Problems and solutions for orthopedic surgeons during COVID-19 pandemic

Vol 35 | Issue 2 | May-Aug 2020 | page: 53-61 | Sandeep Kumar¹, Rajesh Arora¹, Arvind Kumar¹, Surabhi Vyas², Shilpee Kumar³, Priyanka Arora⁴, Owais Ahmed Qureshi¹, Javed Jameel¹

Authors: Sandeep Kumar¹, Rajesh Arora¹, Arvind Kumar¹, Surabhi Vyas², Shilpee Kumar³, Priyanka Arora⁴, Owais Ahmed Qureshi¹, Javed Jameel¹

¹Department of Orthopaedics, Hamdard Institute of Medical Sciences & Research, New Delhi, India
²Department of Radiodiagnosis, AIIMS, New Delhi, India
³Department of Microbiology, VMMC & Safdarjung Hospital, New Delhi, India
⁴Department of Obstetrics & Gynaecology, ESIC Medical College, Faridabad, Haryana, India

Address of Correspondence:
Dr. Rajesh Arora
Hamdard Institute of Medical Sciences & Research, New Delhi, India


Background: SARS-Cov-2 is believed to have infected over two million humans to date. Lack of complete knowledge about the epidemiology of this virus and doubts about perioperative management of orthopedic patients is further curtailing patient care. This review article discusses the pertinent virology and relevant precautionary practices that help in reducing the risk of contamination of health care workers from an orthopedic point of view.
Methodology: The review was prepared by authors belonging to different disciplines of health care. Recent PubMed-based literature and national and international guidelines related to the CoViD-19 pandemic and its implications on orthopedic practice were reviewed.
Result: Elective surgeries should be avoided. All patients undergoing surgical procedures should be CoViD-19 tested whenever possible. CT chest may be used as a screening tool when CoViD-19 testing is not available considering the risk of exposure to healthcare workers and setup; and higher perioperative mortality (if the patient tests positive later). A full personal protection kit should be used in all surgical cases. Aerosol generating procedures should be avoided. Safety measures should be taken during the shifting of patients to prevent contamination of health care setup and workers. Biowaste from the CoViD zone should be properly segregated and well labeled.
Conclusion: Orthopaedic surgeons should be well updated about the CoViD-19 disease, and should help and support regional policies for both containment and mitigation measures. Simultaneously, one should triage his/her patients in order to use available resources with maximal efficiency without contaminating other patients, healthcare setup and its workers.
Keywords: Orthopaedic surgery; CoViD-19; Pandemic; Perioperative management; Aerosol generating procedures (AGPs), SARS-CoV-2, Orthopaedic trauma, Personal Protective Equipment (PPE), Preoperative workup; Postoperative management.


1. WHO (2020) Coronavirus disease 2019 (COVID-19) situation reports. Available from: emergencies/diseases/novelcoronavirus-2019/situationreports. Cited Mar 20, 2020.
2. Fauci AS, Lane HC, Redfield RR (2020) Covid-19 – N a v i g a t i n g t h e U n c h a r t e d . N E n g l J Med,382(13):1268–1269.
3. Perlman S (2020) Another Decade, Another Coronavirus. N Engl J Med,382(8):760–762.
4. Cascella M, Rajnik M, Cuomo A, et al (2020) Features, evaluation and treatment coronavirus (COVID-19). In StatPearls [Internet]. StatPearls Publishing, 2020
5. Zhu N, Zhang D, Wang W, et al (2019) A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J
6. Zhang W, Du RH, Li B, et al (2020) Molecular and serological investigation of 2019-nCoV infected patients: implication of m u l t i p l e s h e d d i n g r o u t e s . E m e r g M i c r o b e s Infect,9(1):386–389.
7. Chen H, Guo J, Wang C, et al (2020) Clinical characteristics and intrauterine vertical transmission potential of COVID- 19 infection in nine pregnant women: a retrospective review of medical records. Lancet,395(10226):809–815.
8. Indian Council of Medical Research (ICMR) (2020) Guidance for Management of Pregnant Women in COVID-
1 9 P a n d e m i c . A v a i l a b l e from: ents/Guidance_for_Management_of_Pregnant_Women_i n_COVID19_Pandemic_12042020.pdf. Cited Mar 20, 2020.
9. Guan WJ, Ni ZY, Hu Y, et al (2020) Clinical Characteristics of Coronavirus Disease 2019 in China [published online ahead of print, 2020 Feb 28]. N Engl J Med,NEJMoa2002032. doi:10.1056/NEJMoa2002032
10. Indian Council of Medical Research (ICMR) and National Institute of Virology (NIV) (2020) Specimen Collection,
Packaging and Transport Guidelines for 2019 novel C o r o n a v i r u s ( 2 0 1 9 – n C o V ) . A v a i l a b l e from: n_packaging%20%202019-nCoV.pdf. Cited Mar 20, 2020.
11. Indian Council of Medical Research (ICMR) (2020) Advisory to start rapid antibody based blood test for COVID-
1 9 . A v a i l a b l e from: ents/Advisory_Antibody_Testing_04042020.pdf. Cited Mar 20, 2020.
12. Wong HYF, Lam HYS, Fong AH, et al (2019) Frequency and Distribution of Chest Radiographic Findings in COVID-19 Positive Patients [published online ahead of print, 2019 Mar 27]. Radiology,201160. doi:10.1148/radiol.2020201160
13. Ai T, Yang Z, Hou H, et al (2020) Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID- 19) in China: A Report of 1014 Cases [published online ahead of print, 2020 Feb 26]. Radiology,200642. doi:10.1148/radiol.2020200642
14. British Orthopaedic Association (2020) BOAST – Management of patients with urgent orthopaedic conditions
and trauma during the coronavirus pandemic. Available from:
9457-4533-9774e973c835246d/COVID-19-BOASTs- Combined-v1FINAL.pdf. Cited Mar 20, 2020.
15. Chang Liang Z, Wang W, Murphy D, Po Hui JH (2020) Novel Coronavirus and Orthopaedic Surgery: Early
Experiences from Singapore [published online ahead of print, 2 0 2 0 M a r 2 0 ] . J B o n e J o i n t S u r g Am,10.2106/JBJS.20.00236. doi:10.2106/JBJS.20.00236
16. American College of Surgeons (2020) COVID-19: Elective Case Triage Guidelines for Surgical Care. Available
f r o m : h t t p s : / / w w w . f a c s . o r g / c o v i d – 1 9 / c l i n i c a l – guidance/elective-case. Cited Mar 20, 2020.
17. American College of Surgeons (2020) COVID-19 Guidelines for Triage of Orthopaedic Patients. Available
f r o m : h t t p s : / / w w w . f a c s . o r g / c o v i d – 1 9 / c l i n i c a l – guidance/elective-case/orthopaedics. Cited Mar 20, 2020.
18. Ti LK, Ang LS, Foong TW, Ng BSW (2020) What we do when a COVID-19 patient needs an operation: operating
room preparation and guidance [published online ahead of p r i n t , 2 0 2 0 M a r 6 ] . C a n J A n a e s t h , 1 – 3 .
19. Wong J, Goh QY, Tan Z, et al (2020) Preparing for a COVID-19 pandemic: a review of operating room outbreak
response measures in a large tertiary hospital in Singapore [published online ahead of print, 2020 Mar 11] Can J
Anaesth,1–14. doi:10.1007/s12630-020-01620-9.
20. Shi H, Han X, Jiang N, et al (2020). Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan,
China: a descriptive study. The Lancet Infectious Diseases,20(4):P425-434.
21. American College of Radiology (2020) ACR recommendations for the use of Chest Radiography and
Computed Tomography (CT) for suspected CoViD-19 infection. Available from:
n d – E c o n o m i c s / A C R – P o s i t i o n – Statements/Recommendations-for-Chest-Radiography-and-
CT-for-Suspected-COVID19-Infection. Cited Mar 20, 2020.
22. WHO (2020) Mental health and psychosocial considerations during the COVID-19 outbreak. Available
f r o m : h t t p s : / / w w w . w h o . i n t / d o c s / d e f a u l t – source/coronaviruse/mental-health-considerations.pdf. Cited Mar 20, 2020.
23. Dodd RY, Stramer SL (2020) COVID-19 and Blood Safety: Help with a Dilemma [published online ahead of print, 2020 Feb 26]. Transfus Med Rev, in press.
24. Lei S, Jiang F, Su W, et al (2020) Clinical characteristics and outcomes of patients undergoing surgeries during the
incubation period of COVID-19 infection. Eclinical Medicine, in press.
25. Indian Council of Medical Research (ICMR) (2020) Recommendation for empiric use of hydroxy-chloroquine for
prophylaxis of SARS-CoV-2 infection. Available from: ents/HCQ_Recommendation_22March_final_MM_V2.p df. Cited Mar 20, 2020.
26. Centre for Disease Control (2020) Sequence for putting on Personal Protective Equipment (PPE). Available
from: Cited Mar 20, 2020.
27. Royal College of Surgeons of Ireland (2020) Intraoperative recommendations when operating on suspected COVID-19 i n f e c t e d p a t i e n t s . A v a i l a b l e from:
clinical-guidance-for-surgeons. Cited Mar 20, 2020.
28. The New York School of Regional Anaesthesia (2020)Personal Protective Equipment (PPE) to protect you
f r o m C O V I D – 1 9 . A v a i l a b l e f r o m : h t t p s : / / w w w . n y s o r a . c o m / w p – content/uploads/2020/03/PPE-Guidance.pdf. Cited Mar 20, 2020.
29. U.S. Food and Drug Administration (2020) N95 Respirators a n d S u r g i c a l M a s k s . A v a i l a b l e f r o m : infection-control/n95-respirators-and-surgicalmasks- face-masks. Cited Mar 20, 2020.
30. Roberts V (2014) To PAPR or not to PAPR?. Can J Respir Ther,50(3):87–90.
31. Nathan N (2020) Waste Not, Want Not: The Re-Usability of N95 Masks [published online ahead of print, 2020 Mar 31]. AnesthAnalg,10.1213/ANE.0000000000004843. doi:10.1213/ANE.0000000000004843
32. Derrick JL, Gomersall CD (2004) Surgical helmets and SARS infection. Emerg Infect Dis,10(2):277–279. doi:10.3201/eid1002.030764
33. Jewett DL, Heinsohn P, Bennett C, Rosen A, Neuilly C (1992) Blood-containing aerosols generated by surgical techniques: a possible infectious hazard. Am Ind Hyg Assoc J,53(4):228–231. doi:10.1080/15298669291359564
34. Yeh HC, Turner RS , Jones RK, et al (1995) Characterization of Aerosols Produced during Surgical Procedures in Hospitals. Aerosol Sci Tech, 22(2):151-161
35. WHO (2020) Q&A on infection prevention and control for health care workers caring for patients with suspected or c o n f i r m e d 2 0 1 9 – n C o V . A v a i l a b l e from:
prevention-and-control-for-health-care-workerscaring- for-patients-with-suspected-or-confirmed-2019-ncov.
Cited Mar 20, 2020.
36. Central Pollution Control Board (2020) Guidelines for Handling, Treatment and Disposal of Waste Generated
during Treatment/Diagnosis/ Quarantine of COVID-19 P a t i e n t s . A v a i l a b l e from: 9501585568987.pdf. Cited Mar 20, 2020.

How to Cite this Article: Kumar S, Arora R, Kumar A, Vyas S, Kumar Shilpee, Arora P, Qureshi O A, Jameel J | Problems and solutions for orthopedic surgeons during COVID-19 pandemic. | Journal of Bone and Joint Diseases | May-Aug 2020;35(2): 53-61.

(Abstract)  (Full Text HTML)   (Download PDF)