The COVID-19 pandemic has presented numerous challenges to the healthcare systems in Japan and throughout the world. Among these issues, surgeries have been canceled due to outbreaks within hospitals. Similarly, patients diagnosed with COVID-19 have only limited access to emergency services and critical diagnostic devices including Magnetic Resonance Imaging (MRI) scanners. While there is substantial ongoing research into the secondary health effects of COVID-19, the impact of this pandemic on orthopedic services has not been clearly established. This case features several of the many challenges faced by orthopedic surgeons when attempting to provide high-quality care to patients with complex co-morbidities who develop COVID-19.
As a first concern, we all recognize that immunocompromised patients may be susceptible to serious infections and the need to intervene early to prevent excessive and ongoing tissue damage [1]. Thus, while corticosteroids may be effective for COVID-19 as they limit the destruction associated with ongoing inflammation, the immunosuppressive effects of these drugs may result in increased susceptibility to bacterial infections [2, 3]. In the case presented here, the uncontrolled growth of a skin infection that is typically amenable to treatment led to the necrosis of both muscle and bone. Furthermore, the major amputation that was ultimately required to prevent further infiltration and necrosis may have resulted in bacterial translocation and secondary systemic infection. Although we initially intended to address this complication with a minor amputation, this was not possible once the patient contracted COVID-19. In this case, surgery was delayed and the infection progressed significantly.
We also recognize that all physicians and surgeons need to adjust their expectations and also their protocols during the ongoing COVID-19 pandemic. This is perhaps most critical when addressing the concerns of complex patients. In many cases, infections may not be adequately controlled by standard methods and/or within the normally-anticipated timespan. Our report documented the case of a lesion at the distal end of the left third digit that progressed to purulent tenosynovitis that spread from the tenosynovium into the bones. To the best of our knowledge, this is the first report that documents this type of progression of what is typically a localized infection. While severe cases of purulent tenosynovitis may require digital or carpal amputation, there are no previous reports that document cases in which a full forearm amputation was required [4].
Numerous secondary effects caused by COVID-19 contributed to the outcome of this case. For example, protocols in place that were designed to limit the spread of COVID-19 played a large role in the development of this patient’s treatment plan and anticipated timelines. There are numerous and varied hospital policies for patients diagnosed with COVID-19, most notably with respect to the use of hospital facilities and operating rooms. At our hospital, COVID-19-positive patients could enter any of the operating rooms for at least two weeks after obtaining a confirmed negative result because of the high risk of disease transmission to anesthesiologists, surgeons, nurses, staff, and other patients. In this case, we believe that the infection was exacerbated by the combined effects of COVID-19 treatment as well as the circulatory disturbances and vasoconstriction resulting from the administration of norepinephrine. Norepinephrine is a catecholamine that stimulates the alpha-1-adrenoreceptor, thereby inducing peripheral vasoconstriction [5]. Our patient was treated with norepinephrine (1 g/mL) administered intravenously five times a day for a full one month to maintain adequate systemic blood pressure. Previous case reports suggest that the use of high-dose norepinephrine and similar inotropes can result in necrosis secondary to severe vasoconstriction and tissue hypoperfusion [6]. Close monitoring for ischemia should be maintained when inotropic agents are used; our case was a good example of this principle. As shown in Fig. 4, the patient exhibited signs of hypoperfusion, notably, her fingers developed a white to purple hue. Likewise, the use of vasopressor drugs results in impaired regional circulation secondary to distal hypoperfusion ischemia syndrome from the shunt. This creates a scenario in which antibiotics may be unable to reach peripheral tissue and may result in poor perfusion and an increased vulnerability to ongoing infection.
This case illustrates the complexity of managing patients with multiple comorbidities as well as the challenges presented by the current pandemic, including lockdowns that limit access to healthcare, various hospital-based restrictions, and overload of the healthcare system due to lack of staff and personal protective equipment [7]. These challenges can exacerbate one another which will lead to even more extensive difficulties when treating these complex patients. Increased mortality rates and poor prognoses have been recognized in at least one study that focused on patients who underwent surgery while infected with SARS-CoV-2 [5]. All physicians need to understand, plan, and prepare for the impact of COVID-19 and consider how pandemic conditions can alter the progression of even seemingly-unrelated diseases. For example, Liu and Zhang [9] reported that both COVID-19 and its treatment may have endovascular effects. Similarly, Makhoul et al. [8] reported on a series of COVID-19 patients who required amputation of their extremities due to endovascular and coagulation disorders following ischemia and arterial occlusion. This case is the first report of a secondary infection that was exacerbated by COVID-19 and/or its treatment. In our case, ischemia secondary to vasoconstriction and coagulopathy most likely permitted the bacterial infection to spread up to the distal forearm and expedited the necrosis process. In this case, there was a particularly high risk associated with bacterial infiltration of the arteriovenous shunt in the left arm and thus the potential for systemic infection. Physicians will need to review the medical literature on an ongoing basis and proceed under the assumption that the presentation and progression of many otherwise controllable conditions may be varied and unanticipated in these patients. For example, while COVID-19 related coagulopathy presents in a fashion that is similar to DIC, recent evidence suggests that conventional treatments may not be effective and must be used in conjuction to other COVID-19 specific treatment [9]. Likewise, atherosclerosis and hypercoagulation have been linked with COVID-19 infection in the literature; these factors increase the risk of arterial occlusion and ischemia [10]. The use of vasopressors may exacerbate these effects by promoting necrosis of peripheral tissues and increasing the risk of infection. Likewise, patients with comorbidities are more susceptible to both vascular complications and the uncontrolled spread of the infection. Physicians need to treat small wounds carefully in patients with comorbidities and provide the same level of care as would be applied to larger wounds. This is critical to prevent the uncontrollable spread and the development of a life-threatening condition. This is especially important to consider now during the COVID-19 pandemic, given the complications associated with long-term COVID-19 treatment, including vasopressors, corticosteroids, and immunosuppresive drugs. Collaboration between caregivers on primary care teams, i.e., nurses, pressure ulcer care teams, and physiotherapists is also a critical factor in early diagnosis and treatment, especially in the age of COVID-19. Early diagnosis and treatment are critical for all patients who are at risk of contracting COVID-19; it is critical to recognize that these patients might ultimately be prevented from entering an operating room and thus face a limited number of treatment modalities. In the future, it might be helpful to prepare operating theaters or create temporary structures that are capable of handling COVID-19 patients to facilitate early diagnosis and treatment and improve patient outcomes and quality of life.