Various papers and articles have suggested guidelines, modifications and standard operative procedures to deal with pandemic situation. Planning is the key factor, in addition to the guidelines and standard operative procedures (SOP) as given by health care organisations. We as Orthopaedicians, also need to plan and modify our practices at each level relating to OPD, admission and surgeries, following all the standard precautions at all the times.
Patients visit in OPD or hospitals, should be minimized by favouring telemedicine or emails if possible, and favouring consultation by prior appointment only. Try to make definitive diagnosis and final treatment decision at first consultation only. Patient prioritisation in favour of non-operative strategies be emphasized. Referrals and transfers for investigation and radiology especially multiple times should be minimized and must outweigh the potential benefit of intervention, particularly for patients in vulnerable groups. Alternative resources such as written and web-based information should be used maximally.
Guard outside the clinic or hospital, can be trained to screen and isolate the suspected patients by taking fever history or by use of thermal screening. In OPD, clinicians should preferably use eye protection shield (face-mask or goggles) and N95 mask which can be re-used again after 5 days of incubation, whereas use of triple layer mask is sufficient for orthopaedic patients attending OPD. Mask dispensers can be installed in OPD and hospitals, so that the no touch mask can be prescribed to the patients coming without mask. The waiting room should be modified to have adequate room ventilation, so that there is at least 1meter distance between the patients allowing limited and restricted patient movement. The risk of infection, in healthcare workers can minimized by use of Personal protective equipment (PPE), which should be used correctly and safely even while donning and doffing.
If possible, staff and helpers should work in rota’s so that all are not exposed and you can have a reserve team if needed. In hospitals, surgical workforces are likely to be further depleted, as they might be working in rota in half strength and rest might be reserved, quarantined or isolated, hence in these times, sub-specialty services may be difficult to run. These healthcare workers should be educated, aware and trained so that they change their behaviour in favour of maintaining social distancing, following standard precautions, frequent hand hygiene, refraining touching their eyes, nose, and mouth with potentially contaminated gloved or un-gloved hands, cleaning and disinfection of equipment and environment.
If possible, use disposable equipment, if not possible then frequent cleaning and disinfection between each patient, be done. Avoid touching or frequently sanitize contaminated environmental surfaces e.g. door handles and light switches. Television, warnings, banners, disclosures and posters should be installed in OPD’s with instruction to cover nose and mouth, maintaining social distancing and information and other preventive measures which can create awareness among people. Best practices for safely managing health care waste should be followed.
Thorough cleaning and disinfection prior, between and after the use of OPD’s as well as the operating theatre facilities should be re-enforced.
Dislocations, minor injuries, stab and penetrating non-contaminated wound without neurovascular deficit and minor to moderate abscess can be treated in the emergency department itself without admission. Most paediatric injuries, upper limb fractures and stable lower limb fractures have high rates of union and can be managed non-operatively, recognising that some patients may require late reconstruction. Delayed primary fixation of up to three months following injury may be acceptable if predictable favourable outcomes in delayed surgeries are weighed against the risks of surgeries.
Patients with poly-trauma, pelvic, acetabular and hip fractures with major haemorrhage, open fractures, compartment syndrome and exsanguinating injury all require emergent resuscitation and management. Only absolute indication should be taken for surgery, like limb or lifesaving surgery, septic arthritis, prosthetic joint infection, amputations and re-implantation, crush injuries, cauda-equina syndrome, abscess and infections. Joint replacement and ligament reconstruction can be done at a later stage. Plan and facilitate the surgery such that multiple visits of patient to the OT and admission can be avoided. Re-surgery like, flaps, bone grafting, soft tissue reconstruction, skin grafting and amputations can be avoided by proper planning. Non-union, malunion or elective orthopaedic and spinal surgery should be deferred. Emphasize on reducing hospital admission and minimising length of stay by encouraging early discharge or day care surgery, if possible.
If surgery is planned, then patients as well as the staff both need to be tested prior, for COVID-19. Isolation prior to surgery will help to reduce transmission further. Surgeries should be planned only when appropriate supportive equipment e.g. ventilators, PPE and intensive care unit beds for post-operative care following surgery are available. Since Orthopaedic surgeries are aerosol-generating procedures use PPE, including gloves, long-sleeved gowns, balaclava, eye protection or face shield and powered air purifier respiratory (PARP) are recommended for all healthcare workers in OT. If PARP is not available then, N95 with goggles and balaclava with additional face shield covering skin to maximum can reduce infection risk.
Use of laminar flow, positive pressure, space suits, pulse lavage or powered tools, drills, saw, reamers, suction irrigation reaming and other aerosol generating equipment’s etc is not recommended. Shifting to un-reamed intramedullary nails, hand reamers and hand drills can be helpful. Surgery should be preferentially being done in adequately ventilated room, with negative pressure rooms with minimum of 12 air changes per hour or at least 160 litres/second in facilities with natural ventilation. Surgical theatre capacity is likely to be working with decreased strength, as they are likely to be redeployed to support non-surgical specialties, still then, unnecessary individuals in the room should be avoided.
