Indian Journal of Orthopaedics

https://doi.org/10.1007/s43465-020-00141-3

REVIEW ARTICLE

Orthopedics and COVID‑19: Scientific Publications Rush

Riccardo D’Ambrosi1 

Received: 24 April 2020 / Accepted: 7 May 2020

© Indian Orthopaedics Association 2020

Abstract
Background  The purpose of this literature review is to analyze all the articles related to COVID-19 and orthopedics and to
shed light on the scientific evidence that has actually been found.
Methods  A systematic review of the existing literature was performed to identify all studies dealing with COVID-19 and
orthopedics. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were fol-
lowed for the identification of the articles. On April 19 2020, a search was performed using MEDLINE and PubMed Central.
For the research, the following terms were used: “COVID-19” OR “SARS-CoV-2” OR “Coronavirus” AND “orthopaedic”
OR “orthopedic” OR “traumatology”.
Results  A total of 23 studies were included in the review, of which 19 (82.6%) were editorials, letters to editors, orthopedic
forums or expert opinions, 3 (13.0%) studies were level IV of evidence and 1 (4.4%) was a literature review. Articles have
been divided into the follow categories: guidelines, traumatology, pediatric, spine surgery, telemedicine, sports medicine,
bioethical, educational, rehabilitation, survey and hand surgery.
Conclusions  Although scientific production is very active on the topic of COVID-19 and orthopedics, the scientific evidence
is practically nil, mainly dealing with editorials, letters to editors or expert opinions. Therefore, future studies should focus
on clinical outcomes and treatments in COVID-19-positive orthopedic patients and prevention strategies. Additionally,
international guidelines and consensus statements must be developed to standardize procedures as much as possible in this
pandemic scenario.

Keywords  COVID-19 · SARS-CoV-2 · Pandemic · Literature review · Scientific publications

Introduction can be isolated in different animal species. Moreover, for

reasons yet to be explained, these viruses can cross species
In December 2019, a new kind of pneumonia disease was barriers and can cause, in humans, illnesses ranging from
recognized in Wuhan, the People’s Republic of China. the common cold to more severe diseases such as MERS
The outbreak was declared a Public Health Emergency of and SARS [2].
International Concern on January 30 2020, and the World The emergence of the COVID-19 pandemic has severely
Health Organization (WHO) announced a name for this impacted medical practices throughout the world, especially
virus [SARS (severe acute respiratory syndrome)-CoV-2] those of infectious disease specialists, emergency room per-
and for the disease (COVID-19) on February 11 2020, and sonnel, anesthetists, intensivists, virologists, epidemiologists
formally declared it a pandemic one month later on March and hygienists. At the same time, researchers have also been
11 2020 [1]. affected. The majority of non-essential clinical staff have
The coronaviruses (CoVs) are considered to be the major been sent home to work remotely, thereby providing oppor-
pathogens behind emerging respiratory disease outbreaks. tunities for increased efforts focused on scientific research
They are a large family of single-stranded RNA viruses that [3].
Just in the context of COVID-19, an increase in scientific
articles on the topic has been noted in recent weeks; this has
* Riccardo D’Ambrosi also been facilitated by the fact that more than 30 leading
[email protected]
publishers have committed to making all their COVID-19
1
IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, and coronavirus-related publications—and the available data
20161 Milan, Italy

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 Indian Journal of Orthopaedics

supporting them—immediately accessible on PubMed Cen- the articles identified and the references of the systematic
tral (PMC) and other public repositories [4]. This will help review. At the first screening, we identified 57 articles, of
to support the ongoing public health emergency response which we selected 23 that satisfied our inclusion criteria
efforts. (Fig. 1). Considering the heterogeneity of the articles, they
The purpose of this literature review is to analyze all the were, therefore, divided by category according to the topic
existing articles related to COVID-19 and orthopedics, and discussed. All types of studies according to “The Oxford
to shed light on what scientific evidence has actually been 2011 Levels of Evidence” were included in this review [6].
found.

Methods Results

A systematic review of the existing literature was per- A total of 23 [7–29] studies were included in the review,
formed to identify all studies dealing with COVID-19 of which 19 [7–9, 11–18, 20–27] (82.6%) were editorials,
and orthopedics. The PRISMA guidelines were followed letters to editors, orthopedic forums or expert opinions, 3
for the identification of the articles. On April 19 2020, [19, 28, 29] studies were level IV (13.0%) of evidence and
a research was performed using MEDLINE and PubMed 1 [10] was a literature review (4.4%). Articles have been
Central [5]. For the research, the following terms were divided in the follow category: guidelines, traumatology,
used: “COVID-19” OR “SARS-CoV-2” OR “Coronavi- pediatric, spine surgery, telemedicine, sports medicine,
rus” AND “orthopaedic” OR “orthopedic” OR “trauma- bioethical, educational, rehabilitation, survey and hand
tology”. The research also included the references of all surgery.

Fig. 1  A flowchart of the litera-

ture screemimg performed in
this study

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Indian Journal of Orthopaedics

Guidelines Vaccaro et al., representing some of the larger muscu-

loskeletal multispecialty groups in the country, provided a
Sarac et al. analyzed current guidelines published by each framework with recommendations to best weather the ensu-
state in the USA, concluding that few states have published ing months. These recommendations allow providers and
guidelines specific to orthopedic surgery during the COVID- their staff to return to an infrastructure that can adjust imme-
19 outbreak, leaving hospital systems and surgeons with the diately to the pent-up healthcare demand that may occur
responsibility of balancing the benefits of surgery with the following the COVID-19 pandemic. In the editorial sugges-
risks to public health [7]. tion, the authors reported about practice finances, staffing,
DePhilippo et al. outlined general guidelines for surgi- telehealth, operational plans following the crisis and ethical
cal procedures that ought to be considered necessary in the considerations [12].
case of: Valshya et Valsh reviewed the current guidelines already
published in the literature and also reported the Royal Col-
• Acute and/or disabling injuries to health-care workers, lege of Surgeons of England’s guidelines for good practice.
first responders, and members of the military and police The authors’ take-home message is as follows:
and fire departments; “It is important to realize that these healthcare workers
• Osseous fractures and/or irreducible joint dislocations; are the ones which are on the frontline in this war against
and the deadly virus and must be supported whole heartedly
• Wound/joint infections or postoperative wound dehis- by the society and the governments, in this time of crisis.
cence. They must be provided adequate numbers of good-quality
personal protective equipment (PPEs) and insurance cover,
Furthermore, the authors stratified surgical procedures to be able fight in this battle for us all. There has been an
according to the joints in which surgical necessity ought acute shortage of these essential PPEs for them and provid-
to be considered, in case of pathologies that could lead to ing them with substandard PPEs (similar to rain coats!) is
long-term disability and chronic pain if acute surgical man- not the solution to overcome the crisis. It is akin to ‘sending
agement is delayed [8]. soldiers into the war with misfiring guns’” [13].
Mauffrey and Trompeter published a long editorial report- The editorial by Sarpong et al. is a return to the past in
ing several issues linked with COVID-19, in particular by which the figure of the orthopedist is re-defined in light of
addressing the following topics: clinical care and how it orthopedic surgeons being asked to perform forgotten pro-
is delivered, communication, education and meetings, cedures changing the normal clinical activity [14].
research, operations, and ethical considerations [9]. In consideration of the extraordinary event we are victims
Massey et al. considered it crucial for orthopaedic depart- of, Halawi et al. analyze how normal clinical and surgical
ments to remain flexible and accommodating in light of the activity must change, suggesting new guidelines ad hoc for
pandemic’s perpetual evolution and its consequential health- pandemic [15].
care implications. Modifying surgical selection is paramount
to fulfilling the needs of the entire health system. Depend- Traumatology
ing on the needs of the local community and the phase of
COVID-19 outbreak in a specific area, the surgical selection Stinner et al. emphasize how it is important to optimize
priorities may change. It remains important that orthopedic medical resource allocation and prevent the spread of
programs emphasize personnel safety and slowing the spread SARS-CoV-2, and how, to this end, orthopedic trauma sur-
of the virus so that the department can still maintain vital geons must remain vigilant and be prepared to optimally
functions. Emerging technologies such as inpatient telemedi- care for the injured trauma patient [22]. Furthermore, they
cine and online file sharing applications can enable ortho- reported three clinical cases demonstrating a change in prac-
pedic programs to still function, while attempting to protect tice to minimize patient morbidity and potential spread of
medical staff and patients from the COVID-19 spread [10]. SARS-CoV-2”.
Awad et al. provided evidence-based recommendations Rodrigues-Pinto et al. underline the importance of the
and measures for the appropriate personal protective equip- protection of health workers and how appropriate training is
ment for different clinical and surgical activities in various of paramount importance to minimizing their infection and
settings. To reduce the occupational risk in treating sus- the stress associated with the physical and mental exhaus-
pected or confirmed COVID-19 orthopedic patients requir- tion they have to endure. The correct application of these
ing urgent care, recommended precautions and preventive procedures is expected to adequately protect health workers
actions (to applied in the triage area, emergency department by giving them access to protective clothing readily available
consultation room, induction room, operating room, and at most operating rooms, thereby minimizing the risks asso-
recovery room) should be reviewed [11]. ciated with the lack of personal protective equipment [21].

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Mi et al. summarized the clinical characteristics and Sports Medicine

early prognosis of COVID-19 infection in a cohort of ten
patients with fractures; these tended to be more severe Corsini et al. analyzed the possible effects of coronavi-
than those reported for adult patients with COVID-19 rus on athletes, particularly on the resumption of football
without fracture. This finding may be related to the dura- activity, reccomending maximal caution to the football
tion between the development of symptoms and presenta- governance on the decision regarding when to restart sport
tion. Surgical treatment should be carried out cautiously activity. Moreover, a specific protocol should be consid-
or non-operative care should be chosen for patients with ered to check cardiological, pulmonary, and, in general,
fracture in COVID-19-affected areas, especially for older systemic sequelae of COVID-19 before resuming sporting
individuals with intertrochanteric fractures [19]. activities [23].
Ashford et al. broadly analyzed the situation of COVID- Gilat and Cole published an editorial recalling the impor-
19 and the role of the orthopedic surgeon, in particular tance of sport and consequently the role of sports medicine.
focusing on 4 key points: Accordingly, health-care providers specializing in sports
medicine who attend to all types of athletes must quickly
• PPE (personal protective equipment); adapt to this new and hopefully transient situation continu-
• Avoid (avoid contact, avoid transfer of patients, avoid ing to serve their community to the best of their ability. Fur-
surgery); thermore, efforts should be made to maximize the use of
• Restrict (restrict number of visits, restrict generation “telemedicine” to continue providing care to patients and
of aerosols, restrict visitors); and identify essential problems that require observation in the
• Abbreviate (abbreviate waiting times, abbreviate treat- clinic: a physical examination, imaging for definitive assess-
ment) [20] ment, emergency department triage, and defining and treat-
ing conditions that require urgent and time-sensitive surgi-
cal care. Staff should be stringent with their own protection
Pediatric at all times, as they can easily become “super-spreaders,”
infecting whole communities [24].
Farrell et al. published guidelines based on expert opinion
and best available evidence, providing a framework for the
management of pediatric orthopaedic patients during the Telemedicine
COVID pandemic. The general principles include limit-
ing procedures to urgent cases such as traumatic injuries Loeb et al. reported the difficulties in the direct relation-
and deferring outpatient visits during the acute phase of ship with the patient during the pandemic, analyzing how
the pandemic. Moreover, non-operative methods should the use of telemedicine can change these scenarios. The
be considered where possible. For patients with develop- authors report the experience in unit care where a robust
mental or chronic orthopaedic conditions, it may be pos- telemedicine program during a 5-day period was introduced.
sible to delay treatment for 2–4 months without substantial Between telemedicine encounters and necessary in-person
detrimental long-term impact [16]. visits, providers may be able to achieve 50% of their typi-
cal clinic volume within 2 weeks. Further, when handling
the massive disruption to the routine patient care workflow,
Spine Surgery it is critical to understand the key factors associated with
an accelerated introduction of telemedicine for the safe and
Donnally III et al. reported some key points to consider in effective continuation of orthopaedic care during this pan-
spine surgery during COVID-19: demic [18].

• Importance of daily’s updates from the hospital.

• The urgency of surgical intervention for each patient Bioethical
being agreed upon by members of the spine depart-
ment. Dunham et al. provided a framework for considering how
• Avoiding the assumption that surgical delays will be a global pandemic changes our moral responsibilities. Pan-
for a short duration. demic environments, however, bring challenges that can only
• Considering alternative surgical plans and less invasive be addressed by moving to a public health ethics frame. The
amoptions depending on hospital bed availabilityfor standard question of my actions at this time is modified to
spine surgeries that cannot be postponed [17]. what we, as a population, ought to do. The authors high-
light a disconnection between one’s pre-COVID-19 sense of

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Indian Journal of Orthopaedics

responsibility and the one that is developing now; disconnect in real-time training on prevention measures was found to
is ripe for moral distress, residue, and injury [25]. have a protective effect against COVID-19. Furthermore,
not wearing an N95 respirator was found to be a risk factor
Educational and wearing respirators or masks all the time was found to
be protective. Severe fatigue was found to be a risk factor
Kogan et al. have assessed the appropriateness of educa- for infection with COVID-19 [28].
tional tools in the form of web-based learning, surgical
simulators, and basic competency tests to help programs
Hand Surgery
ensure continued resident growth, development, and well-
being, while maintaining high-quality patient care. The
Ducornau et al. described the different measures used in
authors conclude that orthopaedic departments must develop
response to the COVID-19 pandemic by hand surgeons all
a list of priorities based on their institutional needs to guide
over the world, comprising 47 surgeons working in 34 coun-
decision-making during these times of uncertainty. In this
tries. They found several protocols exist in terms of visitors,
scenario, residents’ roles should be redefined, in particular,
health professionals in the operating room, patient waiting
changing the perspective on learning methods. New learing
areas, wards, and emergency rooms [29].
tools include the use of virtual meeting platforms, independ-
ent home study, surgical simulation, and fostering leadership
opportunities. Furthermore, it is mandatory for the residents
to feel safe, protected, and heard [26]. Discussion

Rehabilitation The main findings of the current review primarily concern

the high number of published studies concerning COVID-19
On March 13th, the Italian Society of Physical and Reha- and orthopedics in such a short time; in fact, the first article
bilitation Medicine decided to produce a short document on a temporal level dates back to March 16, thus showing an
with the aim of providing recommendations fully compliant average of almost one article per day [27].
with the national and regional provisions, but specifically At the same time, however, almost all published articles
focused upon the rehabilitation sector, to support the physi- have a very low scientific value (editorial, expert opinion)
cal and rehabilitation medicine physicians, other medical and only 3 studies have scientific evidence (Level of Evi-
specialists, other health professionals, and policy markers dence-4) [6].
in taking decisions during an unusual and largely unknown This shows how all the efforts we are carrying out on
circumstance [27]. COVID-19 in orthopedics are empirical, without a demon-
strated and demonstrable scientific value and how numerous
Survey articles still have to be published on the topic, reporting clin-
ical data, results about treatment, and prevention strategies.
Guo et al. conducted a survey to identify the orthopaedic In particular, it is possible in the current review to see
surgeons infected with COVID-19 in Wuhan. Social demo- how several articles trace the guidelines at hospital and sur-
graphic variables, clinical manifestations, exposure his- gical and outpatient level in the COVID-19 era, but many
tory, awareness of the outbreak, infection control training open questions still remain: how should patients with ortho-
provided by hospitals, and individual protection practices pedic and COVID-19 diseases be treated?
were analyzed throgh the questionnaire. Furthermore, the Moreover, do the traumatology emergency patients
possible risk factors at the individual level—a 1:2 matched COVID-19 positive deserve a different anesthesiological
case–control study—was observed. A total of 26 orthopaedic and pharmacological rehabilitation treatment?
surgeons from 8 hospitals in Wuhan were identified as hav- Furthermore, these clinical results will have to be evalu-
ing COVID-19. The incidence in each hospital varied from ated over time to understand if the employed measures were
1.5% to 20.7%. The onset of symptoms was from January correct without affecting health and quality of life; these
13 to February 5, 2020, peaking on January 23, 8 days prior observations will not only be of orthopedic relevance but
to the peak of the public epidemic. The suspected sites of also must concern infectious disease specialists, pulmonolo-
exposure were general wards (79.2%), public places at the gists, and anesthesiologists.
hospital (20.8%), operating rooms (12.5%), the intensive Future studies will, therefore, have to create “gold stand-
care unit (4.2%), and the outpatient clinic (4.2%). There was ard” treatment, with international and multi-disciplinary
transmission from these doctors to others in 25% of cases, guidelines in patients with COVID-19 through the publi-
including to family members (20.8%), colleagues (4.2%), cation of scientific papers of the highest level of evidence
patients (4.2%), and friends (4.2%). Moreover, participation possible.

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 Indian Journal of Orthopaedics

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Conflict of interest  The authors declare that they have no conflict of
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