The impact of COVID-19 on mortality in trauma patients undergoing orthopedic surgery: a systematic review and meta-analysis.

Objective: The global spread of the COVID-19 pandemic has affected all aspects, including orthopedic trauma surgery. This study aims to investigate whether COVID-19-positive patients who underwent orthopedic surgery trauma had a higher risk of postoperative mortality. Methods: ScienceDirect, the Cochrane COVID-19 Study Register, and MEDLINE were searched for original publications. This study adhered to the PPRISMA 2020 statement. The validity was evaluated using a checklist developed by the Joanna Briggs Institute. Study and participant characteristics, as well as the odds ratio, were extracted from selected publications. Data were analyzed using RevMan ver. 5.4.1. Results: After applying the inclusion and exclusion criteria, 16 articles among 717 total were deemed eligible for analysis. Lower-extremity injuries were the most common condition, and pelvic surgery was the most frequently performed intervention. There were 456 COVID-19-positive patients (6.12%) and 134 deaths among COVID-19-positive patients, revealing a mortality escalation (29.38% vs. 5.30% among COVID-19-negative patients; odds ratio, 7.72; 95% confidence interval, 6.01-9.93; P<0.00001). Conclusion: Among COVID-19-positive patients, the postoperative death rate increased by 7.72 times. It may be possible to improve prognostic stratification and perioperative care by identifying risk factors.

Ensuring safety from COVID-19 in arthroscopic surgery

In the current time of coronavirus disease-2019 (COVID-19) pandemic, orthopedic procedures have been shelved and guidelines to establish the safety of medical professionals and patients are still evolving. Although sports injuries are not life threatening, a spectrum of these injuries requires urgent intervention. To ensure the safety of medical professionals and patients of sports injuries in COVID times, the following guidelines are suggested. Such surgery needs to be performed only in COVID-free facility (green zone). Patients from red zone and containment zone should be avoided. Young, fit individuals without medical comorbidities should be considered. Wherever possible, regional anesthesia should be used. As COVID virus is present in all body fluids, aerosol generation (coughing, sneezing, intubation, use of power instruments, and cautery) should be minimized. Operation theater (OT) should be fumigated on the prior night and ideally between the cases. The number of cases per OT should be kept under three to get adequate time in-between for sterilization. The ventilation setup of OT should be negative pressure in addition to positive pressure. If there are hindrances in setting up negative pressure, a simple exhaust can be added to the existing setup. The ventilation system should ideally provide more than 20 air changes per hour. During surgery, movement of doors of OT and OT personnel should be minimal so as to minimize the air turbulence and eddy current. This will reduce the risk of infection. Surgical team should wear personal protective equipment (PPE) and helmet hood to reduce the chances of respiratory droplet infection. The doffing of helmet and PPE should be done with utmost care and should be discarded in a chloro-derivate solution. The motorized drill used for surgical procedure should be used at low revolution per minute (RPM). Usage of sterile transparent polythene hood while irrigating during drilling and sequential drilling will help in minimizing aerosol generation. Spillage of arthroscopic fluid should be avoided at all times. These basic norms will minimize the chance of accidental spread of COVID.

IMPACT OF MEASURES TO FIGHT THE PANDEMIC COVID-19 ON KNEE ARTHROPLASTIES IN BRAZIL.

Objective: To assess the impacts of measures to face COVID-19 on total knee arthroplasty procedures in the country, based on data provided by the SUS Information and Informatics Department (DATASUS). Methods: Cross-sectional study of secondary data in the public domain, available on the website of the Department of Information and Informatics of SUS (DATASUS), containing information about hospital admissions in the SUS. Results: Brazil suffered a 51.82% decrease, on average, in the performance of total knee arthroplasty by the Unified Health System (SUS) in 2020, due to measures to face COVID-19. The analysis by region offers more details on this reduction in the number of procedures. In the Northeast, the decrease was on average 48.02%, whereas in the Center-West it was 65.61%. Southeast, North, and South registered an average decrease of 49.38%, 51.81%, and 55.06%, respectively. Conclusion: COVID-19 impacted the realization of TKA in Brazil, with greater and lesser levels of decline observed in different Brazilian regions. In the Southeast region, for example, the states of São Paulo and Minas Gerais were the most affected, mainly due to the large population concentration, as well as Paraná, which has high numbers of procedures and a sharp decrease in 2020. Level of Evidence III, Retrospective Comparative Study.

Objetivo: Avaliar os impactos das medidas de combate à COVID-19 nos procedimentos de artroplastia total do joelho (ATJ) no país, com base nos dados fornecidos pelo Departamento de Informações e Informática do Sistema Único de Saúde (SUS). Métodos: Estudo transversal realizado com dados secundários de domínio público, disponíveis no site do Departamento de Informações e Informática do SUS (DATASUS), contendo informações sobre as internações hospitalares realizadas no SUS. Resultados: O Brasil sofreu uma queda de 51,82%, em média, na realização da artroplastia total do joelho pelo SUS em 2020, decorrente das medidas de combate à COVID-19. A análise por região oferece mais detalhes dessa redução no número de procedimentos. Na região Nordeste, a queda foi, em média, de 48,02%, enquanto no Centro-Oeste foi de 65,61%. Sudeste, Norte e Sul registraram queda, em média, de 49,38%, 51,81% e 55,06%, respectivamente. Conclusão: A COVID-19 impactou a realização de ATJ no Brasil, com níveis de maior e menor declínio observados nas diferentes regiões brasileiras. Na região Sudeste, por exemplo, os estados de São Paulo e Minas Gerais foram os mais afetados, devido principalmente à grande concentração populacional, assim como o Paraná, que apresenta números altos de procedimentos realizados e forte queda em 2020. Nível de Evidência III, Estudo Retrospectivo Comparativo.

The effect of COVID-19 on orthopedic elective/emergency procedures in a tertiary hospital Riyadh Saudi Arabia. A cross-sectional study.

Background: The occurrence of the COVID-19 pandemic in late December 2019 created a worldwide emergency. It affected most surgical subspecialties in many ways. Therefore, we aimed to quantitate the early effect of COVID-19 on elective and emergency orthopedic surgeries. Moreover, to identify the most affected orthopedic subspecialties during this crisis. Materials and methods: Our study was conducted in a tertiary hospital in Saudi Arabia. We included all patients who underwent orthopedic procedures from January 1, 2020 - June 30, 2020, with the same period of 2019 for comparison. Emergency procedures were considered if a patient had an acute fracture, joint dislocation, compartment syndrome, infection, and infected non-union. Results: The impact of procedure cancellation in the early COVID-19 phase was significant. Our department procedures decreased in the 2nd quarter of 2020 by 75.6% from the previous quarter of the same year and 61.1% from the 2nd quarter of 2019. No admission restrictions were made for oncology and trauma patients, though they had a reduction in their cases. The most affected subspecialties in our study were sports medicine, upper limb, arthroplasty, and pediatrics. Conclusion: During the COVID-19 crisis, elective surgeries were held in our hospital and most of Saudi Arabia. Our cohort showed a significant decrease during this period. All subspecialties were affected by elective procedure cancellation, but some were affected more because of the elective nature of their operations, such as sports and upper limb, pediatric, and arthroplasty.

Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation.

Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.

Evaluation of early complications, outcome, and mortality in Coronavirus Disease 2019 (COVID-19) infection in patients who underwent orthopedic surgery.

BACKGROUND: A higher mortality and morbidity rate has been reported in COVID-19 patients undergoing surgery. To reduce the morbidity and mortality rate in COVID-19 patients undergoing orthopedic procedures, we aimed to increase the threshold for surgical planning. METHODS: In a prospective cohort study, COVID-19 patients who underwent elective or emergent orthopedic surgery in three orthopedic surgery centers from February 2020 to September 2020 were included. In this period, 6751 patients were scheduled for orthopedic surgery. To increase surgical threshold planning, all patients with grade 5 of the American Society of Anesthesiologists (ASA) classification and patients with COVID-19 related moderate to severe pulmonary involvement were identified as high-risk patients and were excluded. RESULTS: 35 deaths occurred during the study. The frequency of deaths was significantly higher in patients with COVID-19, 6 (9.4%) than patients without COVID-19, 29 (0. 43%). The average hospitalization stay was 12.8 ± 12.1 days. The odds ratio (OR) for death was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 8.13, Confidence interval 95% (CI95%) (5.02-11.25), P: 0.001]. Four (6.3%) COVID-19-associated complications were recorded in this series that all were respiratory failure requiring unexpected postoperative ventilation. Twenty surgical complications (31.3%) were recorded. The odds ratio for ICU admission was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 5.46, CI 95% (2.68-8.68), P: 0.001]. CONCLUSIONS: An increased threshold for orthopedic surgery is suggested for COVID-19 patients with a mortality rate of 9.3%, which is less than the mortality rate in other studies. Level of evidence III.

[How to Resume Elective Orthopaedic Surgical Procedures during the COVID-19 Pandemic?] / Como Retomar a Atividade Cirúrgica Eletiva em Ortopedia durante a Pandemia COVID-19?

This document was prepared by the College of Orthopedics of the Portuguese Medical Association with the aim of developing the guidelines on the resumption of elective surgical activity in Orthopedics during the COVID-19 pandemic. It sets the criteria that allow the prioritization of surgeries according to the severity of the clinical situation, based on existing and published classifications. Moreover, it provides an organizational model for patient preparation and describes the patient pathways in the preoperative, intraoperative and postoperative periods. It also describes safety rules for elective surgery and a model for monitoring patients after discharge according to scientific evidence.

Este documento foi elaborado pelo Colégio de Ortopedia da Ordem dos Médicos com o objetivo de estabelecer as orientações sobre a retoma da atividade cirúrgica programada em Ortopedia durante a pandemia COVID-19. As presentes normas de orientação: a) definem os critérios que permitem a priorização das cirurgias de acordo com a gravidade da situação clínica, com base em classificações existentes e publicadas; b) fornecem um modelo de organização para a preparação dos doentes, descrevendo os circuitos do doente nos períodos pré-operatório, intraoperatório e pós-operatório; c) realçam as regras de segurança para a realização de cirurgias e desenham um modelo de acompanhamento após a alta de acordo com a evidência científica.

Effect of COVID-19 Pandemic on Orthopedic Surgery in Three Centers from Romania.

The COVID-19 pandemic has put an enormous burden on healthcare systems. As a direct consequence, many elective procedures were cancelled and available resources were relocated to emergencies and COVID-19 patients. We aimed to analyze the impact on orthopedic surgery in Romania. We performed a retrospective analysis of orthopedics and trauma cases admitted over the first six months of 2019 and 2020 in three representative clinics. In total, there were 1900 patients: 1241 from Timisoara, 216 from Cluj-Napoca, and 443 from Bucharest. In April, activity for all cases in the regional trauma center dropped to 23.8% and stopped in the other two. No arthroscopies or elective joint replacements were performed in April. By June, hospital admissions resumed for trauma cases while arthroscopies and joint replacements still lagged behind.

Experience of clinical screening for COVID-19 among patients undergoing elective orthopedic surgeries: an alternative proposal.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is the largest global event in recent times, with millions of infected people and hundreds of thousands of deaths worldwide. Colombia has also been affected by the pandemic, including by the cancellation of medically necessary surgical procedures that were categorized as nonessential. The objective of this study was to show the results of the program implemented in two institutions in Bogotá, Colombia, in April 2020 to support the performance of elective essential and nonessential low- and medium-complexity orthopedic surgeries during the mitigation phase of the COVID-19 pandemic, which involved a presurgical clinical protocol without serological or molecular testing. METHODS: This was a multicenter, observational, retrospective, descriptive study of a cohort of patients who underwent elective orthopedic surgery at two institutions in the city of Bogota, Colombia, in April 2020. We implemented a preoperative clinical protocol that did not involve serological or molecular tests; the protocol consisted of a physical examination, a survey of symptoms and contact with confirmed or suspected cases, and presurgical isolation. We recorded the types of surgeries, the patients' scores on the medically necessary, time-sensitive (MeNTs) scale, the presence of signs, symptoms, and mortality associated with COVID-19 developed after the operation. RESULTS: A total of 179 patients underwent orthopedic surgery. The average age was 47 years (Shapiro-Wilk, P = 0.021), and the range was between 18 and 81 years. There was a female predominance (61.5%). With regard to the types of surgeries, 86 (48%) were knee operations, 42 (23.5%) were hand surgeries, 34 (19%) were shoulder surgeries, and 17 (9.5%) were foot and ankle surgeries. The average MeNTs score was 44.6 points. During the 2 weeks after surgery, four patients were suspected of having COVID-19 because they developed at least two symptoms associated with the disease. The incidence of COVID-19 in the postoperative period was 2.3%. Two (1.1%) of these four patients visited an emergency department where RT-PCR tests were performed, and they tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). No patients died or were hospitalized for symptoms of COVID-19. CONCLUSION: Through the implementation of a presurgical clinical protocol consisting of a physical examination; a clinical survey inquiring about signs, symptoms, and epidemiological contact with suspected or confirmed cases; and presurgical isolation but not involving the performance of molecular or serological diagnostic tests, positive results were obtained with regard to the performance of low- and medium-complexity elective orthopedic surgeries in an early stage of the COVID-19 pandemic. LEVEL OF EVIDENCE: IV.