|
 
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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 17
| Issue : 2 | Page : 43-48 |
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Impact of COVID-19 on orthopedic practices: A schematic review
Raju Karuppal
Department of Orthopaedics, Government Medical College, Manjeri, Kerala, India
| Date of Submission | 30-Nov-2020 |
| Date of Acceptance | 13-Dec-2020 |
| Date of Web Publication | 08-Mar-2021 |
Correspondence Address:
Raju Karuppal
Department of Orthopaedics, Government Medical College, Manjeri, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joasis.joasis_14_20
It is our responsibility to be aware of the current knowledge on COVID-19 such as the pathogenesis, clinical features, and the precautions that we have to follow while handling orthopedic patients. A detailed look into the current protocol and suggestions of orthopedic practices in the COVID-19 outbreak has done here. A review of articles indexed for MEDLINE on PubMed and Scopus using the keywords COVID-19 and orthopedics and as a Boolean search was used. The review included evidence from 44 articles from orthopedic literature. There are risks associated with orthopedic practices in the COVID-19 pandemic, and many standard protocols are available to confront the situation. This article highlights useful recommendations and directions for orthopedic practices in the COVID-19 outbreak.
Keywords: COVID-19 outbreak, negative pressure operating room, operating room precautions, orthopedic practices, orthopaedic protocol
How to cite this article:
Karuppal R. Impact of COVID-19 on orthopedic practices: A schematic review. J Orthop Assoc South Indian States 2020;17:43-8 |
| Introduction | |  |
The WHO declared on January 30, 2020, about the COVID-19 outbreak to be a high risk to countries with vulnerable health systems and it has been deemed a global health emergency.[1] As an orthopedic community, it is also our responsibility to be aware of the current information about the pathogenesis, clinical features and the precautions that we have to follow while handling orthopedic patients. It is evident globally in the COVID-19 pandemic that there is a shortage of doctors, paramedics, and even medical equipment and medicines.[2],[3] The COVID-19 virus affects the musculoskeletal system, and there is a requirement of compulsory training to the orthopedics community to understand the symptoms of this disease.[4] Performing orthopedics and trauma surgery has become a real challenge in the COVID-19 pandemic. It also has a significant effect on the manufacturing field of orthopedic implants and equipment as well.[4] This virus has affected the day to day practice of orthopedics surgeons. They are forced to cancel their elective surgeries, delayed the regular check-ups date and semi-emergency surgeries, limited the number of patients in the regular clinics, and adopted to the conservative mode of treatments in possible conditions.
Cases of emergency surgeries and in-patient care need to have a minimum day of hospital stay, to avoid the effect of corona virus.[5] Moreover, many precautions have to be observed, such as social distancing, facial masks, and frequent washing of hands to corroborate for the prevention of its spread. It is necessary to triage the patients during the COVID-19 outbreak to avoid unnecessary admission related to minor trauma and other ailments. There are many articles have published on the orthopedic practices during the COVID-19 outbreak. PubMed and the Scopus search shows more than 2100 publications on COVID-19, where only 29 articles are related to orthopedic practices during the COVID-19 pandemic. These articles highlight the suggestions and direction of in-patient care, out-patient care, and surgical practices.
| General Guidelines | | |
All nonessential/semi-essential hospital or office staff should be allowed to stay home as a backup resource and telework.[6] All academic activities should be shifted to online resources. The minimum number of necessary staff should attend patients during the daily check-up, out-patient service, and in surgical procedures. Strict adherence have to be maintained to the protocols such as hand washing, hand sanitiser usage, and appropriate use of PPE(Personal protective equipment). Inter-departmental consultations, when needed should be performed by decision-makers only. All kinds of meetings, including multidisciplinary team meetings, should be held virtually as possible.
| Triage and Out-patient Care | | |
The COVID-19 outbreak has led to well-recognized surgical care guidelines from many professional agencies such as the American College of Surgeons, the Center for Medicare and Medicaid Services, and the American Academy of Orthopedic Surgeons has recommended for appropriate triage and plan for a surge of COVID-19 cases.[7],[8],[9] Hospitals have recommended to prioritize their services and care to those with emergent cases and acute pain to optimize the use of essential medical supplies, equipment, and workforce. Emergency departments (ED) were disproportionately affected as an additional burden due to the visits of patients with urgent non-traumatic, non-COVID-19-related health problems. Data show 17% to 26% of all cases presented to the ED were due to musculoskeletal complaints.[10] As the pandemic continued to evolve, the patient load to the ED continued to rise, leading to an overburdened on it.
To lessen this kind of burden and to ensure resource availability and capacity, many methods have been adopted, such as Orthopaedic Walk-In Clinics (OWICs).[11] This would reduce the number of referrals of nonemergency cases from the ED and relieve personnel and equipment to combat the COVID-19 surge.[11] Countries like Italy have made a workflow for patients who arrived in the emergency room during the COVID-19 pandemic. Body temperature is measured in every incoming patient entering the Orthopedic area where an oropharyngeal swab and a chest X-ray are also obtained, to detect asymptomatic or latent phase, severe acute respiratory syndrome (SARS)-COVID-2 patients. They have completely rearranged the management of Orthopedic and Traumatology patients.[12] COVID-19 pandemic has significantly altered the methodology of treating Orthopedic emergency cases.[13]
| Orthopaedic Surgeries | | |
During the initial days of the COVID-19 pandemic almost all elective surgical and endoscopic cases were postponed. This was to minimizes the potential risk to both patient and health-care teams, as well as minimizes utilization of necessary resources, such as beds, ventilators, and PPE.[14] Now decisions, however being made institution wise, based on COVID-19 burden and in the context of logistical, medical, and organizational considerations.[14]
Preoperative considerations
In the preoperative setting, we should give diligence in the indications, timing, and location in which a surgical procedure is to be performed.[15] Patients should be managed conservatively where ever possible, such as certain fractures of clavicle, humerus, wrist fractures, and tibial fractures, which usually have high rates of the union.[15],[16],[17] Similarly, ligamentous injuries of the knee joint can also be treated with bracing in preference to early ligament reconstruction.[18] If a surgical procedure is indicated, it is mandatory to have COVID-19 tests before it and in very urgent situations where there is no time to wait for COVID-19 results (e.g., badly contaminated high-grade open fractures, compartment syndrome, fractures with vascular compromise, cauda equina, or infections such as necrotizing fasciitis)., the surgical team should don in full protective gear.[14] There should be a dedicated COVID-19 infectious disease team in every institution to supervise all activities in the hospital for patient and health-care worker protection.[14] To avoid the exhaustion of the resources, orthopedic surgeons have a great role in defines essential and nonessential orthopedic surgery.[19] The definitions of essential and nonessential orthopedic surgery need to be reviewed regularly, with adjustments tailored to each hospital's workforce, resources, and COVID-19 situation. For those patients with COVID-19, the decision of surgical treatment should also be based on the patient's clinical status, in particular with the respiratory function.[14] Patients of long bone fractures have some inherent chances of developing fat embolism, which can worsen respiratory function in COVID-19-positive patients, which will definitely add stresses on anesthesia and in the post-operative period. Surgical masks need to be worn for all non-intubated patients during the transfer process, and accompanying staff has to wear full PPE, including N95 masks, visors, or goggles.[14] Aerosol-generating procedures such as endotracheal intubations have 6.6 times more infective risks compared with staff who did not.[20] In view of this, it is recommended to use of the regional anesthesia techniques over general anesthesia where ever possible.[21] In the event that airway manipulation is deemed necessary (e.g., from surgical necessity or failure of the regional blockade), all personnel involved in intubation must don full PPE, including powered air-purifying respirators.[22] Staff not involved in intubation (including the orthopedic surgical team) should stay at least 2 m away, or preferably outside the operating room (OR).
The World Health Organization still recommends precautions against droplets and contact, the U. S. Centers for Disease Control and Prevention (CDC) has strongly recommended more precautions against airborne transmission during the care of patients with COVID-19. Orthopedic surgeries need frequent handling of high-speed drills and hammers and sharp types of equipment. To reduce blood and fluid splatter in relation with the use of such equipment can be reduced by the placement of transparent plastic covers over wounds when drilling and minimizing the use of pulsatile lavage.[22] The surgical time can be minimized by considering steps like always do familiar and confident surgical approaches, replacement over fixation in complex fractures in elderly patients where ever possible, definitive external fixation should be considered for fractures due to its minimal invasiveness and the relative ease, uncemented implants, and unreamed nails. By taking these precautions, we protect both ourselves and our patients during surgical procedures.[14]
The Society of American Gastrointestinal and Endoscopic Surgeons and The European Association for Endoscopic Surgeons have made certain recommendations for the surgical practice, staff safety, and overall patient care.[23]
- All emergent endoscopic procedures performed during the COVID-19 outbreak should be considered as high risk and PPE must be used by all endoscopy staff. However, as the numbers of COVID-19 patients requiring care are expected to escalate over the next few weeks, the surgical care of patients should be limited to those whose needs are imminently life-threatening. These may include malignant conditions that could progress or with active symptoms that require urgent care. All others should be better delayed until after the peak of the COVID-19 pandemic. This reduces the risk to both, patient and health care teams, as well as minimizes utilization of necessary resources, which are likely to be essential for more needed cases
- All nonessential hospital or office staff should be allowed for telework at home. All in-person educational sessions should be cancelled and could be replaced by online resources. The minimum number of medical person should attend patients during rounds and other encounters. Adherence to hand hygiene and appropriate use of PPE should be strictly enforced. Only decision-makers should be allowed for surgical consultation
- Insignificant hospital visits and admissions should be postponed unless needed to triage active symptoms or manage wound care. Access to clinics should be well maintained for those special circumstances to avoid patients seeking care in the ED. Only a minimum of required support personnel with protective measures should be present for these visits. When in critical need, consideration should be given to redeploying OR resources for intensive care needs
- Promote virtual meetings only and/or limited to core team members only. The multidisciplinary team is responsible for the decision-making and prioritizing need for surgery.
Procedural considerations
- Though there are very little evidence on the relative risks of minimally invasive surgery (MIS) versus the conventional open approach, specific to COVID-19,[24] researchers have continuing to monitor these issues
- There is high possibility of viral contamination to staff during surgery either open, laparoscopic, or robotic. Hence, protective measures should be strictly employed for staff safety and to maintain a functioning workforce
- Though there are reports on aerosolization of blood-borne viruses with laparoscopy, there is no evidence to link it with COVID-19[25],[26],[27]
- Proven benefits of MIS of reduced length of stay and complications should be strongly considered in these patients, in addition to the potential for ultrafiltration of the majority or all aerosolized particles. Filtration of aerosolized particles may be more difficult during open surgery
- Strict use of PPE should be considered for the whole team of proceduralists/endoscopists, following the Centers for Disease Control or the WHO guidelines for droplets or airborne precautions. This likely includes, at minimum, N95 masks and face shields.[5],[6]
Practical measures for surgery
- Consent discussion with patients must cover the risk of COVID-19 exposure and potential consequences
- All surgical patients should be tested for COVID-19 preoperatively
- Intubation and extubation should preferably be done within a negative pressure room if possible[7],[8]
- ORs of COVID-19-positive patients should be appropriately cleaned, filtered, and ventilated. Moreover, it should be a different negative pressure OR
- Strictly essential staff only should be participating in the surgical case, and unless there is an emergency, there should be no exchange of room staff
- All members of the OR staff should use protective measures recommended by the WHO or CDC. Observe strict adherence of CDC guidelines should be made in the placement and removal of PPE
- Equipment like electrocautery and ultrasonic dissectors should be minimized, as these can lead to particle aerosolization.[6],[9],[10],[11],[23] It is recommended use monopolar diathermy pencils with attached smoke evacuators should be used
- Separate cleaning of equipment should be used for COVID-19 positive or suspected patients.
It is highly recommended to follow the standardized guidelines for surgical smoke safety from surgical diathermy since surgical smoke carries full virus particles (such as COVID-19 virus). Hence, it is strongly recommended to minimize or avoid surgical diathermy during the COVID-19 outbreak.[28]
| Negative Pressure Operating Room | | |
The SARS crisis led to the construction of a negative pressure OR. Negative pressure OR is currently used for the treatment of suspected or confirmed airborne infection cases. A standard positive pressure operating theatre can be converted into a negative pressure environment. When COVID-19 patients required surgical procedures, a negative pressure theater would be considered to be more suitable than a positive pressure environment. The risk of cross-contamination from airborne infection is low if adequately protected with appropriate personal protection equipment.
A negative pressure operating theater offers optimal protection to personnel working in adjacent areas.[29] Whereas a positive pressure operating theater with adequate air changes cross-contamination from airborne infection is low if the staff is adequately protected with appropriate PPE.[30] A negative pressure room is particularly crucial in the COVID-19 outbreak, but the need for such rooms can put extreme stress on hospitals. The management of patients with known or suspected COVID-19 requires specific considerations to safety for staff and patients. In the OR doctors should avoid unreliable, unfamiliar, or repeated techniques during airway management and surgical procedures, thus enabling it to be accurate, safe, and swift.[31] Other recommendations in OR during the COVID-19 pandemic are mandatory to minimize the number of staff, a dedicated team comprising a senior member and two senior residents for any case.[32]
| New Rulings in COVID-19 Outbreak | | |
The virus has knocked thousands of health workers out of action, as the medical team falls sick, the burdens increase on health care systems already groaning under the strain of the pandemic.[23] In many countries, orthopedic surgeons are urged to work outside their specific areas of training and expertise; hence, they are re-trained and transferred to primary and emergency care units to help in overwhelmed specialties. Outpatient clinics are shut down; elective operations are cancelled, the operating theatres are transformed into intensive care units, and reserved for ventilation and respiratory management of these patients.[33] It is noted that there is a temporary increased oxygen demand during the postoperative period of hip fracture patients who were asymptomatic or mild COVID-19 infection.[34] Hip fracture patients can safely undergo early surgical intervention after appropriate medical optimization.
There is another useful suggestion that non-obligatory fractures such as distal radius fractures can be managed conservatively with the use of telemedicine applications.[35] COVID-19 pandemic has triggered a near-total shutdown of arthroplasty surgeries in many places. Only life-threatening pathologies such as periprosthetic fractures and acute septic total joint arthroplasties are currently being treated surgically.[36] Orthopedic health-care services such as arthroscopic surgeries and elective total joint arthroplasty of many countries are suffering a drastic cutback due to COVID-19. This drastic cutback in orthopedic health-care services has to be viewed as historic.[37]
| Research and Future Perspective | | |
Orthopedic surgeons have the opportunity to think and work to produce meaningful research and to design and implement strategies to overcome barriers to the delivery of care to the injured during the COVID-19 outbreak.[33] During this time, a large number of medical research, including Orthopedic studies has been paused. Many academic meetings of all levels have been cancelled or rescheduled.[33] COVID-19 pandemic will definitely give us the opportunity to learn many lessons and we hope the outcome will be better coordinated. Since we live in a digital age, the transmission of information will happen rapidly and shall have the opportunity to evaluate hospital registries of different countries. It is the responsibility of every Orthopedic doctor to provide medical information and transfer knowledge despite casualties and to continue research and scientific writings without any fear in this pandemic.[38]
Recently it is observed an unprecedented rise of scientific submissions to Orthopedic journals. It is believed to be due to services lockdown, which makes the surgeons staying more at home to write and submit their papers that were pending for a long.[33] Editors have warned to be vigilant to the quality of submissions as many old studies that were not published or rejected are submitting for publication.[33] Research structure under the current circumstances will be negatively affected.[39] The majority of nonessential clinical staff, such as research coordinators and research fellows, has been sent home to work on at home basis. This will affect the department's academic productivity. Hence, it is advisable that research coordinators and fellows can prepare research protocols ready which can be deadly used as soon as the crisis hopefully fades.[39]
| Conclusion | | |
The delivery of care and services toward the patients during the COVID-19 pandemic must be strengthened, and the capacity to provide its services and its quality must be enhanced. There are several useful recommendations and directions of orthopedic practices in the COVID-19 outbreak. It is advisable to strictly follow the general recommendation and to observe other recommendations tailor-made according to the situation demands of each institution. We need to be conscious of specific refinement with regard to orthopedics when surgically managing patients with COVID-19.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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