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Medically Necessary Orthopaedic Surgery During the COVID-19 Pandemic: Safe Surgical Practices and a Classification to Guide Treatment
Abstract
Background:
Coronavirus disease 2019 (COVID-19) has rapidly evolved as a viral pandemic. Countries worldwide have been affected by the recent outbreak caused by the SARS (severe acute respiratory syndrome)-CoV-2 virus. As with prior viral pandemics, health-care workers are at increased risk. Orthopaedic surgical procedures are common in health-care systems, ranging from emergency to elective procedures. Many orthopaedic surgical procedures are life or limb-saving and cannot be postponed during the COVID-19 pandemic because of potential patient harm. Our goal is to analyze how orthopaedic surgeons can perform medically necessary procedures during the pandemic and to help guide decision-making perioperatively.
Methods:
We performed a review of the existing literature regarding COVID-19 and prior viral outbreaks to help guide clinical practice in terms of how to safely perform medically necessary orthopaedic procedures during the pandemic for both asymptomatic patients and high-risk (e.g., COVID-19-positive) patients. We created a classification system based on COVID-19 positivity, patient health status, and COVID-19 prevalence to help guide perioperative decision-making.
Results:
We advocate that only urgent and emergency surgical procedures be performed. By following recommendations from the American College of Surgeons, the Centers for Disease Control and Prevention, and the recent literature, safe orthopaedic surgery and perioperative care can be performed. Screening measures are needed for patients and perioperative teams. Surgeons and perioperative teams at risk for contracting COVID-19 should use appropriate personal protective equipment (PPE), including N95 respirators or powered air-purifying respirators (PAPRs), when risk of viral spread is high. When preparing for medically necessary orthopaedic procedures during the pandemic, our classification system will help to guide decision-making. A multidisciplinary care plan is needed to ensure patient safety with medically necessary orthopaedic procedures during the COVID-19 pandemic.
Conclusions:
Orthopaedic surgery during the COVID-19 pandemic can be performed safely when medically necessary but should be rare for COVID-19-positive or high-risk patients. Appropriate screening, PPE use, and multidisciplinary care will allow for safe medically necessary orthopaedic surgery to continue during the COVID-19 pandemic.
Level of evidence:
Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.
... The current COVID-19 global pandemic has brought this term back into the common discussion, with various 'stay at home' orders prohibiting non-essential services, including medical services, from being offered. 1 Different fields of medicine define medical necessity differently. For example, when classifying which orthopaedic surgeries could go ahead during COVID lockdowns, Service et al. applied a standard of those expected to be 'life or limb-saving' or which could not wait without risking serious harm to the patient. 1 In this context, medical necessity referred to 'urgent, emergency, and time-sensitive procedures', and excluded anything where the risks of COVID infection were deemed higher than the risk of postponing the relevant surgery. 1 When it comes to public funding and waitlisting for medical interventions, distinctions are often drawn between emergency and elective procedures, and therapeutic versus cosmetic. ...
... For example, when classifying which orthopaedic surgeries could go ahead during COVID lockdowns, Service et al. applied a standard of those expected to be 'life or limb-saving' or which could not wait without risking serious harm to the patient. 1 In this context, medical necessity referred to 'urgent, emergency, and time-sensitive procedures', and excluded anything where the risks of COVID infection were deemed higher than the risk of postponing the relevant surgery. 1 When it comes to public funding and waitlisting for medical interventions, distinctions are often drawn between emergency and elective procedures, and therapeutic versus cosmetic. In this way, plastic surgery for a burns victim may attract public subsidy, while a nose job for aesthetic reasons may not. ...
... For example, when classifying which orthopaedic surgeries could go ahead during COVID lockdowns, Service et al. applied a standard of those expected to be 'life or limb-saving' or which could not wait without risking serious harm to the patient. 1 In this context, medical necessity referred to 'urgent, emergency, and time-sensitive procedures', and excluded anything where the risks of COVID infection were deemed higher than the risk of postponing the relevant surgery. 1 When it comes to public funding and waitlisting for medical interventions, distinctions are often drawn between emergency and elective procedures, and therapeutic versus cosmetic. In this way, plastic surgery for a burns victim may attract public subsidy, while a nose job for aesthetic reasons may not. ...
When restrictive abortion policies are presented there are often two questions posed: will there be an exception to save the life of the ‘mother’ and will there be an exception in the case of rape or incest. This article will demonstrate that there are no distinctive elements to the first ‘exception’, that do not also apply to all abortions on demand. Through consideration of the potentially lethal impacts of pregnancy on physical and mental health, the case will be made that all requested abortions fit the criteria of ‘medically necessary’.
... 5 A recent commentary provides support for this notion, endorsing the reclassification of "elective" procedures as "medically-necessary, time sensitive (MeNTS) procedures". 8,9 This approach applies a scoring system designed to weigh the necessity of the procedure and the risks of delaying against the potential strain on the hospital system. As such, MeNTS allows for the consideration of all relevant factors and strikes a balance between the need for overall prompt surgical management and pandemic safety restrictions. ...
... From an orthopaedic surgery perspective, numerus arthroplasty, sports, and even spine surgeries were deemed elective and disproportionally cancelled during initial stages of the pandemic. 8,10,11 In terms of spine surgery, emergent cases were designated to continue as expected, including traumatic injuries, acute progressive neurological deterioration, epidural abscesses, and neuro-oncologic cases. However, other insidious spinal conditions, such as degenerative cervical myelopathy, radiculopathy, and fractures or stenosis with secondary neurological compression, were classified as "elective" and thereby not encouraged during pandemic conditions. ...
... The risk-benefit analysis of patient surgery must be considered within the scope of the local context of a pandemic. 5,8,17,18 Particularly, as the exclusive level 1 trauma center in the area, consideration must be given to the possible harm to patients by delaying care. Each case must be reviewed by the provider, especially in the setting of predisposing risk factors such as obesity, diabetes, and immunosuppression, all of which would both make spine surgery more technically difficult and increase the risk for perioperative virus exposure and subsequent complications. ...
Introduction
Determination of what constitutes necessary surgery in the setting of acute hospital resource strain during the COVID-19 pandemic is an unprecedented challenge for healthcare systems. Over the past two years during the COVID-19 pandemic, there have been many changes in reviews of medically necessary spine surgery. There continues to be no clear guidelines on recommendations and further discussion is necessary to continue to provide appropriate and high-level care during future pandemics.
Significance
This review critically appraises and evaluates current barriers to medically necessary spine surgery during the COVID-19 pandemic and evaluates future decision making to maintain spine surgery during future pandemics or limitations in medical care.
Results
Multiple studies included in this review have shown that while various orthopaedic surgeries may be considered elective, medically necessary spine surgery will need to continue during settings of limited medical care. This review discussed multiple methods and recommendations to limit transmission of virus from patients to providers and providers to patients.
Conclusion
Continued medically necessary spine surgery in the setting of the COVID-19 pandemic and future pandemics should continue while limiting risk of transmission to continue providing high-level medical care and allowing hospitals to maintain financial responsibility.
... Worldwide, joint replacements in particular were stopped and orthopedic departments were converted toCOVID-19 facilities [1][2][3][4][5]. However, while this process followed similar guidelines, it had significant regional variability [1][2][3][4][5][6][7][8][9]. ...
... As the pandemic progressed and evolved, more and more data became available. The American College of Surgeons and the Centers for Disease Control and Prevention cautioned that orthopedic surgery should be rare for COVID-19-positive or high-risk patients [9]. ...
... In an effort to stop the spread of the virus, a state of emergency was declared on 16 March. To prepare for the treatment of a potential surge in the number of cases, following global trends, elective procedures were cancelled and many orthopedic departments were converted to COVID-19 facilities [1][2][3][4][5][6][7][8][9]. The first wave of the disease was kept under control and the lockdown ended on 14 May. ...
The COVID-19 pandemic has put an enormous burden on healthcare systems. As a direct consequence, many elective procedures were cancelled and available resources were relocated to emergencies and COVID-19 patients. We aimed to analyze the impact on orthopedic surgery in Romania. We performed a retrospective analysis of orthopedics and trauma cases admitted over the first six months of 2019 and 2020 in three representative clinics. In total, there were 1900 patients: 1241 from Timisoara, 216 from Cluj-Napoca, and 443 from Bucharest. In April, activity for all cases in the regional trauma center dropped to 23.8% and stopped in the other two. No arthroscopies or elective joint replacements were performed in April. By June, hospital admissions resumed for trauma cases while arthroscopies and joint replacements still lagged behind.
... 4 The practical application of this is to guide patient selection based on the burden of COVID-19 on resources at any point in time. 5,6 In essence then, when the prevalence and resource demand is great, limit surgery only to emergency cases, but allow ongoing management of the routine burden when the COVID load is low. Singapore has adopted into policy DORSCON levels which represents phasing of their response based on resource demands and disease prevalence. ...
... Secondly, the incubation period is on average 5-14 days and the virus has proven highly contagious with a reproduction number (R 0 ) of 2.68, meaning that on average each COVID-positive person will infect 2.7 people. 5,[9][10][11] Thirdly, there is a growing body of evidence to suggest patients with COVID-19 that undergo surgery have high morbidity and mortality rates. [12][13][14][15] This should give us pause to earnestly evaluate the benefits of surgery in such patients who require life-or limb-saving surgery and should prompt us to involve a multidisciplinary team early on. ...
... Two studies stratified community infection rates as a means to guide index of suspicion on patient positivity. 5,13 They considered infection rates as low, medium or high, corresponding to infections of <50, 50-100 or >100 COVID-19 cases per 100 000 inhabitants. For example then, if the prevalence is high, an institution should be more aggressive in testing asymptomatic patients and in adopting the practice of treating all individuals as suspects. ...
BACKGROUND: The coronavirus disease of 2019 (COVID-19) pandemic is taxing South Africa's already over-burdened healthcare system. Orthopaedics is not exempt; patients present with COVID-19 and musculoskeletal pathology and so surgeons should be familiar with the current evidence to best manage patients and themselves. The aims of this scoping review were firstly to inform peri-operative decision-making for COVID-positive patients as well as the routine orthopaedic milieu during the pandemic; secondly to assess the outcomes of orthopaedic patients managed in endemic areas; and Anally to determine the effect the pandemic has had on our orthopaedic peersMETHODS: A scoping review was conducted following the PRISMA-ScR guidelines of 2018. The search terms 'Orthopaedics' or 'Orthopedics' and 'COVID-19' or 'Coronavirus' were used to perform the search on Scopus, PubMed and Cochrane databases. All peer-reviewed articles utilising evidence-based methodology and addressing one of the objectives were eligible. A thematic approach was used for qualitative data synthesisRESULTS: Seventeen articles were identified for inclusion. All articles represented level 4 and 5 evidence and comprised ten review-type articles, one consensus statement, two web-based surveys and four observational studies. Most articles (n=11) addressed the objective of peri-operative considerations covering the stratification and testing of patients, theatre precautions and personal protective equipment (PPE). Evidence suggests that patients should be stratified for surgery according to the urgency of their procedure, their risk of asymptomatic disease (related to the community prevalence of COVID-19) and their comorbidities. The consensus is that all patients should be screened (asked a set of standardised questions with regard their symptoms and contacts). Only symptomatic patients and those asymptomatic patients from high prevalence areas or those with high-risk contacts should be tested. Healthcare workers (HCWs) in theatre should maintain safety precautions considering every individual is a potential contact. In the operating room in addition to the standard orthopaedic surgery PPE, if a patient is COVID positive, surgeons should don an N95 respirator. The three articles that addressed the effects on the orthopaedic surgeon showed a significant redeployment rate, effects on monetary renumeration of specialists and also effects on surgeons in training causing negative emotional ramifications. Of the surgeons who have contracted the illness and have been investigated, all showed mild symptomatology and recovered fully. The final three articles concentrated on orthopaedic patient considerations; they all showed high mortality rates in the vulnerable patient populations investigated, but had significant limitationsCONCLUSION: Orthopaedics is significantly affected by the COVID pandemic but there remains a dearth of high-quality evidence to guide the specialtyLevel of evidence: Level 3
... As a result of the dissemination of SARS-CoV-2 pathogen, the condition was declared as a "Global Pandemic" by the World Health Organization (WHO) in March 2020 9 . Because of this declaration, a series of mandatory safety precautions in hospitals were implemented worldwide, including those related to orthopedic surgeries 10 . ...
... Previous studies 10,20 have shown that the incidence of hip fractures decreased during the pandemic, but no comparison in respect of FIF and FNF hospitalization rates in the same period has been reported as yet. In the whole group in current study, patients in Only Clinic follow-ups with intertrochanteric hip fractures were higher in both pre-pandemic and pandemic periods. ...
... It is advised to do daily screening and close monitoring of perioperative teams with temperature assessment to identify early disease. 17 Service BC et al. 17 recommend using surgical teams separated physically performing work on alternate weeks to avoid exposure of the entire staff. If patient is to be operated under GA and intubated, surgical team should not be present inside the OR during intubation and around 20 min after that depending on the air change frequency as intubation is an aerosol generating procedure. ...
... It is advised to do daily screening and close monitoring of perioperative teams with temperature assessment to identify early disease. 17 Service BC et al. 17 recommend using surgical teams separated physically performing work on alternate weeks to avoid exposure of the entire staff. If patient is to be operated under GA and intubated, surgical team should not be present inside the OR during intubation and around 20 min after that depending on the air change frequency as intubation is an aerosol generating procedure. ...
Purpose
Worldwide COVID 19 has affected the medical practices and Orthopaedics is not any different. Despite risk, the surgeons cannot deny the surgical procedure on patients with suspected or confirmed COVID 19 infection. The purpose of this manuscript is to review various operating room measures which are recommended and being followed to carry out orthopaedic surgeries in the current scenario of COVID 19 pandemic. The information would be useful for orthopaedic surgeons to carry out safe surgical practice for reducing the transmission of COVID 19 infection.
Method
ology: A systematic literature search was performed using search engines- PubMed, Google Scholar and Scopus from January to August 2020 for relevant research articles. The keywords utilized for systematic literature search were “COVID 19”, “Corona virus” and “Operating room”, “Orthopaedic procedure” in 4 combinations. Duplicates were excluded. Further sorting was done according to the pre-set inclusion and exclusion criteria. Original articles pertaining to orthopaedic surgery and operating room in COVID 19 and available in English language were included. Editorials, case reports, other speciality articles were excluded.
Results
16 articles were finally included in review after screening for titles, abstracts and full texts. The information obtained is presented as a narrative review.
Conclusion
Various important recommendations include use of negative pressure OR, HEPA filters, dedicated separate OR for COVID positive and suspected patients with well defined separate corridors for transport, avoid AGP wherever possible, minimize the number of assistants and staff and follow strict sanitation protocols after each surgery. A well planned systematic approach is warranted to mitigate the risk of transmission of COVID 19 while carrying out orthopaedic surgeries.
... Therefore, the capacity of surgical wards and operation theaters was reduced, and elective surgery was postponed, decreasing the number of surgical procedures [13]. However, there are small studies showing that the care of COVID-19 patients and emergency or orthopedic surgery were possible due to changes in hospital structures and isolation measures [35,36]. ...
Introduction
Coronavirus disease 2019 (COVID-19) is an acute virus infection, which was declared a pandemic by the World Health Organization. The Swiss government decreed a public lockdown to reduce and restrict further infections. The aim of this investigation was to analyze the impact of the first COVID-19 lockdown on the performance of general and visceral surgery procedures.
Materials and Methods
A retrospective study was performed on the basis of the surgical registry of the working group for quality assurance in surgery (“Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie” or AQC). All patients with specific surgical diagnoses (complicated gastric or duodenal ulcer, acute appendicitis, hernia, diverticular disease, gallstone disease, pilonidal sinus, cutaneous and perianal abscess) were analyzed during 2019 and the corresponding lockdown period of March 14 through April 26, 2020. Data regarding patients’ characteristics, diagnoses, and treatments were analyzed.
Results
In total, 3,330 patients were analyzed, with 2,203 patients treated in 2019 and 1,127 patients treated in 2020. There was a reduction in the number of all investigated diagnoses during the pandemic period, with statistically significant differences in acute appendicitis, hernia, diverticular disease, gallstone disease, pilonidal sinus (all p < 0.001), and cutaneous abscess (p = 0.01). The proportion of complicated appendicitis (p = 0.02), complicated hernia (p < 0.001), and complicated gallstone disease (choledocholithiasis p = 0.01; inflammation, p = 0.001) was significantly higher during the lockdown period. The surgical urgency rate in all patients was higher during the lockdown period compared to the control period (p < 0.001).
Conclusions
The socioeconomic lockdown significantly impacted the number of general and visceral surgery procedures in Switzerland. The reasons for the reduction are multifactorial.
... As part of this response, elective orthopedic surgical procedures were postponed across the United States [8]. However, many conditions treated by orthopedic surgeons continued to be prioritized according to published guidelines [9][10][11]. Despite best efforts to triage orthopedic patients requiring urgent and emergent surgery, suboptimal conditions created by widespread disruption to the healthcare system may have broadly impacted the outcomes of these surgeries. ...
Introduction
During the coronavirus disease 2019 (COVID-19) pandemic, a rapid and significant transformation in patient management occurred across the healthcare system in order to mitigate the spread of the disease and address resource constraints. Numerous surgical cases were either postponed or canceled, permitting only the most critical and emergent cases to proceed. The impact of these modifications on patient outcomes remains uncertain. The purpose of this study was to compare time-to-surgery and outcomes of open reduction and internal fixation for trimalleolar ankle fractures during the pandemic to a pre-pandemic group. We hypothesized that the pandemic group would have a prolonged time-to-surgery and worse outcomes compared to the pre-pandemic cohort.
Materials and methods
This retrospective cohort study was conducted within a single healthcare system, examining the treatment of trimalleolar ankle fractures during two distinct periods: April to July 2020 (COVID-19 group) and January to December 2018 (2018 group). Cases were identified using Current Procedural Terminology code 27822. Information on demographics, fracture characteristics, and outcomes was obtained through chart review. Outcomes analyzed included time-to-surgery, mean visual analog scale scores, ankle strength and range of motion, and complications.
Results
COVID-19 and 2018 groups consisted of 32 and 100 patients, respectively. No significant difference was observed in group demographics and comorbidities (p > 0.05). Fracture characteristics were similar between groups apart from tibiofibular syndesmosis injury, 62.5% (20/32) in COVID-19 vs 42.0% (42/100) in 2018 (p = 0.03). Time-to-surgery was not significantly different between the two groups (8.84 ± 6.78 days in COVID-19 vs 8.61 ± 6.02 days in 2018, p = 0.85). Mean visual analog scale scores, ankle strength, and ankle range of motion in plantarflexion were not significantly different between the two groups at three and six months postoperatively (p > 0.05). Dorsiflexion was significantly higher in the COVID-19 group at three months (p = 0.03), but not six months (p = 0.94) postoperatively. No significant difference in postoperative complication was seen between groups, 25.0% (8/32) COVID-19 group compared to 15.0% (15/100) 2018 group (p = 0.11).
Conclusions
Patients who underwent surgery during the early months of the COVID-19 pandemic did not experience prolonged time-to-surgery and had similar outcomes compared to patients treated prior to the pandemic.
... Road accidents remain the same, but bicycle injuries have increased [23]. Acute referral of trauma patients was reduced to 50%, and there was a reduction in isolated limb injuries and emergency operations compared to the previous year in the golden month of the pandemic in a trauma center in London [24]. There was a 30% reduction in operations due to a reduction in RTA and sports-related injuries during the early phase of the lockdown in the UK. ...
Background. The pattern of hospital admissions and medical care changed during the COVID pandemic.
The aim of the study to describe the nature of patients attending the orthopedic emergency department of a level 1 trauma center in terms of number and proportion based on demographic characteristics and the nature of the injury before the lockdown, during the lockdown, and during the unlocking period of the nationwide lockdown for controlling the COVID-19 pandemic in India.
Methods. We conducted a longitudinal study from 01.01.2020 to 31.12.2020. Patients attending the orthopedic emergency were grouped based on cause, type, and site of injury. The median number observed each day with IQR. The distribution of the same was compared between the prelockdown with lockdown period and the lockdown period with a phased unlocking period.
Results. A total of 10513 patients were included. There was a statistically significant reduction in the proportion of patients needing inpatient care between the prelockdown phase and lockdown phase (p = 0.008). However, this was not seen between lockdown and postlockdown periods (p = 0.47). The proportion of road traffic accidents dropped from 26% to 15% during this time (p0.001). The proportion of contusions was reduced and that of soft tissue injuries increased (p0.001). The proportion of lower limb injuries decreased from the prelockdown phase to the lockdown phase, and that of spinal injury patients increased (p = 0.007). The proportion of patients with contusions increased and soft tissue injuries decreased during this period (p0.001). Lower limb injuries and road traffic accidents increased, and spinal injuries were reduced (p0.001).
Conclusion. The lockdown for controlling the spread of the pandemic affected the demographic and epidemiological aspects of injuries attending the orthopedic emergency department of a level 1 trauma center in a developing country. There was a decrease in the proportion of females and children attending the ED during the lockdown. The number of road traffic accedents s decreased during the lockdown. The number of patients with contusions attending the trauma center during the lockdown decreased, but there was an increase in the number of patients with spine injuries. We suggest that improvement in triage facilities, wider use of telemedicine, and increasing the stock of PPEs are essential for tackling such situations in the future.
... Early on in the pandemic, a ban on elective surgeries temporarily went into effect in the US State of Minnesota on March 16, 2020 [12]. The leadership of a large private orthopedic practice in the US quickly developed and subsequently implemented a universal testing protocol by utilizing available guidelines for patients undergoing time-sensitive elective orthopedic surgery in their ASCs [12,[22][23][24]. Simultaneously, the practice developed and implemented an additional universal testing protocol for the ASC surgeons/personnel. ...
Background and objective
The coronavirus disease 2019 (COVID-19) pandemic has presented tremendous challenges to the healthcare systems worldwide. Consequently, ambulatory surgery centers (ASCs) have been forced to find new and innovative ways to function safely and maintain operations. We conducted a study at a large United States (US) private orthopedic surgery practice, where a universal screening policy and testing protocol for COVID-19 was implemented for patients and ASC personnel including surgeons, in order to examine the incidence of COVID-19 in patients scheduled for orthopedic surgery in ASC settings as well as the incidence among the surgeons and ASC personnel.
Methods
The universal screening protocol was implemented in the ASCs of the facility during the early stage of the pandemic for an eight-month period from April 28, 2020, to December 31, 2020. All ASC personnel including surgeons had their symptoms tracked daily and were rapid-tested every two weeks. All patients were screened and tested before they entered the ASC.
Results
A total of 70 out of 12,115 patients and 41 out of 642 ASC personnel tested positive for COVID-19, resulting in infection rates of 0.6% and 6.4%, respectively. Individual symptoms, age, the American Society of Anesthesiologists (ASA) scores, and comorbidities were documented, and no single factor was found to be common among positive (+) tests.
Conclusions
The implementation of universal screening and symptom-reporting procedures was associated with a very low rate of infections among ASC patients, staff, and surgeons, and it offers a reproducible framework for other facilities to continue to provide orthopedic outpatient operations in ASC settings during the ongoing iterations of the COVID-19 pandemic.
... The COVID-19 pandemic has placed a tremendous strain on the U.S. healthcare system, necessitating fundamental changes in practice across all specialties including orthopaedic surgery and emergency medicine [20][21][22][23][24]. The impact of the pandemic on MSK injury presentation, particularly UE injuries, has not been fully elucidated. ...
Introduction
During the emergence of the SARS-CoV-2 (COVID-19) pandemic, there were substantial changes in United States (U.S.) emergency department (ED) volumes and acuity of patient presentation compared to more recent years. Thus, the purpose of this study was to characterize the incidence of specific upper extremity (UE) injuries presenting to U.S. EDs during the COVID-19 pandemic and analyze trends across age groups and rates of hospital admission compared to years prior.
Methods
The National Electronic Injury Surveillance System (NEISS) database was queried to identify patients who presented to U.S. EDs for an UE orthopaedic injury between 2016 and 2020. Chi-square analysis and logistic regression were used to assess for differences in ED presentation volume and hospital admissions between pre-pandemic (2016 through 2019) and during-pandemic (2020) times.
Results
These queries returned 285,583 cases, representing a total estimate of 10,452,166 injuries presenting to EDs across the U.S. The mean incidence of UE orthopaedic injuries was 640.2 (95% CI, 638.2–642.3) injuries per 100,000 person-years, with the greatest year to year decrease in incidence occurring between 2019 and 2020 (20.1%). The largest number of estimated admissions occurred in 2020, with a total 135,018 admissions (95% CI, 131,518–138,517), a 41.6% increase from the average number of admissions between 2016 and 2019.
Conclusion
There was a 20.1% decrease in the incidence of UE orthopaedic injuries presenting to EDs after the start of the COVID-19 pandemic with a concomitant 41.2% increase in the number of hospital admissions from the ED in 2020 compared to recent pre-pandemic years. We speculate that at least some elective, semi-elective or urgent ambulatory surgeries were canceled or delayed due to the pandemic and were subsequently directed to the ED for admission. Regardless of the cause of increased UE orthopaedic admissions, policy planners and administrators should be aware of the additional stresses placed on already burdened ED and inpatient services.
Level of evidence
Level III – Retrospective Cohort Study.
... Trauma procedures due to the nature of the injuries are necessary and time-critical, and nobody can afford to postpone trauma care even during a global pandemic. 22 Furthermore, the Corona Hands Collaborative 23 published that upper limb trauma patients had SARS-CoV-2 complication rate of 0.18% (n=2) with 0.09% (n=1) overall mortality at the peak of the first wave in April 2020. However, their collaborative looked into a shorter postoperative period (30 vs 42 days) but they agreed that patients who had been hospitalised for a prolonged period before their surgery were at increased risk of both COVID-19related and postoperative complications. ...
Objective
This is the first British multicentre study observing the impact of the COVID-19 pandemic on orthopaedic trauma with respect to referrals, operative caseload and mortality during its peak.
Design
A longitudinal, multicentre, retrospective, observational, cohort study was conducted during the peak 6 weeks of the first wave from 17 March 2020 compared with the same period in 2019.
Setting
Hospitals from six major urban cities were recruited around the UK, including London.
Participants
A total of 4840 clinical encounters were initially recorded. 4668 clinical encounters were analysed post-exclusion.
Primary and secondary outcome measures
Primary outcomes included the number of acute trauma referrals and those undergoing operative intervention, mortality rates and the proportion of patients contracting COVID-19. Secondary outcomes consisted of the mechanism of injury, type of operative intervention and proportion of aerosolising-generating anaesthesia used.
Results
During the COVID-19 period, there was a 34% reduction in acute orthopaedic trauma referrals compared with 2019 (1792 down to 1183 referrals), and a 29.5% reduction in surgical interventions (993 down to 700 operations). The mortality rate was more than doubled for both risk and odds ratios during the COVID-19 period for all referrals (1.3% vs 3.8%, p=0.0005) and for those undergoing operative intervention (2.2% vs 4.9%, p=0.004). Moreover, mortality due to COVID-19-related complications (vs non-COVID-19 causes) had greater odds by a factor of at least 20 times. For the operative cohort during COVID-19, there was an increase in odds of aerosolising-generating anaesthesia (including those with superimposed regional blocks) by three-quarters, as well as doubled odds of a consultant acting as the primary surgeon.
Conclusion
Although there was a reduction of acute trauma referrals and those undergoing operative intervention, the mortality rate still more than doubled in odds during the peak of the pandemic compared with the same time interval 1 year ago.
... 28 Many institutions stopped elective surgery, and guidelines were developed to classify orthopaedic injuries as elective versus timesensitive to define medically necessary orthopaedic surgery during the COVID-19 pandemic. 29 In instances such as hip fractures, with 1-year mortality rates after surgical treatment of 20% to 30%, 4,30-32 the outcomes of undergoing surgical intervention with COVID-19positive status are needed for health care providers and patients to make informed decisions. Our study found a 30-day all-cause mortality rate of 14.6% (27/185) Two other multicenter studies on patients undergoing hip fracture surgery reported a 30.4% (7/23) and 30.5% (25/82) mortality rate within 14 and 30 days, respectively. ...
Background:
This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database.
Methods:
This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality.
Results:
In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period.
Dicussion:
We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.
... Surgeons are increasingly taking due cognizance to follow standard recommendations to limit aerosol generation during procedure, such as limited use of power tools (drill, saw, and reamer), use of tourniquet, limited use of cautery, and liberal use of suction to suck fumes and aerosol. [11,12] OT floor and tables are being disinfected in between two cases. There needs to be adequate time gap or changeover time between the surgical procedures in OT to avoid the accumulation of aerosols and prevent cross contamination. ...
... Proper PPE was used as recommended by the World Health Organization 15 and other authors. [16][17][18] At the time of writing this article, detected DDH are now mature hips or are still in treatment with none needed to switch to open reduction. ...
Purpose
Developmental dysplasia of the hip (DDH) ultrasound screening (USS), which is usually performed in Italy as an outpatient, was halted for an indefinite period in most centres during lockdown. The aim of this study was to analyze the effect of COVID-19 on DDH-USS, in two paediatric orthopaedic centres in one of the most critical areas of the western World.
Methods
An academic teaching hospital and paediatric trauma centre (T) and a University hospital and DDH referral centre (H), classified as national COVID-19 hubs, were involved. Graf’s method was applied in both centres. In T, paediatricians directly referred only patients with delayed DDH-USS or suspicious unstable hips; in H, paediatricians or parents could directly refer to the screening service.
Results
The mean age of the 95 patients (190 hips) who were referred for DDH-USS in T, was 3.85 months (0.1 to 7.4); 175 were type I, nine were type IIa (+ and -), five type D and one type IV. In H, the screened patients in 2020 were only 78% of the same period in 2019. A total of 28 patients with 32 hips (8 IIb, 5 IIc, 8 D, 11 III) had late diagnosis at a mean age of 114 days (96 to 146). In the same period in 2019 only eight patients with 11 hips (8 IIb, 1 D, 1 III, 1 IV) at a mean age of 142 days (92 to 305) had late diagnosis.
Conclusion
DDH-USS was the only screening in newborns which halted during lockdown. Few centres, which still performed diagnosis and treatment, were overloaded causing a delay in DDH management.
Level of evidence
IV.
... Moreover, the risks of contamination must be considered both in COVID-19 areas and in "COVID-19-free" environments. Particularly in the latter, the risk could be underestimated by caregivers and it is paramount to remember that a COVID-19 free area is not SARS-CoV-2 free [47][48][49]: in the present study we could estimate around 7% of carriers among the asymptomatic patients while those values are probably an underestimation as the sensitivity of the swab test was about 70% [50,51]). In addition to the risk of physical contagion, another very important aspect to consider is the emotional risk. ...
Background: From 10 March up until 3 May 2020 in Northern Italy, the SARS-CoV-2 spread was not contained; disaster triage was adopted. The aim of the present study is to assess the impact of the COVID-19-pandemic on the Orthopedic and Trauma departments, focusing on: hospital reorganization (flexibility, workload, prevalence of COVID-19/SARS-CoV-2, standards of care); effects on staff; subjective orthopedic perception of the pandemic. Material and Methods: Data regarding 1390 patients and 323 surgeons were retrieved from a retrospective multicentric database, involving 14 major hospitals. The subjective directors’ viewpoints regarding the economic consequences, communication with the government, hospital administration and other departments were collected. Results: Surgical procedures dropped by 73%, compared to 2019, elective surgery was interrupted. Forty percent of patients were screened for SARS-CoV-2: 7% with positive results. Seven percent of the patients received medical therapy for COVID-19, and only 48% of these treated patients had positive swab tests. Eleven percent of surgeons developed COVID-19 and 6% were contaminated. Fourteen percent of the staff were redirected daily to COVID units. Communication with the Government was perceived as adequate, whilst communication with medical Authorities was considered barely sufficient. Conclusions: Activity reduction was mandatory; the screening of carriers did not seem to be reliable and urgent activities were performed with a shortage of workers and a slower workflow. A trauma network and dedicated in-hospital paths for COVID-19-patients were created. This experience provided evidence for coordinated responses in order to avoid the propagation of errors.
... However, many orthopaedic surgical procedures are either lifeor limb-saving and cannot be postponed during the COVID-19 pandemic because of potential harm to patients [2]. It is important to prevent clusters and transmission of COVID-19 in the inpatients wards to perform essential orthopaedic surgery during the second wave of COVID-19. ...
Background
Elective orthopaedic surgery has been severely curtailed because of coronavirus disease, 2019. There is scant scientific evidence to guide surgeons in assessing the protocols that must be implemented before resuming elective orthopaedic surgery safely after the second wave of the coronavirus disease, 2019.
Methods
A retrospective review of elective orthopaedic surgeries performed between May 15, 2020, and November 20, 2020, was conducted. A screening questionnaire was used, and reverse transcription-polymerase chain reaction and severe acute respiratory syndrome coronavirus-2 immunoglobulin G and IgM antibodies testing were assessed in all admitted patients. Screening and testing data for coronavirus disease was reviewed for all patients.
Results
Of 592 patients tested for severe acute respiratory syndrome coronavirus-2 during the study period, 21 (3.5%) tested positive. There were 2 patients (0.3%) with positive reverse transcription-polymerase chain reaction tests, 3 (0.5%) with positive IgG and IgM antibodies, 13 (2.2%) with positive IgG antibodies, and 10 (1.7%) with positive IgM antibodies. Among these 21 patients, 20 (95.2%) were asymptomatic.
Conclusions
Our findings suggest that most elective orthopaedic surgery patients with severe acute respiratory syndrome coronavirus-2 are asymptomatic. In the second wave of coronavirus disease, 2019, universal testing of all patients should be strongly considered as an important measure to prevent clusters of in-hospital transmission of the disease.
... Arguably, this is the worst healthcare crisis faced by humanity in the last century since the Spanish flu outbreak in 1918 9 . The pandemic has had a massive effect on the delivery of orthopaedic and trauma care services across the globe [10][11][12][13][14][15][16][17][18][19] . Non-urgent, elective surgeries have been deferred, and there has been an increased emphasis on non-operative management of fractures. ...
Introduction
Orthopedic surgical procedures (OSPs) are known to generate bioaerosols, which could result in transmission of infectious diseases. Hence, this review was undertaken to analyse the available evidence on bioaerosols in OSPs, and their significance in COVID-19 transmission.
Methods
A systematic review was conducted by searching the PubMed, EMBASE, Scopus, Cochrane Library, medRxiv, bioRxiv and Lancet preprint databases for studies on bioaerosols in OSPs. Random-effects metanalysis was conducted to determine pooled estimates of key bioaerosol characteristics. Risk of bias was assessed by the RoB-SPEO tool; overall strength of evidence was assessed by the GRADE approach.
Results
17 studies were included in the systematic review, and 6 in different sets of meta-analyses. The pooled estimate of particle density was 390.74 μg/m³, Total Particle Count, 6.08 × 10⁶/m³, and Microbial Air Contamination, 8.08 CFU/m³. Small sized particles (</ = 0.5 μm) were found to be 37 and 1604 times more frequent in the aerosol cloud in comparison to medium and large sized particles respectively. 4 studies reported that haemoglobin could be detected in aerosols, and one study showed that HIV could be transmitted by blood aerosolized by electric saw and burr. The risk of bias for all studies in the review was determined to be high, and the quality of evidence, low.
Conclusion
Whereas there is evidence to suggest that OSPs generate large amounts of bioaerosols, their potential to transmit infectious diseases like COVID-19 is questionable. High-quality research, as well as consensus minimum reporting guidelines for bioaerosol research in OSPs is the need of the hour.
... [2][3][4] When surgery cannot be postponed to mitigate the risk associated with COVID-19, guidelines suggest that urgent and emergent surgical procedures be performed with multidisciplinary perioperative management, appropriate personal protective equipment, and regional anesthesia when appropriate. 5 Universal testing for surgical admissions has been implemented in many institutions, and a large proportion of COVID-positive patients present without symptoms. 6 Acute spinal cord injury (SCI) often necessitates urgent or emergent operative intervention to mitigate devastating neurological consequences. ...
Study design:
This was a case series.
Objective:
The authors sought to examine the high-risk population of COVID-positive patients with acute cervical spinal cord injury (SCI) in a large level 1 trauma and tertiary referral center.
Summary of background data:
There are limited studies regarding the surgical management of patients with acute SCI in the setting of the recent coronavirus pandemic.
Methods:
The authors describe the cases of 2 patients who died from COVID-related complications after acute cervical SCI.
Results:
Patients with SCI are at increased risk of pulmonary complications. COVID-19 infection represents a double hit in this patient population, increasing potential morbidity and mortality in the perioperative time frame. Careful consideration must be made regarding the timing of potential surgical intervention in the treatment of acute SCI.
Conclusions:
Nationwide database of COVID-positive patients with acute spinal cord injury should be collected and analyzed to better understand how to manage acute SCI in the COVID-19 era. The authors recommend preoperative discussion in patients with acute cervical SCI with COVID-19, specifically emphasizing the increased risk of respiratory complications and mortality.
... (3,4,12) the primary focus of this guideline is rationally to triage the patients who need urgent action. (13,14) The need for COVID-19 testing is a controversial issue before surgical procedures. While routine RT-PCR combined with CRP, ESR and CBC is routinely recommended by many guidelines (15), various reports questioned its need in all patients. ...
Beheshti University of Medical Sciences, Tehran, Iran, Kamali St. 13334
Abstract:
Background:
The pandemics of Coronavirus disease 2019 (COVID-19) has still several unknown aspects in the medical
centers. Its exact route of spreading, best methods for diagnosis, its impact on the patients before and after the
surgery, involvement of the hospital staff, and the rate of its morbidity and mortality are among the unknown
factors that make confronting this virus very complex.
Objective:
To report our trend in COVID-19 as well as experience in surgery in the pandemic of COVID-19
Design:
Retrospective description
Settings:
Academic tertiary general medical center
Patients and Methods:
In this comparative cross-sectional study, all consecutive patients undergoing an emergency minor or major
surgical procedure; between 17 February to 17th May2020 and patients at the same period in 2019 were
enrolled and reviewed.
Main outcome measure:
Comparison of mortality between pandemic and no pandemic time
Sample size:
251
Results:
One-hundred and forty-seven patients underwent emergency surgical procedures in 2020 (Group A) while the
corresponding value was one-hundred and four patients in 2019 (Group B).
The male consisted 102 (69.4%) in group A and 85 (81.7%) in-group B. (P= 0.027). the average age of the
patients was (46.0 ± 21.4) years in group A and (40.9 ± 17.7) years in-group B.
Conclusion:
We found that emergency surgery mortality rates in two groups, group A (pandemic of COVID-19) had
significantly higher mortality rate compared with group B (no pandemic COVID-19)
... In response to COVID-19, an abundance of viewpoints, guidelines, and reviews on best surgical practices during a pandemic have been published 3,[9][10][11][12][13][14][15][16] . Comparatively fewer original research studies have documented the impact of the current pandemic on the incidence and surgical outcomes of non-elective cases. ...
The world currently faces the novel severe acute respiratory syndrome coronavirus 2 pandemic. Little is known about the effects of a pandemic on non-elective neurosurgical practices, which have continued under modified conditions to reduce the spread of COVID-19. This knowledge might be critical for the ongoing second coronavirus wave and potential restrictions on health care. We aimed to determine the incidence and 30-day mortality rate of various non-elective neurosurgical procedures during the COVID-19 pandemic. A retrospective, multi-centre observational cohort study among neurosurgical centres within Austria, the Czech Republic, and Switzerland was performed. Incidence of neurosurgical emergencies and related 30-day mortality rates were determined for a period reflecting the peak pandemic of the first wave in all participating countries (i.e. March 16th–April 15th, 2020), and compared to the same period in prior years (2017, 2018, and 2019). A total of 4,752 emergency neurosurgical cases were reviewed over a 4-year period. In 2020, during the COVID-19 pandemic, there was a general decline in the incidence of non-elective neurosurgical cases, which was driven by a reduced number of traumatic brain injuries, spine conditions, and chronic subdural hematomas. Thirty-day mortality did not significantly increase overall or for any of the conditions examined during the peak of the pandemic. The neurosurgical community in these three European countries observed a decrease in the incidence of some neurosurgical emergencies with 30-day mortality rates comparable to previous years (2017–2019). Lower incidence of neurosurgical cases is likely related to restrictions placed on mobility within countries, but may also involve delayed patient presentation.
... Hospitals developed systems to isolate patients suspected or confirmed to have COVID-19, triage fracture patient acuity, limit external traffic through the hospital, and protect health care personnel from exposures, including in nonelective surgical cases. [11] Similarly, governments and organizations implemented strategies to limit the spread of infection, including encouraging masking, hand washing, and social distancing, as well as issuing stay-at-home orders, travel restrictions, and self-quarantine policies. [12] This limitation of movement was associated with reports of decreases in trauma and fracture incidence. ...
The coronavirus disease 2019 (COVID-19) has significantly affected the treatment of patients with surgical conditions, including those with acute and chronic musculoskeletal issues. While different global regions experienced different levels of COVID-19 activity and had different resources with which to deal with the pandemic, there were many consistent approaches to injury care and musculoskeletal trauma management. Understanding these approaches is necessary to improve current and future strategies to taking care of orthopaedic trauma patients in an infectious disease outbreak. This supplement focuses on approaches to musculoskeletal trauma care during the first months of the COVID-19 pandemic in 19 countries from 6 continents. This work represents a collaborative work of member societies of the International Orthopaedic Trauma Association (IOTA), an international association of orthopaedic societies dedicated to the promotion of musculoskeletal trauma care through advancements in patient care, research, and education. The information in these reports will aid efforts to understand and ultimately better address musculoskeletal trauma care worldwide during the first waves of the pandemic.
... In another study, mortality was substantially higher in patients with COVID-19 and to a lesser extent in COVID-19-suspected patients, whereas surgical complications in patients who tested negative were no different than those observed in pre-COVID patients. This underscores the importance of patient testing prior to hospital admission for both urgent and elective procedures [7]. ...
... e COVID-19 pandemic has introduced many challenges to healthcare systems around the world, presenting added changes, pressures, and strains at all levels of the system, including but not limited to doctor-patient relationships and health organization resources [1,2]. e pandemic has, in turn, produced several changes in the patient's behavior and clinical outcomes. ...
To evaluate the effects of COVID-19 and stay-at-home orders in traumatic hip fractures presentation, we conducted a retrospective chart review cohort study from March 13 to June 13 in 2020 compared to 2019 from a single-hospital Trauma Level 2 Center. Males and females, 18 years of age and older presenting with a diagnosis of displaced or nondisplaced, intracapsular, or extracapsular hip fracture, underwent standard of care—comparative analysis of the patient’s characteristics and clinical outcomes. The primary study outcomes included age, sex, ethnicity, and body mass index, the onset of injury, date of arrival, payer, the primary type of injury and comorbidities, mechanism of injury, treatment received, postoperative complications, days in an intensive care unit (ICU), discharge disposition, pre- and postinjury functional status, and COVID-19 test. Age, sex, ethnicity, and body mass index were similar in the patients in 2019 compared to 2020. The patients’ average age was 76 years old, 80% reported Hispanic ethnicity, and 63% of the patients were females. Most injuries (90%) occurred due to falls. On average, patients in 2020 presented 4.8 days after the injury onset as compared to 0.7 days in 2019 (p
... Arthroplasty is thus a procedure in high demand and in April 2020 there were 238 applicants for adult reconstruction (AR) fellowships in the United States with 189 positions filled [1]. The current worldwide COVID-19 pandemic led to the cancellation of many elective orthopedic surgical procedures, including total hip and knee arthroplasties [2]. These events have had profound impacts on trainee education. ...
Introduction
COVID-19 has created a void in surgical education. Given social distancing and postponed surgeries, unique educational opportunities have arisen. Attendings from 10 adult reconstruction (AR) fellowships led a multi-institution web-based weekly collaborative, the Arthroplasty Consortium (AC), developed to educate trainees through complex arthroplasty case-based discussions.
Methods
We performed an anonymous survey of AC participants and AAHKS AR fellows. Participants were polled with regards to educational tools used before and after COVID-19 and their value. Specifically, participation in the AC, AAHKS FOCAL lectures, institutional lectures, industry lectures, textbooks, online videos, journal articles and webinars were assessed.
Results
57 participants responded with 49 (86%) at the fellow level. There was an increase in the use of web-based learning, including the AC (NA pre, 61% post), AAHKS FOCAL lectures (NA pre, 82% post), industry lectures (53% pre, 86% post), and AAHKS/AAOS webinars (35% pre, 56% post). Usage declined with institutional lectures (89% pre, 80% post), textbooks (68% pre, 49% post), and journal articles (97% pre, 90% post), with minimal change in the use of online surgical videos (84% pre, 82% post). The majority of fellows not involved in the AC, would like to see the addition of a multi-institutional case conference added to fellowship education. Of AC participants, the two most valuable educational tools were the AC and FOCAL lectures.
Conclusion
Trainee education has changed post-Covid-19 with a greater focus on web-based learning. Multi-institutional collaborative lectures and case-based discussions have significant perceived value among trainees and should be considered important educational tools post-COVID 19.
... With regard to the epidemiological context at the time the study was conducted (April 2020), Colombia was in the early mitigation phase, with an estimated 10% of the cases due to community transmission [10]. At the time, the prevalence of COVID-19 in Colombia was low, with fewer than 50 cases per 100,000 population, although strict lockdown measures were already being implemented throughout the country [10,11]. By April 30, 6507 cases and 293 deaths had been reported, and Bogotá was the epicenter of the pandemic [12]. ...
Background
The coronavirus disease 2019 (COVID-19) pandemic is the largest global event in recent times, with millions of infected people and hundreds of thousands of deaths worldwide. Colombia has also been affected by the pandemic, including by the cancellation of medically necessary surgical procedures that were categorized as nonessential. The objective of this study was to show the results of the program implemented in two institutions in Bogotá, Colombia, in April 2020 to support the performance of elective essential and nonessential low- and medium-complexity orthopedic surgeries during the mitigation phase of the COVID-19 pandemic, which involved a presurgical clinical protocol without serological or molecular testing.
Methods
This was a multicenter, observational, retrospective, descriptive study of a cohort of patients who underwent elective orthopedic surgery at two institutions in the city of Bogota, Colombia, in April 2020. We implemented a preoperative clinical protocol that did not involve serological or molecular tests; the protocol consisted of a physical examination, a survey of symptoms and contact with confirmed or suspected cases, and presurgical isolation. We recorded the types of surgeries, the patients’ scores on the medically necessary, time-sensitive (MeNTs) scale, the presence of signs, symptoms, and mortality associated with COVID-19 developed after the operation.
Results
A total of 179 patients underwent orthopedic surgery. The average age was 47 years (Shapiro-Wilk, P = 0.021), and the range was between 18 and 81 years. There was a female predominance (61.5%). With regard to the types of surgeries, 86 (48%) were knee operations, 42 (23.5%) were hand surgeries, 34 (19%) were shoulder surgeries, and 17 (9.5%) were foot and ankle surgeries. The average MeNTs score was 44.6 points. During the 2 weeks after surgery, four patients were suspected of having COVID-19 because they developed at least two symptoms associated with the disease. The incidence of COVID-19 in the postoperative period was 2.3%. Two (1.1%) of these four patients visited an emergency department where RT-PCR tests were performed, and they tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). No patients died or were hospitalized for symptoms of COVID-19.
Conclusion
Through the implementation of a presurgical clinical protocol consisting of a physical examination; a clinical survey inquiring about signs, symptoms, and epidemiological contact with suspected or confirmed cases; and presurgical isolation but not involving the performance of molecular or serological diagnostic tests, positive results were obtained with regard to the performance of low- and medium-complexity elective orthopedic surgeries in an early stage of the COVID-19 pandemic.
Level of evidence
IV.
... In the US, Afshin et al. formulated a list of procedures by urgency, and agree with a similar set of consensus to the British Orthopaedic Association guidelines and our own recommendations that neck of femur fracture surgery should be performed within 1-2 days [41]. Similarly, a study by Service et al. have produced a classification system detailing the steps necessary required for high risk SARS-CoV-2 positive patients [42]. Overall, these study results and recommendations add to the available information and published guidelines to inform local orthopaedic trauma units on the management of this vulnerable patient group. ...
Background
The coronavirus disease 19 (COVID-19) pandemic has presented modern healthcare with an unprecedented challenge. At the peak of the pandemic, trauma and orthopaedic services at our institutions undertook internal restructuring, diverting resources to frontline medical care. Consequently, we sought to assess the impact on the elderly and comorbid patients presenting with femoral neck fractures, with a particular focus on 30-day mortality, length of stay, multidisciplinary team involvement and departmental structuring.
Method
A retrospective analysis of patients presenting with femoral neck fractures at three separate West London NHS Trusts was undertaken between March 11, 2020, to April 30, 2020. Length of stay, 30-day mortality and adherence to parameters constituting the best care evidence-based practice tariffs were compared between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and negative patients. A similar comparison was also conducted between our cohort and the equivalent period in 2018 using data from the National Hip Fracture Database.
Results
A total of 68 patients presenting with femoral neck fractures were identified, mean age 81 (range 38–98), 73% female. There were 10 confirmed/suspected cases of COVID-19 on admission and a further seven confirmed as inpatients. The 30-day mortality within our cohort was 11.76% compared to 6% nationally in 2018 (p = 0.045). Orthogeriatric reviews occurred within 72 h in 71% of cases compared to 88% in the equivalent 2018 period. Within the cohort, mean length of stay was 17.13 days (SD 5.6, range 8-27 days) for SARS-CoV-2 positive patients compared to 10 days (SD 8.7, range 1–53 days) for negative patients (p < 0.05). Thirty-two patients (47%) required increased packages of care on discharge or rehabilitation.
Conclusions
The increase in 30-day mortality for SARS-CoV-2 positive patients presenting with femoral neck fractures is multifactorial, resulting from a combination of the direct effects of COVID-19 pneumonia as well as changes to the delivery of orthopaedic services. The provision of multidisciplinary care was directly affected by staff redeployment, particularly reorganisation of orthogeriatric services and lack of continuity of ward based clinical care. Our experiences have re-directed efforts towards the management of theatre teams, patient services and staffing, should we be faced with either a resurgence of COVID-19 or a future pandemic.
... In the US, Afshin et al. formulated a list of procedures by urgency, and agree with a similar set of consensus to the British Orthopaedic Association guidelines and our own recommendations that neck of femur fracture surgery should be performed within 1-2 days [41]. Similarly, a study by Service et al. have produced a classification system detailing the steps necessary required for high risk SARS-CoV-2 positive patients [42]. Overall, these study results and recommendations add to the available information and published guidelines to inform local orthopaedic trauma units on the management of this vulnerable patient group. ...
Abstract Background The coronavirus disease 19 (COVID-19) pandemic has presented modern healthcare with an unprecedented challenge. At the peak of the pandemic, trauma and orthopaedic services at our institutions undertook internal restructuring, diverting resources to frontline medical care. Consequently, we sought to assess the impact on the elderly and comorbid patients presenting with femoral neck fractures, with a particular focus on 30-day mortality, length of stay, multidisciplinary team involvement and departmental structuring. Method A retrospective analysis of patients presenting with femoral neck fractures at three separate West London NHS Trusts was undertaken between March 11, 2020, to April 30, 2020. Length of stay, 30-day mortality and adherence to parameters constituting the best care evidence-based practice tariffs were compared between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and negative patients. A similar comparison was also conducted between our cohort and the equivalent period in 2018 using data from the National Hip Fracture Database. Results A total of 68 patients presenting with femoral neck fractures were identified, mean age 81 (range 38–98), 73% female. There were 10 confirmed/suspected cases of COVID-19 on admission and a further seven confirmed as inpatients. The 30-day mortality within our cohort was 11.76% compared to 6% nationally in 2018 (p = 0.045). Orthogeriatric reviews occurred within 72 h in 71% of cases compared to 88% in the equivalent 2018 period. Within the cohort, mean length of stay was 17.13 days (SD 5.6, range 8-27 days) for SARS-CoV-2 positive patients compared to 10 days (SD 8.7, range 1–53 days) for negative patients (p
... Following the recommendations from Nhs England, the British Orthopaedic association (BOa), the association of paediatric anaesthetists of Great Britain and ireland (apaGBi), and taking into consideration the experience and lessons learned from colleagues worldwide, [15][16][17][18][19] we rapidly implemented extraordinary changes to our pathways and protocols. During this period, we have provided orthopaedic care to a large cohort of paediatric patients through the three different referral streams. ...
Introduction
In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.
Methods
All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge.
Results
Overall, 100 children underwent surgery or interventional radiological procedures under GA between 20 March and 8 May 2020. There were 35 trauma cases, 20 urgent elective orthopaedic cases, two spinal emergency cases, 25 admissions for interventional radiology procedures, and 18 tumour cases. 78% of trauma cases were performed within 24 hours of referral. In the 97% who responded at two weeks following discharge, there were no cases of symptomatic COVID-19 in any patient or member of their households.
Conclusion
Despite the extensive restructuring of services and the widespread concerns over the surgical and anaesthetic management of paediatric patients during this period, we treated 100 asymptomatic patients across different orthopaedic subspecialties without apparent COVID-19 or unexpected respiratory complications in the early postoperative period. The data provides assurance for health care professionals and families and informs the consenting process. Cite this article: Bone Joint Open 2020;1-6:287–292.
... (1) To reduce the extent of community transmission, numerous countries experienced lockdowns, allowing only essential services to continue. Orthopaedic departments have reported on measures taken to ensure business continuity and resource optimisation, including postponement of non-essential surgeries, (2) modification of perioperative protocols, (3) continuation of medical education and training via web-based platforms, (4) and a push towards telemedicine in ambulatory care. (5)(6)(7) For ambulatory clinics specifically, a reduction in non-essential visits is crucial to reduce patient crowding in waiting areas and hospital premises, and prevent patients from being exposed to COVID-19 while commuting to or from the hospital. ...
... Regarding the epidemiological moment in which the study was conducted, April 2020, it can be stated that Colombia was at the beginning of the mitigation phase, with an estimated 10% of the cases being of local circulation (10). The country was at a time of low prevalence of the pandemic with less than 50 cases per 100,000 habitants, although strict lockdown was already in place throughout the country (10) (11). By April 30, 6507 cases and 293 deaths had been reported, with Bogotá being the epicenter of the pandemic (12). ...
Background: The COVID-19 (Coronavirus disease 2019) pandemic is the largest global event of recent times, leaving millions infected and hundreds of thousands of dead worldwide. Colombia is no stranger to this situation, being subject to massive cancellations of medically necessary surgical procedures categorized as ¨non vital¨. The objective of this study is to show the results of a program of elective essential and non-essential low and medium complexity orthopedic surgeries performed during the mitigation phase of the COVID-19 pandemic with a pre-surgical clinical protocol, without serological or molecular testing, during April, 2020 in two institutions in Bogotá, Colombia.
Methodology : A multicenter, observational, retrospective, descriptive study of a cohort of patients who underwent elective orthopedic surgery at two institutions in the city of Bogota, Colombia, during April 2020. We performed a preoperative clinical protocol without including serological or molecular tests, an epidemiological survey, describing the type of surgery, their score in the MeNTs (medically necessary time sensitive) scale, and the presence of suggestive symptoms of COVID-19 postoperatively.
Results : A total of 179 patients underwent orthopedic surgery with an average age of 47 years (swilk= 0.021) (Shapiro-Wilk) ranging between 18 and 81 years, with a majority of females (61.5%). As for the surgeries, 86 (48%) were knee operations, 42 (23.5%) hand surgeries, 34 (19%) shoulder surgeries, and 17 (9.5%) foot and ankle surgeries. The average MeNTS of all patients was 44.6 points. During the two weeks after surgery, four patients were considered suspects for COVID-19 for presenting at least two symptoms associated with the disease representing an incidence of 2.3%. Two (1.1%) of these four patients consulted an emergency department where RT-PCR(reverse transcription polymerase chain reaction) type tests were performed, obtaining a negative result for SARSCov-2 (severe acute respiratory syndrome Coronavirus-2). No patients died or were hospitalized for symptoms associated with COVID-19.
Conclusion : Through the implementation of a pre-surgical clinical protocol (physical examination, clinical survey inquiring about signs, symptoms and epidemiological contacts), a pre-surgical isolation and without the performance of molecular or serological diagnostic tests, the present study showed good results in the performance of low and medium complexity elective orthopedic surgery at an early stage of the COVID-19 pandemic.
Level of evidence : IV.
... Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. [1][2][3][4][5][6] These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, 7,8 redeployment of orthopaedic surgeons/ residents to the frontline battle against COVID-19, [9][10][11][12][13] continuation of education and research through web-based means, 14 and cancellation of non-essential elective procedures. ...
The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.
Cite this article: Bone Joint Open 2020;1-6:222–228.
... Review of the literature revealed that a preliminary assessment was made for COVID-19 not only in otolaryngologyhead and neck clinics, but also in clinics which continued to provide active service during the pandemic. [16][17][18] In accordance with this, all of the patients who applied to our outpatient clinic were questioned on the complaints suggesting COVID-19 and their body temperature was measured. Patients with any of these complaints (anosmia, fever, sore throat, cough, and shortness of breath) and patients with a history of close contact with patients diagnosed with COVID-19 were referred to the triage area established in front of the emergency units (EU) of our hospital. ...
... The mechanisms by which the disease produces these symptoms is unknown and an open mind must be given to the possibility of a post COVID-19 syndrome which includes pathology in the musculoskeletal system (16). Finding a balance in providing an appropriate level of care at a reasonable level of risk to those involved is hugely challenging and consensus statements and algorithms will aid in the optimisation of care (17). ...
Background
The current global pandemic has impacted heavily on health systems, making unprecedented demands on resources, and forcing reconfiguration of services. Trauma and orthopaedic units have cancelled elective surgery, moved to virtual based clinics and have been forced to reconsider the provision of trauma. Our national elective orthopaedic centre has been re-designated as a trauma centre to allow tertiary centres re-direct triaged trauma. Many governments, as part of their COVID-19 management, have significantly restricted activity of the general population. We proposed that trauma patterns would change alongside these changes and maintaining existing standards of treatment would require dedicated planning and structures.
Methods
Referrals over a six-week period (March 15th – April 30th) were retrospectively reviewed. Data was collected directly from our referral database and a database populated. Analysis was performed to assess trauma volume, aetiology, and changes in trends.
Results
There were one hundred and fifty-nine referrals from three individual hospitals within the timeframe. Mean age of patient’s referred was 55 (range17-92). Males accounted for 45% of cases. F&A injuries were the most common (32%), followed by H&W (28%), UL (17%), H&F (16%) and K&T (7%). In comparison to the corresponding time-period in 2019, trauma theatre activity reduced by almost one half (45.3%)
Conclusion
The majority of trauma referred to our Dublin based centre during COVID-19 related population restrictions appears to be home based and trauma volumes have decreased. Significant reductions are apparent in work and sport related injuries suggestive of compliance with COVID-19 activity guidelines. Maintaining existing standards of treatment requires dedicated planning.
... After lockdown, we noticed a decreased number of undisplaced femoral neck fractures (treated with cannulated screws), while there was an increase in the relative percentage of hemiarthroplasties over THAs for displaced fractures. In this sense, a change in practice due to the pandemic has not only involved the use of special personal protective equipment, use of absorbable skin sutures (in order to minimize unnecessary follow-up) and systematic PCR testing of all surgical patients [26,27] but has also affected implant selection, though the criteria for indication remained the same. Stinner et al. have emphasized on how to mitigate in-person clinic visits adjusting surgical variables (e.g. ...
Purpose: To analyse the impact of prolonged mandatory lockdown due to COVID-19 on hip fracture epidemiology.
Methods: Retrospective case-control study of 160 hip fractures operated upon between December 2019 and May 2020. Based on the date of declaration of national lockdown, the cohort was separated into two groups: 'pre-COVID time' (PCT), including 86 patients, and 'COVID time' (CT), consisting of 74 patients. All CT patients tested negative for SARS-CoV-2. Patients were stratified based on demographic characteristics. Outcome measures were 30-day complications, readmissions and mortality. A logistic regression model was run to evaluate factors associated with mortality.
Results: Age, female/male ratio, body mass index and American Society of Anaesthesia score were similar between both groups (p > 0.05). CT patients had a higher percentage of Charlson ≥ 5 and Rockwood Frailty Index ≥ 5 scores (p < 0.05) as well as lower UCLA and Instrumental Activities of Daily Living scores (p < 0.05). This translated into a higher hemiarthroplasty/total hip arthroplasty ratio during CT (p = 0.04). Thromboembolic disease was higher during CT (p = 0.02). Readmissions (all negative for SARS-CoV-2) were similar between both groups (p = 0.34). Eight (10.8%) casualties were detected in the CT group, whereas no deaths were seen in the control group. Logistic regression showed that frailer (p = 0.006, OR 10.46, 95%CI 8.95-16.1), less active (p = 0.018, OR 2.45, 95%CI 1.45-2.72) and those with a thromboembolic event (p = 0.005, OR 30, 95%CI 11-42) had a higher risk of mortality.
Conclusion: Despite testing negative for SARS-CoV-2, CT patients were less active and frailer than PCT patients, depicting an epidemiological shift that was associated with higher mortality rate.
... Following the recommendations from Nhs England, the British Orthopaedic association (BOa), the association of paediatric anaesthetists of Great Britain and ireland (apaGBi), and taking into consideration the experience and lessons learned from colleagues worldwide, [15][16][17][18][19] we rapidly implemented extraordinary changes to our pathways and protocols. During this period, we have provided orthopaedic care to a large cohort of paediatric patients through the three different referral streams. ...
Introduction
In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.
Methods
All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge.
Results
Overall, 100 children underwent surgery or interventional radiological procedures under GA between 20 March and 8 May 2020. There were 35 trauma cases, 20 urgent elective orthopaedic cases, two spinal emergency cases, 25 admissions for interventional radiology procedures, and 18 tumour cases. 78% of trauma cases were performed within 24 hours of referral. In the 97% who responded at two weeks following discharge, there were no cases of symptomatic COVID-19 in any patient or member of their households.
Conclusion
Despite the extensive restructuring of services and the widespread concerns over the surgical and anaesthetic management of paediatric patients during this period, we treated 100 asymptomatic patients across different orthopaedic subspecialties without apparent COVID-19 or unexpected respiratory complications in the early postoperative period. The data provides assurance for health care professionals and families and informs the consenting process. Cite this article: Bone Joint Open 2020;1-6:287–292.
... Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. [1][2][3][4][5][6] These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, 7,8 redeployment of orthopaedic surgeons/ residents to the frontline battle against COVID-19, [9][10][11][12][13] continuation of education and research through web-based means, 14 and cancellation of non-essential elective procedures. ...
The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.
Cite this article: Bone Joint Open 2020;1-6:222–228.
... Lastly, surgical scrubs worn during the procedure should be changed immediately afterward. During this pandemic, essential surgical services must be performed while minimizing risk of COVID transmission to healthcare workers [10,11], and in some circumstances chest CT scan can help [12] for that. ...
Purpose:
Based on the recent literature, chest computed tomography (CT) examination could aid for management of patients during COVID-19 pandemic. However, the role of chest CT in management of COVID-19 patients is not exactly the same for medical or surgical specialties. In orthopaedic or trauma emergency, abdomen, pelvis, cervical, dorsal, and lumbar spine CT are performed to investigate patients; the result is a thoracic CT scan incorporating usually the thorax; however, information about lung parenchyma can be obtained on this thorax CT, and manifestations of COVID-19 can be diagnosed. The objective of our study was to evaluate this role in orthopedic patients to familiarize orthopaedists with the value and limits of thoracic CT in orthopaedic surgery.
Materials and methods:
Among the 1397 chest CT scans performed during the pandemic period from 1 March 2020 to 10 May 2020, in two centres with orthopaedic surgery, we selected all the 118 thoracic or chest CT performed for patients who presented to the Emergency Department of the hospital with a diagnosis of trauma for orthopaedic surgical treatment. Thirty-nine of these 118 patients were tested with PCR for the diagnosis of COVID-19 infection. Depending on clinical status (symptomatic or non-symptomatic), the information useful for the orthopaedist surgeon and obtained from the Chest CT scan according to the result of the PCR (gold standard) was graded from 0 (no or low value) to 3 (high value). The potential risks of chest CT as exposure to radiation, and specific pathway were analyzed and discussed. A group of patients treated during a previous similar period (1 March 2018 to 15 April 2018) was used as control for evaluation of the increase of CT scanning during the COVID-19 pandemic.
Results:
Among the 118 patients with chest CT, there were 16 patients with positive COVID-19 chest CT findings, and 102 patients with negative chest CT scan. With PCR results as reference, the sensitivity, specificity, positive predictive value of chest CT in indicating COVID-19 infection were 81%, 93%, and 86%, respectively (p = 0.001). A useful information for the orthopaedic surgeon (graded as 1 for 71 cases, as 2 for 5 cases, and as 3 for 11 cases) was obtained from 118 chest CT scans for 87 (74%) patients, while the CT was no value in 30 (25%) cases, and negative value in one (1%) case. Roughly 20% of the total number of CT scanner performed over the pandemic period was dedicated to COVID-19, but only 2% were for orthopaedic or trauma patients. However, this was ten times higher than during the previous control period of comparison.
Conclusion:
Although extremely valuable for surgery management, these results should not be overstated. The CT findings studied are not specific for COVID-19, and the positive predictive value of CT will be low unless disease prevalence is high, which was the case during this period.
Purpose
The purpose of this study is to characterize how SARS-CoV-2 infection in the perioperative period affects the medical adverse event rates in arthroscopic sports medicine procedures.
Methods
The Mariner COVID-19 database was queried for all shoulder, hip, or knee arthroscopies, 2010-2020. Patients with COVID-19 in the 3 months before to 3 months after their surgery were matched by age, gender, and Charlson Comorbidity Index (CCI) to patients with an arthroscopy but no perioperative COVID-19 infection, or a COVID-19 infection but no arthroscopic procedure. Medical adverse events (MAEs) in the 3 months after surgery or illness were compared between groups.
Results
The final cohort consisted of 1,299 matched patients in 3 groups: COVID alone, arthroscopy and perioperative COVID-19, and arthroscopy alone. There were 265 MAEs if a patient had COVID alone (20.4%), 200 MAEs if a patient had arthroscopy with COVID (15.4%), and 71 (5.5%) MAEs if a patient had arthroscopy alone (P<0.01). If a patient had an arthroscopy, having COVID was associated with 3.1-fold elevated odds (95% CI 2.9-3.4, P<0.01) of MAE. Amongst patients with an arthroscopy, MAEs were more common if a patient acquired COVID-19 in the 3 months after their surgery, (pooled OR=7.39, 95% CI 5.49-9.95, P<0.01), but not if a patient had preoperative COVID-19 (pooled OR=0.66, 95% CI 0.42-1.03, P=0.07).
Conclusion
Having COVID-19 during the postoperative period appears to confer a 7-fold elevated risk of medical adverse events after shoulder, hip, and knee arthroscopy compared to matched patients with arthroscopy and no perioperative COVID, but equivalent to that of patients with COVID and no arthroscopy. However, there was no increase in postoperative medical adverse events if a patient had COVID-19 during the 3 months preceding surgery. Therefore, it appears safe to conduct an arthroscopic procedure shortly after recovery from COVID-19 without an increase in acute medical complication rates.
Background
The National COVID Cohort Collaborative (N3C) is an innovative approach to integrate real-world clinical observations into a harmonized database during the time of the COVID-19 pandemic when clinical research on ankle fracture surgery is otherwise mostly limited to expert opinion and research letters. The purpose of this manuscript is to introduce the largest cohort of US ankle fracture surgery patients to date with a comparison between lab-confirmed COVID-19–positive and COVID-19–negative.
Methods
A retrospective cohort of adults with ankle fracture surgery using data from the N3C database with patients undergoing surgery between March 2020 and June 2021. The database is an NIH-funded platform through which the harmonized clinical data from 46 sites is stored. Patient characteristics included body mass index, Charlson Comorbidity Index, and smoking status. Outcomes included 30-day mortality, overall mortality, surgical site infection (SSI), deep SSI, acute kidney injury, pulmonary embolism, deep vein thrombosis, sepsis, time to surgery, and length of stay. COVID-19–positive patients were compared to COVID-19–negative controls to investigate perioperative outcomes during the pandemic.
Results
A total population of 8.4 million patient records was queried, identifying 4735 adults with ankle fracture surgery. The COVID-19–positive group (n=158, 3.3%) had significantly longer times to surgery (6.5 ± 6.6 vs 5.1 ± 5.5 days, P = .001) and longer lengths of stay (8.3 ± 23.5 vs 4.3 ± 7.4 days, P < .001), compared to the COVID-19–negative group. The COVID-19–positive group also had a higher rate of 30-day mortality.
Conclusion
Patients with ankle fracture surgery had longer time to surgery and prolonged hospitalizations in COVID-19–positive patients compared to those who tested negative (average delay was about 1 day and increased length of hospitalization was about 4 days). Few perioperative events were observed in either group. Overall, the risks associated with COVID-19 were measurable but not substantial. Level of Evidence: Level III, retrospective cohort study.
Background: Coronavirus disease 19 (COVID-19) is regarded as an independent risk factor for acute ischemic stroke (AIS) due to the induction of endothelial dysfunction, coagulopathy, cytokine storm, and plaque instability.
Method: In this retrospective cohort study, a total of 42 COVID-19 patients with type 2 diabetes mellitus (T2DM) who presented with AIS within 1 week of displaying COVID-19 symptoms were recruited. According to the current anti-DM pharmacotherapy, patients were divided into two groups: a Metformin group of T2DM patients with COVID-19 and AIS on metformin therapy (850 mg, 3 times daily (n = 22), and a Non-metformin group of T2DM patients with COVID-19 and AIS under another anti-DM pharmacotherapy like glibenclamide and pioglitazone (n = 20). Anthropometric, biochemical, and radiological data were evaluated.
Results: Ferritin serum level was lower in metformin-treated patients compared to non-metformin treated patients (365.93 ± 17.41 vs. 475.92 ± 22.78 ng/mL, p = 0.0001). CRP, LDH, and D-dimer serum levels were also lowered in metformin-treated patients compared to non-metformin treated patients (p = 0.0001). In addition, lung CT scan scores of COVID-19 patients was 30.62 ± 10.64 for metformin and 36.31 ± 5.03 for non-metformin treated patients.
Conclusion: Metformin therapy in T2DM patients was linked to a lower risk of AIS during COVID-19. Further studies are needed to observe the link between AIS in COVID-19 diabetic patients and metformin therapy.
Introducción: La enfermedad por coronavirus se expandió rápidamente, esto llevó a un aumento de la demanda de los servicios sanitarios, por lo cual fue necesario adaptarse de manera acorde. Nuestro objetivo es proporcionar una visión general del impacto en la atención y de nuestra experiencia, identificar aspectos positivos y aquellos por mejorar para futuras planificaciones. Materiales y Métodos: Se registraron el número de consultas diarias, la edad, el sexo, la presencia de traumatismo, el lugar de la lesión, el motivo de consulta, el diagnóstico y el tratamiento. Se comparó la cantidad de atenciones con las flexibilizaciones y con igual período de 2019. Resultados: Se realizaron 120 consultas, 33 procedimientos quirúrgicos, 185 atenciones por guardia, 160 con traumatismo. El lugar más frecuente de traumatismo fue el domicilio (56,25%). El 30% eran fracturas de muñeca y el 28,8%, supracondíleas. Las consultas aumentaron con las flexibilizaciones del confinamiento. Conclusiones: Es fundamental adaptarse rápido teniendo en cuenta que las fracturas comunes seguirán ocurriendo, pese al confinamiento al igual que las infecciones osteoarticulares. No descuidar tampoco la enfermedad crónica impostergable. Nivel de Evidencia: III
Background:
Healthcare facilities in low- and middle-income countries are inadequately resourced to adhere to current COVID-19 prevention recommendations. Recommendations for surgical emergency trauma care measures need to be adequately informed by available evidence and adapt to particular settings. To inform future recommendations, we set to summarise the effects of different personal protective equipment (PPE) on the risk of COVID-19 infection in health personnel caring for trauma surgery patients.
Methods:
We conducted an umbrella review using L·OVE (Living OVerview of Evidence) platform for COVID-19, that performs regular automated searches in MEDLINE, Embase, CENTRAL, and over thirty other sources. Systematic reviews of experimental and observational studies assessing the efficacy of PPE were included. Indirect evidence from other healthcare settings was also considered. Risk of bias was assessed with the AMSTAR II tool, and the GRADE approach for grading the certainty of the evidence is reported. (Registered in PROSPERO: CRD42020198267).
Results:
Eighteen studies that fulfilled selection criteria were included. There is high certainty that the use of N95 respirators and surgical masks is associated with a reduced risk of COVID-19 when compared with no mask use. In moderate to high-risk environments N95 respirators are associated with a further reduction in risk of COVID-19 infection compared with surgical masks. Eye protection also reduces the risk of contagion in this setting. Decontamination of masks and respirators with ultraviolet germicidal irradiation, vaporous hydrogen peroxide, or dry heat is effective and does not affect PPE performance or fit.
Conclusions:
The use of PPE drastically reduces the risk of COVID-19 compared with no mask use in HCWs. N95 and equivalent respirators provide more protection than surgical masks. Decontamination and reuse appear feasible to overcome PPE shortages and enhance the allocation of limited resources. These effects are applicable to emergency trauma care and should inform future recommendations.
Level of evidence:
Review, level II.
Introduction:
The purpose of this study was to quantify the impact of the COVID-19 pandemic on rising fourth-year medical students' plans to apply to residency in orthopaedic surgery.
Methods:
We conducted a survey of rising fourth-year medical students. Primary outcome was the change in students' plans to apply to residency in orthopaedic surgery as measured by Likert scale response. Secondary outcomes were students' concerns about applying to residency during the pandemic.
Results:
A total of 462 students were planning to apply to residency in orthopaedic surgery. Women said that they were "less likely" to apply to orthopaedic surgery because of the pandemic (14.9% versus 5.5% of men, P < 0.001). Students identifying as Black/African American said that they were "less likely" to apply (16.9% compared with 8.8 of non-Hispanic White, P < 0.001). Students said that they had "somewhat fewer" or "many fewer" opportunities to get adequate exposure to orthopaedic surgery to make a specialty choice (88.9% of students).
Discussion:
We support the development of robust student advising and mentorship networks to address the uncertainty inherent in applying to residency during a global pandemic and curtail the racial and sex disparities discovered in this survey.
Proximal femoral fractures in older adults are not uncommon and represent a great challenge for orthopedic surgeons because of the high risks of complications. In the COVID-19 panorama, fractures occurring in infected older adults become an even more intricate task because of concomitant metabolic derangements due to SARS-CoV-2. Multidisciplinary protocols are mandatory and pharmacological treatment in infected patients should be tailored. Regrettably, the spread of the virus in northern Italy, has been faster than scientific progress in characterizing the disease and many hospitals have had to manage the symptoms on a daily clinical bases. Our Italian hospital in the region of Lombardy, which has been the epicenter of the Italian pandemic, has admitted sixteen patients with fractured femurs in March and April 2020. The first seven patients were treated with the antithrombotic prophylaxis of a single daily dose of low-molecular-weight heparin, but we observed the highest prevalence of deaths from cardiovascular complications (four deaths). By doubling the daily dose of anticoagulants in the subsequent patients, we observed a reduction in the incidence of death (one death out of nine). Controversies exist about the surgical treatment of fractures in older adults during this pandemic. However, we have observed an increased survival after fall trauma in infected older adults if treated with high doses of anticoagulant. Although not being statistically significant, our results are in line with the current knowledge of the pathophysiology of SARS-CoV-2 infection, but more studies should be shared about the efficacy and dosage of anticoagulants in traumatic injuries of the elderly.
COVID-19 (coronavirus disease, described in 2019) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Most confirmed cases are mild or asymptomatic, but the most severe cases can progress to severe pneumonia with respiratory failure and death. In Brazil, there is a scenario of an exponential increase in cases, making it challenging to identify the source of contagion. We cannot yet specify when the peak of the COVID-19 outbreak will occur in our country or when the numbers of new contaminants and deaths will begin to decrease. So, the most important thing is protection against a virus for which all the details about contagion, transmission, and treatment are not known. The pandemic impacted and modified medical care, especially for surgical specialties, where face-to-face care is essential and cannot be replaced entirely by telemedicine. Thus, this review aimed to compile theoretical and practical aspects regarding the pandemic COVID-19 and its impact on plastic surgery activity routine. Protocols are proposed for resuming our routines, analyzing countries’ experience at an advanced stage of the pandemic.
Keywords:
Coronavirus infections; Surgery; Plastic; Patient safety; Elective surgical procedures; Protective devices; Pandemics.
Aims
The worldwide COVID-19 pandemic is directly impacting the field of orthopaedic surgery and traumatology with postponed operations, changed status of planned elective surgeries and acute emergencies in patients with unknown infection status. To this point, Germany's COVID-19 infection numbers and death rate have been lower than those of many other nations.
Methods
This article summarizes the current regimen used in the field of orthopaedics in Germany during the COVID-19 pandemic. Internal university clinic guidelines, latest research results, expert consensus, and clinical experiences were combined in this article guideline.
Results
Every patient, with and without symptoms, should be screened for COVID-19 before hospital admission. Patients should be assigned to three groups (infection status unknown, confirmed, or negative). Patients with unknown infection status should be considered as infectious. Dependent of the infection status and acuity of the symptoms, patients are assigned to a COVID-19-free or affected zone of the hospital. Isolation, hand hygiene, and personal protective equipment is essential. Hospital personnel directly involved in the care of COVID-19 patients should be tested on a weekly basis independently of the presence of clinical symptoms, staff in the COVID-19-free zone on a biweekly basis. Class 1a operation rooms with laminar air flow and negative pressure are preferred for surgery in COVID-19 patients. Electrocautery should only be utilized with a smoke suction system. In cases of unavoidable elective surgery, a self-imposed quarantine of 14 days is recommended prior to hospital admission.
Conclusion
During the current COVID-19 pandemic, orthopaedic patients admitted to the hospital should be treated based on an interdisciplinary algorithm, strictly separating infectious and non-infectious cases. Cite this article: Bone Joint Open 2020;1-6:309–315.
Community transmission of coronavirus disease 2019 (COVID-19) was first detected in the United States in February 2020. By mid-March, all 50 states, the District of Columbia (DC), New York City (NYC), and four U.S. territories had reported cases of COVID-19. This report describes the geographic distribution of laboratory-confirmed COVID-19 cases and related deaths reported by each U.S. state, each territory and freely associated state,* DC, and NYC during February 12-April 7, 2020, and estimates cumulative incidence for each jurisdiction. In addition, it projects the jurisdiction-level trajectory of this pandemic by estimating case doubling times on April 7 and changes in cumulative incidence during the most recent 7-day period (March 31-April 7). As of April 7, 2020, a total of 395,926 cases of COVID-19, including 12,757 related deaths, were reported in the United States. Cumulative COVID-19 incidence varied substantially by jurisdiction, ranging from 20.6 cases per 100,000 in Minnesota to 915.3 in NYC. On April 7, national case doubling time was approximately 6.5 days, although this ranged from 5.5 to 8.0 days in the 10 jurisdictions reporting the most cases. Absolute change in cumulative incidence during March 31-April 7 also varied widely, ranging from an increase of 8.3 cases per 100,000 in Minnesota to 418.0 in NYC. Geographic differences in numbers of COVID-19 cases and deaths, cumulative incidence, and changes in incidence likely reflect a combination of jurisdiction-specific epidemiologic and population-level factors, including 1) the timing of COVID-19 introductions; 2) population density; 3) age distribution and prevalence of underlying medical conditions among COVID-19 patients (1-3); 4) the timing and extent of community mitigation measures; 5) diagnostic testing capacity; and 6) public health reporting practices. Monitoring jurisdiction-level numbers of COVID-19 cases, deaths, and changes in incidence is critical for understanding community risk and making decisions about community mitigation, including social distancing, and strategic health care resource allocation.
Background:
Coronavirus disease 2019 (COVID-19) broke out in Wuhan, the People’s Republic of China, in December 2019 and now is a pandemic all around the world. Some orthopaedic surgeons in Wuhan were infected with COVID-19.
Methods:
We conducted a survey to identify the orthopaedic surgeons who were infected with COVID-19 in Wuhan. A self-administered questionnaire was distributed to collect information such as social demographic variables, clinical manifestations, exposure history, awareness of the outbreak, infection control training provided by hospitals, and individual protection practices. To further explore the possible risk factors at the individual level, a 1:2 matched case-control study was conducted.
Results:
A total of 26 orthopaedic surgeons from 8 hospitals in Wuhan were identified as having COVID-19. The incidence in each hospital varied from 1.5% to 20.7%. The onset of symptoms was from January 13 to February 5, 2020, and peaked on January 23, 8 days prior to the peak of the public epidemic. The suspected sites of exposure were general wards (79.2%), public places at the hospital (20.8%), operating rooms (12.5%), the intensive care unit (4.2%), and the outpatient clinic (4.2%). There was transmission from these doctors to others in 25% of cases, including to family members (20.8%), to colleagues (4.2%), to patients (4.2%), and to friends (4.2%). Participation in real-time training on prevention measures was found to have a protective effect against COVID-19 (odds ratio [OR], 0.12). Not wearing an N95 respirator was found to be a risk
factor (OR, 5.20 [95% confidence interval (CI), 1.09 to 25.00]). Wearing respirators or masks all of the time was found to be protective (OR, 0.15). Severe fatigue was found to be a risk factor (OR, 4 [95% CI, 1 to 16]) for infection with COVID-19.
Conclusions:
Orthopaedic surgeons are at risk during the COVID-19 pandemic. Common places of work
could be contaminated. Orthopaedic surgeons have to be more vigilant and take more
precautions to avoid infection with COVID-19.
We report epidemiologic, laboratory, and clinical findings for 7 patients with 2019 novel coronavirus disease in a 2-family cluster. Our study confirms asymptomatic and human-to-human transmission through close contacts in familial and hospital settings. These findings might also serve as a practical reference for clinical diagnosis and medical treatment.
What is already known about this topic? Once SARS-CoV-2 is introduced in a long-term care skilled nursing facility (SNF), rapid transmission can occur. What is added by this report? Following identification of a case of coronavirus disease 2019 (COVID-19) in a health care worker, 76 of 82 residents of an SNF were tested for SARS-CoV-2; 23 (30.3%) had positive test results, approximately half of whom were asymptomatic or presymptomatic on the day of testing. What are the implications for public health practice? Symptom-based screening of SNF residents might fail to identify all SARS-CoV-2 infections. Asymptomatic and presymptomatic SNF residents might contribute to SARS-CoV-2 transmission. Once a facility has confirmed a COVID-19 case, all residents should be cared for using CDC-recommended personal protective equipment (PPE), with considerations for extended use or reuse of PPE as needed. © 2020 Department of Health and Human Services. All rights reserved.
Background:
Since December 2019, 2019 novel coronavirus pneumonia emerged in Wuhan city and rapidly spread throughout China and even the world. We sought to analyse the clinical characteristics and laboratory findings of some cases with 2019 novel coronavirus pneumonia .
Methods:
In this retrospective study, we extracted the data on 95 patients with laboratory-confirmed 2019 novel coronavirus pneumonia in Wuhan Xinzhou District People's Hospital from January 16th to February 25th, 2020. Cases were confirmed by real-time RT-PCR and abnormal radiologic findings. Outcomes were followed up until March 2th, 2020.
Results:
Higher temperature, blood leukocyte count, neutrophil count, neutrophil percentage, C-reactive protein level, D-dimer level, alanine aminotransferase activity, aspartate aminotransferase activity, α - hydroxybutyrate dehydrogenase activity, lactate dehydrogenase activity and creatine kinase activity were related to severe 2019 novel coronavirus pneumonia and composite endpoint, and so were lower lymphocyte count, lymphocyte percentage and total protein level. Age below 40 or above 60 years old, male, higher Creatinine level, and lower platelet count also seemed related to severe 2019 novel coronavirus pneumonia and composite endpoint, however the P values were greater than 0.05, which mean under the same condition studies of larger samples are needed in the future.
Conclusion:
Multiple factors were related to severe 2019 novel coronavirus pneumonia and composite endpoint, and more related studies are needed in the future.
We estimate the distribution of serial intervals for 468 confirmed cases of 2019 novel coronavirus disease reported in China as of February 8, 2020. The mean interval was 3.96 days (95% CI 3.53–4.39 days), SD 4.75 days (95% CI 4.46–5.07 days); 12.6% of case reports indicated presymptomatic transmission.
https://wwwnc.cdc.gov/eid/article/26/6/20-0357_article
In December 2019, a new virus (initially called 'Novel Coronavirus 2019-nCoV' and later renamed to SARS-CoV-2) causing severe acute respiratory syndrome (coronavirus disease COVID-19) emerged in Wuhan, Hubei Province, China, and rapidly spread to other parts of China and other countries around the world, despite China's massive efforts to contain the disease within Hubei. As with the original SARS-CoV epidemic of 2002/2003 and with seasonal influenza, geographic information systems and methods, including, among other application possibilities, online real- or near-real-time mapping of disease cases and of social media reactions to disease spread, predictive risk mapping using population travel data, and tracing and mapping super-spreader trajectories and contacts across space and time, are proving indispensable for timely and effective epidemic monitoring and response. This paper offers pointers to, and describes, a range of practical online/mobile GIS and mapping dashboards and applications for tracking the 2019/2020 coronavirus epidemic and associated events as they unfold around the world. Some of these dashboards and applications are receiving data updates in near-real-time (at the time of writing), and one of them is meant for individual users (in China) to check if the app user has had any close contact with a person confirmed or suspected to have been infected with SARS-CoV-2 in the recent past. We also discuss additional ways GIS can support the fight against infectious disease outbreaks and epidemics.
Importance
In December 2019, novel coronavirus (2019-nCoV)–infected pneumonia (NCIP) occurred in Wuhan, China. The number of cases has increased rapidly but information on the clinical characteristics of affected patients is limited.
Objective
To describe the epidemiological and clinical characteristics of NCIP.
Design, Setting, and Participants
Retrospective, single-center case series of the 138 consecutive hospitalized patients with confirmed NCIP at Zhongnan Hospital of Wuhan University in Wuhan, China, from January 1 to January 28, 2020; final date of follow-up was February 3, 2020.
Exposures
Documented NCIP.
Main Outcomes and Measures
Epidemiological, demographic, clinical, laboratory, radiological, and treatment data were collected and analyzed. Outcomes of critically ill patients and noncritically ill patients were compared. Presumed hospital-related transmission was suspected if a cluster of health professionals or hospitalized patients in the same wards became infected and a possible source of infection could be tracked.
Results
Of 138 hospitalized patients with NCIP, the median age was 56 years (interquartile range, 42-68; range, 22-92 years) and 75 (54.3%) were men. Hospital-associated transmission was suspected as the presumed mechanism of infection for affected health professionals (40 [29%]) and hospitalized patients (17 [12.3%]). Common symptoms included fever (136 [98.6%]), fatigue (96 [69.6%]), and dry cough (82 [59.4%]). Lymphopenia (lymphocyte count, 0.8 × 10⁹/L [interquartile range {IQR}, 0.6-1.1]) occurred in 97 patients (70.3%), prolonged prothrombin time (13.0 seconds [IQR, 12.3-13.7]) in 80 patients (58%), and elevated lactate dehydrogenase (261 U/L [IQR, 182-403]) in 55 patients (39.9%). Chest computed tomographic scans showed bilateral patchy shadows or ground glass opacity in the lungs of all patients. Most patients received antiviral therapy (oseltamivir, 124 [89.9%]), and many received antibacterial therapy (moxifloxacin, 89 [64.4%]; ceftriaxone, 34 [24.6%]; azithromycin, 25 [18.1%]) and glucocorticoid therapy (62 [44.9%]). Thirty-six patients (26.1%) were transferred to the intensive care unit (ICU) because of complications, including acute respiratory distress syndrome (22 [61.1%]), arrhythmia (16 [44.4%]), and shock (11 [30.6%]). The median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days. Patients treated in the ICU (n = 36), compared with patients not treated in the ICU (n = 102), were older (median age, 66 years vs 51 years), were more likely to have underlying comorbidities (26 [72.2%] vs 38 [37.3%]), and were more likely to have dyspnea (23 [63.9%] vs 20 [19.6%]), and anorexia (24 [66.7%] vs 31 [30.4%]). Of the 36 cases in the ICU, 4 (11.1%) received high-flow oxygen therapy, 15 (41.7%) received noninvasive ventilation, and 17 (47.2%) received invasive ventilation (4 were switched to extracorporeal membrane oxygenation). As of February 3, 47 patients (34.1%) were discharged and 6 died (overall mortality, 4.3%), but the remaining patients are still hospitalized. Among those discharged alive (n = 47), the median hospital stay was 10 days (IQR, 7.0-14.0).
Conclusions and Relevance
In this single-center case series of 138 hospitalized patients with confirmed NCIP in Wuhan, China, presumed hospital-related transmission of 2019-nCoV was suspected in 41% of patients, 26% of patients received ICU care, and mortality was 4.3%.
On December 31, 2019, Chinese health officials reported a cluster of cases of acute respiratory illness in persons associated with the Hunan seafood and animal market in the city of Wuhan, Hubei Province, in central China. On January 7, 2020, Chinese health officials confirmed that a novel coronavirus (2019-nCoV) was associated with this initial cluster (1). As of February 4, 2020, a total of 20,471 confirmed cases, including 2,788 (13.6%) with severe illness,* and 425 deaths (2.1%) had been reported by the National Health Commission of China (2). Cases have also been reported in 26 locations outside of mainland China, including documentation of some person-to-person transmission and one death (2). As of February 4, 11 cases had been reported in the United States. On January 30, the World Health Organization (WHO) Director-General declared that the 2019-nCoV outbreak constitutes a Public Health Emergency of International Concern.† On January 31, the U.S. Department of Health and Human Services (HHS) Secretary declared a U.S. public health emergency to respond to 2019-nCoV.§ Also on January 31, the president of the United States signed a "Proclamation on Suspension of Entry as Immigrants and Nonimmigrants of Persons who Pose a Risk of Transmitting 2019 Novel Coronavirus," which limits entry into the United States of persons who traveled to mainland China to U.S. citizens and lawful permanent residents and their families (3). CDC, multiple other federal agencies, state and local health departments, and other partners are implementing aggressive measures to slow transmission of 2019-nCoV in the United States (4,5). These measures require the identification of cases and their contacts in the United States and the appropriate assessment and care of travelers arriving from mainland China to the United States. These measures are being implemented in anticipation of additional 2019-nCoV cases in the United States. Although these measures might not prevent the eventual establishment of ongoing, widespread transmission of the virus in the United States, they are being implemented to 1) slow the spread of illness; 2) provide time to better prepare health care systems and the general public to be ready if widespread transmission with substantial associated illness occurs; and 3) better characterize 2019-nCoV infection to guide public health recommendations and the development of medical countermeasures including diagnostics, therapeutics, and vaccines. Public health authorities are monitoring the situation closely. As more is learned about this novel virus and this outbreak, CDC will rapidly incorporate new knowledge into guidance for action by CDC and state and local health departments.
Since the SARS outbreak 18 years ago, a large number of severe acute respiratory syndrome-related coronaviruses (SARSr-CoV) have been discovered in their natural reservoir host, bats1–4. Previous studies indicated that some of those bat SARSr-CoVs have the potential to infect humans5–7. Here we report the identification and characterization of a novel coronavirus (2019-nCoV) which caused an epidemic of acute respiratory syndrome in humans in Wuhan, China. The epidemic, which started from 12 December 2019, has caused 2,050 laboratory-confirmed infections with 56 fatal cases by 26 January 2020. Full-length genome sequences were obtained from five patients at the early stage of the outbreak. They are almost identical to each other and share 79.5% sequence identify to SARS-CoV. Furthermore, it was found that 2019-nCoV is 96% identical at the whole-genome level to a bat coronavirus. The pairwise protein sequence analysis of seven conserved non-structural proteins show that this virus belongs to the species of SARSr-CoV. The 2019-nCoV virus was then isolated from the bronchoalveolar lavage fluid of a critically ill patient, which can be neutralized by sera from several patients. Importantly, we have confirmed that this novel CoV uses the same cell entry receptor, ACE2, as SARS-CoV.
Background:
A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients.
Methods:
All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not.
Findings:
By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0-58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0-13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα.
Interpretation:
The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies.
Funding:
Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
Objectives/Hypothesis
Human papillomavirus (HPV) is a DNA virus that causes cancer in multiple sites. Although sexual activity is the primary means of oropharyngeal HPV acquisition, studies suggest HPV transmission through occupational exposure from medical instruments and surgical fumes. We assess if aerosolization of HPV16 DNA via electrocautery places otolaryngologists at risk for exposure.
Study Design
Animal and human laboratory model.
Methods
Plasmid (pLXSN16E6E7) expressing HPV p16 E6/E7 genes was transformed into DH5α Escherichia coli cells using the heat shock method. Miniprep and maxiprep purification of transformed DNA with subsequent restriction enzyme double digestion confirmed presence of E6E7 fragment. We injected 2 μg plasmid DNA in 20 μL TE (Tris and ethylenediaminetetraacetic acid) buffer intradermally into freshly severed mouse tail then cauterized for 5 to 10 seconds. Generated fumes were collected through a suction tube fitted with Whatman filter paper. Filter paper was placed in 100 μL TE buffer. Additionally, six patients undergoing transoral robotic surgery for resection of oropharyngeal cancer were identified, three with p16‐negative tumors and three with p16‐positive tumors. Intraoperatively, Whatman filter paper was exposed to electrocautery fumes, then placed in 100 uL TE buffer. Additional samples were collected from the suction tubing and filter, the surgical mask of the surgeon at head of the bed, and the robot arm.
Results
Samples were analyzed via polymerase chain reaction with an assay sensitivity of 1.5 ng E6E7 DNA. None of the patient or mouse tail samples yielded detectable HPV16 DNA in the electrocautery fumes. We did not detect HPV16 DNA on the surgical masks, suction apparatus, or robot arm intraoperatively.
Conclusions
There is likely minimal risk of occupational exposure to HPV16 via electrocautery fumes.
Level of Evidence
NA Laryngoscope, 130:2366–2371, 2020
The ability to disinfect and reuse disposable N95 filtering facepiece respirators (FFRs) may be needed during a pandemic of an infectious respiratory disease such as influenza. Ultraviolet germicidal irradiation (UVGI) is one possible method for respirator disinfection. However, UV radiation degrades polymers, which presents the possibility that UVGI exposure could degrade the ability of a disposable respirator to protect the worker. To study this, we exposed both sides of material coupons and respirator straps from four models of N95 FFRs to UVGI doses from 120 to 950 J/cm(2). We then tested the particle penetration, flow resistance and the bursting strengths of the individual respirator coupon layers, and the breaking strength of the respirator straps. We found that UVGI exposure led to a small increase in particle penetration (up to 1.25%) and had little effect on the flow resistance. UVGI exposure had a more pronounced effect on the strengths of the respirator materials. At the higher UVGI doses, the strength of the layers of respirator material was substantially reduced (in some cases, by >90%). The changes in the strengths of the respirator materials varied considerably among the different models of respirators. UVGI had less of an effect on the respirator straps; a dose of 2360 J/cm(2) reduced the breaking strength of the straps by 20% to 51%. Our results suggest that UVGI could be used to effectively disinfect disposable respirators for reuse, but the maximum number of disinfection cycles will be limited by the respirator model and the UVGI dose required to inactivate the pathogen.
Viral infections have detrimental impacts on neurological functions, and even to cause severe neurological damage. Very recently, coronaviruses (CoV), especially severe acute respiratory syndrome CoV 2 (SARS-CoV-2), exhibit neurotropic properties and may also cause neurological diseases. It is reported that CoV can be found in the brain or cerebrospinal fluid. The pathobiology of these neuroinvasive viruses is still incompletely known, and it is therefore important to explore the impact of CoV infections on the nervous system. Here, we review the research into neurological complications in CoV infections and the possible mechanisms of damage to the nervous system.
We read with interest the excellent Association guidelines [1] for the anaesthetic management of patients during a COVID‐19 outbreak. We concur with these guidelines, which are not dissimilar to our hospital’s protocols since Singapore reported its first case of COVID‐19 on 23 January 2020.
To date, there have been 226 confirmed cases in Singapore with no deaths reported [2]. We are preparing for many more when community transmission becomes widespread and every patient presenting for surgery becomes a potential asymptomatic infected case. We would like to highlight additional anaesthetic considerations in this COVID‐19 pandemic. Our discussion is limited to patients not known to be COVID infected.
Coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization on 11 March 2020 because of its rapid worldwide spread. In the operating room, as part of hospital outbreak response measures, anesthesiologists are required to have heightened precautions and tailor anesthetic practices to individual patients. In particular, by minimizing the many aerosol-generating procedures performed during general anesthesia, anesthesiologists can reduce exposure to patients’ respiratory secretions and the risk of perioperative viral transmission to healthcare workers and other patients. To avoid any airway manipulation, regional anesthesia should be considered whenever surgery is planned for a suspect or confirmed COVID-19 patient or any patient who poses an infection risk. Regional anesthesia has benefits of preservation of respiratory function, avoidance of aerosolization and hence viral transmission. This article explores the practical considerations and recommended measures for performing regional anesthesia in this group of patients, focusing on control measures geared towards ensuring patient and staff safety, equipment protection, and infection prevention. By doing so, we hope to address an issue that may have downstream implications in the way we practice infection control in anesthesia, with particular relevance to this new era of emerging infectious diseases and novel pathogens. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not the first, and certainly will not be the last novel virus that will lead to worldwide outbreaks. Having a well thought out regional anesthesia plan to manage these patients in this new normal will ensure the best possible outcome for both the patient and the perioperative management team.
Background and purpose
Approximately 2000 trochanteric fractures are operated in Finland annually. These fractures make a major burden to health care system and affected individuals. The role of routine follow-up has been questioned in multiple fracture types.
Patients and methods
We analyzed routine follow-up visits after intramedullary fixation of trochanteric fractures (n=995). Patients were followed up from patient registries until 2 years or death. Planned and unplanned follow-up visits were analyzed.
Results
: Altogether 9 patients (0.9 %) had a change in treatment at planned outpatient visit. 6 of these were due to mechanical complication, 1 due to refracture and 2 due to delayed unions. 64 (6.4 %) patients had a change in treatment plan because of an unplanned visit: 28 infections, 6 pressure sores, 15 mechanic complications and 14 refractures and 1 AVN, respectively.
Interpretation
Routine follow-up visits are a burden both to the patients and health care system, with less than 1 % leading to changes in treatment. Our suggestion is to give good instructions to patients and rehabilitation facilities instead of routine follow-up.
Background:
A novel human coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified in China in December 2019. There is limited support for many of its key epidemiologic features, including the incubation period for clinical disease (coronavirus disease 2019 [COVID-19]), which has important implications for surveillance and control activities.
Objective:
To estimate the length of the incubation period of COVID-19 and describe its public health implications.
Design:
Pooled analysis of confirmed COVID-19 cases reported between 4 January 2020 and 24 February 2020.
Setting:
News reports and press releases from 50 provinces, regions, and countries outside Wuhan, Hubei province, China.
Participants:
Persons with confirmed SARS-CoV-2 infection outside Hubei province, China.
Measurements:
Patient demographic characteristics and dates and times of possible exposure, symptom onset, fever onset, and hospitalization.
Results:
There were 181 confirmed cases with identifiable exposure and symptom onset windows to estimate the incubation period of COVID-19. The median incubation period was estimated to be 5.1 days (95% CI, 4.5 to 5.8 days), and 97.5% of those who develop symptoms will do so within 11.5 days (CI, 8.2 to 15.6 days) of infection. These estimates imply that, under conservative assumptions, 101 out of every 10 000 cases (99th percentile, 482) will develop symptoms after 14 days of active monitoring or quarantine.
Limitation:
Publicly reported cases may overrepresent severe cases, the incubation period for which may differ from that of mild cases.
Conclusion:
This work provides additional evidence for a median incubation period for COVID-19 of approximately 5 days, similar to SARS. Our results support current proposals for the length of quarantine or active monitoring of persons potentially exposed to SARS-CoV-2, although longer monitoring periods might be justified in extreme cases.
Primary funding source:
U.S. Centers for Disease Control and Prevention, National Institute of Allergy and Infectious Diseases, National Institute of General Medical Sciences, and Alexander von Humboldt Foundation.
With the outbreak of unknown pneumonia in Wuhan, China, in December 2019, a new coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), aroused the attention of the entire world. The current outbreak of infections with SARS-CoV-2 is termed Coronavirus Disease 2019 (COVID-19). The World Health Organization declared COVID-19 in China as a Public Health Emergency of International Concern. Two other coronavirus infections-SARS in 2002-2003 and Middle East Respiratory Syndrome (MERS) in 2012-both caused severe respiratory syndrome in humans. All 3 of these emerging infectious diseases leading to a global spread are caused by β-coronaviruses. Although coronaviruses usually infect the upper or lower respiratory tract, viral shedding in plasma or serum is common. Therefore, there is still a theoretical risk of transmission of coronaviruses through the transfusion of labile blood products. Because more and more asymptomatic infections are being found among COVID-19 cases, considerations of blood safety and coronaviruses have arisen especially in endemic areas. In this review, we detail current evidence and understanding of the transmission of SARS-CoV, MERS-CoV, and SARS-CoV-2 through blood products as of February 10, 2020, and also discuss pathogen inactivation methods on coronaviruses.
Background:
In December, 2019, a pneumonia associated with the 2019 novel coronavirus (2019-nCoV) emerged in Wuhan, China. We aimed to further clarify the epidemiological and clinical characteristics of 2019-nCoV pneumonia.
Methods:
In this retrospective, single-centre study, we included all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data. Outcomes were followed up until Jan 25, 2020.
Findings:
Of the 99 patients with 2019-nCoV pneumonia, 49 (49%) had a history of exposure to the Huanan seafood market. The average age of the patients was 55·5 years (SD 13·1), including 67 men and 32 women. 2019-nCoV was detected in all patients by real-time RT-PCR. 50 (51%) patients had chronic diseases. Patients had clinical manifestations of fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). According to imaging examination, 74 (75%) patients showed bilateral pneumonia, 14 (14%) patients showed multiple mottling and ground-glass opacity, and one (1%) patient had pneumothorax. 17 (17%) patients developed acute respiratory distress syndrome and, among them, 11 (11%) patients worsened in a short period of time and died of multiple organ failure.
Interpretation:
The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection.
Funding:
National Key R&D Program of China.
Background:
Safe and effective decontamination and reuse of N95 filtering facepiece respirators (FFRs) has the potential to significantly extend FFR holdings, mitigating a potential shortage due to an influenza pandemic or other pandemic events. Ultraviolet germicidal irradiation (UVGI) has been shown to be effective for decontaminating influenza-contaminated FFRs. This study aims to build on past research by evaluating the UVGI decontamination efficiency of influenza-contaminated FFRs in the presence of soiling agents using an optimized UVGI dose.
Methods:
Twelve samples each of 15 N95 FFR models were contaminated with H1N1 influenza (facepiece and strap), then covered with a soiling agent-artificial saliva or artificial skin oil. For each soiling agent, 3 contaminated FFRs were treated with 1 J/cm2 UVGI for approximately 1 minute, whereas 3 other contaminated FFRs remained untreated. All contaminated surfaces were cut out and virus extracted. Viable influenza was quantified using a median tissue culture infectious dose assay.
Results:
Significant reductions (≥3 log) in influenza viability for both soiling conditions were observed on facepieces from 12 of 15 FFR models and straps from 7 of 15 FFR models.
Conclusions:
These data suggest that FFR decontamination and reuse using UVGI can be effective. Implementation of a UVGI method will require careful consideration of FFR model, material type, and design.
Cool vapors and aerosols produced by several common surgical power instruments and hot smoke plumes generated with electrocautery on known HIV-1 innoculated blood were gently bubbled through sterile viral culture media. Tissue culture cells were then added and cell infection was detected by the appearance of HIV-1 P-24 core antigen assayed by ELISA in the culture medium. HIV-1 was cultured from cool aerosols and vapors generated by a 30,000 RPM spinning router tip, an instrument similar to the Midas Rex and the Stryker oscillating bone saw. No infectious HIV-1 was detected in aerosols generated by a Valley Lab electrocautery or with a manual wound irrigation syringe known as a Travenol Uromatic irrigator. We have demonstrated that HIV-1 can remain viable in cool aerosols generated by certain surgical power tools and this raises the possibility of HIV transmission to medical personnel exposed to aerosols similarly generated during the care of HIV infected patients. Further work is required to determine whether such a risk exists but caution should be exercised by those exposed to aerosols generated during procedures on HIV-1 infected patients.
A major concern among health care experts is a projected shortage of N95 filtering facepiece respirators (FFRs) during an influenza pandemic. One option for mitigating an FFR shortage is to decontaminate and reuse the devices. Many parameters, including biocidal efficacy, filtration performance, pressure drop, fit, and residual toxicity, must be evaluated to verify the effectiveness of this strategy. The focus of this research effort was on evaluating the ability of microwave-generated steam, warm moist heat, and ultraviolet germicidal irradiation at 254 nm to decontaminate H1N1 influenza virus.
Six commercially available FFR models were contaminated with H1N1 influenza virus as aerosols or droplets that are representative of human respiratory secretions. A subset of the FFRs was treated with the aforementioned decontamination technologies, whereas the remaining FFRs were used to evaluate the H1N1 challenge applied to the devices.
All 3 decontamination technologies provided >4-log reduction of viable H1N1 virus. In 93% of our experiments, the virus was reduced to levels below the limit of detection of the method used.
These data are encouraging and may contribute to the evolution of effective strategies for the decontamination and reuse of FFRs.
A 44-year-old laser surgeon presented with laryngeal papillomatosis. In situ DNA hybridization of tissue from these tumors revealed human papillomavirus DNA types 6 and 11. Past history revealed that the surgeon had given laser therapy to patients with anogenital condylomas, which are known to harbor the same viral types. These findings suggest that the papillomas in our patient may have been caused by inhaled virus particles present in the laser plume.
Cool vapors and aerosols produced by several common surgical power instruments and hot smoke plumes generated with electrocautery on known HIV-1 innoculated blood were gently bubbled through sterile viral culture media. Tissue culture cells were then added and cell infection was detected by the appearance of HIV-1 P-24 core antigen assayed by ELISA in the culture medium. HIV-1 was cultured from cool aerosols and vapors generated by a 30,000 RPM spinning router tip, an instrument similar to the Midas Rex and the Stryker oscillating bone saw. No infectious HIV-1 was detected in aerosols generated by a Valley Lab electrocautery or with a manual wound irrigation syringe known as a Travenol Uromatic irrigator. We have demonstrated that HIV-1 can remain viable in cool aerosols generated by certain surgical power tools and this raises the possibility of HIV transmission to medical personnel exposed to aerosols similarly generated during the care of HIV infected patients. Further work is required to determine whether such a risk exists but caution should be exercised by those exposed to aerosols generated during procedures on HIV-1 infected patients.
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