key: cord-1030014-mg0ahhwu authors: Tarun, Verma; Anurag, Tiwari; Yugal, Karkhur; Raj, Kumar; Lalit, Maini title: Orthopaedic operating room considerations in covid-19 pandemic: A systematic review. date: 2021-02-23 journal: Journal of arthroscopy and joint surgery DOI: 10.1016/j.jajs.2021.02.008 sha: 3f8a477d4cfb7469c68c14b5dff939ef81240403 doc_id: 1030014 cord_uid: mg0ahhwu Purpose Worldwide COVID 19 has affected the medical practices and Orthopaedics is not any different. Despite risk, the surgeons cannot deny the surgical procedure on patients with suspected or confirmed COVID 19 infection. The purpose of this manuscript is to review various operating room measures which are recommended and being followed to carry out orthopaedic surgeries in the current scenario of COVID 19 pandemic. The information would be useful for orthopaedic surgeons to carry out safe surgical practice for reducing the transmission of COVID 19 infection. Method ology: A systematic literature search was performed using search engines- PubMed, Google Scholar and Scopus from January to August 2020 for relevant research articles. The keywords utilized for systematic literature search were “COVID 19”, “Corona virus” and “Operating room”, “Orthopaedic procedure” in 4 combinations. Duplicates were excluded. Further sorting was done according to the pre-set inclusion and exclusion criteria. Original articles pertaining to orthopaedic surgery and operating room in COVID 19 and available in English language were included. Editorials, case reports, other speciality articles were excluded. Results 16 articles were finally included in review after screening for titles, abstracts and full texts. The information obtained is presented as a narrative review. Conclusion Various important recommendations include use of negative pressure OR, HEPA filters, dedicated separate OR for COVID positive and suspected patients with well defined separate corridors for transport, avoid AGP wherever possible, minimize the number of assistants and staff and follow strict sanitation protocols after each surgery. A well planned systematic approach is warranted to mitigate the risk of transmission of COVID 19 while carrying out orthopaedic surgeries. Covid-19 or SARS-CoV-2 is an infectious disease that has spread rapidly over the entire world 1, 2 . The outbreak was started from Wuhan province, China in December 2019, and World Health Organisation (WHO) has declared it as pandemic in March, 2020 3 . Covid-19 has heavily affected the healthcare system. Elective orthopaedic procedures were postponed in order to reduce the burden on health system. As the number of cases are now decreasing, the elective surgeries may have to be resumed. While operating on covid suspected or positive patient, there is high probability of getting infection to surgeons and other staff in operating room, it must be ensured that all surgeries be done safely, without exposing patients or health-care providers to infection 4 . The purpose of this systematic review is to look at the current literature on methods required for conducting safe orthopaedic surgeries during COVID-19 pandemic and formulate practical recommendations on desired changes in the operating room while performing orthopaedic procedure on a covid-19 suspected or positive patient. A systematic literature search was performed using PubMed, Google scholar and Scopus. The electronic database was screened of all the articles published between January 2020 to August 2020. The search was conducted using following keywords-"COVID 19", "coronavirus", "orthopaedic procedures" and "operating room" in different combinations. The selected articles were sorted in an excel sheet and the duplicate articles were removed. Original articles pertaining to orthopaedic surgeries in COVID patients available in English language were included in the review. Case reports and editorials were excluded from the study. The selected articles were initial screened through titles and thereafter by abstract reading and final list were prepared after full text reading. After removing the duplicate articles, we obtained 630 articles from our electronic search using the combinations of keywords. These 630 articles were screened using our exclusion criterion and 229 articles were obtained. A second screening of these 229 articles was conducted by going through the titles. One hundred seven articles were excluded and 122 articles were selected. When conducting the second screening of 122 articles on the basis of abstract reading, 106 articles were removed. The final list of 16 articles was made ( Figure 1 ). These 16 articles were randomly distributed amongst 4 authors for full text reading. These 16 articles are listed in Table 1 . As the data was heterogenous, it was not possible to perform a systematic review and the obtained information is provided as a narrative review. The data extracted from the included articles is discussed under the following headings for simplification. It has become a practice to screen each patient requiring surgery for COVID 19 J o u r n a l P r e -p r o o f Usually, the direction of airflow in the operating room complex is from the OR towards the surrounding area (positive pressure) 24 also not be u as alternative to N95/FFP2 as it also fails to filter virus loaded particles 8 . In addition to the type of masks used, the fitting and sizing of the mask is of utmost importance. Only a perfect-sized and well-fitted mask leads to efficient sealing of the respiratory tract. PAPR respirator filters out contaminants from air using a battery powered unit. Ding BTK et al advise to use PAPR for prolonged surgeries (> 4 hours) in COVID 19 patients 6 . However, PAPR's higher cost, reduced visual field, regular requirement of maintenance, difficulties in hearing etc are its disadvantage. Orthopaedic surgeries involve multiple procedures which generate aerosol. These include use of power drill, oscillating saw, harmonic scalpel, pulse lavage, burr, cautery, reaming etc which are very often utilized. Nogler et al. demonstrated that aerosols spread in up to [6] [7] [8] metres are generated by high-speed cutters during revision hip arthroplasty 27 . Electro-cautery should be used minimally and in minimum setting possible along with a smoke evacuator 5, 6, 13, 15, 17, 18, 19, 26 . Power devices like drills, saws, reamers and burr should also be used minimally and the power settings should be as low as possible 5-7, 9, 11, 12, 15-19 . Considering using a Gigli saw, sharp osteotomes, and manual reaming whenever possible 15, 18 . Use of J o u r n a l P r e -p r o o f negative pressure OR, HEPA filter and proper PPE is imperative to attenuate crossinfection 11 . Recommendations include use of negative pressure OR, HEPA filters, dedicated separate OR for COVID positive and suspected patients with well defined separate corridors for transport, avoid aerosol generating procedures wherever possible, minimize the number of assistants and staff and follow strict sanitation protocols after each surgery. COVID-19. An update for orthopedic surgeons The role of the orthopaedic surgeon in the COVID-19 era: cautions and perspectives In the Extraordinary Times of Coronavirus Disease 2019: Clinical Strategies for Performing Spinal Surgery Operational strategies of a trauma hub in early coronavirus disease 2019 pandemic Returning to orthopaedic business as usual after COVID-19: strategies and options Operating in a Pandemic: Lessons and Strategies from an Orthopaedic Unit at the Epicenter of COVID-19 in Aerosol generating procedures in orthopaedics and recommended protective gear Organizing an Orthopaedic Department During COVID-19 Pandemic to Mitigate In-Hospital Transmission: Experience From Greece. Cureus COVID-19 Orthopaedic Safe Care Toolset: Guidelines for the Diagnosis and Management of Patients with Fracture and COVID-19 International Consensus Group (ICM) and Research Committee of the American Association of Hip and Knee Surgeons (AAHKS). Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines Developed by the International Consensus Group (ICM) Resuming arthroplasty: A well aligned and a balanced approach in the COVID-19 era Medically Necessary Orthopaedic Surgery During the COVID-19 Pandemic: Safe Surgical Practices and a Classification to Guide Treatment Adapting Policy Guidelines for Spine Surgeries During COVID-19 Pandemic in View of Evolving Evidences: An Early Experience From a Tertiary Care Teaching Hospital. Cureus Recommendations of protective measures for orthopedic surgeons during COVID-19 pandemic The Orthopaedic Trauma Service and COVID-19: Practice Considerations to Optimize Outcomes and Limit Exposure CLEARING THE AIR. 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