Management of Outpatient Elective Surgery for Arthroplasty and Sports Medicine During the COVID-19 Pandemic: A Scoping Review

Impact of the SARS-CoV-2 outbreak on ACGME-accredited orthopaedic trauma fellowship training

INTRODUCTION

The SARS-CoV-2 viral outbreak created unprecedented challenges in surgical education. Yet, its impact on reported case volume during orthopaedic trauma fellowship training remains poorly understood. We hypothesized that cases performed during orthopaedic trauma fellowship training would decrease by 8 %-17 % during the 2019-2020 academic year corresponding to the 1-2 month moratorium of non-essential cases during the initial SARS-CoV-2 outbreak in the United States.

METHODS

We designed a retrospective cohort study of orthopaedic trauma fellows at Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs (2018-2019 to 2021-2022). Mean case volumes were compared by case category across academic years.

RESULTS

There was a -13 % year-over-year decrease in reported case volume during the 2019-2020 academic year (505 ± 126 vs 441 ± 94, P = 0.079, Fig. 1). Case categories with the greatest percentage declines were Treatment of Nonunion / Malunion (-31 %), Fasciotomy (-25 %), External Fixation (-21 %), Forearm / Wrist (-21 %), and Intra-articular Distal Humerus Fracture (-17 %). There was a 7 % year-over-year increase in case volume during the subsequent 2020-2021 academic year with near universal increases in case volume across case categories.

CONCLUSION

There was a 13 % decrease in orthopaedic trauma case volume during the 2019-2020 academic year, corresponding to the SARS-CoV-2 outbreak. Certain trauma case categories experienced the greatest negative impact, which subsequently recovered during the next academic year. These results may help inform accrediting bodies and surgical educators on the impact of future viral outbreaks on orthopaedic trauma fellowship training.

Navigating ACL Injuries Amid the COVID-19 Pandemic: A Retrospective Analysis

Introduction In the United Kingdom, musculoskeletal injuries represent a substantial proportion of primary care appointments, and within this category, acute knee injuries are prominent in accident and emergency department cases. Notably, diagnosing anterior cruciate ligament (ACL) injuries is a recognized challenge, often leading to extended diagnostic delays. The COVID-19 pandemic has significantly affected the management of musculoskeletal disorders, driven by reduced surgical capacities, creating a backlog of patients awaiting necessary surgical interventions. Delayed ACL reconstruction poses risks of prolonged knee instability and secondary injuries. To address these concerns, this study evaluates the impact of COVID-19 on the timeline from ACL injury diagnosis to MRI and surgical intervention, with a specific focus on an internal acute knee clinic pathway designed to expedite the evaluation, diagnosis, and management of soft tissue knee injuries. Methods In this cross-sectional study, we retrospectively reviewed all the patients who underwent primary ACL reconstruction from January 2019 to November 2022 in a district general teaching hospital (DGH). Besides demographic data of the patients, we recorded the dates of injury, primary presentation, first knee specialist review, knee MRI, and ACL reconstruction surgery, as well as the injury-to-surgery, injury-to-MRI, and MRI-to-surgery periods. Patients were divided based on the date of operation to pre- and post-COVID, and outcomes were compared to see the possible effects of COVID-19. Data were analyzed using a quantitative and qualitative test with a P < 0.05 significance level. Results Our cohort included 97 patients, and the mean age of patients was 30.6 years (17-53 years). The median time of injury-to-MRI was 46.5 days during the pre-COVID period, which decreased to 44 days in the post-COVID period (P = 0.596). The median time of injury-to-surgery was 287.5 days during the pre-COVID period, which increased to 289 days in the post-COVID period (P = 0.019). The median MRI-to-surgery duration was 200 days during the pre-COVID period, which increased to 225 days in the post-COVID period (P = 0.006). Around 35% of patients had an MRI prior to getting evaluated by a specialist. Conclusion The COVID-19 pandemic had a significant impact on the management of ACL injuries, with delays in elective knee clinics and surgery potentially leading to delays in the diagnosis and management of such injuries. However, our study showed that the delay from ACL injury to subsequent surgery actually reduced post-pandemic due to hospital-based acute knee pathway, which is particularly important in the context of associated meniscal injury that can worsen while patients wait for surgery.

Impact of COVID-19 on the Reported Case Volume of Orthopaedic Sports Medicine Fellows in the United States

Background

The impact of the coronavirus 2019 (COVID-19) pandemic on reported case volume during orthopaedic sports medicine fellowship training remains poorly understood from a national perspective.

Hypothesis

It was hypothesized that reported case volume during orthopaedic sports medicine fellowship training would decrease during the 2019-2020 academic year, which corresponded to the COVID-19 outbreak. It was also hypothesized that there would be a subsequent rebound in case volume during the 2020-2021 academic year.

Study Design

Cohort study.

Methods

Reported mean case volumes were extracted for 4 academic years (2017-2018, 2018-2019, 2019-2020, and 2020-2021), and year-over-year percentage changes were calculated. Parametric tests were used for interyear comparisons.

Results

There was a 7% decrease in mean ± SD case volume between the 2018-2019 and 2019-2020 academic years (339 ± 123 vs 316 ± 108; P = .042). Case categories with the greatest percentage declines were foot and ankle (-20%), knee instability (-11%), meniscus (-8%), and glenohumeral instability (-7%). There was a 13% year-over-year increase in case volume between the 2019-2020 and 2020-2021 academic years (316 ± 108 vs 357 ± 117; P < .001).

Conclusion

There was a slight decrease in total orthopaedic sports medicine case volume during the 2019-2020 academic year, corresponding to widespread lockdowns during the COVID-19 outbreak. Certain case categories experienced the greatest negative impact. Results from this study may inform accrediting bodies and surgical educators on the impact of future disruptions to health care delivery.

Impact of the COVID-19 Pandemic on Sports Medicine Patient Care

The COVID-19 pandemic has necessitated new practices in sports medicine patient care. Telehealth has been validated as a reliable tool for consultations and physical examinations and increases access to care in a cost-efficient manner. Social distancing and avoiding team members who have tested positive are the most effective ways to reduce spread. For screening, daily self-reported symptom checklists and fever monitoring help identify potentially infected athletes who should be instructed to isolate and seek care. Polymerase chain-reaction (PCR) testing for the virus via nasopharyngeal swab is not recommended for screening and should be reserved for symptomatic individuals with fever, cough, or shortness of breath. Face masks and personal protective equipment (PPE) may be beneficial in high-risk settings, but there is little evidence to support use in athletic populations. Median return to play after COVID-19 in elite athletes has been reported as 18 days (range: 12 to 30), with 27% not fully available at 28 days. Chest pain at diagnosis was the only symptom associated with time loss longer than 28 days. Finally, canceled competitions or time loss results in grief, stress, and frustration for athletes, as well as loss of a social support network and routine training regimens. Mental health support services may be indicated.

Trends in Pediatric Anterior Cruciate Ligament Reconstruction: The Effect of COVID-19

CONTEXT

The number of pediatric anterior cruciate ligament reconstructions (ACLRs) occurring yearly increased almost 6-fold from 2004-2014. We find it interesting that limited recent data exist on rates of ACL injury and reconstruction in children and adolescents, especially in the context of COVID-19.

OBJECTIVE

Given the effect of the COVID-19 pandemic on youth sports seasons and the postponement of many elective surgeries, we sought to examine the changes in rates of ACLR during this period.

DESIGN

Retrospective cohort study.

SETTING

This study used the Pediatric Health Information System (PHIS) database to identify eligible patients at PHIS-participating hospitals nationwide from January 2016-June 2021, with March 1, 2020, considered the start of the COVID-19 pandemic.

PATIENTS OR OTHER PARTICIPANTS

Using Current Procedural Terminology codes, patients 18 years old and younger who underwent ACLR surgery were identified.

MAIN OUTCOME MEASURE(S)

Patient demographics and overall rates of surgery prepandemic and intrapandemic were compared. Data were analyzed using bivariate, mixed-model, and time series analyses.

RESULTS

A total of 24 843 ACLRs were identified during this time period. In total, 1853 fewer surgeries than expected were performed after March 2020 given prepandemic trends. Intrapandemic demographics revealed an increase in the proportion of patients who identified as White and with private insurance and a decrease in the proportion who identified as Black and with public insurance. Also, the proportion of ACLRs by region shifted, with more surgeries performed in the Midwest and fewer in the Northeast. In the model adjusted for hospital-level variability, only race and insurance status remained significant.

CONCLUSIONS

Based on prepandemic trends, fewer patients than projected underwent ACLR once the pandemic began, likely due to a combination of decreased rates of injury and delayed surgery.