A Cadaveric Study of Cutaneous Vascular Anatomy about the Elbow Using Computed Tomography Angiography.

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc.

Effect of Total Joint Arthroplasty Surgical Day of the Week on Length of Stay and Readmissions: A Clinical Pathway Approach.

BACKGROUND: The demand for total joint arthroplasty (TJA) is increasing at the same time that alternative payment models place increased scrutiny on the cost of these procedures. Using a clinical pathway model, this study aimed to examine the effect of day of surgery on length of stay (LOS). METHODS: A retrospective electronic chart review was conducted on 2968 cases over 20 months at a single hospital. Least square means analysis of the effect of surgical day of the week on LOS was conducted using Statistical Analysis Software 9.3, followed by Tukey's multiple comparison test. Logistic regression assessed the effect of surgical day of week on readmission. RESULTS: Within the primary TJA group, there was no significant difference in mean LOS for each day of the week (1.17, 1.32, 1.29, 1.27, and 1.27 for Monday through Friday, respectively). Of all days, mean LOS for revision TJA (1.51, 1.57, 1.57, 2.49, and 2.03) only differed significantly for Thursday (P < .0001), although in adjusted analysis with age and American Society of Anesthesiologist, this difference was no longer significant (P = .3954). Readmission was likewise not significantly affected by surgical day of week (chi sq = 1.426, P = .8396) in the sample. CONCLUSION: As the volume of joint arthroplasties increases and alternative payment models are implemented, programs that promote decreased LOS regardless of operative day of the week are critical. Practices can use clinical pathway models to reduce costs related to LOS while maintaining a high level of patient care.

Technique for Periarticular Local Infiltrative Anesthesia Delivery Using Liposomal Bupivacaine in Total Knee Arthroplasty.

Postoperative pain control after total knee arthroplasty is a major contributing factor to patient satisfaction, rehabilitation, and length of stay. Current clinical practice guidelines recommend a multimodal pain management protocol, including the use of regional anesthesia. Periarticular injection (PAI) has been shown to provide excellent pain relief after total knee arthroplasty. Recently, liposomal bupivacaine has been introduced as a long-acting alternative to traditional local anesthetics, such as bupivacaine or ropivacaine. Liposomal bupivacaine is a sustained-release preparation designed to provide local analgesia up to 72 hours after initial application. The efficacy of PAI relies significantly on a meticulous, systematic injection technique. This article details recommendations for solution preparation and injection during total knee arthroplasty on the basis of the experience of a high-volume orthopaedic reconstruction service.