The role of the orthopaedic surgeon in the COVID-19 era: cautions and perspectives

Impact of the COVID-19 pandemic on the productivity and career prospects of musculoskeletal researchers

Academic researchers faced a multitude of challenges posed by the COVID-19 pandemic, including widespread shelter-in-place orders, workplace closures, and cessation of in-person meetings and laboratory activities. The extent to which these challenges impacted musculoskeletal researchers, specifically, is unknown. We developed an anonymous web-based survey to determine the pandemic's impact on research productivity and career prospects among musculoskeletal research trainees and faculty. There were 116 musculoskeletal (MSK) researchers with varying demographic backgrounds who completed the survey. Of respondents, 48.3% (n = 56) believed that musculoskeletal funding opportunities decreased because of COVID-19, with faculty members more likely to hold this belief compared to nonfaculty researchers (p = 0.008). Amongst MSK researchers, 88.8% (n = 103) reported research activity was limited by COVID-19, and 92.2% (n = 107) of researchers reported their research was not able to be refocused on COVID-19-related topics, with basic science researchers less likely to be able to refocus their research compared to clinical researchers (p = 0.030). Additionally, 47.4% (n = 55) reported a decrease in manuscript submissions since the onset of the pandemic. Amongst 51 trainee researchers, 62.8% (n = 32) reported a decrease in job satisfaction directly attributable to the COVID-19 pandemic. In summary, study findings indicated that MSK researchers struggled to overcome challenges imposed by the pandemic, reporting declines in funding opportunities, research productivity, and manuscript submission. Trainee researchers experienced significant disruptions to critical research activities and worsening job satisfaction. Our findings motivate future efforts to support trainees in developing their careers and target the recovery of MSK research from the pandemic stall.

The impact of COVID-19 on hip and knee arthroplasty surgical volume in China

PURPOSE

The reduction of hip and knee arthroplasty surgical volume has been reported in many countries during the COVID-19 pandemic. In China, there is no national joint registry system and the impact of COVID-19 towards surgical volume remains unclear. The aim of this study was to investigate the hip and knee arthroplasty surgical volume in China during the pandemic and evaluate its change trends.

METHODS

Annual sale numbers of prostheses used in total knee arthroplasty (TKA), total hip arthroplasty (THA), and femoral head replacement (FHR) from 2011 to 2021 was collected from providers registered in National Medical Products Administration (NMPA). Annual surgical volume of TKA, THA, FHR, unicompartmental knee arthroplasty (UKA), and revision of hip/knee arthroplasty (RJA) was collected from member hospitals of Beijing Joint Society (BJS). We used linear regression to estimate the loss of surgical volume. Annual surgical volume obtained from Britain and Australian joint registries were used to make comparison.

RESULTS

In China, the surgical volume of THA/FHR, TKA, and UKA in 2020 all decreased compared to the predicted value, with a reduction of 82,525 cases (13.46%), 165,178 cases (33.50%), and 151 cases (0.65%), respectively. All the three procedures showed significant recovery in 2021. The surgical volumes of THA/FHR and UKA were 68,813 and 9402 cases higher than predicted levels, respectively, while TKA volume remained slightly below the predicted level. The regional statistics in Beijing showed similar change mode. In 2020, the surgical volume of THA/FHR, TKA, FHR, and UKA all decreased compared to the predicted value, with a reduction of 5031 cases (43.37%), 5290 cases (40.69%), 620 cases (29.18%), and 925 cases (39.11%), respectively. In 2021, with the exception of FHR, the number of these procedures increased compared to 2020, but remained below the predicted value. Compared with the data from Britain and Australia, China experienced less reduction and faster recovery in the proportions of elderly people (> 65 years old) who undergo hip and knee arthroplasty during the COVID-19 pandemic.

CONCLUSION

During the COVID-19 pandemic, although hip and knee arthroplasty surgical volume in China showed a similar "restoration-recovery" change pattern with other countries, China took fewer losses in this field.

The Effect of Transitioning to Remote Working in Patients Affected by Chronic Low Back Pain: A Cross-Sectional Study

OBJECTIVE

To assess the effect of transitioning to remote working during the coronavirus disease 2019 pandemic in a population of adults affected by chronic low back pain (cLBP).

METHODS

An online questionnaire was sent by email to teleworkers affected by cLBP. Demographic data, remote working features and tasks, and LBP burden were analyzed. The psychological burden of remote working was evaluated with the World Health Organization Five Well-Being Index and the Patient Health Questionnaire-2. LBP severity was evaluated using a visual analogue scale. LBP-related disability was assessed using the Oswestry Disability Index. The effect of LBP on working capacity was examined with the Occupational Role Questionnaire. Independent risk factors related to LBP worsening were identified using a multivariate logistic regression model.

RESULTS

During remote working, LBP severity was significantly higher compared to previous in-person working (p < 0.0001), as well as average weekly work hours (p < 0.001). Furthermore, the risk of LBP worsening was associated with higher depression scores (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.00-1.91; p = 0.048), increased stress levels (OR: 3.00, 95% CI: 1.04-8.65; p = 0.042), and being divorced (OR: 4.28, 95% CI: 1.27-14.47; p = 0.019). Conversely, living with others (OR: 0.24, 95% CI: 0.07-0.81; p = 0.021), and reporting unchanged stress levels (OR: 0.22, 95% CI: 0.08-0.65; p = 0.006) were associated with a lower risk of LBP worsening.

CONCLUSION

Our findings highlight key factors to consider for improving remote workers' physical and mental wellbeing and decrease their LBP burden.

Pain management recommendations during the progression of SARS-CoV-2 infection

COVID-19, an infection caused by SARS-CoV-2, had a devastating impact on people's lives. The pandemic placed a heavy burden on healthcare systems and impacted the care of patients, including those with pain. This narrative review aims to highlight the challenges in managing pain and fever resulting from COVID-19 and pre-existing conditions, and to discuss the role of over the counter analgesics as a key part of the COVID-19 treatment regimen. As most patients with COVID-19 are being managed in the outpatient setting, lifestyle interventions and over the counter analgesics are readily available options to effectively treat pain and fever, which can help to decrease the burden on the healthcare system during the COVID-19 pandemic.

Trends in osteoporotic fracture and related in-hospital complications during the COVID-19 pandemic in Alberta, Canada

Fragility fractures (i.e., low-energy fractures) account for most fractures among older Canadians and are associated with significant increases in morbidity and mortality. Study results suggest that low-energy fracture rates (associated with surgical intervention and outcomes) declined slightly, but largely remained stable in the first few months of the COVID-19 pandemic.

PURPOSE/INTRODUCTION

This study describes rates of low-energy fractures, time-to-surgery, complications, and deaths post-surgery in patients with fractures during the coronavirus disease (COVID-19) pandemic in Alberta, Canada, compared to the three years prior.

METHODS

A repeated cross-sectional study was conducted using provincial-level administrative health data. Outcomes were assessed in 3-month periods in the 3 years preceding the COVID-19 pandemic and in the first two 3-month periods after restrictions were implemented. Patterns of fracture- and hospital-related outcomes over the control years (2017-2019) and COVID-19 restrictions periods (2020) were calculated.

RESULTS

Relative to the average from the control periods, there was a slight decrease in the absolute number of low-energy fractures (n = 4733 versus n = 4308) during the first COVID-19 period, followed by a slight rise in the second COVID-19 period (n = 4520 versus n = 4831). While the absolute number of patients with low-energy fractures receiving surgery within the same episode of care decreased slightly during the COVID-19 periods, the proportion receiving surgery and the proportion receiving surgery within 24 h of admission remained stable. Across all periods, hip fractures accounted for the majority of patients with low-energy fractures receiving surgery (range: 58.9-64.2%). Patients with complications following surgery and in-hospital deaths following fracture repair decreased slightly during the COVID-19 periods.

CONCLUSIONS

These results suggest that low-energy fracture rates, associated surgeries, and surgical outcomes declined slightly, but largely remained stable in the first few months of the pandemic. Further investigation is warranted to explore patterns during subsequent COVID-19 waves when the healthcare system experienced severe strain.

COVID-19 Elderly Patients Treated for Proximal Femoral Fractures during the Second Wave of Pandemic in Italy and Iran: A Comparison between Two Countries

Background and objevtive: The worldwide spread of SARS-CoV-2 has affected the various regions of the world differently. Italy and Iran have experienced a different adaptation to coexistence with the pandemic. Above all, fractures of the femur represent a large part of the necessary care for elderly patients. The aim of this study was to compare the treatment in Italy and Iran of COVID-19-positive patients suffering from proximal femur fractures in terms of characteristics, comorbidities, outcomes and complications. Materials and Methods: Medical records of COVID-19-positive patients with proximal femoral fractures treated at IRCCS Istituto Ortopedico Galeazzi in Milan (Italy) and at Salamat Farda and Parsa hospitals in the province of Tehran (Iran), in the time frame from 1 October 2020 to 16 January 2021, were analyzed and compared. Results: Records from 37 Italian patients and 33 Iranian patients were analyzed. The Italian group (mean age: 83.89 ± 1.60 years) was statistically older than the Iranian group (mean age: 75.18 ± 1.62 years) (p value = 0.0003). The mean number of transfusions for each patient in Italy was higher than the Iranian mean number (p value = 0.0062). The length of hospital stay in Italy was longer than in Iran (p value < 0.0001). Furthermore, laboratory values were different in the post-operative value of WBC and admission and post-operative values of CRP. Conclusions: The present study shows that differences were found between COVID-19-positive patients with proximal femoral fractures in these two countries. Further studies are required to validate these results and to better explain the reasons behind these differences.

COVID-19 Pandemic Increases the Impact of Low Back Pain: A Systematic Review and Metanalysis

In March 2019, the World Health Organization (WHO) recognized the COVID-19 pandemic as a global issue. To reduce the spread of this disease, health safety pathways were implemented worldwide. These extraordinary measures changed people's lifestyles, e.g., by being forced to isolate, and in many cases, to work remotely from home. Low back pain (LBP), the most common cause of disability worldwide, is often a symptom of COVID-19. Moreover, it is often associated with different lifestyle features (type of job, physical activity, body weight). Therefore, the purpose of this systematic review and meta-analysis was to estimate the effect of the COVID-19 lockdown on LBP intensity and prevalence compared with LBP rates before the pandemic. A systematic search was performed on Scopus, PubMed, and Cochrane Central. Overall, eight studies with 2365 patients were included in the analysis. We used the Joanna Briggs Institute (JBI) critical appraisal tool to evaluate the risk of bias: six studies (75%) were at moderate risk of bias and two studies (25%) were at low risk of bias. These studies showed an increase in both the prevalence and intensity of LBP during the COVID-19 lockdown.

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.

Rising within the leadership of an orthopaedic society: learning from the presidents

Orthopaedic societies, with their diverse membership from across the world, serve a mission to endorse the progress and innovation in the field of orthopaedics and traumatology with a focus on improving patient care, as well as to encourage and develop education, teaching and research. Such organizations, whether small or large, have been successful in meeting the professional, educational and training needs of its members. The past and future presidents of these societies share insights addressing their professional experiences, lessons learnt and their vision for future leaders of the field. The objective of this article is to summarize the thoughts of presidents of orthopaedic societies from around the globe and to inspire younger and aspiring members of the global orthopaedic fraternity.

Virtual Orthopaedic Examination of the Lower Extremity: The Know-How of an Emerging Skill

»

Telemedicine has become an emerging necessity in the practice of orthopaedic surgery following the paradigm shift that was brought on by the COVID-19 pandemic.

»

Physical examination is an integral component of orthopaedic care and plays a crucial role in diagnosis.

»

Based on our experience and expert opinion in the literature, we recommend the following infrastructure for a virtual orthopaedic physical examination: a computing device with a functioning camera and high-definition input/output audio, a 720p (high-definition) display, a processing speed of 3.4 GHz, an internet connection speed range from 1 to 25 Mbps, adequate lighting, a steady camera that is positioned 3 to 6 ft (0.9 to 1.8 m) from the patient, a quiet environment for the examination, and clothing that exposes the area to be examined.

»

When performing a virtual examination of the lower extremity, inspection, range of motion, and gait analysis can be easily translated by verbally instructing the patient to position his or her body or perform the relevant motion. Self-palpation accompanied by visual observation can be used to assess points of tenderness. Strength testing can be performed against gravity or by using household objects with known weights. Many special tests (e.g., the Thessaly test with knee flexion at 20° for meniscal tears) can also be translated to a virtual setting by verbally guiding patients through relevant positioning and motions.

»

Postoperative wound assessment can be performed in the virtual setting by instructing the patient to place a ruler next to the wound for measuring the dimensions and using white gauze for color control. The wound can be visually assessed when the patient's camera or smartphone is positioned 6 to 18 in (15 to 46 cm) away and is held at a 45° angle to the incision.

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.

The Epidemiology of Knee Arthroscopy during Coronavirus Disease 2019 Pandemic

Introduction: Coronavirus disease (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus (SARS Cov-2) has made a huge impact on global health service including in orthopaedic surgical service. Knee surgery (including arthroscopy) is one of the emerging surgical services in Indonesia. As the pandemic goes on, some of the patients prefer to postpone or cancel the surgery planning. We tried to evaluate the epidemiology of knee arthroscopy procedure during Covid-19 pandemic at our institution. Material and methods: Retrospective data collection was performed on all patients who received knee arthroscopy procedure at Prof dr. R. Soeharso Orthopaedic Hospital, Surakarta, Indonesia during the year 2020. The study evaluated the demographic data, the indication of surgery, and trends of the number of surgeries according to period time. This study also compared the data of knee arthroscopy procedures performed during the corresponding period before the pandemic in Indonesia (January to December 2019). Results: There was a total of 88 knee arthroscopy surgery performed during the period January to December 2020. There was a decrease in the number of knee arthroscopy during April and May 2020.  The decreasing number of surgeries also occurred in November 2020 which was later followed by the increasing number of surgeries in December 2020. Among all patient received knee arthroscopy during 2020, none have post-operative complication or infection due to SARS Cov-2. Conclusion: There was some difference in the epidemiology of knee arthroscopy during the COVID-19 pandemic compared to the non-pandemic era. Comprehensive preoperative screening is needed before resume elective surgical service.  

Impact of the COVID-19 pandemic on the activity of private medical practices in Morocco

INTRODUCTION

The aim of this study was to assess the impact of the COVID-19 pandemic on the activity of private medical practices in Morocco.

METHODS

An online survey was carried out in June 2020. The study population consisted of physicians (General practitioners and specialists) who run private practices in different regions of Morocco. The questionnaire comprised three sections: demographic and professional data, the impact noticed by the physicians and the strategies they adopted to tackle this impact.

RESULTS

We analysed 225 responses. Specialists represented 71.6% of the respondents. The majority (94.2%) of the private practices were located in urban areas. Almost all respondents have noticed a change in the demand for medical services, mainly a decrease (96.4%). There was an increase in urgent consultations (30.7%) and consultations for acute motives (39.1%). Respondents also reported less (69.3%) or no (23.1%) regular follow-up visits for patients with chronic diseases. Decreased incomes concerned 97.3% of the practices. Practitioners reacted by working less hours (87.6%), delaying some procedures (78.2%) and applying recommended safety measures (100%). Telemedicine was used in an informal way to facilitate the communication with patients.

DISCUSSION AND CONCLUSION

During this pandemic, private practices were challenged to contribute to the continuity of healthcare services while ensuring the safety of the staff and the patients. Several strategies were adopted to cope with the new situation and to survive its many challenges.

Impact of COVID-19 pandemic on orthopaedic surgeons in terms of anxiety, sleep outcomes and change in management practices: A cross-sectional study from India

PURPOSE

The aim of this study was to assess the effects of the COVID-19 pandemic on anxiety, sleep outcomes and change in clinical management practices among orthopaedic surgeons following a nation-wide lockdown.

METHODS

We conducted an online cross-sectional study using piloted structured questionnaires with self-reported responses from Indian orthopaedic surgeons. Study participants were identified through social networking sites: Facebook and WhatsApp. The extent of anxiety and sleep quality was assessed by the standardised seven-item Generalised Anxiety Disorder (GAD-7) scale, single-item sleep quality scale, questions on unavailability of personal protective equipment, training module on COVID-19 and change in orthopaedic patient management.

RESULTS

One hundred male orthopaedic surgeons responded to the survey with majority (79%) in 30-44 years age group. Severe anxiety scores were observed in 8%; moderate, mild and minimal anxiety was observed in 12%, 27% and 53% surgeons respectively. Changes in management practice due to the pandemic was admitted by 65% respondents. We also observed an association between higher anxiety among surgeons and primary or secondary level of healthcare facility: (p = 0.04). Sleep disturbance was significantly associated with change in management practice to non-operative procedures (p = 0.03).

CONCLUSION

Anxiety among orthopaedic surgeons during the COVID-19 pandemic is related to factors like younger age group, working in a primary or secondary healthcare facility. Early recognition of anxiety is essential to prevent serious psychological sequelae.

Impact of the 1st and 2nd Wave of the COVID-19 Pandemic on Primary or Revision Total Hip and Knee Arthroplasty-A Cross-Sectional Single Center Study

The aim of this study was to evaluate the number of primary and revision total joint arthroplasties (TJA/rTJA) in 2020 compared to 2019. Specifically, the first and the second waves of the COVID-19 pandemic were evaluated as well as the pre-operative COVID-19 test. A cross-sectional single-center study of our prospectively maintained institutional arthroplasty registry was performed. The first COVID-19 wave and the second COVID-19 wave led to a socioeconomic lockdown in 2020. Performed surgeries, cause of revision, age, gender, and American Society of Anesthesiologists-level were analyzed. Preoperative COVID-19 testing was evaluated and nationwide COVID-19 data were compared to other countries. In 2020, there was a decrease by 16.2% in primary and revision TJAs of the hip and knee compared to 2019. We observed a reduction of 15.8% in primary TJAs and a reduction of 18.6% on rTJAs in 2020 compared to 2019. There is an incline in total hip arthroplasties (THAs) and a decline in total knee arthroplasties (TKAs) comparing 2019 to 2020. During the first wave, there was a reduction in performed primary TJAs of 86%. During the second wave, no changes were observed. This is the first study quantifying the impact of the COVID-19 pandemic on primary and revision TJAs regarding the first and second wave.

Systematic review: bioethical implications for COVID-19 research in low prevalence countries, a distinctly different set of problems

Background

The COVID-19 pandemic has presented extraordinary challenges to worldwide healthcare systems, however, prevalence remains low in some countries. While the challenges of conducting research in high-prevalence countries are well published, there is a paucity from low COVID-19 countries.

Methods

A PRISMA guided systematic review was conducted using the databases Ovid-Medline, Embase, Scopus and Web of Science to identify relevant articles discussing ethical issues relating to research in low prevalence COVID-19 countries.

Results

The search yielded 133 original articles of which only 2 fit the inclusion criteria and aim, with neither specific to low prevalence. Most of the available literature focused on clinical management and resource allocation related to high prevalence countries. These results will be discussed under the ethical dimensions of equity, individual liberty, privacy and confidentiality, proportionality, public protection, provision of care, reciprocity, stewardship and trust..

Conclusions

A systematic review failed to identify articles relating to COVID-19 research ethics, specific to low prevalence countries. It shows that there is a significant gap in the literature that warrants further investigation. Common ethical principles were used to present a distinct set of challenges experienced by a country with a low prevalence of COVID-19. This unique perspective of some of the common ethical problems surrounding research, may help guide further discussion and guide research in similar countries.

Orthopaedic operating room considerations in covid-19 pandemic: A systematic review

Purpose

Worldwide COVID 19 has affected the medical practices and Orthopaedics is not any different. Despite risk, the surgeons cannot deny the surgical procedure on patients with suspected or confirmed COVID 19 infection. The purpose of this manuscript is to review various operating room measures which are recommended and being followed to carry out orthopaedic surgeries in the current scenario of COVID 19 pandemic. The information would be useful for orthopaedic surgeons to carry out safe surgical practice for reducing the transmission of COVID 19 infection.

Method

ology: A systematic literature search was performed using search engines- PubMed, Google Scholar and Scopus from January to August 2020 for relevant research articles. The keywords utilized for systematic literature search were "COVID 19", "Corona virus" and "Operating room", "Orthopaedic procedure" in 4 combinations. Duplicates were excluded. Further sorting was done according to the pre-set inclusion and exclusion criteria. Original articles pertaining to orthopaedic surgery and operating room in COVID 19 and available in English language were included. Editorials, case reports, other speciality articles were excluded.

Results

16 articles were finally included in review after screening for titles, abstracts and full texts. The information obtained is presented as a narrative review.

Conclusion

Various important recommendations include use of negative pressure OR, HEPA filters, dedicated separate OR for COVID positive and suspected patients with well defined separate corridors for transport, avoid AGP wherever possible, minimize the number of assistants and staff and follow strict sanitation protocols after each surgery. A well planned systematic approach is warranted to mitigate the risk of transmission of COVID 19 while carrying out orthopaedic surgeries.

Increased perioperative mortality for femoral neck fractures in patients with coronavirus disease 2019 (COVID-19): experience from the United Kingdom during the first wave of the pandemic

BACKGROUND

The coronavirus disease 19 (COVID-19) pandemic has presented modern healthcare with an unprecedented challenge. At the peak of the pandemic, trauma and orthopaedic services at our institutions undertook internal restructuring, diverting resources to frontline medical care. Consequently, we sought to assess the impact on the elderly and comorbid patients presenting with femoral neck fractures, with a particular focus on 30-day mortality, length of stay, multidisciplinary team involvement and departmental structuring.

METHOD

A retrospective analysis of patients presenting with femoral neck fractures at three separate West London NHS Trusts was undertaken between March 11, 2020, to April 30, 2020. Length of stay, 30-day mortality and adherence to parameters constituting the best care evidence-based practice tariffs were compared between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and negative patients. A similar comparison was also conducted between our cohort and the equivalent period in 2018 using data from the National Hip Fracture Database.

RESULTS

A total of 68 patients presenting with femoral neck fractures were identified, mean age 81 (range 38-98), 73% female. There were 10 confirmed/suspected cases of COVID-19 on admission and a further seven confirmed as inpatients. The 30-day mortality within our cohort was 11.76% compared to 6% nationally in 2018 (p = 0.045). Orthogeriatric reviews occurred within 72 h in 71% of cases compared to 88% in the equivalent 2018 period. Within the cohort, mean length of stay was 17.13 days (SD 5.6, range 8-27 days) for SARS-CoV-2 positive patients compared to 10 days (SD 8.7, range 1-53 days) for negative patients (p < 0.05). Thirty-two patients (47%) required increased packages of care on discharge or rehabilitation.

CONCLUSIONS

The increase in 30-day mortality for SARS-CoV-2 positive patients presenting with femoral neck fractures is multifactorial, resulting from a combination of the direct effects of COVID-19 pneumonia as well as changes to the delivery of orthopaedic services. The provision of multidisciplinary care was directly affected by staff redeployment, particularly reorganisation of orthogeriatric services and lack of continuity of ward based clinical care. Our experiences have re-directed efforts towards the management of theatre teams, patient services and staffing, should we be faced with either a resurgence of COVID-19 or a future pandemic.

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.

A look at the global impact of SARS CoV-2 on orthopedic services

BACKGROUND

The COVID-19 pandemic profoundly impacted healthcare institutions worldwide. Particularly, orthopedic departments had to adapt their operational models.

PURPOSE

This review aimed to quantify the reduction in surgical and outpatient caseloads, identify other significant trends and ascertain the impact of these trends on orthopedic residency training programs.

METHODS

Medline and Embase were searched for articles describing case load for surgeries, outpatient clinic attendance, or emergency department (ED) visits. Statistical analysis of quantitative data was performed after a Freeman-Tukey double arcsine transformation. Results were pooled with random effects by DerSimonian and Laird model. When insufficient data was available, a systematic approach was used to present the results instead.

RESULTS

A total of 23 studies were included in this study. The number of elective surgeries, trauma procedures and outpatient attendance decreased by 80% (2013/17400, 0.20, CI: 0.12 to 0.29), 47% (3887/17561, 0.53, CI: 0.37 to 0.69) and 63% (84174/123967, 0.37, CI: 0.24 to 0.51) respectively. During the pandemic, domestic injuries and polytrauma increased. Residency training was disrupted due to diminished clinical exposure and changing teaching methodologies. Additionally, residents had more duties which contributed to a lower quality of life.

CONCLUSIONS

The COVID-19 pandemic has made an unprecedented impact on orthopedics departments worldwide. The slow return of orthopedic departments to normalcy and the compromised training of residents due to the pandemic points to an uncertain future for healthcare institutions worldwide, wherein the impact of this pandemic may yet still be felt far in the future.

Guidelines for the orthopedic surgeon in the era of COVID-19

Amid the current pandemic of coronavirus disease 2019 (COVID-19), orthopaedic surgery was one of the fewer specialties that remained active managing emergent and urgent orthopaedic and trauma cases. On the other hand, with the continued spread of this pandemic and its associated socioeconomic confinement and unpredictability of the pandemic curve; many health care facilities were forced into halting all elective and non-urgent activities including orthopaedic specialties. This in part was to help in reallocation of required resources and focusing on the proper management of COVID-19 patients, and to prevent the transmission of infection among health care workers and patients. In this article we analyzed developments and recommendations of international reports about the current outbreak and its impact on the practice of orthopaedic surgery. Our aim was to provide comprehensive and easy guidelines for the management of urgent and emergent cases in hot zones and for the process of returning to usual orthopaedic work flow in a balanced strategy to assure safe practice and providing quality care without the risk of exhausting institutional resources or the risk of COVID- 19 transmission among health care workers or patients.

Urgent Arthroplasty Interventions During the COVID-19 Pandemic: Operating Risks in Low-Prevalence Areas

Background and objective Orthopaedic services have reorganised their delivery of care in response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. In this study, we aimed to share our operating experience during the coronavirus disease 2019 (COVID-19) pandemic and analyse its effect on urgent hip and knee arthroplasty. Our study involved a comparative analysis between a cohort of patients from 2019 (pre-COVID) and another from 2020. Methods Tha data relating to patients undergoing urgent operations requiring arthroplasty interventions such as for infection, periprosthetic fracture (PPF) and neck of femur fracture (NOF) between April and July of 2020 and 2019 were reviewed prospectively and retrospectively. Patients were categorised according to the Royal College of Surgeons (RCS) case prioritisation and the COVID-19 risk assessment. Data were collected on 30-day mortality, readmissions, reoperations, complications, length of hospital stay and theatre efficiency. This was analysed, matched and compared. Statistical analysis was performed on categorical variables including the time to the theatre as well as dual consultant operating. Results A total of 46 consecutive patients were included in the 2020 cohort with a mean age of 78 years (range: 58-108 years). The median length of stay was 6.5 days (range: 3-35 days) and the median time to theatre for NOF patients was 23.8 hours (range: 16.2-87.7 hours). There were six complications and two deaths; one of the deaths was COVID-19-related. A total of 56 patients were included from 2019 with a mean age of 74.6 years (range: 45-88 years). The median length of stay was five days (range: 1-18 days) and the median time to theatre for NOF patients was 40.8 hours (range: 18.9-167 hours). There were four complications and one death. Conclusion Based on our findings, it is safe to perform complex surgery in a region of low community prevalence of COVID-19, and the outcomes were comparable to those from a pre-COVID-19 cohort.

COVID-19: Current and future challenges in spine care and education - a worldwide study

BACKGROUND

The COVID-19 pandemic has impacted spine care around the globe. Much uncertainty remains regarding the immediate and long-term future of spine care and education in this COVID-19 era.

STUDY DESIGN

Cross-sectional, international study of spine surgeons.

METHODS

A multi-dimensional survey was distributed to spine surgeons around the world. A total of 73 questions were asked regarding demographics, COVID-19 observations, personal impact, effect on education, adoption of telemedicine, and anticipated challenges moving forward. Multivariate analysis was performed to assess factors related to likelihood of future conference attendance, future online education, and changes in surgical indications.

RESULTS

A total of 902 spine surgeons from seven global regions completed the survey. Respondents reported a mean level of overall concern of 3.7 on a scale of one to five. 84.0% reported a decrease in clinical duties, and 67.0% reported a loss in personal income. The 82.5% reported being interested in continuing a high level of online education moving forward. Respondents who personally knew someone who tested positive for COVID-19 were more likely to be unwilling to attend a medical conference 1 year from now (OR: 0.61, 95% CI: [0.39, 0.95], P = .029). The 20.0% reported they plan to pursue an increased degree of nonoperative measures prior to surgery 1 year from now, and respondents with a spouse at home (OR: 3.55, 95% CI: [1.14, 11.08], P = .029) or who spend a large percentage of their time teaching (OR: 1.45, 95% CI: [1.02, 2.07], P = .040) were more likely to adopt this practice.

CONCLUSIONS

The COVID-19 pandemic has had an adverse effect on surgeon teaching, clinical volume, and personal income. In the future, surgeons with family and those personally affected by COVID-19 may be more willing to alter surgical indications and change education and conference plans. Anticipating these changes may help the spine community appropriately plan for future challenges.

Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe

PURPOSE

This study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic and trauma surgery training in Europe by conducting an online survey among orthopaedic trainees.

METHODS

The survey was conducted among members of the Federation of Orthopaedic and Trauma Trainees in Europe (FORTE). It consisted of 24 questions (single-answer, multiple-answer, Likert scales). Orthopaedic trainees' demographic data (six questions), clinical role changes (four questions), institutional changes due to the COVID-19 pandemic (nine questions), and personal considerations (five questions) were examined.

RESULTS

Three hundred and twenty-seven trainees from 23 European countries completed the survey. Most trainees retained their customary clinical role (59.8%), but a significant number was redeployed to COVID-19 units (20.9%). A drastic workload decrease during the pandemic was reported at most institutions. Only essential activities were performed at 57.1% of institutions and drastic disruptions were reported at 36.0%. Of the respondents, 52.1% stated that faculty-led education was restricted and 46.3% pursued self-guided learning, while 58.6% stated that surgical training was significantly impaired. Concerns about the achievement of annual training goals were expressed by 58.2% of the participants, while 25.0% anticipated the need for an additional year of training.

CONCLUSIONS

The SARS-CoV-2 pandemic significantly affected orthopaedic and trauma training in Europe. Most trainees felt the decrease in clinical, surgical, and educational activities would have a detrimental effect on their training. Many of them consulted remote learning options to compensate training impairment, stating that after the COVID-19 pandemic electronic educational approaches may become more relevant in future.

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations

PURPOSE

To plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections.

METHOD

A systematic review was conducted using the terms "COVID-19" or "SARS-Cov-2" and "second wave". No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations.

RESULTS

Overall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family's lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves.

CONCLUSIONS

The recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.

It is not 'business as usual' for orthopaedic surgeons in May 2020- the Austrian-German-Swiss experience

PURPOSE

To document the status-quo of orthopaedic health-care services as the COVID-19 pandemic recedes, and to determine the rate of resumption of orthopaedic surgery in the German-speaking countries in May 2020.

METHODS

A prospective online survey was sent out to 4234 surgeons of the AGA - Society of Arthroscopy and Joint-Surgery (Gesellschaft für Arthroskopie und Gelenkchirurgie, AGA). The survey was created using SurveyMonkey software and consisted of 23 questions relating to the reduction of orthopaedic services at the participating centres and the impact that the pandemic is having on each surgeon.

RESULTS

A total of 890 orthopaedic surgeons responded to the online survey. Approximately 90% of them experienced a reduction in their surgical caseload and patient contact. 38.7% stated that their institutions returned to providing diagnostic arthroscopies. 54.5% reported that they went back to performing anterior cruciate ligament reconstructions (ACLR), 62.6% were performing arthroscopic meniscus procedures, and 55.8% had resumed performing shoulder arthroscopy. Only 31.9% of the surgeons were able to perform elective total joint arthroplasty. 60% of the participants stated that they had suffered substantial financial loss due to the pandemic.

CONCLUSION

A gradual resumption of orthopaedic health-care services was observed in May 2020. Typical orthopaedic surgical procedures like ACLR, shoulder arthroscopy and elective total joint arthroplasty were reported to be currently performed by 54%, 56% and 32% of surgeons, respectively. Despite signs of improvement, it appears that there is a prolonged curtailment of orthopaedic health-care at present in the middle of Europe.

Impact of the COVID-19 pandemic on orthopaedic and trauma surgery training in Europe

Purpose

This study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic and trauma surgery training in Europe by conducting an online survey among orthopaedic trainees.

Methods

The survey was conducted among members of the Federation of Orthopaedic and Trauma Trainees in Europe (FORTE). It consisted of 24 questions (single-answer, multiple-answer, Likert scales). Orthopaedic trainees’ demographic data (six questions), clinical role changes (four questions), institutional changes due to the COVID-19 pandemic (nine questions), and personal considerations (five questions) were examined.

Results

Three hundred and twenty-seven trainees from 23 European countries completed the survey. Most trainees retained their customary clinical role (59.8%), but a significant number was redeployed to COVID-19 units (20.9%). A drastic workload decrease during the pandemic was reported at most institutions. Only essential activities were performed at 57.1% of institutions and drastic disruptions were reported at 36.0%. Of the respondents, 52.1% stated that faculty-led education was restricted and 46.3% pursued self-guided learning, while 58.6% stated that surgical training was significantly impaired. Concerns about the achievement of annual training goals were expressed by 58.2% of the participants, while 25.0% anticipated the need for an additional year of training.

Conclusions

The SARS-CoV-2 pandemic significantly affected orthopaedic and trauma training in Europe. Most trainees felt the decrease in clinical, surgical, and educational activities would have a detrimental effect on their training. Many of them consulted remote learning options to compensate training impairment, stating that after the COVID-19 pandemic electronic educational approaches may become more relevant in future.

Electronic supplementary material

The online version of this article (10.1007/s00264-020-04742-3) contains supplementary material, which is available to authorized users.

Were protective procedures against SARS-CoV-2 effective in an orthopaedic and trauma centre during the lockdown period? A retrospective study

Purpose

The SARS-CoV-2 epidemic started in December 2019 in Wuhan. The lockdown was declared on March 16, 2020 in France. Our centre had to adapt daily practices to continue to take care of bone and soft tissue tumours and emergencies. Through this study, we wanted to assess the various procedures implemented during the lockdown period between March 17 and May 10.

Methods

A monocentric retrospective cohort study was conducted in Cochin Hospital (Paris, France). Patients included were those who had surgery during the lockdown period. To take care of COVID-19 positive and negative patients, various procedures have been set up: reverse transcriptase polymerase chain reaction (RT-PCR) tests for all hospitalized patients, a specific unit for COVID-positive patients, a specific surgical room, and use of protective personal equipment.

To allow the effectiveness of the procedures implemented, we evaluated the number of complications attributed to SARS-CoV-2 and the number of patients who became COVID positive during hospitalization.

Results

During the lockdown period, there were 199 procedures of three types of procedures in our centre: 79 traumatology procedures (39.7%), 76 of bone and soft tissues tumours (38.2%), and 44 procedures related to infection (22.1%). We observed 13 complications (6.5%) during hospitalization, and only one patient became COVID-19 positive during the hospitalization.

Conclusion

The COVID-19 epidemic has been a challenge for organization and adaptation to manage all COVID-19 positive and COVID negative. Through this study, we wanted to assess our procedures taken. They had been effective due to the low number of contamination and complications.

The impact of COVID-19 on trauma and orthopaedic surgery in the United Kingdom

The coronavirus 2019 (COVID-19) global pandemic has had a significant impact on trauma and orthopaedic (T&O) departments worldwide. To manage the peak of the epidemic, orthopaedic staff were redeployed to frontline medical care; these roles included managing minor injury units, forming a “proning” team, and assisting in the intensive care unit (ICU). In addition, outpatient clinics were restructured to facilitate virtual consultations, elective procedures were cancelled, and inpatient hospital admissions minimized to reduce nosocomial COVID-19 infections. Urgent operations for fractures, infection and tumours went ahead but required strict planning to ensure patient safety. Orthopaedic training has also been significantly impacted during this period. This article discusses the impact of COVID-19 on T&O in the UK and highlights key lessons learned that may help to proactively prepare for the next global pandemic.

Cite this article: Bone Joint Open 2020;1-7:420–423.