Changing Trend in COVID 19 Pandemic, Orthopaedic Care

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Jebmh.comOriginal Research Article(a)(b)(c)(d)(e)Figure 3. (a) 40 Years Old Male with Sequelae of HealedTuberculosis (Mortar-and-Pestle Types) Left Hip, (b) PatientPositioned in Right Lateral Position and after Part Preparation andDraping Incision for Lateral Approach was Marked. (c)Postoperative Radiograph on Day 21. (d) The Patient Developed aDeep Infection. Which was Managed Successfully throughDebridement and VAC Application, (e) Pelvis with Both HipAnteroposterior Radiograph was taken after the Subsidence ofInfection Showing the Development of Heterotropic Ossificationalthough There is no Restriction of Range of Movement or PainPostoperative and Follow Up Protocol We limit visitors at office encounters and around theperioperative period. Taking appropriate precautionduring dressings on day two and five.In case of postoperative dyspnoea, or fever isolation ofpatient and repeat RTPCR for COVID-19.Starting assisted ambulation and gait training on day twoafter the first dressing and postoperative check x rayevaluation. No undue delay in discharge. Usual discharge aftersecond dressing on day five. Follow up in ortho OPD after one week of discharge forsuture removal, assessment and physiotherapy (gaittraining and muscle strengthening, range of motionexercises).Statistical AnalysisIn this observational study we have compared the casestotal hip arthroplasty before and after government-imposedlockdown due to COVID 19. We have compared the cases interms of four variables mean age, gender wise proportion,side of total hip replacement and cemented versusuncemented immediate postoperative complications.RES ULTSGroup I: Pre Group II: PostLockdown Period in Lockdown PeriodGroupOur Study(December 2019 -February 2020)in Our Study(September 2020- January 2021)Period of study 3 months 5 monthsTotal number of cases 16 24Mean age 45.4 years 49.2 yearsM:F ratio 13 : 03 19 : 05Right: Left (Side of Hipreplacement)07 : 09 14 : 10Cemented vs Cementless THR 03 : 13 04 : 20Immediate postoperativecomplications: Infection1 1Table 2. Statistical AnalysisWe have studied 40 cases of total hip arthroplasty over8 months period. Which is divided into two groups. Groupone consists of 16 cases of THR done during pre-lockdownperiod, that is done between December 2019 to February2020. Group two consists of 24 cases of THR done duringpost lockdown period, that is done between September 2020to January 2021.There is no logical difference between twogroups other than the time period. There is one complicationas infection in each group. By using chi square test revealingJ Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 8 / Issue 28 / July 12, 2021 Page 2547
Jebmh.comP value more than 0.05 there is no significant difference inimmediate postoperative complication between prelockdownand post lockdown group.GroupNumber ofreadmissionsReason ofreadmission/complicationDuration of secondhospitalizationMode ofmanagementGroup I: PreLockdown Period inOur Study (16 Cases)One readmission due toinfectionSigns of infection without anydischarge on Postoperativeday 20Group II: PostLockdown Period in OurStudy (24 Cases)One readmission due toinfectionSigns of infection with serousdischarge on Postoperative day27(noticed during first follow up14 days 12 daysConservativeTable 3. Readmission, Complicationsand Mode of ManagementWound debridement followedby Vacuum assisted closureThere is one superficial infection in group I and one ingroup II. Patient of group I presented with signs of infectionafter 20 days of operation suggested by local rise oftemperature and erythema around suture site, increasedESR and CRP titre. He was managed successfully withreadmission in hospital and injectable broad-spectrumantibiotic for two weeks. Patient had been discharged fromhospital with oral antibiotic for another four weeks. Patientof group II presented with similar signs of infection but alsohad serous discharge from surgical scar site. We havenoticed it when patient came for first follow up onpostoperative day 27. We decided for readmission. Patientmanaged successfully with debridement, partial closure ofwound and Vacuum assisted closure (VAC) (fig 3). During aperiod of 12 days of hospitalization, patient was on broadspectrum injectable antibiotic, as culture of the dischargehad no growth. VAC removal was done on day four, andsecondary closure was done and on 13 th day afterdebridement patient was discharged after suture removalwith oral antibiotic. We have given oral antibioticlevofloxacin 750 mg daily for four weeks. In both of thecases, third generation cephalosporin: ceftriaxone one gramtwice daily through intravenous route during hospitalization.Apart from surgery related complications, none of ourpatients in either of two groups reported COVID 19symptoms in follow-up period.Physiotherapy: There is slight difference in postoperativeregimen in group two as, physiotherapist used to help instrengthening muscle exercise and range of motion exerciseand ambulation with walking frame with the intension toteach that patient with the help of attendant should do itwithout any difficulty. This was not done so carefully ingroup one patient: we also include changes in physiotherapyregimen due to imposed lockdown.Postoperative patient reported outcome measures wereused to evaluate any difference in short term functionaloutcome shown no significant difference. We have includedthe protocol followed by the hospital administration, preandpost-operative protocols to add new dimension of ourknowledge to help deciding the line of treatment by learningfrom our current experience, mistakes and achievements forthe future surge of the current pandemic or similarpandemic. During the lockdown we have used socialplatform YouTube, WhatsApp for short video link ofphysiotherapy to learn and demonstration on video calling.Original Research ArticleLimitation of this StudyIn is a short-term study with limited number of cases. Thereare many potential variables which can cause bias in theresult of study. E.g., different age group of patients (45.4years is the mean age in group one while 49.2 years in group2, postoperative regimen is not uniform due to unavoidablecircumstances during lockdown in group one patient).DISCUSSIONIn our study we have observed predominantly malepopulation those underwent total hip arthroplasty.Predominately younger population underwent surgerymainly because of osteonecrosis of femoral head. Thus,more and more uncemented arthroplasty were done topreserve the bone stock to deal with future need of revisionarthroplasty. We do not operate on COVID-19 patientsconsidering the our hospital administration guidelines andthe poor consequences viz, half of those need ICU care andreported mortality rate in literature up to 20 %. 7 The goodthing for Orthopaedic surgeon is that using high speedinstruments like saw, drill, bur etc. has not been proven toorisky as there was no isolation or spread of coronavirus frombone marrow. 8,9 While considering the appropriateprecautions in outpatient, emergency or operation theatre,the importance of face mask is well proven and it is worthto mention that, orthopaedic surgical hoods alone are not atall recommended. 9,10Elderly, obese and patients with any other comorbiditiesconsidered to have at high risk for complications, mortalityand morbidity. 11,12,13,14,15 4 - 7 % mortality rate due toCOVID 19 reported in this group, which is as high as, fourtimes of the influenza virus. 11,13 In our study, we found sixmedical personnel COVID 19 positives in the orthopaedicsdepartment during the pandemic in different time periods.Out of six-person one required hospitalization and the restrecovered with home quarantine and supportive treatment.We followed the CDC recommendation for return of workafter COVID-19. These recommendations are gettingupdated frequently. Recommendations includes thefollowing: No fever without antipyretic use, nobreathlessness at rest, and two negative COVID-19 tests ontwo consecutive days 24 hours apart. Although we foundnone of the infections had a direct relation with operativework but may have from outpatient, inpatient, andemergency patient care. All of the people had an infectionduring the initial surge of COVID-19, during that time onlyemergency surgery was allowed after ruling out COVID-19in the patients.Wilson et al 16 done a survey on 111 patient whounderwent arthroplasty to study psychological implicationsdue to delay in arthroplasty.90 % of patient reportedsurgical delay and 68 % reported emotional distress due todelay. Brown et al 17 in his study which was done in 15institutions over a large sample of patient reported that mostof the patient was anxious due to delay and 7 % of themreported delay due to fear of contracting COVID-19 in thehospital. In our study also most of the patient reportedJ Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 8 / Issue 28 / July 12, 2021 Page 2548
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Changing Trend in COVID 19 Pandemic, Orthopaedic Care

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