Telemedicine in the Era of COVID-19: The Virtual Orthopaedic Examination

How Are Orthopaedic Sports Medicine Physicians Triaging Cases and Using Telehealth in Response to COVID-19? A Survey of AOSSM Membership

BACKGROUND

The COVID-19 pandemic has changed the practice of orthopaedic sports medicine. The threat of COVID-19 persists, and future restrictions to elective procedures are possible. It is important to understand how sports surgeons are prioritizing surgical cases during elective case restrictions and how telehealth is being incorporated into practice.

PURPOSE

To understand how orthopaedic sports surgeons have triaged surgical sports cases and how telehealth is being utilized in response to COVID-19.

STUDY DESIGN

Cross-sectional study.

METHODS

A survey was presented to participants of the American Orthopaedic Society for Sports Medicine (AOSSM) webinar "Handling Sports and COVID-19" and distributed through email to all members of the AOSSM. The survey consisted of 25 questions with 3 sections: demographics, clinical practice, and telehealth. Descriptive statistics were performed.

RESULTS

Overall, 104 respondents participated. Respondents varied with respect to their location, type of clinical practice, and years in practice. The cases with the highest priority during triage included infections, fractures, and traumatic tendon ruptures (eg, quadriceps tendon). Before COVID-19, <14.0% of surgeons used telehealth, and 76.7% had never used telehealth. Now, however, 81.4% of respondents plan to use telehealth at least once a week in their practice. Respondents indicated postoperative visits and return patients as the most appropriate for telehealth. The majority felt that telehealth was not appropriate for new shoulder (65.9%) or knee (55.6%) evaluation. The leading barriers to telehealth use that were identified included, in decreasing order, concerns about clinical appropriateness, accuracy of physical examination, billing/reimbursement, and medicolegal concerns.

CONCLUSION

Telehealth has seen rapid adoption during the COVID-19 pandemic, and the majority of respondents plan to continue using it. It is being used more for established patients rather than new patient visits. For surgical cases, there was a clear triage priority of sports medicine cases, including infections, fractures, and traumatic tendon ruptures. Lower extremity cases had higher priority than upper extremity.

Telemedicine for Musculoskeletal Rehabilitation and Orthopedic Postoperative Rehabilitation

Telehealth visits result in high-quality care, with high patient and provider satisfaction. Strong evidence suggests that virtual physical therapy is noninferior to conventional face-to-face physical therapy for a variety of musculoskeletal disorders. Postoperative telerehabilitation has a strong positive effect on clinical outcomes, and the increased intensity telerehabilitation programs offer is a promising option for patients. Studies demonstrate effective virtual postoperative management. The novel coronavirus disease 2019 pandemic has led to improved reimbursement for telehealth visits and accelerated widespread implementation of telemedicine. This article establishes experience and evidence-based practice guidelines for conducting telemedicine visits, with emphasis on the virtual physical examination.

Rapid Transition to Virtual Care during the COVID-19 Epidemic: Experience of a Supportive Care Clinic at a Tertiary Care Cancer Center

Background: COVID-19 pandemic necessitated rapid adoption of telemedicine at our supportive care center (SCC) to ensure continuity of care while maintaining social distancing. Objective: To document the process of transition from in-person to virtual care. Design: The charts of 1744 consecutive patients in our SCC located in the United States were retrospectively reviewed during the four weeks before transition (February 14-March 12), four weeks after transition (March 20-April 16), and transition week (March 13-March 19). Patient demographics, vital aspects of a supportive care visit such as assessments (Edmonton Symptom Assessment Scale-Financial and Spiritual [ESAS-FS], Cut-down, Annoyed, Guilty, Eye-opener Screen-Adapted to Include Drugs [CAGE-AID], and Memorial Delirium Assessment Scale [MDAS]), interdisciplinary team involvement, and visit type were recorded. Results: In total 763 patients were seen before transition, 168 during the transition week, and 813 after transitioning to virtual care. Patient characteristics, ESAS-FS, CAGE-AID, and nurse assessment did not significantly differ among the three groups. The after-transition group had a small reduction in counseling intervention compared with before (20.2% vs. 26.2%; p = 0.0068). MDAS completion was higher after transition (99.6% vs. 98%; p = 0.007). In-person visits decreased from 100% before to 12.7% after transition (p < 0.0001) and virtual visits increased to 49.3% (video) and 38% (telephone). In-person visits decreased to 49% in the week one, 3% in week two, and <2% in week four after transition (p < 0.0001). Conclusions: Our supportive care team transitioned from in-person care to virtual visits within weeks while maintaining a high patient volume, continuity of care, and adherence to social distancing. Our transition can serve as a model for other centers.

Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm

The telehealth revolution in response to COVID-19 has increased essential health care access during an unprecedented public health crisis. However, virtual patient care can also limit the patient-provider relationship, quality of examination, efficiency of health care delivery, and overall quality of care. As we witness the most rapidly adopted medical trend in modern history, clinicians are beginning to comprehend the many possibilities of telehealth, but its limitations also need to be understood. As outcomes are studied and federal regulations reconsidered, it is important to be precise in the virtual patient encounter approach. Herein, we offer some simple guidelines that could assist health care providers and clinic schedulers in determining the appropriateness of a telehealth visit by considering visit types, patient characteristics, and chief complaint or disease states.

Perspective of Attending Physicians on the Use of Telemedicine in an Outpatient Arthroplasty Setting During the COVID-19 Pandemic

Background: During the worldwide COVID-19 pandemic, physicians had to improvise and adapt new ways to provide care to patients. Purposes: The purpose of this study was to assess physicians' sentiments regarding telemedicine and its use in orthopedic practices. Methods: We performed a cross-sectional study of attending orthopedic physicians, the majority of whom integrated telemedicine into their practices from March to October 2020. A survey was sent to 517 physicians who had registered for an orthopedics conference. The survey included questions pertaining to various factors regarding telemedicine and each physician's practice. Results: Of the 517 physicians who received the survey, 328 responded, for a 63.4% response rate. Of the 328 respondents, 84.1% did not use telemedicine in their practice prior to the COVID-19 pandemic. Even during the pandemic, the physicians most commonly responded that less than 5% of their practice was conducted by telemedicine (n = 103, 31.4%). The second most common response was that more than 20% of visits were done via telemedicine (n = 72, 22.0%); 43.0% of physicians noted that they would not use telemedicine technology in their practice after the pandemic, but 59.1% of physicians would be willing to do annual visits by telemedicine. Ability to examine the patient (2.0 ± 1.0) was rated worse, overall, than either the experience using the technology (3.2 ± 1.0) or the capacity to communicate with the patient (3.6 ± 1.0). Conclusions: Our survey of orthopedic surgeons demonstrates that while the use of telemedicine technology was minimal prior to the pandemic, its use was widely adopted during the pandemic. Nearly half of physicians said that they will continue to use telemedicine.

An Overview of Telehealth in Total Joint Arthroplasty

With the increase in technological advances over the years, telehealth services in orthopedic surgery have gained in popularity, yet adoption among surgeons has been slow. With the onset of the COVID-19 pandemic, however, orthopedic surgery practices nationwide have accelerated adaptation to telemedicine. Telehealth can be effectively applied to total joint arthroplasty, with the ability to perform preoperative consultations, postoperative follow-up, and telerehabilitation in a virtual, remote manner with similar outcomes to in-person visits. New technologies that have emerged, such as virtual goniometers, wearable sensors, and app-based patient questionnaires, have improved clinicians' ability to conduct telehealth visits. Benefits of using telehealth include high patient satisfaction, cost-savings, increased access to care, and more efficiency. Notably, some challenges still exist, including widespread accessibility and adaptation of new technologies, inability to conduct an in-person orthopedic physical examination, and regulatory barriers, such as insurance reimbursement, increased medicolegal risk, and privacy and confidentiality concerns. Despite these hurdles, telehealth is here to stay and can be successfully incorporated in any total joint arthroplasty practice with the appropriate adjustments.

The Role of Telehealth in Sideline Management of Sports-Related Injuries

The COVID-19 pandemic has affected the ability of the sports medicine physician to be present to participate in in-person sideline evaluation of the injured athlete. The purpose of this review is to assess existing literature regarding the utilization of telehealth for sideline evaluation and management of the injured athlete, as well as to identify further areas of research. With the rapid incorporation of telehealth visits, the utilization and capabilities of telemedicine continue to expand. A number of evidence-based resources are available to support medical providers to develop and utilize video evaluation for the sideline evaluation of sports-related injuries. Future research, including the development of validated, modified examination techniques and technologies, will allow for improved interactive physical examinations, which may be better utilized for sideline evaluation.

Telemedicine in an Outpatient Arthroplasty Setting During the COVID-19 Pandemic: Early Lessons from New York City

Background: The early months of the coronavirus disease 19 (COVID-19) pandemic in New York City led to a rapid transition of non-essential in-person health care, including outpatient arthroplasty visits, to a telemedicine context. Questions/Purposes: Based on our initial experiences with telemedicine in an outpatient arthroplasty setting, we sought to determine early lessons learned that may be applicable to other providers adopting or expanding telemedicine services. Methods: A cross-sectional study was performed by surveying all patients undergoing telemedicine visits with 8 arthroplasty surgeons at 1 orthopedic specialty hospital in New York City from April 8 to May 19, 2020. Descriptive statistics were used to analyze demographic data, satisfaction with the telemedicine visit, and positive and negative takeaways. Results: In all, 164 patients completed the survey. The most common reasons for the telemedicine visit were short-term (less than 6 months), postoperative appointment (n = 88; 54%), and new patient consultation (n = 32; 20%). A total of 84 patients (51%) noted a reduction in expenses versus standard outpatient care. Several positive themes emerged from patient feedback, including less anxiety and stress related to traveling (n = 82; 50%), feeling more at ease in a familiar environment (n = 54; 33%), and the ability to assess postoperative home environment (n = 13; 8%). However, patients also expressed concerns about the difficulty addressing symptoms in the absence of an in-person examination (n = 28; 17%), a decreased sense of interpersonal connection with the physician (n = 20; 12%), and technical difficulties (n = 14; 9%). Conclusions: Patients were satisfied with their telemedicine experience during the COVID-19 pandemic; however, we identified several areas amenable to improvement. Further study is warranted.

Telehealth Can Be Implemented Across a Musculoskeletal Service Line Without Compromising Patient Satisfaction

Background: The COVID-19 pandemic has led to changes to in-office orthopedic care, with a rapid shift to telemedicine. Institutions' lack of established infrastructure for these types of visits has posed challenges requiring attention to confidentiality, safety, and patient satisfaction. Purpose: The aim of this study was to analyze the feasibility of telemedicine in orthopedics during the pandemic and its effect on efficiency and patient satisfaction. Methods: Patients seen by the Emory University Department of Orthopaedics Sports Medicine and Upper Extremity Divisions via telemedicine from March 23 to April 24, 2020, were contacted by telephone. Each patient was asked to respond to questions on satisfaction, ease of use, and potential future use; satisfaction with telemedicine and previous clinical visits were measured using a modified 5-point Likert scale. Results: Of the 762 patients seen, 346 (45.4%) completed the telemedicine questionnaire. Satisfaction varied by visit type, with average scores of 4.88/5 for in-office clinic visits versus 4.61/5 for telemedicine visits. There was no significant difference among age groups for satisfaction ratings. Patients 65 years old or older reported significantly longer visit times and decreased ease of use with the telemedicine platform. Conclusion: Telemedicine in a large orthopedics department was successfully implemented without compromising patient satisfaction. The use of telemedicine allows many patients to be seen quickly and efficiently without diminishing their musculoskeletal clinical experience.

The result of the use of remote consultation in orthopaedic and trauma surgery during the COVID-19 pandemic

The COVID pandemic has made telematic consultations a basic tool in daily practice.

Aims

The main objective of the study is to assess the results of the application of telematic consultations to limit the mobility of patients.

The operational objectives are; to propose a consultation plan, to know how attendance limits consultations and to define which pathologies benefit the most from this plan.

Methods

A scheme is proposed with the creation of pre-scheduled clinic to assess suitability and the possibility of carrying them out in a single non face-to-face act.

Results

Phone call to 5619 patients were made with a lack of response of 19%

The cases of 74% of the patients that answered were resolved virtually. There is a difference between units, obtaining a higher answering rate from patients appointed to specific clinic units, OR = 0.60, or to general trauma ones, OR = 0.67. The lowest answering rate was obtained from those derived from the emergency department.

Twenty per cent of the consultations were not accompanied by complementary tests that would have favored the resolution in a single act. The general trauma consultations, OR = 0.34, postoperative control, OR = 0.49, and specific unit ones, OR = 0.40, were the ones that better met this requirement.

Out of the remaining patients, the general trauma consultations, OR = 0.50, and those referred to units, OR = 0.54, were the ones that had a higher resolution rate without in- person consultation.

Conclusions

The cases of 74% of the patients who answered the phone call were resolved virtually.

Cases of 20% of the patients cannot be solved in a single act because they are derived without complementary tests.

Osteosynthesis and postoperative arthroscopic follow-up consultations are the ones that need to be carried out in person the most.

Telemedicine in research and training: spine surgeon perspectives and practices worldwide

Purpose

To utilize a global survey to elucidate spine surgeons’ perspectives towards research and resident education within telemedicine.

Methods

A cross-sectional, anonymous email survey was circulated to the members of AO Spine, an international organization consisting of spine surgeons from around the world. Questions were selected and revised using a Delphi approach. A major portion of the final survey queried participants on experiences with telemedicine in training, the utility of telemedicine for research, and the efficacy of telemedicine as a teaching tool. Responses were compared by region.

Results

A total of 485 surgeons completed the survey between May 15, 2020 and May 31, 2020. Though most work regularly with trainees (83.3%) and 81.8% agreed that telemedicine should be incorporated into clinical education, 61.7% of respondents stated that trainees are not present during telemedicine visits. With regards to the types of clinical education that telemedicine could provide, only 33.9% of respondents agreed that interpretation of physical exam maneuvers can be taught (mean score = − 0.28, SD =  ± 1.13). The most frequent research tasks performed over telehealth were follow-up of imaging (28.7%) and study group meetings (26.6%). Of all survey responses provided by members, there were no regional differences (p > 0.05 for all comparisons).

Conclusions

Our study of spine surgeons worldwide noted high agreement among specialists for the implantation of telemedicine in trainee curricula, underscoring the global acceptance of this medium for patient management going forward. A greater emphasis towards trainee participation as well as establishing best practices in telemedicine are essential to equip future spine specialists with the necessary skills for navigating this emerging platform.

Supplementary Information

The online version contains supplementary material available at (10.1007/s00586-020-06716-w).

Examining the Hand in the Video Consultation

BACKGROUND

Video consultations could support patient care in hand surgery during social distancing in the COVID-19 era. According to the literature, images of hand and fingers can support telediagnosis in hand emergencies. We present this feasibility study on online video consultation in hand surgery.

METHODS

A structured examination was designed to query the medical history and examine motor skills, sensitivity, strength and function tests of the hand. Thirty examinations on both hands were carried out by online video consultation, then in direct contact and compared with each other.

RESULTS

With 4560 evaluated range of movement of the hand and finger joints, there was a high correlation between the measurement methods of R = 0.995 (p < 0.0001, confidence interval 0.9946 - 0.9954). In the video-based examination, 84.6% of the measured values showed a deviation of less than 5° compared to the direct examination, 92.8% less than 10° deviation. Good accordance was also found in the patient's medical history. An estimating examination of sensitivity, function and strength during video examination is feasible with simple auxiliary aids. Deficits are evident in the detection of scars, in function tests and the absence of haptic findings.

CONCLUSION

Online video consultation allows hand examination with sufficient documentation of hand and finger movements (range of motion) and proper evaluation of symptoms. It cannot replace direct examination but complement patient care in hand surgery even beyond the current COVID-19 pandemic.

Remote Musculoskeletal Assessment Framework: A Guide for Primary Care

Introduction

Remote consulting has exploded into primary care following the initial COVID-19 surge as a measure to reduce potential cross-infection (staff-patient or patient-patient). Musculoskeletal (MSK) conditions comprise up to 21% of the annual primary care caseload in England. Established techniques for MSK examination, however, rely on face-to-face attendance. Evidence-based guidance for remote MSK assessment is required to ensure the quality of care is maintained with the move from face-to-face to virtual consultations.

Method

A literature review of published evidence and current guidelines was conducted. The most appropriate remote consultation techniques and MSK examinations were identified and where there was no evidence, modified examination tests were developed from established face-to-face examination techniques. A concise, accessible framework for remote MSK assessment in primary care was then created and tested on a non-medically trained volunteer.

Results

Over 2232 papers and articles were identified by search headings, reducing to 28 sources that had relevant content. At the time of searching, there was no published evidence relating to MSK remote consultation in a primary care setting. However, evidence was found in the physiotherapy and rehabilitation literature for the efficacy and practicality of MSK teleconsultation.

MSK remote examination framework

From this literature and with the addition of modified established examinations, an MSK assessment framework was constructed. This framework provides pre-consultation guidance and step-by-step remote examination instructions. Patient and clinician resources (including a patient information leaflet and photographic examples of examinations) were created as supplementary material.

Conclusion

Due to the frameshift away from face-to-face consultation, primary care clinicians have found themselves lacking an evidence base or practical guidance to support remote MSK assessment. This paper is a systematic literature review of MSK telemedicine from which practical advice and evidence-based MSK tests have been developed. Where there is no evidence, modified traditional tests are suggested to allow a complete framework for remote MSK examination - using a system approach of ‘look, point, move’ followed by modified special tests, for use in a primary care setting as a ‘ready-to-use’ practical guide to remote MSK assessment, presented in a downloadable format.

What did this add?

With 21% of primary care consultations relating to MSK conditions and limited means of performing face-to-face MSK examination due to COVID-19, there needs to be a recognised framework for assessing the MSK system remotely. To the best of our knowledge, this evidence does not exist for primary care remote MSK examination. This paper demonstrates evidence-based practical advice (from non-primary care settings) and modified MSK examinations to be used in a primary care MSK remote consultation.

COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study

PURPOSE

The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery.

METHODS

A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020.

RESULTS

902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication.

CONCLUSION

COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.

Spine surgeon perceptions of the challenges and benefits of telemedicine: an international study

Introduction

While telemedicine usage has increased due to the COVID-19 pandemic, there remains little consensus about how spine surgeons perceive virtual care. The purpose of this study was to explore international perspectives of spine providers on the challenges and benefits of telemedicine.

Methods

Responses from 485 members of AO Spine were analyzed, covering provider perceptions of the challenges and benefits of telemedicine. All questions were optional, and blank responses were excluded from analysis.

Results

The leading challenges reported by surgeons were decreased ability to perform physical examinations (38.6%), possible increased medicolegal exposure (19.3%), and lack of reimbursement parity compared to traditional visits (15.5%). Fewer than 9.0% of respondents experienced technological issues. On average, respondents agreed that telemedicine increases access to care for rural/long-distance patients, provides societal cost savings, and increases patient convenience. Responses were mixed about whether telemedicine leads to greater patient satisfaction. North Americans experienced the most challenges, but also thought telemedicine carried the most benefits, whereas Africans reported the fewest challenges and benefits. Age did not affect responses.

Conclusion

Spine surgeons are supportive of the benefits of telemedicine, and only a small minority experienced technical issues. The decreased ability to perform the physical examination was the top challenge and remains a major obstacle to virtual care for spine surgeons around the world, although interestingly, 61.4% of providers did not acknowledge this to be a major challenge. Significant groundwork in optimizing remote physical examination maneuvers and achieving legal and reimbursement clarity is necessary for widespread implementation.

Telemedicine for patients with rheumatic and musculoskeletal diseases during the COVID-19 pandemic; a positive experience in the Netherlands

To describe the delivery of care for patients with rheumatic and musculoskeletal diseases (RMDs) from the perspective of rheumatologists in the Netherlands during the first months of the COVID-19 pandemic. A mixed methods design was used with quantitative and qualitative data from a cross-sectional survey sent to all members of the Dutch Rheumatology Society in May 2020. The survey contained questions on demographics, the current way of care delivery, and also on usage, acceptance, facilitators and barriers of telemedicine. Quantitative data were analyzed descriptively. The answers to the open questions were categorized into themes. Seventy-five respondents completed the survey. During the COVID-19 pandemic, continuity of care was guaranteed through telephone and video consultations by 99% and 9% of the respondents, respectively. More than 80% of the total number of outpatient visits were performed exclusively via telephone with in-person visits only on indication. One-quarter of the respondents used patient reported outcomes to guide telephone consultations. The top three facilitators for telemedicine were less travel time for patients, ease of use of the system and shorter waiting period for patients. The top three barriers were impossibility to perform physical examination, difficulty estimating how the patient is doing and difficulty in reaching patients. During the COVID-19 epidemic, care for patients with RMDs in the Netherlands continued uninterrupted by the aid of telemedicine. On average, respondents were content with current solutions, although some felt insecure mainly because of the inability to perform physical examination and missing nonverbal communication with their patients.

Telemedicine Utilization by Orthopedic Patients During COVID-19 Pandemic: Demographic and Socioeconomic Analysis

Background: The relaxation of telemedicine (TM) restrictions during the COVID-19 pandemic accelerated adoption of this technology by many orthopedic practices. The purpose of this study was to examine the demographics of the orthopedic patients who utilized TM visits during the COVID-19 pandemic to identify opportunities to improve access. Methods: All patients who underwent orthopedic TM visits at one urban academic medical center between January and April 2020 were included. Demographic data including primary zip code, primary language, and visit type were collected. The demographics of the TM cohort were compared with those of patients seen in the outpatient (OP) setting at the same institution the prior year as well as with patients in the metropolitan area (M). Results: Five thousand thirty-five TM visits met the inclusion criteria. The TM cohort was significantly younger than the OP cohort, with mean age of 48.7 ± 19.0 years for TM and 55.2 ± 18.0 years for OP, and with 22% of TM being 65 or older versus 35% of OP being 65 or older (p  = 0.001). The TM cohort had a lower percentage of minority patients (41.3%) than the OP cohort (48.2%). The TM cohort had a significantly lower percentage of black 12.9% versus 14.1%, Asian. 5.1% versus 5.8%, and Spanish/Hispanic 1.9% versus 15.4%, than the M and the OP cohort from the prior year (p < 0.026, p < 0.001, p < 0.001). For socioeconomic status, only 13.8% of TM patients were from ZIP codes with median household incomes <50k. A total of 96.2% of TM visits were performed in English, where only 61% of individuals in the metropolitan area report English as their primary language. Conclusions: As the largest analysis of the use of TM in orthopedics, this study highlights both the future potential of TM and areas of improvement to ensure better access to care for all patient populations. Maintenance of the provisions to allow audio-only visits to be considered TM and billed as such is one important measure.

Clinical Analysis of Causes and Countermeasures of Hand Injury During the COVID-19 Outbreak and Work Resumption Period: A Retrospective Study in a Designated Hospital in China

A total of 95 patients with hand injuries were admitted to the orthopedics department within half a year of the COVID-19 outbreak. Data were collected between January 23, 2020 and July 23, 2020. Data such as patients' demographics, type of injury, location, side of lesions, mechanism of injury, injury site, and surgical management were collected and subsequently analyzed. On the one hand, the total number of emergency visits due to hand injury during the COVID-19 outbreak decreased by 37%, compared to the same period in the previous year. On the other hand, work resumption injuries increased by 40%. Injuries within the resumption period occurred predominantly at work (64.7%) and were significantly higher than the same period in 2019 (37.3%) (P < .001). Machine-related injuries were the most frequent injuries seen in our hospital (58.8%). The majority of cases were from cut injuries (82.4%), with fingers being the most common site of these injuries. Simple fractures and dislocations were also reported during the study. Most injuries were classified as either minor or moderate (90%) during the outbreak. However, during the resumption of work, major injuries were more prevalent (40%). The proportion of major injuries this year's work resumption stage (40%) has almost doubled compared to the previous year (21.8%, P = .006). The resumption of work following the COVID-19 outbreak is a time of high-risk for hand injuries. The overall number of patients with hand injuries admitted into our department has decreased compared to the corresponding period last year. However, workplace injuries, particularly machine-related ones, considerably increased during the first six months after the COVID-19 outbreak. As a result, the proportion of major injuries drastically increased. Emergency and surgical health care providers should be aware of this pattern of hand injuries during this untypical time in order to effectively prepare and plan services.

Telemedicine Foot and Ankle Visits in the COVID-19 Era

Background:

The COVID-19 pandemic created a difficult environment to provide musculoskeletal care to patients with foot and ankle pathology given the limitations placed on in-office visits. Telemedicine offered a unique avenue to reach these patients; however, the efficacy of telemedicine visits in patients with foot and ankle pathology is not well studied. We propose a telemedicine protocol that has allowed us to effectively see and treat patients with foot and ankle pathology.

Methods:

A 12-step standardized telemedicine protocol was created within the Foot and Ankle division that was used for seeing patients through telemedicine. Also included in this is previsit preparation and follow-up recommendations. Press Ganey surveys were retrospectively reviewed to understand patient experience with telemedicine.

Results:

85.2% of patients surveyed responded with scores indicating excellent care. When comparing patients who were seen in-office and through telemedicine, 89.2% and 83.4% responded with scores indicating excellent care, respectively (P = .37).

Conclusion:

Telemedicine offers an effective and convenient way to provide excellent musculoskeletal care to patients affected with foot and ankle pathology. This is the first study that evaluated a comprehensive protocol for telemedicine encounters and can be used to implement telemedicine by others using this approach.

Level of Evidence:

Level V, expert opinion.

Perspectives on the Impact of the COVID-19 Pandemic on the Sports Medicine Surgeon: Implications for Current and Future Care

As the COVID-19 (Coronavirus disease 2019) pandemic continues, the paradigm of treatment continues to rapidly evolve, especially for sports medicine surgeons, because treatment before the pandemic was considered predominantly elective. This article provides subjective and objective data on the changes implicated by the COVID-19 pandemic with regard to the interactions and practices of sports medicine surgeons. This perspective also considers the potential impact on the patients and athletes treated by sports medicine surgeons. This article discusses the impact of the COVID-19 pandemic on sports medicine and provides thoughts on how the landscape of the field may continue to change.

Making sense of the infodemic – A bibliometric analysis of publications on COVID-19 in trauma and orthopedics

The COVID-19 pandemic has prompted an explosion of publications to report, understand, further research, and manage this condition. While publications are analyzing the bibliometrics on this condition, there are none available specifically for the impact of COVID-19 on trauma and orthopedics. The aim of this study, therefore, was to perform a bibliometric analysis on COVID-19 and trauma and orthopedics to assess its impact on the specialty. A search for articles on COVID-19 concerning trauma and orthopedics, with the keywords: “COVID-19, New coronavirus, SARS-Cov-2, Orthopedic*, trauma, bone, and joint” were performed on the June 19, 2020, using SCOPUS and PUBMED and this resulted in 272 and 887 articles, respectively. Later, on the same day, we searched for orthopedic journals exclusively and extracted 258 articles from 58 journals. Furthermore, we analyzed the Altmetric data through the dimensions website to find the most popular articles on social media on this topic. After analyzing the data, we found that review articles were the most commonly published articles. The leading journal publishing this content were; The Journal of Bone and Joint Surgery (JBJS) American (35), followed by the Journal of Arthroplasty (22). There were 6936 authors involved in publishing 887 articles in 2020. Most articles were published by Vaishya (5) followed by Liang (5), and Iyengar (5). Analysis of Altmetric data showed a total number of citations of 5000 with a mean of 1.98. MedRxiv with 781 publications and 1616 citations was the preprint server with the most publications on dimensions. We studied details of the article with maximum AAS score of 25226 is with 840 citations. We have listed useful protocols from the search and top five cited articles from each search strategy. Publications on COVID-19 commenced from the 9th week of this year and have increased exponentially. Review articles (PubMed) and articles (Scopus) were the most published. The JBJS (Am) and J Arthroplasty have published the maximum number of articles on COVID-19. We found that for a fast evolving condition and for the short term, altmetrics may be better indicators than citations to follow directions of research. Publications with a low number of citations could have immense social media attention. This study should help in quantifying the value of research and publications related to orthopedics and trauma aspects of COVID-19 and therefore help the readers, researchers, and health-care providers to use this information effectively.

Evaluation of the Feasibility of a Telemedical Examination of the Hip and Pelvis - Early Lessons from the COVID-19 Pandemic

Introduction Due to the current COVID-19 pandemic, the German Health Ministry has issued restrictions applying to the field of orthopaedics and trauma surgery. Besides postponement of elective surgeries, outpatient consultations have been drastically reduced. Parallel to these developments, an increase in telemedical consultations has reflected efforts to provide sufficient patient care. This study aims to evaluate the feasibility of a clinical examination of the hip joint and pelvis by way of a telemedical consultation.

Materials and Methods Twenty-nine patients of a German university clinic were recruited and assessed in both telemedical and conventional examinations. Agreement between the two examinations was then assessed, and connections between the observed agreement and patient-specific factors such as age, BMI and ASA classification were investigated.

Results The inspections agreed closely with a mean Cohenʼs kappa of 0.76 ± 0.37. Palpation showed adequate agreement with a mean Cohenʼs kappa of 0.38 ± 0.19. Function showed good agreement with a mean Cohenʼs kappa of 0.61 ± 0.26 and range of motion showed adequate agreement with a mean Cohenʼs kappa of 0.36 ± 0.19. A significant positive correlation was observed between the number of deviations in the different examinations and age (p = 0.05), and a significant positive correlation was shown between the number of non-feasible examinations and age (p < 0.01), BMI (p < 0.01) and ASA classification score (p < 0.01).

Discussion Inspection and function can be reliably evaluated, whereas the significance of palpation, provocation and measurement of range of motion is limited. The small sample size puts limitations on the significance of a statistically relevant correlation between patient-specific factors such as age, BMI and ASA classification score and valid and successful implementation of a telemedical examination. The authors recommend targeted patient selection. If, however, patients are being evaluated who are very old (> 75 years), obese (BMI > 30) or with multiple comorbidities (ASA 3 and above), caution is advised. Large, prospective studies are needed in the future to fully validate telemedical consultations in the fields of orthopaedics and trauma surgery.

Conclusion A telemedical examination of the hip joint and pelvis can be performed with certain limitations. Patient-specific factors such as age, BMI, and extent of comorbidities appear to have a relevant impact on validity and execution of the examination. Patients with multiple comorbidities (ASA 3 and above), advanced age (> 75 years) or obesity (BMI > 30) should, whenever possible, be examined in a conventional outpatient setting.

Maintaining Access to Orthopaedic Surgery During Periods of Operating Room Resource Constraint: Expanded Use of Wide-Awake Surgery During the COVID-19 Pandemic

INTRODUCTION

Wide-awake local anesthesia no tourniquet (WALANT) presents a nonstandard anesthetic approach initially described for use in hand surgery that has gained interest and utilization across a variety of orthopaedic procedures. In response to operating room resource constraints imposed by the COVID-19 pandemic, our orthopaedic service rapidly adopted and expanded its use of WALANT.

METHODS

A retrospective review of 16 consecutive cases performed by 7 surgeons was conducted. Patient demographics, surgical details, and perioperative outcomes were assessed. The primary end point was WALANT failure, defined as intraoperative conversion to general anesthesia.

RESULTS

No instances of WALANT failure requiring conversion to general anesthesia occurred. In recovery, one patient (6%) required narcotics for pain control, and the average postoperative pain numeric rating scale was 0.6. The maximum pain score experienced was 4 in the patient requiring postoperative narcotics. The average time in recovery was 42 minutes and ranged from 8 to 118 minutes.

CONCLUSION

The WALANT technique was safely and effectively used in 16 cases across multiple orthopaedic subspecialties, including three procedures not previously described in the literature. WALANT techniques hold promise for use in future disaster scenarios and should be evaluated for potential incorporation into routine orthopaedic surgical care.

Rapid Conversion of a Palliative Care Outpatient Clinic to Telehealth

PURPOSE

The coronavirus pandemic has transformed the practice of medicine, forcing a rapid transition to telehealth. As a specialty, palliative care relies upon expert-level communication and interdisciplinary care. We describe the transition of the Dana-Farber Cancer Institute palliative care clinic into a predominantly telemedicine model.

RESULTS

We document how we significantly increased goals of care conversations while maintaining patient volume and interdisciplinary care. We present how the components of a palliative visit translate into a virtual model.

DISCUSSION

While the transition away from in person visits occurred rapidly, telehealth is likely here to stay. We define the challenges and benefits encountered through increased use of telehealth and identify disparities in healthcare access that will become more pronounced as we move into a communication technology dependent future. We discuss how the pandemic changed the delivery of palliative care in ways that will endure beyond the coronavirus pandemic.

Impact of the COVID-19 pandemic on paediatric orthopaedic trauma workload in central London: a multi-centre longitudinal observational study over the "golden weeks"

Background and purpose - The COVID-19 pandemic has been recognised as an unprecedented global health crisis. This study assesses the impact on a large acute paediatric hospital service in London, evaluating the trends in the acute paediatric orthopaedic trauma referral caseload and operative casemix before (2019) and during (2020) COVID-19 lockdown. Patients and methods - A longitudinal retrospective observational prevalence study of both acute paediatric orthopaedic trauma referrals and operative caseload was performed for the first 6 "golden weeks" of lockdown. These data were compared with the same period in 2019. Statistical analyses included median (± median absolute deviation), risk and odds ratios as well as Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results - Acute paediatric trauma referrals in 2020 were reduced by two-thirds compared with 2019 (n = 302 vs. 97) with a halving risk (RR 0.55) and odds ratios (OR 0.43) of sporting-related mechanism of injuries (p = 0.002). There was a greater use of outpatient telemedicine in the COVID-19 period with more Virtual Fracture Clinic use (OR 97, RR 84, p < 0.001), and fewer patients being seen for consultation and followed up face to face (OR 0.55, RR 0.05, p < 0.001). Interpretation - The impact of the COVID-19 pandemic has led to a decline in the number of acute paediatric trauma referrals, admissions, and operations during the COVID period. There has also been a significant change in the patient pathway with more being reviewed via the means of telemedicine to reduce the risk of COVID-19 transmission and exposure. More work is required to observe for similar trends nationwide and globally as the pandemic has permanently affected the entire healthcare infrastructure.

The new 'normal': Rapid adoption of telemedicine in orthopaedics during the COVID-19 pandemic

BACKGROUND

Telemedicine provides a safe and effective means for the delivery of care by physicians amongst many subspecialties. Historically, orthopaedic practices in the United States have not widely utilized telemedicine for the delivery of orthopaedic care. As technology improves the adoption and utilization of telemedicine will likely grow, especially in light of the novel coronavirus (COVID-19) pandemic. Our study aims to assess patient and surgeon satisfaction and efficacy of telemedicine during a rapid adoption due to the global pandemic.

METHODS

All patients who completed a telemedicine encounter (telephone or video) with an orthopaedic surgeon were contacted. Patients were individually contacted after their visit, and a standardized validated post-visit satisfaction survey was completed. Orthopaedic surgeons completed a standardized post-encounter survey after each visit. Pre-COVID-19 patient satisfaction data was used for comparison.

RESULTS

Orthopaedic surgeons completed 612 telehealth encounters either via phone or video consultation between April 6, 2020 and May 22, 2020. 95% of patients rated both surgeon sensitivity to their needs and response to their concerns as 'good' or 'very good.' 93% of patients reported they would participate in a telemedicine encounter again. Surgeons reported high satisfaction with telemedicine encounters (80%, 86% phone and video respectively), and that 78.4% of the time a telemedicine encounter was successful in replacing an in-person visit.

CONCLUSION

Patients and orthopaedic surgeons documented high levels of satisfaction with telehealth encounters during the novel coronavirus (COVID-19) pandemic. Telemedicine does not appear to be a replacement for all in-person clinic encounters, however, when used in the appropriate context demonstrated favourable results.

LEVEL OF EVIDENCE

Level 4 Study.

The impact of COVID-19 on the future of orthopaedic training in the UK

The COVID-19 pandemic has had a major impact on global healthcare systems, has drastically affected patient care, and has had widespread effects upon medical education. As plans are being devised to reinstate elective surgical services, it is important to consider the impact that the pandemic has had and will continue to have on surgical training. We describe the effect COVID-19 has had at all levels of training in the UK within trauma and orthopaedics and evaluate how training might change in the future. We found that the COVID-19 pandemic has significantly impacted trainees within trauma and orthopaedics at all levels of training. It had led to reduced operative exposure, cancellations of examinations and courses, and modifications to speciality recruitment and annual appraisals. This cohort of trainees is witnessing novel methods of delivering orthopaedic services, which will continue to develop and become part of routine practice even once the pandemic has resolved. It will be important to observe the extent to which the rapid changes currently being introduced will impact the personal health, safety, and career progression of current trainees.

Provider confidence in the telemedicine spine evaluation: results from a global study

Purpose

To utilize data from a global spine surgeon survey to elucidate (1) overall confidence in the telemedicine evaluation and (2) determinants of provider confidence.

Methods

Members of AO Spine International were sent a survey encompassing participant’s experience with, perception of, and comparison of telemedicine to in-person visits. The survey was designed through a Delphi approach, with four rounds of question review by the multi-disciplinary authors. Data were stratified by provider age, experience, telemedicine platform, trust in telemedicine, and specialty.

Results

Four hundred and eighty-five surgeons participated in the survey. The global effort included respondents from Africa (19.9%), Asia Pacific (19.7%), Europe (24.3%), North America (9.4%), and South America (26.6%). Providers felt that physical exam-based tasks (e.g., provocative testing, assessing neurologic deficits/myelopathy, etc.) were inferior to in-person exams, while communication-based aspects (e.g., history taking, imaging review, etc.) were equivalent. Participants who performed greater than 50 visits were more likely to believe telemedicine was at least equivalent to in-person visits in the ability to make an accurate diagnosis (OR 2.37, 95% C.I. 1.03–5.43). Compared to in-person encounters, video (versus phone only) visits were associated with increased confidence in the ability of telemedicine to formulate and communicate a treatment plan (OR 3.88, 95% C.I. 1.71–8.84).

Conclusion

Spine surgeons are confident in the ability of telemedicine to communicate with patients, but are concerned about its capacity to accurately make physical exam-based diagnoses. Future research should concentrate on standardizing the remote examination and the development of appropriate use criteria in order to increase provider confidence in telemedicine technology.

Significance of Health Information Technology (HIT) in Context to COVID-19 Pandemic: Potential Roles and Challenges

Health information technology (HIT) refers to the concept of applying cloud-based services, internet, connected network, etc. in healthcare. It mainly utilizes electronic health records, information, and data related to the patients for providing the treatment and services in a more effective and advanced manner. This study attempts to propose roles and applications and identify the impact of the concept of HIT on serving the patients during the ongoing COVID-19 pandemic period. This paper also assesses the significant impact of HIT in the healthcare sector during the COVID-19 crisis. The medical decision support, e-sign-off tools, bar-coding approach, advanced medicine dispensing, e-patient portals, etc. are numerous data-sharing and network system-based HIT services. It has many capabilities to shift the working culture of medical facilities while serving and treating patients with a higher care level and impressive satisfaction, especially so during this COVID-19 pandemic. Interoperability and tele-healthcare have also become practicable with the proposed HIT approach.

Satisfaction Survey of Patients and Medical Staff for Telephone-Based Telemedicine During Hospital Closing Due to COVID-19 Transmission

Introduction: Telephone-based telemedicine was temporarily permitted in Korea during the COVID-19 pandemic. The purpose of this study was to assess satisfaction with the telemedicine done during temporary hospital closing when in-person visits were not allowed due to in-hospital COVID-19 transmission. Methods: Survey questionnaires partially taken from a telehealth usability questionnaire (TUQ) were sent to 6,840 patients who used telephone-based telemedicine from February 24 to March 7, 2020. Questionnaires sent to patients and additionally created questionnaires to evaluate telemedicine were sent to medical staff (182 doctors and 138 nurses). Results: Response rates of patients and medical staff were 13.2% and 17.2%, respectively. Patients' satisfaction with telemedicine was significantly greater than medical staff's satisfaction for all five components taken from TUQ (all p = 0.000). In addition, created questionnaires showed good reliability, obtaining similar results between doctors and nurses (all p > 0.05). More than 85% of medical staff replied that telemedicine was needed in COVID-19, whereas more than 80% of them worried about incomplete assessment and communication of medical condition. Overall satisfaction with telemedicine by medical staff was 49.7%. The strength of telephone-based telemedicine was patients' convenience (53.4%). However, incomplete assessment of patients' condition (55.0%) was its weakness. Conclusion: Satisfaction with telephone-based telemedicine by patients was significantly greater than that by medical staff (doctors and nurses). Negative views for safety and inconvenience resulted in a greater proportion of dissatisfaction among medical staff. For safe application of telemedicine, medical staff insisted that developing a platform and creating guidelines should be needed.

Challenges faced by orthopaedic trainees during the Covid-19 pandemic - An Irish perspective

Background

The recent SARS-CoV2/COVID-19 pandemic has caused a change in most aspects of our daily lives. Our health systems have had to adjust at an unprecedented rate to accommodate care for patients affected by the virus. As a result there has been widespread disruption to trauma and elective services throughout the Orthopaedic community Worldwide. We discuss the changes facing orthopaedic residents in training and the adaptations that have been made.

Methods

We discuss the challenges posed from a reduction in caseload to surgeons in training, teaching activities, patient interaction, workforce reinforcement and support networks in Ireland.

Results

A structured deployment of residents has taken place ensuring maximum exposure to operative cases to maintain competency. Teaching activities have been virtualised into a new curriculum that provides trainees with convenient access to a wide range of specialists at defined time periods during the week. Strategies have been employed to reinforce the workforce in anticipation of an acute reduction in staff due to the Covid-19 virus.

Conclusions

The changes have been rapid and despite many of these adjustments being borne out of necessity, the innovation displayed will almost certainly alter how training is ultimately delivered long after the crisis has ceased.

Adoption of Digital Technologies in Health Care During the COVID-19 Pandemic: Systematic Review of Early Scientific Literature

BACKGROUND

The COVID-19 pandemic is favoring digital transitions in many industries and in society as a whole. Health care organizations have responded to the first phase of the pandemic by rapidly adopting digital solutions and advanced technology tools.

OBJECTIVE

The aim of this review is to describe the digital solutions that have been reported in the early scientific literature to mitigate the impact of COVID-19 on individuals and health systems.

METHODS

We conducted a systematic review of early COVID-19-related literature (from January 1 to April 30, 2020) by searching MEDLINE and medRxiv with appropriate terms to find relevant literature on the use of digital technologies in response to the pandemic. We extracted study characteristics such as the paper title, journal, and publication date, and we categorized the retrieved papers by the type of technology and patient needs addressed. We built a scoring rubric by cross-classifying the patient needs with the type of technology. We also extracted information and classified each technology reported by the selected articles according to health care system target, grade of innovation, and scalability to other geographical areas.

RESULTS

The search identified 269 articles, of which 124 full-text articles were assessed and included in the review after screening. Most of the selected articles addressed the use of digital technologies for diagnosis, surveillance, and prevention. We report that most of these digital solutions and innovative technologies have been proposed for the diagnosis of COVID-19. In particular, within the reviewed articles, we identified numerous suggestions on the use of artificial intelligence (AI)-powered tools for the diagnosis and screening of COVID-19. Digital technologies are also useful for prevention and surveillance measures, such as contact-tracing apps and monitoring of internet searches and social media usage. Fewer scientific contributions address the use of digital technologies for lifestyle empowerment or patient engagement.

CONCLUSIONS

In the field of diagnosis, digital solutions that integrate with traditional methods, such as AI-based diagnostic algorithms based both on imaging and clinical data, appear to be promising. For surveillance, digital apps have already proven their effectiveness; however, problems related to privacy and usability remain. For other patient needs, several solutions have been proposed, such as telemedicine or telehealth tools. These tools have long been available, but this historical moment may actually be favoring their definitive large-scale adoption. It is worth taking advantage of the impetus provided by the crisis; it is also important to keep track of the digital solutions currently being proposed to implement best practices and models of care in future and to adopt at least some of the solutions proposed in the scientific literature, especially in national health systems, which have proved to be particularly resistant to the digital transition in recent years.

Early Peri-operative Outcomes Were Unchanged in Patients Undergoing Spine Surgery During the COVID-19 Pandemic in New York City

BACKGROUND

Healthcare resources have been greatly limited by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic halting non-essential surgical cases without clear service expansion protocols.

QUESTIONS/PURPOSES

We sought to compare the peri-operative outcomes of patients undergoing spine surgery during the SARS-CoV-2 pandemic to a matched cohort prior to the pandemic.

METHODS

We identified a consecutive sample of 127 adult patients undergoing spine surgery between March 9, 2020, and April 10, 2020, corresponding with the state of emergency declared in New York and the latest possible time for 1-month surgical follow-up. The study group was matched one-to-one based on age, gender, and body mass index with eligible control patients who underwent similar spine procedures prior to the SARS-CoV-2 outbreak. Surgeries performed for infectious or oncologic indications were excluded. Intra- and post-operative complication rates, re-operations, hospital length of stay, re-admissions, post-operative visit format, development of post-operative fever and/or respiratory symptoms, and SAR-CoV2 testing.

RESULTS

A total of 254 patients (127 SARS-CoV-2 pandemic, 127 matched controls) were included. One hundred fifty-eight were male (62%), and 96 were female (38%). The mean age in the pandemic group was 59.8 ± 13.4 years; that of the matched controls was 60.3 ± 12.3. All patients underwent general anesthesia and did not require re-intubation. There were no significant differences in 1-month post-operative complication rates (16.5% pandemic vs. 12.6% control). There was one death in the pandemic group. No patients tested positive for the virus.

CONCLUSION

This study represents the first report of post-operative outcomes in a large group of spine surgical patients in an area heavily affected by the SARS-CoV-2 pandemic.

The Efficacy of Telehealth for the Treatment of Spinal Disorders: Patient-Reported Experiences During the COVID-19 Pandemic

BACKGROUND

The use of telehealth saw a rapid surge during the early months of the COVID-19 pandemic. There remains little data on how effectively telehealth replicates traditional office visits in the treatment of spinal disorders and how telehealth is perceived by patients with spinal disorders.

QUESTIONS/PURPOSES

We sought to evaluate patient satisfaction with telehealth visits as a platform for delivering care for the treatment of spinal pathology.

METHODS

Patients undergoing a telehealth visit with providers specializing in the treatment of spinal disorders (one surgeon and two physiatrists) were provided with an anonymous, online survey. Data on patient satisfaction, effectiveness of the telehealth visit (in comparison with in-person visits), and clarity of communication were collected through 5-point Likert scales; visit characteristics and free-text responses were also collected.

RESULTS

Eighty-four patients responded to the survey. Their attitudes were largely positive, with an overall mean patient satisfaction score of 4.79. Patients gave high scores for clarity of communication during the visit, and for satisfaction with the formulation of treatment plans and their ability to ask questions, they gave the lowest scores to the effectiveness of telemedicine in replacing an in-person visit and ease of interface navigation.

CONCLUSIONS

The high overall patient satisfaction reported by our patients seeking care for a spinal pathology supports the growing body of evidence promoting the use of telehealth for orthopedic care. Further research is needed in a standardized telehealth examination of patients with spinal disorders.

Telemedicine: Is It a Tool for Orthopedics?

PURPOSE OF REVIEW

The purpose of this paper is to illustrate how telemedicine can be beneficial in many areas of orthopedic clinical practice through a literature narrative review. In addition, we discuss advantages, barriers, and enablers of such technology.

RECENT FINDINGS

Telemedicine in orthopedics was initially described to discuss simple cases among non-specialist doctors through videoconferencing. Recently, it evolved to postoperative follow-up on selected cases, physical examination, and even teleconsultations direct to patients. Studies have reported that consultation can be offered safely to selected patients. Although this topic is already being addressed for a long time, recent studies have reported that there is still resistance among many orthopedic surgeons. Telemedicine for orthopedics has safely expanded its operations. It can be used in postoperative follow-up of selected cases, fracture follow-up, and even in pediatric cases. Remote diagnosis of fractures is done successfully on an outpatient basis in many countries. Protocols and methods to standardize the virtual orthopedic examination for common musculoskeletal conditions have been developed. Satisfaction with teleconsultations as well as cost-effectiveness of remote care orthopedics were already well reported by some studies. We believe that remote care will be expanded in several hospitals around the world due to its huge potential. This fact is explained by natural technological development and by change and obliteration of habits accelerated exponentially after COVID-19 crisis.

Virtual risk assessment pathway for deep venous thrombosis: a preliminary model

BACKGROUND

COVID-19 has necessitated the reduction in conventional face-to-face patient consultation to reduce the risk of novel coronavirus SARS-CoV-2 transmission. Traditional pathways to risk assess for deep venous thrombosis (DVT) would involve face-to-face assessment to formulate an appropriate management plan following an initial presentation usually in secondary care or in-hospital settings. Appropriate antithrombotic measures can prevent complication of DVT such as pulmonary embolism with prompt early diagnosis and treatment.

METHODS

This observational, pilot study evaluates the possibility of combining telemedicine technology and a virtual examination pathway for remote triage and assessment of patients with suspected DVT.

RESULTS

Piloting and development of a virtual risk assessment pathway for DVT involves various challenges and multidisciplinary co-ordination.

CONCLUSION

Advances in telecommunication technology can enable clinicians, specialist nurses and hospital departments to develop a virtual examination pathway for remote triage and assessment of patients with suspected DVT. This pathway is not a replacement for conventional 'face-to-face' evaluation, but we believe the template can be explored and refined to act as a blueprint for future applications even when the pandemic has stabilised.

Outpatient Physical, Occupational, and Speech Therapy Synchronous Telemedicine: A Survey Study of Patient Satisfaction with Virtual Visits During the COVID-19 Pandemic

The COVID-19 pandemic transformed health care delivery, including rapid expansion of telehealth. Telerehabilitation, defined as therapy provided by physical therapy, occupational therapy, and speech and language pathology, was rapidly adopted with goals to provide access to care and limit contagion. The purpose of this brief report was to describe the feasibility of and satisfaction with telerehabilitation. A total of 205 participants completed online surveys after a telerehabilitation visit. Most commonly, participants were women (53.7%), 35-64 yrs old, and completed physical therapy (53.7%) for established visits of 30-44 mins in duration for primary impairments in sports, lower limb injuries, and pediatric neurology. Overall, high ratings ("excellent" or "very good" responses) were observed for all patient-centered outcome metrics (range, 93.7%-99%) and value in future telehealth visit (86.8%) across telerehabilitation visits. Women participated more frequently and provided higher ratings than male participants did. Other benefits included eliminating travel time, incorporating other health care advocates, and convenience delivering care in familiar environment to pediatric patients. Technology and elements of hands-on aspects of care were observed limitations. Recognizing reduced indirect costs of care that telerehabilitation may provide along with high patient satisfaction are reasons policy makers should adopt these services into future health care delivery models.

The Virtual Shoulder and Knee Physical Examination

The COVID-19 crisis has forced a sudden and dramatic shift in the way that clinicians interact with their patients, from outpatient encounters to telehealth visits utilizing a variety of internet-based videoconferencing applications. Although many aspects of pre–COVID-19 outpatient sports medicine care will ultimately resume, it is likely that telehealth will persist because of its practicality and because of patient demand for access to efficient and convenient health care. Physical examination is widely considered a critical obstacle to a thorough evaluation of sports medicine patients during telehealth visits. However, a closer reflection suggests that a majority of the examination maneuvers are possible virtually with limited, if any, modifications. Thus, we provide a comprehensive shoulder and knee physical examination for sports medicine telehealth visits, including (1) verbal instructions in layman’s terms that can be provided to the patient before or read verbatim during the visit, (2) multimedia options (narrated videos and annotated presentations) of the shoulder and knee examination that can be provided to patients via screen-share options, and (3) a corresponding checklist to aid in documentation.

Result of the implementation of telematic consultations in orthopaedic surgery and traumatology during COVID-19 laparoscopic surgery

La pandemia COVID ha hecho de las consultas telemáticas una herramienta básica en la práctica diaria. El objetivo principal del estudio es valorar los resultados de la aplicación de consultas telemáticas para limitar la movilidad de los pacientes.

Son objetivos operativos: proponer un plan de consultas, conocer cómo limita la asistencia a las consultas, definir qué patologías se benefician más con este plan.

Material y métodos

Se propone un esquema con la creación de consultas previas a las agendadas para valorar idoneidad y posibilidad de realizarla en acto único no presencial.

Resultados

Se han realizado 5.619 consultas con una falta de respuesta telefónica del 19%. El 74% de los pacientes fueron resueltos de forma virtual. Existe diferencia entre unidades, siendo más probable la respuesta telefónica para las consultas de unidad, OR = 0,60 o de traumatología general, OR = 0,67 y menos para los derivados desde urgencias.

El 20% de las consultas no se acompañaban de pruebas complementarias. Las consultas de traumatología general, OR = 0,34, control postoperatorio, OR = 0,49, y unidades, OR = 0,40, cumplieron mejor este requisito. De los pacientes restantes, las consultas de traumatología general, OR = 0,50, y las derivadas a unidades, OR = 0,54 fueron las que más se resolvieron sin acudir presencialmente.

Conclusiones

Se han resuelto de forma no presencial el 74% de los pacientes que atendieron a la llamada telefónica. El 20% de los pacientes acuden a la visita sin pruebas complementarias. Las consultas de seguimiento de osteosíntesis y postoperatorio de cirugía artroscópica son las que más precisan de ser realizadas de forma presencial.