Contactless Remote 3D Splinting during COVID-19: Report of Two Patients.

We used calibrated 2D images uploaded by patients to an online platform to generate a 3D digital model of the limb. This was used to 3D print a splint. This method of 3D printing of splints was used for two patients who were not able to visit the hospital in person due to restrictions placed by the COVID-19 pandemic. Both patients were satisfied with the splint. We feel that this technology could be used to offer additional options to conventional splinting that allows contactless splint fitting. Level of Evidence: Level V (Therapeutic).

Are telemedicine cardiac clearance visits safe prior to lumbar fusion?

BACKGROUND CONTEXT Since the start of the coronavirus (COVID-19) pandemic, telemedicine has increased in popularity to deliver health care via a remote setting. Preoperative spine surgery clearance visits are imperative for assessing and stratifying patients based on cardiac risk factors for potential invasive testing prior to surgery. However, it is unclear if moving these visits to a remote setting delivers the same quality of care as in person visits. PURPOSE To compare the rates of complications, readmissions, mortality, and cancellations for all patients who underwent spine procedures based on the setting of the preoperative cardiac clearance. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE Patients >18 years-old who underwent any spine procedure performed by one of our fellowship-trained spine surgeons at a single tertiary academic center from January 1st, 2019 to June 30th, 2021. OUTCOME MEASURES Complications, readmissions, inpatient and 90-day mortality and cancellations. METHODS Patients were split into in-person or telemedicine cohorts based on their preoperative cardiac clearance visit. Patients were also split into cohorts based on their medical cardiac history. Cancellations, inpatient complications, 90-day readmission and inpatient and 90-day mortality were compared between the cohorts. Secondary analysis included multiple logistic regression to determine independent predictors of cancellations, 90-day readmission and 90-day mortality and multiple linear regression for inpatient complications. RESULTS A total of 1,963 patients were included with 1,407 patients having an in-person preoperative cardiac clearance visit and 556 having telemedicine clearance. The two cohorts had similar inpatient complications (0.6 vs 0.6, p=0.812), 90-day readmission (5.2% vs 4.9%, p=0.763), inpatient mortality (0.1% vs 0.2%, p=0.486), and 90-day mortality (0.6% vs 0.9%, p=0.370). The telemedicine cohort had more cancelled surgeries (4.5% vs 6.7%, p=0.048). Patients with a medical cardiac history had more inpatient complications (mean, 0.6 vs 0.8, p=0.011), and higher inpatient (0.0% vs 0.3%, p=0.039) and 90-day mortality (0.4% vs 1.3%, p=0.023). A subgroup analysis of patients with a medical cardiac history showed that patients who had a telemedicine visit had more cancellations (3.9% vs 10.3%, p=0.005) and higher 90-day mortality (0.8% vs 3.4%, p=0.024) than in-person visits. On regression, having a telemedicine visit was an independent predictor of preoperative cancellation (OR 1.57, p=0.039). Similarly, age (OR 1.02, p=0.042) and Elixhauser (OR 1.18, p=0.012) were associated with cancellation. A medical cardiac history (0.16, p=0.005), age (0.005, p=0.002), female sex (0.18, p <0.001), CCI (0.06, p=0.005), surgery in the thoracolumbar region (0.84, p <0.001), anterior approach (ref: posterior, 0.20, p=0.047), and combined approach (ref: posterior, 0.37, p <0.001) were independent predictors of increased inpatient complications while surgery in the cervical region was associated with decreased inpatient complications (ref: lumbar, -0.38, p <0.001). CCI was an independent predictor of 90-day mortality (OR 2.02, p <0.001). CONCLUSIONS Patients with a cardiac history who undergo telemedicine visits have increased cancellations and 90-day mortality. Telemedicine for preoperative cardiac clearance is safe for appropriately selected patients but carries increased risk of case cancellation and in-person visits should be strongly considered for patients with a history of heart disease. FDA DEVICE/DRUG STATUS This does not discuss or include any applicable devices or drugs.

Lumbar Spine Surgery and What We Lost in the Era of the Coronavirus Pandemic: A Survey of the Lumbar Spine Research Society.

STUDY DESIGN: This was a survey of the surgeon members of the Lumbar Spine Research Society (LSRS). OBJECTIVE: The purpose of this study was to assess trends in surgical practice and patient management involving elective and emergency surgery in the early months of the coronavirus pandemic. SUMMARY OF BACKGROUND DATA: The novel coronavirus has radically disrupted medical care in the first half of 2020. Little data exists regarding the exact nature of its effect on spine care. METHODS: A 53-question survey was sent to the surgeon members of the LSRS. Respondents were contacted via email 3 times over a 2-week period in late April. Questions concentrated on surgical and clinical practice patterns before and after the pandemic. Other data included elective surgical schedules and volumes, as well as which emergency cases were being performed. Surgeons were asked about the status of coronavirus disease 2019 (COVID-19) virus testing. Circumstances for performing surgical intervention on patients with and without testing as well as patients testing positive were explored. RESULTS: A total of 43 completed surveys were returned of 174 sent to active surgeons in the LSRS (25%). Elective lumbar spine procedures decreased by 90% in the first 2 months of the pandemic, but emergency procedures did not change. Patients with "stable" lumbar disease had surgeries deferred indefinitely, even beyond 8 weeks if necessary. In-person outpatient visits became increasingly rare events, as telemedicine consultations accounted for 67% of all outpatient spine appointments. In total, 91% surgeons were under some type of confinement. Only 11% of surgeons tested for the coronavirus on all surgical patients. CONCLUSIONS: Elective lumbar surgery was significantly decreased in the first few months of the coronavirus pandemic, and much of outpatient spine surgery was practiced via telemedicine. Despite these constraints, spine surgeons performed emergency surgery when indicated, even when the COVID-19 status of patients was unknown. LEVEL OF EVIDENCE: Level IV.

Evaluating Patient Interest in Orthopedic Telehealth Services Beyond the COVID-19 Pandemic.

Background Patient interest and demand may have an impact on dictating the scope of orthopedic telehealth utilization beyond the coronavirus disease 2019 (COVID-19) pandemic. The purpose of this study was to assess whether current interest in orthopedic telehealth services is higher than pre-pandemic levels. Specific trends in interest, subspecialty differences, and regional differences were secondarily assessed. Methodology A Google Trends search was performed to assess orthopedic telehealth search interest over the last five years using the terms "Orthopedic surgeon/doctor/injury/pain + Telehealth" as well as subspecialty-specific terms. The results were formulated into combined search interest values (CSIVs), with a maximum possible value of 400, and compared between the pre-pandemic period, pre-vaccine period during the pandemic, and post-vaccine period. Results The pre-pandemic period mean CSIV was 40.3 (SD = 6.3), compared to 134.7 (SD = 72.1) during the pre-vaccine period, and 96.3 (SD = 4.4) during the post-vaccine period (p < 0.001). There was a positive correlation between CSIV and time (increasing weeks) during the pre-pandemic period (rs = .77, p < 0.001) and no significant correlation between CSIV and time during the post-vaccine period (rs = -.12, p = 0.610). Using the slope of the interest line during the post-vaccine period (y = 97.06 - 0.08x) it would take an additional 13.3 years beyond the study period to reach the mean pre-pandemic CSIV level of 40.3. Hand surgery was the subspecialty with the highest mean CSIV over the study period and general search interest was highest in Northeastern and Southeastern states during the post-vaccine period. Conclusions Orthopedic telehealth interest was growing before the COVID-19 pandemic and remains significantly elevated beyond pre-pandemic levels despite the reopening of clinical offices and vaccine availability across the country. It appears that a subset of patients will continue to seek telehealth services beyond the pandemic.

What was the Prevalence of COVID-19 in Asymptomatic Patients Undergoing Orthopaedic Surgery in One Large United States City Mid-pandemic?

BACKGROUND: Many patients with coronavirus disease 2019 (COVID-19) are asymptomatic. The prevalence of COVID-19 in orthopaedic populations will vary depending on the time and place where the sampling is performed. The idea that asymptomatic carriers play a role is generalizable but has not been studied in large populations of patients undergoing elective orthopaedic surgery. We therefore evaluated this topic in one large, metropolitan city in a state that had the ninth-most infections in the United States at the time this study was completed (June 2020). This work was based on a screening and testing protocol that required all patients to be tested for COVID-19 preoperatively. QUESTIONS/PURPOSES: (1) What is the prevalence of asymptomatic COVID-19 infection in patients planning to undergo orthopaedic surgery in one major city, in order to provide other surgeons with a framework for assessing COVID-19 rates in their healthcare system? (2) How did patients with positive test results for COVID-19 differ in terms of age, sex, and orthopaedic conditions? (3) What proportion of patients had complications treated, and how many patients had a symptomatic COVID-19 infection within 30 days of surgery (recognizing that some may have been missed and so our estimates of event rates will necessarily underestimate the frequency of this event)? METHODS: All adult patients scheduled for surgery at four facilities (two tertiary care hospitals, one orthopaedic specialty hospital, and one ambulatory surgery center) at a single institution in the Philadelphia metropolitan area from April 27, 2020 to June 12, 2020 were included in this study. A total of 1295 patients were screened for symptoms, exposure, temperature, and oxygen saturation via a standardized protocol before surgical scheduling; 1.5% (19 of 1295) were excluded because they had COVID-19 symptoms, exposure, or recent travel based on the initial screening questionnaire, leaving 98.5% (1276 of 1295) who underwent testing for COVID-19 preoperatively. All 1276 patients who passed the initial screening test underwent nasopharyngeal swabbing for COVID-19 via reverse transcription polymerase chain reaction before surgery. The mean age at the time of testing was 56 ± 16 years, and 53% (672 of 1276) were men. Eighty-seven percent (1106), 8% (103), and 5% (67) were tested via the Roche, Abbott, and Cepheid assays, respectively. All patients undergoing elective surgery were tested via the Roche assay, while those undergoing nonelective surgery received either the Abbott or Cepheid assay, based on availability. Patients with positive test results undergoing elective surgery had their procedures rescheduled, while patients scheduled for nonelective surgery underwent surgery regardless of their test results. Additionally, we reviewed the records of all patients at 30 days postoperatively for emergency room visits, readmissions, and COVID-19-related complications via electronic medical records and surgeon-reported complications. However, we had no method for definitively determining how many patients had complications, emergency department visits, or readmissions outside our system, so our event rate estimates for these endpoints are necessarily best-case estimates. RESULTS: A total of 0.5% (7 of 1276) of the patients tested positive for COVID-19: five via the Roche assay and two via the Abbott assay. Patients with positive test results were younger than those with negative results (39 ± 12 years versus 56 ± 16 years; p = 0.01). With the numbers available, we found no difference in the proportion of patients with positive test results for COVID-19 based on subspecialty area (examining the lowest and highest point estimates, respectively, we observed: trauma surgery [3%; 2 of 68 patients] versus hip and knee [0.3%; 1 of 401 patients], OR 12 [95% CI 1-135]; p = 0.06). No patients with negative preoperative test results for COVID-19 developed a symptomatic COVID-19 infection within 30 days postoperatively. Within 30 days of surgery, 0.9% (11 of 1276) of the patients presented to the emergency room, and 1.3% (16 of 1276) were readmitted for non-COVID-19-related complications. None of the patients with positive test results for COVID-19 preoperatively experienced complications. However, because some were likely treated outside our healthcare system, the actual percentages may be higher. CONCLUSION: Because younger patients are more likely to be asymptomatic carriers of disease, surgeons should emphasize the importance of taking proper precautions to prevent virus exposure preoperatively. Because the rates of COVID-19 infection differ based on city and time, surgeons should monitor the local prevalence of disease to properly advise patients on the risk of COVID-19 exposure. Further investigation is required to assess the prevalence in the orthopaedic population in cities with larger COVID-19 burdens. LEVEL OF EVIDENCE: Level III, therapeutic study.

Spine Patient Satisfaction With Telemedicine During the COVID-19 Pandemic: A Cross-Sectional Study.

STUDY DESIGN: Original research, cross-sectional study. OBJECTIVES: Evaluate patient satisfaction with spine care delivered via telemedicine. Identify patient- and visit-based factors associated with increased satisfaction and visit preference. METHODS: Telemedicine visits with a spine surgeon at 2 practices in the United States between March and May 2020 were eligible for inclusion in the study. Patients were sent an electronic survey recording overall satisfaction, technical or clinical issues encountered, and preference for a telemedicine versus an in-person visit. Factors associated with poor satisfaction and preference of telemedicine over an in-person visit were identified using multivariate logistic regression. RESULTS: A total of 772 responses were collected. Overall, 87.7% of patients were satisfied with their telemedicine visit and 45% indicated a preference for a telemedicine visit over an in-person visit if given the option. Patients with technical or clinical issues were significantly less likely to achieve 5 out of 5 satisfaction scores and were significantly more likely to prefer an in-person visit. Patients who live less than 5 miles from their surgeon's office and patients older than 60 years were also significantly more likely to prefer in-person visits. CONCLUSIONS: Spine telemedicine visits during the COVID-19 pandemic were associated with high patient satisfaction. Additionally, 45% of respondents indicated a preference for telemedicine versus an in-patient visit in the future. In light of these findings, telemedicine for spine care may be a preferable option for a subset of patients into the future.

Safety and Efficacy of Casting during COVID-19 Pandemic: A Comparison of the Mechanical Properties of Polymers Used for 3D Printing to Conventional Materials Used for the Generation of Orthopaedic Orthoses.

To reduce the risk of spread of the novel coronavirus (COVID-19), the emerging protocols are advising for less physician-patient contact, shortening the contact time, and keeping a safe distance. It is recommended that unnecessary casting be avoided in the events that alternative methods can be applied such as in stable ankle fractures, and hindfoot/midfoot/forefoot injuries. Fiberglass casts are suboptimal because they require a follow up for cast removal while a conventional plaster cast is amenable to self-removal by submerging in water and cutting the cotton bandages with scissors. At present, only fiberglass casts are widely available to allow waterproof casting. To reduce the contact time during casting, a custom-made 3D printed casts/splints can be ordered remotely which reduces the number of visits and shortens the contact time while it allows for self-removal by the patient. The cast is printed after the limb is 3D scanned in 5-10 seconds using the commercially available 3D scanners. In contrast to the conventional casting, a 3D printed cast/splint is washable which is an advantage during an infectious crisis such as the COVID-19 pandemic.

Practice Management During the COVID-19 Pandemic.

On March 14, 2020, the Surgeon General of the United States urged a widespread cessation of all elective surgery across the country. The suddenness of this mandate and the concomitant spread of the COVID-19 virus left many hospital systems, orthopaedic practices, and patients with notable anxiety and confusion as to the near, intermediate, and long-term future of our healthcare system. As with most businesses in the United States during this time, many orthopaedic practices have been emotionally and fiscally devastated because of this crisis. Furthermore, this pandemic is occurring at a time where small and midsized orthopaedic groups are already struggling to cover practice overhead and to maintain autonomy from larger health systems. It is anticipated that many groups will experience financial demise, leading to substantial global consolidation. Because the authors represent some of the larger musculoskeletal multispecialty groups in the country, we are uniquely positioned to provide a framework with recommendations to best weather the ensuing months. We think these recommendations will allow providers and their staff to return to an infrastructure that can adjust immediately to the pent-up healthcare demand that may occur after the COVID-19 pandemic. In this editorial, we address practice finances, staffing, telehealth, operational plans after the crisis, and ethical considerations.