Osteoporosis and Covid-19: Detected similarities in bone lacunar-level alterations via combined AI and advanced synchrotron testing.

While advanced imaging strategies have improved the diagnosis of bone-related pathologies, early signs of bone alterations remain difficult to detect. The Covid-19 pandemic has brought attention to the need for a better understanding of bone micro-scale toughening and weakening phenomena. This study used an artificial intelligence-based tool to automatically investigate and validate four clinical hypotheses by examining osteocyte lacunae on a large scale with synchrotron image-guided failure assessment. The findings indicate that trabecular bone features exhibit intrinsic variability related to external loading, micro-scale bone characteristics affect fracture initiation and propagation, osteoporosis signs can be detected at the micro-scale through changes in osteocyte lacunar features, and Covid-19 worsens micro-scale porosities in a statistically significant manner similar to the osteoporotic condition. Incorporating these findings with existing clinical and diagnostic tools could prevent micro-scale damages from progressing into critical fractures.

Remote Management of Patients after Total Joint Arthroplasty via a Web-Based Registry during the COVID-19 Pandemic.

BACKGROUND: In 2020, due to the outbreak of the COVID-19 (Coronavirus Disease 2019) pandemic, patients who underwent total joint arthroplasty were not able to undergo the proper postoperative surgical and rehabilitative care. This study aims to evaluate the potential of a web-cloud-based database on patients' follow-up in extraordinary situations, when a traditional in-person follow-up cannot be warranted. METHODS: Patients who underwent joint arthroplasty at our Institute between 21 February and 16 March 2020 were included in the study group and were matched to a similar population undergoing joint arthroplasty in February/March 2019. All patients routinely complete questionnaires before and after treatment, including patient-reported outcome measures such as the Visual Analogues Scale (VAS), Knee/Hip Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS/HOOS-PS) and Short-Form Health Survey (SF-12) for the monitoring of clinical improvements. RESULTS: 56 (study group) and 144 (control group) patients were included in the study. Both groups demonstrated significant improvements at 3 months. HOOS-PS improvement was significantly reduced in the 2020 group compared to 2019 (21.7 vs. 33.9, p < 0.001). This reduction was related to intense physical activities. Similarly, the functional score improvement related to these activities was reduced for patients undergoing knee replacement (8 vs. 10, p < 0.05). CONCLUSIONS: The web-based Institute Registry emerged as a meaningful and sensitive tool during an extraordinary situation such as the COVID-19 pandemic to monitor patients' progression after total joint arthroplasties. Thanks to this tool, it was possible to observe that the prevention of usual postoperative care due to pandemic-related restrictions did not alter the benefits observed after joint replacement surgeries, even if this condition reduced the postoperative improvements in the most burdensome physical activities. A broader use of this kind of tool would improve and potentially reduce the burden and costs of postoperative patients' monitoring in standard and extraordinary conditions. In addition, the systematic remote collection of data would allow for the identification of relevant differences in clinical outcomes in specific conditions or following the modification of treatment and rehabilitation protocols.

Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study.

BACKGROUND: Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy. MATERIALS AND METHODS: Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included. RESULTS: Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home. CONCLUSIONS: The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future. LEVEL OF EVIDENCE: IV.

Clinical Activities, Contaminations of Surgeons and Cooperation with Health Authorities in 14 Orthopedic Departments in North Italy during the Most Acute Phase of Covid-19 Pandemic.

Background: From 10 March up until 3 May 2020 in Northern Italy, the SARS-CoV-2 spread was not contained; disaster triage was adopted. The aim of the present study is to assess the impact of the COVID-19-pandemic on the Orthopedic and Trauma departments, focusing on: hospital reorganization (flexibility, workload, prevalence of COVID-19/SARS-CoV-2, standards of care); effects on staff; subjective orthopedic perception of the pandemic. Material and Methods: Data regarding 1390 patients and 323 surgeons were retrieved from a retrospective multicentric database, involving 14 major hospitals. The subjective directors' viewpoints regarding the economic consequences, communication with the government, hospital administration and other departments were collected. Results: Surgical procedures dropped by 73%, compared to 2019, elective surgery was interrupted. Forty percent of patients were screened for SARS-CoV-2: 7% with positive results. Seven percent of the patients received medical therapy for COVID-19, and only 48% of these treated patients had positive swab tests. Eleven percent of surgeons developed COVID-19 and 6% were contaminated. Fourteen percent of the staff were redirected daily to COVID units. Communication with the Government was perceived as adequate, whilst communication with medical Authorities was considered barely sufficient. Conclusions: Activity reduction was mandatory; the screening of carriers did not seem to be reliable and urgent activities were performed with a shortage of workers and a slower workflow. A trauma network and dedicated in-hospital paths for COVID-19-patients were created. This experience provided evidence for coordinated responses in order to avoid the propagation of errors.

A seven week observational analysis of clinical activities in a North Italian orthopaedic hospital during the second wave of SARS-CoV-2 pandemic: far from usual volumes, but different from the first wave.

PURPOSE: We previously described the radical changes occurred in an orthopaedic hospital in Milan (Italy) during the first SARS-CoV-2 pandemic outbreak. Currently, during the second wave, the situation is still far from normality. Here we describe the changes that took place, and are still ongoing, in the clinical practice. METHODS: Number and type of admissions, outpatients activity, ER and urgent procedures in SARS-CoV-2 negative and positive patients have been analyzed over seven weeks (October 26th-December 13th, 2020) and compared with the correspondent period in 2019 and the same timeframe during the first wave (February 24th-April 10th). RESULTS: 2019 vs. 2020: Overall admissions decreased by 39.8%; however, while admissions for elective surgery dropped by 42.0%, urgent surgeries increased by 117.0%. Rehabilitation admissions declined by 85.2%. White and green priority ER consultations declined by 41.6% and 52.0%, respectively; yellow and red increased by 766.7% and 400.0%, respectively. Second vs. first wave: Overall admissions increased by 58.6% with a smoother decrement in weekly admissions than during the first wave. Disparity of acute admissions vs. rehabilitation expanded: Acute cases increased by 63.6% while rehabilitation cases decreased by 8.7%. Admissions to triage procedures increased by 72.3%. CONCLUSIONS: Activity levels are far from normality during the second COVID-19 wave. Elective surgery and outpatients-related activities are still strongly limited compared to 2019 while the number of urgent cases treated increased consistently. SARS-CoV-2 positive emergencies are slightly higher than during the first wave. These important changes are expected to impact on health service and hospital budget for long.

Early mortality in hip fracture patients admitted during first wave of the COVID-19 pandemic in Northern Italy: a multicentre study.

BACKGROUND: Treatment of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic has posed unique challenges for the management of COVID-19-infected patients and the maintenance of standards of care. The primary endpoint of this study is to compare the mortality rate at 1 month after surgery in symptomatic COVID-positive patients with that of asymptomatic patients. A secondary endpoint of the study is to evaluate, in the two groups of patients, mortality at 1 month on the basis of type of fracture and type of surgical treatment. MATERIALS AND METHODS: For this retrospective multicentre study, we reviewed the medical records of patients hospitalised for proximal femur fracture at 14 hospitals in Northern Italy. Two groups were formed: COVID-19-positive patients (C+ group) presented symptoms, had a positive swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and received treatment for COVID-19; COVID-19-negative patients (C- group) were asymptomatic and tested negative for SARS-CoV-2. The two groups were compared for differences in time to surgery, survival rate and complications rate. The follow-up period was 1 month. RESULTS: Of the 1390 patients admitted for acute care for any reason, 477 had a proximal femur fracture; 53 were C+ but only 12/53 were diagnosed as such at admission. The mean age was > 80 years, and the mean American Society of Anesthesiologists (ASA) score was 3 in both groups. There was no substantial difference in time to surgery (on average, 2.3 days for the C+ group and 2.8 for the C- group). As expected, a higher mortality rate was recorded for the C+ group but not associated with the type of hip fracture or treatment. No correlation was found between early treatment (< 48 h to surgery) and better outcome in the C+ group. CONCLUSIONS: Hip fracture in COVID-19-positive patients accounted for 11% of the total. On average, the time to surgery was > 48 h, which reflects the difficulty of maintaining normal workflow during a medical emergency such as the present pandemic and notwithstanding the suspension of non-urgent procedures. Hip fracture was associated with a higher 30-day mortality rate in COVID-19-positive patients than in COVID-19-negative patients. This fact should be considered when communicating with patients and/or their family. Our data suggest no substantial difference in hip fracture management between patients with or without COVID-19 infection. In this sample, the COVID-19-positive patients were generally asymptomatic at admission; therefore, routine screening is recommended. LEVEL OF EVIDENCE: Therapeutic study, level 4.

Prioritising of hip and knee arthroplasty procedures during the COVID-19 pandemic: the European Hip Society and the European Knee Associates Survey of Members.

PURPOSE: During the COVID-19 pandemic there has been a massive reduction of arthroplasty services due to reallocation of hospital resources. The unique challenge for clinicians has been to define which arthroplasty patients most urgently require surgery. The present study aimed to investigate priority arthroplasty procedures during the pandemic and in the reinstatement period from the surgeon's perspective. MATERIAL AND METHODS: An online survey was conducted among members of the European Hip Society (EHS), European Knee Associates (EKA) and other invited orthopaedic arthroplasty surgeons (experts) from across the world. The survey consisted of 17 different arthroplasty procedures/indications of which participants were asked to choose and rank the most important 10. RESULTS: Four hundred and thirty-nine arthroplasty surgeons from 44 countries responded. The EHS and EKA had a 43% response rate of members. In weighted average points, the majority of respondents (67.5 points) ranked 'acute fractures requiring arthroplasty (Periprosthetic fractures, THA/hemi-arthroplasty for femoral neck fractures)' as priority indication number one, followed by 'first-stage explantations for acute PJI (periprosthetic joint infection)' in second place and priority indication (45.9 points) three as 'one-stage revision for acute PJI' (39.7 points). CONCLUSIONS: There was agreement that femoral neck fractures, periprosthetic fractures, and acute infections should be prioritised and cannot be postponed in the setting of the COVID-19 pandemic. As arthroplasty procedures are being resumed in most countries now, there has also been a relaxation of lockdown rules in most countries, which might cause a so-called second wave of the pandemic. Therefore, the results of the current study present a proposal by experts as to which operations should be prioritised in the setting of a second wave of the pandemic.

Changes of clinical activities in an orthopaedic institute in North Italy during the spread of COVID-19 pandemic: a seven-week observational analysis.

PURPOSE: The COVID-19 pandemic is importantly affecting the orthopaedic practice all over the world with Northern Italy being the first European area that faced the worst scenario. In this study, the changes in clinical practice occurred in an orthopaedic center in Milan are described. METHODS: Number and type of admissions, outpatients cancelled and preserved, emergency room, and intensive care unit activities have been analyzed in the timeframe of seven weeks since the beginning of the pandemic (from February 24th to April 10th) and compared with the same period in 2019. RESULTS: The planned surgical admissions declined from 2172 in 2019 to 664 in 2020 (69.42%, p < 0.0001), while emergencies increased from 158 to 268 (69.62%). The rehabilitation admissions declined from 414 to 69 (83.33%). The overall admission decreased by 63.52%, the trend showed a drop in the last weeks. Surgery performed in the COVID-19 operating room increased by 16.7% in the last week. Seven deaths occurred (0.7% of all orthopaedics and trauma admissions) compared with four (0.1%) which happened in the same period in 2019 (p = 0.004). Six of these patients were suffering from COVID-19. A total of 23,580 outpatients (93.8%) were cancelled. Emergency room consultations declined by 68.14% and 63.47% among white and green priority, respectively, while increased by 25% and 100% among yellow and red, respectively. CONCLUSION: These numbers show the radical changed scenario in an orthopaedic center in Milan during COVID-19 pandemic. Elective surgery declined rapidly going close to zero, outpatient admissions were restricted to cases that cannot be postponed, while emergencies increased due to the role played by the hospital as referral orthopaedic centre during the pandemic. The still ongoing emergency will have important impacts on the overall orthopaedic healthcare management for the next months.

Operating room efficiency and timing during coronavirus disease 2019 outbreak in a referral orthopaedic hospital in Northern Italy.

PURPOSE: The SARS-CoV-2 outbreak affected health care systems at different levels with important consequences on health, economy, and social structures. This paper aims to analyse the impact on surgical block utilisation and efficiency in an orthopaedics reference centre in Northern Italy. METHODS: The timeframe chosen for the current analysis was April 2020, to be compared with the corresponding period in 2019. Number and type of procedures, first case delay, occupancy rate, and turnover time were used as indicators to benchmark the activities. RESULTS: The overall number of surgical procedures decreased by 57%, from 537 in 2019 to 230 in the same timeframe in 2020. Orthopaedic procedures predominated in 2019, with 434 cases (80.8%), while in 2020, trauma was the leading activity, with 200 cases (86.9%). Orthopaedic surgery had a relative decrement of 93% while trauma has relatively increased by 94%. Mean first case delay in orthopaedic room (OR) was two hours and 36 minutes (SD 01:40:21) in 2020 compared with only 19 minutes (SD 00:02:15) in 2019. OR occupancy rate was 59% in 2020 compared with 89% in 2019. Turnover time raised from 21 minutes in 2019 to 53 min in 2020. CONCLUSIONS: These data clearly show the deep impact of COVID-19 pandemic on OR facilities. Efficiency indicators fell dramatically in April 2020 compared with the corresponding period in 2019. This scenario will deeply affect both the waiting lists and the economic burden of the hospital. Regaining efficiency and maintaining the quality and safety of the process while restoring elective orthopaedic surgery are among the main challenges that surgeons will face in the next time.

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations.

PURPOSE: To plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections. METHOD: A systematic review was conducted using the terms "COVID-19" or "SARS-Cov-2" and "second wave". No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations. RESULTS: Overall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family's lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves. CONCLUSIONS: The recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.

Resuming hip and knee arthroplasty after COVID-19: ethical implications for wellbeing, safety and the economy.

Reinstating elective hip and knee arthroplasty services presents significant challenges. We need to be honest about the scale of the obstacles ahead and realise that the health challenges and economic consequences of the COVID-19 pandemic are potentially devastating.We must also prepare to make difficult ethical decisions about restarting elective hip and knee arthroplasty. These decisions should be based on the existing evidence-base, reliable data, the recommendations of experts, and regional circumstances.

Survey of AAHKS International Members on the Impact of COVID-19 on Hip and Knee Arthroplasty Practices.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic poses an important risk to global health. METHODS: This study surveyed 370 international orthopedic surgeons affiliated with the American Association of Hip and Knee Surgeons to help identify the global impact of the COVID-19 pandemic on patient care. RESULTS: A total of 99 surgeons (27% of those surveyed) completed the questionnaire representing 32 different countries. Except for surgeons in Japan, all respondents noted that their practice had been affected to some degree and 70% of the surgeons have canceled elective procedures. More than a third of the surgeons have had to close their practices altogether and the remaining open practices were estimated to be sustainable for 7 weeks on average given their current situation. CONCLUSION: The COVID-19 pandemic has resulted in marked changes to the majority of international arthroplasty practices.

Disruption of Arthroplasty Practice in an Orthopedic Center in Northern Italy During the Coronavirus Disease 2019 Pandemic.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) outbreak has put strain on many healthcare systems around the world, with important consequences. The aim of this paper is to describe the impact of the COVID-19 pandemic on hip and knee arthroplasties in an Italian high-volume orthopedic center, located in the region of the country first and worst affected by the Coronavirus. METHODS: Data from an institutional database were retrospectively analyzed to obtain the number of hip and knee arthroplasties performed from February 24 to April 10 2020. The figures were compared with those of the same 7-week period of the last year (2019). RESULTS: The number of hip and knee arthroplasties showed a decrease from 706 in the same period of 2019 to 166 (76.5% less) in the current year. In 2019, a mean of 101 ± 9 hip and knee arthroplasties were performed per week compared with a mean of 24 ± 34 in 2020. Ten patients tested positive for SARS-CoV2 during their hospital stay. Two of these patients died after a regular postoperative period after developing unexpectedly COVID-19 during rehabilitation. The mortality in the 7-week period of the current year was 1.2% compared with 0% in 2019. CONCLUSION: The outbreak of COVID-19 had a considerable effect in our center on the number of hip and knee arthroplasties that rapidly decreased to 0 in parallel to the worsening of the situation in the country. Efforts will be soon requested because our practice is going to deal with the after-effects of the pandemic in the near future.