Emergency surgery is often performed on the elderly and susceptible patients with significant comorbidities; as a consequence, the risk of death or severe complications are high. Consent for surgery is a fundamental part of medical practice, in line with legal obligations and ethical principles. Obtaining consent for emergency services (for surgical patients with chronic or acute mental incapacity, due to surgical pathology) is particularly challenging, and meeting the standards requires an up-to-date understanding of legislation, professional body guidelines, and ethical or cultural aspects. The guidance related to consent requires physicians and other medical staff to work with patients according to the process of 'supported decision-making'. Despite principles and guidelines that have been exhaustively established, the system is sometimes vulnerable in actual clinical practice. The combination of an 'emergency' setting and a patient without mental 'capacity' is a challenge between patient-centered and 'paternalistic' approaches, involving legislation and guidelines on 'best interests' of the patient.

Introducere: Pe parcursul ultimelor 3 decenii a existat o nevoie recunoscută pentru chirurgie de urgenţă (ES). Studiile asupra ES au demonstrat variaţii ale rezultatelor pacienţilor în funcţie de momentul sau ziua internării. ES ca specialitate este încă pe lista specialităţilor de luat în considerare în Europa, deşi în SUA a fost deja recunoscută ca atare. Lucrarea de faţă evaluează această necesitate şi abordează problemele legate de dezvoltarea chirurgiei de urgenţă ca subspecialitate chirurgicală separată în Europa. Metodă: Un sondaj privind chirurgia de urgenţă a fost elaborat de către Comitetul Educaţional al Societăţii Europene de Chirurgie Traumatică şi de Urgenţă (Educational Committee of the European Society for Trauma and Emergency Surgery -ESTES) şi trimis tuturor membrilor ESTES, primindu-se înapoi 102 răspunsuri. Rezultate: Dintre răspunsuri, 93,1% au provenit de la chirurgi care şi-au încheiat pregătirea. 75,3% dintre persoanele care au răspuns semnalează că ES ar trebui recunoscută ca subspecialitate, iar 79% afirmă că ES ar putea oferi o carieră merituoasă. 90% afirmă că ES ar trebui să beneficieze de programe de pregătire postuniversitare, 69,8% fiind de acord că medicii chirurgi dedicaţi chirurgiei de urgenţă prezintă rezultate îmbunătăţite după ES. Concluzii: Dezvoltarea chirurgiei de urgenţă ca subspecialitate în Europa ar îmbunătăţi rezultatele pacienţilor şi alocarea resurselor. Acest demers este, însă, abia la început, iar continuarea sa ar necesita revizuirea generală a sistemului european actual, a metodelor de training şi a înţelegerii rolului chirurgilor în chirurgia de urgenţă.Cuvinte cheie: chirurgie de urgenţă, subspecializare, efectul Ringlemann

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Summary:The authors propose an offginal route of approach to the shoulder that allows direct access to this articulation. Thanks to this route, complex fractures of the proximal end of the humerus can be treated by ostosynthesis or prosthesis, and shoulder arthroses, whether centered or not by prosthesis. Two technical methods are used: first, the creation of an anterio r digastric trapezio-deltoid muscle flap, and then; in cases of elective prosthetic surgery, osteotomy of the lesser tubercle to open the articulation and provide direct access to the humeral head and the glenoid. The patient is installed in the semiseated position, with the apex of the shoulder projecting widely from the operating table. The incision is anterolateral, in the direction of the fibers of the deltoid and measures 8-1o cm from the anterolateral angle of the acromion (ALAA), which constitutes a convenient surgical landmark. One third of the incision is proximal; the other two-thirds are distal. The trapezio-deltoid digastric muscle flap is created: the deltoid is divided in the direction of its fibers between the anterior and middle bundles, straddling the ALAA. The acromial periosteum is incised vertically. The incision is extended upwards into the trapezius. The digastric muscle flap thus created is reflected forward together with the coraCoa~romial lighment: An acr6rnioplasty can be performed. This approach by itself allows access to the upper end of the humerus in complex fractures and allows osteosynthesis if called for. In cases of elective prosthetic surgery, and if the rotator cuff is intact, complete access to the articulation is obtained by osteotomy of the lesser tubercle in a plane parallel to its humeral base. This allows reflection of the subscapularis muscle with the tubercular fragment and opening of the articulation. Retro, pulsion of the elbow and lateral rotation displays the humeral head, which is osteotomized, and in this way access to the glenoid is immediate. The different stages of prosthetic surgery can then be performed. Closure is made most simply by reattachment of the lesser tubercle with a stout transosseous suture. The trapezio-deltoid digastric flap is closed by interrupted sutures without tension.

Introduction It has been shown that direct fixation of the posterior malleolus improves functional outcomes. Our aim was to audit the functional outcome of patients with these fractures which were fixed with an isolated posterolateral approach. Method A consecutive case series of patients who underwent direct fixation of the posterior malleolus using a posterolateral approach between 20/12/2012 and 23/1/2020 was identified. Fractures were classified according to Mason and Molloy classification based on preoperative CT. Type 2a and 2b fractures were included. Functional outcome was assessed using Olerud-Molander score. Result 18 patients were included. Mean age at time of surgery was 52 years (range 20 to 75 years). 56% (n = 10) were female. Mean follow up was 18.1 months (range 4.2 months to 7.2 years). OMAS score for type 2a fractures (n = 9) was 71.1 (95% CI 65.3 to 77.0). OMAS score for type 2b fractures (n = 9) was 67.8 (95% CI 54.6 to 81.0). There was no significant difference between groups (p = 0.65). Conclusions Fixation of Mason and Molloy Type 2 fractures using an isolated posterolateral approach results in satisfactory functional results for the majority of patients. Further prospective comparative study is needed to identify which patients benefit most from alternative approaches.