. In severe infections, systemic inflammation occurs irrespective of the infecting microorganism(s), resulting in microcirculatory dysregulation and dysfunction, which impairs tissue perfusion and often precedes end-organ failure. The common hallmarks of microvascular dysfunction in both septic shock and dengue shock, are endothelial cell activation, glycocalyx degradation and plasma leak through a disrupted endothelial barrier. Microvascular tone is also impaired by a reduced bioavailability of nitric oxide. In vitro and in vivo studies have however demonstrated that the nature and extent of microvascular dysfunction as well as responses to volume expansion resuscitation differ in these two clinical syndromes. This review compares and contrasts the pathophysiology of microcirculatory dysfunction in septic versus dengue shock and the attendant effects of fluid administration during resuscitation.

Background Patella resurfacing is performed in >80% of primary total knee arthroplasties (TKAs) in the United States, yet far fewer patellae are resurfaced internationally. Recent registry data have begun to question the long-held belief that patellar resurfacing yields lower revision rates. Multiple current meta-analyses have not shown a difference in patient satisfaction, anterior knee pain, or knee society scores based on patellar resurfacing. Methods We sought to determine how the rates of patellar resurfacing have changed over the past 10 years worldwide (2004-2014). Data were abstracted from the annual reports of 7 national joint registries, literature review, or via direct correspondence with registry administrators. Results Average rates of patellar resurfacing from 2004 to 2014 ranged from 4% (Norway) to 82% (United States). The largest decrease in resurfacing rates was in Sweden (15%-2%), whereas the biggest increase was in Australia (44%-59%). In 2010, only 48,367 of 137,813 (35%) primary TKAs from all registries outside the United States were resurfaced. Meta-analyses have demonstrated no difference in anterior knee pain or satisfaction scores but do consistently report increased revision rates for unresurfaced patellae. Recent Swedish registry data, however, showed a reverse trend toward higher revision rates after resurfacing. Conclusion Despite recent registry data and meta-analyses demonstrating equivalent outcomes among resurfaced and unresurfaced patellae in primary TKA, worldwide trends in patellar resurfacing have changed little over the past decade. Most countries outside the United States continue to resurface a much smaller proportion of patellae.

The second half of the twentieth century witnessed the introduction and relatively rapid expansion of industrial robots. On the other hand, robotic infiltration in healthcare has been much slower and more limited. The past decade has experienced a surge in robotic assistance in surgery, sparked by unprecedented interest in the precision and ergonomic benefits of this rapidly evolving class of technology. While robots have been introduced more broadly in surgical fields such as urology, general surgery, and gynecology, adoption in orthopedic surgery is only recently, but rapidly, expanding and likely will remain on the leading edge of the robotic revolution.

The objective of this study was to determine if implementation of a simplified care pathway for total knee arthroplasty (TKA) would affect outcomes of total hip arthroplasty (THA) patients in the same health care system. Data were collected from a total of 5,095 consecutive THA patients in the year before and 2 years after implementation of the care pathway for TKA patients. Postimplementation increases were observed in both early activity (p

As total hip arthroplasty (THA) gains popularity in ambulatory surgery centers, it is important to understand the causes of failed same-day discharge (SDD). The purpose of this study is to (1) identify reasons for an overnight stay among patients selected as candidates for SDD following THA and (2) determine what pre-operative factors are more common among patients who fail SDD.This is a prospective cohort study of patients undergoing THA who were identified as candidates for SDD (75 years, ambulate without walker, American Society of Anesthesiologists score 1-3, body mass index40 kg/mSeventy-eight of 106 (74%) patients pre-selected for SDD were successfully discharged per protocol. Of the 28 (26%) patients who failed SDD, the most common reasons for failure were patient preference (12), dizziness or hypotension (8), failure to clear physical therapy (5), urinary retention (2), and pain management (1). There was a higher percentage of patients in the failed SDD group who reported multiple allergies (P = .02), anxiety/depression (P = .24), obstructive sleep apnea (P = .38), and rheumatoid arthritis (P = .02).SDD is a viable option for surgeons interested in rapid recovery THA. In a pool of patients selected for SDD, the main cause of SDD failure was a change in patient preference post-operatively, despite having agreed to SDD pre-operatively and meeting all discharge criteria.

Background The original Charnley-type negative-pressure body exhaust suit reduced infection rates in randomized trials of total joint arthroplasty (TJA) decades ago. However, modern positive-pressure surgical helmet systems have not shown similar benefit, and several recent studies have raised the question of whether these gowning systems result in increased wound contamination and infections. The gown-glove interface may be one source of particle contamination.

Wear and osteolysis are common problems that often require revision surgery following total knee arthroplasty (TKA). Wear rates can be reduced through proper implant positioning and the use of modern, highly cross-linked polyethylene liners. More research is needed to identify medications that could prevent or treat the bone loss associated with osteolysis. Bone defects resulting from osteolysis can be managed with a variety of bone-preserving strategies and often require the use of structural augmentation, either in the form of bulk allografts or metal augments. Recently, porous metal augments such as tantalum cones have gained popularity among surgeons performing revision TKA for osteolytic bone defects with promising early clinical results. A megaprosthesis with a rotating hinge device may be used in salvage cases for severe bone deficiencies.

Background A central concern for providers in a bundled payment model is determining how the bundle is distributed. Prior studies have shown that current reimbursement rates are often not aligned with patients' values. While willingness-to-pay (WTP) surveys are perhaps useful in a fee-for-service arrangement to determine overall reimbursement, the percentage of payment distribution might be as or more important in a bundled payment model. Methods All patients undergoing primary total joint arthroplasty by a single surgeon were offered participation in a preoperative WTP survey. At a minimum 3 months postoperatively, patients were mailed instructions for an online follow-up survey asking how they would allocate a hypothetical bonus payment. Results From January through December 2014, 45 patients agreed to participate in the preoperative WTP survey. Twenty patients who were minimum 3 months postoperative also completed the follow-up survey. Patients valued total knee and hip arthroplasty at $28,438 (95% confidence interval [CI]: $20,551-36,324) and $39,479 (95% CI: $27,848-$51,112), respectively. At 3 months postoperatively, patients distributed a hypothetical bonus payment 55.5% to the surgeon (95% CI: 47.8%-63.1%), 38% to the hospital (95% CI: 30.3%-45.7%), and 6.5% (95% CI: −1.2% to 14.2%) to the implant manufacturer ( P Conclusion The data suggest that total joint arthroplasty patients have vastly different perceptions of payment distributions than what actually exists. In contrast to the findings of this study, the true distribution of payments for an episode of care averages 65% to the hospital, 27% to the implant manufacturer, and 8% to the surgeon. While many drivers of payment distribution exist, this study suggests that patients would allocate a larger proportion of a bundled payment to surgeons than is currently disbursed. This finding may also provide a plausible explanation for patients' consistent overestimation of surgeon reimbursements.

Most historians agree that modern plastic surgery was born out of the efforts of reconstructive surgeons in World War I (WW I). In a single British hospital, over 8000 wounded soldiers were treated for disfiguring facial wounds. These gruesome injuries provided surgeons with enough cases to make unprecedented advances in tissue reconstruction. After the war, however, surgeons returned to civilian society where they found relatively few cases to support their new niche. In England, plastic surgery failed to establish itself while, in the United States, plastic surgeons had much greater success in founding their new specialty. Emphasizing this trend is the staggering statistic that, at the outbreak of World War II (WW II), the US boasted 60 trained plastic surgeons compared with only 4 in Britain. This article analyzes a variety of primary sources (speeches, journal articles, letters, and live interviews) obtained from several libraries and special collections to argue that the relative success of US plastic surgery in the interwar period (1920-1940) can be attributed to (1) the efforts of pioneering American plastic surgeons (Varaztad Kazanjian, Vilray Blair, and John Davis), (2) the post-Flexner report restructuring of US medical training, and (3) a much warmer reception both by the US public and general surgical community to plastic surgery.

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 ( R 2 = 0.86) and cost ( R 2 = 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.