Telemedicine in orthopaedics and trauma surgery during the first year of COVID pandemic: a systematic review.

PURPOSE: Prior to the COVID-19 pandemic, telemedicine in orthopaedics and trauma surgery had mostly developed for joint arthroplasty, fracture management, and general pre- and postoperative care including teleradiology. With the corona-outbreak, telemedicine was applied on a broad scale to prevent assemblage and to guarantee access to medical care protecting critical areas. The purpose of the present study was to give an overview of the spectrum of clinical applications and the efficacy of telemedicine in orthopaedic and trauma surgery as published in times of the COVID-19 pandemic. METHODS: All published studies investigating the application of telemedicine related to orthopaedics and trauma during the COVID-19 pandemic were accessed and screened for suitability. The primary outcome of interest was the efficacy of telemedicine in various clinical applications. The secondary outcome of interest was the spectrum of different applications in which telemedicine applications were investigated. RESULTS: The literature search resulted in 1047 articles. After the removal of duplicates, 894 articles were screened of which 31 finally met the inclusion criteria. Dimensions that were described by studies in the literature to have positive effects were preoperative patient optimisation, the usefulness of telemedicine to correctly diagnose a condition, conservative treatment, willingness to and feasibility for telemedicine in patients and doctors, and postoperative/post-trauma care improvement. The efficacy of telemedicine applications or interventions thereby strongly varied and seemed to depend on the exact study design and the research question addressed. CONCLUSION: Various successful applications of telemedicine have already been reported in orthopaedics and trauma surgery, with a strong increase in scientific output during the COVID-19 years 2020-2021. Whether the advantages of such an approach will lead to a relevant implementation of telemedicine in everyday clinical practice should be monitored after the COVID-19 pandemic.

Telemedicine in Orthopedic Oncology During COVID-19: Patient Satisfaction, Reimbursement, and Physical Examination Competency.

The coronavirus disease 2019 (COVID-19) pandemic forced many institutions to implement telemedicine to facilitate continued patient care at a distance. The quality of patient care with telemedicine in orthopedic oncology has not been assessed. Between March and June 2020, a telephone survey of 64 patients was conducted in an academic orthopedic oncology practice. Patient satisfaction was assessed with a Likert scale metric, open-ended feedback, and direct comparisons between telemedicine and in-office visits. Billing and collection financial data of the telemedicine cohort and of a separate cohort of in-office visits during the same time period were compared. The clinical competency of telemedicine visits was measured by delayed or missed diagnoses and surgical site infections that may be attributable to lack of an in-person physical examination. Overall, patients were largely satisfied with their telemedicine experience. More than 90% of patients described telemedicine as equal to or better than in-office visits regarding convenience, time, privacy, and overall quality. Patients reported that better assessment of their physical condition may be indicated, particularly in early postoperative and early sarcoma surveillance visits. Two of 64 patients had adverse events (both local recurrences) potentially attributable to lack of an in-person physical examination. Institutional financial reimbursement of telemedicine visits was comparable to that of in-office visits. These findings have supported continued use of telemedicine in our practice, particularly for patients traveling significant distance and those returning for sarcoma surveillance. However, the limitations of lack of an in-person physical examination should be considered on a case-by-case basis. [Orthopedics. 2021;44(5):274-279.].

Virtual Orthopaedic Examination of the Lower Extremity: The Know-How of an Emerging Skill.

¼: Telemedicine has become an emerging necessity in the practice of orthopaedic surgery following the paradigm shift that was brought on by the COVID-19 pandemic. ¼: Physical examination is an integral component of orthopaedic care and plays a crucial role in diagnosis. ¼: Based on our experience and expert opinion in the literature, we recommend the following infrastructure for a virtual orthopaedic physical examination: a computing device with a functioning camera and high-definition input/output audio, a 720p (high-definition) display, a processing speed of 3.4 GHz, an internet connection speed range from 1 to 25 Mbps, adequate lighting, a steady camera that is positioned 3 to 6 ft (0.9 to 1.8 m) from the patient, a quiet environment for the examination, and clothing that exposes the area to be examined. ¼: When performing a virtual examination of the lower extremity, inspection, range of motion, and gait analysis can be easily translated by verbally instructing the patient to position his or her body or perform the relevant motion. Self-palpation accompanied by visual observation can be used to assess points of tenderness. Strength testing can be performed against gravity or by using household objects with known weights. Many special tests (e.g., the Thessaly test with knee flexion at 20° for meniscal tears) can also be translated to a virtual setting by verbally guiding patients through relevant positioning and motions. ¼: Postoperative wound assessment can be performed in the virtual setting by instructing the patient to place a ruler next to the wound for measuring the dimensions and using white gauze for color control. The wound can be visually assessed when the patient's camera or smartphone is positioned 6 to 18 in (15 to 46 cm) away and is held at a 45° angle to the incision.

Experience of Using Telehealth for Foot and Ankle Examination During The SARS-COV-2 Crisis.

The era of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) is rapidly evolving. To comply to the guidelines for social distancing and reducing travel to prevent the spread of disease, many centers made rapid adjustments to conduct follow-up appointments through telehealth mediums. We explore our center's adaptation to the pandemic, reflecting on how we formulated telehealth clinics for our patients. We share our experience, discuss the challenges encountered, the feedback received, as well as consider the future role of telehealth in everyday orthopaedic practice.Levels of Evidence: Level V.

The result of the use of remote consultation in orthopaedic and trauma surgery during the COVID-19 pandemic.

The COVID pandemic has made telematic consultations a basic tool in daily practice. AIMS: The main objective of the study is to assess the results of the application of telematic consultations to limit the mobility of patients.The operational objectives are; to propose a consultation plan, to know how attendance limits consultations and to define which pathologies benefit the most from this plan. METHODS: A scheme is proposed with the creation of pre-scheduled clinic to assess suitability and the possibility of carrying them out in a single non face-to-face act. RESULTS: Phone call to 5619 patients were made with a lack of response of 19%The cases of 74% of the patients that answered were resolved virtually. There is a difference between units, obtaining a higher answering rate from patients appointed to specific clinic units, OR = 0.60, or to general trauma ones, OR = 0.67. The lowest answering rate was obtained from those derived from the emergency department.Twenty per cent of the consultations were not accompanied by complementary tests that would have favored the resolution in a single act. The general trauma consultations, OR = 0.34, postoperative control, OR = 0.49, and specific unit ones, OR = 0.40, were the ones that better met this requirement.Out of the remaining patients, the general trauma consultations, OR = 0.50, and those referred to units, OR = 0.54, were the ones that had a higher resolution rate without in- person consultation. CONCLUSIONS: The cases of 74% of the patients who answered the phone call were resolved virtually.Cases of 20% of the patients cannot be solved in a single act because they are derived without complementary tests.Osteosynthesis and postoperative arthroscopic follow-up consultations are the ones that need to be carried out in person the most.

La pandemia COVID ha hecho de las consultas telemáticas una herramienta básica en la práctica diaria.El objetivo principal del estudio es valorar los resultados de la aplicación de consultas telemáticas para limitar la movilidad de los pacientes.Son objetivos operativos; proponer un plan de consultas, conocer como limita la asistencia a las consultas, definir qué patologías se benefician mas con este plan. MATERIAL Y MÉTODOS: Se propone un esquema con la creación de consultas previas a las agendadas para valorar idoneidad y posibilidad de realizarla en acto único no presencial. RESULTADOS: Se han realizado 5619 consultas con una falta de respuesta telefónica del 19%.El 74% de los pacientes fueron resueltos de forma virtual. Existe diferencia entre unidades, siendo mas probable la respuesta telefónica para las consulta de unidad, OR = 0.60 o de traumatología general, OR = 0.67 y menos para los derivados desde urgencias.El 20% de las consultas no se acompañaban de pruebas complementarias. Las consultas de traumatología general, OR = 0.34, control postoperatorio, OR = 0.49, y unidades, OR = 0.40, cumplieron mejor este requisito.De los pacientes restantes, las consultas de traumatología general, OR = 0.50, y las derivadas a unidades, OR = 0.54, fueron las que se mas se resolvieron sin acudir presencialmente. CONCLUSIONES: Se han resuelto de forma no presencial el 74% de los pacientes que atendieron a la llamada telefónica. El 20% de los pacientes acuden a la visita sin pruebas complementarias. Las consultas de seguimiento de osteosíntesis y postoperatorio de cirugía artroscópica son las que mas precisan de ser realizadas de forma presencial.

Telephone consultation service in orthopedics during COVID-19 pandemic.

BACKGROUND AND AIM: The current COVID-19 pandemic scenario has driven surgical departments to a transformation.The worldwide spread of the disease has led to a public health quarantine where health care professionals are at high risk of infection. In this context, telemedicine has been promoted and scaled up to reduce the risk of transmission. This study aims to demonstrate that a combined framework based on telematics and in-person clinical encounter not only ensures medical care but the safety of healthcare professionals and patients. MATERIAL AND METHOD: Descriptive observational study on the follow-up of patients during the COVID19 Pandemic, combining telephone and traditional. RESULTS: A total of 5031 telephone calls were made, differentiating between medical referrals, specialised primary care visits, and outpatient consultation.They were classified as successful, required an in-person visit, or no successful telephone contact. Furthermore, we divided them into 2 groups: resolved and unresolved.53% of all telematic visits were successful. CONCLUSIONS: Telematic medical systems are a feasible option in a orthopedics department and an interesting resource to preserve once the pandemic is resolved. Future lines of research should be opened to improve system success, analyze its cost-effectiveness ratio, and correct any legal conflicts that may exist.

ANTECEDENTES Y OBJETIVO: Durante la pandemia COVID-19 la actividad de los servicios quirúrgicos se ha visto obligada a adaptarse y transformarse. La telemedicina se está implantando como nunca antes en esta nueva situación en la que los pacientes están confinados y los profesionales sanitarios presentan riesgo de infectarseEl objetivo es mostrar que una reestructuración combinada telemática y presencial de las visitas permite asegurar la asistencia médica, garantizando la protección del personal sanitario y de los pacientes. MATERIAL Y MÉTODO: Estudio descriptivo observacional sobre el seguimiento de pacientes durante la Pandemia COVID combinando la consulta telefónica con la presencial. RESULTADOS: Se realizaron un total de 5031 llamadas telefónicas diferenciando entre Derivaciones, Visitas de atención primaria especializada y Consulta externa hospitalaria.Se registraron como efectivas, tributarias de visita presencial y no se logra contacto telefónico. Y las dividimos en 2 grupos resueltas y no resueltas.Del total de visitas no presenciales telefónicas fueron efectivas un 53%. CONCLUSIONES: La medicina telemática es una opción factible en un servicio de traumatología y de manera adecuada será una opción interesante de mantener tras la pandemia.Futuras líneas de investigación deberían ser abiertas para mejorar la capacidad de resolución de este sistema, analizar su relación coste-efectividad y subsanar los conflictos legales que pudieran existir.

The Efficacy of Orthopedic Telemedicine Encounters During the COVID-19 Crisis.

Telemedicine technology was rapidly and widely adopted during the early phase of the coronavirus disease 2019 (COVID-19) response, and its efficacy in orthopedic surgery is still undetermined. The objective of this study was to determine the efficacy of new patient orthopedic surgery ambulatory encounters performed using telemedicine during the early phase of the COVID-19 crisis. Failure of the telemedicine encounter was assessed in this study by 2 separate criteria: (1) an unplanned visit to the emergency department (ED) within 6 weeks of the telemedicine encounter and (2) a planned subsequent in-person encounter for inability to formulate a complete diagnosis virtually. The authors retrospectively identified all new patient orthopedic surgery ambulatory encounters performed using telemedicine in the orthopedic surgery department of an academic tertiary care center during the first 6 weeks of the COVID-19 response, from March 16, 2020, to April 26, 2020. The study cohort included 298 new patients treated by 41 providers. The mean age of the 298 patients was 48 years, and 59% were women. Two hundred encounters were performed with video, and 98 were performed with telephone only. Three (1%) patients presented to the ED within 6 weeks of their new patient telemedicine encounter, and 8 (3%) patients presented for a planned in-person encounter. The authors concluded that new patient orthopedic surgery ambulatory encounters performed using telemedicine were able to effectively direct patients to a variety of treatments and dispositions, with a low rate of unplanned presentation to the ED or need for supplementary in-person assessment. [Orthopedics. 2021;44(2):e211-e214.].

Public perceptions and disparities in access to telehealth orthopaedic services in the COVID-19 era.

BACKGROUND: We used online crowdsourcing to explore public perceptions and attitudes towards virtual orthopaedic care, and to identify factors associated with perceived difficulty navigating telehealth services during the COVID-19 pandemic. METHODS: A modified version of the validated Telemedicine Satisfaction and Usefulness Questionnaire was completed by 816 individuals using crowd-sourcing methods. Multivariable logistic regression modelling was used to determine population characteristics associated with perceived difficulty using telehealth technology. RESULTS: Most respondents (85%) believed that telehealth visits would be a convenient form of healthcare delivery, and 64% would prefer them over in-person office visits. The majority (92%) agreed that telehealth would save them time, but 81% had concerns regarding the lack of physical contact during a musculoskeletal examination. More respondents would feel comfortable using telehealth for routine follow-up care (81%) compared to initial assessment visits (59%) and first postoperative appointments (60%). Roughly 1 in 15 (7%) expressed difficulty with using telehealth; these respondents were more often unmarried, lower-income, and more medically infirm, and reported greater symptoms of depression. After multivariable adjustment, lower income and poor health were retained as predictors of difficulty with navigating telehealth technology (p = 0.027,p = 0.036, respectively). CONCLUSION: The majority of the public appears receptive to telehealth for orthopaedic care for both new patient visits and follow-up appointments. The finding that people with multiple chronic conditions and psychosocial needs struggle to engage with telehealth suggests that those who arguably stand to benefit the most from continued care are the ones being unintentionally left out of this digitization boom.

The efficacy of remote virtual care in comparison to traditional clinical visits for elective orthopaedic patients: A meta-analysis of prospective randomised controlled trials.

INTRODUCTION: The Orthopaedic Trauma Association has recommended limitation of in-person encounters to absolute necessity. One method of ensuring standard patient care within these guidelines is through the implementation of telemedicine. AIMS: To evaluate the efficacy of telemedicine for elective orthopaedic patients in the recovery and/or rehabilitation period. METHODS: A systematic review and meta-analysis of articles in Medline/PubMed and The Cochrane Library databases was performed according to the PRISMA guidelines for prospective randomised controlled trials to compare clinical and symptomatic measures for elective patients managed routinely with remote care compared to those managed with standard in-clinic management. To be included for meta-analysis, parameters must be evaluated in ≥3 studies. RESULTS: Eleven studies were included in the meta-analyses. Both telemedicine and control cohorts were comparable for patient satisfaction (RR, 0.98; 95% CI, 0.90-1.07; I2 = 0%; p = 0.52) and patient retention analysis (RR, 1.25; 95% CI, 0.51-3.06; p = 0.54; I2 = 0%). Similarly, there was no statistical difference appreciated between cohorts for overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (p = 0.30), Timed Up and Go Test (p = 0.40), and Stair Test (p = 0.18). Significant difference did exist for visual analogue scale (VAS) scores (p = 0.02) in favour of in-clinic management. CONCLUSION: Telemedicine will serve an integral aspect of healthcare delivery throughout the current COVID-19 pandemic and beyond in an effort to deliver safe, efficient and time-sensitive care to the orthopaedic patient population. The results of our meta-analyses indicate that virtual consultations are as effective as traditional in-person consultations for the care of elective orthopaedic patients in the recovery and rehabilitation period. However, further studies are needed to evaluate for initial consultations and certain sub-specialties of orthopaedics.

Telephone consultation service in orthopedics during COVID-19 pandemic. / Consultoría telefónica en COT durante la pandemia por COVID-19. ¿Ha venido para quedarse?

BACKGROUND AND AIM: The current COVID-19 pandemic scenario has driven surgical departments to a transformation. The worldwide spread of the disease has led to a public health quarantine where health care professionals are at high risk of infection. In this context, telemedicine has been promoted and scaled up to reduce the risk of transmission. This study aims to demonstrate that a combined framework based on telematics and in-person clinical encounter not only ensures medical care but the safety of healthcare professionals and patients. MATERIAL AND METHOD: Descriptive observational study on the follow-up of patients during the COVID19 Pandemic, combining telephone and traditional. RESULTS: A total of 5031 telephone calls were made, differentiating between medical referrals, specialized primary care visits, and outpatient consultation. They were classified as successful, required an in-person visit, or no successful telephone contact. Furthermore, we divided them into 2 groups: resolved and unresolved. 53% of all telematic visits were successful. CONCLUSIONS: Telematic medical systems are a feasible option in a orthopedics department and an interesting resource to preserve once the pandemic is resolved. Future lines of research should be opened to improve system success, analyze its cost-effectiveness ratio, and correct any legal conflicts that may exist.

Result of the implementation of telematic consultations in orthopaedic surgery and traumatology during COVID-19 laparoscopic surgery. / Resultado de la implantación de consultas telemáticas en cirugía ortopédica y traumatología durante la pandemia COVID-19.

The COVID pandemic has made telematic consultations a basic tool in daily practice. AIMS: The main objective of the study is to assess the results of the application of telematic consultations to limit the mobility of patients. The operational objectives are; to propose a consultation plan, to know how attendance limits consultations and to define which pathologies benefit the most from this plan. METHODS: A scheme is proposed with the creation of pre-scheduled clinic to assess suitability and the possibility of carrying them out in a single non face-to-face act. RESULTS: Phone call to 5,619 patients were made with a lack of response of 19%. The cases of 74% of the patients that answered were resolved virtually. There is a difference between units, obtaining a higher answering rate from patients appointed to specific clinic units, OR = 0.60, or to general trauma ones, OR = 0.67. The lowest answering rate was obtained from those derived from the emergency department. Twenty per cent of the consultations were not accompanied by complementary tests that would have favored the resolution in a single act. The general trauma consultations, OR = 0.34, postoperative control, OR = 0.49, and specific unit ones, OR = 0.40, were the ones that better met this requirement. Out of the remaining patients, the general trauma consultations, OR = 0.50, and those referred to units, OR = 0.54, were the ones that had a higher resolution rate without in- person consultation. CONCLUSIONS: The cases of 74% of the patients who answered the phone call were resolved virtually. Cases of 20% of the patients cannot be solved in a single act because they are derived without complementary tests. Osteosynthesis and postoperative arthroscopic follow-up consultations are the ones that need to be carried out in person the most.

Thoracic computerised tomography scans in one hundred eighteen orthopaedic patients during the COVID-19 pandemic: identification of chest lesions; added values; help in managing patients; burden on the computerised tomography scan department.

PURPOSE: Based on the recent literature, chest computed tomography (CT) examination could aid for management of patients during COVID-19 pandemic. However, the role of chest CT in management of COVID-19 patients is not exactly the same for medical or surgical specialties. In orthopaedic or trauma emergency, abdomen, pelvis, cervical, dorsal, and lumbar spine CT are performed to investigate patients; the result is a thoracic CT scan incorporating usually the thorax; however, information about lung parenchyma can be obtained on this thorax CT, and manifestations of COVID-19 can be diagnosed. The objective of our study was to evaluate this role in orthopedic patients to familiarize orthopaedists with the value and limits of thoracic CT in orthopaedic surgery. MATERIALS AND METHODS: Among the 1397 chest CT scans performed during the pandemic period from 1 March 2020 to 10 May 2020, in two centres with orthopaedic surgery, we selected all the 118 thoracic or chest CT performed for patients who presented to the Emergency Department of the hospital with a diagnosis of trauma for orthopaedic surgical treatment. Thirty-nine of these 118 patients were tested with PCR for the diagnosis of COVID-19 infection. Depending on clinical status (symptomatic or non-symptomatic), the information useful for the orthopaedist surgeon and obtained from the Chest CT scan according to the result of the PCR (gold standard) was graded from 0 (no or low value) to 3 (high value). The potential risks of chest CT as exposure to radiation, and specific pathway were analyzed and discussed. A group of patients treated during a previous similar period (1 March 2018 to 15 April 2018) was used as control for evaluation of the increase of CT scanning during the COVID-19 pandemic. RESULTS: Among the 118 patients with chest CT, there were 16 patients with positive COVID-19 chest CT findings, and 102 patients with negative chest CT scan. With PCR results as reference, the sensitivity, specificity, positive predictive value of chest CT in indicating COVID-19 infection were 81%, 93%, and 86%, respectively (p = 0.001). A useful information for the orthopaedic surgeon (graded as 1 for 71 cases, as 2 for 5 cases, and as 3 for 11 cases) was obtained from 118 chest CT scans for 87 (74%) patients, while the CT was no value in 30 (25%) cases, and negative value in one (1%) case. Roughly 20% of the total number of CT scanner performed over the pandemic period was dedicated to COVID-19, but only 2% were for orthopaedic or trauma patients. However, this was ten times higher than during the previous control period of comparison. CONCLUSION: Although extremely valuable for surgery management, these results should not be overstated. The CT findings studied are not specific for COVID-19, and the positive predictive value of CT will be low unless disease prevalence is high, which was the case during this period.

Telemedicine During COVID-19 and Beyond: A Practical Guide and Best Practices Multidisciplinary Approach for the Orthopedic and Neurologic Pain Physical Examination.

BACKGROUND: The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience. OBJECTIVES: To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine. STUDY DESIGN: Consensus-based multispecialty guidelines. SETTING: Tertiary care center. METHODS: Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting. RESULTS: Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests. LIMITATIONS: Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed. CONCLUSIONS: The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.

The new 'normal': Rapid adoption of telemedicine in orthopaedics during the COVID-19 pandemic.

BACKGROUND: Telemedicine provides a safe and effective means for the delivery of care by physicians amongst many subspecialties. Historically, orthopaedic practices in the United States have not widely utilized telemedicine for the delivery of orthopaedic care. As technology improves the adoption and utilization of telemedicine will likely grow, especially in light of the novel coronavirus (COVID-19) pandemic. Our study aims to assess patient and surgeon satisfaction and efficacy of telemedicine during a rapid adoption due to the global pandemic. METHODS: All patients who completed a telemedicine encounter (telephone or video) with an orthopaedic surgeon were contacted. Patients were individually contacted after their visit, and a standardized validated post-visit satisfaction survey was completed. Orthopaedic surgeons completed a standardized post-encounter survey after each visit. Pre-COVID-19 patient satisfaction data was used for comparison. RESULTS: Orthopaedic surgeons completed 612 telehealth encounters either via phone or video consultation between April 6, 2020 and May 22, 2020. 95% of patients rated both surgeon sensitivity to their needs and response to their concerns as 'good' or 'very good.' 93% of patients reported they would participate in a telemedicine encounter again. Surgeons reported high satisfaction with telemedicine encounters (80%, 86% phone and video respectively), and that 78.4% of the time a telemedicine encounter was successful in replacing an in-person visit. CONCLUSION: Patients and orthopaedic surgeons documented high levels of satisfaction with telehealth encounters during the novel coronavirus (COVID-19) pandemic. Telemedicine does not appear to be a replacement for all in-person clinic encounters, however, when used in the appropriate context demonstrated favourable results. LEVEL OF EVIDENCE: Level 4 Study.

Are Virtual Fracture Clinics During the COVID-19 Pandemic a Potential Alternative for Delivering Fracture Care? A Systematic Review.

BACKGROUND: Virtual fracture clinics are an alternative to the traditional model of fracture care. Since their introduction in 2011, they have become increasingly used in the United Kingdom and Ireland. The coronavirus disease 2019 (COVID-19) health crisis has driven institutions to examine such innovative solutions to manage patient care. The current controversies include quantifying safety outcomes, such as potential delayed or missed injuries, inadequate treatment, and medicolegal claims. Questions also exist regarding the potential for cost reductions and efficiencies that may be achieved. Physical distancing has limited the number of face-to-face consultations, so this review was conducted to determine if virtual fracture clinics can provide an acceptable alternative in these challenging times. QUESTIONS/PURPOSES: The aim of this systematic review was to describe (1) adverse outcomes, (2) cost reductions, and (3) efficiencies associated with the virtual fracture clinic model. METHODS: A systematic review of the PubMed, MEDLINE, and Embase databases was conducted from database inception to March 2020. The keywords "virtual" or "telemedicine" or "telehealth" or "remote" or "electronic" AND "fracture" or "trauma" or "triage" AND "clinic" or "consultation" were entered, using the preferred reporting items for systematic reviews and meta-analyses. Inclusion criteria included adults and children treated for injuries by a virtual clinic model at the initial review. Eligible injuries included injuries deemed to not need surgical intervention, and those able to be treated remotely using defined protocols. Exclusion criteria consisted of patients reviewed by telemedicine using video links or in person at the initial review. Initially, 1065 articles were identified, with 665 excluded as they did not relate to virtual fracture clinics. In all, 400 articles were screened for eligibility, and 27 full-text reviews were conducted on 18 studies (30,512 virtual fracture clinic encounters). Three subdomains focusing on adverse outcomes, cost reductions, and efficiencies were recorded. The term adverse outcomes was used to describe any complications, further surgeries, re-referrals back to the clinic, or deviations from the protocols. Efficiency described the number of patients reviewed and discharged using the model, savings in clinic slots, reduced waiting times, or a reduction in consumption of resources such as radiographs. All studies were observational and the quality was assessed using Newcastle-Ottawa tool, which demonstrated a median score of 6 ± 1.8, indicating moderate quality. RESULTS: Six studies reported adverse outcomes in detail, with events ranging from inappropriate splinting, deviations from protocols, and one patient underwent an osteotomy for a malunion. Efficiency varied from direct discharge proportions of 18% in early studies to 100% once the virtual fracture clinic model was more established. Cost reductions compared with estimates derived from conventional fracture clinics varied from USD 53 to USD 297 and USD 39,125 to USD 305876 compared with traditional fracture clinic visits. CONCLUSIONS: Virtual fracture clinics may provide a means to treat patients remotely, using agreed-upon protocols. They have an important role in the current COVID-19 pandemic, due to the possibility to provide ongoing care in an otherwise challenging setting. More robust studies looking at this model of care will be needed to assess its long-term effects on patients, institutions, and health care systems. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The Virtual Foot and Ankle Physical Examination.

The COVID-19 pandemic has necessitated a rapid and drastic shift for clinicians and patients away from traditional in-person visits and toward internet-based virtual visits. The adoption of telehealth services is likely to persist in some capacity even as in-person visits resume, given the convenience and efficiency of telehealth consultations for patients and perhaps surgeons. A primary challenge of virtual visits, particularly in the field of orthopedic surgery, is the physical examination. However, for the foot and ankle, routine physical examination maneuvers can be completed virtually with little modification given proper patient instruction. We present a comprehensive virtual foot and ankle examination for telehealth visits, including instructions that can be provided to patients verbatim and a corresponding checklist for provider documentation.Level of Evidence: Level V, expert opinion.