|Year : 2022 | Volume
| Issue : 3 | Page : 224-233
Patient-reported Outcomes of SARS-CoV-2 Positive Adult Orthopedic Trauma Patients Treated During the Ongoing Pandemic: An Experience from Single Center
Vineet Bajaj, Yasim Khan, Abhishek Kashyap, Bharat Ram Devajee, Saurabh Arora, Sumit Arora, Vinod Kumar, Lalit Maini
Department of Orthopaedic Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, India
|Date of Submission||12-Apr-2022|
|Date of Decision||21-Jun-2022|
|Date of Acceptance||23-May-2022|
|Date of Web Publication||07-Dec-2022|
MS (Ortho), DNB (Ortho) Yasim Khan
Department of Orthopaedic Surgery, HN-72, VPO Nangal Thakran, Delhi - 110039
Source of Support: None, Conflict of Interest: None
Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has become a matter of concern all over the world. It has resulted in delay in surgery or, at times, preference for nonoperative treatment for SARS-CoV-2 positive orthopedically injured adult patients which may adversely affect the clinical outcomes. In this study, we report the outcomes of orthopedic adult trauma patients who tested positive for SARS-CoV-2 at admission. Methods: We retrospectively reviewed the prospectively collected data from the period between April 1, 2020 and December 31, 2020. We reviewed 521 out of total 2435 patients presenting in the casualty that required orthopedic trauma surgery. Thirty-eight out of total 521 patients, that tested positive for SARS-CoV-2, were followed-up using telecommunication for final outcome of fracture treatment. A telecommunication patient satisfaction score after injury (TPSSI) was used to evaluate the patient satisfaction. Results: The mean age was 37.94 years (range: 18–72 years). They were followed-up for mean duration of 8.18 months (range: 6–13 months). Out of total 38, 23 underwent orthopedic trauma surgeries and rest 15 were managed nonoperatively. There was a mean delay in surgery of 5 weeks (range: 3–12 weeks). Five patients lost their lives and seven others had nonunion. The median TPSSI score was three. Conclusions: Nonoperative and delayed surgical management of adult orthopedic trauma patients, who tested positive for SARS-CoV-2 at admission, result adversely in activities of daily living and return to original occupation and, thus, have poor patient satisfaction.
Keywords: Covid-19, orthopedic trauma, patient-reported outcomes, SARS-CoV-2
|How to cite this article:|
Bajaj V, Khan Y, Kashyap A, Ram Devajee B, Arora S, Arora S, Kumar V, Maini L. Patient-reported Outcomes of SARS-CoV-2 Positive Adult Orthopedic Trauma Patients Treated During the Ongoing Pandemic: An Experience from Single Center. MAMC J Med Sci 2022;8:224-33
|How to cite this URL:|
Bajaj V, Khan Y, Kashyap A, Ram Devajee B, Arora S, Arora S, Kumar V, Maini L. Patient-reported Outcomes of SARS-CoV-2 Positive Adult Orthopedic Trauma Patients Treated During the Ongoing Pandemic: An Experience from Single Center. MAMC J Med Sci [serial online] 2022 [cited 2023 Feb 2];8:224-33. Available from: https://www.mamcjms.in/text.asp?2022/8/3/224/362891
| Introduction|| |
Novel coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has posed threat to human life globally. Developing countries are struggling with their already compromised health infrastructure which is now getting overwhelmed with the ever-increasing load of patients suffering from Covid-19. The contagion has profoundly impacted the day-to-day routine activities of humans as significant proportion of the global population battles to contain it. As of June 30, 2021, over 182 million people have reportedly tested positive worldwide with the death toll touching the figure of 4 million. India has been one of the most severely affected countries with the figure of over 30 million patients. The pandemic has affected the practice of nearly all the subspecialties including orthopedics. With the near-total halt in the routine surgeries, the orthopedic surgeons are managing trauma patients following Covid protocols prevalent in their location., Whenever feasible, nonoperative form of treatment is being preferred to save already precarious hospital resources.,, It has been suggested that the emergency procedures should be performed in standard manner with all appropriate Covid-19 precautions.,,
In the present study, we share our experience with managing adult orthopedically injured patients who tested positive for SARS-CoV-2 at admission. We sought to evaluate the outcome of such patients as they were managed nonoperatively or underwent delayed surgery. We suggest a telecommunication patient satisfaction score after injury (TPSSI) to evaluate the patients’ outcome.
| Patients and Methods|| |
We retrospectively reviewed the prospectively collected data in the period between April 1, 2020 and December 31, 2020 at a government-run trauma center (non-Covid facility) attached with teaching referral institute (Covid-dedicated facility). The standard operating procedures were implemented which were based on the recommendations of ICMR (Indian Council of Medical Research); Ministry of Health and Family Welfare, Government of India; and Indian Orthopaedic Association. The ethical clearance was taken from departmental and institutional review board. Informed consent was taken from patients for publication of data.
A total of 2435 patient visited trauma center for orthopedic complains during the period. Out of which, 625 required surgeries for various indications. Sixty-six out of total 625 patients underwent minor surgical procedures under local anesthesia after being tested negative on rapid antigen test for SARS-CoV-2. Rest 521 out of total 625 patients necessitating admission or major orthopedic procedures under regional or general anesthesia were admitted in isolation ward [Figure 1]. Forty-two out of these 521 patients had tested positive for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) and, thus, were shifted to an attached Covid-dedicated facility. All the patients were treated nonoperatively initially (41 patients) or underwent surgery for limb-saving or life-saving conditions only (one patient). They were shifted back to trauma center after testing negative by RT-PCR for SARS-CoV-2 on two consecutive samples obtained 24 hours apart. They were treated either nonoperatively or operatively considering the fracture geometry, location, clinical condition of the patient, and delay in definitive treatment and discharged subsequently. Four patients were lost to follow-up that left 38 patients for final analysis of clinical outcome [Table 1].
|Figure 1 Flow chart showing the patient flow and treatment categorization.|
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They were followed in outpatient department and received standard care in early postoperative phase. Since majority of the patients were from far-off places and Covid-related restrictions made their regular follow-up in the hospital difficult. Thus, we contacted these 38 patients telephonically through the contact numbers available from the record. An enquiry about the limitations in their activities of daily living (ADLs) and change in occupation was made. Additionally, they were advised to get follow-up radiographs from the nearby diagnostic center and send the images digitally to analyze the outcomes of management. We propose a TPSSI for assessment of outcome in midterm follow-up [Table 2]. This was based on the ability of the patients to do ADLs and return to occupation. We considered six activities pertaining to upper limb (donning, doffing, buttoning, combing, feeding, and maintaining personal hygiene) and three activities pertaining to lower limb (sitting, squatting, and ambulation) in ADLs. A score five was considered when the patient was satisfied as the injury did not limit his/her ADLs and also did not result in modification/change of occupation. A score four was considered when he/she was mildly unsatisfied despite the injury did not limit his/her ADLs and also there was no change of occupation. A score three was considered when he/she was moderately unsatisfied as the injury limited his/her ADLs to certain extent but he/she could return to original occupation with modifications. A score two was considered when he/she was moderately unsatisfied as the injury limited his/her ADLs to significant extent and he/she had to change their occupation. A score one was considered when he/she was highly unsatisfied as the injury limited his/her ADLs to significant extent and complete restriction of his/her occupation. Lastly, a score zero was considered when the patient had lost his/her life during the course.
|Table 2 Telecommunication patient satisfaction scoring after injury (TPSSI) for outcome assessment in orthopedic trauma surgery on follow-up|
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We also performed a literature review to find studies reporting outcomes of orthopedic surgery in Covid-19 affected patients after making a PubMed search with MeSH major topics of “Covid-19,” “trauma surgery,” “orthopedic trauma,” and “outcomes” [Table 3].
|Table 3 Studies reporting outcomes of orthopedic trauma in Covid-19 patients|
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The collected data were transformed into variables, coded, and entered in Microsoft Excel. Data were analyzed and statistically evaluated using IBM SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc. Quantitative data were expressed in median, mean, standard deviation, and difference between two comparable groups. Qualitative data were expressed in percentage. “P” value <0.05 was considered statistically significant.
| Results|| |
The mean age of the patients was 37.94 years (range: 18–72 years). There were 28 males and 10 female patients. They were followed-up for a minimum duration of 6 months with mean value of 8.18 months (range: 6–13 months). Twenty-three out of total 38 patients underwent orthopedic trauma surgery under appropriate anesthesia and rest 15 were managed nonoperatively. There was mean delay in surgery of 5 weeks (range: 3–12 weeks) since injury. Five patients, from this cohort of 38 patients, succumbed during the period of follow-up. The mean age of patients that lost their life was 38.87 years (range: 26–71 years). The death happened after the mean duration of 5 weeks (range: 3 days–12 weeks) from the injury/testing positive for SARS-CoV-2 by RT-PCR. Out of these five patients, two had underwent surgical stabilization of fractures and rest three were managed nonoperatively [Table 1].
These 38 patients had 53 different fractures which included lower limb (37), upper limb (10), spine (four), and pelvis-acetabulum (two) fractures [Figure 2]. The most common fractured bones were femur (eight shaft, seven pertrochanteric, two femoral neck, and two distal femur) and tibia (six shaft, three distal tibia, and two proximal tibia) in our study. Intramedullary nailing and plating were the most commonly performed surgeries [Figure 3]. All resulted in radiological union except seven fractures that resulted in nonunion, eight in delayed union, and additional two in gross malunion [Figure 4]. Out of these seven patients, that had nonunion, six had underwent surgery (two tibia shaft, one femoral neck, one femoral shaft, and two distal humerus fractures) after a mean delay of 5 weeks (range: 4–8 weeks) after injury; another was treated nonoperatively (one tibia shaft).
|Figure 2 Bar chart showing region wise distribution of orthopedic trauma in Covid-19 patients.|
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|Figure 3 Bar chart showing various orthopedic surgeries performed in Covid-19 positive trauma patients.|
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|Figure 4 Pie chart showing the outcomes of 32 fractures on final follow-up using telecommunication.|
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The median TPSSI score was three. Poor scores of one and two were associated with nonunion and delayed union of fracture. There was a mean delay in surgery of 7.5 weeks (range: 3–12 weeks) after injury in patients who had poor scores in TPSSI (score one and two). The patients, which had good TPSSI (score four and five), were either treated by surgery after a mean delay of 3.1 weeks (range: 1–6 weeks; eight patients) or treated nonoperatively (five patients). Out of total 38 patients, 13 returned to their original occupation without any restriction. Additionally, 14 patients returned to their original occupation with certain modifications, and four had to change their occupation to earn livelihood. Whereas, two patients were unable to return to any occupation [Figure 5].
|Figure 5 Bar chart showing TPSSI scores of patients (n = 38) at final follow-up.|
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| Discussion|| |
Covid-19 pandemic has significantly impacted the operative care in orthopedics during the ongoing pandemic. The patients requiring elective orthopedic procedures are at halt as all the hospital resources are being dedicated to management of symptomatic Covid-19 patients. It has been observed that the nonoperative management of such cases are being preferred in Covid-19 patients, whenever feasible. Such changes in the practice may be associated with suboptimal clinical outcome. Additionally, delayed surgery may also impact the outcome adversely. In the present study, we share the data of the adult patients that sustained orthopedic trauma and were detected to have SARS-CoV-2 infection that were treated in our institute.
There were several limitations in our study: (1) we retrospectively collected the data of Covid-19 adult patients with orthopedic injuries; (2) we did not include any comparison group of orthopedic trauma patients without Covid-19 disease; (3) the outcome assessment was done using a telecommunication score which is a subjective assessment and validation of which has not been performed; and (4) we had heterogeneous cases in our study which posed difficulty in grouping them for analysis.
Currently, there are very few studies in literature that have investigated the relationship between Covid-19 and operative outcomes in terms of fracture management. Most of these studies report short-term data including comorbidities, total mortality, 30-days mortality rates, American Society of Anesthesiologists (ASA) grading, operating time, perioperative blood transfusions, need for mechanical ventilation or ICU care, perioperative complications, and medical management of Covid-19 disease with associated orthopedic trauma. ,,,,,,, The present study emphasizes the outcomes in terms of fracture management in SARS-CoV-2 patients with orthopedic trauma.
We managed 38 such patients between April 1, 2020 and December 31, 2020. The 15 out of 38 patients were managed nonoperatively as the fracture reduction was considered acceptable and rest underwent major surgical intervention after the clinical recovery from the viral illness.
Though there are various guidelines for timing of fixation of hip fractures,, the mean delay in fracture fixation of 5 weeks is seen in the patients of the present study. Mi et al. reported a mean delay of 33 days in hip fracture surgery during the pandemic caused by SARS-CoV-2. Delaying the surgery might reduce the perioperative complications, which might occur from combined effect of compromised pulmonary function due to Covid-19 and systemic response of body to major surgical trauma. However, the outcomes in terms of fracture union may be affected. In our study there was nonunion in seven (out of 38 cases), delayed union in eight, and malunion in two cases. At this point in literature, we do not have any comparative study to compare the fracture outcomes to our study. Most case series have reported hip fractures and lower limb trauma surgeries as major orthopedic operations done on Covid patients during pandemic., This may be attributed to relatively conservative plan of management for upper limb fractures in view of pandemic.
Batko et al. reported a mean duration of hospital stay of 9.27 days in Covid patients and 11.91 days in non-Covid patients. The average length of surgery was 2.77 hours in Covid group as compared to 2.65 hours in non-Covid group. The mean postoperative duration of hospital stay was 7.39 days in Covid patients and 9.68 days in non-Covid group. However, Zaheer et al. have reported a mean duration of hospital stay of 15.2 days in Covid patients and 3.35 days in non-Covid patients which is significantly different. These results were not significantly higher as compared to Covid negative patients. They also reported that mechanical ventilation was needed in two (out of total 71) Covid patients and ICU was required in 10 (out of total 71) Covid patients postoperatively. Edward et al. have reported a mean surgical time of 5.2 hours in Covid patients. The mean blood loss was 513.5 mL in Covid positive patients and mean volume of 3330 mL crystalloid fluid was given in operating room. A higher surgical time may be expected because of extra precautions being taken in Covid positive patient surgery.
Perioperative complications have been reported by various studies. Sobti et al. reported hemiarthroplasty dislocation in one, heel ulcers in two, wound ooze in one, and wound infection in one patient, out of 94 neck of femur patients. Batko et al. has reported five out of 148 cases of surgical site infection (SSI) in Covid group as compared to 11 out of 201 in non-Covid group. There is no significant difference in SSI rates in both groups. Zaheer et al. has also reported SSI in one out of 71 cases and systemic infection in four out of 71 cases. In our study we had SSI in one out of 38 Covid patients.
The mortality rate has been variable in literature of Covid-19 patients with orthopedic trauma. Sobti et al. reported mortality in nine out of 94 (9.5%) neck of femur operated cases. Balakumar et al. reported mortality of 19 out of 47 (40.4%) out of which 17 patients had neck of femur fracture. Five patients died out of 32 (15.6%) in our study. The mortality rate in our study and reported study is higher than what is observed without Covid-19 disease.,,,,, Such higher mortality rates among studies may be due to older age and coexisting comorbidities in study cohort. It may also be due to the significant compromise of pulmonary function after Covid-19 (Acute Respiratory Distress Syndrome) or the sudden thromboembolic events occurring in Covid-19 disease. Patients undergoing major surgery had an added risk of further deterioration of already compromised condition. Patients with acute fractures are particularly susceptible to pulmonary infection, especially those with lower limb fractures, significant preexisting comorbidities, and impaired ambulatory abilities. In our study, out of five patients who had mortality, three patients were >60 years and all of them had a lower limb fracture. One patient who was 26 years old had polytrauma with acute renal failure. The results from our study supports that the patients who have significant preexisting comorbidities and active Covid-19 respiratory infections face an elevated risk of mortality and Covid-19-related complications.
Telecommunication in trauma surgery
During the Covid-19 pandemic because of strict nation-wise lockdowns and restrictions by government the use of telecommunication has been uplifted in various aspects of patient management like diagnosing disease, advising investigations, guiding management, and follow-up visits. The meta-analysis done by Chaudhry et al. concluded that telemedicine in orthopedic assessments does not result in significant differences in patient or surgeon satisfaction compared with in-person assessments. In the present study, we have used telecommunication to assess the follow-up of fracture treatment and also purposed a simple scoring system (TPSSI) to assess the functional outcome in such patients.
| Conclusions|| |
Nonoperative and delayed surgical management of adult orthopedic trauma patients, who tested positive for SARS-CoV-2 at admission, result adversely in ADL and return to original occupation and, thus, have poor patient satisfaction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]