The current study presents the clinical data of patients in orthopedic surgery during the COVID-19 outbreak and the corresponding period last year in Wuhan, China. Eighty-two inpatients underwent preliminary emergency or outpatient screening and repeated screening in comprehensive and orthopedic buffer wards. The findings indicate that orthopedic inpatients have unique epidemiological characteristics; in particular, traumatic factures mainly presented with low-energy fractures. Our experience of using a double-buffered diagnosis and treatment mode provides a reliable reference for the future treatment of orthopedic patients.
The diagnosis and treatment of orthopedic patients was significantly affected by the outbreak of COVID-19, which changed the mode of orthopedic clinical practice. The guiding principles of clinical orthopedic work include the following aspects: (1) the urgency of the patient’s condition, (2) the protection of patients and medical staff, and (3) the reasonable use of medical resources. In our hospital, orthopedic surgery and ward management changes were adjusted accordingly on the basis of these principles. Patients who required emergency or early orthopedic surgery intervention were admitted to the orthopedic hospital as soon as possible. During the COVID-19 epidemic, patients with fractures due to high-energy injuries, such as transportation and engineering construction were relatively rare because of the strict control in Wuhan, China. Accidental fall injuries during home isolation activities are common, and the majority of these fracture patients were relatively stable, especially among the elderly . Our results showed that the age of epidemic period was significantly older than that of non-epidemic period. Orthopedic patients in need of emergency treatment, including open fractures, osteofascial compartment syndrome, blood vessels and nerves injury, and large area avulsion skin injuries, were significantly reduced because of strict city control measures . During the epidemic period, the orthopedic emergencies and expedited surgeries were indicative of admission and surgery, while the elective surgery was 37.7% during the non-epidemic period. In this work, several patients with closed fractures caused by low-energy injuries needed to be treated, and most of these treatments were limited-time surgeries. Limited-time operations performed within 1–2 weeks will not affect their clinical effect. Considering the potential risk of SARS-CoV-2 transmission and spread in the hospital, patients who need elective surgery could choose outpatient prescriptions and consider temporary pain-alleviating measures, arthroscopy (shoulders, knees, and ankles), knee and hip arthroplasty, spinal deformity corrections, and implant removals, in their care . Elective surgical cases were postponed, which could greatly reduce the workload of orthopedic surgeons and avoid a major drain of healthcare resources during an epidemic . Orthopedists have also been advised to prolong the duration between non-urgent follow-ups to avoid patient overcrowding in hospitals.
During the COVID-19 epidemic in Wuhan, osteoporotic fractures in the elderly, especially hip fractures and vertebral fractures, were common. Among the cases included in this study, 28 (49.1% of the fracture cases) had osteoporotic fractures. The patients were mostly in poor physical condition and presented with a combination of various diseases, including hypertension, heart disease, and diabetes . These patients were recommended for hospitalization for early surgical treatment, which can reduce various complications caused by long-term bed rest, including lung infections, urinary system infections, deep vein thrombosis, and bedsores [15,16]. In the present study, two cases who fell from a vertical height of over 3 meters presented multiple fractures. These two patients had an average age of 24.5 years and a history of previous mental illness. During an epidemic, patients may feel a sense of uncertainty and helplessness, resulting in different levels of psychological/behavioral stress responses, psychological problems, and even mental disorders . Therefore, counseling and health management are recommended for this group of patients. Patients with bone tumors and tuberculosis, especially vertebral tumors and tuberculosis, have strong requests for hospitalization . Pain symptoms and paralysis due to deterioration of the lesion may become unbearable, and the urgency of medical treatment is only slightly lower than that of trauma fracture. In the present study, eight patients hospitalized with vertebral tumors and tuberculosis delayed diagnosis and treatment until the most severe period of the epidemic. When serious complications occurred, including unbearable pain and paralysis caused by spinal cord compression, patients chose to be hospitalized in time. The diagnosis and treatment of these patients’ diseases were delayed because of COVID-19, which may eventually lead to poor prognosis.
There is conflicting evidence regarding the relationship between surgical delay and clinical outcome in patients with traumatic fractures . Most trauma patients were afraid of going out or did not realize the severity of their traumatic condition. They chose to stay at home for temporary observation. In addition, the 2-day COVID-19 RNA and antibody detection assays were the necessary prerequisite for allowing patients to enter the buffer ward. These factors could explain the patients’ delay from admission to surgery. The increase in waiting time was closely related to the increased risk of perioperative complications in surgical patients, especially those with traumatic fractures. Common complications during the perioperative period mainly included cardiovascular complications, venous thromboembolism and pneumonia, which were related to the patients’ limb dysfunction, reduced activity and long-term bed rest . In the epidemic group, the postoperative complication rate was 12.2%, which was higher than that in the non-epidemic period.
National recommendations and local infection control guidelines are tailored based on the availability of medical resources and the severity of the epidemic. The staff in Department of Bone & Joint Surgery, Peking University Shenzhen Hospital had benefited from the strict flowcharts, smart robot, and protection equipment during the perioperative managements for orthopedic patients. With the help of the strict flow charts and smart equipment, post-operation outcomes of the patients revealed that the rates of the complications and re-operation had been reduced significantly . The Department of Orthopedics and Orthopedic Oncology, University of Padova shared their experience. They made changes by medical direction to reallocate resources to COVID-19 patients, and a decrease in the number of beds and surgical activity was stabilized . Former researchers have provided good prevention and control facilities for the benefits of prevention and control. These strategies are beneficial to both the orthopedic patients and the medical staff.
Preventive and control measures should be formulated in a targeted manner according to the clinical characteristics of inpatients during an epidemic to standardize procedures for patient visits and hospitalization, treat patients rationally, and reduce the incidence of nosocomial infection. Patients may either be carriers of COVID-19 or asymptomatic cases. Thus, establishing strategies to prevent and control COVID-19 while implementing good orthopedic treatment and avoid SARS-CoV-2 spreads between doctors and patients is of great important. The workflow of the double-buffered diagnosis and treatment mode was implemented to standardize the treatment of orthopedic patients. After screening through the emergency triage process, patients undergo clinical medical observation in the surgical comprehensive buffer ward, receive COVID-19-related examinations, and perform primary buffering. During the screening process, confirmed COVID-19 patients are immediately transferred to the isolation ward to prevent patients missed during outpatient screening from entering the orthopedic ward. In our double-buffer mode, patients in the comprehensive buffer zone were transferred to the orthopedic buffer protection room after a clinical observation period of 2–3 days. Then, they undergo a second buffer to improve the operating efficiency of the whole buffer ward and ensure a safe treatment environment for doctors and patients. The entire COVID-19 screening buffer transition period is approximately 4–6 days, consistent with the timing of surgical treatment for most patients with trauma fractures; this period does not affect the patient’s condition and orthopedic treatment. The average waiting time of patients before surgery in this study was 7.0 days, which is relatively longer than that in the non-epidemic period. After strict emergency triage and double-buffering procedures, the patients are transferred to the orthopedic safe patient ward to ensure the safety of patients and orthopedic medical staff. For patients with life-threatening or multiple injuries, when emergency surgery is required, level III protection and multidisciplinary collaboration should be adopted in the negative pressure operation without confirmation of whether the patient is suspected or confirmed, and screening can be conducted in a separate isolated environment postoperatively. Each link has the risk of infection, which needs to be implemented in accordance with the requirements of level III protection to reduce the risk of nosocomial infection. Thus, our mode lays a good foundation for the safe diagnosis and treatment of orthopedic patients. We believe that our double-buffer mode can solve difficulties related to epidemic prevention and control during the treatment of orthopedic patients.
Surgeons must provide utmost care to patients in the preoperative, intraoperative, and postoperative settings to minimize the risk of nosocomial spread . The risks and benefits of surgical management should be reasonably considered for each patient. In this study, all patients were contacted 1 day before the operation and checked for respiratory symptoms, risk factors, or recent travel history (within 14 days) that may put them at risk of COVID-19. Operative personnel should be minimized, and surgical times should be kept as short as possible . Doctors may be segregated into an inpatient team that attends to patients in wards, operates, and provides on-call service and an outpatient team who is responsible for special orthopedic outpatient services. Hospitals should be in lockdown with no visitors allowed. The emergence of such a crisis provides a timely opportunity for clinicians to reﬂect and evaluate the use of novel technologies in the workplace . For example, the traditional work mode of ward round and shift handover could be adjusted, and a modern network technology could be adopted to transmit information. Clinical affairs, such as hospital consultation, difficult case discussion, and disease communication, could be conducted through WeChat, QQ and other ways. Furthermore, a simple, convenient, and efficient ward round system and management mode could be implemented to reduce medical staff gathering and doctor-patient contact.
The role of orthopedic surgeons in alleviating the COVID-19 crisis is certainly an important one. Even when reviewing low-risk elective patients, doctors should be vigilant, advocate good hygiene, and maintain an open mind when adopting novel workplace techniques. The shortcomings of this study are that the current diagnosis and treatment mode is fairly new, and the diagnosis and treatment process requries further adjustment according to the different stages of epidemic prevention and control. However, we believe that the proposed diagnosis and treatment mode will eventually be finetuned to provide a reliable and accurate reference for clinical work during an epidemic.
Several limitations to our work should be discussed. Firstly, the inherent limitations of retrospective design may compromise the accuracy of data collection. Secondly, due to the relatively small number of patients included and the data from a single-center study, selection bias was a concern. Our findings should be confirmed in a large-scale randomized trial in the future.