The safe resumption of elective orthopaedic services following the first wave of the COVID-19 pandemic : a review of 2,316 consecutive cases and implications for recovery following further waves

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

Methods

A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019.

Results

A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery.

Conclusion

Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery.

Level of evidence: III

Cite this article: Bone Jt Open 2022;3(1):42–53.

SP2.2.4National multi centre cohort study of transferable skills acquired among redeployed core surgical trainees to intensive care units during the COVID-19 pandemic

Aim

Due to the COVID-19 pandemic a large number of core surgical trainees have been redeployed to intensive care units across the country. This study analyses the procurement of transferable skills by trainees mapped to the ISCP curriculum among a large national cohort.

Methods

An anonymous questionnaire mapped to common areas in the ISCP syllabus, including basic sciences, post-operative care, critical care and management of the dying patient, was administered to a nationwide group of core surgical trainees redeployed to ITU. The results were compared with responses from a cohort of trainees that were not redeployed. Subgroup analysis was also performed on the redeployed cohort to compare skills before and after redeployment.

Result

A total of 72 complete responses from among 3 deaneries nationwide were received, 39 who were redeployed, and 33 who were not. Mean age (24.5 vs 24.9 years) and time post-graduation (37.5 vs 38.2 months) were similar in each group. The average length of redeployment was 12 ±0.157 weeks. The mean score in those not redeployed was 1.85 ±0.167, compared to 4.02±0.175 in the redeployed cohort (p &lt; 0.05). Among those redeployed, scores prior to redeployment were significantly lower 1.89 ±0.122 (p &lt; 0.05).

Conclusion

This study demonstrates that even a brief period of intensive care experience significantly increases knowledge of key aspects of the ISCP curriculum. It is the authors’ opinion that a module of intensive care experience during core surgical training should be considered. Our cohort will be followed to assess performance in postgraduate examinations.

The impact of the COVID-19 pandemic on the length of stay following total hip and knee arthroplasty in a high volume elective orthopaedic unit

Aims

Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. The primary aim was to determine the effects of the COVID-19 pandemic length of stay following hip and knee arthroplasty at a high-volume, elective orthopaedic centre.

Methods

A retrospective cohort study was performed. Patients undergoing primary or revision hip or knee arthroplasty over a six-month period, from 1 July to 31 December 2020, were compared to the same period in 2019 before the COVID-19 pandemic. Demographic data, American Society of Anesthesiologists (ASA) grade, wait to surgery, COVID-19 status, and length of hospital stay were recorded.

Results

A total of 1,311 patients underwent hip or knee arthroplasty in the six-month period following recommencement of elective services in 2020 compared to 1,527 patients the year before. Waiting time to surgery increased in post-COVID-19 group (137 days vs 78; p < 0.001). Length of stay also significantly increased (0.49 days; p < 0.001) despite no difference in age or ASA grade. There were no cases of postoperative COVID-19 infection.

Conclusion

Time to surgery and length of hospital stay were significantly higher following recommencement of elective orthopaedic services in the latter part of 2020 in comparison to a similar patient cohort from the year before. Longer waiting times may have contributed to the clinical and radiological deterioration of arthritis and general musculoskeletal conditioning, which may in turn have affected immediate postoperative rehabilitation and mobilization, as well as increasing hospital stay.

Cite this article: Bone Jt Open 2021;2(8):655–660.

Paroxysmal nocturnal hemoglobinuria and myelodysplastic syndrome: Disappearance of cytogenetic abnormalities

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare life-threatening disease resulting from clonal hematopoietic stem cell evolution. There is a strong link between PNH and other acquired bone marrow failure syndromes, including myelodysplastic syndrome (MDS). Cytogenetic, morphological abnormalities or both are observed in the range of MDS/PNH diagnosis. Herein, we investigate cytogenetic abnormalities in PNH patients. We found two patients with PNH clones and MDS-associated abnormalities that later disappeared. The first patient, originally diagnosed with MDS and Trisomy 6, developed a large PNH clone. At the time of PNH diagnosis, the abnormal cytogenetic clone was no longer detectable despite persistent trilineage dysplasia. In the second patient, a large PNH clone and MDS-defining abnormality were detected at diagnosis, without evidence of dysplasia. No cytogenetic abnormalities were evident after complement inhibition. Our report adds significant information on the complex link between MDS and PNH, suggesting that distinction between these entities may be difficult in some cases. Especially in transplant eligible patients, the clinical phenotype may be the leading feature for treatment decisions in the era of complement inhibition. Lastly, the transient presence of cytogenetic abnormalities is a unique characteristic of our patients' course that needs to be further elucidated in larger studies.