COVID-19’s Musculoskeletal Manifestations
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 SARS-CoV-2 coronavirus that causes COVID-19 induces the expression of several cytokines and signaling molecules. The impact of these inflammatory mediators on the lungs is the most lethal effect and thus has drawn the most attention. However, COVID-19 can have potentially longer-lasting (but less deadly) musculoskeletal effects.
COVID-19 has not been affecting people long enough to study its effects completely, but we do know that the virus predominantly infects type-II pneumocytes that line the respiratory epithelium. These cells express angiotensin converting enzyme-2 (ACE2) and transmembrane protease, serine 2 (TMPRSS2). Disser et al. note that TMPRSS2 is also expressed in muscle tissue, while only smooth muscle cells and pericytes express ACE2. They add that either ACE2 or TMPRSS2 is expressed in cartilage, menisci, bone, and synovium.
Myalgia has been reported to occur in COVID-19 patients 25% to 50% of the time. The effect on muscle can be severe, with more seriously ill patients having higher levels of creatine kinase. After recovery, patients often show decreased strength and endurance, but it is not clear how much of that is due to deconditioning or to persisting muscle effects. Although arthralgia can also occur, it is hard to separate those symptoms from myalgia, and both may exist at the same time.
Examination of muscle specimens from autopsies of COVID-19 patients shows significant muscle destruction. It is not clear whether the osteoporosis and osteonecrosis sometimes seen with SARS-CoV-2 is due to the virus’s direct effect on bone or to the steroids used to treat patients with more severe cases.
Because it is probable that inflammation associated with cytokine release has an impact on musculoskeletal tissues, orthopaedic surgeons are likely to be faced with a variety of musculoskeletal symptoms in post COVID-19 patients. Preliminary data suggest that rehabilitation for both strength and endurance is effective among patients who recover from COVID-19, but it is not clear whether return to former conditioning levels occurs. The use of immunotherapies, such as IL-1 and IL-6 inhibitors, may have a positive impact on initial treatment in these patients.
Pledge from JBJS Regarding Race-Based Inequalities
The JBJS Board of Trustees published a statement today that addresses the global COVID pandemic and the worldwide demonstrations against systematic racism. As an organization, JBJS has pledged to take the following actions to promote racial equality in health care and in other aspects of human affairs that we influence:
- In addition to the >100 articles already published in JBJS that explore health care disparities, The Journal will now prioritize manuscripts that delineate solutions to these widespread inequities.
- JBJS will continue to support initiatives that increase minority representation in orthopaedic surgery programs throughout the US—including minority members of academic faculties. We will also publish data on the results of those efforts.
- JBJS will look inward to promote greater diversity within our own organization.
We hope the readers of JBJS and OrthoBuzz are also taking action in their homes, workplaces, and communities to ensure that all people are treated fairly and equally.
Screening Orthopaedic Patients for Asymptomatic COVID-19
During the initial surge of COVID-19, symptomatic patients were thought to be mainly responsible for spreading the virus, and guidelines therefore focused on identifying and isolating patients with fever, cough, or shortness of breath. However, as the asymptomatic spread became better understood, the need for more widespread, consistent molecular testing protocols became evident—and this is especially important now that elective orthopaedic surgery has resumed. Performing a surgical procedure on an asymptomatic patient with COVID-19 could lead to contamination of the operating room and other hospital zones, possibly infecting staff and other patients.
In the latest JBJS fast-track article related to COVID-19, Gruskay et al. describe a protocol for universal PCR swab testing of all orthopaedic surgery admissions at their New York City hospital during the 3 weeks between April 5, 2020 and April 24, 2020. At that time, only urgent orthopaedic procedures were being performed. Swab testing of 99 patients revealed a high rate of COVID-19 infections—the majority of which were in patients with no symptoms. With these published findings, the authors “hope to… make a case for nasopharyngeal testing of all preoperative patients.”
During those 3 weeks in April, 7 (58.3%) of the 12 patients who tested positive for COVID-19 had no symptoms consistent with the infection on presentation, and only 1 of those patients had pneumonia that appeared on a preoperative chest radiograph. Three asymptomatic patients who tested positive developed postoperative hypoxia, with 2 requiring intubation.
In recommending routine preoperative PCR testing for orthopaedic patients, the authors acknowledge the high specificity but only moderate sensitivity of the swab test, “but few other practical options exist,” they say. Evidence suggests that CT evaluation is the most accurate diagnostic test for COVID-19 pneumonia, but its use for screening is impractical. Chest radiography is more widely available, faster, and cheaper and emits less radiation than CT, but the sensitivity for diagnosing COVID-19 pneumonia with radiographs is reported as only 70%.
COVID-19 Patients: Better Breathing After Fracture Surgery
COVID-19 infections spread rapidly in northern Italy from February to April of 2020. During that time, the orthopaedic unit at Humanitas Gavazzeni Hospital in Bergamo focused on elderly patients with both a femoral neck fracture and COVID-19. In a fast-tracked JBJS study, Catellani et al. report on what happened to 16 COVID-19-positive patients who were admitted to the hospital’s emergency department with a proximal femoral fracture:
- 3 patients died from severe respiratory insufficiency and multiple-organ failure before surgery could be considered or performed.
- 10 patients underwent fracture surgery on the day after admission; 3 had surgery on the third day after admission to allow washout of direct thrombin inhibitors.
- Oxygen saturation improved in all patients who underwent surgery except 1
- Hemodynamic and respiratory stability was achieved in 9 patients at an average of 7 days postsurgery.
- 4 patients who underwent surgery died of respiratory failure—1 on the first day after surgery, 2 on the third day after surgery, and 1 on the seventh day after surgery.
In general, the advantages of early treatment of proximal femoral fractures in the elderly include early mobilization and better pain control. On the other hand, orthopaedists consider severe respiratory insufficiency to be a contraindication to anesthesia and surgery. The anesthesiology team working with Catellani et al. recommended early surgery in these patients if their oxygen saturation was >90% and their body temperature was <38°C. Spinal anesthesia was used for all patients to avoid sedation and was combined with a peripheral femoral nerve block to achieve better pain management.
The authors concluded that most of these COVID19-positive patients who presented in less critical condition and underwent carefully planned and executed surgery for proximal femoral fractures experienced a notable stabilization of their respiratory parameters.
A Primer on Coding and Documentation for Telemedicine
Under the best of circumstances, coding and documenting medical visits and procedures for Medicare and private payers can be a headache. Now, with the pandemic-related increased use of electronic communication between physicians and patients—including video, telephone, and portal-based email—things have gotten even more challenging. Thankfully, in a recent fast-tracked JBJS article, Hinckley et al. offer some valuable assistance with how to code and document telemedicine and other electronic interactions with patients.
The authors summarize the electronic-communication guidelines from the Centers for Medicare and Medicaid Services (CMS) for documenting these visits and for selecting the appropriate CPT codes and modifiers as of April 20, 2020. They emphasize that private payers may not follow CMS guidelines, so “continued attention to CMS, CPT, and private payer websites is necessary.”
Hinckley et al. also emphasize that CPT codes now distinguish between telemedicine (video) visits, email visits, and telephone services. One of the most useful tools the authors offer appears in an Appendix, where 4 sample grids for musculoskeletal documentation and coding are provided.
It might be wise to familiarize yourself and/or your office staff with these new policies, procedures, and codes, because, as the authors conclude, whatever “new normal” eventually emerges, electronic communication with patients “will likely become a more prominent aspect of our clinical presence and platforms.”
Virtual-Meeting Best Practices from OrthoEvidence
In addition to medical appointments between physicians and patients, many medical meetings and conferences have moved to online platforms due to the COVID-19 pandemic. That prompted the OrthoEvidence team, led by renowned orthopaedic surgeon and researcher Mohit Bhandari, MD, to publish a 32-page, downloadable resource titled “Best Practice Recommendations for Virtual Meetings.”
The document—developed from extensive reviews of the literature and private and public-sector documents, consultation with experts, and stakeholder surveys—is designed to help guide healthcare and academic groups as well as policymakers and funders.
The guidelines are organized into 5 sections:
- Preplanning Considerations
- Planning
- Accomplishing goals
- Response
- Engaging the audience for future activities
A virtual-meeting planning checklist, a helpful table of virtual-meeting platform vendors, and many other practical resources are included in the document’s 6 Appendices.
How to Safely Restart Elective Surgery Amid a Pandemic
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad A. Krueger, MD, co-author of a recent fast-tracked review article in JBJS.
I’ll admit that when I first started hearing about COVID-19, I didn’t pay much attention. Life was busy, and I wasn’t going to worry about something that I figured would come and go without much fuss over the next few months. While that was obviously a faulty assumption, I think few of us could have predicted just how deadly, anxiety-provoking, and disruptive this virus would be. We are now 5 or so months into this pandemic and nothing is ”normal,” but some of the measures we have taken to help flatten the curve seem to be working. In the months ahead, figuring out how to safely regain some normalcy in our lives will require careful planning, nimble adjustments, and well-coordinated cross-functional execution.
Those three actions were also required to produce the fast-tracked Current Concepts Review article in JBJS about resuming elective orthopaedic surgery during the pandemic, which I had the privilege to co-author. Amazingly, that article progressed from an idea to a published manuscript, with input from 77 physicians, in the span of 2 weeks. This fast-paced project was driven by our knowledge that many facilities worldwide were getting ready to start performing elective surgeries again, and we wanted to ensure that practical, accurate, and relevant information was available as those plans were being made.
All the expert author-contributors offered unique insights as to how the pandemic was affecting healthcare delivery in their region of the globe, allowing us to keep the recommendations as balanced as possible. Although much of the research incorporated in this review came from outside the orthopaedic literature, it all touched on our ability to safely care for patients. The process of creating this article was a great example of how strong leadership, teamwork, and compromise can help us navigate through all aspects of these uncharted waters. Everyone who worked on this manuscript, including the peer-review and editorial teams at JBJS, had one goal in mind: to help orthopaedic surgeons safely return to caring for their patients.
The international consensus group that created this review is well aware that some of the recommendations will need to be updated, changed, or maybe even scrapped altogether as we learn more about the behavior of this virus. We drafted, discussed, and revised these guidelines while appreciating that some regions of the world have not been as adversely affected as others and that there are stark global differences in testing capabilities and supplies of personal protective equipment and other resources. We are painfully aware that some of our strongest recommendations might be impossible to implement in certain settings.
Developing a one-size-fits-all framework for restarting elective orthopaedic surgery was not possible; there are simply too many variables at play with this pandemic that are beyond any individual’s or health system’s control. However, this review provides as much evidence-based guidance as possible so that individual surgeons, practices, hospitals, and municipalities can make informed decisions about how elective surgery should reemerge. We are fully aware that some people may object to some of the recommendations in this article, even though 94% to 100% of the 77-member consensus group agreed on all of them. Nevertheless, we hope that this guidance—and updates to it as more evidence becomes available—will help us all continue to make highly informed decisions before, during, and after elective surgery to keep ourselves and our patients safe.
Chad A. Krueger, MD is an orthopaedic fellow in adult reconstructive surgery at the Rothman Institute and former Deputy Editor for Social Media at JBJS.
Number of COVID-19 Infections: Vastly Underestimated?
Many scientists worldwide are engaged in predicting the course of the COVID-19 pandemic, but the exact nature of this disease and the “novel” virus that causes it remains largely mysterious.
The numbers of confirmed cases in media reports are dependent on the extent of testing, which has varied markedly from region to region in North America. The scientific community has cautioned policymakers not to rely entirely on “observable” data (i.e., testing-confirmed COVID-19 cases) because such measures are likely to under-report the extent of the problem. That’s one reason why orthopaedic surgeon Mohit Bhandari, MD and his colleagues applied machine-learning tools to estimate the number of “unobserved” COVID-19 infections in North America.
The authors’ stated goal was to contribute to the ongoing debate on detection bias (one form of which can occur when outcomes—infections in this case—cannot be reliably counted) and to present statistical tools that could help improve the robustness of COVID-19 data. Their findings suggest that “we might be grossly underestimating COVID-19 infections in North America.”
The authors’ estimates relied on 2 sophisticated analyses: “dimensionality reduction” helped uncover hidden patterns, and a “hierarchical Bayesian estimator approach” inferred past infections from current fatalities. The dimensionality-reduction analysis presumed a 13-day lag time from infection to death, and it indicated that, as of April 22, 2020, the US probably had at least 1.3 million undetected infections, and the number of undetected infections in Canada could have ranged from 60,000 to 80,000. The Bayesian estimator approach yielded similar estimates: The US had up to 1.6 million undetected infections, and Canada had at least 60,000 to 86,000 undetected infections.
In contrast, data from the Johns Hopkins University Center for Systems Science and Engineering on April 22, 2020, reported only 840,476 and 41,650 confirmed cases for the US and Canada, respectively. Based on these numbers, as of April 22, 2020, the US may have had 1.5 to 2.02 times the number of reported infections, and Canada may have had 1.44 to 2.06 times the number of reported infections.
The authors emphasize that the “real” number of asymptomatic carriers cannot be determined without widespread use of validated antibody tests, which are scarce. Bhandari et al. conclude that policymakers should “be aware of the extent to which unobservable data—infections that have still not been captured by the system—can damage efforts to ‘flatten’ the pandemic’s curve.”
8 Work-from-Home Tips
During the COVID-19 pandemic, perhaps the luckiest among us are working from home (WFH), although doing so brings multiple challenges. On yesterday’s Scholarly Kitchen blog, Gabe Harp, Digital Products & Software Services team leader at the MIT Press, shared 8 hard-learned tips for sane and successful WFH. Whether you work in healthcare or some other field, you should be able to apply at least a few of these practical pieces of advice.
His “favorite and most earnest” recommendation: trim 15 minutes from all your meetings. But Harp saves the most important WFH reminder for the end of his post: be grateful for stable employment in a relatively safe environment, reliable internet, good health, and the many other privileges that much of the world’s population lacks right now.
Updated Guidelines on COVID-19 Submissions to JBJS
Since the start of the COVID-19 pandemic, The Journal of Bone & Joint Surgery and our associated journals have received >175 submissions related to the novel coronavirus; we have accepted >40 of those manuscripts and have already published three-quarters of the accepted papers.
Due to the unprecedentedly large number of submissions, the only new submissions on this topic that we will consider for peer review and possible publication are those with scientific data and with a truly unique perspective on this topic. In this way, we will keep our readers informed with the highest-quality orthopaedic information related to the pandemic and keep our COVID collection relevant and useful.
We appreciate the efforts of current and future authors of accepted papers for providing potentially life-saving guidance for patients and orthopaedic surgeons during this pandemic.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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