Medically Necessary Orthopaedic Surgery During the COVID-19 Pandemic: Safe Surgical Practices and a Classification to Guide Treatment

BACKGROUND

Coronavirus disease 2019 (COVID-19) has rapidly evolved as a viral pandemic. Countries worldwide have been affected by the recent outbreak caused by the SARS (severe acute respiratory syndrome)-CoV-2 virus. As with prior viral pandemics, health-care workers are at increased risk. Orthopaedic surgical procedures are common in health-care systems, ranging from emergency to elective procedures. Many orthopaedic surgical procedures are life or limb-saving and cannot be postponed during the COVID-19 pandemic because of potential patient harm. Our goal is to analyze how orthopaedic surgeons can perform medically necessary procedures during the pandemic and to help guide decision-making perioperatively.

METHODS

We performed a review of the existing literature regarding COVID-19 and prior viral outbreaks to help guide clinical practice in terms of how to safely perform medically necessary orthopaedic procedures during the pandemic for both asymptomatic patients and high-risk (e.g., COVID-19-positive) patients. We created a classification system based on COVID-19 positivity, patient health status, and COVID-19 prevalence to help guide perioperative decision-making.

RESULTS

We advocate that only urgent and emergency surgical procedures be performed. By following recommendations from the American College of Surgeons, the Centers for Disease Control and Prevention, and the recent literature, safe orthopaedic surgery and perioperative care can be performed. Screening measures are needed for patients and perioperative teams. Surgeons and perioperative teams at risk for contracting COVID-19 should use appropriate personal protective equipment (PPE), including N95 respirators or powered air-purifying respirators (PAPRs), when risk of viral spread is high. When preparing for medically necessary orthopaedic procedures during the pandemic, our classification system will help to guide decision-making. A multidisciplinary care plan is needed to ensure patient safety with medically necessary orthopaedic procedures during the COVID-19 pandemic.

CONCLUSIONS

Orthopaedic surgery during the COVID-19 pandemic can be performed safely when medically necessary but should be rare for COVID-19-positive or high-risk patients. Appropriate screening, PPE use, and multidisciplinary care will allow for safe medically necessary orthopaedic surgery to continue during the COVID-19 pandemic.

LEVEL OF EVIDENCE

Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of the Acquisition of Ultrasound Proficiency in Hand Surgery Fellows

OBJECTIVES

To evaluate hand surgery fellow ultrasound (US) evaluations and performance of clinically relevant tasks after brief instruction.

METHODS

Six hand surgery fellows completed an US assessment and a survey on US use before and 1 month after a 30-minute US course.

RESULTS

The time to obtain an adequate image decreased from 4 minutes 42 seconds (4:42; range, 3:57-7:55) to 0:52 (range, 0:30-1:14; P < .001). Participants' performance for structure identification improved from 9.7 (range, 8-13) to 12 (range, 10-13) of 14 structures (P < .05). The average time to completion decreased from 14:6 (range, 12:08-18:30) to 9:34 (range, 4:40-15:54; P < .01). After instruction, all 6 participants identified and measured the cross-sectional area of the median nerve, identified and measured a zone 3 flexor tendon gap, and identified a simulated flexor digitorum profundus avulsion and its level of retraction (P < .05). Five of 6 successfully administered an US-guided injection to the extensor carpi ulnaris subsheath.

CONCLUSIONS

After a 30-minute instructional session, hand surgery fellows can achieve a basic level of US competency.

The Effect of Carpal Tunnel Release on Typing Performance

PURPOSE

To describe the effect of carpal tunnel release (CTR) on typing performance.

METHODS

We prospectively studied 27 patients undergoing open CTR. Patient demographics and clinical characteristics including nerve conduction studies, electromyography results, and duration of symptoms were collected. Before surgery and at 8 time points after surgery, ranging from 1 to 12 weeks, typing performance for an approximately 500-character paragraph was assessed via an on-line platform. The Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire functional component (BCTQ-F) and symptom severity component (BCTQ-S) component were completed before surgery and at 1, 3, 6, and 12 weeks after surgery. We used repeated-measures analyses of variance and follow-up dependent-samples t tests to analyze change in typing performance across sessions, and linear regressions to assess relationships between typing performance and demographic and outcome measures. We compared typing speed with the MHQ, BCTQ-F, and BCTQ-S using the Pearson correlation test.

RESULTS

Average typing speed decreased significantly from 49.7 ± 2.7 words per minute (wpm) before surgery to 45.2 ± 3.1 wpm at 8 to 10 days after surgery. Mean typing speed for the group exceeded the preoperative value between weeks 2 and 3, with continued improvement to 53.5 ± 3.5 wpm at 12 weeks after surgery. No clinical or demographic variables were associated with the rate of recovery or the magnitude of improvement after CTR. The MHQ, BCTQ-F, and BCTQ-S each demonstrated significant improvement from preoperative values over the 12-week period. The MHQ and BCTQ-F scores correlated well with typing speed.

CONCLUSIONS

On average, typing speed returned to preoperative levels between 2 and 3 weeks after CTR and typing speed showed improvement beyond preoperative levels after surgery. The MHQ and BCTQ-F correlate well with typing speed after CTR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Narcotic Use and Postoperative Doctor Shopping in the Orthopaedic Trauma Population

BACKGROUND

The negative consequences of narcotic use and diversion for nonmedical use are on the rise. A growing number of narcotic abusers obtain narcotic prescriptions from multiple providers ("doctor shopping"). This study sought to determine the effects of multiple postoperative narcotic providers on the number of narcotic prescriptions, duration of narcotics, and morphine equivalent dose per day in the orthopaedic trauma population.

METHODS

Our prospective cohort study used the state-controlled substance monitoring database to identify all narcotic prescriptions filled three months prior to admission and six months following discharge for enrolled patients. Patients were assigned into two groups: a single narcotic provider group with prescriptions only from the treating surgeon (or extenders) or a multiple narcotic provider group with prescriptions from both the treating surgeon and an additional provider or providers.

RESULTS

Complete data were available for 130 of 151 eligible patients. Preoperative narcotic use, defined by three or more narcotic prescriptions within three months of admission, was noted in 8.5% of patients. Overall, 20.8% of patients sought multiple narcotic providers postoperatively. There were significant increases in postoperative narcotic prescriptions (p < 0.001) between the single narcotic provider group (two prescriptions) and the multiple narcotic provider group (seven prescriptions), in duration of postoperative narcotic use (p < 0.001) between the single narcotic provider group (twenty-eight days) and the multiple narcotic provider group (110 days), and in morphine equivalent dose per day (p = 0.002) between the single narcotic provider group (26 mg) and the multiple narcotic provider group (43 mg). Patients with a high school education or less were 3.2 times more likely to seek multiple providers (p = 0.02), and patients with a history of preoperative narcotic use were 4.5 times more likely to seek multiple providers (p < 0.001).

CONCLUSIONS

There is a 20.8% prevalence of postoperative doctor shopping in the orthopaedic trauma population. Patients with multiple postoperative narcotic providers had a significant increase in postoperative narcotic prescriptions, duration of narcotics, and morphine equivalent dose per day.

Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients

BACKGROUND

The Venous Thromboembolism Prevention Study (VTEPS) Network is a consortium of 5 tertiary referral centers established to examine venous thromboembolism (VTE) in plastic surgery patients. We report our midterm analyses of the study's control group to evaluate the incidence of VTE in patients who receive no chemoprophylaxis, and validate the Caprini Risk Assessment Model (RAM) in plastic surgery patients.

STUDY DESIGN

Medical record review was performed at VTEPS centers for all eligible plastic surgery patients between March 2006 and June 2009. Inclusion criteria were Caprini score ≥3, surgery under general anesthesia, and postoperative hospital admission. Patients who received chemoprophylaxis were excluded. Dependent variables included symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) within the first 60 postoperative days and time to DVT or PE.

RESULTS

We identified 1,126 historic control patients. The overall VTE incidence was 1.69%. Approximately 1 in 9 (11.3%) patients with Caprini score >8 had a VTE event. Patients with Caprini score >8 were significantly more likely to develop VTE when compared with patients with Caprini score of 3 to 4 (odds ratio [OR] 20.9, p < 0.001), 5 to 6 (OR 9.9, p < 0.001), or 7 to 8 (OR 4.6, p = 0.015). Among patients with Caprini score 7 to 8 or Caprini score >8, VTE risk was not limited to the immediate postoperative period (postoperative days 1-14). In these high-risk patients, more than 50% of VTE events were diagnosed in the late (days 15-60) postoperative period.

CONCLUSIONS

The Caprini RAM effectively risk-stratifies plastic and reconstructive surgery patients for VTE risk. Among patients with Caprini score >8, 11.3% have a postoperative VTE when chemoprophylaxis is not provided. In higher risk patients, there was no evidence that VTE risk is limited to the immediate postoperative period.