Archives of Bone and Joint Surgery
Volume:8 Issue: 3, Apr 2020

Iranian Orthopedic Community as a part of the national health system feels deeply responsible to take part in the battle against the new coronavirus (COVID-19) pandemic. Although we might not be considered the front-line defenders, we do have a key role in this challenge. As the crisis continues to grow in Iran, the risk of contracting the virus increases with subsequent increase in the number of seriously ill and dying patients. The shortage of ventilators and personal protective equipment (PPE) is a main concern that may even worsen as the number grows. In response to the burden on the health system, the elective part of our practice has to be suspended for now so that the resources can be deployed to more critical patients. There is a social responsibility to preserve vital resources for those who are in greater need. Moreover, we follow the recommended social distancing by postponing elective surgeries which should help reduce further spread of this disease. The recommendations in this document are valid through the evolving period of the current pandemic. Future amendments and updates will be announced in line with the action plans of the Ministry of Health. Nonetheless in this crisis, we should be prepared to treat non-elective and trauma patients who are in need of emergency care. We should seek the best local solutions to continue the proper management for these trauma patients while preserving resources for the response to COVID-19. Furthermore, we need to plan for probable shortages in our resources including staff, spaces and supplies. The Iranian Orthopedic Association (IOA) supports shared decision-making policy in these extraordinary circumstances and acknowledges that non-operative management of many orthopedic injuries as well as reducing face-to-face follow-ups are a reasonable path.

We started 2020 while facing the largest pandemic of infectious diseases in the last one hundred years and also the most widespread recession in human life. The relatively small size COVID-19 virus has now placed more than half of the world in lockdown and is passing through countries borderless without discrimination. Although our health is primarily at risk due to the disease itself, we cannot ignore subsequent damages of the disease and especially its economic damages. The Orthopedic Society, as a member of the health care family, is at the frontline of the defense against these damages. This makes us, as a conscious commander, to first examine the current situation and then find appropriate ways to deal with it. Physicians in the orthopedic community, as a referral social group, are working in various aspects to deal with this unpleasant situation although these efforts may need to be redoubled or more purposive.

New emerging viruses like coronavirus 2019 (COVID-19) infections are always frightening. We know little about theirtransmission, behaviors, clinical manifestations, and outcomes. There is no vaccine or therapeutic strategies to dealwith these infections yet. In this situation, preventive measures may be promising. Hand hygiene is a very importantissue in preventing viral infection; however, there are other entities that can enhance the immune response and help ininfection prevention. Herein we review some measures for boosting the immune system.Level of evidence: Moderate

Coronaviruses are a group of enveloped viruses with single-stranded non-segmented positive-sense RNA genomes. InDecember 2019, SARS-CoV-2 appeared in China for the first time and quickly spread throughout the world. Althoughcertain medications suggested for other afflictions tend to be potentially effective for curing the infection, there is noapproved vaccination or drug available for this virus yet. Comprehension of the disease molecular pathogenesis couldprovide useful tools for COVID-19 patients in surveillance, prognosis, treatment, vaccine development and therapeutictargeting. The present research aims to summarize the association in COVID-19 patients between molecular dimensionsof comorbidities with clinical and preclinical information.Developing an ACE2 inhibitor could be a possible therapeutic target. Plasmin is another possible candidate both indiagnosis and treatment areas. All predicted biomarkers must be validated either through randomized clinical trials orexperimental assays before clinical application in patients.Level of evidence: V

The outbreak of a novel coronavirus, referred to as coronavirus disease-19 (COVID-19), with its sentinel case in Wuhan,China, in December 2019, has spread rapidly around the globe. On March 11, 2020, the World Health Organization(WHO) declared COVID-19 a worldwide pandemic, which led to most countries implementing social distancingprotocols. Most non-essential medical practices have been halted to direct resources to the facilities caring for patientswith COVID infection. The pediatric orthopaedic practice is in a unique position, with the treatment of many conditionsbeing treated by pediatric orthopedists being non-emergent, but time-sensitive. We hereby review the current literatureand guidelines surrounding the practice change around the world and give recommendations regarding the practice ofpediatric orthopaedics during the COVID pandemic.Level of evidence: V

The COVID-19 disease is rapidly spreading around the world, affecting many countries and their healthcare systems.Like many other countries, Iran is struggling with the current situation. In this article, we aim to share our perspectiveson confronting obstacles mentioned above using appropriate hospital protocols during the COVID-19 crisis.We investigated and compared the number of referred patients to the emergency room, elective, and emergentorthopedic operations in our hospital, along with a number of residents and faculty participants in the morning reportsand virtual classes before and after the outbreak of COVID-19 in our hospital.The number of referred patients to the emergency room was significantly reduced; the number of orthopedic operationswas also decreased to almost zero in March 2020. Meanwhile, we managed to dismiss our residents and reducethe number of in-hospital morning reports and conferences. Instead, we designed virtual classes, and the number ofparticipants in our virtual classes grew to almost two-third of the whole participant. We also managed to fortify our virtualoffice system to reduce the number of in-hospital visits.Since our hospital had become a leading center for the treatment of COVID-19 patients, and the number of referredtrauma patients, elective, and trauma operations, along with educational activities, was reduced. There was also asignificant concern about the management of elective, trauma, and post-operative patients in this era. Orthopedicfaculty members needed to react to the current situation cautiously. We were able to manage the situation withconsideration of our educational path, along with the management of personal protective equipment (PPE), and theuse of communication technologies and specific protocols to overcome the obstacles mentioned above. Yet involvedour staff andWith orthopedic faculties active involvement at in-hospital activitie and establishment of hospital protocols consideringtechnological facilities and WHO guidelines, we can improve education, management of PPE, and both orthopedicelective and trauma patients.Level of evidence: IV

Workplaces are susceptible places for exposure to the new coronavirus (Covid-19) infection due to gathering of manypeople. Hence, different instructions have been promoted by international organizations regarding high-risk employeesand the necessity of implementing health policies to prevent exposure and infection in the workplace. Here we reviewedthe required strategies to prevent and control COVID-19 in the workplace. In conclusion, considering the fast spreadingand growing prevalence of the new corona virus disease in the world over, all managers, employers, and businessowners should receive the necessary information and training on prevention and control strategies based on scientificguidelines and standards.Level of evidence: III

In this study, we aimed to assess the prevalence of comorbidities in the confirmed COVID-19 patients. Thismight help showing which comorbidity might pose the patients at risk of more severe symptoms.

We searched all relevant databases on April 7th, 2020 using the keywords (“novel coronavirus” OR COVID-19OR SARS-CoV-2 OR Coronavirus) AND (comorbidities OR clinical characteristics OR epidemiologic*). We reviewed 33papers’ full text out of 1053 papers. There were 32 papers from China and 1 from Taiwan. There was no language orstudy level limit. Prevalence of comorbidities including hypertension, diabetes mellitus, cardiovascular disease, chroniclung disease, chronic kidney disease, malignancies, cerebrovascular diseases, chronic liver disease and smoking wereextracted to measure the pooled estimates. We used OpenMeta and used random-effect model to do a single armmeta-analysis.

The mean age of the diagnosed patients was 51 years. The male to female ratio was 55 to 45. The mostprevalent finding in the confirmed COVID-19 patients was hypertension, which was found in 1/5 of the patients (21%).Other most prevalent finding was diabetes mellitus (DM) in 11%, cerebrovascular disease in 2.4%, cardiovasculardisease in 5.8%, chronic kidney disease in 3.6%, chronic liver disease in 2.9%, chronic pulmonary disease in 2.0%,malignancy in 2.7%, and smoking in 8.7% of the patients.

COVID-19 infection seems to be affecting every race, sex, age, irrespective of health status. The risk ofsymptomatic and severe disease might be higher due to the higher age which is usually accompanied with comorbidities.However, comorbidities do not seem to be the prerequisite for symptomatic and severe COVID-19 infection, excepthypertension.Level of evidence: IV

COVID-19 epidemic rapidly spread all around the world with over 1500 thousand infected cases and95000 deaths. This rapid pandemic may overwhelm health care capacity and shortage of resources is a major concern.Literature provided guidelines on management of COVID-19 patients but healthcare service to the normal populationshould be continued meanwhile. Health system should act immediately and wisely to support essential surgical care whilefighting against COVID-19. We conducted a comprehensive search in the major data bases since 2020, using the combination of MeSHwords of “COVID-19 “ and “surgery” and finally 34 full texts entered to data extraction phase to define a plan for surgicalpractice during COVID-19 pandemic. Healthcare workers are at the higher risk of contamination by COVID-19 especially in early stage of outbreakwhen they were not aware of the different aspects of COVID-19 pandemic. All healthcare staff must be trained toproperly use PPE. All patients have to be screened at the hospital triage. All elective surgical interventions must bepostponed. Operation room is considered as a place with high risk of cross infection so the highest level of protectionshould be maintained. Anesthesia, endoscopy and oral surgery are considered as aerosol producing procedureswith very high risk of contamination. There is not any evidence to support the risk of infection trough blood products.Postoperative respiratory problems are more common among COVID-19 patients that may increases the estimatedrisk of morbidity and mortality. COVID-19 pandemic is a dynamic challenge for health system to save the healthcare staff andequipment resources by timely decisions. Healthcare workers are at the higher risk of contamination by COVID-19especially in early phase of epidemic when the protection is sub-optimal.Level of evidence: III

Large-scale events such as COVID-19 show that there are situations that can lead to huge stress on healthinfrastructure systems (HIS). The pandemic reveals that it is very difficult to protect HIS from all kinds of possible hazards.They can be unpredictable and spread rapidly; hence, it is hard to find an effective mitigation strategy to completely protectsociety and its important HIS.

An often raised central question is what we should do if we cannot protect HIS from these types of hazards. Toanswer this question, the focus should move from HIS protection to HIS resilience. Therefore, in this paper, the CriticalInfrastructure Resilience Index (CIRI) is used to estimate the resilience of health infrastructure systems.

The results of the case study show that HIS resilience was enhanced significantly after the implementation ofmeasures. The results indicate that among the resilience phases the learning phase of resilience is the weakest part.This requires a root cause analysis, which should be prioritized by HIS managers and stakeholders.

This paper discusses how the resilience concept will help decision- and policy-makers to have a clearview of HIS performance before, during, and after the disaster. An easy-to-use and applicable methodology for HISassessment and evaluation was employed. It can be concluded that resilience and its identified phases can help HISmanagers to allocate available resources accordingly in the phases during and post-crisis.Level of evidence: V

COVID-19 was first identified in Iran in February 2020 and since then it spread rapidly through all over the country and soon after reported as a pandemic. The current study present a preliminary report of spine trauma management during COVID-19 pandemic. Method and Material: A cross sectional study was designed to evaluate patients admitted for vertebral fractures with diagnosis of COVID-19 infection on February, and March 2020. Analysis was made based on clinical and laboratory data in addition to imaging findings from chest HRCT. Seven patient with spine trauma including 5 males and 2 females ranged from 14 to 59 years were diagnosed for COVID-19 infection through CT-scan findings. Except one, all other patients were asymptomatic for COVID-19 at the time of admission. In three cases the COVID diagnosis was made the day after arrival and in others after 10, 14 and 35 days. Five Patients treated surgically in which 4 admitted to ICU soon after. The mean ICU stay for operated patients were 8 days and mean hospital stay was 22.6 days. Proper diagnosis of COVID-19 is the keystone to protect both patients and health care providers. During the pandemic all admitted patients should be screened for COVID-19 infection. Unnecessary procedures for spine trauma patients should be avoided in order to reduce complications related to surgery and preserve ICU beds.

Coronavirus pandemic has been announced by World Health Organization Director General on March 11th, 2020.Imam Khomeini Hospital Complex, affiliated to Tehran University of Medical Sciences, was one the first referral hospitalsin the capital city of Tehran, I.R.Iran that entered the crisis and started a serious battle with the disease. Thehospital had to change many routine operations to cope with the situation and during this journey, we used previouslyleadership principles and reached to some new experiences. As this is probably the most severe health-related crisis inIran in the past 100 years, we gathered our lessons learned in the first fifty days of epidemic from the leadership pointof view to share those with all colleagues worldwide. We know that leadership is of pivotal role in such a massive crisisand focused leadership experiences can help health care providers to manage the crisis while we are in the middle of it.Level of evidence: IV-V

To reduce the risk of spread of the novel coronavirus (COVID-19), the emerging protocols are advising for less physicianpatientcontact, shortening the contact time, and keeping a safe distance. It is recommended that unnecessary castingbe avoided in the events that alternative methods can be applied such as in stable ankle fractures, and hindfoot/midfoot/forefoot injuries. Fiberglass casts are suboptimal because they require a follow up for cast removal while aconventional plaster cast is amenable to self-removal by submerging in water and cutting the cotton bandages withscissors. At present, only fiberglass casts are widely available to allow waterproof casting. To reduce the contact timeduring casting, a custom-made 3D printed casts/splints can be ordered remotely which reduces the number of visitsand shortens the contact time while it allows for self-removal by the patient. The cast is printed after the limb is 3Dscanned in 5-10 seconds using the commercially available 3D scanners. In contrast to the conventional casting, a 3Dprinted cast/splint is washable which is an advantage during an infectious crisis such as the COVID-19 pandemic.Level of evidence: V

After the COVID-19 outbreak worldwide, we will sooner or later encounter trauma patients with COVID-19 in thedeveloping countries. It is a challenging decision-making process for an orthopedic surgeon to provide the patients withthe best practice in the crisis. Here we discuss the issue in terms of clinical severity of COVID-19 pneumonia, priorityof orthopedic surgical trauma procedures and standard of care for the treatment of trauma injuries. We finally proposean algorithm for better management of trauma patients in the setting of COVID-19 mass spread.Level of evidence: IV

The severe acute respiratory syndrome caused by COVID-19 is now a global catastrophic event. Currently thereis no approved drug or vaccine for the disease. Methylene blue (MB, oxidized form, blue color) has been used inmany different areas of clinical medicine, ranging from malaria to orthopedics. Leucomethylene Blue (reduced formof MB, colorless) may be applied for the treatment of COVID-19 according to the scientific evidences. In severepatients, there is a cytokine storm (hyperinflammation) and high oxidative stress (OS). Inflammation and OS hasa mutual correlation and exacerbate each other. In human body, MB first induces OS through absorbing electron(like a free radical) from other molecules, if the body could counteract to this OS, then reduced MB decreasesOS through other mechanisms. Reduced MB could prevent inflammation, propagation of the virus RNA, and alsoimproves hypoxia through reducing methemoglobin. Therefore, to avoid the increment of OS, we suggest usingLeucomethylene Blue through the following protocol: The IV cocktail contains 50 mg MB (1mg/kg, 50-kg weight),1000-2000 mg vitamin C, 500-1000 mg N-Acetylcysteine (or glutathione or cysteine or α-lipoic acid) and 10-20 grurea (optional) in 100 ml dextrose 5%. Before the injection, the cocktail should be kept in a dark place for 1-2 hourto become fade or colorless.Level of evidence: V

The first pandemic of the coronavirus family was caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) in late 2019. As a result of the pandemic critical condition, specialized orthopedic services were obviouslyaffected. To respond properly, we initiated a series of strategic measures, aiming at the safety of staff, minimizing theexposure, and prevention of possible disruption in providing services.Level of evidence: V

The novel coronavirus-induced infection (COVID-19) was declared a pandemic by the World Health Organization onMarch 11, 2020. Iran is one of the countries with a high incidence of COVID-19 infection.Data on three patients with fragility hip fracture and COVID-19 infection were collected from one hospital located inBadrud, Isfahan, Iran, from March 1, 2010, to March 30, 2020. All patients were elderly and had fracture induced by fallfrom standing height.All patients (n=3) were admitted with fragility hip fracture due to low energy trauma. The most common symptoms wereweakness and fatigue. Positive C-reactive protein (CRP) and Leukopenia were the most common abnormal laboratoryevaluations. According to the results, two patients underwent surgical treatment, and one patient had negative reversetranscription-CRP; however, all of them underwent medical treatment for COVID-19 infection.There is a possible relationship between COVID-19 infection and fragility hip fracture in elderly patients. It could beinduced by fatigue and weakness due to COVID-19 disease. COVOID-19 infection should be considered in elderlypatients with fragility hip fracture during the coronavirus pandemic.Level of evidence: IV

During the course of novel coronavirus pandemic ,Shariati hospital in Tehran , as a tertiary center in both orthopedictrauma and COVID-19 , we detected 7 cases with definite diagnosis of COVID-19 and concomitant emergent orthopedicproblem.This paper represents considerations and special issues in managing and decision making in these patients.Level of evidence: IV

Despite all protective measures, the number of contacts and cumulative contact duration in the frontline screening seem to be the influencing factors. Three out 5 of our first year orthopedic residents showed symptoms of the disease 2-3 weeks after starting their tasks in the COVID-19 floor. Other residents that were only visiting patients in the COVID floor did not become symptomatic which also highlights the role of ventilation. We assumed that the ventilation in the Emergency Screening area was not as efficient as the COVID floors and ICUs because only the residents visiting patients in the frontline became symptomatic. The bright side of this scenario was that the symptoms were mild with no or minimal pathology on chest X-ray, which deemed unlikely if the protective measures were insufficient as mortalities were high among providers in the beginning of the crises.

Telemedicine has seen a recent surge in utilization with the current global Coronavirus pandemic. Prior to this increase in use, its application has been proven to be both safe and effective in primary care and surgical medicine. Its value has been demonstrated for utilization in both initial consultation and post-operative evaluation of orthopedic surgery patients, especially those with pathology about the upper extremity. Telemedicine provides a unique opportunity to deliver health care to patients with limited access, whether it is due to location, cost, or restrictions during times of global crises. Emerging technologies employing smartphone cameras for digitalization of the limb are forthcoming and will allow for the remote delivery of custom fit or fully customized orthoses.

COVID-19 has imposed an unusual effect on all aspects of medicine. Many elective measures have been canceled and medical facilities are reserved for this critical situation. Although a comprehensive approach is needed in entire fields of medicine to prevent spreading of corona virus and to protect the life of health care providers and patients, decreasing disabilities in orthopedic patients who are affected by trauma or those were in the process of rehabilitation, demands to apply some home-based or contact less policies. We assessed the available potentials that could be implemented easily for continuing the rehabilitation process of upper limb conditions because of significant role of this part of treatment, there.

Effectiveness of rehabilitation process is undeniable in many musculoskeletal and joint conditions. There are increasing evidences that elecronic visits and tele-rehabalition programs are useful. When social distancing policies limit orthopedic surgeons to use hospital or clinic-based rehabilitation, developing of Home-based & Tele-rehabilitation modalities are highly recommended by Orthopedic surgeons , physiatrists and physiotherapists societies.

Coronavirus disease 2019 (COVID-19) was first emerged in Wuhan, China in December 2019, and on March 11, 2020, WHO announced COVID-19 outbreak as a pandemic. Because chloroquine is now one of the mainstay therapies of COVID-19 all over the world, we assumed that it may play a role in preventing COVID-19 in malaria-endemic countries. So, we decided to compare the distribution map of COVID-19 with areas at risk of malaria.

During COVID-19 pandemia, orthopedic ward of Shariati Hospital continued its work as the refferral ward for trauma patients. As an educational center with undergrad and postgrad medical students, we were forced to acutely change our policies and the ward workflow in a way to limit the danger of disease transmission and continue education and giving medical service at the same time. Here we reported our strategies that were adopted in our center to continue educational process as efficient as possible.