Sustainable orthopaedic surgery: Initiatives to improve our environmental, social and economic impact

In response to appeals from the WHO and The Lancet, a collaborative statement from over 200 medical journals was published in September 2021, advising international governments to combat the "catastrophic harm to health" from climate change. Healthcare, specifically surgery, constitutes a major contributor to environmental harm that remains unaddressed. This article provides practical guidance that can be instituted at a departmental, hospital and national level to institute transformative, sustainable efforts into practice. We also aim to provoke healthcare leaders to discuss policy-making with respect to this issue and highlight the necessity for sustainability to become a core domain of quality improvement. The average orthopaedic service produces 60% more waste than any other surgical specialty. Fortunately, simple measures such as a comprehensive education programme can decrease waste disposal costs by 20-fold. Other simple and effective "green" measures include integrating carbon literacy into surgical training, prioritising regional anaesthesia and conducting recycling audits. Furthermore, industry must take accountability and be incentivised to limit the use of single-item packaging and single-use items. National policymakers should consider the benefits of reusable implants, reusable surgical drapes and refurbishing crutches as these are proven cost and climate-effective interventions. It is crucial to establish a local sustainability committee to maintain these interventions and to bridge the gap between clinicians, industry and policymakers.

Rates of complications in Achilles tendon rupture repair using absorbable and nonabsorbable suture material; A systematic review

BACKGROUND

The impact of suture type on tensile strength, re-rupture rates and infection risk in Achilles tendon rupture repair is not been well established. The aim of this review is to evaluate existing literature on the associated risk of postoperative infection with absorbable and non-absorbable suture materials in Achilles tendon rupture repair.

METHODS

A systematic review of search databases PubMed; Google Scholar; and OVID Medline was made to identify studies related to complications associated with Achilles tendon rupture repair. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare rupture rates and infections following rupture repair.

RESULTS

12 studies with a total of 460 patients, 230 in both nonabsorbable and absorbable suture groups were included for analysis. Risk of wound complications was significantly higher in patients with non-absorbable sutures (p < 0.001).

CONCLUSION

Nonabsorbable braided sutures is associated with the highest risk of postoperative wound complications following Achilles tendon rupture repair.

Achilles' tendon rupture dancing the 'Jerusalema' - A case series

Introduction and importance

The weekend warrior has long been prey to musculoskeletal injuries as a result of intermittent, high intensity activity. The Achilles tendon is known to be particularly vulnerable in this population cohort but during the COVID-19 lockdowns in Ireland and all over the world there has been a certain level of detraining and deconditioning among all age groups and populations.

Throughout the worldwide restrictions, viral internet challenges and dances have encapsulated the spirit of a global community with the ‘Jerusalema’ dance being no exception. The rise of this particular viral sensation was at the detriment of the Achilles tendons of three middle aged gentlemen on who we base our case series.

Presentation of cases

Over the space of ten days three cases of Achilles tendon rupture repair presented to the emergency department in Midlands Regional Hospital Tullamore (MRHT) with the mechanism of tendon rupture being through the ‘Jerusalema’ dance.

These patients were surgically managed in line with local institution practice and postoperative outcomes were good with no complications noted. Follow up is ongoing.

Clinical discussion

This retrospective case series is based on the impact of the ‘Jerusalema Dance’ on presentations of Achilles tendon rupture to the Emergency Department in a single regional hospital from January to March 2021. We used these cases in conjunction with a review of current literature to highlight the benefit of an integrated Achilles Tendon rehabilitation programme in this at-risk patient cohort.

Conclusion

This paper highlights the dangers inherent when well intentioned, but physically deconditioned individuals endeavour to perform a physical exercise which is deceptively demanding. Going forward, viral challenges such as the ‘Jerusalema’ may contribute to new and interesting mechanisms of injuries in our ‘weekend warrior’ cohort. In addition to this, given the global deconditioning seen due to the COVID 19 pandemic and subsequent lockdowns we may see a higher rate of Achilles tendon injuries in the near future across a multitude of patient cohorts. Level one evidence suggests that conservative treatment is just as effective as surgical treatments in the majority of patients with an Achilles tendon rupture, as long as a protocol of rehabilitation with early weightbearing is performed. Our accelerated rehabilitation programme in MRHT is in line with others however internal audit and new literature in the future may enable us to refine it further.

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Achilles Tendon Rupture is common amongst the conditioned and deconditioned population.

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Surgical and conservative management options are widely explored in the literature.

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Viral dance challenges such as the Jerusalema offer new and interesting patterns of injury.

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An early weightbearing rehabilitation programme after TA rupture shows lower re-rupture rates.

A Rare Coincidence—a Second Trimester Ectopic Pregnancy Following Early Medical Abortion: a Case Report

We describe a case of a woman in her mid-30s who presented to a tertiary level maternity hospital 17 days following early medical abortion with a positive pregnancy test. On the ultrasound examination, it was discovered that she had a second trimester ectopic pregnancy which was treated surgically with a unilateral salpingectomy. We discuss in depth factors related to this woman’s care, such as appropriate assessment and evaluation of early medical abortion cases, the diagnostic challenges of early pregnancy scanning as well as the implications of the COVID-19 pandemic on the provision of care in these scenarios, and how this affected this woman’s care.

Clinical pregnancy from a vitrified/warmed human blastocyst

The first pregnancy after vitrification of a human blastocyst (day 5 of embryo culture) was reported by Yokota et al. in 2000. Since then more attention has been given to the technique of vitrification and its safe application in ART. To the best of our knowledge, this is the first report of a clinical pregnancy resulting in a live birth from the transfer of a vitrified/ warmed human blastocyst in the Republic of Ireland.

Assisted reproductive technology treatment outcomes

Information on the outcomes of ART treatments in Ireland is not readily available to Irish practitioners. The data for hospital affiliated clinics has been made available for many years and is included in the hospital reports. We present a 10-year analysis of the Irish ART results voluntarily reported by six out of seven IVF clinics. The data was collected from published ESHRE reports and from results (2007-8) not yet published. Data collected included: number of clinics and ART cycles, female age, clinical and multiple pregnancy rates and treatment complications. The clinical pregnancy rate per embryo transfer was 31.7% for IVF and 29.8% for ICSI. The proportion of singleton, twin and triplet deliveries for IVF and ICSI combined was 75%, 23.35% and 1.64%. The rate of ovarian hyperstimulation was 0.8%. ART practice in Ireland is safe, effective and responsible. Financial and societal savings could result from the introduction of state funded IVF with compulsory eSET where recommended.

Perinatal outcome after ultrasound diagnosis of anhydramnios at term

The aim was to assess the maternal and fetal outcome in women who had labour induced for anhydramnios after 37 completed weeks of gestation. A retrospective study was conducted at the Rotunda Hospital from 1 January 2003 to 31 December 2007. All women with anhydramnios at term were identified from a review of ViewPoint® (computer software for antenatal scans performed), hospital data and the labour ward register. All women with a history of previous lower segment caesarean section (LSCS), current significant medical illness such as diabetes, hypertension, pre-eclampsia or ruptured membranes were excluded because the aim of the study was to focus specifically on low risk pregnancies with an incidental diagnosis of anhydramnios after 37 weeks' gestation. The maternal and fetal outcome parameters reviewed included: maternal age, parity, gestation, method of induction, mode of delivery, Apgar score and the requirement for obstetric or neonatal intervention. This study showed that anhydramnios is associated with a 56.6% LSCS rate in primigravida and a 19.0% LSCS rate in multigravida. Our study did not show any significant neonatal morbidity and there were no cases of mortality.

Homocysteine in assisted reproduction: Does oestradiol influence homocysteine levels?

Steroid hormones including oestradiol have been identified as non-genetic factors that may influence plasma homocysteine. In advanced assisted reproduction, plasma oestradiol levels fluctuate markedly during the treatment cycle starting with normal followed by sub- and then supra-physiological levels. Because of the diverse harmful effects that hyperhomocysteinaemia has been associated with, it is imperative to understand how it may be manipulated during assisted reproduction. A total of 30 women undergoing treatment for infertility were recruited and followed through an advanced assisted reproduction cycle. Blood samples were analysed for oestradiol, homocysteine, vitamin B12, red cell folate and plasma folate during each phase. All patients had normal vitamin B12 and folate levels. Predictably, oestradiol showed marked changes as patients progressed through each treatment phase. However, there were no corresponding significant fluctuations in plasma homocysteine. Oestradiol concentration does not influence plasma homocysteine in women with normal vitamin B12 and folate levels undergoing advanced assisted reproduction.

An assessment of mood in males attending an infertility clinic

This study was undertaken to assess the mood profile in men seeking treatment for infertility and also to investigate if aetiological factors of infertility have any impact on mood. This was a prospective questionnaire study and the setting was the Human Assisted Reproduction Ireland (H.A.R.I.) unit in the Rotunda Hospital. Fifty men participated in the study and were required to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire. The results were analysed using an ordered logit regression analysis on the statistical software package DATA DESK 5.0.1. There were no cases of depression in the study population. However, detectable anxiety levels were displayed in 31.9% of men. Those with severe oligospermia had a higher mean anxiety score (8.5) compared with other patient subgroups. Clinically significant anxiety was found in 8.5%; all of these men had a male-factor problem. The study population was relatively small but some interesting trends were observed. A larger trial is warranted to assess if genuine at-risk groups exist.

Choriocarcinoma-presenting as a primary lesion of the cervix

A 25 year old nulliparous Russian lady presented to the hospital complaining of abdominal pain and mild vaginal bleeding. In 1999 she was diagnosed with a molar gestation and required a dilatation and curettage. On this occasion, Beta human Chorionic Gonadotrophin (BhCG) levels were elevated and a trans-vaginal ultrasound scan suggested the presence of a left-sided pelvic mass. Investigations confirmed the presence of a choriocarcinoma of the cervix. Complete assessment by a multidisciplinary team was performed and chemotherapy (methotrexate) was commenced. This case of a twenty-five year old nulliparous woman highlights the importance of appropriate follow-up in cases of irregular genital tract bleeding with a past history of trophoblastic disease.

Detecting mood disorders in men diagnosed with cancer who seek semen cryopreservation: a chance to improve service

To assess the prevalence of mood disorders in patients diagnosed with cancer and who pursue fertility preservation. Prospective questionnaire. The Human Assisted Reproduction (H.A.R.I.) unit, Rotunda Hospital. Twenty nine men were recruited between August 2001 and January 2002. Patients were informed about the study and requested to sign a consent form prior to completing the Hospital Anxiety and Depression Scale (HADS). Information regarding the patients diagnosis and prognosis were obtained from a standard referral form completed by the referring oncologists. The prevalence of mood disorders and to determine if this is related to the pretreatment prognosis. Anxiety was diagnosed in 44.8% and depression in 17.2% of patients. However clinically significant anxiety and depression was diagnosed in 13.8% and 6.9% respectively. There was no significant difference in the scores for anxiety and depression in the good prognosis group compared with the guarded group. Reduced sperm count was diagnosed in 26.9% of men and decreased motility in 30.8%, but neither of these were influenced by mood.

CONCLUSION

Anxiety and depression are commonly encountered in patients with cancer. Most cases are of mild to moderate severity. Knowledge of our patients' psychological status will contribute to an improved service.

Maternal deaths associated with caesarean section

Twelve Caesarean section-associated maternal deaths were encountered over a 15-year period. The major operative risk factors were pregnancy-induced hypertension, obesity and general anaesthesia. Severe preeclampsia was the forerunner to postoperative cardiac failure, consumptive coagulopathy and difficult airway manipulation. We conclude that pregnancy-induced hypertension and its ramifications pose the greatest threat to maternal survival from a Caesarean section.