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      Fracture management during COVID-19 pandemic: A systematic review

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          Abstract

          Purpose

          The COVID-19 pandemic has affected orthopedic practices worldwide. Few studies focusing on epidemiology and management of fractures in COVID-19 patients have been published. We conducted a systematic review to evaluate the fracture types, presentation, treatment, complications, and early outcomes of fractures occurring amidst COVID-19 pandemic.

          Methods

          A systematic review of the all published papers was conducted with a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Library database using keywords ‘COVID-19’, ‘Coronavirus’, ‘trauma∗’and ‘fracture’ from January–April 2020.

          Results

          The searches yielded a total of ten studies with 112 Patients who were positive for COVID-19 associated with fractures was performed for six studies, reporting data separately for 44 patients with COVID 19 and an associated fracture. A diagnosis of COVID 19 was made on the basis of positive Computed Tomography scan in 39 patients and 30 patients had a positive Reverse Transcription-Polymerase Chain Reaction test. Overall, there were 29 proximal femoral fractures, 8 spine fractures, 7 fractures of the other bones. The fractures were treated surgically in 30 cases (68.18%) and the remaining 14 cases (31.82%) were managed conservatively. There were 16 patients (36.36%) who died, mostly due to respiratory failure with a median age of 82 years.

          Conclusion

          COVID-19 has led to a significant reduction in a load of fracture patients globally, though the incidence of fragility fractures continues to be unaffected. There is a significantly higher risk of mortality in elderly patients with fractures and hence they should only be operated in a facility with a robust intensive care. Conservative treatment should be adopted as far as possible in non-obligatory fractures and in lesser equipped centers. Surgery in patients with proximal femur fragility fractures when judiciously selected did result in improvement in respiratory status. Reorganizing medical services is vital to deliver effective fracture care and also mitigate disease transmission.

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          Most cited references29

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          Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

          Summary Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
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            What we do when a COVID-19 patient needs an operation: operating room preparation and guidance

            To the Editor, We read with interest the recent review in the Journal by Wax and Christian1 on coronavirus disease 2019 (COVID-19). The first case of COVID-19 in Singapore was confirmed on 23 January 2020.2 In the week of February 13–19, the World Health Organization reported that Singapore had more cases of COVID-19 than any other country outside of mainland China.3 We wish to share the protocol that we use in our hospital in preparing an operating room (OR) for confirmed or suspected COVID-19 patients coming for surgery. An OR with a negative pressure environment located at a corner of the operating complex, and with a separate access, is designated for all confirmed (or suspected) COVID-19 cases. The OR actually consists of five interconnected rooms, of which only the ante room and anesthesia induction rooms have negative atmospheric pressures. The OR proper, preparation, and scrub rooms all have positive pressures (eFig. 1 in the Electronic Supplementary Material [ESM]). Understanding the airflow within the OR is crucial to minimizing the risk of infection. The same OR and the same anesthesia machine will only be used for COVID-19 cases for the duration of the epidemic. An additional heat and moisture exchanger (HME) filter is placed on the expiratory limb of the circuit. Both HME filters and the soda lime are changed after each case. The anesthetic drug trolley is kept in the induction room. Before the start of each operation, the anesthesiologist puts all the drugs and equipment required for the procedure onto a tray to avoid handling of the drug trolley during the case. Nevertheless, if there is a need for additional drugs, hand hygiene and glove changing are performed before entering the induction room and handling the drug trolley. A fully stocked airway trolley is also placed in the induction room. As far as possible, disposable airway equipment is used. The airway should be secured using the method with the highest chance of first-time success to avoid repeated instrumentation of the airway, including using a video-laryngoscope.4 Equipment in limited supply, such as bispectral index monitors or infusion pumps, may be requested but need to be thoroughly wiped down after use. The Figure  details the roles and responsibilities of each OR team member. Hospital security is responsible for clearing the route from the ward or intensive care unit (ICU) to the OR, including the elevators. The transfer from the ward to the OR will be done by the ward nurses in full personal protective equipment (PPE) including a well-fitting N95 mask, goggles or face shield, splash-resistant gown, and boot covers. For patients coming from the ICU, a dedicated transport ventilator is used. To avoid aerosolization, the gas flow is turned off and the endotracheal tube clamped with forceps during switching of ventilators. The ICU personnel wear full PPE with a powered air-purifying respirator (PAPR) for the transfer. Figure Complete operating room workflow for a coronavirus disease 2019 (COVID-19) case. CD = controlled drugs; ICU = intensive care unit; NM = nurse manager; OR = operating room; PAPR = powered air-purifying respirator; PC = personal computer; PPE = personal protection equipment; pre-op = preoperative In the induction room, a PAPR is worn during induction and reversal of anesthesia for all personnel within 2 m of the patient. For operative airway procedures such as tracheostomy, all staff keep their PAPR on throughout the procedure. For other procedures, regional anesthesia is preferable, but if general anesthesia is required, the principles of management are similar to those previously published.1,4 During the procedure, a runner is stationed outside the OR if additional drugs or equipment are needed. These are placed onto a trolley that will be left in the ante room for the OR team to retrieve. This same process in reverse is used to send out specimens such as arterial blood gas samples and frozen section specimens. The runner wears PPE when entering the ante room. Personnel exiting the OR discard their used gowns and gloves in the ante room and perform hand hygiene before leaving the ante room (ESM, eFig. 2). Any PAPR will be removed outside the ante room. Patients who do not require ICU care postoperatively are fully recovered in the OR itself. When the patient is ready for discharge, the route to the isolation ward or ICU is again cleared by security. A minimum of one hour is planned between cases to allow OR staff to send the patient back to the ward, conduct through decontamination of all surfaces, screens, keyboard, cables, monitors, and anesthesia machine. All unused items on the drug tray and airway trolley should be assumed to be contaminated and discarded. All staff have to shower before resuming their regular duties. As an added precaution, after confirmed COVID-19 cases, a hydrogen peroxide vaporizer will be used to decontaminate the OR. In summary, as healthcare workers are at increased risk of coronavirus infection, a comprehensive and robust infection control workflow has been put into place.5 Electronic supplementary material Below is the link to the electronic supplementary material. Supplementary material 1 (PDF 604 kb)
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              Impact of the COVID-19 Pandemic on an Emergency Traumatology Service: Experience at a Tertiary Trauma Centre in Spain

              Highlights • Contingency plans need to be careful when reallocating resources, and not assume that all trauma presentations will decrease during a State of Emergency. • Health problems such as osteoporotic hip fractures may in fact remain stable during the State of Emergency (implementation of stringent lock-down measures for the population). • Given that osteoporotic hip fractures are in elderly population with multiple comorbidities, operative delays may increase the risk of mortality as well as of nosocomial infections in this pandemic virus.
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                Author and article information

                Contributors
                Journal
                J Clin Orthop Trauma
                J Clin Orthop Trauma
                Journal of Clinical Orthopaedics and Trauma
                Elsevier
                0976-5662
                2213-3445
                30 June 2020
                30 June 2020
                Affiliations
                [a ]Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
                [b ]Sports Injury Centre, Vardhman Mahavir Medical College& Safdarjung Hospital, New Delhi, 110029, India
                [c ]Senior Medical Officer & Orthopaedic Surgeon,Central Institute of Orthopaedics, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, 110029, India
                [d ]Department of Orthopaedics, Indraprastha Apollo Hospital, SaritaVihar, Mathura Road, 110076, New Delhi, India
                Author notes
                []Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee institute of medical sciences, Dr. Ram Manohar Lohia Hospital, New Delhi, 110001, India. drvijayortho@ 123456gmail.com
                Article
                S0976-5662(20)30268-X
                10.1016/j.jcot.2020.06.035
                7324923
                32774008
                4b01a1db-d2a9-47d5-add6-0214ed24d527
                © 2020.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 14 June 2020
                : 24 June 2020
                : 25 June 2020
                Categories
                Article

                fracture,hip,covid- 19,pneumonia,systematic review,conservative,operative,mortality,pandemic

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