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

Prepatellar Bursal Infection Caused by Mycobacterium tuberculosis with an In Situ Total Knee Arthroplasty: A Case Report and Comprehensive Literature Review

Prepatellar bursal infection is a rare occurrence. The incidence of tuberculosis, including musculoskeletal type, is increasing. We present a case of isolated prepatellar bursal swelling associated with a discharging sinus; the condition developed in an elderly patient 4 years after total knee arthroplasty. Aspiration of the bursa revealed acid-fast bacilli on Ziehl–Neelsen staining, typical of Mycobacterium tuberculosis; this was confirmed later on culture. The patient was successfully treated with a 6-month course of antituberculous chemotherapy. To the best of our knowledge, only two previous cases of tuberculous prepatellar bursal infection have been reported in English literature. Our case illustrates the importance of considering tuberculous prepatellar bursal infection in the differential diagnosis of anterior knee swelling. All physicians treating patients with musculoskeletal disease should be aware of the possibility of this diagnosis and maintain a high index of suspicion; this is especially true in areas where tuberculosis is still endemic and in high-risk patients, such as the elderly

Cementless Metaphyseal Sleeve Fixation in Revision Knee Arthroplasty: Our Experience with an Arabic Population at the Midterm

Objective. Metaphyseal sleeve (MS) fixation in revision knee arthroplasty (RKA) among Western populations has been reported with very encouraging outcomes. The aim of this study was to report our experience with the use of MS in RKA among an Arabic population. Clinical and radiographic outcomes and implant survivorship were reported at a minimum follow-up of 2 years and a mean follow-up of 4.1 years. Methods. A retrospective analysis was conducted on prospectively collected data of patients who underwent RKA with a MS in combination with a cementless stem (femoral or tibial). Range of motion (ROM) and Knee Society Score (KSS) were obtained pre- and postoperatively. Complications, occurrence of stem-tip pain, and implant survival were documented. Knee radiographs were obtained to evaluate the alignment and osseointegration or loosening of the MS. Results. A total of 52 sleeves (27 tibial and 25 femoral) implanted in 27 RKAs (27 patients) were included. The mean follow-up period was 4.1 ± 1.8 (2–7.5) years. Postoperatively, the ROM improved from 89.3 ± 9.2 to 106.3 ± 11.4 (p = 0.19) and the KSS also significantly improved, from 102.9 ± 35.6 to 130.2 ± 33.7 (p < 0.001). One patient (3.7%) developed heterotopic ossification, and another one (3.7 %) had a stem-tip pain on the tibial side; both were managed conservatively. One patient (3.7 %) sustained a fracture and required reoperation. None of the sleeves showed progressive radiolucent lines, and none required revision. The aseptic survivorship and overall survivorship at a mean of 4.1 years were 100% and 96.3%, respectively. Conclusion. MS provided successful midterm outcomes that were maintained in obese patients with different levels of constraint. Our series supports their use as a viable option in RKA

Clinical and Radiological Outcomes of Extracorporeal Shock Wave Therapy in Early-Stage Femoral Head Osteonecrosis

Objective. Femoral head osteonecrosis is a progressive clinical condition with significant morbidity and long-term disability. Several treatment modalities including both surgical and nonsurgical options have been used with variable levels of success. High-energy extracorporeal shock wave therapy is a nonoperative treatment option that has been described for early-stage disease. We aimed to assess the functional and radiological outcomes of extracorporeal shockwave therapy (ESWT) in the treatment of osteonecrosis of the femoral head (ONFH). Methods. Thirty-three hips of 21 patients were included in this study. Adult patients with ONFH of any etiology and in the precollapse stage were included. Clinical (visual analogue scale [VAS] and Harris hip score [HHS]) and radiological (plain radiographs and magnetic resonance imaging [MRI]) evaluations were performed before and after intervention. We used 3000–4500 pulses in a single session performed under general anesthesia. Results. At an average of 8 months after ESWT, pain scores and HHS were significantly improved compared with the preintervention scores (p<0.001). The overall clinical outcomes were improved in 21 hips (63.3%), unchanged in 5 hips (15.15%), and worsened in 7 hips (21.2%). A trend toward a decrease in the size of the ONFH was observed although not of clinical significance (p=0.235). MRI revealed significant resolution of bone marrow edema (p<0.003). Regression was observed in 9 lesions (42.9%) and progression in 1 lesion (4.7%); no change was observed in the remaining 23 lesions (52.4%). Conclusion. ESWT is a viable noninvasive treatment option for early-stage ONFH. It significantly improves clinical outcomes and may halt or delay the radiographic progression of the disease in the precollapse stage

Delayed Horner′s syndrome following ultrasound- guided interscalene brachial plexus block

We describe a case of Horner′s syndrome that occurred shortly after post-operative bolus administration of interscalene brachial plexus analgesia

Cadaveric device-injected very high-viscosity cement during vertebroplasty

Introduction: Cement extravasation during vertebroplasty (VP) is the most commonly reported complication. Cement viscosity is considered the single most important predictor of the risk of extravasation. Certainly, injecting high-viscosity cement (HVC) is difficult to utilize in real practice. We invented a new device capable of injecting high-viscosity with ease and at a distance to avoid radiation. The aim of this study is to confirm the efficacy and safety of the new device on cadaveric vertebrae. Methodology: A 126 osteoporotic vertebral bodies were harvested from cadavers. Eighty vertebrae were included in the study. Computer-randomization software was used to allocate specimens over two main groups, Conventional VP and New Device. Both groups were further subdivided into two subgroups; high-viscosity and low-viscosity. A custom device was used on each vertebra to induce a compression fracture. Results: Injecting HVC was associated with a lower leakage volume compared with low-viscosity cement. HVC was associated with no leakage into the spinal canal. It was also associated with a low incidence of vascular extravasation (P < 0.001). The mean volume of cement leakage in the low-viscosity group was 0.23 and 0.15 cc, for the Conventional VP and New Device, respectively. In both groups, the most common site for leakage was the vertebral end plate, which was exhibited more in the low-viscosity group (71.5%) compared with the high-viscosity group (42.5%). The preset target amount of cement to be injected was reached in 99% of the time when injecting HVC with the New Device, compared with 62% using the Conventional VP. In both groups, there was no correlation between the amount of cement injected and the amount of leakage. Conclusion: The new device is capable of injecting HVC easily, with a lower incidence of cement leakage. It also minimized the risk of radiation exposure to the surgeon