JBJS has already fast-tracked an article by Mi et al. about the best way to manage patients who have a bone fracture as well as COVID-19. The latest fast-tracked COVID-19 article from JBJS comes from Portuguese authors Rodrigues-Pinto et al. It provides an exquisitely detailed protocol for operating room set-ups and staff workflows when treating surgical patients who are COVID-19-positive, with an emphasis on the specifics required for trauma and orthopaedic surgery.
The authors describe a 5-zone operative complex, as shown in the Figure above. Most of the details from Rodrigues-Pinto et al. explain precautionary procedures to be taken in Zones 1 and 2 and Zones 3 and 4, areas preceding and following the operating room.
For Zone 3, the OR itself, the authors recommend a portable HEPA filtration system with a high frequency of air changes to rapidly reduce the viral load within the OR. Another in-the-OR tip for trauma and orthopaedic surgical procedures is to use power tools (such as electrocautery, bone saws, reamers, and drills) sparingly, and to set their power levels as low as possible. That’s because such tools release aerosols, which increase the risk of virus spread. Suction devices to remove smoke and aerosols should also be used during surgical procedures on COVID-19 patients.
At a time when the general public is being encouraged to isolate and maintain physical distance, healthcare professionals are coming together as never before. This unprecedented level and type of collaboration and teamwork is the theme of 2 JBJS fast-track “What’s Important” articles related to the COVID-19 pandemic.
In the first, Mohamad Halawi, MD and colleagues from Baylor University College of Medicine in Houston say that this extraordinary event calls for physician leadership and unity. The authors encourage the orthopaedic community to “focus on supporting our medical colleagues” and for all healthcare professionals to demonstrate “resilience, vigilance, and common resolve.”
For Boston orthopaedists George S.M. Dyer, MD and Mitchel B Harris, MD “things are changing so quickly around us that every day feels like a week,” and “fear appears to be the new ingredient.” Faced with feelings of anxiety and vulnerability, these authors sought advice from three quarters: a group of military veterans affiliated with their medical school, several orthopaedic surgeons who currently serve in the military, and patients who are police officers and firefighters.
The collective wisdom in their advice boils down to this:
- Remind yourself why you became a doctor; it’s a privilege to be able to help.
- Take care of yourselves and of each other.
- Buddy up and stay close to your teammates.
- Keep lines of communication open; in times of stress, unfettered communication is essential.
- Remember that you are capable and resilient.
- Don’t force yourself into “heroism”; volunteer to support and assist in any way you feel comfortable.
Computer-assisted surgery (CAS) for total knee arthroplasty (TKA) has become popular largely based on claims that the technology improves accuracy of component positioning and alignment. Theoretically, that leads to superior patient-reported outcomes. However, the use of CSA has not reliably yielded improvements in implant survival or clinical outcomes. A large registry study by Roberts et al. in the April 1, 2020 issue of The Journal sheds additional light on this perplexing question.
An earlier study by the same author group used data from the same New Zealand Joint Registry and showed no difference in functional outcomes or implant survival between TKAs performed with and without CAS.1 However, that study did not account for the potential bias introduced by surgeons who use CAS only for complex cases.
In this study, Roberts et al. analyzed data from 2 carefully selected groups of surgeons: those who used CAS in 90% of their TKAs (“routine CAS” surgeons) and those who used CAS in <10% of their TKAs (“routine conventional” surgeons). Further limiting their analysis to surgeons with >50 TKAs recorded in the registry between 2006 and 2018, Roberts et al. identified 25 “routine CAS” surgeons and 22 “routine conventional” surgeons. This allowed a comparison between 9,501 TKAs performed by routine CAS surgeons and 7,672 TKAs performed by routine conventional surgeons. While analyzing revision rates and Oxford Knee Scores (OKS) at 6 months, 5 years, and 10 years, the authors also controlled for confounding variables such as age, body-mass index, and implant type.
With a mean follow-up of 4.5 years, the authors found a revision rate per 100 component-years of 0.437 in the group operated on by routine CAS surgeons, compared to a mean 4.9-year revision rate of 0.440 in the group operated on by routine conventional surgeons (p=0.724). When stratifying outcomes of patients <65 years old, the authors again found no statistical difference in revision rates. They also found no between-group differences in OKS within the full and <65 cohorts at 6 months, 5 years, or 10 years.
The findings prompt the authors (and I) to wonder whether continually improving design and durability of modern implants make it difficult to discern any advantage from computer assistance in implant positioning.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
- Roberts TD, Clatworthy MG, Frampton CM, Young SW. Does computer assisted navigation improve functional outcomes and implant survivability after total knee arthroplasty? J Arthroplasty. 2015 Sep; 30(9)Suppl: 59-63.
Ankle fusion continues to be a predictable treatment for degenerative tibiotalar arthritis. It improves both pain and function from primary osteoarthritis and degeneration related to chronic instability or trauma. JBJS has published several recent studies demonstrating that the outcomes of fusion compare favorably with those of total ankle replacement, particularly in higher-demand patients. (See, for example, Effectiveness and Safety of Ankle Arthrodesis Versus Arthroplasty and Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis.)
Many clinicians have wondered why outcomes after ankle arthrodesis are typically so much better than those after arthrodesis of other mobile joints. In the April 1, 2020 issue of The Journal, Lenz et al. provide an answer. Using dual fluoroscopy integrated with 3-D CT, the authors compared the subtalar motion of the surgically fused ankle in 10 patients with the motion of the untreated, asymptomatic side. The findings strongly suggest that compensatory increased plantar flexion of the subtalar joint allows improved function following successful arthrodesis. The authors found that this increased motion occurred during both normal plantigrade ambulation and bilateral heel raises.
Clinicians can use this important information to explain to patients who are deciding between ankle arthrodesis and arthroplasty how fusion can not only improve pain, but can also result in good functional range of motion. On the other hand, the authors surmise that the compensatory increase in subtalar joint plantar flexion may explain the reported increased risk of future subtalar osteoarthritis in surgically fused ankles. However, to answer that question, we’ll need larger, longitudinal clinical studies that evaluate the relationship between the compensatory post-fusion subtalar kinematics discovered by Lenz et al. and radiographic findings and patient-reported pain and function.
Marc Swiontkowski, MD
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.
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?
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.
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.”
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.
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.
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.
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.
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.”
—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.
- 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.
- 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.
- 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.
- 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.
- 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.