Changes in Orthopaedic diagnoses during the COVID-19 pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has been accompanied by significant reductions in patient volumes for non-COVID-19-related conditions ranging from acute coronary syndrome to ischemic strokes to acute trauma. However, the impact of the COVID-19 pandemic on patient volumes for a broad range of orthopedic conditions remains unknown. The purpose of this study was to investigate the association of the COVID-19 pandemic with changes in patient volumes of 35 emergent (e.g. dislocations, open fractures), urgent (e.g. fractures), and nonurgent orthopedic conditions (e.g. osteoarthritis, sprains).MethodsA retrospective interrupted time-series analysis of patient volumes was conducted for 35 orthopedic conditions based on ICD-10 diagnosis codes. Patient hospitalizations and new problem visits were aggregated across two institutions in New York state, including one urban tertiary care orthopedic hospital, one urban academic medical center, and all state outpatient facilities affiliated with the orthopedic institution. Patient volumes in the COVID-19 peak period (03/2020–05/2020) and COVID-19 recovery period (06/2020–10/2020) were compared against pre-COVID-19 vol (01/2018–02/2020).ResultsOverall, 169,047 cases were included in the analysis across 35 conditions with 3775 emergent cases, 6376 urgent cases, and 158,896 nonurgent cases. During the COVID-19 peak period, patient caseloads for 1 out of 7 emergent conditions (p = 0.02) and 26 out of 28 urgent and nonurgent conditions (p < 0.05) were significantly reduced compared to the pre-COVID-19 period. During the COVID-19 recovery period, patient volumes in 3 out of 13 emergent and urgent conditions (p < 0.03) and 11 out of 22 nonurgent conditions (p < 0.04) were decreased compared to pre-COVID-19 vol.ConclusionsThis study found that the pandemic was associated with considerable changes in patient patterns for non-COVID-19 orthopedic conditions. The long-term effects of patient volume reductions on both patient outcomes and orthopedic health systems remain to be seen.Level of evidenceCohort study; level of evidence IV.     

Hospital transmission rates of the SARS-CoV 2 disease amongst orthopaedic in-patients in a secondary care centre: A quantitative review

IntroductionOrthopaedic practice changed during COVID-19 with elective work ceasing, trauma reducing and work forces redistributed to medical areas. During the United Kingdom lockdown, hospitals were stretched thinly with admissions of SARS-CoV-2 positive patients.AimEvaluate orthopaedic admissions to a district general hospital during lockdown and the volume of those who subsequently were found to be COVID-19 positive.MethodRetrospective study of patients admitted under trauma and orthopaedics between March 23, 2020–June 18, 2020. Data includes; diagnosis, COVID-19 swab dates, results and mortality using orthopaedic admission sheets, patient and pathology electronic recording system.Results3/4 of admitted patients tested negative for SARS-CoV-2 initially. Of these 240 patients, 12.5% subsequently tested positive during their stay, often within one week of their admission. 17.8% of patients were never tested. 7.8% mortality rate of which 48% were neck of femur fracture (NOF#) patients. 28 NOF# were confirmed COVID-19 positive; mortality rate of 21.4%. 87 NOF# were COVID-19 negative; mortality rate 6.9%. Mortality relative risk (RR) for NOF# and COVID-19 positive was 2.6. COVID-19 positive mortality 27% as compared to 4% in COVID-19 negative patients. Patients who acquired COVID-19 whilst in hospital had a mortality relative risk 6.4Conclusion12.5% orthopaedic in-hospital viral transmission rate amongst orthopaedic patients despite the segregation measures taken, possibly due to asymptomatic health care workers or inpatients awaiting swab results. We emphasize the importance of testing all inpatients and regular testing of healthcare workers.     

Breast cancer survivorship care during the COVID-19 pandemic within an urban New York Hospital System

PurposeTo examine clinicodemographic determinants associated with breast cancer survivorship follow-up during COVID-19.MethodsWe performed a retrospective, population-based cohort study including early stage (Stage I-II) breast cancer patients who underwent resection between 2006 and 2018 in a New York City hospital system. The primary outcome was oncologic follow-up prior to and during the COVID-19 pandemic. Secondary analyses compared differences in follow-up by COVID-19 case rates stratified by ZIP code.ResultsA total of 2942 patients with early-stage breast cancer were available for analysis. 1588 (54%) of patients had attended follow-up in the year prior to the COVID-19 period but failed to continue to follow-up during the pandemic, either in-person or via telemedicine. 1242 (42%) patients attended a follow-up appointment during the COVID-19 pandemic.Compared with patients who did not present for follow-up during COVID-19, patients who continued their oncologic follow-up during the pandemic were younger (p = 0.049) more likely to have received adjuvant radiation therapy (p = 0.025), and have lower household income (p = 0.031) on multivariate modeling. When patients who live in Bronx, New York, were stratified by ZIP code, there was a modest negative association (r = −0.56) between COVID-19 cases and proportion of patients who continued to follow-up during the COVID-19 period.ConclusionWe observed a dramatic disruption in routine breast cancer follow-up during the COVID-19 pandemic. Providers and health systems should emphasize reintegrating patients who missed appointments during COVID-19 back into regular surveillance programs to avoid significant morbidity and mortality from missed breast cancer recurrences.     

Manejo perioperatorio de cirugías oncológicas no diferibles durante la pandemia de covid-19 en Madrid,España ¿Es seguro?

IntroductionSurgical treatment during COVID-19 pandemic is controversial. Currently, most clinical guidelines advise to defer surgical patients during the COVID-19 pandemic, although the supporting data is sparse. We assumed that a COVID-19-free hospital, on the back of strong isolation measures and targeted screening, could reduce complications and enable us to continue treating high-risk patients.MethodsProspective study with retrospective analysis of 355 patients who had undergone nondeferrable oncological surgery between March 16th, 2020, and April 14th, 2020, at our institution. The aim of the study was to assess the hospital restructuring and surgical protocols to be able to safely handle non-deferrable surgeries during the first wave of the COVID-19 pandemic. We implemented structural changes and an updated surgical-anesthetic protocol in order to isolate COVID-19 patients from other surgical patients. Comprehensive targeted screening for COVID-19 patients was made. PCR tests were requested for suspected COVID-19 patients. We analyzed mortality and complications related to both surgery and COVID-19 during hospital admission and also 15 and 30 days after surgery. We compared it with a sample of similar patients in the pre-pandemic period.ResultsOf the 355 patients enrolled in our study, 21 were removed due to COVID-19 infection, leaving a total of 334 patients in our final analysis. Post-operative complications were found in 37 patients (11.07%). Two patients died after surgery (0.6%). At the end of the study, COVID-19-related adverse outcomes were detected in six patients (1.79%). When comparing the complications of our original sample with the complications that occurred in the pre-COVID era, we found no statistically significant differences.ConclusionsOur results show that the surgical treatment of oncologic patients during the COVID-19 pandemic is safe, as long as the hospital performs surgeries under strict isolation measures and a robust screening method. It is necessary to select COVID-19 free hospitals for this matter in this and future pandemics.     

Hip Fracture Management during the COVID-19 Pandemic in South Korea

BackgroundThe purpose of this study was to introduce a screening system for coronavirus disease 2019 (COVID-19), to evaluate the overall orthopedic management in hip fracture patients during the COVID-19 pandemic in South Korea, and to compare the surgical results in hip fracture patients during the COVID-19 pandemic with those of the previous year.MethodsHip fracture patients who visited emergency rooms were screened at the screening clinics before admission. The medical management was carried out with the medical staff wearing surgical masks, meticulous hand hygiene observed, and a minimum distance of 2 m between patients maintained. The demographics, operative parameters, and surgical results of patients treated during the pandemic were compared with those from the previous year.ResultsFrom January 2020 to July 21, 2020, 119 patients with hip fractures (33 men and 86 women) were admitted to our institution for surgical treatment. Five patients showed symptoms of pneumonia, but no patient was positive for COVID-19. The mortality rate during the study period was 4.2%, and none of the patients died due to COVID-19. The interval between admission and surgery and the length of hospital stay were significantly shorter (p = 0.008, p = 0.002) and the proportion of spinal anesthesia was greater in hip fracture patients during the COVID-19 pandemic compared to those from the previous year (p = 0.011).ConclusionsThe COVID-19 screening system for hip fracture patients has proven to be effective in preventing intrahospital spread of the disease. Hip fracture surgery performed during the COVID-19 pandemic has shown comparable results without any COVID-19 infection and COVID-19-related mortality.     

Lessons Learnt from Managing Orthopaedic Trauma During the First Wave of the COVID-19 Pandemic at a UK District General Hospital

BackgroundThe Coronavirus disease (COVID-19) pandemic has contributed to over 1,000,000 deaths worldwide. Hospitals responded by expanding services to accommodate the forecasted rise in COVID-19-related admissions. We describe the effects these changes had on management of orthopaedic trauma and patient outcomes at a district general hospital in Southern England.MethodsData were extrapolated retrospectively from two separate 6-week periods in 2019 and 2020 (1st April–13th May) using electronic records of patients referred to the orthopaedic team. Soft tissue injuries were included where a confirmed diagnosis was made with radiological evidence. Patients were excluded if no orthopaedic intervention was required. Data were compared between the two time periods.ResultsThere were fewer attendances to hospital in 2020 compared with 2019 (178 vs. 328), but time from presentation to surgery significantly increased in 2020 (2.94 days vs. 4.91 days, p = 0.009). There were fewer operative complications in 2020 (36/145 vs. 11/88, p < 0.001). However, ordinal logistic regression analysis found a significantly greater complication severity in 2020 including death (p = 0.039). Complication severity was unrelated to COVID-19 status.ConclusionsRestructuring of orthopaedic services in response to the COVID-19 pandemic has been associated with significant delays to surgery and higher post-operative complication severity. Our results demonstrate the need for fast-track emergency operative orthopaedic services in UK district general hospitals whilst the COVID-19 pandemic continues.     

Pacientes críticos COVID-19 atendidos por anestesiólogos en el Noroeste de España: estudio multicéntrico,prospectivo, observacional

Background and objectivesThere are limited information on outcome, complications and treatments of critically ill COVID-19 patients requiring admission to an intensive care unit (ICU). The aim of this study is to describe the clinical ICU course, treatments used, complications and outcomes, of critically ill COVID-19 patients admitted in seven ICU in Galicia region during the 2020 March-April pandemic peak.MethodsBetween March 21 and April 19, 2020, we evaluated critically ill COVID-19 patients admitted to the ICU of Anesthesia of seven hospitals in Galicia, northwestern Spain. Outcome, complications, and treatments were monitored until May 6, 2020, the final date of follow-up.ResultsA total of 97 critically ill COVID-19 patients were included. During ICU stay, mechanical ventilation became necessary in 80 (82.5%) patients, and tracheostomy in 22 (22.7%) patients. Prone position was used frequently in both intubated (67.5%) and awake (27.8%) patients. Medications consisted of antivirals agents (92.7%), corticosteroids (93.8%), tocilizumab (57.7%), and intermediate or high doses of anticoagulants (83.5%). The most frequent complications were ICU-acquired infection (52.6%), thrombosis events (16.5%), and reintubation (9.3%). After a median follow-up of 42 (34-45) days, 15 patients (15.5%) deceased, 73 patients (75.2%) had been discharged from ICU, and nine patients (9.3%) were still in the ICU.ConclusionsA high proportion of our critically ill COVID-19 patients required mechanical ventilation, prone positioning, antiviral medication, corticosteroids, and anticoagulants. ICU complications were frequent, mainly infections and thrombotic events. We had a relatively low mortality of 15,5%.     

The Impact of COVID-19 on Orthopedic Surgery Fellowship Training: A Survey of Fellowship Program Directors

Background: The COVID-19 pandemic has had a wide-reaching impact. Graduate medical education of orthopedic surgeons was not spared from the jarring changes. Purpose: We sought to survey fellowship program directors in the field of orthopedic surgery about how the COVID-19 pandemic affected the education of the 2019 to 2020 and 2020 to 2021 fellowship classes and the future of their programs. Methods: In October 2020, an 18-item survey was distributed by an official of the American Academy of Orthopedic Surgeons (AAOS) to the specialty societies that govern fellowship training. Each specialty society then distributed the survey to its respective program directors. A reminder email was sent during the enrollment period. Each respondent was able to complete the survey once. Survey questions were grouped into 3 sections: general information about the fellowship training programs, the impact of COVID-19 on the 2019 to 2020 fellowship class, and the future impact of COVID-19 on the fellowship training programs. Results: Of the 564 accredited orthopedic surgery fellowship programs in the United States, 190 directors responded. Of these, 73.59% reported COVID-19 had a negative impact on the 2019 to 2020 fellowship class. A normal distribution of responses was found regarding didactic and academic learning, research, and mentorship opportunities. A majority of respondents said they believe that there will be no negative impact on patient care the fellows provide in the years to come. Conclusion: Orthopedic surgery fellowship program directors acknowledged that while there were negative effects to training in the pandemic, they did not think these would negatively affect patient care provided by 2019 to 2020 fellows in the short and medium term. They also reported positive outcomes from the experience of the pandemic, including new ways to educate fellows.     

Impact of the COVID-19 pandemic on a trauma center of a university hospital in Japan

BackgroundThe Coronavirus disease 2019 pandemic caused the Japanese government to declare a State of Emergency on April 7, 2020. The aim of this study is to provide an overview of the effects of the pandemic on surgical cases at a university hospital trauma center.MethodsAn observational study was performed at a trauma center in a tertiary hospital in Tokyo, Japan. The number of surgeries was compared between two periods: a historical control period (Tuesday April 9 to Monday May 27, 2019) and the period of the Japan State of Emergency due to COVID-19 (Tuesday April 7–Monday May 25, 2020). Information on patient age, gender, and surgical diagnosis, site, and procedure was collected for cases operated on in each period. The number of trauma surgeries was compared between the two periods. Data from the two periods were compared statistically.ResultsThe total number of surgical cases was 151 in the control period and 83 in the COVID-19 period (including no cases with COVID-19), a decrease of 45.0%. There were significantly more surgeries for patients with hip fractures in the COVID-19 period (9 vs. 19, P < 0.001 by Fisher exact test).ConclusionsDuring the State of Emergency in Japan, the number of operations for trauma patients at the trauma center decreased, but surgeries for hip fracture increased.     

Collaborative Overview of coronaVIrus impact on ORTHopaedic training in the UK (COVI - ORTH UK)

IntroductionCOVID-19 was declared a pandemic by the World Health Organization on the 11th of March 2020 with the NHS deferring all non-urgent activity from the 15th of April 2020. The aim of our study was to assess the impact of COVID-19 on Trauma and Orthopaedic trainees nationally.MethodsTrauma and Orthopaedic (T&O) specialty trainees nationally were asked to complete an electronic survey specifically on the impact of COVID-19 on their training. This UK based survey was conducted between May 2020 and July 2020.ResultsA total of 185 out of 975 (19%) T&O specialty trainees completed the survey. Redeployment was experienced by 25% of trainees. 84% of respondents had experienced a fall in total operating numbers in comparison with the same time period in 2019. 89% experienced a fall in elective operating and 63% experienced a fall in trauma operating. The pandemic has also had an effect on the delivery of teaching, with face to face teaching being replaced by webinar-based teaching. 63% of training programmes delivered regular weekly teaching, whilst 19% provided infrequent sessions and 11% provided no teaching.ConclusionThis study has objectively demonstrated the significant impact of the COVID-19 pandemic on all aspects of T&O training.     

The impact of COVID-19 on emergency general surgery admissions and operative volumes: A single centre experience

IntroductionThe COVID-19 pandemic has placed a significant strain on healthcare resources and utilisation globally. The appearance of the disease in the Republic of Ireland resulted in a broad postponement of scheduled and routine surgical care. The influence of the novel coronavirus, and the associated imposition of public health measures such as school closures and social distancing, on the burden of emergency surgical disease is less clear.AimThe aim of this study was to examine the impact of COVID-19 on the number of patients presenting to our institution with emergent surgical illnesses or requiring emergency general surgical procedures.MethodsAll patients attending our service between March 1st 2020 and April 30th 2020 were identified retrospectively by examining electronic handover and electronic discharge summaries, and data were collected relating to demographics, presenting illness, critical care utilisation, length of stay, operative or endoscopic procedure performed, and in-hospital mortality. Similar data were collected March 1st to April 30th 2019, 2018, and 2017 respectively to allow direct comparison.Results151 patients were admitted during the study period, compared to a total of 788 during the proceeding three years (mean 2.49 admissions per night versus 4.35 per night, 42.8% reduction, p < 0.001). Median age of admitted patients was 51.8 years, compared to 50.3 years formerly (p = 0.35). 53 emergency procedures were performed, compared to a median of 70 over the same period in the previous years (mean 0.87 per day versus 1.16 per day, 25.4% reduction, p = 0.05).ConclusionA significant overall reduction in the number of patients being admitted to our unit and requiring emergency surgical procedures during March and April 2020 was seen, in line with patterns reported internationally.     

Orthopedic Specialty Hospital Reasons for Transfer and Subsequent Outcomes

BackgroundSurgical specialty hospitals provide patients, surgeons, and staff with a streamlined approach to elective surgery but may not be equipped to handle all complications arising postoperatively. The purpose of this study is to evaluate the immediate postoperative and 90-day outcomes of patients who were transferred from a high-volume specialty hospital following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).MethodsAll patients who were admitted to one orthopedic specialty hospital for primary THA or TKA between January 2015 and December 2019, and subsequently transferred to a tertiary care hospital, were identified and propensity matched to nontransferred patients. Emergency department visits, complications, readmissions, mortality, and revisions within 90 days of surgery were identified for each group.ResultsThere were 26 TKAs (0.78%) and 20 THAs (0.48%) transferred, representing 0.62% of all primary THAs and TKAs performed over the study duration. Arrhythmia and chest pain were the most common reasons for transfer. Ninety-day readmissions were significantly higher in the transfer group (15.2% vs 4.3%, P = .020) with an odds ratio for readmission after transfer of 3.9 (95% confidence interval 1.3-12.4). Overall complications and orthopedic complications did not differ significantly, although transferred patients had a higher rate of medical complications (13.0% vs 2.2%, P = .008) with an odds ratio of 6.7 (95% confidence interval 1.6-28.2).ConclusionTransfer from a specialty hospital is rarely required following primary TKA and THA. Although not at increased risk for orthopedic complications, these transferred patients are at increased risk for readmissions and medical complications within the first 90 days of their care, necessitating increased vigilance.     

The COVID-19 pandemic in Singapore: what does it mean for arthroplasty?

Background and purpose — The ongoing Coronavirus Disease-19 (COVID-19) pandemic has taken a toll on healthcare systems around the world. This has led to guidelines advising against elective procedures, which includes elective arthroplasty. Despite arthroplasty being an elective procedure, some arthroplasties are arguably essential, as pain or functional impairment maybe devastating for patients, especially during this difficult period. We describe our experience as the Division of Arthroplasty in the hospital at the epicenter of the COVID-19 pandemic in Singapore.Patients and methods — The number of COVID-19 cases reported both nationwide and at our institution from February 2020 to date were reviewed. We then collated the number of arthroplasties that we were able to cope with on a weekly basis and charted it against the number of new COVID-19 cases admitted to our institution and the prevalence of COVID-19 within the Singapore population.Results — During the COVID-19 pandemic period, a significant decrease in the volume of arthroplasties was seen. 47 arthroplasties were performed during the pandemic period from February to April, with a weekly average of 5 cases. This was a 74% reduction compared with our institutional baseline. The least number of surgeries were performed during early periods of the pandemic. This eventually rose to a maximum of 47% of our baseline numbers. Throughout this period, no cases of COVID-19 infection were reported amongst the orthopedic inpatients at our institution.Interpretation — During the early periods of the pandemic, careful planning was required to evaluate the pandemic situation and gauge our resources and manpower. Our study illustrates the number of arthroplasties that can potentially be done relative to the disease curve. This could serve as a guide to reinstating arthroplasty as the pandemic dies down. However, it is prudent to note that these situations are widely dynamic and frequent re-evaluation is required to secure patient and healthcare personnel safety, while ensuring appropriate care is delivered.

Tan Tock Seng Hospital (TTSH) in Singapore is a unique institution, functioning almost as a single unit with the National Centre of Infectious Disease (NCID), which has been at the epicenter of the Coronavirus Disease-19 (COVID-19) pandemic in the nation. Following the 2002–2004 Severe Acute Respiratory Syndrome (SARS) epidemic, the NCID was built in an effort to prepare Singapore for future outbreaks and to allow for continued management of patients with chronic conditions (Kurohi 2019).The NCID handled about 70% of the screening load at the start of the COVID-19 pandemic in Singapore, a country with a population of around 5.8 million. Operational manpower required for the running of the screening centers, wards, and intensive care units in NCID had been solely derived from TTSH until April 1, 2020, after which other hospitals in Singapore began contributing manpower to aid with the crisis.The Division of Arthroplasty, within the Department of Orthopaedic Surgery in TTSH, consists of 8 surgeons who performed an average of 84 arthroplasties, including knee replacements, hip replacements, and elective revision arthroplasties, per month prior to the COVID-19 outbreak. When evidence of community spread of the disease first surfaced on February 7, 2020, the Ministry of Health (MOH) of Singapore responded by declaring the Disease Outbreak Response System Condition (DORSCON) alert level of Orange (Ministry of Health, Singapore 2020c [last accessed April 19, 2020]). At the epicenter of the outbreak, TTSH began reassigning manpower to ensure that NCID was adequately staffed to handle the situation. At that point, one-quarter of the manpower from the Department of Orthopaedic Surgery was deployed to assist with the screening effort in NCID. Considering the available resources, the hospital management advised a reduction in the “Business As Usual (BAU)” activities to half its capacity, which included elective surgeries like arthroplasty.Throughout this period, the Ministry of Health remained in close contact with all public health institutions to provide directives regarding the deferment of elective surgeries, with an eye on the rising incidence of COVID-19 in Singapore, and in anticipation of the potential increase in the number of patients requiring critical care (Ministry of Health, Singapore 2020a, b [last accessed April 19, 2020]).We describe our experience in the Division of Arthroplasty at the epicenter of the COVID-19 pandemic in Singapore.     

Racial and Neighborhood-Level Disparities in COVID-19 Incidence among Patients on Hemodialysis in New York City

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected socially disadvantaged populations. Whether disparities in COVID-19 incidence related to race/ethnicity and socioeconomic factors exist in the hemodialysis population is unknown.MethodsOur study involved patients receiving in-center hemodialysis in New York City. We used a validated index of neighborhood social vulnerability, the Social Vulnerability Index (SVI), which comprises 15 census tract–level indicators organized into four themes: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. We examined the association of race/ethnicity and the SVI with symptomatic COVID-19 between March 1, 2020 and August 3, 2020. COVID-19 cases were ascertained using PCR testing. We performed multivariable logistic regression to adjust for demographics, individual-level social factors, dialysis-related medical history, and dialysis facility factors.ResultsOf the 1378 patients on hemodialysis in the study, 247 (17.9%) developed symptomatic COVID-19. In adjusted analyses, non-Hispanic Black and Hispanic patients had significantly increased odds of COVID-19 compared with non-Hispanic White patients. Census tract–level overall SVI, modeled continuously or in quintiles, was not associated with COVID-19 in unadjusted or adjusted analyses. Among non-Hispanic White patients, the socioeconomic status SVI theme, the minority status and language SVI theme, and housing crowding were significantly associated with COVID-19 in unadjusted analyses.ConclusionsAmong patients on hemodialysis in New York City, there were substantial racial/ethnic disparities in COVID-19 incidence not explained by neighborhood-level social vulnerability. Neighborhood-level socioeconomic status, minority status and language, and housing crowding were positively associated with acquiring COVID-19 among non-Hispanic Whites. Our findings suggest that socially vulnerable patients on dialysis face disparate COVID-19–related exposures, requiring targeted risk-mitigation strategies.     

A comparison of patient same-day discharge selection after shoulder arthroplasty before and after the COVID-19 pandemic

BackgroundEarly discharge has been a target of cost control efforts, given the growing demand for joint replacement surgery. Select patients are given the choice for same-day discharge (SDD) or overnight stay after shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD after shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD.MethodsA retrospective continuous review was performed on 370 patients who underwent a primary anatomic (total shoulder arthroplasty) or reverse shoulder arthroplasty between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic and the first 185 patients after the start of the pandemic. April 1, 2020, was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer’s exact were performed where appropriate.ResultsThe 2 groups were similar in age, body mass index, gender distribution, and Outpatient Arthroplasty Risk Assessment score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (P = .029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have an SDD (P < .001), with 85.4% (158/185) of patients being discharged the same day after COVID-19, compared with 34.6% (64/185) before COVID-19. Discharge disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared with 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the 2 groups.ConclusionOur study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon’s practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients after total shoulder arthroplasty and reverse shoulder arthroplasty.Level of evidenceLevel III; Retrospective Comparative Study     

Hospital Management and Ambulatory Patient Care After COVID-19 Infection in Kidney Transplant

BackgroundA large number of registries have been collected for kidney transplant recipients infected with COVID-19.MethodsFrom March 2020 to April 2021, our team conducted an observational study, which included all patients who showed a polymerase chain reaction positive for COVID-19. Patients were divided into 2 groups: patients who required ambulatory care and patients who needed hospital admission.ResultsA total of 76 kidney transplant recipients were infected with COVID-19. A total of 33% required hospital admission and 65% received ambulatory treatment; 28% of our patients were asymptomatic and 6.8% died. Immunosuppressive treatment was modified in both study groups, and there were not any acute rejection episodes or changes in the human leukocyte antigen antibodies profile in our patients during our clinical trial.ConclusionsIn our study there was a significant percentage of patients who did not require hospital admission compared with other studies. In addition, we think that the reduction of immunosuppression can be a safe and reliable treatment.     

The financial implications of telemedicine practice patterns across pediatric surgical specialties

BackgroundTelemedicine has played an increasingly important role in surgical care during the coronavirus disease 2019 (COVID-19) pandemic, yet little is known about its usage and correlation to cost both within and across surgical specialties during the pandemic.Study DesignWe collected data on telehealth encounters from April 2020 to June 2021 for all surgical specialties at a pediatric academic institution. The percent of total encounters that were telemedicine vs. in-person were analyzed over time. Data on charge and reimbursement were averaged for each encounter type, and the percent difference in average charge and reimbursement was calculated and compared between surgical specialties.ResultsOf the 147,007 surgical clinical visits identified, 6,566 encounters (4.5%) were telemedicine. Usage peaked in April and plateaued in June of 2020. The specialties with the highest total percentages of telemedicine visits were neurosurgery (23.2%) and cardiovascular-thoracic (11.9%). Orthopedics reported the lowest usage at 2%. Charges for in-person encounters were higher for nearly all specialties while reimbursements remained equal.ConclusionOur institutional trends reveal that conversion to telemedicine varied across surgical specialty during the COVID-19 pandemic. Charges for in-person encounters were higher than telehealth ones for nearly all specialties, but the reimbursements were fairly the same. Understanding trends in telemedicine volume instigated by and following the pandemic may better prepare pediatric institutions to navigate the accelerated adoption and influence policy changes. This is particularly relevant given the fluctuating impact of the pandemic on healthcare institutions as new strains of COVID-19 emerge.EVIDENCE LEVELLevel V