Impact of COVID-19 on the practice of orthopaedics and trauma-an epidemiological study of the full pandemic year of a tertiary care centre of New Delhi

Retrospective Analysis of Nosocomial SARS-CoV-2 Infections in Orthopedic and Traumatological Inpatients

SARS-CoV-2 has had a measurable impact on the field of orthopedic and traumatological surgery. To date, scarce data on intramural SARS-CoV-2 infections in orthopedic and traumatological patients have been reported. Therefore, the aim of our study was to investigate the effect of nosocomial SARS-CoV-2 infections in orthopedic and traumatological inpatients regarding symptoms of infection, mortality, duration of hospitalization, and other relevant patient-dependent factors. Patients admitted to hospital for an orthopedic or traumatological indication were screened retrospectively for nosocomial SARS-CoV-2 infections and included in this study. An age-, sex-, and ICD 10-matched control group was assigned and demographic data, clinical symptoms of a SARS-CoV-2 infection as well as mortality, length of hospital stays, time to surgery, pre-existing conditions, LKF-points representing the financial effort, and the Charlson Comorbidity Index were collected. A significantly higher length of stay was observed in the SARS-CoV-2 group (25 days; 4-60; SD 12.5) when compared to the control group (11 days; 2-36; SD 7; p < 0.05). LKF points were significantly higher in the SARS-CoV-2 group (13,939 points vs. 8542 points). No significant difference in mortality could be observed. An infection with SARS-CoV-2 in inpatients significantly increases length of hospital stay and cost of treatment. Although no significant difference in mortality was found, care should be taken to avoid intramural SARS-CoV-2 infections, resulting in prolonged hospitalization, higher costs, and potentially further individual risks.

Impact of COVID-19 on healthcare system in India: A systematic review

Despite an extensive healthcare system in India, the COVID-19 Pandemic created havoc upon the existing Indian healthcare system by disrupting the supply of essential healthcare services to patients. It has also highlighted the significant-quality discrepancies of healthcare facilities between the rural-urban areas and between public and private healthcare providers. The not so advanced healthcare system of India was exposed through the lack of oxygen and essential drugs required for the treatment of COVID-19. Additionally, during the pandemic period there was a drastic decline in seeking non-COVID-19 disease related healthcare services. The objective of this systematic review is to determine whether COVID-19 has impacted the healthcare system in India.

Application of Virtual Reality Systems in Bone Trauma Procedures

Background and Objectives: Bone fractures contribute significantly to the global disease and disability burden and are associated with a high and escalating incidence and tremendous economic consequences. The increasingly challenging climate of orthopaedic training and practice re-echoes the established potential of leveraging computer-based reality technologies to support patient-specific simulations for procedural teaching and surgical precision. Unfortunately, despite the recognised potential of virtual reality technologies in orthopaedic surgery, its adoption and integration, particularly in fracture procedures, have lagged behind other surgical specialities. We aimed to review the available virtual reality systems adapted for orthopaedic trauma procedures. Materials and Methods: We performed an extensive literature search in Medline (PubMed), Science Direct, SpringerLink, and Google Scholar and presented a narrative synthesis of the state of the art on virtual reality systems for bone trauma procedures. Results: We categorised existing simulation modalities into those for fracture fixation techniques, drilling procedures, and prosthetic design and implantation and described the important technical features, as well as their clinical validity and applications. Conclusions: Over the past decade, an increasing number of high- and low-fidelity virtual reality systems for bone trauma procedures have been introduced, demonstrating important benefits with regard to improving procedural teaching and learning, preoperative planning and rehearsal, intraoperative precision and efficiency, and postoperative outcomes. However, further technical developments in line with industry benchmarks and metrics are needed in addition to more standardised and rigorous clinical validation.

Association of COVID-19 Lockdown With Increased Rate of Cyclops Syndrome in Patients With Unexpected Home-Based Self-Guided Rehabilitation After ACL Reconstruction

Background

The risk of cyclops syndrome increases significantly after anterior cruciate ligament (ACL) reconstruction (ACLR) if complete extension is not recovered before the sixth postoperative week. The lockdown in France due to the COVID-19 pandemic led to an absence of supervised rehabilitation, requiring unexpected self-rehabilitation in patients who underwent ACLR just before lockdown.

Purpose

To determine the rate of cyclops syndrome after ACLR in patients who underwent self-rehabilitation during lockdown.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 75 patients receiving a hamstring graft for ACLR during the COVID-19 pandemic between February 10, 2022, and March 16, 2020, carried out self-rehabilitation during part of their first 6 postoperative weeks using exercise videos on a dedicated website. Clinical examination was performed at a minimum 1-year follow-up with International Knee Documentation Committee (IKDC), Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI) scores. This group was compared with a matched-pair control group of 72 patients who underwent surgery in 2019 and completed postoperative supervised rehabilitation with a physical therapist. Rates and reasons for second surgery (arthrolysis, meniscal procedure) were also recorded.

Results

In the COVID group (n = 72; 3 patients were lost to follow-up), the mean follow-up was 14.5 ± 2.1 months (range, 13-21) and rate of reoperation for clinical cyclops syndrome was 11.1% (n = 8). The rate of cyclops syndrome was significantly lower (1.4%) in the control group (P = .01). In the COVID group, 8 patients underwent anterior arthrolysis at a mean of 8.6 months after the primary surgery, and 4 patients underwent another surgical intervention (meniscal procedure [n = 3], device removal [n = 1]). In the COVID group, mean Lysholm was 86.6 ± 14.1 (range, 38-100), Tegner was 5.6 ± 2.3 (range, 1-10), subjective IKDC was 80.3 ± 14.7 (range, 32-100) and ACL-RSI score was 77.3 ± 19.7 (range, 33-100).

Conclusion

The rate of cyclops syndrome after ACLR was significantly greater in the COVID group versus the matched controls. The dedicated website was not effective at supporting self-guided rehabilitation and could benefit from interactive improvements so it is at least as effective as supervised rehabilitation.

Lockdown imposition due to COVID-19 and its effect on orthopedic emergency department in level 1 trauma center in South Asia

BACKGROUND

The coronavirus pandemic brought the entire world to a standstill. One of the most stringent lockdowns in the world was implemented in India. With the entire healthcare system being stretched, emergency orthopaedic services also take a hit. We studied the trends in patient presentation, testing, management, and restructuring of doctors at a tertiary care orthopaedic centre and compared them with the data from the same time period the previous year (2019).

METHOD

Data was collected separately for all the 5 different phases of lockdown and unlock, as well as for the same duration of months in 2019, and was analysed for epidemiological trends.

RESULTS

A rapid fall in the total number of cases was seen during the lockdown, followed by a skewed rise during the unlock. Forearm, wrist, and hip fractures were the most common fractures. Once nucleic acid testing of all patients intended to be admitted was started, a steep rise in coronavirus positivity was seen. There was a reduction in the total number of cases compared to 2019, but it was not as significant as would have been expected due to the complete standstill of activity during the lockdown.

CONCLUSION

During a pandemic, with the healthcare system under a crisis of workforce and infrastructure, there needs to be a separate task force for catering to orthopaedic emergencies since all fractures cannot be managed conservatively and the numbers of trauma-related patients did not show a stark fall as compared to normal months of last year.

LEVEL OF EVIDENCE

Level 3 Retrospective Case Series.

Emergency trauma care during the COVID-19 pandemic: A phenomenological study of nurses’ experiences

Objective

This study aimed to explore nurses’ experiences in delivering emergency trauma care during the COVID-19 pandemic at a level I trauma centre in Saudi Arabia.

Methods

A qualitative, descriptive phenomenological design was utilised, in which face-to-face, unstructured interviews were carried out with emergency and trauma nurses at a level I trauma centre in Saudi Arabia. The study included nine registered emergency and trauma nurses who were interviewed twice from February to April 2021. The collected data were analysed using Colaizzi’s descriptive phenomenological method.

Results

The analysis of the data revealed an overarching theme that was about the inevitable change on the ground due to the pandemic and two primary themes, each containing two subthemes: 1 dealing with an interrupted path of care; 1.1 experiencing additional complexity; 1.2 encountering extra demands; 2 optimising the path of care; 2.1 modifying the steps; and 2.2 transforming the system.

Conclusion

The COVID-19 pandemic imposed change on how trauma patients would be handled and treated. Nurses took an active and critical role in creating another form of change, which helped optimise the path of trauma care and accommodate urgent treatment needs of the injured patients.

Decreases in pediatric fractures during the COVID-19 pandemic - a nationwide epidemiological cohort study

The COVID-19 pandemic led to fundamental changes in daily routines of children. Our aim was to evaluate the incidence and characteristics of fractures among Israeli children during 2020 compared with 2015-2019. Demographic, clinical data, and incidence rates of fractures in individuals aged < 18 years were derived from the electronic database of Meuhedet Health Services, which provides healthcare services to 1.2 million people in Israel. We further subdivided the year to five periods according to government regulations of lockdown and isolation at each period. Fracture sites were determined according to ICD9 definitions. During 2020, 10,701 fractures occurred compared with 12,574 ± 599 fractures per year during 2015-2019 (p-value < 0.001). Fracture rates were lower during all periods in 2020. The largest decline was observed during the first lockdown for both boys (56% decline, 95% confidence interval [CI] 52-60%) and girls (47% decline CI 41-53%). While the fracture rate declined for most age groups, the largest decline was recorded for the age group 11-14 years, with significant reduction rates of 66% (CI 59-71%) for boys and 65% (CI 54-73%) for girls. The most prominent declines were of fractures of the hand bones of both boys and girls (64% and 59%, respectively). Conclusions: Our data showed a significant decrease in fracture rate in 2020 compared to the previous 5 years, as well as differences between periods within that year. What is New: •The COVID-19 pandemic led to fundamental change in daily routines of children with significant decrease in school attendance and sport activities. •Consequent to these public health measures, the incidence rate of pediatric fractures decreased significantly. What is New: •This study demonstrates declines in fracture rates during lockdown periods, with only partial reversing of the trends between the lockdown periods. •The most pronounced decline was observed during the first lockdown period. •The decline was most prominent in children aged 11-14 years; there was no significant change in fracture incidence of children aged <3 years.

Bibliometric analysis of COVID-19 related publications in Indian orthopaedic journals

BACKGROUND

The COVID-19 pandemic has resulted in an infodemic about the novel coronavirus SARS-CoV-2 outbreak to build knowledge and develop mitigation strategies. In addition, scientific journals across the world have studied the impact of COVID-19 on trauma and orthopaedics.

METHODS

A cross-sectional, bibliometric analysis of the literature was undertaken on COVID-19 related articles from three Pubmed and Scopus indexed orthopaedic journals from India, namely, Indian Journal of Orthopaedics(IJO),Journal of Clinical Orthopaedics and Trauma(JCOT), and Journal of Orthopaedics (JOO), in May 2021. All the article types and study designs were included for this review. The authors, institutions, countries, keywords, and co-authorship mapping were studied.

RESULTS

A total of 112 COVID-19 related documents were retrieved. Period of these publications was from 2^nd April 2020 to 31^st May 2021. Vaishya R. (n = 16) was the most cited author, and Indraprastha Apollo Hospitals (n = 16) was the most cited research Institution. India led the list of countries in academic publication output. On keyword mapping, telemedicine was the most prominent Medical Subject Headings (MeSH) search word.

CONCLUSION

The Indian orthopedic journals have addressed the impact of COVID-19 on orthopaedic practice in India and aborad whilst continuing to publish knowledge about basic science and clinical orthopaedic research studies. The JCOT has outperformed and become the most leading orthopaedic journal from India during the pandemic. COVID -19 articles have been fast tracked, open accessed and attracted more citations in reduced duration of time compared to non-COVID-19 papers.

Pooling of neglected and delayed trauma patients - Consequences of 'lockdown' and 'Unlock' phases of COVID-19 pandemic- A retrospective cohort analysis from a tertiary centre

BACKGROUND

The COVID-19 pandemic resulted in nationwide lockdown and quarantine strategies to break the chain of transmission of the SARS-CoV-2 virus in India. Management of patients with trauma has been particularly challenging across the country.

AIMS

To evaluate the effect of delay in surgery in patients with traumatic injuries along with the peri-operative outcomes during the 'Lockdown' and 'Unlock' phases of the COVID-19 pandemic at a Level I Trauma centre in the National Capital Region (NCR) of India.

METHODS

This retrospective, observational cohort study included 488 patients. Comparative analysis to assess patient characteristics, mechanism of trauma, clinical outcomes in patients managed operatively during 'Lockdown period' (24 March 2020 to 31 May 2020) Group A with Group B, who presented during 'Unlock phases' (01 June 2020 to 31 December 2020).

RESULTS

The average delay in surgery, surgical time and hospital stay was significantly increased in group B patients (p-value <0.05). The average blood loss, stay in the Intensive Care Unit (ICU) and blood transfusion requirement were clinically higher in group B but these differences were not statistically significant (p-value >0.05). Only in group B; 9.01% patients (42 out of 466) required bone grafting.

CONCLUSION

'Neglect' and delay in receiving operative management of orthopaedic trauma has led to unprecedented rise in number of complications of fractures, such as mal-union, delayed union or non-union during COVID-19 Pandemic. Patients have had to undergo longer surgical procedures with increased risk of intra-operative blood loss, need of peri-operative blood transfusion and bone grafting supplementation to facilitate union. Diligent attention to achieve the most optimal configuration of fractures should be planned in conservatively managed injuries during the pandemic to minimize future intra-operative difficulties.

A One-year COVID-19 Pandemic Effect on the Orthopaedic Field in Indonesia: A Cross-sectional Multi-center Study

BACKGROUND: The World Health Organization announced the COVID-19 outbreak as a global pandemic on March 11, 2020. Despite the fact that orthopedists are not considered front-line staff in the fight against the pandemic, the pandemic has had an enormous impact on orthopedics daily practice. A few studies have looked at the pandemic effect on the orthopedics field, but none have looked at the impact of a 1-year pandemic, especially in Indonesia. MATERIALS AND METHODS: This cross-sectional multi-center study was conducted at seven tertiary referral hospitals in Indonesia. Through hospital medical records, data were collected for a year, starting from the month the Indonesian government announced the first case of COVID-19 (March 2020–February 2021) and compared to data from the year before COVID-19 as a control (March 2019–February 2020). In addition, the researchers analyzed the number of patients in the emergency room (ER), outpatient clinic, inpatient, and operating room. RESULTS: Overall, the number of orthopedic patients in the ER declined by 44% from 11.053 to 6.139 patients during the 1st year of the pandemic, with 28 patients reported as getting COVID-19. The outpatient clinic decreased by 34%, from 10.9780 to 72.200 patients, with two confirmed cases. Furthermore, the inpatient unit decreased from 15.365 to 9.526 patients, a 38% decrease, with the highest recorded case confirmed at 78 patients. The last, with 73 confirmed, showed a 27% reduction in OR from 12.954 to 9.431 patients. CONCLUSION: In this study, analysis on the effect of the COVID-19 pandemic on the field of orthopedics in seven tertiary referral hospitals in Indonesia shows a significant decrease almost in all units. LEVEL EVIDENCE: III, Cross-sectional multi-center study.

Impact of the COVID-19 Outbreak on Orthopedic Surgery: A Nationwide Analysis of the First Pandemic Year

Purpose

To analyze the impact of the coronavirus disease 2019 (COVID-19) outbreak during the first pandemic year in a single country.

Methods

A cross-sectional study was designed. The free access database of the Chilean Department of Statistics and Health Information (DEIS) was used to compare the number of orthopedic procedures between 2019 and 2020. Country mobility was exported from the Institute of Complex Engineering Systems (ISCI) free-access database; this corresponds to a direct measurement of the degree of confinement of the country. Spearman correlation (rho) was used to analyze the total monthly COVID infection trend and mobility to orthopedics procedures.

Results

The number of orthopedic surgeries fell by 22.8% during the first year of the pandemic. All surgical procedures were adversely affected, with the fracture/trauma surgeries being the least affected. The maximum adverse impact was seen in knee arthroplasty (-64%), followed by hip arthroplasty (-41%) and knee ligament reconstruction (-44%). The number of orthopedic procedures had a mild correlation to the monthly number of COVID-19 cases (rho=-0.53, p=0.08) and a strong correlation with the country's mobility (rho=0.94, p=0.0001).

Conclusions

The COVID-19 outbreak diminished the number of orthopedic procedures during 2020, and the impact was directly correlated to the country's mobility. The public health network did have a more significant adverse impact in elective surgeries due to a slower recovery than private institutions. An increase in the waiting list should be expected, which will widen the difference in access to orthopedic surgery in Chile.

Has the time to reinstate elective orthopedic procedures come?

BACKGROUND

The coronavirus pandemic changed how we manage and operate patients in orthopaedic practice. Although elective orthopaedic procedures were halted to prevent spread of the disease as well as sustain supplies of essential protective equipment and healthcare workers, trauma services were continued. We studied the orthopaedic trauma cases operated over 6 months of the pandemic, and discuss the protocols used to minimize disease spread.

METHODS

Data was collected for all orthopaedic emergency cases operated at our centre from 1 st March - 10 th August 2020. During this time specific protocols were used for first aid, pre-operative care, inside the operation theatre, post-operative stay as well as for follow ups.

RESULTS

A total of 851 patients were operated. A sharp decline in surgeries was seen during the lockdown. Average stay in the hospital was 4 days. Only 44% of the patients came for follow-up visits. None of the contacted patients or their relatives developed symptoms or tested positive for COVID after discharge.

CONCLUSION

Multiple waves and various mutant strains of COVID-19 have made this pandemic longer than expected. Elective orthopaedic cases cannot be ignored for forever, as it leads to poor quality of life and an increasing burden of such patients. We suggest, that using the protocols used at our centre, we have successfully operated on cases without risking spread of the virus. Thus, we believe it's time to reinstate elective orthopaedic procedures, in a phased manner.

Is performing joint arthroplasty surgery during the COVID-19 pandemic safe?: A retrospective, cohort analysis from a tertiary centre in NCR, Delhi, India

PURPOSE

Resuming joint replacement arthroplasty amidst the COVID-19 pandemic and lockdown has come with various challenges that had to be dealt with utmost caution. Patients with severe arthritis experiencing a state of intolerable pain, could not be left unaddressed. Guidelines published by surgical associations, collaborative surgical author groups including public health organisations had to be modified to suit the Indian scenario and obtain optimal functional outcomes in these patients.

METHODS

A retrospective cohort analysis of 147 patients who underwent arthroplasty during the pandemic (March 2020 to April 2021), for either primary or secondary arthritis, was performed. We assess the efficacy and safety of the newly established Institutional surgical peri-operative protocol at our tertiary care centre in the National Capital Region, India in response to COVID-19 guidelines. The primary outcome measures appraised was 30-day mortality and the secondary outcome measures included length of stay, peri-operative complications and COVID-19 infection.

RESULT

The most common indication for arthroplasty during the pandemic was neglected trauma. One patient died, due to myocardial infarction during the follow-up period. About 67% of patients were discharged to their usual residence within 7 days of admission. Two patients tested positive for COVID-19 postoperatively, but none required Intensive Care Unit admission.

CONCLUSION

Joint replacement arthroplasty can be undertaken safely with diligent patient selection, application of a stringent COVID appropriate behaviour and a 'ring-fenced' peri-operative pathway.

Resilience Against COVID-19: How Italy Faced the Pandemic in Pediatric Orthopedics and Traumatology

Background: We aimed to investigate the variation of medical and surgical activities in pediatric orthopedics in Italy, during the year of the COVID-19 pandemic, in comparison with data from the previous two years. The differences among the first wave, phase 2 and second wave were also analyzed. Methods: We conducted a retrospective multicenter study regarding the clinical and surgical activities in pediatric orthopedics during the pandemic and pre-pandemic period. The hospital databases of seven tertiary referral centers for pediatric orthopedics and traumatology were queried for events regarding pediatric orthopedic patients from 1 March 2018 to 28 February 2021. Surgical procedures were classified according to the “SITOP Priority Panel”. An additional classification in “high-priority” and “low-priority” surgery was also applied. Results: Overall, in 2020, we observed a significant drop in surgical volumes compared to the previous two years. The decrease was different across the different classes of priority, with “high-priority” surgery being less influenced. The decrease in emergency department visits was almost three-fold greater than the decrease in trauma surgery. During the second wave, a lower decline in surgical interventions and a noticeable resumption of “low-priority” surgery and outpatient visits were observed. Conclusion: Our study represents the first nationwide survey quantifying the impact of the COVID-19 pandemic on pediatric orthopedics and traumatology during the first and second wave.