Outcomes of orthopaedic trauma patients undergoing surgery during the peak period of COVID-19 infection at a UK major trauma centre

BackgroundTo review the clinical outcomes of all patients undergoing emergency orthopaedic trauma surgery at a UK major trauma centre during the first 6 weeks of the COVID-19 related lockdown.MethodsA retrospective review was performed of all patients who underwent emergency orthopaedic trauma surgery at a single urban major trauma centre over the first six-week period of national lockdown. Demographics, co-morbidities, injuries, injury severity scores, surgery, COVID-19 status, complications and mortalities were analysed.ResultsA total of 76 patients were included for review who underwent multiple procedures. Significant co-morbidity was present in 72%. The overall COVID-19 infection rate of the study population at any time was 22%. Sub-group analysis indicated 13% had active COVID-19 at the time of surgery. Only 4% of patients developed COVID-19 post surgery with no mortalities in this sub-group. The overall mortality rate was 4%. The overall complication rate was 14%. However mortality and complications rates were higher if the patients had active COVID-19 at surgery, if they were over 70 years and had sustained life-threatening injuries.ConclusionThe overall survival rate for patients undergoing emergency orthopaedic trauma surgery during the COVID-19 peak was 96%. The rate of any complication was more significant in those presenting with active COVID-19 infections who had sustained potentially life threatening injuries and were over 70 years of age. Conversely those without active COVID-19 infection and who lacked significant co-morbidities experienced a lower complication and mortality rate.     

Crisis change management during COVID-19 in the elective orthopaedic hospital: Easing the trauma burden of acute hospitals

IntroductionWith the emergence of the 2019 novel coronavirus and its resulting pandemic status in March 2020 all routine elective orthopaedic surgery was cancelled in our institution. The developing picture in Italy, of acute hospitals becoming overwhelmed with treating patients suffering with severe and life-threatening symptoms from the disease, prompted the orthopaedic surgeons to formulate a plan to transfer trauma patients requiring surgery to the elective hospital to unburden the acute hospital system.MethodsUnder the threat of this pandemic; protocols and algorithms were established for referral, acceptance and care of trauma patients from acute hospitals in the region. Each day, as new guidance on COVID-19 emerged, our process and algorithms were adjusted to reflect pertinent change.ResultsThe screening of all patients referred, worked well in keeping our hospital “COVID-free” with respect to patients undergoing operations. An upward trend in cases referred reflected the decreased capacity in the acute hospitals due to rising cases of COVID-19 within the hospital network. During the first 7 weeks of the pandemic 308 operations were performed, (31.1% upper limb, 33.4% lower limb, 4.1% spine, 14.1% urgent elective, 17.4% plastic surgery cases). Regular review and audit of the activity in the hospital as well as communication with the referring teams enabled appropriate planning to accommodate the increase in case-mix as the need arose.DiscussionThis paper details the steps that were taken in planning for such a change in management specific to the orthopaedic surgery setting and the lessons learnt during this process. The success of the development of this pathway was facilitated by clear communication channels, flexibility to adapt to changing process and feedback from all stakeholders. The implementation of this pathway allowed the unburdening of acute hospitals dealing with the pandemic that was steadily reducing access to operating theatres and anaesthetic resources.     

Epidemiological pattern of orthopaedic fracture during the COVID-19 pandemic: A systematic review and meta-analysis

IntroductionThis systematic review and meta-analysis aimed evaluate the 30-day mortality, number and site of fracture, mechanism of injury, and location where injury was sustained during the pandemic compared to pre-pandemic.MethodsWe performed a systematic literature search from PubMed and Embase on original articles, research letters, and short reports which have data about the number of fractures, site of fracture, mechanism of injury, location where injury was sustained, percentage of operative intervention, mortality during the pandemic compared to a specified period of time before the pandemic. The search was finalized in October 14, 2020.ResultsA total of 11,936 participants from 16 studies were included in our study. The pooled analysis indicated a higher 30-days mortality associated with fractures during the pandemic (9% vs 4%, OR 1.86 [1.05, 3.27], p = 0.03; I²: 36%, p = 0.15). The number of fractures presenting to hospitals has declined 43% (35–50%) compared to pre-pandemic. Hand fracture was fewer during the pandemic (18% vs 23%, OR 0.75 [0.58, 0.97], p = 0.03; I²: 69%, p = 0.002). Work-related traumas, high-energy falls, and domestic accidents were more common during the pandemic, while sports-related traumas were found to be less. Injuries that occurred in the sports area were lower than before the pandemic.ConclusionThe present meta-analysis showed that during the COVID-19 pandemic, the number of fractures has decreased, but there is a higher mortality rate associated with fractures.     

Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre

IntroductionThe Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions adversely impacted the care of open fractures in our major trauma unit in London.MethodsThis is a prospective case control study comparing the management of patients presenting pre-COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, control cohort presented between the 1st October and the November 30, 2019. The COVID cohort presented between the April 1, 2020 and the May 31, 2020. Data was collected that related to the 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, as well as early complications.ResultsOf the 11 domains, 100 % compliance was achieved in 6 components, across both groups where applicable. During pre-COVID times, the timing to initial debridement was within 12 h for High energy trauma in 16/28 (57.1 %), dropping to 7/22 (31.8 %) during COVID, (p = 0.004). Definitive soft tissue closure within 72 h If not achievable at initial debridement dropped from 9/10 (90.0%) to 4/6 (66.7 %), (p = 0.006). There was no significant difference in early complication rates.ConclusionCoronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by increasing time to theatre. This had no effect on early complication rate but longer term effects remain to be seen.     

Social media growth of orthopaedic surgery residency programs in response to the COVID-19 pandemic

BACKGROUNDIn the Spring of 2020, residency programs across the country experienced rapid and drastic changes to their application process as a result of the coronavirus disease 2019 (COVID-19) pandemic. In response, residency programs shifted to virtual events and began harnessing social media to communicate with applicants.AIMTo analyze the changes in social media usage by orthopaedic surgery programs in response to the COVID-19 pandemic.METHODSBased on the 2019 residency and fellowship electronic database, accredited US orthopaedic surgery programs were reviewed for social media presence on Instagram and Twitter. Approximately 47000 tweets from 2011-2021 were extracted through the Twitter application programming interface. We extracted: Total number of followers, accounts following, tweets, likes, date of account creation, hashtags, and mentions. Natural language processing was utilized for tweet sentiment analysis and classified as positive, neutral, or negative. Instagram data was collected and deemed current as of August 11, 2021. The account foundation date analysis was based on the date recognized as the start of the COVID-19 outbreak in the United States, before or after March 1, 2020.RESULTSA total of 85 (42.3%) orthopaedic surgery residency program Twitter handles were identified. Thirty-five (41.2%) programs joined Twitter in the nine months after the 2020 covid outbreak. In 2020, there was a 126.6% increase in volume of tweets by orthopaedic surgery residency accounts as compared to 2019. The median number of followers was 474.5 (interquartile range 205.0-796.5). The account with the highest number of tweets was Hospital for Special Surgery (@HSpecialSurgery) with 13776 tweets followed by University of Virginia (@UVA_Ortho) with 5063 and Yale (@OrthoAtYale) with 899. Sentiment analysis before 2020 revealed 30.4% positive, 60.8% neutral, and 8.8% negative sentiments across tweets. Interestingly, the positive sentiment percentage increased in 2020 from 30.4% to 34.5%. Of the 201 ACGME-accredited orthopaedic residency programs on Fellowship and Residency Electronic Interactive Database, 115 (57.2%) participate on Instagram, with 101 (87.8%) identified as “resident”-managed vs 14 (12.2%) identified as “department”-managed. Over three quarters (77.4%) of Instagram accounts were created after March 1, 2020. The average number of followers per account was 1089.5 with an average of 58.9 total posts. CONCLUSIONOur study demonstrates a substantial growth of Instagram and Twitter presence by orthopaedic surgery residency programs during the COVID-19 pandemic. These data suggest that orthopaedic residency programs have utilized social media as a new way to communicate with applicants and showcase their programs in light of the challenges presented by the pandemic.     

Internet of Medical Things (IoMT) for orthopaedic in COVID-19 pandemic: Roles,challenges, and applications

Internet of Medical Things (IoMT) is an innovative mean of amalgamating medical devices and their applications to connect with the healthcare information technology systems by using networking technologies. We have explored the possibilities of confronting the ongoing COVID-19 pandemic by implementing the IoMT approach while offering treatment to orthopaedic patients. The data sharing, report monitoring, patients tracking, information gathering and analysis, hygiene medical care, etc. are the various cloud and connected network-based services of IoMT. It can completely change the working layout of the healthcare facilities while treating orthopaedic patients with a superior level of care and more satisfaction, especially during this pandemic COVID-19 lockdown. Remote-location healthcare has also become feasible with the proposed IoMT approach.     

Global orthopaedic trauma surgeons highlight telenomics during the COVID-19 era: A case for advancing telemedicine in orthopaedics

The Coronavirus (COVID-19) pandemic sparked rapid widespread adoption of telemedicine throughout specialties, including orthopaedics. A succession of factors, starting with payers, followed by provider adoption, and reciprocated by patient approval, created newly accepted telehealth practices that have moved from trial to norm in a short time span. Orthopaedic surgeons believe telehealth will endure as a permanent change to their practice beyond the COVID-19 era, however, many permanent changes must take place by payers, providers, and patients to sustain telehealth into the future. The goal of this paper is to highlight the indelibility of telemedicine adoption in orthopaedic practices globally, characterize the chain of events that led to its large-scale adoption, and catalyze discussion around actionable next steps to sustain its benefits.     

The effect of COVID-19 pandemic on the care of fragility hip fracture patients in the United Kingdom. A case control study in a major trauma centre

IntroductionCoronavirus disease 2019 is a pandemic that forced a transformation in the services provided by the National Health Service in the United Kingdom. Fragility hip fractures account for over 65,000 cases per year in the elderly population. The study aims to assess the impact of the pandemic on fragility hip fractures.MethodsA retrospective data gather was performed to identify fragility hip fractures from the 23rd of March 2020 to the 13th of May 2020, and from the 23rd of March 2019 to the 13th of May 19. Two groups were formed and compared over their 30 day follow up.ResultsThe control group comprised of 97 patients, with a mean age of 82.1 years old (62–102 years) and M:F ratio of 38:59. The case group comprised of 102 patients, with a mean age of 82.3 years old (60–100 years) and a M:F ratio of 16:86. Significant differences between groups were identified for gender (p < 0.001), time to theatre (p = 0.002), length of stay (p < 0.001) and COVID-19 status (p = 0.001). In the Case group, association with mortality was found for male gender (p = 0.041), right side (p = 0.031) and COVID-19 positive test results (p = 0.011).ConclusionEarly surgical intervention is advocated wherever possible, and sufficient optimisation, prior to surgery whenever a COVID-19 positive patient is identified. A safe rehabilitation environment is paramount for recovery in this group of patients. Further studies are required to understand the effect of this pandemic on the fragility hip fractures.Level of evidenceLevel III: Retrospective case–control study.     

The increase in paediatric orthopaedic trauma injuries following the end of the curfew during the COVID-19 period

PurposeThe aim of this study was to compare the injury patterns of orthopaedic trauma patients in the paediatric age group who presented to our hospital during and after lifting the curfew due to the pandemic, with the patients of the same age group who presented to our institution during the same time period last year.MethodsPatients, aged 0 years to 18 years, who presented to our clinic between 21 March 2020 and 31 May 2020 (during curfew) (Group A1, n = 111), between 01 June 2020 and 31 August 2020 (Group A2, n = 214) and during the same periods in 2019 Group B1 (n = 220) and Group B2 (n = 211) were included. Patients with pathological fractures, traumas occurring earlier than the aforementioned date range and those consulted while being hospitalized in another department were excluded from study. Patients’ demographics, the department they presented to, the anatomical region affected by trauma, trauma mechanism, the location of trauma, the treatment applied and the length of hospital stay were recorded.ResultsThe prevalence of outdoor traumas (72.9% versus 61.1%), high-energy traumas (40.1% versus 26.5%), the rate of the patients treated with surgery (28% versus 17.1%) and the rate of admission to the emergency department (90.2% versus 58.3%) were significantly higher in Group A2 when compared with Group B2 (p < 0.05).ConclusionThe significant increase was observed in the number of outdoor injuries, high-energy traumas and fracture patterns that require surgical treatment during the first three months following the lift of the curfew, in comparison with the corresponding dates from last year. We think that children’s lower extremity muscle strength and neuromuscular control was decreased due to staying home for a prolonged period of time.Level of EvidenceLevel III, Case-control study.     

Re-starting elective orthopaedic services in NHS Tayside during the COVID-19 pandemic

BackgroundElective orthopaedic operations were suspended at the start of the COVID-19 lockdown. Three pathways were created to allow patients to undergo urgent elective operations in NHS Tayside as soon as it was deemed safe to do so.MethodsWe examined elective orthopaedic activity in NHS Tayside during and immediately after the Scottish lockdown. Elective operations performed between 27 March 2020 and 10 August 2020 were included and compared with cases performed between 27 March and 10 August in both 2018 and 2019. Primary outcomes were 30-day mortality, 30-day complications, and nosocomial infection rates of COVID-19.FindingsFewer elective operations were performed in 2020 (258) compared with 2019 (1196) and 2018 (1261). The rate of nosocomial infection in the 2020 cohort was 0%. The 30-day mortality rate was 0%. Over 98% of patients agreed to undergo surgery after a detailed consenting process.InterpretationWe were able to re-start a safe elective orthopaedic service in the early stages of recovery from the COVID-19 pandemic, compatible with the guidelines set by the Royal College of Surgery of England and the British Orthopaedic Association. Our findings will serve to reassure regions with sufficient resources that it is acceptable to restart elective surgery for urgent priority cases. They may provide a template for planned surgical care in the event of further pandemics.     

The hidden dangers of staying home: a London trauma unit experience of lockdown during the COVID-19 virus pandemic

IntroductionThe COVID-19 pandemic resulted in reconfiguration of the NHS. Elective services were stopped and trauma services focused on decreasing patient–clinician interactions and managing injuries nonoperatively wherever possible. The everyday life of the general public changed dramatically with the introduction of a national lockdown to prevent the spread of COVID-19. This paper looks at the experience of a South West London trauma unit.Materials and methodsAll patients reviewed in fracture clinic and by the orthopaedic on-call team between 23 March to 23 April 2020 were included. Data on the mechanism of injury and whether this was a usual activity, the injury sustained and its management were collected.ResultsA total of 167 trauma injuries were seen, compared with 735 new patients with injuries in the previous month. The number of trauma operations completed decreased by 38%; 55% of injuries occurred inside the home and 44% outside the home during daily exercise. Some 31% of injuries were secondary to a new activity taken up during lockdown. Three open fractures and two polytrauma cases were seen that would have normally been managed at the local major trauma centre.ConclusionOverall, both the number of injuries seen and trauma operations completed during the enforced lockdown decreased. This is probably due to a change in the way the general public are living their lives, and the reconfigurations within the NHS in response to the COVID-19 pandemic. This is an interesting time within trauma and orthopaedic departments, as they continue to adapt to the changing injuries and working environment.     

The impact of COVID-19 on foot and ankle surgery in a major trauma centre

Introduction and aimsCOVID-19 has had a significant impact on orthopaedic surgery globally. This paper aims to evaluate the impact of COVID-19 on foot and ankle trauma in a major trauma centre.MethodsA retrospective observational study of prospectively collected data was performed. All foot and ankle trauma patients over a 33 week period (1st December 2019–16th July 2020) were analysed. All patients with trauma classified by the AO/OTA as occurring at locations 43 and 81–88 were included.ResultsOver the 33 weeks analysed, there was a total of 1661 trauma cases performed; of these, only 230 (13.85%) were foot and ankle trauma cases. As percentage of cases during each period of lockdown, foot and ankle made up 15.20% (147 out of 967) pre-lockdown, 8.81% (17 out of 193) during lockdown and 13.17% (66 out of 501) post lockdown. This difference was statistically significant (p < .001). The most significant change in trauma management was the treatment of malleolar fractures.Further analysis showed that during the lockdown period 29 foot and ankle fractures were treated the same and 13 were treated differently, (i.e. 31% of fractures were treated conservatively, when the consultants preferred practice would have been surgical intervention). Of the 13 patients, 3 have had surgical management since lockdown has been eased.ConclusionIt is evident that the trauma case activity within foot and ankle was significantly reduced during the COVID-19 period. The consequences of change in management were mitigated due to a reduction in case load.     

Increased proportion of alcohol-related trauma in a South London major trauma centre during lockdown: A cohort study

PurposeAlcohol has been associated with 10%–35% trauma admissions and 40% trauma-related deaths globally. In response to the COVID-19 pandemic, the United Kingdom entered a state of “lockdown” on March 23, 2020. Restrictions were most significantly eased on June 1, 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions.MethodsAll adult patients admitted as “trauma calls” to a London major trauma centre during April 2018 and April 2019 (pre-lockdown, n = 316), and 1st April–31st May 2020 (lockdown, n = 191) had electronic patient records analysed retrospectively. Patients’ blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre-lockdown and lockdown cohorts were compared using multiple regression analyses.ResultsAlcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), vs. pre-lockdown 62/316 (19.6%); (odds ratio (OR): 0.83, 95% CI: 0.38–1.28, p < 0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs. pre-lockdown 179/316 (56.7%); OR: 0.40, 95% CI: 0.79 to −0.02, p = 0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p > 0.05).ConclusionsThe United Kingdom lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of further global “waves” of COVID-19, the long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.     

Foot and ankle trauma management during the COVID-19 pandemic: Experiences from a major trauma unit

The COVID-19 pandemic has resulted in a paradigm shift in clinical practice, particularly in ways in which healthcare is accessed by patients and delivered by healthcare practitioners. Many of these changes have been serially modified in adaptation to growing service demands and department provision capacity. We evaluated the impact of the pandemic on the foot and ankle service at our trauma unit, assessing whether these adaptations to practice were justifiable, successful and sustainable for the future. This was a single-centre, retrospective cohort study analysing the patient care pathway from admission to discharge, for two pre-defined timeframes: Phase 0 (pre-lockdown phase) and Phase 1 (lockdown phase). Patients were split into stable and unstable injuries depending on their fracture pattern. The follow-up modality and duration were evaluated. Trauma throughput for the equivalent timeframe in 2019 was also analysed for comparison. There were 106 unstable fractures and 100 stable fractures in 2020.78 interventional procedures were performed on 72 patients with unstable fractures in Phase-1. Close contact casting was performed on 13 patients at presentation in the ED. Selective patients underwent partial fixation in theatre, which still provided adequate stability. 35% of patients with a stable fracture were discharged directly from the ED with written advice from a review letter. The treatment modality in selective patients, particularly the vulnerable should be carefully assessed. Interventions performed at presentation often negate the need for admission. Partial fixation reduces intraoperative time and surgical insult. Integrating telemedicine into the care pathway, particularly for stable ankle fractures reduces the need for physician-patient contact and eases follow-up burden. Many of our recommended changes are easily replicated in other clinical settings. Should these adaptations demonstrate long-term sustainability, it is likely they will remain incorporated into future clinical practice.     

The Pan London Emergency Cardiac Surgery service: Coordinating a response to the COVID-19 pandemic

Over the last 4 months, the novel coronavirus, SARS-CoV-2, has caused a significant economic, political, and public health impact on a global scale. The natural history of the disease and surge in the need for invasive ventilation has required the provision of intensive care beds in London to be reallocated. NHS England have proposed the formation of a Pan-London Emergency Cardiac surgery (PLECS) service to provide urgent and emergency cardiac surgery for the whole of London. In this initial report, we outline our experience of setting up and delivering a pan-regional service for the delivery of urgent and emergency cardiac surgery with a focus on maintaining a COVID-free in-hospital environment. In doing so, we hope that other regions can use this as a starting point in developing their own region-specific pathways if the spread of coronavirus necessitates similar measures be put in place across the United Kingdom.     

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme’s ‘Safe Tracheostomy Care’ workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.     

A protocol for wide awake local anaesthetic no tourniquet (WALANT) hand surgery in the context of the coronavirus disease 2019 (COVID-19) pandemic

There are new and unique challenges to emergency surgery service provision posed by the Coronavirus disease 2019 global pandemic. It is in the best interests of patients for care providers to streamline services where possible to maximise the number of cases that can be performed by limited surgical and anaesthetic teams, as well as minimising patient interactions and admission times to reduce potential spread of the virus.There is evidence that wide awake local anaesthetic no tourniquet (WALANT) hand and upper limb surgery can meet this need in a number of ways, including reduced pre-operative work up, the lack of a need for an anaesthetist or ventilator, shorter inpatient stays and improved cost efficiencies.Though updated national guidelines exist that advocate increased use of WALANT surgery in response to the pandemic there are not yet clear protocols to facilitate this.We outline a protocol being developed at one UK Major Trauma Centre tailored to the expansion of WALANT hand and upper limb emergency surgery with particular emphasis on facilitating timely surgical care while minimising healthcare encounters pre and post-operatively. This will serve to reduce potential transmission of the virus and create cost efficiencies to free funding for COVID-19 related care.Our protocol is easily replicable and may be of benefit to other centres dealing with emergency upper limb surgery in the new climate of COVID-19.