Archive | March 2020

Learnings from Orthopaedists Infected with COVID-19

One serious challenge in responding to COVID-19 is how to better protect healthcare workers and prevent nosocomial infection. A fast-track JBJS Orthopaedic Forum article by Guo et al. provides instructive data about this challenge from 24 orthopaedic surgeons in Wuhan, China who contracted the illness. Orthopaedic surgeons generally don’t work on the front lines of infectious-disease pandemics, but these cases help us understand the overall infection situation of healthcare workers.

Twenty-six orthopaedic surgeons from 8 of 24 investigated hospitals in Wuhan were identified as having COVID-19, and 24 of them completed a self-administered questionnaire. From that information, the authors found that the peak date of onset of orthopaedic surgeons’ infection was 8 days earlier than the peak of the public epidemic, indicating that these surgeons were probably exposed to COVID-19 in the hospitals, rather than in the community. Fifteen surgeons were admitted to the hospital for treatment, and 9 surgeons self-isolated at home or hotels with medicine for at least 2 weeks. All 24 surgeons recovered after treatment.

According to questionnaire responses, the suspected in-hospital sites of exposure were general wards (79.2%), public places in the hospital (20.8%), operating rooms (12.5%), the intensive care unit (4.2%), and the outpatient clinic (4.2%). Three surgeons were exposed during operations on patients who were diagnosed as having COVID-19 several days after the surgical procedures.

This and other findings underscore an already-known but worrisome feature of this disease: many asymptomatic patients with COVID-19 are shedding the virus and unwittingly exposing other people—inside and outside of hospitals—to the risk of infection.

Also worrisome: these 24 orthopaedists infected others in 25% of cases, with a 20.8% transmission rate to family members. The authors therefore recommend that orthopaedic surgeons who work in hospital settings during the COVID-19 pandemic period avoid close contact with family members at home.

Risk Factors for Infection
The authors also conducted a 1:2 matched case-control study to explore possible risk factors for COVID-19 infection. The controls were selected from uninfected orthopaedic surgeons who worked in the same department as the case(s) at each hospital.

Severe fatigue of orthopaedic surgeons during the 2 months before the outbreak was found to be a risk factor for COVID-19 infection. (Fatigue from overwork, less sleep, and mental stress are issues for orthopaedic surgeons under many “normal” circumstances.)

Real-time training in infection-prevention measures was found to have a protective effect against COVID-19, as was wearing respirators or masks all the time. More specifically, not wearing an N95 respirator was found to be a risk factor.

Generally, Guo et al. conclude that orthopaedic surgeons must be highly vigilant to avoid infection with COVID-19. They recommend the following approaches:

  • Work with medical and orthopaedic associations to provide real-time infection-control training and to address any shortages of personal protective equipment.
  • Minimize, postpone, or cancel elective operations. Test patients for COVID-19 before any operation if resources allow. Place face masks on all patients.
  • Wear N95 respirators all the time while in a hospital during the pandemic.
  • If you are exposed to the virus by patients with confirmed or suspected COVID-19, avoid close contact with family members at home and maintain physical distance in other situations.
  • If possible, avoid long-term overwork and fatigue, which could compromise immunity against COVID-19.

What Is a “High-Priority” Knee Replacement?

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

The coronavirus epidemic has caused all of us to “rethink” many things. Several days ago, a radiologist asked me whether 3 of my requested imaging studies were high priority in light of the pandemic. My response was, “God bless you. No, none of those is urgent.”

I am 79 years old and think back to my first year of orthopaedic residency, 1968. In 2020, the expectation among many patients is for immediate relief, and many orthopaedists try to deliver that. Whatever “new normal” emerges after the COVID-19 surge subsides, how will patients and physicians work together to arrive at a decision when to proceed to a knee replacement? Although knee replacement can result in pain and function salvation for patients with end-stage knee osteoarthritis, as many as 20% of patients report “unsatisfactory” results.

A recent “appropriateness” analysis of data from 2 multicenter cohort studies classified 3,417 potential knee replacements as follows:

  • Timely—total knee replacement took place within 2 years after the procedure had met “potentially appropriate” criteria
  • Potentially Appropriate but Not Replaced (for >2 years after the procedure had met appropriateness criteria)
  • Premature—a replacement that the authors deemed inappropriate but was performed anyway.

The authors found that surgery for 9% of the knees for which replacement was potentially appropriate took place in a “timely” manner. But overall, there was a high prevalence of both delayed and premature surgery. Specifically, 91% of the knees for which replacement was potentially appropriate were not replaced, and 26% of the 1,114 total knee replacements that were performed were considered to be “likely inappropriate” and therefore “premature.”

The likelihood of a knee being classified as potentially appropriate but not undergoing replacement was greater among black patients, and the likelihood of having premature total knee replacement was lower among participants with a body mass index of >25 kg/m2 and those with depression.

In a Commentary on this study, Michael G. Zywiel, MD noted that the Escobar appropriateness criteria used in the analysis focuses predominantly on physician-assessed rather than patient-assessed factors. This all begs the question: Now that we have joint-replacement tools that we could not even dream of in 1968, how do we as responsible surgeons help guide our patients in deciding when the time is right to use them?

Managing Fractures in Patients with COVID-19

As JBJS Editor-in-Chief Marc Swiontkowski, MD observed in a recent editorial, some musculoskeletal health professionals “have been set aside to some degree” during the COVID-19 pandemic. However, Dr. Swiontkowski also emphasized that “emergency/urgent procedures [still] need to be carried out.” Which leads to the question: What are the best medical practices for patients who have both fracture and COVID-19 infection.

To help answer that question, JBJS fast-tracked the publication of an article by Mi et al., which retrospectively reviewed the medical records of 10 patients from 8 hospitals in China who had both a bone fracture and COVID-19 infection.

Presenting Symptoms
All of the fractures were caused by accidents, most of them low-velocity. Flu-like symptoms of patients with a fracture and COVID-19 disease were diverse, as follows:

  • 7 patients (70%) reported fever, cough, and fatigue.
  • 4 (40%) had a sore throat.
  • 5 (50%) presented with dyspnea.
  • 3 (30%) reported dizziness.
  • 1 patient (10%) reported chest pain, nasal congestion, and headache.
  • 1 patient (10%) reported abdominal pain and vomiting.

Imaging and Lab Results
Six of the 10 patients were positive for SARSCoV-2 based on quantitative reverse transcription polymerase chain reaction (qRT-PCR) of throat-swab samples. All patients ultimately showed evidence of viral pneumonia on computed tomography (CT) scans, but on admission 3 patients did not exhibit severe symptoms or have obvious evidence of COVID-19 on CT scans, and they therefore underwent a surgical procedure. Fever and fatigue signs were observed in these 3 patients after the operation.

The overall results of laboratory tests were as follows:

  • 6 patients had lymphopenia (<1.0 x 109 cells/L)
  • 9 patients had a high level of C-reactive protein.
  • 9 patients had D-dimer levels that exceeded upper normal limits. The authors suggest that this finding “could represent the special laboratory characteristics of fractures in patients with COVID-19.”

Management
Three of the 10 patients underwent surgery; the others were managed nonoperatively due to their compromised status.

All patients received antiviral therapy and antibacterial therapy, and 9 patients were managed with supplemental oxygen. None of the patients received invasive mechanical ventilation or extracorporeal membrane oxygenation because of local limitations in medical technology.

Outcomes
Four patients died in the hospital. Among those who died, surgery had been performed on 1. The clinical outcomes for the 6 surviving patients have not yet been determined.

Conclusions
Because 7 of the 10 patients were determined to have developed a nosocomial infection, the authors emphasize the need “to adopt strict infection-control measures…Doctors, nurses, patients, and families should be wearing protective devices such as an N95 respirator and goggles.”

Mi et al. propose the following 3 additional strategies for patients with a fracture and COVID-19 pneumonia:

  • Consider nonoperative treatment for older patients with fractures, such as distal radial fractures, in endemic areas.
  • Give patients with a fracture and COVID-19 pneumonia more intensive surveillance and treatment.
  • Perform surgery on patients with a fracture and COVID-19 pneumonia in a negative-pressure operating room.

Homemade Mask-Making Made Simple

In terms of knowledge, skill, and compassion, the US healthcare workforce is pretty well prepared to respond effectively to the current pandemic. But, as the news media keep emphasizing, many healthcare facilities are not prepared with enough equipment and supplies.

The video below, featuring Raleigh, NC-based foot and ankle surgeon Sarah E. DeWitt, MD, demonstrates step-by-step instructions for making washable, adjustable masks for healthcare workers.

Dr. Dewitt is quick to point out that the two main materials she uses, the paper portion of an air-conditioner filter and 100% cotton (e.g., a pillowcase), will not result in a mask that replicates anything like the virus-filtering N95 mask. But the materials will provide a general barrier, and washing the masks in detergent with bleach will remove nearly 100% of pathogens.

Please feel free to share this video with your friends, family, and colleagues. Thank you, Dr. DeWitt. #jbjstogether

COVID-19 Evidence from Dr. Bhandari

We are now experiencing the third human coronavirus epidemic of the 21st century. COVID-19 has rapidly endangered the health and well-being of all people, especially vulnerable populations. The offending pathogen, SARS-CoV-2, is a novel coronavirus hitherto unknown to the medical field.

Some of what is known about the virus and the disease it causes has been compiled into a fast-track JBJS Orthopaedic Forum article by orthopaedic surgeon and researcher Mohit Bhandari, MD, PhD and his colleagues. Whether you are an orthopaedist, health care professional in another specialty, or a patient, you may find the following excerpts from the article useful.

The authors begin with a quote from Microsoft founder and philanthropist Bill Gates, who notes that “we’ve invested a huge amount in nuclear deterrents, but we’ve actually invested very little in a system to stop an epidemic.”

Epidemiology
Evidence suggests that asymptomatic, pre-symptomatic, or mildly symptomatic individuals could be drivers of the community spread of the virus. Early evidence from pre-published studies of 2 cohorts indicate that the virus is spread, on average, 2 to 3 days before symptoms present.

The CDC recently published a report on US patients with COVID-19, using data from February 12, 2020, to March 16, 2020 and found that younger age groups had appreciable risks of both hospitalizations and ICU admissions. This is contrary to data from other countries, where serious cases of COVID-19 occurred predominantly in older people with underlying illnesses.

Infection curves with a steep rise place huge demands on health-care systems and can overwhelm limited health-care resources and force clinicians to make agonizing decisions about which patients receive life-saving treatment and which do not. Hence, all the talk about precautions designed to flatten the curve instead of steepening it.

Vaccine Development
Although there has been impressive and rapid progress toward a vaccine already, a vaccine for widespread use is still likely months or years away, because of the testing, regulatory, and manufacturing hurdles that will need to be cleared.

One possible vaccine-development strategy is a subunit vaccine. Subunit vaccines elicit an immune response against the protein on the surface of a coronavirus to prevent its docking with host receptors. Given the similarities between SARS-CoV (the virus that caused the SARS outbreak in 2002 and 2003) and SARS-CoV-2, focusing on a subunit vaccine may be the most promising short-term approach.

Treatment
No specific treatment is currently recommended for COVID-19. Similar to many other viral illnesses, the current mainstays of treatment include early recognition and isolation, along with symptomatic and oxygen therapy.

A randomized controlled trial of the antiviral lopinavir-ritonavir compared with standard care included 199 adult patients with confirmed COVID-19, pneumonia, and compromised oxygen saturation. There was no significant difference between the 2 groups in terms of time to clinical improvement or mortality, with more adverse events occurring in the intervention group.

Dr. Bhandari and his colleagues also offer 9 pieces of practical guidance for surgeons, one of which echoes the experience of Emory University orthopaedists and the orthopaedic community in Singapore: Create multiple teams of clinicians who are completely isolated from one another.

The authors concede that it is impossible to accurately predict the trajectory of COVID-19. Even with aggressive containment procedures, the outbreak is unlikely to see meaningful resolution for weeks to months. Their final message to the health-care community: Exercise continued vigilance and preparedness for a possible second wave and a high index of suspicion for any new cases of undifferentiated respiratory illness in the weeks to months following a slowdown in new cases.

Platooning Orthopaedic Residents Amid COVID-19

Under the best of circumstances, an orthopaedic residency requires trainees and trainers to balance clinical work, surgical skills, didactics, and academic investigations. The global COVID-19 crisis is certainly not the best of circumstances. A fast-track article just published in JBJS explains how the urban, high-volume orthopaedic department at Emory University School of Medicine in Atlanta created a two-team system that helps residents keep learning, helps maintain a healthy workforce, and addresses the needs of orthopedic patients amid this unprecedented situation.

Emory is now dividing its orthopaedic residents into “active duty” and “working remotely” teams. In observation of the presumed incubation period of COVID-19 symptoms, transitions between active and remote activities occur every two weeks. A similar “platooning” system is in place for both faculty and administrators to safeguard a healthy network of leaders and command-and-control decision makers.

Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters. Orthopaedic surgical cases deemed essential present an ideal opportunity for active-duty education, the authors observe, and there is also a role for supplementation of surgical education in the form of virtual reality or simulation training. Faculty members cover their in-person clinics without resident assistance when possible, but most musculoskeletal subspecialty visits can be performed with video-enabled telemedicine, and active-duty residents are part of these virtual clinic visits in real time.

Remotely working residents participate by videoconference in daily faculty-led, case-based didactics. The authors recommend virtually conducted one-and-a-half-hour collaborative, interactive learning sessions on predetermined schedules and topics. Each session includes question-based learning, facilitated with the use of an audience-response system. Remotely working residents also study for their boards and work on clinical research projects, grant writing, and quality improvement projects.

Finally, this team system, championed by strong departmental leadership, allows for isolation of any resident who acquires COVID-19, allowing them time to recover, while diminishing the risk of rapid, residency-wide disease transmission.

What’s New in Hand and Wrist Surgery 2020

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, author Christopher J. Dy, MD, MPH selected the 5 most clinically compelling findings from the more than 50 studies summarized in the March 18, 2020 “What’s New in Hand and Wrist Surgery.

Scaphoid Nonunion
—A retrospective case series investigating 3 treatments for scaphoid nonunion among >100 patients1 found the following:

  • Those receiving iliac crest bone graft (n=31), most of whom had carpal collapse with preserved proximal pole vascularity, had a union rate of 71%, a time-to-union of 19 weeks, and a reoperation rate of 23%.
  • Those receiving an intercompartmental supraretinacular artery flap (n=33), most of whom had osteonecrosis of the proximal pole and half of whom had carpal collapse, had a union rate of 79%, a time-to-union of 26 weeks, and a reoperation rate of 12%.
  • Those receiving a free vascularized medial femoral condyle flap (n=45), most of whom had carpal collapse, osteonecrosis, and prior surgery, had a union rate of 89%, a time-to-union of 16 weeks, and a reoperation rate of 16%.

—Among 13 patients with scaphoid nonunion and osteonecrosis who were treated with cancellous autograft packing and volar-plate fixation,2 there was 100% fracture union, with most achieving union within 18 weeks. However, preoperative carpal-collapse rates were not reported, making it difficult to assess the role of this procedure.

Finger Replantation: Financial Issues
—The frequency and success rates of finger replantation have been decreasing in the US. A review of physician reimbursement for these procedures3 found that replantation has lower reimbursement per work relative value unit (RVU) than many other common hand surgeries, including revision amputation, carpal tunnel release, and trigger finger surgery. This “relative devaluation” may help explain the decline in frequency and success of finger replantation.

Socioeconomics of Carpal Tunnel Syndrome
—Among patients seeking treatment for carpal tunnel syndrome, those from areas of “increased social deprivation” had worse physical function, pain interference, anxiety, and depression than patients from more affluent areas.4

Cubital Tunnel Syndrome
—A study of preoperative dynamic ultrasound in patients with cubital syndrome5 found that ultrasound was far more reliable than preoperative clinical examinations in predicting ulnar nerve stability within the cubital tunnel (88% match with intraoperative findings vs 12% match, respectively). Preoperative ultrasound may therefore help surgeons counsel patients about the possible need for nerve transposition.

References

  1. Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?Hand (N Y). 2019 Mar;14(2):217-22. Epub 2017 Oct 27.
  2. Putnam JG, DiGiovanni RM, Mitchell SM, Castañeda P, Edwards SG. Plate fixation with cancellous graft for scaphoid nonunion with avascular necrosis. J Hand Surg Am.2019 Apr;44(4):339.e1-7. Epub 2018 Aug 10.
  3. Hooper RC, Sterbenz JM, Zhong L, Chung KC. An in-depth review of physician reimbursement for digit and thumb replantation. J Hand Surg Am.2019 Jun;44(6):443-53. Epub 2019 Apr 17.
  4. Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2019 Apr;44(4):335.e1-9. Epub 2018 Jun 23.
  5. Rutter M, Grandizio LC, Malone WJ, Klena JC. The use of preoperative dynamic ultrasound to predict ulnar nerve stability following in situ decompression for cubital tunnel syndrome. J Hand Surg Am.2019 Jan;44(1):35-8. Epub 2018 Nov 27.

More Data on Periprosthetic Hip Infections

Among >100,000 total hip arthroplasty (THA) patients ≥55 years of age whose data resides in a Canadian arthroplasty database, the 15-year cumulative incidence of periprosthetic joint infection (PJI) was 1.44%, according to a study by the McMaster Arthroplasty Collaborative in the March 18, 2020 issue of JBJS.

In addition to finding that the overall risk of developing PJI after THA has not changed over the last 15 years in this cohort, the authors found the following factors associated with increased risk of developing a PJI:

  • Male sex (absolute increased risk of 0.48% at 10 years)
  • Type 2 diabetes (absolute increased risk of 0.64% at 10 years)
  • Discharge to a convalescent-care facility (absolute increased risk of 0.46% at 10 years)

The authors view the third bulleted item above as “a surrogate marker of frailty and poorer general health.”

Patient age, surgical approach, surgical setting (academic versus rural), use of cement, and patient income were not associated with an increased risk of PJI. Nearly two-thirds of PJI cases occurred within 2 years after surgery, and 98% occurred within 10 years postoperatively.

The authors conclude that these and other substantiated findings about PJI risk factors “should be reviewed with the patient during preoperative risk counseling.”

Displaced Proximal Humeral Fractures: Fix or Replace?

Nonoperative management of proximal humerus fractures in the elderly used to be fairly common, but multiple studies have shown poor outcomes. Open reduction and internal fixation (ORIF) with locked-plate constructs has shown some promise, but it has been fraught with complications. Most recently, reverse total shoulder arthroplasty (rTSA) has emerged as a possible surgical solution, but this is a complicated procedure, and questions have arisen about long-term outcomes.  Compounding this conundrum are the varying degrees of severity of proximal humeral fractures.

In the March 18, 2020 issue of The Journal, Fraser et al. share 2-year results from a multicenter, single-blinded randomized trial that compared rTSA to ORIF for severely displaced proximal humeral fractures in patients 65 to 85 years of age. Included patients (n=124) had OTA/AO 11-B2 or 11-C2 fractures with >45° valgus or >30° varus in the anteroposterior view, or >50% displacement of the humeral head. Using the Constant shoulder score as the primary outcome measure, the authors demonstrated both a statistically significant and clinically meaningful difference favoring rTSA in this cohort.

The mean Constant score was 68.0 points for the rTSA group compared to 54.6 points for the ORIF group. The mean between-group difference, 13.4 points, was significant (p<0.001) and exceeded the minimal clinically important difference of 10 points.  The Constant-score difference between ORIF and rTSA was most pronounced (18.7 points) in patients with C2 fractures, but there was no significant score difference in those with B2 fractures. Secondary outcomes (Oxford Shoulder Scores) showed a consistent trend of the rTSA group scoring higher than the ORIF group at 2 years.

Although this study indicates an advantage for rTSA, one must consider that only severely displaced fractures were investigated and that 2-year follow-up for joint arthroplasty is considered short term. In a Commentary about this article, Peter A. Cole, MD points out that “if there was a 25% revision rate for reverse TSA at 5 to 10 years, then the superior results would be reversed, and we would be reinventing another wheel in orthopaedics.”

Clearly, longer-term studies in this population are a necessity, and Fraser et al. say they plan to follow these patients in 5-year intervals.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

The Fate of Chris Sale’s Left Elbow

Disclosure: The co-authors of this post are lifelong, die-hard, pathological fans of the Boston Red Sox.

At this time of a global public-health emergency, we probably should not be distracted by things like this, but… Yesterday the Boston Red Sox announced that left-handed pitcher Chris Sale, one of the best hurlers in baseball, would undergo Tommy John surgery, otherwise known as ulnar collateral ligament reconstruction (see related Clinical Summary). This, by itself, is not surprising, because by some estimates, one-third of all Major League Baseball pitchers have that operation.

What puts the hitch in our windup is this: In August of 2019, Sale, who was experiencing his worst season ever stat-wise, received an injection of platelet-rich plasma (PRP) in his left elbow and was shut down for the rest of the season. Here we are, 8 months later, and he is facing a surgery that was veritably inevitable and could have happened then rather than now.

PRP has shown promise in treating some musculoskeletal conditions, but its effectiveness in elbow injuries is unproven at best. In response to a surge of research interest in PRP, JBJS recently published an article calling for standardization of PRP preparation protocols and more responsible reporting of methods and findings in the literature so that any positive findings can be replicated in future investigations.

No surgery date for Sale has been announced (most elective orthopaedic surgeries are being postponed to redirect resources to the COVID-19 pandemic), and we don’t know who will perform the surgery. What we do know is that this year is the first of a 5-year, $145 million contract for Sale. While it’s silly to use the words “schedule” or “timeline” for anything now, a best-case scenario would have Sale back on the mound in games in June or July of 2021. We are not privy to the terms of Sale’s contract, but we assume the clock on it is ticking, and several months of an elite pitcher’s career was wasted waiting for a treatment to work that is not backed by any solid science.

Click here for a compendium of JBJS content related to PRP.

Lloyd Resnick
JBJS Developmental Editor

Jason Miller
JBJS Chief Operating Officer