Carbon footprint of a laser unit: a study of two centres in the UK.

PURPOSE: Climate change has serious consequences for our wellbeing. Healthcare systems themselves contribute significantly to our total carbon footprint, of which emissions from surgical practice are a major component. The primary sources of emissions identified are anaesthetic gases, disposal of single-use equipment, energy usage, and travel to and from clinical areas. We sought to quantify the waste generated by laser surgery which, to our knowledge, has not been previously reported. METHODS: The carbon footprint of two laser centres operating within the United Kingdom were measured. The internationally recognised Greenhouse Gas Protocol was used as a guiding framework to classify sources of waste and conversion factors issued by the UK government were used to quantify emissions. RESULTS: The total carbon footprints per day at each unit were 299.181 carbon dioxide equivalents (kgCo2eq) and 121.512 kgCO2eq, respectively. We found the carbon footprint of individual laser treatments to be approximately 15 kgCO2eq per procedure. The biggest overall contributor to the carbon footprint was found to be the emissions generated from staff, patient and visitor travel. This was followed by electricity usage, and indirect emissions from physical waste and laundry. CONCLUSIONS: The carbon footprint of laser procedures was considerably less than the average surgical operation in the UK. This initial study measures the carbon footprint of a laser center in a clinical setting and allows us to identify where improvements can be made to eventually achieve a net carbon zero health care system.

Health economics of diabetic foot ulcer and recent trends to accelerate treatment.

Diabetic foot ulcer is a preventable complication of diabetes that imposes a significant burden on the community. It leads to amputation and increased disability if left untreated and thus bears profound implications on the individual, the community and the health system at large. Diabetic foot (DF) is an area of research interest where interdisciplinary researchers are trying to elucidate the best strategy to halt the progression of chronic diabetic wounds. It is an area where tissue engineering research is making a strong impact through the use of scaffolds and skin substitutes for diabetic wound healing. This review aims at discussing the geographical health economics, its impact on healing and factors influencing financial costs of DFU. The upcoming economic and clinical impacts due to disease outbreak such as the 2020 COVID-19 has also been discussed. Finally, it will discuss novel therapy available with emphasis on skin tissue engineering scaffolds with a cost-benefit analysis. The review aims at promoting better management of people with diabetes with emphasis on emerging treatments and technologies.

Management of the Two-Week Wait Pathway for Skin Cancer Patients, before and during the Pandemic: Is Virtual Consultation an Option?

BACKGROUND: Although telemedicine emerged more than 100 years ago, the recent pandemic underlined the role of remote assessment of different diseases. The diagnoses of cutaneous conditions, especially malignant lesions, have placed significant stress on the fast-track pathway for general practitioners (GPs), dermatologists, and plastic surgeons. The aim of the study was to compare (pre- and during the pandemic) the ability of professionals to face the challenge. METHODS: The study was composed of 1943 consecutive patients (mean age 61.9 ± 18.3, 53.8% female) assessed by GPs, face-to-face (988 patients, 50.8%, between October 2019 and March 2020) and by virtual (video/photo) visits (955 patients, 49.2%, between March 2020 and October 2020) for skin lesions, and referred to secondary care via the two-week wait pathway for suspected skin malignancy. RESULTS: The two groups had similar primary skin malignancies identification rates (24.3% vs. 22.1%, p = 0.25). The virtual visits identified squamous cell carcinoma (SCC) better than face-to-face consultations (p = 0.04), but identified basal cell carcinoma less-well (BCC, p = 0.02), whereas malignant melanoma (MM) was equally identified in the two groups (p = 0.13). There was no difference in the median breach time (days) of the two-week wait pathway (12, IQR = 6 vs. 12, IQR = 5, p = 0.16) in the two groups. Virtual assessments (by GPs) of skin lesions suspected of malignancy, and referred via the two-week wait pathway, increased the probability of diagnosing SCC by 42.9% (p = 0.03), while for malignant melanomas, face-to-face and virtual consultations were alike (p = 0.12). CONCLUSIONS: The equivalent outcomes in the management of skin cancers (SCC, MM) via the two-week pathway through virtual consultations and face-to-face appointments underline the role of telemedicine as a reliable alternative to face-to-face assessments.

Bridging the Gap - A Traffic Light System to Ease Communication Amongst Surgeons, Hand Therapists and Patients.

Communication in the healthcare setup is essential for patient safety and for seamless delivery of services to the patient. We have adopted a novel way of communication in the form of a colour-coded visual aid in the form of a traffic light system to guide the patients through the course of their treatment. This shows the treatment plan in the form of Red, Amber, Green and Blue. The Red (Stop) denotes complete immobilisation with Splints, Amber (Proceed with caution) denotes active movements only, Green (Go forward) denotes Passive and Active movements and Blue shows when the patient can undergo guided weight bearing and strengthening exercises without a splint. The implementation of this system has created a streamlining of our protocol and improvement in the quality of the care we deliver. Level of Evidence: Level V (Therapeutic).

Groin dissections in skin cancer: Effect of a change in prophylactic antibiotic protocol.

OBJECTIVES: To determine whether groin dissection surgical site infection (SSI) incidence changed with shorter post-operative antibiotic prophylaxis. BACKGROUND: Post-operative prophylaxis changed due to antimicrobial stewardship, from regular oral antibiotics until drain removal, to three intravenous doses. Both groups had a single intravenous dose at induction. METHODS: A prospective database of groin dissections for metastatic skin cancer was retrospectively reviewed for SSI according to Public Health England criteria. Eighty groin dissections in 79 consecutive patients were included: 40 had oral antibiotics until drain removal [mean 26±7 (range 19-36) days] and 39 had three post-operative intravenous doses. RESULTS: Longer prophylaxis was associated with lower SSI incidence [10 (25%) versus 21 (54%), odds ratio (OR) 3.50, 95% confidence interval (CI) 1.34-9.08, p = 0.009], fewer deep infections [5 (13%) versus 16 (41%), OR 4.89, 95% CI 1.57-15.13, p = 0.004], fewer readmissions for infection [5 (13%) versus 15 (38%), OR 4.38, 95% CI 1.40-13.65, p = 0.008], but similar seroma incidence [18 (45%) versus 16 (41%), OR 0.85, 95% CI 0.35-2.07, p = 0.72] and wound dehiscence [7 (18%) versus 5 (13%), OR 0.69, 95% CI 0.20-2.40, p = 0.56]. BMI ≥30 (n = 21) was associated with SSI, occurring in 13 of 21 (62%) (OR 3.859, 95% CI 1.34-11.10, p = 0.01). Median infection onset was 22 days (IQR 12-27) versus 17 (IQR 13-22), (p = 0.53). Multiple organisms were cultured in 21 of 31 (68%) patients with positive microbiological samples. CONCLUSIONS: SSI rates doubled with shorter prophylaxis; deep infections and readmissions for infection tripled. Obesity was independently associated with infection. Seroma and wound dehiscence incidence were unchanged. Infections mainly occurred in the third week after surgery and were polymicrobial.

Rare Presentation of Pilar Cyst of the Thumb.

Pilar cysts are common cysts on the scalp and hair bearing area of the body. We found one such cyst on the dorsum of the thumb. There have been previous reports of them in the finger tips as a very rare occurrence. The site of this lesion supports the theory of a possible origin from the nail matrix. These lesions, even when found at unusual sites should have pilar cyst as a differential diagnosis. They must always be excised and subjected to careful histopathology to rule out proliferating trichilemmal cysts, which carry a rare risk of malignancy.

Risk Factors, Disease Associations, and Dupuytren Diathesis.

Dupuytren disease (DD) is a benign, fibroproliferative disease of unknown cause. The disease predominantly affects the palms of the hands, causing permanent digital contracture of affected digits. DD is a late-onset disease and is often progressive, irreversible, and bilateral. The disease has a significant impact on the health care economy. The mainstay of treatment of DD is surgical excision of diseased palmar fascia. There is evidence of genetic susceptibility. This article introduces the epidemiology of DD and examines the Dupuytren diathesis to highlight the importance of identifying clinical severity in relation to patient counseling and recurrence risk following treatment.

The Role of Wrist Fusion and Wrist Arthroplasty in Rheumatoid Arthritis.

Rheumatoid arthritis is the most common form of inflammatory arthritis with a predilection for the hand and wrist. The aggressive nature of the disease can lead to severe joint destruction causing significant disability. Surgical options for pan-carpal arthritis include total wrist arthroplasty and total wrist fusion both with varying outcomes, yet both have a role in the carefully selected patients. Fusion remains a popular procedure with consistent reliable results with few complications. We present a review of current evidence, indications and guidance for both fusion and arthroplasty in rheumatoid arthritis.

Use of stem cells and growth factors in rotator cuff tendon repair.

In this review, we analysed the role of stem cell and growth factor therapy on rotator cuff tendon repair. The injury to the rotator cuff tendons can be sustained in numerous ways and generally causes significant pain and disability to the affected individual. Following surgical repair of ruptured rotator cuff tendons re-rupture rates can be as high as 20-60%. In order to augment this repair process and to decrease the re-rupture rates tissue engineering methods can be used. These include the use of stem cells and growth factors. Mesenchymal stem cells are stem cells which can differentiate into a variety of connective tissue cell types and can therefore be utilised in repairing tendons. So far there has only been one human study using stem cells in rotator cuff tendon repair. This study has produced a positive result but consisted of only 14 patients and lacks a control group for comparison. Similar work has also been done using growth factors. Both individual and combination growth factor therapy have been used to improve rotator cuff tendon repair. However, the results so far have been disappointing with growth factors. For the purpose of future studies better techniques should be explored with regards to the delivery of stem cells and growth factors as well as the possibility of combining growth factor and stem cell therapy to improve repair rates.

The ortho-plastic approach to soft tissue management in trauma.

Fractures with associated soft tissue injuries, or those termed 'open,' are not uncommon. There has been much discussion regarding there management, with the guidance from the combined British Orthopaedic Association and British Association and Aesthetic Surgeons teams widely accepted as the gold level of therapy. We aim to discuss the current evidence about the initial management of this group of injuries, taking a journey from arrival in the accident and emergency department through to the point of definitive closure. Other modes of therapy are also reviewed.

Flap decisions and options in soft tissue coverage of the upper limb.

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

The development and future of reconstructive and microvascular surgery of the hand.

The hand is often thought of as a key discriminator in what makes humans human. The hand is both intricate and fascinating in its design and function, allowing humans to interact with their surroundings, and each other. Due to its use in manipulation of the person's environment, injury to the hand is common. Devastating hand injuries have a profound, physical, psychological, financial and socially crippling effect on patients. Advances in operative techniques and improvements in microscopes and instruments allowed Malt &McKhann to perform the first successful arm replantation in 1962 [1]. This was followed by a myriad of autologous free flaps of varying composition, that were discovered after the mapping of the cutaneous blood circulation by Taylor and Palmer [2] and Mathes & Nahai's classification of muscle flaps [3] providing us with countless options to harvest and transfer healthy, well vascularised tissues into areas of injury. Since the late sixties, with the emerging subspecialty of microvascular reconstruction, surgeons have had the technical ability to salvage many amputated parts, even entire limbs. The measure of functional outcomemust incorporate the evaluation and severity ofthe initial injury and the subsequent reconstructive surgeries [4].

Pilon fracture: a case report of a 45-year-old dental technician.

Pilon fractures are complex and difficult-to-treat fractures of the lower extremity that account for about 1% of all lower extremity fractures and up to 10% of tibial fractures. The injury is caused by high energy axial load either from motor vehicle accidents or a fall from height. The treatment of these fractures has caused controversy among surgeons due to mixed outcomes. Here we report a case of pilon fracture in a 45 year old male patient who has sustained the injury as a result of a fall from a height of approximately 12 feet. We describe why it is absolutely crucial that the patient is treated with external fixation initially and evaluate its merits and drawbacks as well as ways to minimize the complications associated with external fixation of open intra-articular distal tibial fractures.

Flap decisions and options in soft tissue coverage of the lower limb.

THE LOWER EXTREMITIES OF THE HUMAN BODY ARE MORE COMMONLY KNOWN AS THE HUMAN LEGS, INCORPORATING: the foot, the lower or anatomical leg, the thigh and the hip or gluteal region. The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the surrounding environment, the legs' primary goals are support and to allow upright ambulation. Essentially, this means that reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function. This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the options in terms of soft tissue coverage. This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a defect of the lower limb. A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.

Orthopaedic approaches to proximal humeral fractures following trauma.

Proximal humeral fractures have been a topic of discussion in medical literature dating back as far as 3rd century BC. Today, these fractures are the most common type of humeral fractures and account for about 5-6% of all fractures in adults with the incidence rising rapidly with age. In broad terms the management of proximal humeral fractures can be divided into two categories: conservative versus surgical intervention. The aim of treatment is to stabilize the fracture, aid better union and reduce pain during the healing process. Failure to achieve this can result in impairment of function, and significantly weaken the muscles inserting onto the proximal humerus. With the rising incidence of proximal humeral fractures, especially among the elderly, the short and long term burden for patients as well as the wider society is increasing. Furthermore, there is a lack of consistency in the definitive treatment and management of displaced fractures. This systematic review of literature compares the surgical treatment of proximal humeral fractures with their conservative management, by evaluating the available randomised controlled trials on this topic.

State of the art regarding the management of multiligamentous injuries of the knee.

Multiligamentous knee injuries are rare but serious injuries that can threaten limb viability. As such, they require careful management to give patients the best chance of immediate and ultimate functional recovery. However, as these injuries are rare, there is paucity in prospective comparative studies large enough to provide high level evidence for best practice. This lack of comprehensive and convincing evidence has made the management of multiligamentous knee injuries an area of active debate and controversy. The debate on whether surgical management leads to better outcomes than non-operative management, the optimal timing of surgery after injury and whether repair is better than reconstruction is still ongoing. Using the Oxford Levels of Evidence, this review summarises the latest high level evidence to provide answers to these issues. Recommendations for practice have also been offered and assigned a grade using a published scale.

Is home monitoring of international normalised ratio safer than clinic-based monitoring?

A best evidence topic was written according to a structured protocol, to answer the question: 'In patients taking warfarin, is home self-monitoring of international normalized ratio (INR) safer than clinic-based testing in reducing bleeding, thrombotic events and death?' Altogether, 268 papers were found using the reported search. Five papers represented the highest level of evidence to answer the clinical question (four systematic reviews with meta-analysis and one meta-analysis). The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The principal outcomes of interest were death, major haemorrhage, major thromboembolism, and time (or percentage time) spent within the therapeutic range, compared between self-monitoring/self-management and conventional management. Self-monitoring/self-management was associated with a significantly reduced risk of all-cause mortality of 26-42%. All meta-analyses reported on major thromboembolism, finding significant reductions in risk of ~50%. One meta-analysis found a 35% reduction in the risk of major haemorrhage, with the other four studies finding no significant difference. Only one study found self-monitoring/self-management to be associated with a significantly greater proportion of time within range, with another finding no significant difference in either the percentage of therapeutic results or in the time within range. The remaining two could not combine data for meta-analysis owing to methodological heterogeneity. We conclude that self-monitoring/self-management appears to be safer than conventional management. It is associated with consistently lower rates of thromboembolism and may also be associated with reduced risk of bleeding and death. This supports the updated guidance from the American College of Chest Physicians, recommending self-management of INR for patients who are both competent and motivated.