Minimising aerosol generation during orthopaedic surgical procedures- Current practice to protect theatre staff during Covid-19 pandemic

Three Years of COVID-19 on Orthopaedic Trauma; Are We Going Back to Normality?

Background and Objective: On March 2020, our country became a protected area due to the COVID-19 pandemic. The consequences of COVID-19 on trauma surgery were great. We aimed to evaluate the activity of the Trauma Centre of a highly populated suburban area over 30 days starting from the first day of restrictions, to compare it with the same period of 2019 and 2022 and to evaluate whether a progressive return to normality has taken place. Materials and Methods: All patients older than 18 years managed in our Trauma Unit between 8 March 2020 and 8 April 2020 (the first COVID-19 period) were compared to the same period of 2019 (a COVID-19 free period) and 2022 (the second COVID-19 period). Clinical records were examined. Five categories of diagnoses and six mechanisms of injury were distinguished. Results: There were 1351 patients [M:719-F:632; mean age (SD):49.9 (18.7)], 451 [M:228-F:223; mean age (SD):55.9 (18.4)] and 894 [M:423-F:471;mean age (SD):54.1 (16.7)] in the COVID-19 free and in the first and second COVID-19 periods, respectively (p < 0.05). In 2020, the most significant decrease was registered for sprains/subluxations (80%); contusions decrease by 77% while fractures decrease only by 37%. The lowest reduction was found for dislocations (26%). In 2022, dislocations decreased by only 16% and both fractures and sprains decreased by about 30% with respect to the pre-pandemic period. Patients with minor trauma (contusions) were half compared to 2019. Accidental falls remain the most frequent mechanism of injury. The incidence of proximal femur, proximal humerus and distal radius fractures remained almost unchanged during both pre-pandemic and pandemic periods. Conclusions: COVID-19 has markedly altered orthopaedic trauma. Injuries related to sports and high energy trauma/traffic accidents drastically reduced in 2020; however, we are slowly going back to normality: the same injuries increased in 2022 due to the progressive easing of restrictions. Elderly fractures related to accidental falls remained unchanged.

Spinal fusion is an aerosol generating procedure

BACKGROUND

Transmission of severe acute respiratory syndrome coronavirus 2 can occur during aerosol generating procedures. Several steps in spinal fusion may aerosolize blood but little data exists to quantify the risk this may confer upon surgeons. Aerosolized particles containing infectious coronavirus are typically 0.5-8.0 μm.

AIM

To measure the generation of aerosols during spinal fusion using a handheld optical particle sizer (OPS).

METHODS

We quantified airborne particle counts during five posterior spinal instrumentation and fusions (9/22/2020-10/15/2020) using an OPS near the surgical field. Data were analyzed by 3 particle size groups: 0.3-0.5 μm/m³, 1.0-5.0 μm/m³, and 10.0 μm/m³. We used hierarchical logistic regression to model the odds of a spike in aerosolized particle counts based on the step in progress. A spike was defined as a > 3 standard deviation increase from average baseline levels.

RESULTS

Upon univariate analysis, bovie (P < 0.0001), high speed pneumatic burring (P = 0.009), and ultrasonic bone scalpel (P = 0.002) were associated with increased 0.3-0.5 μm/m³ particle counts relative to baseline. Bovie (P < 0.0001) and burring (P < 0.0001) were also associated with increased 1-5 μm/m³ and 10 μm/m³ particle counts. Pedicle drilling was not associated with increased particle counts in any of the size ranges measured. Our logistic regression model demonstrated that bovie (OR = 10.2, P < 0.001), burring (OR = 10.9, P < 0.001), and bone scalpel (OR = 5.9, P < 0.001) had higher odds of a spike in 0.3-0.5 μm/m³ particle counts. Bovie (OR = 2.6, P < 0.001), burring (OR = 5.8, P < 0.001), and bone scalpel (OR = 4.3, P = 0.005) had higher odds of a spike in 1-5 μm/m³ particle counts. Bovie (OR = 0.3, P < 0.001) and drilling (OR = 0.2, P = 0.011) had significantly lower odds of a spike in 10 μm/m³ particle counts relative to baseline.

CONCLUSION

Several steps in spinal fusion are associated with increased airborne particle counts in the aerosol size range. Further research is warranted to determine if such particles have the potential to contain infectious viruses. Previous research has shown that electrocautery smoke may be an inhalation hazard for surgeons but here we show that usage of the bone scalpel and high-speed burr also have the potential to aerosolize blood.

Detection of SARS-CoV-2 in Cancellous Bone of Patients with COVID-19 Disease Undergoing Orthopedic Surgery: Laboratory Findings and Clinical Applications

An emerging issue for orthopedic surgeons is how to manage patients with active or previous COVID-19 disease, avoiding any major risks for the surgeons and the O.R. personnel. This monocentric prospective observational study aims to assess the prevalence of SARS-CoV-2 viral RT-PCR RNA in cancellous bone samples in patients with active or previous COVID-19 disease. We collected data about 30 consecutive patients from our institution from January 2021 to March 2021 with active or previous COVID-19 disease. The presence of SARS-CoV-2 in the samples was determined using two different PCR-based assays. Eighteen of the thirty patients included in the study had a positive nasopharyngeal swab at the time of surgery. Twelve patients had a negative nasopharyngeal swab with a mean days since negativization of 138 ± 104 days, ranging from 23 to 331 days. Mean days of positivity to the nasal swab were 17 ± 17. Twenty-nine out of thirty (96.7%) samples were negative for the presence of SARS-CoV-2 RNA. In one sample, low SARS-CoV-2 load (Cycle threshold (Ct) 36.6.) was detected but not confirmed using an additional confirmatory assay. The conducted study demonstrates the absence of the viral genome within the analyzed cancellous bone. We think that the use of personal protection equipment (PPE) to only protect from aerosol produced during surgery, both in active and recovered patients, is not strictly necessary. We think that the use of PPE should not be employed by surgeons and the O.R. personnel to protect themselves from aerosols produced from the respiratory tract. Moreover, we think that our results could represent a valid basis for further studies related to the possibility of bone donation in patients that suffered and recovered from COVID-19.

Characteristics and clinical outcomes of hip fracture patients during the first lockdown of COVID-19, lessons learnt: A retrospective cohort analysis

BACKGROUND

The management of hip fracture patients has been challenging across the UK in the wake of emergency coronavirus disease 2019 guidelines.

AIMS

This retrospective, observational cohort study analyses the impact of the first lockdown during the early part of the coronavirus disease 2019 pandemic on the management of hip fracture patients at a district general hospital in the UK.

METHODS

Comparative analysis to assess hip fracture patients treated at this Trust between 1 April to 31 May 2019 and 1 April to 31 May 2020 was undertaken. The primary outcome measures appraised were 30 and 60-day mortality and the secondary outcome measure included time to surgery.

RESULTS

There was a higher 30 and 60-day mortality rate in the first lockdown period at 8.1% and 13.5%, respectively, compared to 1.96% and 5.88% in 2019. A significantly lower proportion of hip fracture patients at 59.46% were operated within the 36h target time frame during the first lockdown.

CONCLUSION

In our Trust, hip fractures were treated as obligatory injuries. However, the mortality was higher in the 2020 cohort with a significant reduction in patients achieving the recommended '36 hours' time to surgery target and accruement of Best Practice Tariff. Enhanced infection control strategies have prepared us for the future.

Reconstructive Microsurgery in the COVID-19 Environment

The COVID-19 pandemic has presented unique challenges to the plastic surgery field. Substantial changes have been incorporated in hospital and practice protocols in all branches of medicine. Organic medical teams were placed on scheduled shifts to prevent cross-infection, and some working teams were discontinued. Remote technology consultations and deliberations were instituted in hospitals and community medical services to maintain the flow of information on patient status. Several mitigation strategies were implemented during these times throughout medical facilities. We present those implemented in our facility to ensure adequate labor, resources, and facilities along with proper protocols for patient selection and management according to predetermined risk assessment criteria with the hope to assist the healthcare staff to minimize mortality risks.

Bioaerosols in orthopedic surgical procedures and implications for clinical practice in the times of COVID-19: A systematic review and meta-analysis

INTRODUCTION

Orthopedic surgical procedures (OSPs) are known to generate bioaerosols, which could result in transmission of infectious diseases. Hence, this review was undertaken to analyse the available evidence on bioaerosols in OSPs, and their significance in COVID-19 transmission.

METHODS

A systematic review was conducted by searching the PubMed, EMBASE, Scopus, Cochrane Library, medRxiv, bioRxiv and Lancet preprint databases for studies on bioaerosols in OSPs. Random-effects metanalysis was conducted to determine pooled estimates of key bioaerosol characteristics. Risk of bias was assessed by the RoB-SPEO tool; overall strength of evidence was assessed by the GRADE approach.

RESULTS

17 studies were included in the systematic review, and 6 in different sets of meta-analyses. The pooled estimate of particle density was 390.74 μg/m3, Total Particle Count, 6.08 × 106/m3, and Microbial Air Contamination, 8.08 CFU/m3. Small sized particles (

CONCLUSION

Whereas there is evidence to suggest that OSPs generate large amounts of bioaerosols, their potential to transmit infectious diseases like COVID-19 is questionable. High-quality research, as well as consensus minimum reporting guidelines for bioaerosol research in OSPs is the need of the hour.

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Key Words

• Aerosol
• Aerosol generating procedure (AGP)
• COVID19
• Coronavirus
• Guideline
• Orthopaedics surgical procedures
• Personal protective equipment (PPE)
• Review
• SARS

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MESH Headings Collapse

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Affiliation(s)

Siddhartha Sharma Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
Rakesh John Department of Orthopaedics, Hull and Yorkshire Royal Infirmary, Hull, United Kingdom
Sandeep Patel Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
Deepak Neradi Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
Kamal Kishore Department of Biostatistics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
Mandeep S. Dhillon Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India

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The MeNT-OS Score for Orthopaedic Surgery: An Objective Scoring System for Prioritisation of Orthopaedic Elective Surgeries During a Pandemic

INTRODUCTION

The reintroduction of elective Orthopaedic surgery during the COVID-19 pandemic is likely to occur in phases, dictated by resource limitations and loco-regional pandemic status. Guidelines providing a general framework for the prioritisation of surgery have largely been based on surgical urgency, while scoring systems such as the MeNTS score may have limited applicability in the setting of Orthopaedic Surgery. We, therefore, propose an Orthopaedic-specific algorithm ('MeNT-OS'), based on a modification of the MeNTS scoring system, that may be used to objectively triage and prioritise Orthopaedic cases during the COVID-19 pandemic.

METHODS

We developed a scoring algorithm modified from the Medically Necessary Time-Sensitive Procedure (MeNTS) score with 13 unique variables, reflecting human and physical resource utilisation, surgical complexity, functional status of patients, as well as COVID-19 transmission risk. This score was then trialled in a sample of 118 cases, comprising 69 completed and 49 postponed cases. A higher overall score was intended to correlate with lower surgical prioritisation.

RESULTS

The use of our scoring system resulted in higher average scores for postponed cases compared to completed cases, as well as higher median, 25th and 75th percentile scores. These results were statistically significant and showed concordance with the ad hoc decisions made before the scoring system was used, with the lower scores for completed cases suggesting a more favourable risk-benefit ratio for being performed as compared to the postponed cases.

CONCLUSION

The utility of the proposed 'MeNT-OS' scoring system has been assessed using data from our institution and offers an objective and systematic approach that is geared towards Orthopaedic procedures. We believe this scoring tool can provide Orthopaedic surgeons a safe and equitable approach to making difficult decisions on prioritisation of surgery during the COVID-19 period, and possibly other resource-limited settings in the future.

Planning and analysing 'Green' post-COVID-19 orthopaedic perioperative recovery pathway

The effect of the severe acute respiratory syndrome coronavirus 2 pandemic on the National Health Service in the United Kingdom has been profound and unprecedented with suspension of most elective surgeries. As we are emerging from lockdown now, restarting elective surgical procedures in a safe and effective manner is an expected challenge. Many perioperative factors including patient prioritisation, risk assessment, health infrastructure and infection prevention strategies need to be considered for patient safety. The British Orthopaedic Association, along with the National Health Service, have provided recent guidelines for restarting non-urgent and orthopaedic care in the United Kingdom. In this article we review the current guidelines and literature to provide some clarity for clinical practice.

The effect of the COVID-19 pandemic on mental health associated trauma, admissions and fractures at a London major trauma centre

INTRODUCTION

Non-injury-related factors have been extensively studied in major trauma and have been shown to have a significant impact on patient outcomes. Mental illness and associated medication use has been proven to have a negative effect on bone health and fracture healing.

MATERIALS AND METHODS

We collated data retrospectively from the records of orthopaedic inpatients in a non-COVID and COVID period. We analysed demographic data, referral and admission numbers, orthopaedic injuries, surgery performed and patient comorbidities, including psychiatric history.

RESULTS

There were 824 orthopaedic referrals and 358 admissions (six/day) in the non-COVID period, with 38/358 (10.6%) admissions having a psychiatric diagnosis and 30/358 (8.4%) also having a fracture. This was compared with 473 referrals and 195 admissions (three/day) in the COVID period, with 73/195 (37.4%) admissions having a documented psychiatric diagnosis and 47/195 (24.1%) having a fracture.

DISCUSSION

There was a reduction in the number of admissions and referrals during the pandemic, but a simultaneous three-fold rise in admissions with a psychiatric diagnosis. The proportion of patients with both a fracture and a psychiatric diagnosis more than doubled and the number of patients presenting due to a traumatic suicide attempt almost tripled.

CONCLUSION

While total numbers using the orthopaedic service decreased, the impact of the pandemic and lockdown disproportionately affects those with mental health problems, a group already at higher risk of poorer functional outcomes and non-union. It is imperative that adequate support is in place for patients with vulnerable mental health during these periods, particularly as we look towards a potential 'second wave' of COVID-19.

Clinical Performance of the Point-of-Care cobas Liat for Detection of SARS-CoV-2 in 20 Minutes: a Multicenter Study

Highly accurate testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at the point of care (POC) is an unmet diagnostic need in emergency care and time-sensitive outpatient care settings. Reverse transcription-PCR (RT-PCR) technology is the gold standard for SARS-CoV-2 diagnostics.

Highly accurate testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at the point of care (POC) is an unmet diagnostic need in emergency care and time-sensitive outpatient care settings. Reverse transcription-PCR (RT-PCR) technology is the gold standard for SARS-CoV-2 diagnostics. We performed a multisite U.S. study comparing the clinical performance of the first U.S. Food and Drug Administration (FDA)-authorized POC RT-PCR for detection of SARS-CoV-2 in 20 min, the cobas Liat SARS-CoV-2 and influenza A/B nucleic acid test, to the most widely used RT-PCR laboratory test, the cobas 68/8800 SARS-CoV-2 test. Clinical nasopharyngeal swab specimens from 444 patients with 357 evaluable specimens at five U.S. clinical laboratories were enrolled from 21 September 2020 to 23 October 2020. The overall agreement between the Liat and 68/8800 systems for SARS-CoV-2 diagnostics was 98.6% (352/357). Using Liat, positive percent agreement for SARS-CoV-2 was 100% (162/162) and the negative percent agreement was 97.4% (190/195). The Liat is an RT-PCR POC test that provides highly accurate SARS-CoV-2 results in 20 min with performance equivalent to that of high-throughput laboratory molecular testing. Rapid RT-PCR testing at the POC can enable more timely infection control and individual care decisions for coronavirus disease 2019.

Total Joint Arthroplasty During the COVID-19 Pandemic: A Scoping Review with Implications for Future Practice

Background

Recent studies have examined the impact of the COVID-19 pandemic on the practice of total joint arthroplasty. A scoping review of the literature with compiled recommendations is a useful tool for arthroplasty surgeons as they resume their orthopedic practices during the pandemic.

Methods

In June 2020, PubMed, Embase (Ovid), Cochrane Library (Wiley), Scopus, LitCovid, CINAHL, medRxiv, and bioRxiv were queried for articles using controlled vocabulary and keywords pertaining to COVID-19 and total joint arthroplasty. Studies were characterized by their region of origin, design, and Center of Evidence Based Medicine level of evidence. The identified relevant studies were grouped into 6 categories: changes to future clinical workflow, education, impact on patients, impact on surgeons, technology, and surgical volume.

Results

The COVID-19 pandemic has had a significant impact on arthroplasty practice, including the disruption of the clinical teaching environment, personal and financial consequences for patients and physicians, and the drastic reduction in surgical volume. New pathways for clinical workflow have emerged, along with novel technologies with applications for both patients and trainees.

Conclusions

The COVID-19 pandemic emphasizes the recent trend in arthroplasty toward risk stratification and outpatient surgery, which may result in improved clinical outcomes and significant cost-savings. Furthermore, virtual technologies are a promising area of future focus that may ultimately improve upon previous existing inefficiencies in the education and clinical environments.

Impact of the COVID-19 lockdown on the epidemiology of maxillofacial trauma activity: a French multicentre comparative study

The coronavirus disease 2019 (COVID-19) outbreak has had a major impact on medical and surgical activities. A decline in facial trauma incidence was noticed during the lockdown period. The aim of this study was to evaluate the decline in maxillofacial trauma in France during this particular period. A retrospective multicentre comparative study was initiated in 13 major French public hospital centres. The incidence of facial trauma requiring surgery during the first month of lockdown was compared to that during equivalent periods in 2018 and 2019. Differences in the types of trauma were also analysed. Thirteen maxillofacial departments participated in the study. A significant decline in maxillofacial trauma volumes was observed when compared to equivalent periods in 2018 and 2019 (106 patients compared to 318 and 296 patients, respectively), with an average reduction of 65.5% (P = 0.00087). The proportion of trauma due to sports and leisure was reduced when compared to reports in the literature. As a consequence, in the context of a pandemic, the material and human resources related to this activity could be reallocated to the management of other pathologies that cannot be postponed.

Management of Orthopaedic Accidental Emergencies Amidst COVID-19 Pandemic: Our Experience in Preparing to Live with Corona

INTRODUCTION

With increasing prevalence of coronavirus cases (including among health care providers), the current advice for orthopaedic surgeons is to favor non-operative management of most injuries and reduce face-to-face follow-up. We present our experience in managing the patients at Government-run non-COVID-19 trauma center in Delhi in an algorithmic form. Our standard operating protocols were mainly based on recommendations of Indian Orthopaedic Association and targeted to provide healthcare at a minimum risk to the treating team as well as other patients admitted to the hospital.

METHODOLOGY

We describe the inflow, in-hospital management and outflow of patients at our facility during the lockdown period and in the following unlock period (from 23 March to 8 July 2020). Those patients who had absolute indications for surgery were offered surgery, while conservative treatment was more favored in those with relative indications. We also highlight the changes incorporated in OT settings as well as in rehabilitative and follow-up period.

RESULTS

Following the described protocol helped us maintain a balance between the safety of patients and our front line workers which was evident by very low COVID-19-positive rate in admitted patients (4.22%) and health care providers (16.67%) in the above-mentioned time period.

CONCLUSIONS

We need to be prepared to cohabitate with this deadly Novel Coronavirus and adapt our surgical practices according to the need of the hour by minimizing surgical indications and strengthening the training in conservative principles.

In vitro evaluation of ultrafast laser drilling large-size holes on sheepshank bone

Bone drilling has been widely used in medical surgeries such as repair and fixation in orthopedics. Traditional drilling method using drill-bits inevitably causes significant thermal and mechanical trauma in the adjacent bone tissues. This paper demonstrates the feasibility of femtosecond laser drilling in vitro large-size holes on the sheepshank bone with high efficiency and minimal collateral damage. A Yb:KGW femtosecond laser was utilized to drill millimeter-scale holes on the bone under different cooling conditions including gas- and water-assisted processes. Scanning electron microscopy, confocal laser scanning microscopy and infrared thermographic imaging system were used to investigate the residual debris, removal rate, bone temperature variation and hole morphology. Histological examination, Fourier transform infrared spectroscopy and Raman spectroscopy were employed to study thermal damage. Results show that a 4 mm hole with smooth and clean surface was successfully drilled on the bone, and the highest removal rate of 0.99 mm³/s was achieved, which was twenty times higher than the previous study of 0.05 mm³/s. Moreover, bone and bone marrow were distinguished by real-time monitoring system during laser drilling. This work demonstrates the potential for clinical applications using an ultrafast laser to produce crack-free large-size bone holes.

Aerosol generating procedures in trauma and orthopaedics in the era of the Covid-19 pandemic; What do we know?

Purpose

COVID-19 pandemic has created havoc all over the globe and spared no one regardless of status, gender, location and ethnicity. There were questions raised if trauma and orthopaedic (T&O) procedures actually generated aerosols? The need for a review of literature highlighting the nature and impact of aerosol generation within T&O surgery was noted.

Methods

A comprehensive online search was performed for all published articles in the English language, evaluating AGPs in T&O surgery and the relevant personal protection equipment used.

Results

The search strategy populated 43 studies. Six studies were identified as duplicates. The shortlisted 37 studies were screened and nine studies were included in the review. An additional four studies were included from the bibliography review.

Conclusion

Most orthopaedic procedures are high-risk aerosol generating procedures (AGPs). Conventional surgical masks do not offer protection against high-risk AGPs. In the current era of COVID-19 pandemic, there is a significant risk to the transmission of infection to the theatre staff. For protection against airborne transmission, appropriate masks should be used. These need proper fitting and sizing to ensure full protection when used.

The impact of the COVID-19 pandemic on orthopaedic services and training in the UK

Introduction

The novel coronavirus disease 2019 (COVID-19) was declared a pandemic by the World Health Organisation on 11 March 2020. The aim of this study is to assess the impact of COVID-19 on orthopaedic practice and training in the UK.

Methods

Surgeons throughout UK hospitals were asked to complete an electronic survey relating to orthopaedic practice and training in their hospital. The nationwide survey was conducted during the first peak of COVID-19 cases in the UK between 20 March 2020 and 20 April 2020.

Results

All 202 UK participants reported disruption to their daily practice. 91% reported all elective operating had been cancelled and trauma continued as normal in only 24% of cases. 70% reported disruption to trauma operating. Elective clinic capacity significantly reduced with no elective clinics running as normal. 55% reported their elective clinics completely cancelled, whilst 38% reported elective clinics running at a reduced capacity, with non-urgent appointments postponed. Only 9% of fracture clinics ran as normal, and 69% had a reduced service. 67% reported teaching and study leave cancelled. Significantly, 69% of participants felt the pandemic would result in a delay to completion of registrar training programmes.

Conclusion

This is the first nationwide survey assessing the impact of the coronavirus disease 2019 on UK orthopaedic practice and training, during the peak of the pandemic. It highlights the scale of the challenge ahead for the specialty, including during the recovery phase and post-recovery phase of the pandemic.

Electronic supplementary material

The online version of this article (10.1007/s00590-020-02748-6) contains supplementary material, which is available to authorized users.

Design, usage and review of a cost effective and innovative face shield in a tertiary care teaching hospital during COVID-19 pandemic

Background

A major challenge of the coronavirus pandemic is personal protective equipment (PPE) shortage. The open source community mobilised solutions to combat this using 3D printing technology. One such solution was the face shield, which protects facial areas from droplet contamination when used by orthopaedic and other front line health care workers (HCWs).

Objectives

To assess the efficacy of an in-house developed face shield based on feedback by HCWs and its usage in triaging zones and operation theatre in a tertiary care hospital.

Methods

A protective face shield was developed and distributed among the orthopaedic surgeons and front line HCWs involved in the ICU in our hospital and neighbouring facilities. Feedback was obtained using a questionnaire utilising a Likert scale.

Results

227 face shields were distributed to the HCWs in our hospital (157) and neighbouring facilities (70). Design modifications were done as per the needs of the HCWs. 37 HCWs provided feedback giving the face shields an overall mean score of 7.92 out of 10. The poly vinyl chloride (PVC) film visors were better for airway management procedures as it can be tucked into PPE suit and visors with overhead projector (OHP) sheets were suitable for ICU and operative procedures.

Conclusion

A locally developed face shield design by an inter disciplinary team in synchrony with HCWs is found to increase its acceptability and efficacy. Face shields can be made more effective in different triaging and treatment situations by varying the device setup.

Adapting Policy Guidelines for Spine Surgeries During COVID-19 Pandemic in View of Evolving Evidences: An Early Experience From a Tertiary Care Teaching Hospital

Introduction The recent novel coronavirus disease 2019 (COVID-19) pandemic has brought the world to a standstill. This outbreak not only affected healthcare systems but the resultant economic losses were also enormous. COVID-19 has demanded that the health care systems globally evolve, develop new strategies, identify new models of functioning, and at times, fall back on the old conservative methods of orthopedic care to decrease the risk of disease transmission. Although, the majority of hospitals are refraining from performing elective surgeries, emergent and urgent procedures cannot be delayed. Various strategies have been developed at the institute level to reduce the risk of infection transmission among the theatre team from an unsuspected patient (asymptomatic and presymptomatic) during the perioperative period. Material and methods The present study is a part of an ongoing project which is being conducted in a tertiary level hospital after obtaining research review board approval. All patients admitted either for vertebral fracture or spinal cord compression from February 2020 to May 2020 were included. The present study included 13 patients (nine males and four females) with an average age of 35.4 years The oldest patient was of 63 years which is considered a risk factor for developing severe COVID-19 infection.  Results Eight patients (61.5%) presented with spinal cord injury (SCI) due to vertebral fracture with fall from height (87.5%) as the most common etiology. Among the traumatic SCI patients, six (75%) were managed surgically with posterior decompression and instrumented fusion with pedicle screws while two patients (25%) were managed conservatively. There were four patients (30.8%) of tuberculosis of the spine of whom two (50%) were managed with posterior decompression, debridement, and stabilization with pedicle screws, samples for culture, biopsy, and cartridge-based nucleic acid amplification test (CBNAAT) were collected during the procedure; for the remaining two patients (50%), a trans-pedicular biopsy was performed to confirm the diagnosis for initiation of anti-tubercular therapy. Prolapsed intervertebral disc causing cauda equina syndrome was the reason for emergency surgery in one patient (7.7%). COVID-19 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription-polymerase chain reaction (RT-PCR) test was performed in four patients (30.8%), in whom the most common symptom was fever (two patients (50%)). These patients were residents of high prevalence area for COVID-19 infection. Sore throat (25%), fatigue (25%), and low oxygen saturation (25%) were present in one patient which prompted us to get the COVID-19 test. All patients were reported negative for COVID-19. Conclusion The structural organization and the management protocol we describe allowed us to reduce infection risk and ultimately hospital stay, thereby maximizing the already stretched available medical resources. These precautions helped us to reduce transmission and exposure to COVID-19 in health care workers (HCW) and patients in our institute. The aim of this article is that our early experience can be of value to the medical communities that will soon be in a similar situation.

IMPACT-Scot report on COVID-19 and hip fractures

AIMS

The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures.

METHODS

A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded.

RESULTS

Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; p < 0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: 1) age, sex, type of residence (hazard ratio (HR) 2.93; p = 0.008); 2) Nottingham Hip Fracture Score (HR 3.52; p = 0.001); and 3) ASA (HR 3.45; p = 0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of < 217 × 10⁹/l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management.

CONCLUSION

COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219-1228.

Outcome of trauma and orthopaedic surgery at a UK District General Hospital during the Covid-19 pandemic

INTRODUCTION

There are suggestions that elective surgery performed during the incubation period of COVID-19 infection may cause an immediate impairment of cell-mediated immunity, leading to high morbidity and mortality. However is contrasting data about the associated mortality. Since the outbreak, our unit has maintained a prospective database recording Trauma and Orthopaedic surgical activity. Our aim was to share our experience of the first 3 months with prospective data on outcome of essential surgery during the covid-19 peak. Our focus in this report was on the mortality rate as services begin to open. Methods: We prospectively collected data during the peak of the pandemic in the UK, for fracture neck of femur patients (NOF) the most commonly performed surgical procedure and the most vulnerable during this period. We compared this Covid-19 cohort of NOFs against a cohort of NOF's during the same time in 2019 and another cohort of NOF's in 2020 outside the lockdown period to compare mortality rates and give a broader perspective.

RESULTS

During the period March 1, 2020 to May 31, 2020, total of 206 patients were operated. Ninety-four fracture NOF and another one hundred twelve essential surgical procedures were performed. In the NOF cohort, there were nine patients that died. Three of them were covid-19 positive, one was not tested and the rest five were covid-19 negative. There was no mortality reported in the non NOF group. Conclusion: In our unit, during the lock down period, mortality rate in patients undergoing fracture NOF was not significantly different from a similar cohort earlier in the year and similar period last year. We have not observed any mortality, to date in the Non NOF procedures carried out.

Post COVID-19: Planning strategies to resume orthopaedic surgery -challenges and considerations

The Coronavirus SARS-CoV-2 (COVID-19) pandemic has had a substantial effect on the health care systems around the world. As the disease has spread, many developed and developing countries have been stretched on their resources such as personnel as well as adequate equipment. As a result of resource disparity, in a populous country like India, the elective orthopaedic surgeries stand cancelled whilst trauma and emergency services have been reorganised following Indian Orthopaedic Association and recent urgent British Orthopaedic association guidelines. Though these guidelines provide strategies to deal with trauma and orthopaedic surgery management in the present scenario, once the COVID-19 pandemic stabilizes, restarting elective orthopaedic surgery and managing delayed trauma conditions in evolving health care systems is going to be a profound task. We look at the future challenges and considerations of re-establishing trauma and orthopaedic flow during the post-COVID-19 phase and suggest an algorithm to follow (Fig. 1).