Does elective orthopaedic surgery in pandemic era increase risk of developing COVID-19? A combined analysis of retrospective and prospective study at Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

BACKGROUND: To date, no recommendations have been published on when and how to start again carrying out elective, non-urgent surgery on COVID-19-negative patients after the epidemic peak has been reached in a given country or region and the pressure on healthcare facilities, healthcare workers and resources has been released by so far that elective surgery procedures can be safely and ethically programmed again. This study aims to investigate whether elective orthopaedic surgery will increase the risk of developing COVID-19. MATERIALS AND METHODS: This was a combined retrospective and prospective studies performed at a national tertiary hospital in Jakarta, Indonesia. Subjects were patients who underwent elective orthopaedic surgeries at our institution from April to May 2020. Those who were previously infected with COVID-19 from polymerase chain reaction (PCR) reverse transcriptase (RT) examination obtained via nasopharynx and oropharynx swab, as well as those who were reluctant to participate were excluded from the study. RESULTS: A total of 35 subjects (mean age 32.89 ± 17.42) were recruited. Fifteen (42.9%) subjects were male, and 20 subjects (57.1%) were female. Mean duration of surgery was 240 min with the longest and shortest duration of 690 and 40 min, respectively. General anaesthesia was performed in the majority of cases in 18 surgeries (51.4%) with local anaesthesia as the least in 2 surgeries (5.7%). Length of stay of our study was 6 days of average. None of the patients developed symptoms suggestive of COVID-19 infection. CONCLUSION: We found that elective orthopaedic surgery may not be associated with increased cases of COVID-19 cases. However, our study was limited by short duration of follow-up. Further studies are required in order to investigate the affect of undergoing elective surgery and the number of COVID-19 cases.

Calcaneotalotibial arthrodesis by retrograde intramedullary nailing using expert tibia nail for charcot osteoneuropathy of the foot: A case series.

INTRODUCTION: Charcot osteoneuroarthopathy (CN) is a progressive degenerative arthropathy determined by the interaction of neuropathy, osteopaenia and proinflammatory cytokines. The aim of treatment is to maintain the foot on plantigrade position, recover foot deformity, osseous stability, and prevent ulceration. Intramedullary fixation in calcaneotalotibial arthrodesis has been described in promotion of rigid internal fixation with minimal soft tissue violation producing deformity correction, minimal periosteal aggression, vascular damaged and good functional outcome, with less postoperative fusion time and able to achieve fusion of the ankle and the subtalar joint after failed fusion. PRESENTATION OF CASE: Two patients with charcot foot underwent tibiocalcaneal arthrodesis with retrograde intramedullary technique by Expert Tibial Nail (ETN). The patients are both male 59 years with right ankle deformity 9 months prior to admission and history of trauma and 40 years old with history of Type 2 Diabetes Mellitus. Visual analog scale (VAS), AOFAS and SF score were assessed pre and post operative. DISCUSSION: A good stability, plantigrade ankle and painless foot on both patients were achieved with a mean score 9 for satisfaction. Pre and 3 months post operative VAS were 4 and 1, AOFAS Scale were 58 and 83, mean of SF-36 were 28.4 and 48.6 for physical condition, 37.3 and 67.2. for mental condition consecutively. No severe postoperative complication were recorded CONCLUSION: Tibiotalocalcaneal arthrodesis with retrograde intramedullary technique using ETN system was proven to have a good option for ankle joint salvage with improvement of clinical and functional score. Hence, its application in the charcot joint is promising.

Sensitivity and specificity of electrocardiographic criteria for left ventricular hypertrophy in children with rheumatic heart disease.

Electrocardiographic criteria for left ventricular hypertrophy (LVH) were examined in 84 unselected pediatric patients with rheumatic heart disease. There were 47 male and 37 female patients, ranging in age from 6 to 19 years. Electrocardiographic LVH was detected in 41 patients (48.8%), i.e. in 55.3% (26/47) of boys and in 36.6% (15/41) of girls. Echocardiographically determined LVH was present in 42 cases (50%) if left ventricular mass (LVM) was indexed for height, or 47 cases (56%) if LVM was indexed for body surface area (BSA). The overall sensitivity of height-indexed electrocardiographic diagnosis of LVH was 71.4% (95% confidence interval = 57.7% to 85.1%), while its sensitivity was 73.8% (95% confidence interval = 60.0% to 87.0%). For BSA-indexed echocardiographic LVH, the sensitivity was 68.1% (95% confidence interval = 54.8 to 81.4%) and the specificity was 75.7% (95% confidence interval = 61.9% to 89.5%). When sex-adjustment was examined, there was no increase of sensitivity of electrocardiographic LVH. Sensitivity of the electrocardiogram for LVH increased when age-adjustment was examined with 13 years of age as a cut-off point, both for height-indexed and BSA-indexed echocardiographic LVH. Reasons for the difference between these findings and the findings in adult patients (remarkably low sensitivity and very high specificity of ECG LVH) were discussed. Electrocardiogram was a moderate diagnostic modality in the detection of LVH in our pediatric patients with rheumatic rheumatic heart disease. Sex did not influence the sensitivity of ECG LVH, but older age group tended to increase its sensitivity.

Bacterial endocarditis in children: clinical and laboratory findings, and the role of echocardiography in its diagnosis and management.

We report clinical and laboratory findings of 15 children with bacterial endocarditis, admitted to the Department of Child Health, University of Indonesia/Cipto Mangunkusumo Hospital from February, 1987 to June, 1989. There were 8 boys and 7 girls with bacterial endocarditis, ranging in age from 10 weeks to 16 years. The diagnosis was suspected because of prolonged fever, with or without other manifestations, i.e. congestive heart failure, refractory anemia, or paroxysmal atrial tachycardia. The underlying heart disease was congenital in 12 cases and rheumatic heart disease in 3 cases. The clinical, electrocardiographic, and radiologic manifestations were generally predominated by the pre-existing heart disease. No 'characteristic' findings of bacterial endocarditis, i.e. Osler's nodes, Janeway lesions or splinter haemorrhages were detected. Positive bacterial culture was obtained in 12 cases; the most frequent bacteria isolated was Pseudomonas aeruginosa (4 cases). Streptococcus viridans was isolated in 2 cases only. Vegetation was visualized echocardiographically in 12 cases; 9 with clear cut evidence of large vegetation, and in the other 3 the vegetation was equivocal. On follow-up they disappeared gradually with clinical improvement. Large vegetation might need 2 full months to disappear echocardiographically. It is concluded that bacterial endocarditis is not a rare complication of structural heart disease in our hospital, with a high mortality rate. The availability of good resolution echocardiography has been very helpful in establishing the diagnosis as well as in following-up patients with bacterial endocarditis.

Secundum atrial septal defect before and after surgery.

Twenty patients with secundum atrial septal defect, who had undergone open heart surgery were studied retrospectively. Girls were more affected than boys; the sex ratio was 1.5:1. Associated cardiac defects were diagnosed in two patients, one with moderate valvular pulmonic stenosis and the other one with small ventricular septal defect. Typical clinical findings consisted of loud first heart sound, widely fixed split second heart sound and soft ejection systolic murmur at the upper left sternal border were heard in all cases. Mid diastolic murmur due to relative tricuspid stenosis was detected in most cases (75%). Electrocardiographic findings included right axis deviation, prolonged PR-interval and right atrial enlargement were found in 50%, 15% and 60% of cases, respectively. Incomplete right bundle branch block and right ventricular enlargement were found in all cases, as was cardiomegaly with increased vascular markings were found in all cases. Paradoxical ventricular septal motion and visualization of the atrial septal defect were seen in 95% and 75% of cases, respectively. Cardiac catheterization was performed in 19 patients (95%). The pulmonary-systemic flow ratio (Qp/Qs) ranged from 1.7 to 6.3 (mean 2.9 +/- 0.67), and was correlated to the presence of mid diastolic tricuspid flow murmur and paradoxical ventricular septal motion. Simple closure of the defect was the procedure of choice, but in one patient (5%) pericardial patch was used to close the very large defect. The mortality rate was 10 per cent. Physical retardation was found in all boys and 50% of girls, before surgery. Body weight percentile increased in most cases (61.1%), while body height percentile increased in only 5.6% of cases, postoperatively. Ejection systolic murmur at the upper left sternal border was still detected in one patient (5.6%). Incomplete right bundle branch block persisted in all cases, while cardiomegaly was still found in 5.6% of cases followed-up six months to five years after surgery. There was no residual left ventricular dysfunction in all cases.

Patent ductus arteriosus before and after surgery.

Twenty five patients with patent ductus arteriosus, who had undergone surgical closure were studied retrospectively. Girls were more affected than boys; the sex ratio was 4:1. Associated cardiac lesions were diagnosed in 3 patients, two with ventricular septal defect and one with congenital mitral stenosis. Congestive heart failure was diagnosed in 5 patients before surgery. Typical continuous murmur was heard in most cases (76%), while in the rest only systolic murmur was detected. Electrocardiographic left atrial enlargement, left ventricular hypertrophy and right ventricular hypertrophy were found in 8%, 48% and 40%, respectively. Cardiomegaly with increased pulmonary vascular markings was found in 60% of cases, while ratio of left atrial to aortic root diameter greater than 1.2 was detected in 60% of patients. The PDA could be directly visualized by echocardiography in 15 cases. Cardiac catheterization was performed in 17 cases, 47% with hyperkinetic pulmonary hypertension, 41% with high pulmonary flow without pulmonary hypertension and 12% with mild increased pulmonary flow. The pulmonary-systemic flow ratio (Qp/Qs) was more correlated to pulmonary vascular markings rather than to cardio-thoracic ratio. Division of the ductus was the procedure of choice, but in 16% of cases ductal ligation was performed because of technical reasons. Postoperative catch-up in both weight and height was observed more clearly in children operated at earlier age. Ejection systolic murmur was still detected in 2 patients, in whom hyperkinetic pulmonary hypertension existed prior to surgery. No cardiomegaly was found in patients followed-up 1 year or more after surgery. The mortality was nil.