Arasteh, P.

Askari, A.

Bagherifard, A.

Jabalameli, M.

Razi, M.

eprints Iran University of Medical Sciences

Downloadedfromhttps://journals.lww.com/jbjsjournalbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3z484KQalTVGvN5i4oIRHiduK3QGArwtu89/rx2MOtZwPl4G3RfjkOw==on09/21/2020Downloadedfromhttps://journals.lww.com/jbjsjournalbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3z484KQalTVGvN5i4oIRHiduK3QGArwtu89/rx2MOtZwPl4G3RfjkOw==on09/21/2020theOrthopaedicforumCOVID-19 and Orthopaedic SurgeryExperiences from IranAlireza Askari, MD, Peyman Arasteh, MD, PhD, Mahmoud Jabalameli, MD, Abolfazl Bagherifard, MD, andMohammad Razi, MDThe first case of coronavirus disease 2019 (COVID-19) wasreported in December 2019 in Wuhan, People’s Republic ofChina1. On February 19, 2020, the first reports of COVID-19were officially announced in Iran, including the death of 2patients. This created the suspicion that the health-care sys-tem in Iran was not keeping up with the speed by whichCOVID-19 was spreading. In other words, COVID-19 hadprobably entered Iran much sooner than we were able todetect it.The disease outbreak has caused a pandemic, which hascreated mass hysteria and panic worldwide. As of April 21,2020, the virus had infected >2,397,216 people worldwideand had caused >162,956 deaths2.As of April 21, 2020, >83,505 cases of COVID-19 hadbeen documented in Iran, and, according to the Iranian Min-istry of Health (MoH), there have been at least 3,739 deaths2.These numbers are expected to increase as the disease is spread-ing with high transmission rates and is involving more andmore individuals on a daily basis.In the beginning of the outbreak of COVID-19, confu-sion existed on different levels of the health-care system inIran, especially in orthopaedic departments. Although on thesurface the COVID-19 pandemic seemed to be unrelated toorthopaedic departments since these patients and surgeonsdo not face infectious disease on a routine basis, widespreadfear gave way to many poorly considered decisions, includingthe decision of many prosthesis companies to stop their ser-vices immediately, even before any official statements fromthe MoH or the hospitals were released to cease electivesurgeries.Hospitals and Orthopaedic Surgeries During theCOVID-19 OutbreakTwo weeks after the detection of the first cases of COVID-19in Iran, the Iranian MoH sent an official letter to all health-care centers to stop all elective surgeries in all private andgovernmental centers. Two days after this letter, the private-sector hospitals obtained permission to restart their electivesurgeries, perhaps due to their lobbying with the MoH.However, all governmental health-care centers discontin-ued all of their elective orthopaedic surgeries, and onlytrauma patients were seen. In the governmental sector, nominor elective surgeries, even those that would include ahospitalization of <24 hours (e.g., removal of plates andimplants or carpal tunnel release), were performed. In theprivate sectors, each institution made its own decision ofwhether or not to perform specific elective surgical proce-dures. Interestingly, the spread of the virus during March2020 coincided with the Iranian New Year holiday known asNowruz, during which the usual elective surgeries that areperformed in private and governmental sectors are post-poned. Because of mass fear and concern regarding thespread of COVID-19, and the fact that some orthopaedicsurgeons contracted the virus, most private-sector hospitalspaused their elective surgeries for a few weeks before com-pletely stopping all of their surgeries at 1 month after thefirst official reports of COVID-19 in Iran. Subsequently,Disclosure: The authors indicated that no external funding was received for any aspect of this work. TheDisclosure of Potential Conflicts of Interest formsare provided with the online version of the article (http://links.lww.com/JBJS/F875).1126COPYRIGHT  2020 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATEDJ Bone Joint Surg Am. 2020;102:1126-8 d http://dx.doi.org/10.2106/JBJS.20.00631all of the empty hospital beds were designated for the treat-ment of patients with COVID-19. The number of traumacases in Iran is much higher than that of other regions in theworld, and all orthopaedic surgery procedures that are re-lated to trauma are still being performed. However, with thepractice of self-quarantining in Iran, the number of trafficaccidents has decreased because fewer people are commut-ing, and this has decreased the number of trauma-relatedsurgeries.In addition to the legislation by the MoH, perhapsthe move by orthopaedists and patients to practice self-quarantining has been the most important factor that stoppedelective surgeriesOrthopaedic Clinics During the COVID-19 OutbreakIn the initial 2 weeks of the COVID-19 outbreak beforethe announcement from the MoH to stop elective surger-ies, governmental orthopaedic clinics were busy as usual,and no specific protection was considered for physiciansand patients. However, with the passing of time and theannouncement from the MoH, the number of referrals toorthopaedic clinics decreased substantially, mainly due tomass fear in the community. Subsequently, stations weredesignated to check for fever in patients and their escorts inall clinics. With regard to personal protective equipment(PPE), physicians were given N95 masks (although not inevery center in the country), and latex gloves and disinfec-tants were placed in all of the clinics. Patients were advisedto buy protective gloves and masks for themselves, whichcaused a lack of availability. Because no official groundrules or instruction were given to private orthopaedicclinics by the MoH, they were free to continue treatingpatients. Almost 3 weeks after the first case of COVID-19, almost all physicians were convinced to close theirclinics, and some started seeing patients online with theuse of special applications and through social media,although not enough infrastructure exists to facilitate suchservices. More importantly, the number of orthopaedicpatients who benefited from this type of consultation wasvery few.Activities and Education During the COVID-19 OutbreakSelf-quarantine measures that were taken in the communitygave orthopaedic surgeons an opportunity to experience lifelike other people in society, away from their busy lives in theoperating rooms. Everyone became united in staying at homein order to stop the spread of the virus.With these measures, the Iranian Orthopaedic Society(IOS) and its branches created multiple social media groupsto maintain a panel for the exchange of scientific ideas andcritique and to promote research among orthopaedic sur-geons. The Iranian Ministry of Communication providedsome limited free use of the internet to the public, whichcovered the need for internet to some extent. Many ortho-paedic personalities in the country also aided in preparingbrochures and video clips to invite people to stay in theirhomes and self-quarantine. With the unexpected pause ofall surgeries and routine activities, orthopaedists were con-fronted with a unique situation. Orthopaedic residentsbecame demoralized as they became more idle because ofthe cancellation of classes and hospital grand rounds; how-ever, the continuity of trauma surgeries and seeing patientsin the emergency department maintained a level of practicaleducation. From another point of view, the lack of a proto-col from the MoH for the care of trauma patients withregard to COVID-19 created a concern for health-careproviders.In our country, according to the MoH, residents inspecialties unrelated to COVID-19 (including orthopaedicresidents) are not obligated to be present in emergencydepartments and in COVID-19-related wards, althoughsome do participate voluntarily. PPE for orthopaedic residentsincludes normal surgical masks and does not differ from that ofother personnel. The main policy for general hospitals withmany different departments (including orthopaedic depart-ments/wards) was to ensure the longest distance possible be-tween wards that were designated for COVID-19 patients andwards that were unrelated to COVID-19, and orthopaedic res-idents are only obligated to respond to consults from the non-COVID-19 wards.In some medical universities across the country, vir-tual education (e-learning) has been started3,4. With regardto orthopaedic residents in some universities such as the IranUniversity of Medical Sciences in Tehran, case studies werebegun using various social media platforms. Online coursesin the orthopaedic departments, which were mainly donewith the use of webinars, are held for 2 main reasons: (1)to maintain orthopaedic education for residents and under-graduate students, and (2) to create a platform to increaseawareness and to exchange up-to-date information regard-ing COVID-19. There have been large disparities across thecountry and among universities for applying this type of e-learning, which has been based mostly on their existingfacilities.Additionally, the IOA released some guidelines to theMoH. These guidelines were classified in 4 sections: (1) edu-cational activities, (2) outpatient management, (3) inpatientmanagement, and (4) guidance for paraclinics. The IOA andits subspecialty divisions have further maintained their casestudies using e-learning platforms, which has been a successfulexperience.ConclusionsThe COVID-19 outbreak, which was concurrent with theIranian New Year, created an unprecedented experience inthe lives of many orthopaedic surgeons in Iran. Orthopae-dists had the opportunity to tend to their normal chores ofeveryday life, which they usually would not have time for,and to take part in large campaigns related to communityhealth, mainly concerning COVID-19. The role of orthopae-dists has been shown to be much more pronounced thanwhat is usually thought of as only tending to fractures. As the1127THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORGVOLUME 102-A d NUMBER 13 d JULY 1, 2020COVID-19 AND ORTHOPAEDIC SURGERYgreat poet Saadi Shrazi said, “Human beings are members of awhole, in creation of one essence and soul.” Orthopaedists,along with other specialists who are battling COVID-19hands-on, can be important influencers in the war againstCOVID-19. nAlireza Askari, MD1Peyman Arasteh, MD, PhD2Mahmoud Jabalameli, MD1Abolfazl Bagherifard, MD1Mohammad Razi, MD31Bone and Joint Reconstruction Research Center, Shafa OrthopedicHospital, Iran University of Medical Sciences, Tehran, Iran2Shiraz University of Medical Sciences, Shiraz, Iran3Department of Orthopedic Surgery, Rasoul Akram Hospital, IranUniversity of Medical Sciences, Tehran, IranEmail address for M. Razi: mrazi@razimd.infoORCID iD for A. Askari: 0000-0003-3314-3094ORCID iD for P. Arasteh: 0000-0001-6499-9093ORCID iD for M. Jabalameli: 0000-0002-1595-4152ORCID iD for A. Bagherifard: 0000-0002-4965-8810ORCID iD for M. Razi: 0000-0003-0273-5599References1. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Vital sur-veillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirusdiseases (COVID-19)—China, 2020. China CDCWeekly. Accessed 2020 Feb 20. http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f512. World Health Organization. Coronavirus disease (COVID-2019)situation reports. 2020. Accessed 2020 Apr 21. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports3. Ruiz JG, Mintzer MJ, Leipzig RM. The impact of e-learning in medical education.Acad Med. 2006 Mar;81(3):207-12.4. Kuhn S, Jungmann F. [Medicine in the digital age: telemedicine in medical schooleducation]. Radiologe. 2018 Mar;58(3):236-40. German.1128THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORGVOLUME 102-A d NUMBER 13 d JULY 1, 2020COVID-19 AND ORTHOPAEDIC SURGERY

COVID-19 and Orthopaedic Surgery: Experiences from Iran

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COVID-19 and Orthopaedic Surgery: Experiences from Iran

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