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.”
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
Time is an enemy of all orthopaedic implants, just as it is the bane of native joints. It is therefore helpful to accurately measure how long and well specific implant types last. That is what Kim et al. have done with their 19-year follow up of 90 patients (107 knees) who underwent total knee arthroplasty (TKA) with a constrained condylar knee prosthesis. Their findings appear in the April 15, 2020 issue of The Journal of Bone & Joint Surgery.
Knee arthroplasty surgeons often choose constrained prostheses to improve joint stability in patients with ligament dysfunction, and the typically longer stems of these implants can also compensate for poor bone stock. Kim et al. evaluated the same patient population (mean age of 65 years; mean BMI of 26.9 kg/m2) that they reported on in an earlier study, finding the following outcomes after a mean follow-up of 19 years:
- 96% survival in terms of mechanical failure
- 91% survival in terms of reoperation for any reason
- Patient-reported outcome scores that remained significantly improved from pre-revision values
- Only 1 knee with osteolysis around a component
Among the few knees that required re-revision, 5 such operations were performed due to aseptic loosening and 4 due to infection. The authors note that these very good long-term results are similar to those in previous studies of revision TKAs using various implant types. Kim et al. attribute these findings to several possible factors:
- Low prevalence of comorbidities, including obesity, among the patients
- Excellent surgical technique, including good cementing and correct flexion and extension gaps
- Use of compression-molded polyethylene
Because of government mandates prohibiting elective surgeries, surgical specialties have been among the hardest hit economically during the COVID-19 pandemic. To reduce overhead, some orthopaedic practices have terminated or furloughed staff or implemented steep pay cuts. But as Powell et al. explain in the latest JBJS fast-tracked COVID-19 article, the pandemic presented a unique opportunity for Orthopedic Physicians Alaska (OPA)–a private, vertically integrated practice based in Anchorage–to transform itself, serve its community, and keep its staff employed and the practice afloat.
Alaska shut down elective surgeries in response to COVID-19 on March 19, 2020, and a statewide stay-at-home order was issued on March 22. While OPA leaders confronted the fact that, under those conditions, the practice would not be financially viable after June 15, the Municipality of Anchorage presented a partnership opportunity to OPA and other local healthcare entities.
Anchorage has a disproportionately large population of homeless people. On any given day in the city of 300,000, the number of shelter beds available is >400 short of meeting the demand. To help prevent COVID-19 deaths on a tragic scale among the homeless, the city emergently created temporary shelters, most of them, apropos of Alaska, in de-iced ice rinks.
But the number of available healthcare workers to staff those facilities was insufficient, so the municipality asked OPA and the other larger healthcare practices in the city whether they’d be willing to provide workers to support both existing and new shelters for the homeless. The proposed tasks were definitely not orthopaedic in nature, Powell et al. report. They included creating workflows for COVID-19 screening, establishing logistics for COVID-19 testing, and providing around-the-clock medical oversight at the isolation and quarantine facilities.
OPA said “yes.” With only days until shelter screening was set to commence, the staff and executive team went into full training mode. Meanwhile, contracts were signed with the city for OPA to be paid an hourly rate compatible with Federal Emergency Management Agency reimbursement for services provided. The surgeons in the practice agreed to assume all clinical orthopaedic duties so physician assistants and other clinical staff could serve at the shelters (see photo above).
OPA transformed an orthopaedic practice delivering musculoskeletal care to a focused COVID-19 healthcare entity within 5 days–while avoiding any furloughs. OPA staff are now screening 1,400 homeless and vulnerable individuals daily. Although the work is neither glamorous nor within the scope of a normal orthopaedic practice, the authors conclude that “cooperation with the Municipality of Anchorage has helped to flatten the curve for the community [and] keep the most vulnerable population safe.”
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, co-author Christopher Y. Kweon, MD selected the 5 most clinically compelling findings from the 40 studies summarized in the April 15, 2020 “What’s New in Sports Medicine.”
ACL Graft Choice
—A randomized controlled trial (RCT) comparing bone-tendon-bone autograft, quadrupled hamstring tendon autograft, and double-bundle hamstring autograft for ACL reconstruction in young adults found the following:
- No between-group differences in patient-reported quality-of-life scores at 5 years
- Significantly higher rates of traumatic graft reinjuries in the hamstring-tendon and double-bundle groups
- Relatively low (37%) return to preinjury level of activity for the entire population, with no significant between-group differences
Meniscal Repairs with Bone Marrow Venting
—A double-blinded RCT1 of patients with complete, unstable, vertical meniscal tears compared isolated meniscal repair to meniscal repair with a bone marrow venting procedure (BMVP). Meniscal healing, as assessed with second-look arthroscopy at a mean of 35 weeks, was 100% in the BMVP group and 76% in the control group (p = 0.0035). Secondary pain and function measures at 32 to 51 months were also better in the BMVP group.
Rotator Cuff Repair Rehab
—A multisite RCT2 among >200 patients who received arthroscopic repair of a full-thickness rotator cuff tear compared standard rehabilitation (patients wore a sling at all times except when performing prescribed exercises) and early mobilization (patients wore a sling only when needed for comfort). Early mobilizers showed significantly better forward flexion and abduction at 6 weeks, but no subjective or objective differences (including retear rate) were found at any other time points.
Remplissage for Anterior Shoulder Instability
—A systematic review3 of studies investigating arthroscopic Bankart repair with and without remplissage found significantly higher instability-recurrence rates with isolated Bankart repair. Overall, the addition of remplissage appears to yield better patient-reported function scores compared with isolated Bankart repair alone.
Syndesmotic Ankle Injuries
—A meta-analysis of 7 RCTs (335 patients)4 comparing dynamic versus static fixation for syndesmotic injuries of the ankle found that the overall risk of complications was significantly lower in the dynamic fixation group. Reoperation rates were similar in the two groups, but implant breakage or loosening was reduced with dynamic fixation devices. Compared with static fixation, the dynamic fixation group also had higher AOFAS scores and lower VAS scores at various time points.
- Kaminski R, Kulinski K, Kozar-Kaminska K, Wasko MK, Langner M, Pomianowski S. Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: a prospective, randomized, double-blind, parallel-group, placebo-controlled study. Arthroscopy.2019 May;35(5):1500-1508.e1. Epub 2019 Mar 20.
- Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M; Shoulder and Upper Extremity Research Group of Edmonton (SURGE). Early active motion versus sling immobilization after arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy.2019 Mar;35(3):749-760.e2.
- Lazarides AL, Duchman KR, Ledbetter L, Riboh JC, Garrigues GE. Arthroscopic remplissage for anterior shoulder instability: a systematic review of clinical and biomechanical studies. Arthroscopy.2019 Feb;35(2):617-28. Epub 2019 Jan 3.
- Grassi A, Samuelsson K, D’Hooghe P, Romagnoli M, Mosca M, Zaffagnini S, Amendola A. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med.2019 Jun 12. [Epub ahead of print].
Most elective surgical procedures in the US have been suspended because of the COVID-19 pandemic, but orthopaedic surgeons continue to provide acute care, and some are being recruited to the COVID-19 “front lines.” Available evidence suggests that older individuals are at higher risk for poor outcomes with COVID-19. In addition, >90% of US orthopaedic surgeons are male, which is thought to be another risk factor for COVID-19 severity.
In the latest fast-track JBJS article on COVID-19, Jella et al. considered those facts when making a geospatial map of US orthopaedic surgeons aged 60 years and older (see Figure above). It turns out that 4 states among those with the highest quintile of orthopaedic surgeons ≥60 years of age are also the 4 states most severely affected by COVID-19: New York, New Jersey, California, and Florida.
The authors did not account for comorbid conditions, nor does their data indicate any direct relationship between older orthopaedic providers and their risk of contracting COVID-19. Nevertheless, Jella et al. make the following observations:
- The high proportion of older surgeons in areas of high rates of disease prevalence may increase their susceptibility.
- The risk of fulminant, possibly fatal disease in older orthopaedic surgeons should be considered in the setting of front-line COVID-19 work.
- These findings could provide a rationale for matching of critically limited personal protective equipment to higher-risk providers.
- The 5-zone before-and-after-surgery protocols described by Rodrigues-Pinto et al. “should be heavily considered if older physicians continue to operate in the midst of this crisis.”
- Implementation of telemedicine services will help minimize contact between older providers and infected patients. Also, older orthopaedic surgeons may serve an important role in resident training during this time, with various digital platforms currently available for remote education.
The authors are quick to add that “the present study does not imply that COVID-19 infection among younger providers is in any way less severe or less important,” nor does it “imply that any particular ethical position should be taken.” The authors emphasize that it is up to individual healthcare systems to choose which surgeons are deployed and in what capacity.
We have all come to realize that promising results from lab studies or preclinical trials in animal models do not always translate into meaningful clinical benefits in humans. Yet it is vitally important to perform those human trials to ascertain that knowledge. This is demonstrated by Schemitsch et al. in the April 15, 2020 edition of The Journal. The authors performed a Level I, double-blinded, randomized controlled trial comparing varying doses of romosozumab to placebo in the treatment of older patients with a hip fracture.
Romosozumab is a sclerostin-inhibiting antibody that helps increase bone formation while decreasing resorption. It is indicated to treat osteoporosis in postmenopausal women, in whom the drug has been shown to increase bone mineral density and reduce the risk of fragility fractures. In multiple preclinical studies, romosozumab has increased bone mass and bone strength in rodent osteotomy models, suggesting it might possibly promote fracture healing in people.
In the current study, Schemitsch et al. randomized patients between 55 and 95 years old who had a low-energy hip fracture amenable to internal fixation to receive 3 postsurgical subcutaneous injections of romosozumab at doses of either 70 mg (60 patients), 140 mg (93 patients), or 210 mg (90 patients), or to receive 3 placebo injections (89 patients). The primary end point was the validated “timed Up and Go” (TUG) score. The authors also measured the Radiographic Union Scale for Hip (RUSH) score, and hip pain on a visual analog scale (VAS).
The authors enrolled 325 patients, with 263 (79.2%) reaching the 24-week follow up and 229 (69.0%) reaching the 52-week follow up. They found no statistically significant between-group differences in the TUG, with all patients improving and plateauing at week 20. Similarly, there were no differences between any of the treatment arms in time to radiographic healing, RUSH scores, or VAS. The safety profile of the medication was similar between the 3 romosozumab doses and the placebo.
Romosozumab may increase bone mineral density and reduce the risk of fragility fracture in patients with osteoporosis, but when it comes to helping heal hip fractures, it did not prove to be more advantageous than placebo. This shows, yet again, that what may glitter in animal studies may not necessarily shine like gold in clinical trials with people.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Transitional fractures of the ankle in adolescents are related to torsional injuries that occur around the time that the distal tibial physis begins to close. In recent years, treatment has moved toward screw fixation when the intra-articular fracture gap in Salter type III (Tillaux) and type IV (triplane) fractures is between 1 mm and 2 mm. The rationale for operative treatment has been that intra-articular fracture gaps should be completely reduced, particularly in younger patients, to limit the long-term risk of post-traumatic osteoarthroses. However, evidence supporting the wisdom of surgical intervention has been thin at best. (See Clinical Summary on Triplane Ankle Fractures.)
In the April 15, 2020 issue of The Journal, Lurie et al. report on a retrospective analysis of 34 patients with a triplane fracture and 23 patients with a Tillaux fracture, all of which had 2 mm to 5 mm of articular displacement. Among those 57 patients, 34 were treated with surgery and 23 with closed reduction and casting.
Based on regression analysis, nonoperative treatment, a larger intra-articular gap after closed reduction, and the presence of a grade-III complication were associated with worse functional outcomes at a mean follow-up of 4.5 years. Patients who were treated nonoperatively and had a gap ≤2.5 mm had significantly better functional scores than similar patients with a gap >2.5 mm. From this data, the authors conclude that “surgical management of these injuries likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm.”
This study has the usual issues of treatment and detection bias inherent in retrospective reviews, and the measurement of fracture gaps, even with the CT scans these authors used, is not always reliable at this level of precision. Nevertheless, this data from Lurie et al. is the best we have to date to indicate that the so-called “2-mm rule” of nonoperative management of transitional ankle-fracture gaps ≤2 mm probably makes sense in most clinical situations.
Marc Swiontkowski, MD
JBJS’s first COVID-19 article was about the experiences of orthopaedic surgeons in Singapore. The latest one also comes from authors in Singapore. Soh et al. focus on the impact the pandemic has had on spine surgery in that country. The authors emphasize the need to constantly review and adapt policies amid the moving target that the COVID-19 pandemic represents.
Here’s what the spine service at Soh et al.’s institution (a tertiary hospital and major trauma center) did during the first 6 weeks of the outbreak, which began in Singapore in January:
- Reduced elective spine surgeries by 50%, cancelling all spinal-deformity or revision cases and prioritizing minimally invasive and endoscopic cases that required a shorter length of stay
- Expedited all discharges with transfers to rehabilitation facilities to free up hospital beds
- Rescheduled all non-urgent spine appointments, such as those for acute back pain without neurologic complications
- Offered day-surgery nerve root injections to patients with intractable radicular symptoms
- Continued to receive and operate on emergency spinal trauma and tumor cases
As of April 7, 2020, Singapore instituted a series of heightened measures, collectively referred to as a “circuit breaker,” to further curb community spread of the virus. When the “circuit breaker” kicked in, the spine service again modified its practices. Regular operating and outpatient caseloads were further cut from 50% to 30%. Spine surgery was limited to instances in which a prolonged delay could lead to an irreversible deterioration of function that would negatively impact both the work status and quality of life of the patient.
Precautions during spine surgery are similar to those described by Liang et al for other orthopaedic procedures. Patients with confirmed or suspected COVID-19 and those with pneumonia and unknown COVID-19 status are operated on in a designated OR to avoid contamination of the main operating room and of other patients. In addition:
- Only selected equipment is brought into the OR to reduce the number of items that require cleaning after the procedure.
- The presence of health-care personnel is kept to a minimum to minimize exposure.
- The use of electrocautery is also minimized, with liberal use of suction to remove smoke and aerosols.
Soh et al. also address resident-training issues that were raised in an earlier JBJS fast-tracked article, urging that trainees be reassured they will not be penalized if called upon to modify or sacrifice their training for other responsibilities during this time.
The authors conclude with an acknowledgment of the emotional stress that accompanies a crisis like the COVID-19 pandemic: “During times of crisis, it is important to manage the fears and anxieties of our colleagues as early as possible,” they say. The orthopaedic community must “not forget to look out for one another and bear burdens for one another during this unprecedented time.”
The JBJS fast-track articles about COVID-19 have so far addressed clinical and education/training challenges, but the latest one, by Anoushiravani et al., examines macro- and microeconomic issues.
The cessation of elective surgery has stressed the financial viability of many healthcare organizations, large and small. The US healthcare system relies disproportionately on elective surgical procedures as a revenue source, with those revenues often used to indirectly subsidize the care of other patients. Private orthopaedic practices spend >$33,000 per month per surgeon to maintain overhead for their offices and are consequently also reliant on elective procedures. Nationally, a substantial contraction within the healthcare sector will greatly contribute to growing unemployment and recession in the overall economy.
The $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act designates $100 billion to hospitals and hospital systems to help defray expenses relating to constructing temporary structures and obtaining medical supplies during the pandemic. The CARES Act also designates $350 billion in new loans to small businesses, which include private orthopaedic practices. The program most applicable to those practices is the Paycheck Protection Program (PPP), which provides a maximum of $10 million or 2.5 times the business’s average monthly payroll in 2019. Unfortunately, given the high capital expenditure inherent in orthopaedic practices, the PPP may not be sufficient for the largest groups.
During times of hardship, healthcare professionals, regardless of their training, tend to come together and do what is best for their patients, families, and colleagues. For example, the Rothman Institute in Philadelphia is currently retaining employees by temporarily not paying its surgeons.
Anoushiravani et al. recommend a continued reduction in all nonessential procedures as we move through the most critical pandemic period. In addition, they urge all private orthopaedic practices to study the PPP guidelines to determine how this program can best apply to their group.
To help prevent a second outbreak after the peak in COVID-19 cases recedes, the authors call for the following 2 measures:
- Availability of accurate, timely testing for all who are involved in surgical care, especially reliable antibody tests demonstrating immunity
- National guidelines for returning to normal elective surgical schedules