Archives of Bone and Joint Surgery
Year:2020 | Volume:8 | Issue:Supplement 1|Papers Count:24

Introduction 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...

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 their transmission, behaviors, clinical manifestations, and outcomes. There is no vaccine or therapeutic strategies to deal with these infections yet. In this situation, preventive measures may be promising. Hand hygiene is a very important issue in preventing viral infection; however, there are other entities that can enhance the immune response and help in infection prevention. Herein we review some measures for boosting the immune system.

Coronaviruses are a group of enveloped viruses with single-stranded non-segmented positive-sense RNA genomes. In December 2019, SARS-CoV-2 appeared in China for the first time and quickly spread throughout the world. Although certain medications suggested for other afflictions tend to be potentially effective for curing the infection, there is no approved vaccination or drug available for this virus yet. Comprehension of the disease molecular pathogenesis could provide useful tools for COVID-19 patients in surveillance, prognosis, treatment, vaccine development and therapeutic targeting. The present research aims to summarize the association in COVID-19 patients between molecular dimensions of comorbidities with clinical and preclinical information. Developing an ACE2 inhibitor could be a possible therapeutic target. Plasmin is another possible candidate both in diagnosis and treatment areas. All predicted biomarkers must be validated either through randomized clinical trials or experimental assays before clinical application in patients.

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 distancing protocols. Most non-essential medical practices have been halted to direct resources to the facilities caring for patients with COVID infection. The pediatric orthopaedic practice is in a unique position, with the treatment of many conditions being treated by pediatric orthopedists being non-emergent, but time-sensitive. We hereby review the current literature and guidelines surrounding the practice change around the world and give recommendations regarding the practice of pediatric orthopaedics during the COVID pandemic.

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 perspectives on 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 emergent orthopedic operations in our hospital, along with a number of residents and faculty participants in the morning reports and 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 operations was also decreased to almost zero in March 2020. Meanwhile, we managed to dismiss our residents and reduce the number of in-hospital morning reports and conferences. Instead, we designed virtual classes, and the number of participants in our virtual classes grew to almost two-third of the whole participant. We also managed to fortify our virtual office 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 referred trauma patients, elective, and trauma operations, along with educational activities, was reduced. There was also a significant concern about the management of elective, trauma, and post-operative patients in this era. Orthopedic faculty members needed to react to the current situation cautiously. We were able to manage the situation with consideration of our educational path, along with the management of personal protective equipment (PPE), and the use of communication technologies and specific protocols to overcome the obstacles mentioned above. Yet involved our staff and With orthopedic faculties active involvement at in-hospital activitie and establishment of hospital protocols considering technological facilities and WHO guidelines, we can improve education, management of PPE, and both orthopedic elective and trauma patients.

Workplaces are susceptible places for exposure to the new coronavirus (Covid-19) infection due to gathering of many people. Hence, different instructions have been promoted by international organizations regarding high-risk employees and the necessity of implementing health policies to prevent exposure and infection in the workplace. Here we reviewed the required strategies to prevent and control COVID-19 in the workplace. In conclusion, considering the fast spreading and growing prevalence of the new corona virus disease in the world over, all managers, employers, and business owners should receive the necessary information and training on prevention and control strategies based on scientific guidelines and standards.

Background: In this study, we aimed to assess the prevalence of comorbidities in the confirmed COVID-19 patients. This might help showing which comorbidity might pose the patients at risk of more severe symptoms. Methods: We searched all relevant databases on April 7th, 2020 using the keywords (“ novel coronavirus” OR COVID-19 OR SARS-CoV-2 OR Coronavirus) AND (comorbidities OR clinical characteristics OR epidemiologic*). We reviewed 33 papers’ full text out of 1053 papers. There were 32 papers from China and 1 from Taiwan. There was no language or study level limit. Prevalence of comorbidities including hypertension, diabetes mellitus, cardiovascular disease, chronic lung disease, chronic kidney disease, malignancies, cerebrovascular diseases, chronic liver disease and smoking were extracted to measure the pooled estimates. We used OpenMeta and used random-effect model to do a single arm meta-analysis. Results: The mean age of the diagnosed patients was 51 years. The male to female ratio was 55 to 45. The most prevalent 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%, cardiovascular disease 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. Conclusion: COVID-19 infection seems to be affecting every race, sex, age, irrespective of health status. The risk of symptomatic 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, except hypertension.

Background: COVID-19 epidemic rapidly spread all around the world with over 1500 thousand infected cases and 95000 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 population should be continued meanwhile. Health system should act immediately and wisely to support essential surgical care while fighting against COVID-19. Methods: We conducted a comprehensive search in the major data bases since 2020, using the combination of MeSH words of “ COVID-19 “ and “ surgery” and finally 34 full texts entered to data extraction phase to define a plan for surgical practice during COVID-19 pandemic. Results: Healthcare workers are at the higher risk of contamination by COVID-19 especially in early stage of outbreak when they were not aware of the different aspects of COVID-19 pandemic. All healthcare staff must be trained to properly use PPE. All patients have to be screened at the hospital triage. All elective surgical interventions must be postponed. Operation room is considered as a place with high risk of cross infection so the highest level of protection should be maintained. Anesthesia, endoscopy and oral surgery are considered as aerosol producing procedures with 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 estimated risk of morbidity and mortality. Conclusion: COVID-19 pandemic is a dynamic challenge for health system to save the healthcare staff and equipment resources by timely decisions. Healthcare workers are at the higher risk of contamination by COVID-19 especially in early phase of epidemic when the protection is sub-optimal.

Large-scale events such as COVID-19 show that there are situations that can lead to huge stress on health infrastructure systems (HIS). The pandemic reveals that it is very difficult to protect HIS from all kinds of possible hazards. Consider the trend of these types of viruses, such as N1H1, SARS and Ebola. These types of hazards could be more frequent and extreme in the future. They can be unpredictable and spread rapidly; hence, it is hard to find an effective mitigation strategy to completely protect society and its important HIS. Therefore, an often raised central question is what we should do if we cannot protect HIS from these types of hazards. To answer this question, the focus should move from HIS protection to HIS resilience. Our experience with COVID-19 has revealed that there is no general agreement on how HIS resilience should be measured, assessed and appropriately enhanced. This paper will discuss how the resilience concept will help decision-and policy-makers to have a clear view of HIS performance before, during and after the disaster. It employs an easy-to-use and applicable methodology for HIS assessment and evaluation. Thereafter, its application is illustrated by a real case study.

Background: COVID-19 was first identified in Iran in February 2020 and since then it spread rapidly through all over the country and soon after that it was reported as a pandemic. The current study presents a preliminary report of spine trauma management during COVID-19 pandemic. Methods: 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 along with the imaging findings from chest HRCT. Results: Seven patients with spine trauma including five males and two females ranging 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 were treated surgically among whom four were admitted to ICU soon after the surgery. The mean ICU stay for operated patients were eight days and the mean hospital stay was 22. 6 days. Conclusion: 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 to 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 hospitals in the capital city of Tehran, I. R. Iran that entered the crisis and started a serious battle with the disease. The hospital had to change many routine operations to cope with the situation and during this journey, we used previously leadership principles and reached to some new experiences. As this is probably the most severe health-related crisis in Iran in the past 100 years, we gathered our lessons learned in the first fifty days of epidemic from the leadership point of view to share those with all colleagues worldwide. We know that leadership is of pivotal role in such a massive crisis and focused leadership experiences can help health care providers to manage the crisis while we are in the middle of it.

To reduce the risk of spread of the novel coronavirus (COVID-19), the emerging protocols are advising for less physicianpatient contact, shortening the contact time, and keeping a safe distance. It is recommended that unnecessary casting be 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 a conventional plaster cast is amenable to self-removal by submerging in water and cutting the cotton bandages with scissors. At present, only fiberglass casts are widely available to allow waterproof casting. To reduce the contact time during casting, a custom-made 3D printed casts/splints can be ordered remotely which reduces the number of visits and shortens the contact time while it allows for self-removal by the patient. The cast is printed after the limb is 3D scanned in 5-10 seconds using the commercially available 3D scanners. In contrast to the conventional casting, a 3D printed cast/splint is washable which is an advantage during an infectious crisis such as the COVID-19 pandemic.

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

The severe acute respiratory syndrome caused by COVID-19 is now a global catastrophic event. Currently there is no approved drug or vaccine for the disease. Methylene blue (MB, oxidized form, blue color) has been used in many different areas of clinical medicine, ranging from malaria to orthopedics. Leucomethylene Blue (reduced form of MB, colorless) may be applied for the treatment of COVID-19 according to the scientific evidences. In severe patients, there is a cytokine storm (hyperinflammation) and high oxidative stress (OS). Inflammation and OS has a 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 decreases OS through other mechanisms. Reduced MB could prevent inflammation, propagation of the virus RNA, and also improves hypoxia through reducing methemoglobin. Therefore, to avoid the increment of OS, we suggest using Leucomethylene 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 gr urea (optional) in 100 ml dextrose 5%. Before the injection, the cocktail should be kept in a dark place for 1-2 hour to become fade or colorless.

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 obviously affected. To respond properly, we initiated a series of strategic measures, aiming at the safety of staff, minimizing the exposure, and prevention of possible disruption in providing services.

The novel coronavirus-induced infection (COVID-19) was declared a pandemic by the World Health Organization on March 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 in Badrud, Isfahan, Iran, from March 1, 2010, to March 30, 2020. All patients were elderly and had fracture induced by fall from standing height. All patients (n=3) were admitted with fragility hip fracture due to low energy trauma. The most common symptoms were weakness and fatigue. Positive C-reactive protein (CRP) and Leukopenia were the most common abnormal laboratory evaluations. According to the results, two patients underwent surgical treatment, and one patient had negative reverse transcription-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 be induced by fatigue and weakness due to COVID-19 disease. COVOID-19 infection should be considered in elderly patients with fragility hip fracture during the coronavirus pandemic.

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

Dear Editor It is almost 3 months since the report of the first case in China and 1. 5 months since the report of the first case in Qom, the epicenter of Iran. The very first reports were assuring about its mortality rate, even lower than 0. 1% in common influenza, which was then proven otherwise after it started spreading in South Korea, Iran, and Italy with mortality rates of as high as 10% (1). The Ministry of Health in Iran took unprecedented actions and escalated infection control almost 3 weeks after detection of coronavirus spread by suspending all elective surgeries throughout the country and designating specific hospitals for caring COVID-19 patients to separate infected people. Among these, the university-based hospital and the orthopedic department was also shut down and emptied to admit the high volume of patients with COVID-19, and suddenly all floors turned to COVID floors. Considering exponential rise in the number of patients, we, the orthopedic surgeons, became part of the same team and we were also assigned to daily visit the admitted COVID-19 patients in our own ward to reduce the burden on pulmonologists, anesthesiologists, and infectious disease specialists. Moreover, orthopedic residents were urged to take some Emergency Medicine calls to screen the pulmonary patients at the frontline...

Dear Editor Telemedicine is a platform of health care delivery involving the use of electronic communication to provide patients with access to health information (1). This includes access to medical staff or to personal or informative health care information. Multiple methods of telemedicine delivery may be employed, including videoconferencing, phone communication, web-based patient portals, text-messaging, and smartphone applications (1, 2). Global crises, including the current Coronavirus pandemic, limit our ability to provide medical care, requiring an alternative means of health care delivery. Though concerns exist regarding the safety and efficacy of telemedicine, its utility in upper extremity orthopedic surgery has been proven (3, 4). Remote management of upper extremity pathology is possible with the use of telemedicine, allowing surgeons to provide care when access is limited. The purpose of this review is to discuss the applications of telemedicine visits (TV) specific to hand and upper extremity surgery...

Dear Editor The elective surgeries have been canceled during the COVID-19 crisis, however, would previous patients’ problems hold their need for specific treatment and rehabilitation? Also, could trauma and emergent conditions stop happening? We could not ignore our main purpose to decline disabilities of all patients meanwhile we are managing the worldwide life crisis of COVID-19. When it comes to the upper limb diseases and trauma, rehabilitation is an essential part of the management, therefore, postponement of process could have irreversible disabilities (e. g. joint stiffness, muscle atrophy and pain syndromes). So, concomitant of respecting to preventive principles of this challenging contagious disease, we need to continue the rehabilitation process differently. Social media has a special power to assist rehabilitation team now; telerehabilitation is a rational strategy to stop contacts when the rehabilitation and its monitoring need to go on. Even when the special conditions do not allow remote approaches, parallel to respecting to personal precaution principles, some technical and administrative solutions still exist. We aim to discuss different possibilities to continue rehabilitation of upper extremity in the era of pandemic COVID-19 condition...

Dear Editor We are facing a public health emergency in relation to coronavirus disease 2019 (COVID-19). Efforts to limit the outbreak show that social distancing by means of limitations in public transportation, restrictions in travel, and closing workplaces as well as mass masking can be successful, at least temporarily. It seems that outpatient and even inpatient rehabilitation schedules should be reevaluated in this status. So, how does this situation affects physiotherapists? Logically, if the exposure risk to COVID-19 for patients and physiotherapy staffs are high, they cannot provide in-patient services furthermore, as a fact, many major health conditions, especially in the field of orthopedics, need prehabilitaion and rehabilitation to improve the outcomes. Now there is an important question. How should physicians approach patients in this situation? Home-based rehabilitation and telerehabilitation may hold the answer, although it is still possible to provide care for out-patient, inpatient, skilled nurse care (SNC) with a limited number of patients...

Dear Editor 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. Within less than 4 months on April 4, 2020, more than 1, 100, 000 people have been infected and the death rate passed 63, 000 (5. 7%) throughout the world. The disease is highly contagious and is thought to spread via direct contact or inhalation of respiratory droplets. Asymptomatic and presymptomatic carriers are substantial sources of transmitting the virus. After China, Europe, United States, Iran and South Korea are among the most infected areas, while malaria-endemic regions in Africa and South Asia have reported only few cases of COVID-19 so far. Given the infectious potential of the disease and the shortage of preventive facilities in low income countries, one recent article has warned about the unfortunate likelihood of a continental outbreak of COVID-19 in these countries...

Dear Editor The health care system is located in the center of pressure of the COVID-19 burden. Prevention of this pandemic has changed medical education to shut down classes or many routines for which gathering of educational elements in close environments is essential (1, 2). Hospitals, as the main place of clinical education, are now the source for COVID-19 patients or at least asymptomatic carriers (staff and patients) of its highly communicable virus (3, 4). To reduce humanhuman and human-surface contacts, we should change our education policies concerning the medical students, interns, residents, fellows, faculty members, and administrative staff. During COVID-19 crisis in Tehran, Shariati Hospital and orthopedic ward have been the referral center of trauma patients among three Tehran University Orthopedic wards. Obviously symptomatic and asymptomatic patients were admitted. The educational team members may also be asymptomatic carriers. The routine weekly educational program of our orthopedic ward used to include one-hour morning report, five days a week; group discussion for fellows and residents; every day bedside resident rounds; 6-days bedside round run by a junior or senior faculty member; outpatient clinics; and inpatient educational rounds for medical students and interns...