Did we do the right thing? The appropriateness of orthopedic operative interventions during the height of the coronavirus disease 2019 pandemic.

PURPOSE: During the coronavirus disease (COVID) pandemic elective surgeries were cancelled and operative indications curtailed to counteract shortages in resources. We aimed to review each orthopedic operative indication at an urban Level 1 Trauma Center inundated with COVID. We aimed to classify the appropriateness of each operative intervention and determine if exposure to COVID impacted morbidity or mortality. METHODS: All orthopedic procedures between March 16, 2020 and May 16, 2020 were reviewed. The most urgent surgical indication for each procedure was classified by 2 fellowship trained orthopedic trauma surgeons and 2 senior residents. The appropriateness of the operative intervention was determined. The American Academy of Orthopedic Surgery (AAOS) and American College of Surgeons (ACS) guidelines for surgery during the pandemic were considered. RESULTS: Seventy-six surgical encounters were performed on 71 inpatients including 99 total procedures. No outpatient procedures were performed. Fifty-four of 71 patients were male. There was a mean age of 51.6 years. Of 71 patients, 41 presented to the emergency department without trauma activation with a mean time to presentation of 2.7 days post injury. The most urgent surgical indications included 18 hip fractures, 18 periarticular fractures, 17 open fractures, 7 severe infections, 5 pelvic fractures, 5 femoral shaft fractures, 3 spinal injuries, 1 tibial fracture, 1 tendon injury, and 1 clavicle fracture. Four procedures could have been delayed for conservative management without causing significant harm. Upon discharge 13/71 patients had tested positive for COVID, 41/71 had remained negative throughout their hospital stay, and 17/71 patients never were tested. Four patients contracted COVID in the hospital. There were 4 in hospital deaths, 2 attributed to hypoxemic respiratory failure secondary to COVID pneumonia. CONCLUSION: It was determined that 72/76 cases were considered appropriate in following guidelines of the AAOS and ACS. This highlights the value of halting outpatient procedures and limiting patient exposure to COVID. Comprehensive patient/provider discussions addressing the risks, benefits, alternatives to surgery, and the risk of exposure to respiratory illness are vital. It behooves the surgical team to follow established guidelines such as those of the AAOS and ACS when triaging orthopedic patients for a surgical admission.

Percutaneous Screw Stabilization of Non-Periacetabular Pelvic Lesions Caused by Metastatic Cancer and Multiple Myeloma.

BACKGROUND: The pelvis is one of the most common locations for metastatic bone disease. While many of the publications that describe surgical treatments focus on periacetabular lesions (Enneking zone II), there is a lack of investigation into lesions in the non-periacetabular areas (zones I, III, and IV). We recently described a minimally invasive percutaneous screw application for metastatic zone-II lesions with excellent results. In the present study, we aimed to extend this approach to the other pelvic areas. METHODS: Twenty-two consecutive patients with painful non-periacetabular pelvic metastatic cancer were included based on retrospective chart review. There were 16 women and 6 men with an average age of 60 years (range, 36 to 81 years). The most common primary cancers were multiple myeloma (7 cases) and breast (5 cases). The most common locations were the sacrum and the ilium. A pathologic fracture was identified in 15 patients. Most of the lesions were treated with multiple large-diameter screws, except for the isolated zone-III lesions. All of the procedures were completed in a standard operating room without the need for special instruments. Radiation therapy was given to 19 patients; the average dose was 15 Gy. The studied outcomes were pain and functionality as assessed by a visual analog scale (VAS) score and the Eastern Cooperative Oncology Group score (ECOG), respectively. RESULTS: There were no surgical complications and no need for blood transfusion. The average follow-up time was 7 months (range, 0.3 to 34.0 months). Two patients died within 4 weeks of surgery due to COVID-19 infection. There was significant improvement in the postoperative VAS pain score (p < 0.0001) and the ECOG score (p < 0.05) when compared with the preoperative scores. There was no implant failure or revision surgery. Local bone-healing was observed in 12 of 14 patients (86%) who survived for >3 months after surgery. CONCLUSIONS: Percutaneous screw application is safe and effective in the treatment of metastatic non-periacetabular pelvic lesions. Given the simplicity of the technique and the instrumentation and the tolerance for concomitant treatments, this approach is worthy of broader consideration. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.