by Elizabeth Hofheinz, M.P.H., M.Ed.
In these tumultuous times, some orthopedic researchers are training their efforts on bringing a bit of clarity to their trauma colleagues. Researchers from Vanderbilt University Medical Center in Nashville, the University of Maryland in Baltimore, Atrium Health in Charlotte, and the University of South Florida/Florida Orthopaedic Institute in Tampa have joined this cause, publishing work on how to help orthopedic surgeons remain safe during COVID-19 while aiming for the best outcomes possible. Their work, “The Orthopaedic Trauma Service and COVID-19: Practice Considerations to Optimize Outcomes and Limit Exposure,” appears in the April 23, 2020 Journal of Orthopaedic Trauma.
Co-author Hassan R. Mir, M.D., M.B.A. is Professor and Director of Orthopaedic Residency Program at the University of South Florida and Director of Orthopaedic Trauma Research at the Florida Orthopaedic Institute. He told OSN, “We wrote this article as the COVID-19 pandemic was intensifying in the US. We wanted to provide guidance for orthopaedic surgeons on the front lines. Orthopaedic surgeons have been called upon to provide care for patients with musculoskeletal injuries during all phases.”
The authors wrote, “As orthopaedic trauma clinics are often busy, drawing patients from well beyond the immediate surrounding area, we have the potential to spread the virus unknowingly across our local region if we are an asymptomatic carrier of the virus.”
Dr. Mir commented to OSN, “We included the early experiences from international colleagues, as well as incorporated real practices from leading centers across the US to provide guidance. We give practical information that can be implemented by practicing orthopaedic surgeons in order to optimize outcomes while limiting patient and provider exposure. We cover a breadth of areas including structure and functions of an orthopaedic trauma service, outpatient fracture clinic, and inpatient surgery during the pandemic.”
The research team asks their colleagues to consider using a three-team approach where one team is working in the hospital (patient care), while the other teams are rotating through 14 days away from the hospital (working remotely in a cyclical “quarantine” between episodes of direct patient care). This approach, they say, may also be used for trainees and midlevel providers to limit exposure and the spread of COVID-19.
They write, “Each case should be performed with a streamlined team of only essential personnel, which at some author’s institutions includes a maximum of one assistant. In addition, consideration should be given to discouraging sales representative presence in the operating room unless critical for patient care to minimize potential virus exposure.”
“If it is determined that a negative pressure room will be used for a surgical procedure, keep the doors to the operating room closed and minimize traffic into and out of the room. The procedure should be performed with the fewest people possible to optimally perform the procedure in the surgical suite. This should require limiting resident and fellow involvement. Owing to the elevated risk of virus aerosolization during intubation and extubation, consideration should be given to regional/peripheral nerve blocks or spinal/epidural anesthesia whenever possible with the patient’s nose and mouth covered with a surgical or N95 mask. If the patient is not already intubated but it is necessary for surgery, intubation and extubation should be performed either in a separate dedicated room for intubation/extubation or in the operating room without the surgical team present.”
The authors recommend only having patients come in for situations including, but not limited to, immediate postop visit for suture removal (when not able to be removed elsewhere or resorbable sutures are not used), fracture reduction check for nonoperatively managed fractures that had a reduction and splint or cast applied, new acute fractures, etc..
Trauma incisions, typically closed with nonabsorbable suture or staples, require that a healthcare worker remove them. To minimize exposure risk, however, some of the authors have begun using absorbable suture when possible. Also, patients can be sent home with a suture or staple removal kit with written instructions and links with instructions on how to do it themselves.
The authors wrote, “In cases where splints were usually placed for “soft-tissue rest” until suture removal, patients are being placed in well-padded soft dressings and removable splints, so that the first postoperative follow-up visit can easily be performed through telehealth. However, patients who require a reduction with splinting or cast placement must still be seen in-person to ensure maintenance of alignment and to transition to the next phase of recovery when appropriate.”
Dr. Mir told OSN, “We continue to learn more about the virus and the pandemic with time. Elective surgery may come and go depending upon local conditions and phases, but orthopaedic trauma will continue as an essential service and many of the included recommendations will help to continue providing patient care while protecting our workforce.”
“We have received feedback from several US and international colleagues that many of the presented outpatient, inpatient, and service line tips were helpful to them in developing their own local guidelines, especially since ours was amongst the first publications on how orthopaedic surgeons could manage patients with acute musculoskeletal injuries during the pandemic and it was available through open access.”