Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Fractures around the shoulder girdle : Unsolved fractures?

This thesis is about the treatment of clavicle and proximal humeral fractures and is the result of a Swiss-Dutch collaboration. Clavicle and proximal humeral fractures are very common and used to be treated non-operatively. The last two decades we have seen a shift however towards more operative treatment. Despite many trials and other studies, until now there is still an ongoing debate about what the best treatment modality is for these fractures. ‘Patient selection’ together with ‘shared decision making’ are hot topics and are probably the key to future indications for operative or non-operative treatment of these fractures. This thesis presents several studies that aim to provide further evidence that can aid in making a decision for the best treatment for every single patient. The first part is about medial, shaft and lateral clavicle fractures. Medial clavicle fractures are rare injuries and generally treated non-operatively. We present an operative technique for displaced medial clavicle fractures. In this retrospective study we found excellent functional results. Furthermore, two studies about the intramedullary treatment of clavicle fractures were performed. One about the application of an end cap and one about the suitability of displaced clavicle shaft fractures. We concluded that the application of an end cap did not result in less implant related irritation and that fractures more lateral from the middle were less suitable for this technique from medial. Another study compared two implants for the treatment of instable lateral clavicle fracture. We concluded that whenever possible the superior plate with lateral extension should be used but that the Hook plate was a good alternative for very lateral fractures. And lastly, the current concepts for the treatment of collar bone fractures are discussed and treatment algorithms proposed. The second part covers the treatment of proximal humeral fractures. A systematic review and meta-analysis on displaced proximal humeral fractures (DPHF) was performed comparing the operative and non-operative treatment. As we found no difference in functional outcome, we concluded that for the typical patient presenting with a DPHF we recommend the non-operative treatment. In addition, a study on the long-term functional outcome and implant-related irritation after minimally invasive plate osteosynthesis (MIPO) of DPHF was performed. Satisfying functional outcomes after a mean of 8 years follow-up were found. However, about one third of the patients had a second operation for implant removal due to implant-related irritation. We also present a minimally invasive technique for proximal humeral fracture-dislocations. Functional results were promising and in 86% the humeral head was preserved. However, there is a high rate of re-operations either because of complications or for implant removal. In a last study we present the current concepts of proximal humeral fracture treatment. In general, non- or slightly-displaced proximal humeral fractures are treated non-operatively. Also, DPHF with elderly, osteoporotic and polymorbid patients can be treated conservatively. Older patients with a proximal humeral fracture-dislocation should be treated with a prosthesis, young and active patients with an osteosynthesis. For active and fit patients with a DPHF there is no consensus

Fractures around the shoulder girdle : Unsolved fractures?

This thesis is about the treatment of clavicle and proximal humeral fractures and is the result of a Swiss-Dutch collaboration. Clavicle and proximal humeral fractures are very common and used to be treated non-operatively. The last two decades we have seen a shift however towards more operative treatment. Despite many trials and other studies, until now there is still an ongoing debate about what the best treatment modality is for these fractures. ‘Patient selection’ together with ‘shared decision making’ are hot topics and are probably the key to future indications for operative or non-operative treatment of these fractures. This thesis presents several studies that aim to provide further evidence that can aid in making a decision for the best treatment for every single patient. The first part is about medial, shaft and lateral clavicle fractures. Medial clavicle fractures are rare injuries and generally treated non-operatively. We present an operative technique for displaced medial clavicle fractures. In this retrospective study we found excellent functional results. Furthermore, two studies about the intramedullary treatment of clavicle fractures were performed. One about the application of an end cap and one about the suitability of displaced clavicle shaft fractures. We concluded that the application of an end cap did not result in less implant related irritation and that fractures more lateral from the middle were less suitable for this technique from medial. Another study compared two implants for the treatment of instable lateral clavicle fracture. We concluded that whenever possible the superior plate with lateral extension should be used but that the Hook plate was a good alternative for very lateral fractures. And lastly, the current concepts for the treatment of collar bone fractures are discussed and treatment algorithms proposed. The second part covers the treatment of proximal humeral fractures. A systematic review and meta-analysis on displaced proximal humeral fractures (DPHF) was performed comparing the operative and non-operative treatment. As we found no difference in functional outcome, we concluded that for the typical patient presenting with a DPHF we recommend the non-operative treatment. In addition, a study on the long-term functional outcome and implant-related irritation after minimally invasive plate osteosynthesis (MIPO) of DPHF was performed. Satisfying functional outcomes after a mean of 8 years follow-up were found. However, about one third of the patients had a second operation for implant removal due to implant-related irritation. We also present a minimally invasive technique for proximal humeral fracture-dislocations. Functional results were promising and in 86% the humeral head was preserved. However, there is a high rate of re-operations either because of complications or for implant removal. In a last study we present the current concepts of proximal humeral fracture treatment. In general, non- or slightly-displaced proximal humeral fractures are treated non-operatively. Also, DPHF with elderly, osteoporotic and polymorbid patients can be treated conservatively. Older patients with a proximal humeral fracture-dislocation should be treated with a prosthesis, young and active patients with an osteosynthesis. For active and fit patients with a DPHF there is no consensus

Displaced medial clavicle fractures: operative treatment with locking compression plate fixation

Objectives: Medial clavicle fractures are rare injuries and historically treated non-operatively. Displaced medial clavicle fractures, however, have a higher incidence of delayed- or non-union compared to non- displaced medial clavicle fractures and might benefit from operative treatment. We describe below a new technique for treating intra-articular fractures or extra-articular fractures with a small medial fragment using special locking plates and present the results of our operatively treated patients. Methods: First we describe our technique for treating very medial fractures with the radial (VA)-LCP™ Distal Humerus Plate (DePuy Synthes, Switzerland). Second, a retrospective cohort study was performed. All patients operated on for a displaced medial clavicle fracture between 2010 and 2017 were included. Primary outcome was the QuickDASH score and the Subjective Shoulder Value (SSV). Secondary outcomes were operative complications including mal- or non-union and implant removal. Results: All 15 patients were available for follow-up. Fourteen patients were included in our analysis. One patient was excluded due to severe concomitant injuries. Six patients were treated with the radial (VA)-LCP™ Distal Humerus Plate, eight patients with the LCP™ Superior Anterior Clavicle Plate with lateral extension (DePuy Synthes, Switzerland) and one with a LCP 3.5 plate. The mean follow-up was 39 months (range 9–79). The mean QuickDASH score was 0.81 (range 0–4.50, SD ± 1.44) and the mean SSV was 96 (range 80–100, SD ± 6.53). One patient had an early revision operation and developed an infection after 1.5 years. No mal- or non-unions occurred. Eight patients had their implants removed. Conclusions: Operative treatment of displaced medial clavicle fractures with well-fitting ‘small fragment’ locking plates provides an excellent long-term functional outcome. Intra-articular fractures or extra-articular fractures with a small medial fragment can be treated with the radial (VA)-LCP™ Distal Humerus Plate

Spontaneous Septic Arthritis of Pubic Symphysis in an Elite Athlete

Septic arthritis of the pubic symphysis is a potentially severe disease. Athletes are at risk of this form of spontaneous arthritis, as inflammation of the pubic bone due to muscular stress is relatively common. Oedema due to inflammation might predispose to infection through bacteraemia or local bacterial translocation. Suspicion should be raised when an athlete complains of groin pain and has signs of infection (i.e., fever, elevated white blood cell count, and elevated C-reactive protein). Diagnosis is made by imaging showing signs of inflammation combined with positive (blood) cultures. Broad spectrum antibiotics should be started upon suspicion and adjusted according to cultures. An abscess causing clinical deterioration under antibiotic treatment is an indication for invasive intervention (i.e., surgical or image-guided drainage). This is the first case of spontaneous septic arthritis of the pubic symphysis in an athlete requiring surgical and additional image-guided drainage

Proximale humerusfracturen : Conservatief of operatief behandelen?

There is an increasing incidence of proximal humerus fractures. Patients with proximal humerus fractures have traditionally been treated conservatively. During the past decades, however, various new osteosynthetic and prosthetic implants have been developed for the shoulder and surgical treatment of proximal humerus fractures has increased. However, recent literature in which conservative and surgical treatment of proximal humerus fractures is compared has shown no difference in functional outcome. The trend towards more frequent surgical treatment is thus not based on scientific evidence. In this article, we present the current state of affairs and attempt to give a nuanced picture of who will not, but also who might profit from surgical treatment of a proximal humerus fracture

Clavicle fractures in adults; current concepts

Background: For decades, clavicle fractures have been treated conservatively. In the last 20 years, however, non-union rates after conservative treatment appear higher than previously reported and more evidence regarding operative treatment has become available. This has led to a paradigm shift towards an increase in operative treatment. The aim of this review is to present the current concepts and available evidence regarding clavicle fracture treatment. Methods: Conservative and operative treatment options together with their indications for medial, shaft and lateral clavicle fractures are discussed. For all three anatomical locations, a treatment algorithm is proposed. Conclusion: In general, non-displaced fractures are treated conservatively. Operative treatment has to be discussed with patients with displaced clavicle fractures, especially in the young and active patient

Behandeling van bevriezingsletsels

In Nederland zijn bevriezingsletsels in de gezonde populatie zeldzaam. Door een groeiend aantal winter- en buitensporters en reizigers naar hooggelegen gebieden, neemt het risico op bevriezingsletsel wel toe. Bevriezing is een koudegeïnduceerd letsel veroorzaakt door 2 processen: bevriezing en microvasculaire occlusie. Een goede eerste opvang, bestaande uit voorkoming van opnieuw bevriezen en van mechanisch letsel in combinatie met snel opwarmen en ibuprofen, is de belangrijkste factor die de uiteindelijke weefselschade kan beperken. Als een patiënt zich presenteert binnen 24 uur nadat het bevroren lichaamsdeel is ontdooid en de ernst van het letsel van dien aard is dat ernstige morbiditeit verwacht kan worden, is behandeling met iloprost en eventueel recombinant weefselplasminogeenactivator geïndiceerd. Als een patiënt zich later presenteert, is hyperbare-zuurstofbehandeling te overwegen; het bewijs hiervoor is echter beperkt