Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease

Abstract

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Keywords

COVID-19 - consensus - recommendations - orthopaedics surgery - initial and mid-lockdown phases - rationale treatment

• References

• 1 Jerome JTJ. Is everything okay? COVID-19. J Hand Microsurg
• 2 Guo X, Wang J, Hu D. et al. Survey of COVID-19 disease among orthopaedic surgeons in Wuhan, People’s Republic of China. J Bone Joint Surg Am 2020; 102 (10) 847-854
• 3 WHO. Coronavirus disease (COVID-19) technical guidance: patient management. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management. Accessed June 11, 2020
• 4 Centers for Disease Control and Prevention. Information for healthcare professionals about coronavirus (COVID-19). Available at: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html. Accessed May 29, 2020
• 5 National Clinical Programme in Surgery. Information for surgeons regarding OPD triage during COVID-19 epidemic. Available at: https://msurgery.ie/wp-content/uploads/2020/03/v3-NCPS-guidance-to-surgeons-for-OPD-triage-during-COVID-19.pdf. Accessed May 29, 2020
• 6 Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. Available at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed May 29, 2020
• 7 Guy DK, Bosco JA, III, Savoie FH., III . AAOS guidelines for elective surgery during the COVID-19 pandemic. Available at: https://www.aaos.org/about/covid-19-information-for-our-members/aaos-guidelines-for-elective-surgery/. Accessed June 11, 2020
• 8 Chen YC, Lin WC. Risk of long-term infection-related death in clinical osteoporotic vertebral fractures: A hospital-based analysis. PLoS One 2017; 12 (08) e0182614
• 9 HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet 2020; 395 (10225) 698-708
• 10 Lizaur-Utrilla A, Lopez-Prats FA. Hip attack for hip fractures: is ultra-early surgery necessary?. Lancet 2020; 395 (10225) 661-662
• 11 Ravi B, Pincus D, Wasserstein D. et al. Association of overlapping surgery with increased risk for complications following hip surgery: a population-based, matched cohort study. JAMA Intern Med 2018; 178 (01) 75-83
• 12 Wong KC, Leung KS, Hui M. Severe acute respiratory syndrome (SARS) in a geriatric patient with a hip fracture. A case report. J Bone Joint Surg Am 2003; 85 (07) 1339-1342
• 13 Mi B, Chen L, Xiong Y, Xue H, Zhou W, Liu G. Characteristics and early prognosis of COVID-19 infection in fracture patients. J Bone Joint Surg Am 2020; 102 (09) 750-758
• 14 Liu VX, Rosas E, Hwang J. et al. Enhanced recovery after surgery program implementation in 2 surgical populations in an integrated health care delivery system. JAMA Surg 2017; 152 (07) e171032
• 15 Pietrafesa CA, Hoffman JR. Traumatic dislocation of the hip. JAMA 1983; 249 (24) 3342-3346
• 16 Zh en, g. MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann Surg 2020;
• 17 Alleblas CC, Velthuis S, Nieboer TE, Sietses C, Stegeman DF. The physical workload of surgeons: a comparison of SILS and conventional laparoscopy. Surg Innov 2015; 22 (04) 376-381
• 18 Janhofer DE, Lakhiani C, Song DH. Addressing surgeon fatigue: current understanding and strategies for mitigation. Plast Reconstr Surg 2019; 144 (04) 693e-699e
• 19 McCormick F, Kadzielski J, Landrigan CP, Evans B, Herndon JH, Rubash HE. Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents. Arch Surg 2012; 147 (05) 430-435
• 20 Nogler M, Lass-Flörl C, Wimmer C, Mayr E, Bach C, Ogon M. Contamination during removal of cement in revision hip arthroplasty. A cadaver study using ultrasound and high-speed cutters. J Bone Joint Surg Br 2003; 85 (03) 436-439
• 21 American Society for Testing and Materials (ASTM) F2407. (2020). Available at: https://www.astm.org/COVID-19/. Accessed June 11, 2020
• 22 He X, Lau EHY, Wu P. et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med 2020; 26 (05) 672-675
• 23 Lee SA, Hwang DC, Li HY, Tsai CF, Chen CW, Chen JK. Particle size-selective assessment of protection of European standard FFP respirators and surgical masks against particles-tested with human subjects. J Healthc Eng 2016; 2016: 8572493
• 24 Burnett RS, Berger RA, Paprosky WG, Della Valle CJ, Jacobs JJ, Rosenberg AG. Extensor mechanism allograft reconstruction after total knee arthroplasty. A comparison of two techniques. J Bone Joint Surg Am 2004; 86 (12) 2694-2699
• 25 Ho, e Gan W. Wah Lim J, Koh D. Preventing intra-hospital infection and transmission of COVID-19 in healthcare workers. Saf Health Work 2020;
• 26 NationalChildren’s Medical Center & Children’s Hospital of Fudan University’s Guideline Formulating Team of Rapid Screening & Clinical Practices for Suspected and Confirmed Cases of Pediatric Novel Coronavirus Infection or Pneumonia Guideline of Rapid Screening & Clinical Practices for Suspected and Confirmed Cases of Pediatric Novel Coronavirus Infection or Pneumonia. Chin J Evid Based Pediatr 2020; 15: 1-4
• 27 Rodrigues-Pinto R, Sousa R, Oliveira A. Preparing to perform trauma and orthopaedic surgery on patients with COVID-19. J Bone Joint Surg Am 2020; 102 (11) 946-950
• 28 Chee VW, Khoo ML, Lee SF, Lai YC, Chin NM. Infection control measures for operative procedures in severe acute respiratory syndrome-related patients. Anesthesiology 2004; 100 (06) 1394-1398
• 29 Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020; 67 (05) 568-576
• 30 Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anaesth 2020; 67 (06) 756-758
• 31 Yeh HC, Turner RS, Jones RK, Muggenburg BA, Lundgren DL, Smith JP. Characterization of aerosols produced during surgical procedures in hospitals. Aerosol Sci Technol 1995; 22: 151-161
• 32 Tellier R, Li Y, Cowling BJ, Tang JW. Recognition of aerosol transmission of infectious agents: a commentary. BMC Infect Dis 2019; 19 (01) 101
• 33 Heinsohn P, Jewett DL. Exposure to blood-containing aerosols in the operating room: a preliminary study. Am Ind Hyg Assoc J 1993; 54 (08) 446-453
• 34 Hirschmann MT, Hart A, Henckel J, Sadoghi P, Seil R, Mouton C. COVID-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon. Knee Surg Sports Traumatol Arthrosc 2020; 28 (06) 1690-1698
• 35 Liang ZC, Chong MSY, Sim MA. et al. Surgical considerations in patients with COVID-19: what orthopaedic surgeons should know. J Bone Joint Surg Am 2020; 102 (11) e50
• 36 Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009; 102 (01) 12-22
• 37 Högel F, Gerlach UV, Südkamp NP, Müller CA. Pulmonary fat embolism after reamed and unreamed nailing of femoral fractures. Injury 2010; 41 (12) 1317-1322
• 38 Anfinrud P, Stadnytskyi V, Bax CE, Bax A. Visualizing speech-generated oral fluid droplets with laser light scattering. N Engl J Med 2020; 382 (21) 2061-2063
• 39 WHO. Infection prevention and control during healthcare when COVID-19 is suspected 2020; Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed April 20, 2020
• 40 Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One 2012; 7 (04) e35797
• 41 Bai Y, Yao L, Wei T. et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA 2020; 323 (14) 1406-1407
• 42 A, wa, d ME. Rumley JCL, Vazquez JA, Devine JG. Perioperative considerations in urgent surgical care of suspected and confirmed coronavirus disease 2019 orthopaedic patients: operating room protocols and recommendations in the current coronavirus disease 2019 pandemic. J Am Acad Orthop Surg 2020;
• 43 Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020; 104 (03) 246-251
• 44 Hulkower RL, Casanova LM, Rutala WA, Weber DJ, Sobsey MD. Inactivation of surrogate coronaviruses on hard surfaces by health care germicides. Am J Infect Control 2011; 39 (05) 401-407
• 45 Kariwa H, Fujii N, Takashima I. Inactivation of SARS coronavirus by means of povidone-iodine, physical conditions and chemical reagents. Dermatology 2006; 212 (Suppl 1) 119-123
• 46 Pottage T, Richardson C, Parks S, Walker JT, Bennett AM. Evaluation of hydrogen peroxide gaseous disinfection systems to decontaminate viruses. J Hosp Infect 2010; 74 (01) 55-61
• 47 Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?. Lancet Respir Med 2020; 8 (04) e21
• 48 St inn, er DJ, Lebrun C, Hsu JR, Jahangir AA, Mir HR. The orthopaedic trauma service and COVID-19 - practice considerations to optimize outcomes and limit exposure. J Orthop Trauma 2020;
• 49 Chang Liang Z, Wang W, Murphy D, Po Hui JH. Novel coronavirus and orthopaedic surgery: early experiences from Singapore. J Bone Joint Surg Am 2020; 102 (09) 745-749
• 50 Loeb AE, Rao SS, Ficke JR, Morris CD, Riley III LH, Levin AS. Departmental experience and lessons learned with accelerated introduction of telemedicine during the COVID-19 crisis. J Am Acad Orthop Surg 2020; 28 (11) e469-e476
• 51 Prada C, Chang Y, Poolman R, Johal H, Bhandari M. Best practices for surgeons. COVID-19 evidence-based scoping review. A unifying report of global recommendations. 2020. Available at: https://myoe.blob.core.windows.net/docs/OE-Best-Practices-for-Surgeons-COVID-19-Evidence-Based-Scoping-Review.pdf. Accessed June 11, 2020
• 52 Bernheim A, Mei X, Huang M. et al. Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection. Radiology 2020; 295 (03) 200463
• 53 CDC. Interim guidelines for COVID-19 antibody testing. Available at: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html. Accessed May 31 2020
• 54 Schwartz A, Wilson J, Boden S. et al. Managing resident workforce and education during the COVID-19 pandemic. J Bone Joint Surg Am 2020; 5 (02) e0045
• 55 Chavez S, Long B, Koyfman A. et al. Coronavirus disease (COVID-19): a primer for emergency physicians. Am J Emerg Med 2020;
• 56 Grimm CA. Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23–27, 2020. Washington, DC: U.S. Department of Health and Human Services OoIG; 2020: 1-41
• 57 Ze. ege. n EN. Yates AJ, Jevsevar DS. After the COVID-19 pandemic: returning to normalcy or returning to a new normal?. J Arthroplasty 2020;
• 58 Toy PC, Fournier MN, Throckmorton TW, Mihalko WM. Low rates of adverse events following ambulatory outpatient total hip arthroplasty at a free-standing surgery center. J Arthroplasty 2018; 33 (01) 46-50
• 59 J, aib. aji M, Volpin A, Haddad FS, Konan S. Is outpatient arthroplasty safe? A systematic review. J Arthroplasty 2020;
• 60 Hoffmann JD, Kusnezov NA, Dunn JC, Zarkadis NJ, Goodman GP, Berger RA. The shift to same-day outpatient joint arthroplasty: a systematic review. J Arthroplasty 2018; 33 (04) 1265-1274
• 61 Kogan M, Klein SE, Hannon CP, Nolte MT. Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg 2020; 28 (11) e456-e464
• 62 Coe TM, Jogerst KM, Sell NM. et al. Practical techniques to adapt surgical resident education to the COVID-19 era. Ann Surg 2020;