INTRODUCTION

COVID- 19 pandemic has brought the need to revisit the conservative management of orthopaedic injuries back into sharp focus. Over the years as trauma and orthopaedics have evolved, operatives techniques have been developed, along with refinement of implants and instruments with an aim of transforming contemporary treatment of fractures to provide anatomical or near anatomical alignment of the fractures, stable fixation, with early pain free range of motion and rehabilitation.[1]. The current Coronavirus outbreak has refocussed orthopaedic minds on managing many injuries conservatively, which would have otherwise been managed with operative fixations. It is mainly because of the restraints put on by this viral infection, limited availability of resources including personnel and operating theatre slots (whilst they were redirected to manage urgent clinical priorities including respiratory emergencies due to COVID- 19 infections on the frontline) and due to reluctance of undertaking operative intervention in an atmosphere of increased risk of viral transmission, responsibility of protecting staff and ‘social distancing’ guidelines [2]. Traditional conservative treatment of fractures is based on three basic principles of fracture management; namely, reduction of fracture, holding the fracture reduced and keeping it reduced in a supported environment (such as a cast or splint) till the fracture heals. “Closed treatment of fractures” was very elaborately and scientifically described by Sir John Charnley is his monograph in 1950.[3]. The current pandemic situation has exposed us to the situation faced by Sir Robert Jones in the midst of chaos of World War- I, with limitations posed by the shortage of resources both personnel and equipment but the need to manage orthopaedic injuries in a safe manner whilst protecting patients including staff. Surgical specialties face unique challenges caused by COVID- 19[4]. For many urgent surgical procedures, additional steps are required to protect both patients and healthcare workers from the virus.5–7Articular and peri- articular fractures may provide a challenge, since principles of fracture fixation (anatomical reduction, rigid fixation, early range of joint motion) and avoidance of posttraumatic arthritis are not possible with conservative management in most of these injuries and hence operative measurements would be required at a later date.

Table 1: Suggested Indications and Contraindications for conservative management of Paediatric fractures and dislocations, during COVID-19 Pandemic.

Table 2: Suggested Indications and Contraindications for Conservative Management of fractures and dislocations in adults, during COVID-19 pandemic.

Table 1 and 2: It is obvious from this table that a majority of paediatric injuries can be adequately managed with conservative treatment.

Operative management is needed in articular and periarticular fractures most in the adult fractures.

However, there are certain absolute indication for the surgery of fractures and dislocation, even in the pandemic times (Table 2), which are also the contraindications for conservative management. The aim should be to minimise risk of viral transmission by avoiding Aerosol Generating Procedures (AGP) and minimising risk of infection with appropriate use of Personal Protective Equipment (PPE). These principles are critically engrained in our current orthopaedic response to the pandemic.

CONTRARY TO THE SITUATION AND EVIDENCE

Within orthopaedics, previous research has demonstrated that postponing major elective surgery, such as total joint arthroplasty or surgical non- union management, causes a considerable decrease in a patients’ quality of life [8- 11] A significant deterioration of patient quality of life may occur over the course of their pre- operative waiting period.[10,11] Globally, a vast number of patients are at risk of suffering major quality of life deterioration as a result of their elective surgery being postponed or cancelled. the current guidance on elective surgery during the COVID- 19 pandemic, assess how this guidance may impact orthopaedic care, to identify current elective surgery guidance globally as a result of the COVID- 19 pandemic within MEDLINE, EMBASE, Global Health and Emcare from the databases from inception until 6 April 2020.[12]

Elective surgery guidance

There were seven (63.6%) guidance reports that suggested a complete postponement of non- elective surgical procedures, whereas four (36.4%) reports suggested the use of selective postponement of these procedures. Throughout the month of March, elective surgery guidance became increasingly strong in its suggestions for completely postponing all elective surgery.

Figure 1 provides an overview of the cumulative number of guidance documents within these categories over time. The guidance for postponement of elective surgeries typically suggested that procedures should be rescheduled to a time after the COVID- 19 pandemic is over; however, it is unclear as to when this will be. Guidance from the British National Health Service (NHS) has suggested elective surgery will postponed until at least mid- July, as guidance suggested a 3 monthpostponement starting 15 April.[13,14]

Stronger recommendations against elective surgery throughout the month of Marchis highlighted by two guidance reports provided by the American College of Surgeons on 13 and 24 March 2020. Guidance on 13 March 2020 suggested to “reschedule elective surgeries as necessary”2 weeks later, guidance from the same organization strengthened their guidance to provide athree- phase plan, which ends in “phase III: to eliminate all elective practice”. This trend was seen across guidance groups. Table 3 provides a brief summary of each report’s guidance on elective surgery in light of the COVID- 19 pandemic.

Fig 1: Guidance documents for elective surgery postponement. Data presented as cumulative number of reports.

Table 3: Elective surgery guidance from health organization.

DISCUSSION

Based on the guidance documents included in this review, it is apparent that elective surgical practices are being postponed globally. Transitions from selective rescheduling to complete rescheduling of all elective patients has been occurring throughout the month of March. Major guidance groups such as the Centers for Disease Control and Prevention

(CDC), NHS, and WHO, have provided guidance on elective surgery, which has been disseminated by smaller organizations and local governments.[15]. The Royal Australasian College of Medicine suggested that “Non operative treatments will confer advantage over operative treatments if similar outcomes, or even slightly downgraded outcomes are expected”, as even slightly worse outcomes than what would be expected with surgery may still be a better option than providing no treatment at all.[16].

CONCLUSION

Global guidance from major medical associations are in agreement that elective surgical procedures require postponement in order to minimize the risk of COVID- 19 spread, as well as increase available hospital resources for managing the influx of COVID- 19 patients. For patients that have their elective surgery postponed, there is no clarity as to how long it will be before their elective surgeries will be rescheduled. It is imperative that clinicians and patients consider non- operative, conservative treatment options in order to manage conditions and symptoms until surgical management options become available again, and to manage the increased surgical waitlists caused by the elective surgery shutdowns.

REFERENCES

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