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Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease
Abstract
With a lot of uncertainty, unclear, and frequently changing management protocols,
COVID-19 has significantly impacted the orthopaedic surgical practice during this
pandemic crisis. Surgeons around the world needed closed introspection, contemplation,
and prospective consensual recommendations for safe surgical practice and
prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries
were sent a Google online form with a questionnaire explicating protocols for
admission, surgeries, discharge, follow-up, relevant information affecting their surgical
practices, difficulties faced, and many more important issues that happened during
and after the lockdown. Ten surgeons critically construed and interpreted the data
to form rationale guidelines and recommendations. Of the total, hand and microsurgery
surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and
arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national
public health care/government college hospitals (44%) and private/semiprivate practitioners
(54%) were involved in the study. Countries had lockdown started as early as
January 3, 2020 with the implementation of partial or complete lifting of lockdown
in few countries while writing this article. Surgeons (58%) did not stop their surgical
practice or clinics but preferred only emergency cases during the lockdown. Most of
the surgeons (49%) had three-fourths reduction in their total patients turn-up and the
remaining cases were managed by conservative (54%) methods. There was a 50 to 75%
reduction in the number of surgeries. Surgeons did perform emergency procedures
without COVID-19 tests but preferred reverse transcription polymerase chain reaction
(RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective
surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%)
fractures were the most commonly performed surgeries. Surgeons preferred full personal
protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of
unavailability, they used surgical masks and normal gowns. Regional/local anesthesia
(70%) remained their choice for surgery to prevent the aerosolized risk of contaminations.
Essential surgical follow-up with limited persons and visits was encouraged by
70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the
surgeons. Despite the protective equipment, one-third of the surgeons were afraid of
getting infected (56%) and infecting their near and dear ones. Orthopaedic surgeons
in private practice did face 50 to 75% financial loss and have to furlough 25% staff
and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual
meetings have become the preferred mode of sharing the knowledge and experiences
avoiding human contacts. Staying at home, reading, and writing manuscripts became
more interesting and an interesting lifestyle change is seen among the surgeons.
Unanimously and without any doubt all accepted the fact that COVID-19 pandemic
has reached an unprecedented level where personal hygiene, hand washing, social distancing,
and safe surgical practices are the viable antidotes, and they have all slowly
integrated these practices into their lives. Strict adherence to local authority recommendations
and guidelines, uniform and standardized norms for admission, inpatient,
and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT
scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency
surgeries and follow-up protocols, use of teleconsultations cautiously, and
working in close association with the World Health Organization and national health
care systems will provide a conducive and safe working environment for orthopaedic
surgeons and their fraternity and also will prevent the resurgence of COVID-19.
... Jerome et al (2) had recommendations based on the perspectives and consensus from 100 Orthopedics surgeons belonging to 50 countries more specific for managing the non-emergency orthopedics cases. The recommendations were based on the Centre for Medicare and Medicaid Services (CMS) which suggested prerequisites for surgery and conservative management especially during the pandemic crisis. ...
... The recommendations were based on the Centre for Medicare and Medicaid Services (CMS) which suggested prerequisites for surgery and conservative management especially during the pandemic crisis. (3) 55% of surgeons in the study conducted by Jerome et al (2) during the early and mid lockdown phase of coronavirus disease (COVID 19) deferred surgery and adopted alternative/conservative methods of treatment. Local steroid injections, splints, cast, and oral analgesics were given to patients during the pandemic. ...
We congratulate the authors for the recent article on " Medically Necessary Orthopaedic Surgery During the COVID-19 Pandemic: Safe Surgical Practices and a Classification to Guide Treatment"(1) which we read with huge interest. Jerome et al (2) had recommendations based on the perspectives and consensus from 100 Orthopedics surgeons belonging to 50 countries more specific for managing the non-emergency orthopedics cases. The recommendations were based on the Centre for Medicare and Medicaid Services (CMS) which suggested prerequisites for surgery and conservative management especially during the pandemic crisis. (3) 55% of surgeons in the study conducted by Jerome et al (2) during the early and mid lockdown phase of coronavirus disease (COVID 19) deferred surgery and adopted alternative/conservative methods of treatment. Local steroid injections, splints, cast, and oral analgesics were given to patients during the pandemic. Among them, 37% of surgeons found that they had one or more COVID 19 symptomatic patients who were referred to the government/private tertiary medical colleges for further evaluation and management. Only 3% of surgeons operated on non-emergency cases such as radial tunnel syndrome where working women presented with severe pain restricting their daily activities. Jerome et al have described the low acuity treatment for conditions such as carpal tunnel syndrome, trigger finger, tennis elbow, DeQuervain's tenosynovitis, and cubital tunnel syndrome from their survey involving 100 surgeons. The intermediate treatment is for conditions requiring joint replacement, spine surgery, arthroscopy, and pediatric orthopedics. High acuity treatment included open fractures, severe trauma-fractures and dislocations, cauda equina syndrome, compartment syndrome, cancer, highly symptomatic, acute infections, necrotizing fasciitis, and vascular injuries. Jerome at al (2) had modified the questionnaire to suit the orthopedics practices taking into 50 country surgeon's considerations and the working conditions. The recommendations were • Low acuity: conservative/steroid injections/oral analgesics/splints.
... Despite the available studies on the impact of the pandemic on the health care system in the world, there are still few reports of how the pandemic and government regulations have affected orthopedic wards. Additionally, the available publications do not directly refer to the level of stress among orthopedic doctors and the process of specialization training for residents, and further education of doctors [6][7][8][9]. Therefore, our research was aimed at identifying the current challenges that orthopedics in Poland is facing in the present circumstances. ...
... The link to the survey was sent to the members of PTOiTr in the form of an e-mail with an invitation to participate in the study and a description of the objectives of the study. The survey was mainly based on a published study by Randau T.M. et al. and others similar publications, adjusting the questions to the situation in Poland [6][7][8][9]. In addition, the survey was to examine more closely the level of stress among orthopedists in Poland and the impact of the pandemic on the process of training orthopedists. ...
The Coronovirus Disease 2019 -(COVID-19) pandemic had a significant impact on the health care system and medical staff around the world. The orthopedic units were also subject to new restrictions and regulations. Therefore, the aim of our research was to assess how the COVID-19 pandemic affected orthopedic wards in the last year in Poland. We created an online survey, which was sent to 273 members of the Polish Society of Orthopedics and Traumatology. The survey contained 51 questions and was divided into main sections: Preparedness, Training, Stress, Reduction, Awareness. A total of 80 responses to the survey were obtained. In Preparedness section the vast majority of respondents (90%) replied, that they used personal protective equipment during the pandemic, however only 50% of the respondents indicated that their facility received a sufficient amount of personal protective equipment. Most of the respondents indicated that the pandemic negatively affected the quality of training of future orthopedists (69.4%) and that pandemic has had a negative impact on their operating skills (66,7%). In Reduction section most of the doctors indicated that the number of patients hospitalized in their departments decreased by 20-60% (61,2% respondents), while the number of operations performed decreased by 60-100% (60% respondents). The negative impact of pandemic on education was noticeable especially in the group of young orthopedic surgeons: 0-5 years of work experience (p = 0,029). Among the respondents, the level of stress increased over the last year from 4.8 to 6.9 (p
... Jerome et al (2) had recently reported an extensive survey involving 100 orthopedics surgeons from 50 countries during the initial and mid-lockdown phases of coronavirus disease. As per their perspectives and recommendations, 77% of the surgeons did not recommend CT scans for their patients irrespective of the emergency and elective nature. ...
... Jerome et al study noted consensus could not be achieved among surgeons from 50 countries for recommending CT scan as an alternative to RT-PCR (Reverse transcription-polymerase chain reaction) because of uncertainty and limitations in identifying the specific viruses and distinguishing between viruses (2) ...
We appreciate the authors for their scientific contribution titled current concepts review based on International Consensus Group (ICM) guidelines for "Resuming elective surgery during the COVID-19 pandemic" (1). COVID 19 has a lot of uncertainty, unclear, and frequently changing management protocols, which has significantly impacted the orthopedic surgical practice. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. Jerome et al (2) had recently reported an extensive survey involving 100 orthopedics surgeons from 50 countries during the initial and mid-lockdown phases of coronavirus disease. As per their perspectives and recommendations, 77% of the surgeons did not recommend CT scans for their patients irrespective of the emergency and elective nature. They also noted that CT scan is reliable for symptomatic patients when it is done 0 to 2 days after symptom onset. A delayed CT scan has limited sensitivity and negative predictive value. (3) Considering the possibility of false-negative PCR results, Orthopaedic surgeons intend to recommend a chest CT scan for their elective patients. It is also agreed that COVID-19 has, in addition, different lung features and presentations similar to outbreaks such as SARS, adenovirus and the Middle East respiratory syndrome. Jerome et al study noted consensus could not be achieved among surgeons from 50 countries for recommending CT scan as an alternative to RT-PCR (Reverse transcription-polymerase chain reaction) because of uncertainty and limitations in identifying the specific viruses and distinguishing between viruses (2) Recommendation of CT scan chest for elective cases should be limited and needs more scientific deliberations.
... Surgeons around the world needed regular introspection, contemplation and an ever-evolving perspective to develop recommendations for safe management while protecting patients from viral contamination. 1 The management of intertrochanteric fractures gave rise to 1 such challenge, especially in the geriatric age group. As public health policymakers tried to control the pandemic by focusing resources on COVID-19, the general population was afraid of contracting coronavirus from hospitals, resulting in changes in their healthcare seeking behaviour. ...
Background
The COVID pandemic challenged the orthopaedic mind on several fronts. 1 of them was in the management of intertrochanteric fractures. A subset of these patients refused surgical intervention during the pandemic for related reasons. Faced with the goal of early verticalisation, the senior author used pain relief as a method to facilitate early mobilisation in 23 patients with peritrochanteric fractures.
Methods
23 patients with stable intertrochanteric fractures received a β 6 distal sodium channel block (DSCB) and were allowed to walk from day 1 without surgery, traction or spica. The goal was to prevent complications of recumbency in this subset of patients. The basic idea of immediate mobilisation from the time of fracture was based on Sarmiento’s sausage theory.
Results
All the fractures united. There were no major complications. No shortening was seen in more than 50% cases and the shortening did not exceed 2 cm in any case. All patients were satisfied with the outcome and had good to excellent Harris Hip Scores.
Conclusions
The block and walk method is a surprisingly satisfactory method of treatment for stable intertrochanteric fractures. It circumvents the risks of surgery whilst allowing immediate mobilisation preventing complications associated with the other modalities of fracture management.
... Many applications are being used nowadays to communicate in business/work settings and for personal use. Zoom, Microsoft Teams, FaceTime, and Skype are among the most popular applications used during the COVID-19 pandemic [12]. Regarding the videoconferencing electronic interface/application used by the applicants, 80.2% of the applicants used Zoom. ...
Background: During the coronavirus disease 2019 (COVID-19) pandemic, structured medical training is challenging because the necessary travel for on-site interviews could increase the spread of the disease.
Aim: This study was conducted to describe an urgently implemented, web-based interview process for selecting medical residents for the National Residency Matching in Saudi Arabia.
Method: A cross-sectional, nationwide survey (appendix 1) was sent to 4,153 residency-nominated applicants in Saudi Arabia to the matching interview for 2020.
Results: Among the 510 candidates who responded, 62.2% applied for medical specialties, 20.2% applied for surgical specialties, and 17.6% applied for critical care and emergency specialties. Most respondents (61.2%) never had video conferences. Besides, most respondents (80.2%) had used Zoom to conduct E-interviews, whereas only 15.9% used FaceTime. Among the respondents, 75.7% agreed that their questions regarding the residency programs were adequately answered during the virtual interviews. The top perceived factors that enhanced the experience were the free application, the clarification emails they received from the organizers, and the organizers’ effective communication. Conversely, what negatively impacted the interviews were the slow and interrupted Internet, the absence of clear instructions, and the lack of previous experience with teleconferencing.
Conclusion: Videoconferencing was successfully implemented on an urgent basis during the COVID-19 pandemic in the medical residency application process in Saudi Arabia. The residency applicants preferred video interviews, along with the cost savings and easier logistics to conduct the interviews from various locations. Future studies to enhance this experience are warranted.
... The pandemic also taught us to adapt to change as many orthopedic residents worked in different teams and specialties. [22,26] The limitations of our study include its cross-sectional design, which might limit the generalizability of the findings to larger populations. It is survey-based; thus, errors in the recall may affect reliability. ...
... Other researchers have studied the effect of the pandemic on many different specialties such as orthopedic surgery, maxillofacial surgery, plastic surgery, minimal access surgery, and transplant surgery [6][7][8][9][10][11][12][13][14][15][16]. However, a comprehensive analysis of the effect of COVID-19 on hand surgery has not been done. ...
Objective The purpose of this study was to determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on the practice of hand and upper extremity surgeons. Methods We assessed how the pandemic affected the practice on multiple fronts including professional, personal, and practice aspects. The survey was conducted through an online questionnaire that had six sections: demographics, clinic, elective surgery, emergency surgery, urgent surgery, and human resources. The survey was sent to 586 Kleinert Society members who are all practicing hand and upper extremity surgeons. Results We received 35 responses from the United States and 53 from the rest of the world. Based on our findings, the clinic volume was reduced by >50% in the early stages, subsequently returning to a level that was 25-50% lower than pre-COVID-19 times in later stages. A corresponding decrease in elective surgeries was also noted. The need for preoperative COVID-19 tests added to the logistics of surgery, causing delays of three to six hours for emergency cases and >24 hours for urgent cases. The hand surgeons witnessed multiple furloughs, layoffs, and even COVID-19 infections among nursing and support staff. Most hand surgeons continued to perform urgent and emergency surgeries during the pandemic. The application of telemedicine was not popular and had multiple drawbacks. Hand surgeons are modifying their practice by adopting measures such as social distancing, reducing the clinic volume, and using personal protective equipment (PPE). Conclusions As COVID-19 is likely to prevail for the foreseeable future, these measures are here to stay. The initial reduction in the clinic and elective volume has improved but has not reached pre-COVID-19 levels, suggesting a slow recovery. As reopening measures will lead to more people rejoining employment, subsequently, more patients with hand-related conditions are likely to present to the clinics. Rapid COVID-19 testing and supply of PPEs will play a crucial role in the near future to enable hand surgeons to continue their service while taking care of their personal health.
... Jerome et al (1) had reported the Orthopaedics surgeries from a survey involving 100 Orthopaedics surgeons from 50 countries during their early and mid-lockdown phase of corona virus disease. They noted Distal radius fractures (53%), hand and carpal bone fractures/dislocations (57%), forearm fractures (39%), elbow fractures/dislocations (40%), shoulder (24%), spine fractures, paraplegia and dislocations (17%), pelvis and acetabulum (15%), hip fractures/dislocations (46%), femur fractures (32%), knee (27%), leg, ankle, and foot fractures (28%), microsurgeries (29%), fingertip injuries (45%), soft tissue injuries (37%), amputations (39%), replants and revascularizations (30%), septic arthritis/infections (38%), tendon, nerve, and muscle injuries (50%), open fractures (57%), and emergency surgeries (57%) happened during the COVID-19 crisis in 50 countries. ...
We read the recently published article “Impact of COVID-19 on Orthopaedic and Trauma Service: An
Epidemiological Study” where the authors reported the Orthopaedics surgery happened during the COVID
19 crisis.
Jerome et al (1) had reported the Orthopaedics surgeries from a survey involving 100 Orthopaedics
surgeons from 50 countries during their early and mid-lockdown phase of corona virus disease. They
noted Distal radius fractures (53%), hand and carpal bone fractures/dislocations (57%), forearm fractures
(39%), elbow fractures/dislocations (40%), shoulder (24%), spine fractures, paraplegia and dislocations
(17%), pelvis and acetabulum (15%), hip fractures/dislocations (46%), femur fractures (32%), knee (27%),
leg, ankle, and foot fractures (28%), microsurgeries (29%), fingertip injuries (45%), soft tissue injuries
(37%), amputations (39%), replants and revascularizations (30%), septic arthritis/infections (38%),
tendon, nerve, and muscle injuries (50%), open fractures (57%), and emergency surgeries (57%) happened
during the COVID-19 crisis in 50 countries.
In total, 75% surgeons did all these surgeries in their normal operating room (OR); 15% had COVID-19
makeshift ORs where the cases were done; <10% had the surgery done in minor ORs or day-care units or
adjacent to ORs.
... Jerome et al (2) recommendations for safety in the operating room for performing Orthopaedic surgeries 1. Respirators (FFP1, FFP2, and FFP3) protect against droplets and aerosols (percentage of filtered particles ?300?nm). 2. N95 masks filter 95% of ?300?nm particles. ...
We read the recently published article " Orthopaedic Systems Response to and Return from the COVID-19 Pandemic: Lessons for Future Crisis Management " (1) where the authors had briefed the safety concerns of the operating room. Jerome et al (2) had reported the safety concerns from their survey involving 100 Orthopaedics surgeons from 50 countries during the early and mid-lockdown phase of corona virus disease. Interestingly 73% of Orthopaedic surgeries were performed in their normal operating room (ORs) and 18% had COVID-19 makeshift ORs with negative pressure control and filters. Minor ORs and emergency ORs were used in 8%. More than one-third of the surgeons (40%) did surgery with full PPE kits, N95 masks, face shields, shoe covers, and protective glass, with proper donning and doffing techniques before and after procedures. Surgeons (25%) performed surgeries with normal surgical masks, operating gowns, shoes, and usual accessories during and after the procedures, partly attributing to non-availability, poor supply, and increased demand for the PPE kits and the accessories. More cautiously 5% wore both surgical and N95 masks together during the procedures. Surgeons had perspirations, heat, fogs, and occasional breathlessness wearing the PPE kits and the accessories. Surgeons (2%) preferred (filtering face piece level 1, 2, and 3) FFP3 masks over N95 masks, which are slightly better and advantageous than N95 masks. (2) PPE kits include surgical gloves, water-resistant gowns with long sleeves, a surgical mask, and full-face protection with a face shield. This reduces intraoperative wound contaminations from blood and body fluids, which get sprayed in an area of 2 to 8 meters around the operating table.(3) There are four levels of safety in gowns: level 1(use in minimal risk environment), level 2 (low risk procedures), level 3 (moderate risk), and level 4 (high-risk procedures/infectious diseases). There are three types of face masks protecting the mouth and the nose. 1. Single-use face mask: it filters large particles of 3 ?m, prevents droplet transfer, and is used by the health care workers (4) to protect and patients to limit COVID-19 transmission. (5) 2. Respirators mask (6): it filters small particles of 0.3 ?m and protects against airborne transmission. The
O tema desta pesquisa é o padrão de colaboração científica estabelecido por pesquisadores filiados a instituições de países periféricos para produção do conhecimento científico em Emergências de Saúde Pública de Importância Internacional (ESPIIs). Uma ESPII é declarada pela Organização Mundial da Saúde, na ocorrência de um evento de caráter extraordinário, que representa elevado risco à saúde pública e que vai além das fronteiras nacionais dos países afetados. Seis ESPIIs já foram declaradas: a gripe H1N1, em 2009; o poliovírus selvagem, em 2014; o Ebola, em 2014 e em 2019; o Zika vírus, em 2016; e a Covid-19, em 2020. Para esta tese, analisam-se os casos do Zika vírus e da Covid-19 no Brasil, uma vez que o país esteve no epicentro dessas duas ESPIIs. A revisão de literatura aponta que o estabelecimento de colaborações entre pesquisadores, instituições e países possibilita dar celeridade à produção do conhecimento científico visto que pode ampliar o acesso a recursos e minimizar a duplicidade de esforços, além de propiciar a construção de redes que viabilizem novas colaborações no futuro. À vista disso, o objetivo geral do trabalho foi caracterizar a dinâmica da colaboração científica de pesquisadores brasileiros sobre as ESPIIs do Zika vírus e da Covid-19 e analisar quais os principais resultados e aprendizados advindos desses processos colaborativos. Da produção científica brasileira, foram analisados 4.895 documentos, publicados entre 2014 e 2020, indexados nas bases bibliográficas Web of Science e SciELO Citation Index, sobre o Zika vírus e a Covid-19. A partir da construção de indicadores bibliométricos e de análise de redes sociais, verificou-se que 96,1% das publicações sobre o Zika vírus e 91,1% sobre a Covid-19 são resultados de colaborações, em que a maior parcela advém de colaborações domésticas: 50,2% no caso do Zika vírus e 60,4% para a Covid-19 (em relação ao total de publicações para cada ESPII). Destaca-se também a presença de pesquisadoras mulheres no topo da elite científica brasileira das pesquisas sobre o Zika vírus. Aponta-se, ainda, que a localização geográfica da doença também se mostrou um fator influente para o estabelecimento de colaborações pelos pesquisadores brasileiros. Ademais, um estudo de caso foi realizado com o Grupo de Pesquisas da Epidemia de Microcefalia (MERG), em que se verificou a formação de um colégio invisível, cuja origem e manutenção da rede tem como um dos suportes a genealogia acadêmica, i.e., os vínculos de orientado e orientador. Tal percepção também foi corroborada por meio de entrevistas com especialistas brasileiros, que ressaltaram, ainda, a importância de uma rede pregressa de colaborações, desenvolvida em fatores pessoais, como confiança e respeito mútuo. Indica-se que uma limitação da pesquisa é a consideração exclusiva de publicações científicas, que pressupõem serem resultado de colaborações bem-sucedidas. Estudos futuros podem aprofundar as análises relacionadas à genealogia acadêmica e as questões de gênero, bem como replicar esta pesquisa para outros países periféricos, à vista de seus contextos locais.
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The world at large has been confronted with several disease outbreaks which have posed and still posing a serious menace to public health globally. Recently, COVID-19 a new kind of coronavirus emerge from Wuhan city in China and was declared a pandemic by the World Health Organization. There has been reported case of about 10,021,401 with global death of 499,913 as of 15.15 GMT, June 29 2020. There are 382,190 and 9664 positive cases and deaths in Africa, respectively as of June 29 at 7:00 GMT. South-Africa, Egypt, Nigeria, Ghana, Algeria and Cameroon are the most affected African countries with this outbreak. The chapter referred to them in this study as Africa epicenters’. Thus, there is a need to monitor and predict COVID-19 prevalence in this region for effective control and management. Different statistical tools and time series model such as the linear regression model and auto-regressive integrated moving average (ARIMA) models have been applied for disease prevalence/incidence prediction in different diseases outbreak. This book chapter adopted the linear regression model and the ARIMA models to forecast the trend of COVID-19 prevalence in the aforementioned African countries. The datasets examined in this analysis spanned from February 21, 2020, to October 4, 2020, and was extracted from the European Centre for Disease Prevention and Control website. The cumulative confirmed cases of COVID-19 cases were subjected to different curve estimation statistical models in simple, quadratic, cubic, and quartic forms. In the chapter, we identified the best model in each country and use the same for prediction and forecasting purposes. In conclusion, we obtained the future trend of this virus across Africa epicenters’ and this, in turn, will assist the government and health authorities to plan and take precautions that will help to curb this pandemic in Africa.
Patient care should never be curtailed in emergency cases and essential lifesaving orthopedics surgeries which are the prime concern in medical law and ethics. The right to the highest attainable standard of health" by WHO constitution (1946) implies a clear set of legal obligations on states to ensure appropriate conditions for the enjoyment of health for all people without discrimination. (2) Every country must focus on the patient's right to health as a supreme obligation to its fellow citizens during this COVID 19. It is also essential that during this pandemic crisis, non-emergency or orthopedics conditions that required specific and timely intervention may not be neglected or postponed. Jerome et al (3) have reported recommendations regarding orthopedics patient care at emergency, non-emergency, and the importance of consent. They stressed the Indian constitutional right article 21. "No person shall be deprived of his life or personal liberty except according to the procedure established by law". (4) All their patients received information about COVID-19, hand hygiene, and safe hygienic practices before surgery. 87 % of surgeons in their study obtained prior informed for procedures during COVID 19 early and mid-lockdown phase. 49% of surgeons had special consent in the bilingual version (English + native language) briefing the risk of contamination and spread to them during the stay. We need to emphasize that the risk of transmission of COVID 19 from hospital asymptomatic carriers. (5) This has to be conveyed with a separate/special informed consent comprehensible to patients' understanding. For patients with severe hypoxia, anxiety, confusion, or restlessness, these informed consents can be obtained from the
Purpose:
With the COVID-19 crisis, recommendations for personal protective equipment (PPE) are necessary for protection in orthopaedics and traumatology. The primary purpose of this study is to review and present current evidence and recommendations for personal protective equipment and safety recommendations for orthopaedic surgeons and trauma surgeons.
Methods:
A systematic review of the available literature was performed using the keyword terms "COVID-19", "Coronavirus", "surgeon", "health-care workers", "protection", "masks", "gloves", "gowns", "helmets", and "aerosol" in several combinations. The following databases were assessed: Pubmed, Cochrane Reviews, Google Scholar. Due to the paucity of available data, it was decided to present it in a narrative manner. In addition, participating doctors were asked to provide their guidelines for PPE in their countries (Austria, Luxembourg, Switzerland, Germany, UK) for consideration in the presented practice recommendations.
Results:
World Health Organization guidance for respiratory aerosol-generating procedures (AGPs) such as intubation in a COVID19 environment was clear and included the use of an FFP3 (filtering face piece level 3) mask and face protection. However, the recommendation for surgical AGPs, such as the use of high-speed power tools in the operating theatre, was not clear until the UK Public Health England (PHE) guidance of 27 March 2020. This guidance included FFP3 masks and face protection, which UK surgeons quickly adopted. The recommended PPE for orthopaedic surgeons, working in a COVID19 environment, should consist of level 4 surgical gowns, face shields or goggles, double gloves, FFP2-3 or N95-99 respirator masks. An alternative to the mask, face shield and goggles is a powered air-purifying respirator, particularly if the surgeons fail the mask fit test or are required to undertake a long procedure. However, there is a high cost and limited availabilty of these devices at present. Currently available surgical helmets and toga systems may not be the solution due to a permeable top for air intake. During the current COVID-19 crisis, it appeared that telemedicine can be considered as an electronic personal protective equipment by reducing the number of physical contacts and risk contamination.
Conclusion:
Orthopaedic and trauma surgery using power tools, pulsatile lavage and electrocautery are surgical aerosol-generating procedures and all body fluids contain virus particles. Raising awareness of these issues will help avoid occupational transmission of COVID-19 to the surgical team by aerosolization of blood or other body fluids and hence adequate PPE should be available and used during orthopaedic surgery. In addition, efforts have to be made to improve the current evidence in this regard.
Level of evidence:
IV.
Background:. The novel coronavirus and associated Coronavirus Disease 2019 (COVID-19) is rapidly spreading throughout the world, with robust growth in the United States. Its drastic impact on the global population and international health care is swift, evolving, and unpredictable. The effects on orthopaedic surgery departments are predominantly indirect, with widespread cessation of all nonessential orthopaedic care. Although this is vital to the system-sustaining measures of isolation and resource reallocation, there is profound detriment to orthopaedic training programs.
Methods:. In the face of new pressures on the finite timeline on an orthopaedic residency, the Emory University School of Medicine Department of Orthopaedics has devised a 5-pronged strategy based on the following: (1) patient and provider safety, (2) uninterrupted necessary care, (3) system sustainability, (4) adaptability, and (5) preservation of vital leadership structures.
Results:. Our 5 tenants support a 2-team system, whereby the residents are divided into cycling “active-duty” and “working remotely” factions. In observation of the potential incubation period of viral symptoms, phase transitions occur every 2 weeks with strict adherence to team assignments. Intrateam redundancy can accommodate potential illness to ensure a stable unit of able residents. Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters, whereas remotely working residents participate in daily video-conferenced faculty-lead, case-based didactics and pursue academic investigation, grant writing, and quality improvement projects. To sustain this, faculty and administrative 2-team systems are also in place to protect the leadership and decision-making components of the department.
Conclusions:. The novel coronavirus has decimated the United States healthcare system, with an unpredictable duration, magnitude, and variability. As collateral damage, orthopaedic residencies are faced with new challenges to provide care and educate residents in the face of safety, resource redistribution, and erosion of classic learning opportunities. Our adaptive approach aims to be a generalizable tactic to optimize our current landscape.
The COVID-19 pandemic has presented challenges to healthcare systems, including the cancellation and then staged resumption of elective procedures. The orthopaedic trauma community has continued to provide care to patients with acute musculoskeletal injuries that cannot be delayed in all scenarios. This article summarizes and provides relevant information (orthopaedic trauma service, outpatient fracture clinic, inpatient surgery) to the practicing orthopaedic traumatologist on maximizing outcomes while limiting exposure during the pandemic. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
We report temporal patterns of viral shedding in 94 patients with laboratory-confirmed COVID-19 and modeled COVID-19 infectiousness profiles from a separate sample of 77 infector–infectee transmission pairs. We observed the highest viral load in throat swabs at the time of symptom onset, and inferred that infectiousness peaked on or before symptom onset. We estimated that 44% (95% confidence interval, 25–69%) of secondary cases were infected during the index cases’ presymptomatic stage, in settings with substantial household clustering, active case finding and quarantine outside the home. Disease control measures should be adjusted to account for probable substantial presymptomatic transmission. Presymptomatic transmission of SARS-CoV-2 is estimated to account for a substantial proportion of COVID-19 cases.
This is a comprehensive scoping review about the current evidence and recommendations/clinical guidelines in orthopaedic surgery during the COVID-19 pandemic.
By April 7, 2020, SARS-CoV-2 was responsible for 1,383,436 confirmed cases of COVID-19, involving 209 countries around the world; 378,881 cases have been confirmed in the United States. During this pandemic, the urgent surgical requirements will not stop. As an example, the most recent CDC reports estimate that there are 2.8 million trauma patients hospitalized in the United States. These data illustrate an increase in the likelihood of encountering urgent surgical patients with either clinically suspected or confirmed COVID-19 in the near future. Preparation for a pandemic involves considering the different levels in the hierarchy of controls as well as the different phases of the pandemic. Apart from the fact that this pandemic certainly involves many important health, economic and community ramifications, it also requires several initiatives to mandate what measures are most appropriate to prepare for mitigating the occupational risks. This article provides evidence-based recommendations and measures for the appropriate personal protective equipment for different clinical and surgical activities in various settings. To reduce the occupational risk in treating suspected or confirmed COVID-19 urgent orthopaedic patients, recommended precautions and preventive actions (triage area, ED consultation room, induction room, operating room, and recovery room) are reviewed.
The COVID-19 global pandemic presents a challenge to orthopaedic education. Around the world, including in the United States, elective surgeries are being deferred, and orthopaedic residents and fellows are being asked to make drastic changes to their daily routines. In the midst of these changes are unique opportunities for resident/fellow growth and development. Educational tools in the form of web-based learning, surgical simulators, and basic competency tests may serve an important role. Challenges are inevitable, but appropriate preparation may help programs ensure continued resident growth, development, and well-being, while maintaining high quality patient care.
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.
Coronavirus disease 2019 (COVID-19) poses an occupational health risk to healthcare workers. Several thousand healthcare workers have already been infected, mainly in China. Preventing intra-hospital transmission of the communicable disease is therefore a priority. Based on the Systems Engineering Initiative for Patient Safety model, the strategies and measures to protect healthcare workers in an acute tertiary hospital are described along the domains of work task, technologies and tools, work environmental factors, and organizational conditions. The principle of zero occupational infection remains an achievable goal that all healthcare systems need to strive for in the face of a potential pandemic.
A global health emergency has been declared by the World Health Organization as the 2019-nCoV outbreak spreads across the world, with confirmed patients in Canada. Patients infected with 2019-nCoV are at risk for developing respiratory failure and requiring admission to critical care units. While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.
Full-text available open access at: https://link.springer.com/article/10.1007/s12630-020-01591-x
Although short-range large-droplet transmission is possible for most respiratory infectious agents, deciding on whether the same agent is also airborne has a potentially huge impact on the types (and costs) of infection control interventions that are required.
The concept and definition of aerosols is also discussed, as is the concept of large droplet transmission, and airborne transmission which is meant by most authors to be synonymous with aerosol transmission, although some use the term to mean either large droplet or aerosol transmission.
However, these terms are often used confusingly when discussing specific infection control interventions for individual pathogens that are accepted to be mostly transmitted by the airborne (aerosol) route (e.g. tuberculosis, measles and chickenpox). It is therefore important to clarify such terminology, where a particular intervention, like the type of personal protective equipment (PPE) to be used, is deemed adequate to intervene for this potential mode of transmission, i.e. at an N95 rather than surgical mask level requirement.
With this in mind, this review considers the commonly used term of ‘aerosol transmission’ in the context of some infectious agents that are well-recognized to be transmissible via the airborne route. It also discusses other agents, like influenza virus, where the potential for airborne transmission is much more dependent on various host, viral and environmental factors, and where its potential for aerosol transmission may be underestimated.
Background
Osteoporotic vertebral fractures adversely impact quality of life and also increase the risk of infection and mortality. Alendronate treatment increases bone mass and reduces the risk of fractures in patients with osteoporosis by suppressing bone resorption. We investigated the relationship between alendronate treatment and infection-related death in patients with osteoporotic vertebral fractures.
Methods
We retrospectively reviewed patients with osteoporosis and vertebral fractures from January 2001 to December 2007. The use of alendronate, glucocorticoid and medical factors including smoking, alcohol consumption, diabetes, hypertension, stroke, liver disease, heart disease, and pulmonary disease were analyzed. Cox regression was used to analyze the factors associated with life-threatening infections.
Results
A total of 210 patients (161 females and 49 males) were included with a mean age of 74.06±7.43 years. Among them, 87 had life-threatening infections and 123 did not. In Cox regression analysis, the patients who used alendronate had a significantly lower risk of life-threatening infections (p = 0.006, HR = 0.845, 95% CI 0.750–0.954), while glucocorticoid users had higher risk of death (p = 0.010, HR = 2.037, 95% CI 1.187–3.498).
Conclusions
Osteoporosis was associated with a high rate of life-threatening infections, and the use of alendronate had a lower rate of infection-related death. Therefore, we suggest that alendronate be used after vertebral fractures in these patients.
This study was conducted to investigate the protection of disposable filtering half-facepiece respirators of different grades against particles between 0.093 and 1.61
μ
m. A personal sampling system was used to particle size-selectively assess the protection of respirators. The results show that about 10.9% of FFP2 respirators and 28.2% of FFP3 respirators demonstrate assigned protection factors (APFs) below 10 and 20, which are the levels assigned for these respirators by the British Standard. On average, the protection factors of FFP respirators were 11.5 to 15.9 times greater than those of surgical masks. The minimum protection factors (PFs) were observed for particles between 0.263 and 0.384
μ
m. No significant difference in PF results was found among FFP respirator categories and particle size. A strong association between fit factors and protection factors was found. The study indicates that FFP respirators may not achieve the expected protection level and the APFs may need to be revised for these classes of respirators.
As extensively reported in the literature, laparoscopic surgery has many advantages for the patient. Surgeons, however, experience increased physical burden when laparoscopic surgery is compared with open surgery. Single-incision laparoscopic surgery (SILS) has been said to further enhance the patient's benefits of endoscopic surgery. Because in this surgical technique only 1 incision is made instead of the 3 to 5, as in conventional laparoscopic surgery (CLS), it is claimed to further reduce discomfort and pain in patients. Yet little is known about its impact on surgeons. This study aims to contribute by indicating the possible differences in physical workload between single-incision laparoscopy and CLS.
A laparoscopic box trainer was used to simulate a surgical setting. Participants performed 2 series of 3 different tasks in the box: one in the conventional way, the other through SILS. Surface electromyography was recorded from 8 muscles bilaterally. Furthermore, questionnaires on perceived workload were completed.
Differences were found in the back, neck, and shoulder muscles, with significantly higher muscle activity in the musculus (M) longissimus, M trapezius pars descendens, and the M deltoideus pars clavicularis. Questionnaires did not indicate any significant differences in perceived workload.
Performing SILS versus CLS increases the objectively measured physical workload of surgeons particularly in the back, neck, and shoulder muscles.
© The Author(s) 2015.
Instruments used in surgery which rotate or vibrate at a high frequency can produce potentially contaminated aerosols. Such tools are in use in cemented hip revision arthroplasties. We aimed to measure the extent of the environmental and body contamination caused by an ultrasound device and a high-speed cutter.
On a human cadaver we carried out a complete surgical procedure including draping and simulated blood flow contaminated with Staphylococcus aureus (ATCC 12600). After cemented total hip arthroplasty, we undertook repeated extractions of cement using either an ultrasound device or a high-speed cutter. Surveillance cultures detected any environmental and body contamination of the surgical team.
Environmental contamination was present in an area of 6 x 8 m for both devices. The concentration of contamination was lower for the ultrasound device. Both the ultrasound and the high-speed cutter contaminated all members of the surgical team. The devices tested produced aerosols which covered the whole operating theatre and all personnel present during the procedure. In contaminated and infected patients, infectious agents may be present in these aerosols. We therefore recommend the introduction of effective measures to control infection and thorough disinfection of the operating theatre after such procedures.
Aerosol generating procedures (AGPs) may expose health care workers (HCWs) to pathogens causing acute respiratory infections (ARIs), but the risk of transmission of ARIs from AGPs is not fully known. We sought to determine the clinical evidence for the risk of transmission of ARIs to HCWs caring for patients undergoing AGPs compared with the risk of transmission to HCWs caring for patients not undergoing AGPs. We searched PubMed, EMBASE, MEDLINE, CINAHL, the Cochrane Library, University of York CRD databases, EuroScan, LILACS, Indian Medlars, Index Medicus for SE Asia, international health technology agencies and the Internet in all languages for articles from 01/01/1990 to 22/10/2010. Independent reviewers screened abstracts using pre-defined criteria, obtained full-text articles, selected relevant studies, and abstracted data. Disagreements were resolved by consensus. The outcome of interest was risk of ARI transmission. The quality of evidence was rated using the GRADE system. We identified 5 case-control and 5 retrospective cohort studies which evaluated transmission of SARS to HCWs. Procedures reported to present an increased risk of transmission included [n; pooled OR(95%CI)] tracheal intubation [n = 4 cohort; 6.6 (2.3, 18.9), and n = 4 case-control; 6.6 (4.1, 10.6)], non-invasive ventilation [n = 2 cohort; OR 3.1(1.4, 6.8)], tracheotomy [n = 1 case-control; 4.2 (1.5, 11.5)] and manual ventilation before intubation [n = 1 cohort; OR 2.8 (1.3, 6.4)]. Other intubation associated procedures, endotracheal aspiration, suction of body fluids, bronchoscopy, nebulizer treatment, administration of O2, high flow O2, manipulation of O2 mask or BiPAP mask, defibrillation, chest compressions, insertion of nasogastric tube, and collection of sputum were not significant. Our findings suggest that some procedures potentially capable of generating aerosols have been associated with increased risk of SARS transmission to HCWs or were a risk factor for transmission, with the most consistent association across multiple studies identified with tracheal intubation.
Traumatic dislocation of the hip (TDH) is an absolute orthopedic emergency that is increasing steadily in incidence. Sixty-two to ninety-three percent of reported cases were the result of high-speed motor vehicle accidents in which seat belts were not used. Post-TDH complications and morbidity, particularly femoral head necrosis, are related to the severity of injury, skeletal maturity, and duration of dislocation. Prompt, gentle reduction within 12 hours remains the cornerstone of successful therapy. In a variety of other clinical condition, TDH may be masked, and specific appropriate evaluation is thus necessary to detect the occasionally occult TDH. The regular use of seat belts would virtually eliminate this injury.
Instruments used in surgery which rotate or vibrate at a high frequency can produce potentially contaminated aerosols. Such tools are in use in cemented hip revision arthroplasties. We aimed to measure the extent of the environmental and body contamination caused by an ultrasound device and a high-speed cutter. On a human cadaver we carried out a complete surgical procedure including draping and simulated blood flow contaminated with Staphylococcus aureus (ATCC 12600). After cemented total hip arthroplasty, we undertook repeated extractions of cement using either an ultrasound device or a high-speed cutter. Surveillance cultures detected any environmental and body contamination of the surgical team. Environmental contamination was present in an area of 6 x 8 m for both devices. The concentration of contamination was lower for the ultrasound device. Both the ultrasound and the high-speed cutter contaminated all members of the surgical team. The devices tested produced aerosols which covered the whole operating theatre and all personnel present during the procedure. In contaminated and infected patients, infectious agents may be present in these aerosols. We therefore recommend the introduction of effective measures to control infection and thorough disinfection of the operating theatre after such procedures.
The novel coronavirus, SARS-CoV-2, pandemic has delivered a profound and negative impact on the United States. The suspension of elective surgeries including arthroplasty will have a lasting effect on all stakeholders including patients, physicians, and healthcare organizations within the US healthcare system. Resumption of elective hip and knee arthroplasty will need to be carefully focused. The purpose of this work is to address potential strategies, concerns, and regulatory barriers in restarting elective hip and knee arthroplasty in the US.
Despite the use of digital technology in healthcare, telemedicine has not been readily adopted. During the COVID-19 pandemic, healthcare systems have begun crisis management planning. To appropriately allocate resources and prevent virus exposure while maintaining effective patient care, our orthopaedic surgery department rapidly introduced a robust telemedicine program during a 5-day period. Implementation requires attention to patient triage, technological resources, credentialing, education of providers and patients, scheduling, and regulatory considerations. This article provides practical instruction based on our experience for physicians who wish to implement telemedicine during the COVID-19 pandemic. Between telemedicine encounters and necessary in-person visits, providers may be able to achieve 50% of their typical clinic volume within 2 weeks. When handling the massive disruption to the routine patient care workflow, it is critical to understand the key factors associated with an accelerated introduction of telemedicine for the safe and effective continuation of orthopaedic care during this pandemic. LEVEL OF EVIDENCE:: V.
Background:
Studies of the novel coronavirus-induced disease COVID-19 in Wuhan, China, have elucidated the epidemiological and clinical characteristics of this disease in the general population. The present investigation summarizes the clinical characteristics and early prognosis of COVID-19 infection in a cohort of patients with fractures.
Methods:
Data on 10 patients with a fracture and COVID-19 were collected from 8 different hospitals located in the Hubei province from January 1, 2020, to February 27, 2020. Analyses of early prognosis were based on clinical outcomes and trends in laboratory results during treatment.
Results:
All 10 patients presented with limited activity related to the fracture. The most common signs were fever, cough, and fatigue at the time of presentation (7 patients each). Other, less common signs included sore throat (4 patients), dyspnea (5 patients), chest pain (1 patient), nasal congestion (1 patient), headache (1 patient), dizziness (3 patients), abdominal pain (1 patient), and vomiting (1 patient). Lymphopenia (<1.0 × 10 cells/L) was identified in 6 of 10 patients, 9 of 9 patients had a high serum level of D-dimer, and 9 of 9 patients had a high level of C-reactive protein. Three patients underwent surgery, whereas the others were managed nonoperatively because of their compromised status. Four patients died on day 8 (3 patients) or day 14 (1 patient) after admission. The clinical outcomes for the surviving patients are not yet determined.
Conclusions:
The clinical characteristics and early prognosis of COVID-19 in patients with fracture tended to be more severe than those reported for adult patients with COVID-19 without fracture. This finding may be related to the duration between the development of symptoms and presentation. Surgical treatment should be carried out cautiously or nonoperative care should be chosen for patients with fracture in COVID-19-affected areas, especially older individuals with intertrochanteric fractures.
Level of evidence:
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Introduction
Rapid worldwide spread of Coronavirus Disease 2019 (COVID-19) has resulted in a global pandemic.
Objective
This review article provides emergency physicians with an overview of the most current understanding of COVID-19 and recommendations on the evaluation and management of patients with suspected COVID-19.
Discussion
Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for causing COVID-19, is primarily transmitted from person-to-person through close contact (approximately 6 ft) by respiratory droplets. Symptoms of COVID-19 are similar to other viral upper respiratory illnesses. Three major trajectories include mild disease with upper respiratory symptoms, non-severe pneumonia, and severe pneumonia complicated by acute respiratory distress syndrome (ARDS). Emergency physicians should focus on identifying patients at risk, isolating suspected patients, and informing hospital infection prevention and public health authorities. Patients with suspected COVID-19 should be asked to wear a facemask. Respiratory etiquette, hand washing, and personal protective equipment are recommended for all healthcare personnel caring for suspected cases. Disposition depends on patient symptoms, hemodynamic status, and patient ability to self-quarantine.
Conclusion
This narrative review provides clinicians with an updated approach to the evaluation and management of patients presenting to the emergency department with suspected COVID-19.
In this retrospective study, chest CTs of 121 symptomatic patients infected with coronavirus disease-19 (COVID-19) from four centers in China from January 18, 2020 to February 2, 2020 were reviewed for common CT findings in relationship to the time between symptom onset and the initial CT scan (i.e. early, 0-2 days (36 patients), intermediate 3-5 days (33 patients), late 6-12 days (25 patients)). The hallmarks of COVID-19 infection on imaging were bilateral and peripheral ground-glass and consolidative pulmonary opacities. Notably, 20/36 (56%) of early patients had a normal CT. With a longer time after the onset of symptoms, CT findings were more frequent, including consolidation, bilateral and peripheral disease, greater total lung involvement, linear opacities, "crazy-paving" pattern and the "reverse halo" sign. Bilateral lung involvement was observed in 10/36 early patients (28%), 25/33 intermediate patients (76%), and 22/25 late patients (88%).
Background
Advances in perioperative care and growing demand for hospital beds has progressively reduced the length of stay in lower limb arthroplasty. Current trends in population demographics and fiscal climate has also added to this change. Individual institutions have reported good outcomes with outpatient hip and knee arthroplasty. Debate remains regarding the safety of this practice, the optimal protocol, and the applicability in different subsections of population. The primary purpose of this review is to assess the complication and re-operation rates of outpatient arthroplasty.
Methods
We performed a systematic review of all papers reporting on 30 and/or 90-day complication rates of outpatient total hip, total knee and unicondylar knee arthroplasty published from 1st January 2009-1st November 2019. Patient demographics, anaesthesia, analgesic protocol, selection criteria and reasons for failed discharge were also extracted.
Results
Nineteen manuscripts with a total of 6519 operations between them were analysed as a part of this systematic review. Mean 90-day readmission rates were 2.3% (range 0-6%) with 1.61% (range 0-4%) rate. Overall rate of successful same calendar day discharge was 93.4%. Nausea/dizziness was the most common reason identified (n=45) for failure of discharge.
Conclusion
The patients recruited for outpatient joint arthroplasty were younger, more active and had suffered from less medical co-morbidities than the more typical lower limb arthroplasty patient. There are significant differences in the reported complications between the studies reviewed. More research is needed to establish if an outpatient program can produce similar outcomes to a fast-track program. Further research is also needed to establish the optimal perioperative protocols.
Background:
Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.
Methods:
HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).
Findings:
Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).
Interpretation:
Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.
Funding:
Canadian Institutes of Health Research.
Currently, the emergence of a novel human coronavirus, temporary named 2019-nCoV, has become a global health concern causing severe respiratory tract infections in humans. Human-to-human transmissions have been described with incubation times between 2-10 days, facilitating its spread via droplets, contaminated hands or surfaces. We therefore reviewed the literature on all available information about the persistence of human and veterinary coronaviruses on inanimate surfaces as well as inactivation strategies with biocidal agents used for chemical disinfection, e.g. in healthcare facilities. The analysis of 22 studies reveals that human coronaviruses such as Severe Acute Respiratory Syndrome (SARS) coronavirus, Middle East Respiratory Syndrome (MERS) coronavirus or endemic human coronaviruses (HCoV) can persist on inanimate surfaces like metal, glass or plastic for up to 9 days, but can be efficiently inactivated by surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute. Other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate are less effective. As no specific therapies are available for 2019-nCoV, early containment and prevention of further spread will be crucial to stop the ongoing outbreak and to control this novel infectious thread.
FREE ACCESS ON JOURNAL HOMEPAGE
Fatigue is inevitable at all stages of a surgical career. The sustained high degree of concentration required for surgery is complicated by long surgeon working hours and sleep deprivation, which force surgeons to learn to manage and mitigate the effects of physical and mental fatigue on their performance. Extensive evidence exists detailing the potentially dangerous effects of surgeon fatigue on patient safety, but few reports exist offering a comprehensive strategy to mitigate the effects of fatigue on clinical performance. To promote improved detection and mitigation of fatigue among surgeons, the authors have highlighted several deliberate fatigue-management techniques that they have found to be particularly effective in their own experiences. These techniques include proper planning to maximize team efficiency, and the use of scheduled and unscheduled intraoperative breaks for mental and physical rest and regeneration. The decision to take a much-needed break is often neglected because of concerns about prolonging the duration of an operation; with proper self-awareness of fatigue and brief mental checks during natural intraoperative slowdowns, however, the surgeon can quickly assess the need for a much-needed moment of recovery. The authors hope surgeons will find the fatigue-mitigation strategies presented here to be helpful in promoting both their own wellness and the safety and wellness of their patients.
Importance
Overlapping surgery, also known as double-booking, refers to a controversial practice in which a single attending surgeon supervises 2 or more operations, in different operating rooms, at the same time.
Objective
To determine if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.
Design, Setting, and Participants
This was a retrospective population-based cohort study in Ontario, Canada (population, 13.6 million), for the years 2009 to 2014. There was 1 year of follow-up. This study encompassed 2 large cohorts. The “hip fracture” cohort captured all persons older than 60 years who underwent surgery for a hip fracture during the study period. The “total hip arthroplasty” (THA) cohort captured all primary elective THA recipients for arthritis during the study period. We matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital.
Exposures
Procedures were identified as overlapping if they overlapped with another surgical procedure performed by the same primary attending surgeon by more than 30 minutes.
Main Outcomes and Measures
Complication (infection, revision, dislocation) within 1 year.
Results
There were 38 008 hip fractures, and of those, 960 (2.5%) were overlapping (mean age of patients, 66 years [interquartile range, 57-74 years]; 503 [52.4%] were female). There were 52 869 THAs and of those, 1560 (3.0%) overlapping (mean age, 84 years [interquartile range, 77-89 years]; 1293 [82.9%] were female). After matching, overlapping hip fracture procedures had a greater risk for a complication (hazard ratio [HR], 1.85; 95% CI, 1.27-2.71; P = .001), as did overlapping THA procedures (HR, 1.79; 95% CI, 1.02-3.14; P = .04). Among overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap; P = .009).
Conclusions and Relevance
Overlapping surgery was relatively rare but was associated with an increased risk for surgical complications. Furthermore, increasing duration of operative overlap was associated with an increasing risk for complications. These findings support the notion that overlapping provision of surgery should be part of the informed consent process.
Background:
Hip and knee arthroplasties length of stay continues to shorten after advances in perioperative and intraoperative management, as well as financial incentives. Some authors have demonstrated good results with outpatient arthroplasty, but safety and general feasibility of such procedures remain unclear. Our hypothesis is that outpatient arthroplasty would demonstrate higher readmission and complication rates than inpatient arthroplasty.
Methods:
We performed a systematic review of all publications on outpatient arthroplasty between January 1, 2000 and June 1, 2016. Included publications had to demonstrate a specific outpatient protocol and have reported perioperative complications and unplanned readmissions. Patient demographics, surgical variables, and protocol details were recorded in addition to complications, readmission, and reoperation.
Results:
Ten manuscripts accounting for 1009 patients demonstrated that 955 (94.7%) were discharged the same day as planned, with the majority of failures to discharge being secondary to pain, hypotension, and nausea. There were no deaths and only 1 major complication. Only 20 patients (1.98%) required reoperation and 20 (1.98%) had readmission or visited the emergency room within 90 days of their operation. In the 2 series recording patient outcomes, 80% and 96% of patients reported that they would choose to undergo outpatient arthroplasty again.
Conclusion:
For carefully selected patients with experienced surgeons in major centers, outpatient arthroplasty may be a safe and effective procedure. Although our data is promising, further study is required to better elucidate the differences between inpatient and outpatient arthroplasty outcomes.
Background:
We proposed to determine the complication and hospital admission rates for patients with total hip arthroplasty (THA) done by a single surgeon in a stand-alone ambulatory surgical center with same-day discharge. Given the recent emphasis on bundled payments for a 90-day episode of care, this same time frame after surgery was chosen to determine patient outcomes.
Methods:
The records of patients with THAs done through a direct anterior approach by a single surgeon at 2 separate ambulatory surgery centers were reviewed. To analyze the learning curve for outpatient THA, the procedures were arbitrarily divided into 2 groups depending on when they were done: early in our experience or later. Complications were recorded, as were hospital admissions and surgical interventions, length of surgery and blood loss, and time spent at the outpatient facility.
Results:
Over a 3-year period, 145 outpatient THAs were done in 125 patients; 73 were considered to be initial procedures, and 72 were considered to be later procedures. Only one of the 145 procedures (0.7%) required transfer from the outpatient facility to the hospital for a blood transfusion. No other direct admissions to the hospital or transfers to the emergency department from the surgery center were necessary. Surgical interventions were required after 3 (2%) of the 145 arthroplasties in the global period (90 days).
Conclusion:
This study demonstrated that same-day discharge to home following THA can be safely done without increased complications, readmissions, reoperations, or emergency room visits.
Importance
Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures.
Objective
To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair.
Design, Setting, and Participants
A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system.
Exposures
A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement.
Main Outcomes and Measures
The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates.
Results
The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients undergoing colorectal resection and 0.67 (95% CI, 0.45-0.99, P = .05) for patients with hip fracture. Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality (0.17; 95% CI, 0.03-0.86; P = .03), whereas among patients with hip fracture, implementation was associated with increased rates of home discharge (1.24; 95% CI, 1.06-1.44; P = .007).
Conclusions and Relevance
Multicenter implementation of an ERAS program among patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair successfully altered processes of care and was associated with significant absolute and relative decreases in hospital length of stay and postoperative complication rates. Rapid, large-scale implementation of a multidisciplinary ERAS program is feasible and effective in improving surgical outcomes.
Background Singapore reported its first case of Severe Acute Respiratory Syndrome (SARS) in early March 2003 and was placed on the World Health Organization's list of SARS-affected countries on March 15, 2003. During the outbreak, Tan Tock Seng Hospital was designated as the national SARS hospital in Singapore to manage all known SARS patients. Stringent infection control measures were introduced to protect healthcare workers and control intrahospital transmission of SARS. Workflow processes for surgery were extensively modified. Methods: The authors describe the development of infection control measures, the conduct of surgical procedures, and the management of high-risk procedures during the SARS outbreak. Results: Forty-one operative procedures, including 15 high-risk procedures (surgical tracheostomy), were performed on SARS-related patients. One hundred twenty-four healthcare workers had direct contact with SARS patients during these procedures. There was no transmission of SARS within the operating room complex. Conclusions: Staff personal protection, patient risk categorization, and reorganization of operating room workflow processes formed the key elements for the containment of SARS transmission. Lessons learned during this outbreak will help in the planning and execution of infection control measures, should another outbreak occur.
In orthopedic surgical procedures, surgical power tools, such as electrocautery, bone saws, reamers, and drills, are commonly used. In laboratory experiments using these tools, it has been demonstrated that inhalable aerosols can be produced. In order to assess the potential exposure of health care workers to these aerosols during orthopedic surgery, it is necessary to characterize the aerosols. In this study, Marple personal cascade impactors (MPCI) and a Quartz Crystal Microbalance (QCM) were used to measure the size distribution of the aerosols, and filter samples were collected to estimate the aerosol mass concentration. A Chemstrip 9 analysis to measure hemoglobin was applied to samples collected at each stage of the MPCIs as well as QCM and filter samples. During ten surgical procedures, including total hip replacements, total knee replacements, a back vertebral fusion, and a hip reconstruction, aerosols were sampled. Aerosol mass concentrations and size distributions varied widely from procedure to procedure and from time to time. Analysis of samples from the MPCIs worn by the surgeons indicated that measurable amounts of aerosols containing hemoglobin-associated particles as indicated by the Chemstrip 9 response were detected for all surgical procedures studied. Comparison between knee operations, in which a tourniquet was applied to reduce or stop the blood flow at the surgical site, and hip replacement operations suggested that irrigation/suction, which was used in all surgical procedures, was one of a key contributor to producing blood-associated aerosols. QCM data indicated that the aerosol mass concentration was highest when the surgical site was opened with the use of a scalpel, electrocautery, and irrigation/ suction. Area filter samples and MPCI samples from personnel other than surgeons occasionally showed trace amounts of hemoglobin-associated particles; this was probably due to splashing during the irrigation/suction procedure. Clean-up of the room after surgery did not appear to re-suspend any blood-associated aerosols. In summary, low concentrations of aerosol particles were produced during orthopedic surgical procedures. The concentration and size distribution of these particles depended on the procedure being performed. Some of these particles contained hemoglobin. However, the existing literature does not provide evidence that the blood-borne pathogens, such as human immunodeficiency virus or hepatitis B virus, have been transferred by inhaling aerosols. Further studies on the amount and viability of pathogens associated with these blood-associated aerosols are required to ascertain the significance of these measurements.
A novel approach to identify at-risk periods among orthopedic surgical residents may direct fatigue risk mitigation and facilitate targeted interventions.
A prospective cohort study with a minimum 2-week continuous assessment period. Data on sleep and awake periods were processed using the sleep, activity, fatigue, and task effectiveness model.
Rotations at 2 academic tertiary care centers.
Twenty-seven of 33 volunteer orthopedic surgical residents (82%) completed the study, representing 65% (33 of 51) of the orthopedic residency program.
Residents' sleep and awake periods were continuously recorded via actigraphy, and a daily questionnaire was used to analyze mental fatigue.
Percentage of time at less than 80% mental effectiveness (correlating with an increased risk of error), percentage of time at less than 70% mental effectiveness (correlating with a blood alcohol level of 0.08%), the mean amount of daily sleep, and the relative risk of medical error compared with chance.
Residents were fatigued during 48% and impaired during 27% of their time awake. Among all residents, the mean amount of daily sleep was 5.3 hours. Overall, residents' fatigue levels were predicted to increase the risk of medical error by 22% compared with well-rested historical control subjects. Night-float residents were more impaired (P = .02), with an increased risk of medical error (P = .045).
Resident fatigue is prevalent, pervasive, and variable. To guide targeted interventions, fatigue modeling can be conducted in hospitals to identify periods, rotations, and individuals at risk of medical error.
In the 2003 severe acute respiratory syndrome outbreak, finding viral nucleic acids on hospital surfaces suggested surfaces could play a role in spread in health care environments. Surface disinfection may interrupt transmission, but few data exist on the effectiveness of health care germicides against coronaviruses on surfaces.
The efficacy of health care germicides against 2 surrogate coronaviruses, mouse hepatitis virus (MHV) and transmissible gastroenteritis virus (TGEV), was tested using the quantitative carrier method on stainless steel surfaces. Germicides were o-phenylphenol/p-tertiary amylphenol) (a phenolic), 70% ethanol, 1:100 sodium hypochlorite, ortho-phthalaldehyde (OPA), instant hand sanitizer (62% ethanol), and hand sanitizing spray (71% ethanol).
After 1-minute contact time, for TGEV, there was a log(10) reduction factor of 3.2 for 70% ethanol, 2.0 for phenolic, 2.3 for OPA, 0.35 for 1:100 hypochlorite, 4.0 for 62% ethanol, and 3.5 for 71% ethanol. For MHV, log(10) reduction factors were 3.9 for 70% ethanol, 1.3 for phenolic, 1.7 for OPA, 0.62 for 1:100 hypochlorite, 2.7 for 62% ethanol, and 2.0 for 71% ethanol.
Only ethanol reduced infectivity of the 2 coronaviruses by >3-log(10) after 1 minute. Germicides must be chosen carefully to ensure they are effective against viruses such as severe acute respiratory syndrome coronavirus.
To determine whether reamed or unreamed intramedullary nailing of femoral fractures results in higher incidence of pulmonary fat embolism, three different methods of intramedullary nailing were compared in sheep. To analyze the presence of bone marrow fat embolism in pulmonary arteries, histological evaluation was undertaken using a quantitative computer-assisted measurement system.
In this experimental model of 27 female Swiss alpine sheep, an osteotomy of the proximal femur was conducted in each animal. Then, the animals were divided into three groups according to the method of treatment: two different reamed intramedullary nailing techniques and an unreamed nailing technique were used. In the first group "ER" (experimental reamer; n=9), the nail was inserted after reaming with an experimental reamer; in the second group "CR" (conventional reamer; n=7), the intramedullary nail was inserted after reaming with the conventional AO-reamer. In the third group "UN" (unreamed; n=8) unreamed nailing was performed. During the operation procedure intramedullary pressure was measured in the distal fragment. After sacrificing the animals, quantitative histological analyses of bone marrow fat embolism in pulmonary arteries were done using osmium tetroxide fixation and staining of the fat.
The measurement of intramedullary pressure showed significantly lower values for reamed nailing than for the unreamed technique. The quantitative histological evaluation of lung vessels concerning bone marrow fat embolism revealed a statistically significant difference between reamed and unreamed insertion of the nail: 7.77%±6.93 (ER) and 6.66%±5.61 (CR) vs. 16.25%±10.05 (UN) (p<0.05) of the assessed lung vessels were filled with fat emboli. However, no difference was found between the traditional and experimental reamer.
Intramedullary nailing after reaming is a safe procedure with low systemic embolisation when compared to the unreamed insertion of the nail.
This study assessed the efficacy of two commonly used gaseous disinfection systems against high concentrations of a resistant viral surrogate in the presence and absence of soiling. MS2 bacteriophage suspensions were dried on to stainless steel carriers and exposed to hydrogen peroxide vapour (HPV) and vapour hydrogen peroxide (VHP) gaseous disinfection systems. The bacteriophages were also suspended and dried in 10% and 50% of horse blood to simulate the virus being present in a spill of blood/bodily fluids in a hospital ward environment. Carriers were removed from the gaseous disinfectant at regular intervals into phosphate-buffered saline, vortexed and assayed using a standard plaque assay. The effectiveness of both the HPV and VHP systems varied with the concentration of the bacteriophage with HPV resulting in a 6log(10) reduction in 10 min at the lowest viral concentration [10(7) plaque-forming units (pfu)/carrier] and requiring 45 min at the highest concentration (10(9) pfu/carrier). For the VHP system a 30 min exposure period was required to achieve a 6log(10) reduction at the lowest concentration and 60-90 min for the highest concentration. The addition of blood to the suspension greatly reduced the effectiveness of both disinfectants. This study demonstrates that the effectiveness of gaseous disinfectants against bacteriophage is a function of the viral concentration as well as the degree of soiling. It highlights the importance of effective cleaning prior to gaseous disinfection especially where high concentration agents are suspended in body fluids to ensure effective decontamination in hospitals.
Bone cement implantation syndrome (BCIS) is poorly understood. It is an important cause of intraoperative mortality and morbidity
in patients undergoing cemented hip arthroplasty and may also be seen in the postoperative period in a milder form causing
hypoxia and confusion. Hip arthroplasty is becoming more common in an ageing population. The older patient may have co-existing
pathologies which can increase the likelihood of developing BCIS. This article reviews the definition, incidence, clinical
features, risk factors, aetiology, pathophysiology, risk reduction, and management of BCIS. It is possible to identify high
risk groups of patients in which avoidable morbidity and mortality may be minimized by surgical selection for uncemented arthroplasty.
Invasive anaesthetic monitoring should be considered during cemented arthroplasty in high risk patients.
A personal sampling study was conducted to assess exposure to blood aerosols in the operating room. The breathing zones of primary and assistant surgeons were monitored using a personal cascade impactor configured with three stages corresponding to effective cut-off aerodynamic diameters of 14.8 microns, 3.5 microns, and 0.52 microns, respectively. Hemastix was used to assess the hemoglobin content of each particle size fraction. The arithmetic mean exposure concentration for primary surgeons (n = 14) was 1.4 micrograms Hb/m3 (range, none detected to 7.4 micrograms Hb/m3), while that for assistant surgeons (n = 12) was 1.8 micrograms Hb/m3 (range, 0.3 to 4.8 micrograms Hb/m3). Hemoglobin was detected in Stage 2 in 26 (90%) of the samples, in Stage 5 in 19 (66%) of the samples, and in Stage 8 in 11 (38%) of the samples. These data show that the mucous membrane lining of the upper respiratory tract and alveolar macrophages in the gas-exchange region are likely to be exposed to aerosolized blood in the operating room. Until further research determines the potential of infected blood aerosols to transmit disease, the authors recommend the proper use of respiratory protection equipment instead of surgical masks because the latter do not offer adequate protection.