Disruptive Effect of COVID-19 on Orthopaedic Daily Practice

Abstract

In December 2019, a series of pneumonia cases of unknown origin emerged in Wuhan, Hubei Province, People’s Republic of China, with clinical presentations that greatly resembled viral pneumonia. Deep sequencing analysis from lower respiratory tract samples indicated a novel coronavirus, which was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and leads to coronavirus disease 2019 (COVID-19)1. This viral outbreak has now spread to countries across multiple continents, and the World Health Organization (WHO) has recently declared this coronavirus to be a global health emergency, calling for global solidarity and a concerted international effort to deal with this pandemic2. Common symptoms at the onset of the illness are fever, cough, myalgia, and fatigue; less-common symptoms are sputum production, headache, hemoptysis, and diarrhea. Dyspnea develops in 55% of patients, and 63% of patients have lymphopenia3. Often, patients develop pneumonia, and abnormal findings are seen on chest computed tomography (CT)4. Recent evidence suggests that asymptomatic, presymptomatic, or low-grade symptomatic individuals could be drivers of the community spread of the virus5. One might think that the field of orthopaedics would not be greatly affected by this pandemic, but experiences from various outbreak areas show that COVID-19 can drive substantial change in the health-care system, disrupting best practices for orthopaedic patients and leaving large numbers of them without adequate care; additionally, orthopaedists are dealing with a dramatically changed work routine6,7. Moreover, because orthopaedic surgeons have been infected with the virus, specific recommendations are being made in order to prevent other surgeons from becoming infected with COVID-198,9. We developed a multicenter European survey that was aimed at evaluating the impact of COVID-19 on orthopaedic daily practice. We sought (1) to summarize the resulting information in order to demonstrate the huge efforts that are being made by colleagues in the areas that are most affected, (2) to highlight the devastating impact that this pandemic is having in terms of denied or delayed orthopaedic treatment, and (3) to help prepare orthopaedic surgeons in areas in which COVID-19 is not yet present to get ready to counteract the pandemic in the best possible way. Materials and Methods One hundred and thirty-six orthopaedic surgeons throughout Europe were asked to complete a survey on how orthopaedic practice has been affected by the emergence of the COVID-19 pandemic. An online questionnaire (see Appendix) was built using Google Forms, a free open-source software survey tool that is available on the internet. On March 29, 2020, the respondents were recruited throughout Europe with convenience sampling. The email included a detailed description of the study along with a link to the questionnaire. The survey required approximately 5 to 10 minutes to complete; it needed to be brief in order to maximize the response rate10. Nonrespondents were sent an email reminder on April 2, 2020; the survey was closed on April 5, 2020. We collected results electronically, and all data were analyzed using Excel (Microsoft). All of the responses are presented as counts and percentages or as means. The questions and the responses that were applicable to this study are included as supplementary material in the tables and the Appendix. Results One hundred and two (75%) of 136 orthopaedic surgeons throughout Europe completed the survey and were included in this analysis. Participants were located in 66 cities in 19 European countries (Fig. 1). Participants from 84 different institutions took the survey; of these institutions, 59 were public hospitals and 25 were private hospitals (70.2% and 29.8%, respectively) (Table I). Among the public institutions, 26 were university hospitals. Italy was the most represented country, with 38 participants from 36 different institutions. The main orthopaedic field of interest for each participant was recorded (Table II).Fig. 1: Distribution of survey participants throughout Europe. TABLE I - Participant Distribution Throughout Europe Country Participants Institutions Public Hospitals Private Hospitals Italy 38 36 21 15 Portugal 22 11 7 4 France 6 4 4 Sweden 6 6 6 Germany 5 5 4 1 Norway 3 1 1 Spain 3 3 2 1 Turkey 3 3 1 2 Kosovo 2 1 1 The Netherlands 2 2 2 Poland 2 2 2 Switzerland 2 2 1 1 United Kingdom 2 2 2 Austria 1 1 1 Belgium 1 1 1 Bosnia and Herzegovina 1 1 1 Czech Republic 1 1 1 Denmark 1 1 1 Romania 1 1 1 Total 102 84 59 25 TABLE II - Participant Orthopaedic Subspecialties Field of Interest Participants Arthroscopy 25 (24.5%) Joint replacement 19 (18.6%) General orthopaedic 18 (17.6%) Trauma 17 (16.7%) Sports medicine 16 (15.7%) Orthopaedic oncology 3 (2.9%) Spine 3 (2.9%) Pediatrics 1 (1%) Confirmed positive cases of COVID-19 were present in all of the countries; only 1 city had no confirmed cases. At least 1 symptomatic confirmed positive case of COVID-19 was present among patients in 82.1% of the institutions (Table III). As for orthopaedic departments, the presence of confirmed COVID-19 in health-care personnel was recorded in 28.6% of the institutions (Tables III and IV). Use of specific COVID-19 guidelines was reported in all of the institutions except for 2 private hospitals. No training regarding COVID-19 was provided to health-care personnel in 27.4% of the institutions. In 20.2% of the institutions, social distancing was not adequately guaranteed. The presence of COVID-19-like symptoms among health-care personnel was routinely noted in 72.6% of the institutions (Table V). As shown in Table VI, 89.2% of participants were routinely using personal protective equipment (PPE). TABLE III - COVID-19 Distribution COVID-19-Positive Patients Yes No Countries 19 Cities 65 1 Public institutions 53 6 Private institutions 16 9 Health-care personnel in public orthopaedic departments 17 42 Health-care personnel in private orthopaedic departments 7 18 TABLE IV - COVID-19 Incidence COVID-19-Positive Patients Institutions Public Private <10 patients 14 8 10-19 patients 9 3 20-29 patients 2 1 ≥30 patients 28 4 TABLE V - Prevention Measures Questions Institutions Public Private Did the institution you work in develop, or apply, specific COVID-19 guidelines? Yes 59 23 No 2 Did the institution you work in provide health-care personnel with any refresher training on COVID-19? Yes 43 18 No 16 7 Is social distancing (e.g., 1 m) being practiced between health-care personnel in the institution you work in? Yes 45 22 No 14 3 Is the presence of any COVID-19-like symptoms among the health-care personnel being routinely registered in the institution you work in? Yes 39 22 No 20 3 Are oropharyngeal or nasopharyngeal swabs being executed on the health-care personnel in the institution you work in? Routinely 3 1 In case of direct contact with confirmed COVID-19-positive patients 14 10 In the presence of symptoms 10 4 In case of direct contact with confirmed COVID-19-positive patients and in the presence of symptoms 24 7 Swabs are not executed 8 3 TABLE VI - PPE Usage* PPE Participants Yes No Disposable gloves 73 29 Surgical mask 72 30 FFP2 26 76 FFP3 8 94 Surgical cuff 30 72 Disposable gown 25 77 Disposable glasses or visor 34 68 No PPE 11 91 *PPE = personal protective equipment, and FFP = filtering face piece. Only 2 participants stated that their routine work had not been affected by the COVID-19 pandemic. The activity of the team of orthopaedic surgeons had been reduced in 72.6% of the institutions that participated in the survey (Table VII). Almost half of the participants (49%) stated that they or an orthopaedic colleague in their department had shifted from their routine orthopaedic work to COVID-19 patient management. An orthopaedic surgical team that was dedicated to COVID-19-positive patients with orthopaedic problems was noted in 12 institutions (14.3%). As for outpatient activity, only 6% of institutions did not interrupt this service (Table VII). In 2 institutions (2.4%), elective nonurgent day surgical procedures were routinely performed, with no changes in preoperative and postoperative management due to the COVID-19 pandemic. These procedures were not performed in 89.3% of institutions (Table VII). Elective nonurgent procedures requiring >23 hours of hospitalization were not performed in 91.5% and 92.0% of public and private hospitals, respectively (Table VII). Urgent surgical patients were routinely treated in 93.2% and 68% of public and private institutions, respectively (Table VII). Six institutions reported cases of missed or postponed operative treatment in patients who required urgent surgery because of the lack of an available recovery room, operating room, or anesthesiologist, or because of a patient’s refusal due to fear of the COVID-19 pandemic. In the cases of missed operative treatment, the patient’s care was managed through telephone, email, and telemedicine and telerehabilitation initiatives, or by a general practitioner (82, 39, 39, and 18 participants, respectively). A scale of 0 to 10 was used to evaluate participants’ concerns with the COVID-19 pandemic; a mean value (and standard deviation) of 9.3 ± 4.9 (range, 3 to 10) was recorded. TABLE VII - Working Habits Modification Questions Institutions Public Private Has the orthopaedic surgeon team of the department you work in been downscaled since the COVID-19 pandemic? Yes 42 19 No 17 6 Have you, or any colleague of the department you work in, executed any surgical procedure on a confirmed positive COVID-19 patient? Yes 21 4 No 38 21 In the institution you work in, is there a “dedicated COVID-19 orthopaedic surgeon team”? Yes 10 2 No 49 23 Did the department you work in stop outpatient clinic activity? Yes 30 18 No 3 2 No, but it has been downscaled 26 5 Did the department you work in stop elective nonurgent day surgical procedures? Yes 52 23 No 1 1 No, but it has been downscaled 6 1 Did the department you work in stop elective nonurgent procedures requiring >23 hours of hospitalization? Yes 54 23 No 2 1 No, but it has been downscaled 3 1 Are urgent surgical patients actually being treated in the department you work in? Yes 55 17 No 4 8 Discussion By using personalized contact with known colleagues, we collected a high percentage of answers (75%) in a very short time period (1 week). The COVID-19 pandemic was present in all of the countries that took part in this survey. Only 1 of the cities (Sokółka, Poland) did not have any positive COVID-19 cases at the time of submission of the survey. Of the 25 private institutions, 9 (36%) were reported as free from infection. Only 6 (10.2%) of 59 public hospitals were free from COVID-19 infection at the time of submission of the survey. Among people working in orthopaedic departments, the distribution of infection appeared to be uniform between public and private institutions (28.8% and 28.0%, respectively) and did not seem to correlate with the type of surgery that was performed (trauma versus elective surgery). Almost all of the institutions (all except 2) adopted proper guidelines. Because the 2 exceptions were both private institutions where urgent procedures are not performed, they had, at the time of the survey, completely stopped their clinical and surgical activities. Most of the institutions emphasized the importance of social distancing and the assessment of any COVID-19-like symptoms in health-care personnel, with 79.8% of participants stating that social distancing is respected at their institution and 72.6% reporting that the presence of symptoms is routinely monitored. Four hospitals were performing routine testing with oropharyngeal or nasopharyngeal swabs, but this did not seem to correlate with a reduced incidence of infection within the department; 11 hospitals did not perform any swabbing, while 69 of the institutions performed testing by swab when symptoms were present, after a health-care worker had contact with confirmed COVID-19-positive patients, or both. Only 13 (12.7%) of 102 participants received testing with an oropharyngeal or nasopharyngeal swab. PPE was routinely being used by 89.2% of the health-care personnel in the included institutions. Sixty-nine orthopaedic surgeons (in 61 different institutions) received specific training for the management of COVID-19 infection or potential infection, while 23 (in 23 different hospitals) did not. Fifteen of the 23 without COVID-19 management training had been shifted from the orthopaedic department to a COVID-19 department. We think that this correlates with the day-by-day planning that was reported by most participants, which represents a weakness in the system that may expose both health-care personnel and patients to a higher risk of infection11. Notably, 50 (49%) of 102 participants had been shifted from orthopaedic duties to COVID-19 patient management, with no large difference between public or private institutions (51.4% and 44.1%, respectively). Twelve hospitals created a “dedicated COVID-19 orthopaedic surgeon team,” but, notably, 2 of them did not provide the health-care personnel with specific training. As in other studies, almost all of the surgeons who took part in the survey stated that their routine work had been strongly affected by the COVID-19 pandemic12. More than 90% of the hospitals had scaled down or stopped outpatient clinic activity, while 5 of 102 surgeons (2 in private and 3 in public hospitals) did not change their outpatient clinic activity, even when 2 of them (1 in a public and 1 in a private hospital) did have COVID-19-positive cases in their institution. Only 2 hospitals (1 public and 1 private) continued to perform elective surgery. One hundred (98%) of 102 participants stopped or scaled down surgical activity, performing only trauma and emergency procedures13. More than 70% of the institutions (75 of 102) reduced their surgical team. Six participants reported that even urgent procedures were not being performed at their institution: with 1 participant, urgent cases were being performed at a dedicated hospital; with the other 5 participants, cases were not performed because patients refused surgery during the pandemic or because of the lack of available anesthesiologists. In 25 hospitals, at least 1 surgical procedure had been performed on a patient who was positive for COVID-19, but only 4 of these hospitals had a COVID-19-dedicated orthopaedic surgical team14,15. The 4 hospitals all had positive cases among the people who work in the orthopaedic department, compared with 42.8% of institutions without a dedicated team. With the exception of the participants from the hospitals that maintained their routine, all of the other participants reported that their activity was currently being planned on a day-by-day basis. If possible, surgery was delayed and clinical conditions were managed through email, telephone consultations, and referrals to general practitioners7,12,13,16. Several limitations of this study must be considered. The question of where people had contracted the virus, either inside or outside of the hospital, remains unanswered, especially since the politics of testing has varied widely among different countries in Europe. Moreover, we did not investigate if personnel from the hospital, when declared positive for COVID-19, continued working or were placed in quarantine, or if there was any difference in protocol for those with or without clinical symptoms. Furthermore, other relevant questions remain unanswered, including the screening modality that was used to test patients before surgery; whether there was a unanimous definition of procedures that are considered to be urgent; and what specific measures had been taken by the teams, both orthopaedics and anesthesiology, in the management of these patients (before, during, and after surgery). Furthermore, it was not possible to describe any specific surgical procedures that were performed on patients who were positive for COVID-19 or whether postoperative care was administered in COVID-19 units or in ordinary units. Conclusions Our data show that the COVID-19 pandemic has had a disruptive effect on the daily practice of orthopaedics. Existing guidelines need to be standardized, adequately disclosed, and strictly followed. Moreover, orthopaedic surgeons should receive specific a priori training for adequately managing patients with the virus if they have to be shifted from their department to a COVID-19 department. Finally, a dedicated COVID-19 orthopaedic team that would perform surgery exclusively on COVID-19-positive patients in dedicated operating rooms should be created in selected hospitals in each geographic area in order to provide safer access for patients without the virus who require urgent surgery. This storm will end, and we will return to the regular practice of orthopaedics again. Appendix Supporting material provided by the authors is posted with the online version of this article as a data supplement at jbjs.org (https://links.lww.com/JBJS/F912).

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