Operative Techniques in Orthopaedics最新文献

Covid-19 has led to an increase in the use of PPE, gowns, masks, sanitizers, air circulators, and much more, all contributing to an increase in medical waste. Waste generation is one issue. Emissions are another. The two are linked because waste and emissions are both indicators of consumption. However, waste is not the biggest driver of environmental emissions for healthcare. It is the production of medical equipment, particularly disposables that have a bigger impact. Energy use during care, including heating and cooling our facilities, is another. Environmental emissions like greenhouse gases may not correlate with waste generation, especially if the waste is plastic. Carbon is stored in plastic. Unless you're burning plastic, you're not emitting carbon. Healthcare has a waste issue and healthcare has an emissions issue. They are not necessarily the same thing, however, the strategies to mitigate each overlap. Life cycle assessment quantifies emissions from the creation to disposal of medical supplies. This allows the medical community to make informed choices with respect to the methods and materials that are used in providing care. As other specialties take the lead in reducing their environmental footprint, so too, must orthopedic surgery.

Health care systems contribute a significant amount of global greenhouse gas (GHG) emissions, and operating rooms are among the most resource intensive and waste producing locations in hospitals. Surgery's high environmental impact is due to many factors including: widespread use of anesthetic and medical gases; pharmaceutical production and waste; substantial non-recycled waste from disposable single-use devices; and energy consumption for equipment use and reprocessing, in addition to the significant energy needed for heating, cooling and ventilation of ORs. As the urgency of addressing global climate change increases, health care providers must do all they can to minimize the environmental impacts of health care in a sustainable, yet safe manner. Thoughtful management techniques by anesthesiologists, surgeons, and operating room staff before, during, and after procedures can minimize the environmental impact of surgery while maintaining cost-efficient, excellent patient care.

“The triple bottom line” is an approach to mitigate the environmental consequences of any business endeavor by considering three important stakeholders - Profit, People, and Planet. While medicine is making appreciable progress on its environmental impact, the field of orthopaedic surgery is only beginning to research and prioritize environmental sustainability. Research, including Quality Improvement projects, is the avenue to understanding how to expand environmentally-conscious orthopaedic care. Research that identifies effective strategies for change cannot be effective without buy-in from medical staff, administrators, insurers, and governing bodies.

Humans are affected in numerous ways by climate change. Drought and water scarcity is an important area that must be addressed. Hospitals use a large amount of their community's water supply and therefore play a part in water conservation. The orthopaedist can minimize water waste in the operating room in multiple ways. The most immediate impact can be made by using less water for pre-operative scrubbing, either by turning off the water when not actively rinsing or by converting to waterless scrub. Eliminating rarely used surgical instruments from trays can save water and decrease costs to the hospital. Conserving water benefits both the hospital and the planet.

Ankle inversion injuries are common and most patients will have complete resolution of symptoms with nonoperative treatment. Some patients will develop chronic ankle instability and may develop associated pathology such as peroneal tendonitis, osteochondral lesions, ankle synovitis, and ankle impingement. A careful physical examination is imperative to evaluate for ankle instability as well as concomitant pathology. Imaging begins with standard radiographs and advanced imaging is used to evaluate for osteochondral lesions, ligament integrity, tendinitis, and other soft tissue lesions. Nonoperative treatment consists of immobilization, bracing, and physical therapy. Surgical treatment is reserved for patients who have symptoms despite nonoperative treatment and often involves imbrication of the lateral ankle ligament complex. Outcomes are typically favorable and most patients can expect to return to athletic activity.

Minimally Invasive lateral ligament repair of the ankle has been developed in recent years. These repairs involve threading sutures to the remnant and can be classified into three types. These include arthroscopy-assisted mini-open procedure, arthroscopic with percutaneous procedure, and all-inside arthroscopic procedures. The all-inside arthroscopic procedure is the most minimally invasive procedure because all steps are performed arthroscopically through one portal. Further, since it is possible to suture the ligament with a direct arthroscopic view all-inside arthroscopic procedures can be performed anatomically. In this chapter, the authors provide the history of arthroscopic lateral ankle ligament repair and a recommended procedure for all-inside arthroscopic ankle lateral ligament repair using a modified lasso-loop stitch technique.

Patients who present with lateral ankle ligament instability always need to be evaluated for cavovarus foot deformity. Cavovarus reconstruction may need to be performed in order to ensure the ankle instability procedure is successful. Which procedures are required will depend on the specific deformity present, and may need to be determined intraoperatively depending on the initial deformity correction achieved through the first procedures performed. A general though not strict algorithm for sequence of procedures involves soft tissue releases first, followed by hindfoot correction, then forefoot correction, and securing ligament reconstruction or tendon transfers as the final step. Tendon transfers can be an effective tool to aid in the deformity correction and several are described. For hindfoot and forefoot deformity correction, traditional calcaneus and metatarsal osteotomies work well, but fusion should be considered for joints with degenerative change or in cases where the deformity is severe or can't be corrected through osteotomy alone.