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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 70-74

Orthopedic practices and orthopedic education amidst COVID-19 pandemic – Changing trends and way ahead


Department of Orthopedics, PGIMER, Chandigarh, India

Date of Submission23-May-2020
Date of Decision03-Jun-2020
Date of Acceptance11-Jun-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Vishal Kumar
Teachers' Flat Number.24, PGIMER Campus, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_16_20

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  Abstract 


The COVID-19 pandemic has affected people from different walks of life. With limited availability of personal protective equipment and testing facilities, the medical fraternity is at high risk of infection. The orthopedicians were also affected. The management protocols of trauma and nontraumatic cases and the orthopedics teaching have undergone a paradigm shift. The management has changed from aggressive surgery to conservative management. The number of patients suffering from physical trauma has come down significantly. The elective cases are postponed. Newer ways of consultation like teleconsultations have begun. Due to the closure of public transport services, follow-up of patients is also not proper. With the judicious use of resources and proper testing of patients, we can overcome this pandemic.

Keywords: Conservative, COVID-19, education, management, orthopedics


How to cite this article:
Patel S, Kumar V, Khan S, Sharma S, Aggarwal S. Orthopedic practices and orthopedic education amidst COVID-19 pandemic – Changing trends and way ahead. J Orthop Dis Traumatol 2020;3:70-4

How to cite this URL:
Patel S, Kumar V, Khan S, Sharma S, Aggarwal S. Orthopedic practices and orthopedic education amidst COVID-19 pandemic – Changing trends and way ahead. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Sep 22];3:70-4. Available from: http://www.jodt.org/text.asp?2020/3/2/70/294728




  Introduction Top


The coronavirus severe acute respiratory syndrome (SARS)-CoV-2 infection was declared a pandemic on March 11, 2020, by the WHO.[1] The disease it caused was named COVID-19.[2] The number of patients suffering from COVID-19 is increasing exponentially every day. People from all age groups are affected; with higher mortality seen in elderly patients.[3] Both mortality and morbidity caused by the infection remain the highlight of all the health policies. Doctors and other health-care workers (HCWs) are at the highest risk in this fight and this virus has already claimed a lot of lives, future, and aspirations. This pandemic has prompted the government of various countries to initiate steps to limit and contain the spread of infection. The Indian government has also taken various steps in this regard. With lockdowns in place for the past 2 months, it is becoming increasingly clear that the main goal of lockdowns was to flatten the curve and delay the peak (India has successfully achieved this target), thereby buying time to strengthen the health infrastructure, procure, and ramp up the production of personal protective equipment (PPE), testing kits, and medical equipment, all of which are going to be crucial for fight against COVID-19. There has been a change in medical practice seen across all systems (private and government sector hospitals) and across all specialties. This pandemic has affected all the medical departments in some way or the other. Majority of the health-care resources and infrastructure are being diverted for fighting the pandemic. The main focus at present is treatment of the COVID-19 cases and containment of spread. The management protocols of all the medical departments have changed dramatically.[4],[5] We discuss some of the changes seen so far during this pandemic and lockdown period and the challenges waiting ahead once lockdown ceases as far as orthopedic practice is concerned.

Changes in orthopedic practice

Due to lockdown, the number of road traffic accidents (RTAs) has decreased significantly. This fact is clearly evident from the lesser number of accident victims presenting to our tertiary level trauma center. The number of orthopedic admission due to trauma in our advanced trauma center during the past 2 months and same months of the last year is presented in [Table 1] for comparison and corroboration.
Table 1: Number of trauma cases and road traffic accident cases in our advanced trauma center in March and April 2019 and 2020

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Trauma cases led to 20 million hospitalizations and 1 million deaths in India.[6] The majority of these cases was contributed by RTAs.[6] Most of the cases of fracture which are reporting during this pandemic are mostly due to falling at home or playing (children) and the osteoporotic fractures in the elderly. Assaults and domestic violence are some other causes prevalent at the present time.

Changes seen in government hospitals

Government hospitals has been the frontline setup in the fight against COVID-19 and hence the primary priorities and resources are primarily directed toward setting up dedicated COVID-19 centers and managing COVID-19 cases. Outpatient departments (OPDs) are shut down as the huge crowd of daily patients seen can lead to humongous spread. The orthopedic practice is exclusively limited to trauma and other orthopedic emergencies such as septic arthritis, acute osteomyelitis, cauda equina syndrome, and other acute-onset neurological deficits and orthopedic malignancies.[4]

Changes in management of trauma

The management of trauma has seen drastic changes. Earlier, the management of trauma involved immediate surgery followed by early mobilization.[7] Now, the trends have changed toward more conservative treatment. The lower limb trauma below the knee level is being managed more frequently with a plaster cast. On the one hand, it is justifiable for tibial diaphyseal fractures, Weber B ankle fractures, or some fractures of foot (undisplaced Talus fractures, metatarsal fractures, most of the calcaneus fractures).[8],[9],[10],[11] However, the management and therefore the suboptimal results of conservative treatment in displaced fracture talus, complex midfoot injuries, and complex ankle fracture need to be seen in coming times as that can have serious morbidity to follow. There is definitely going to be a surge in neglected trauma cases. It is interesting that injuries and fractures of the lower limb below the knee and those of the upper limb are perceived as casual by patients and their attenders, and there is an increased demand by the patients for nonoperative management. We have come across two high-energy Lisfranc injury patients and two displaced intra-articular elbow fractures who refused for surgery and went against medical advice. This is a disturbing trend as it is clearly seen that the fear of SARS-CoV-2 infection has got into the minds of general public, thereby influencing optimal treatment.

It is true that in the past decade, the indications for surgery in trauma patients. This is done for early rehabilitation and early return to work. At present times, it is an ideal opportunity to revisit the older principles of functional casting and treatment wherever possible and apply them accordingly. Closed fractures of the clavicle, humerus, single forearm bone, wrist, selected distal femur and proximal tibial fractures, tibial diaphyseal fractures, and some foot fractures are suitable for them.[11],[12],[13] However, the treating orthopedic surgeon has to be more cautious in choosing the right patient and right fracture for optimal nonoperative management. The fractures which are absolute indications for surgery need to be operated whichever body segment they may belong to.

Injuries which can be definitely operated at a later stage are being managed accordingly, and immediate surgery is strongly not advised in this scenario and circumstances. Ligamentous injury of the knee is one such scenario and is being managed conservatively in the brace.[14],[15] Spine injuries other than unstable traumatic injuries and cauda equina syndrome are being managed conservatively where ever possible.[16]

Loss to follow-up is another worrisome problem encountered. Reasons are both closure of routine OPDs, transportation problems, and patients' reluctance to come to tertiary centers for follow-up. We have noticed failure of turning up of patients who have been advised the second surgery for conversion of external fixators to definitive fixation which is usually advised at the 2nd–3rd week after the first surgery.

The use of bioabsorbable sutures is also being advocated, as this can prevent the need for one unnecessary follow-up for suture removal.[17],[18] The rehabilitation is also affected due to closure of physiotherapy OPD, and therefore, every effort should be made to teach and educate patients and their attendees before the discharge of the course of physiotherapy which we intend to plan for patient for the next 6 weeks overemphasizing its importance. Provision of printed handouts, getting video recordings of exercises to the patients and their caregivers at home during admission, and sharing relevant online links for exercise are some ways of addressing the problem.

Changes in nontrauma orthopedics practice

Closure of OPD has been a concern for management of chronic musculoskeletal disorders. One particular challenge has been the closure of physiotherapy setups which are the backbone for management of chronic ailments.

There has been a surge in teleconsultation services for needy patients and the problem in India is that telemedicine facilities are best utilized and restricted to educated people hardly constituting 5%–10% of the total population. The availability of good exercise videos in YouTube and other online platforms is being explored and verified by orthopedic surgeons before sharing those links to patients for addressing their problem of lack of access to physiotherapists.[19] This has been a successful module of management of chronic ailments. There has almost been a complete stop to elective surgeries.[4] Joint replacement, arthroscopic procedures, deformity correction, and surgeries for the degenerative spine are some which have been stopped.

Challenges in orthopedic practices ahead

There are many challenges in a developing country like India. The doctor-to-patient ratio in India is skewed with less doctors.[20] Currently, universal testing for all presenting patients is not done and only the symptomatic ones are being tested. PPE is not available in all centers across the country. There are no clear cut guidelines regarding the use of PPE for non-COVID-19 cases. With the increasing number of COVID-19 cases, it is expected that asymptomatic cases will increase, and finally, there will be an element of community transmission.[21] Tertiary centers face the added challenge of getting referrals from across state borders. A second wave following the relaxation of lockdown can further complicate things.[22] This is the real challenge ahead, as asymptomatic patients may spread infection within hospital and the whole system may collapse. There are already instances wherein the whole hospital or nursing homes had to be shut in view of treating cases, and there is evidence of HCWs getting infected.[23] To prevent such a mishap from happening, it is important to frame ideal guidelines for adequate screening of non-COVID-19 cases. Across the globe, it is very clear that the successful hospital setups are those which have a separate designated COVID-19 setup and every effort needs to be done to safeguard health-care setups for non-COVID-19 cases.[24] Trauma patients' bodies cannot bear an added second hit due to iatrogenic acquired SARS-CoV-2 infection. Studies from Wuhan have clearly highlighted the increased mortality in fracture patients with COVID-19 as opposed to those fracture patients without COVID-19.[25]

With SARS-CoV-2 infection, the picture is much more complicated as compared to other viral infections. An adequate top design PPE use and other protective measures can prevent infection to HCWs but cannot stop iatrogenic infection to patients. The economics also do not favor the use of high-end PPEs for non-COVID-19 cases. At least 10 PPE kits are required just to perform a single orthopedic surgery (surgeon, assistants, anesthetist, nursing staff, sanitation worker, and hospital attendants). This is not economically feasible in a country like India where numerous surgeries are performed daily. The only logical and economically viable solution is point-of-care testing of all patients presenting to a particular specialty (for example, a trauma center). Testing each patient presenting to a trauma center or emergency department and with strict protocols in place, it is possible to avoid a mishap which can lead to collapse of the system. We have presented an ideal algorithm [Figure 1] for functioning of a trauma center and the same can be applied to other designated centers.
Figure 1: Algorithm for management of trauma cases in COVID-19 pandemic

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There are various COVID-19 tests available currently and the most popular ones are real-time polymerase chain reaction (RT-PCR)-based tests and antibody-based rapid tests.[26] RT-PCR tests are currently recommended by the Indian Council of Medical Research (ICMR) and WHO for COVID-19 testing and are considered as the gold standard as they have better specificity and can diagnose infection at the earliest.[27] Nasopharyngeal swabs are used for the testing. Rapid antibody-based tests detect immunoglobulin (Ig) M/IgG antibodies in blood. The major disadvantage is that it cannot pick up early infections and the best possible kits can detect infection only after a week.[28] However, the advantages are that it can give results within minutes and hence are currently used and recommended for only community testing in containment zones as per the ICMR guidelines.[29] Positive antibody results need confirmation with RT-PCR testing and negative tests do not exclude infection. However, it could be a potential screening tool in non-COVID-19 hospital setup and this needs to be explored further.

It is high time to start taking stringent steps to adequately protect non-COVID-19 hospital setups and prevent them from being hot spots. It is well known that HCWs are at high risk for COVID-19 infection, and strict protocols are need of the hour to boost the morale of HCW's as there is a growing fear among all HCWs working in non-COVID-19 areas without screening and adequate PPEs. If this growing concern is not addressed, this fear can seriously cripple the working of non-COVID-19 departments.

Changing orthopedic education and training

COVID-19 has brought a huge change in the education system as a whole and it is clearly reflected in the orthopedic education and training system as well.

Postgraduate (PG) teaching – there are both pros and cons with respect to the PG teaching in medical colleges and institutes. The major disadvantage is the decreasing number of cold cases in OPDs and complete absence of bedside teaching which is the core for harboring basic examination skills. However, there have been a lot of positives. The major advantage is the availability of more time for dedicated academics and learning. The PGs usually are overworked and there was a lack of time for academics before COVID-19 times, and hence, their theoretical knowledge is shouldered. Due to less duty hours the students get more time to go through the pages of their books. There has also been a tremendous increase in webinars from esteemed faculty of all subspecialties in orthopedics, and its easy access is a big advantage for PG trainees. Increased time for faculty members is again a boost as it provides an opportunity for sharing their knowledge and wisdom.

Academicians have been utilizing the free time among lockdown effectively as evident by the increasing number of submissions being received by all journals. It is the ideal time to look back at patients' data, organize them, and compile and disseminated information of scientific relevance.

The downside for advanced skill training is clearly evident as there has been a total stop of all fellowship opportunities and cadaver skill laboratory training due to the existing crisis. All the scheduled programs for 2020 have been canceled and they have been postponed to the next year.

There is also an expected slowdown in ongoing research due to various factors. Patient recruitment, adherence to the time frame, and suspended elective surgeries can all delay ongoing research. There is also going to be a lack of funds for newer orthopedic related research, as part of the available resources are obviously being used for tackling the current pandemic.

Trends in orthopedic industry

The global downfall of economy and industries will impact the orthopedic industry as well. Orthopedics is closely associated with industry due to dependence on implants and equipment. There is expected to be a delay in the development and availability of the latest innovations. Smaller setups and industries may shut down due to the subsequent economic sluggishness.


  Conclusion Top


The orthopedic community is passing through a drastic phase due to COVID-19 crisis, and the immediate concern is to prepare the setups for efficient managing of cases and avoiding COVID-19 infection from infecting the HCW's and collapsing the existing systems. The need of the hour is the screening of all non-COVID-19 cases and judicious use of PPE. The disturbances and changes seen with respect to education, research, and training opportunities will take time to normalcy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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