Dr.

Agustin Tellez Duarte

Original Article.
COVID 19 in Orthopedics

Agustin Tellez Duarte MD

Orthopedic Surgeon Abstract

Spine surgeon Orthopedic surgery and it´s branches require safety
Master in Education protocols when attending patients with risk of infection, or
transmission for COVID-19 and comorbidities in the
outpatient and inpatient hospital setting. Recent
Instituto de Alta
knowledge for this disease about finding it´s capsular
Investigación
capability to adhere to metallic and plastic surfaces, and
Académica. the present search to find a medical treatment for it. We
Mail Adress: made an analysis for it´s consequences on the most
Orthopedics and fragile patient population. Determining the need for
Research. special preventative measures as cleaning surfaces,
Costamed Cozumel canes, walkers and crutches after being in a populated
Av. Sur 1 indoor or outdoor area and for postop patients with spine
Quintna Roo surgeries and total joint replacements in surgical devices
Zip 77675 a viral biofilm may be present, and comorbidities in an
outpatient setting that are receiving ACE inhibitor and
anti-inflammatory therapy, orthopedic physicians must
Conflict of interest: None
change the pharmacological plan and educate in new
preventative measures on the use of orthopedic devises.
New lines of research are needed.

Introduction:
The Covid-19 disease is a pandemic disease which is
presenting a high mortality rate, a lot of it´s effect on the
Palabras clave: COVID 19, lungs and upper respiratory system has been analyzed,
prevención, Ortopedia y but little about the multiorganic consequences, its
Virología capability to survive on surfaces in the outer enviornment
like metal, plastic and cardboard1. The relevance of this is
that the first contact with patients happen many times
thru the external consultation2 or the emergency room
Key words: COVID 19,
Orthopedic Surgeons must response adequately and give
prevention, treatment their own care regarding the orthopedic fields to this
Orthopedics Virology. disease.
COVID-19 is also known as SARS-Cov-2 or HCoV-19; all
these names define the same virus which is a Beta-Corona
Virus that belongs to the RNA encapsulated family of
viruses1.
This Capsule is formed by glucopolisacarides and a lipid
layer which gives the virus it´s capability to adhere to cells
and Attach to them transmiting their RNA in to the cell for
viral proliferation1.
 COVID-19 in Orthopedics

The Aerosol from the patients with this infected3. The diagnosis is thru the use
disease, tend to spread the virus to of nasopharyngeal swabs and RNA
their surroundings, in the case of detection for SARS-CoV-2. 1,391
orthopedic patients many depend on children were tested finding only 171,
Crutches, canes, walkers and that is 12.3% 3.
prosthetic devises to move around, it is Fever is the cardinal symptom found in
common to see this devices get dirty over 41.5% of all patients, with
and in few occasions being cleaned pharyngeal erythema 15.8%,
by their owners. radiologic reports show pneumonia
The adherence peculiarity of this virus images, and 12 patients presented
is shared with it´s common kind SARS- radiologic pneumonia images but no
CoV-11. symptoms 3.
The viral capsule is also the viruses There are other symptoms in the
weakness due to it´s inability to survive gastrointestinal system like diarrhea,
for long periods of time in the vomiting, and radiologically some
enviorment, and it´s weakness to all intestinal abnormalities 3, It also found
sponifiable substances like soap an the affection of other organs in the
alcohol, Chloroquine (in current body like the liver, kidneys, and more1.
research)13.

Background Transmission:

On December 31, 2019 the Aerosol flush is the main way of

pneumonia of unknown etiology was contagious transmission 2. The COVID-
identified in Wuhan City, Hubei 19 may adhere to almost any kind of
Province of China and from surface with a life span of 1 to 24 hrs1;
December 31st 2019 to January 3rd So touching with the hands this
2020; 44 patients with pneumonia of surfaces or having any contact thru
unkwon etiology were identified, the face or any mucose surfaces may
January 11th and 12th exposure to food let a clear entrance of the virus in to
in a fish market was identified; January the body. The human-human contact
7th Chinese authorities identified the may also let the virus in to the body.
virus, and on the 12th the information The virus has an asymptomatic period
was shared with other countries. On of latency in which it may be
the 13th the first case was reported contagious up to two weeks.
from Thailand, 15th Japan reported it´s Rehabilitation and Physiotherapy
first case, 20th in Korea 2. centers have a diverse use of
This virus is responsible for over 110,000 instruments which are in continuous
infections and more than 4000 deaths contact with patient hands and
worldwide up this day, and it has been aerosol these must be cleaned
observed that only 1% of the patients continuously and we recommend the
infected are children 3. The Chinese use of masks N-95 by the patients and
Center for Disease Control studied a the physical therapist´s that are in
series of 72,314 showing that only 1% of contact with the patients.
children under 10 years old are

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 COVID-19 in Orthopedics

Method:
A literature review was made of the Treatment:
most recent situation reports from Bin Cao, M.D, et. Al; made a trial
WHO and publications on COVID-19. testing regular protective measures vs
lopinavir and ritonavir, finding no
Diagnosis: improvement versus the control group
Clinical Signs and Symptoms: fever, and some gastrointestinal discomfort
sore throat, cough, dyspnea, added to the symptoms of the
headache, gastrointestinal disorders. lopinavir and ritonavir group 6.
Fever may present itself 2 to 4 days Waldersmith and Fisher 8 published a
after infection 4,5. recommendation for isolation
Laboratory: Nasopharyngeal measures to be energized by the
swabbing and rRT-PCR looking for the Goverments. And enhance
OrF1ab gene 4,5. containment measures, closing
CPK, ALT, AST are altered, Leukopenia borders between countries down and
is also observed 5. declaring Europe it´s epicenter 8,9 with
Xrays: A lobar pattern pneumonia is more new cases and mortality being
developed after one week of reported until today March 19, 2020 8,9.
symptoms appeared in some Remdesivir has been used in treatment
patients5. Even thou some remain and study results are pending 10.
asymptomatic when radiographic Chloroquine in vitro stops replication of
control is taken 3. the COVID-19 12, Safe clinical trials
Pharmacological Response Trial using Chloroquine and
Diagnosis: Ritonavir and Lopinavir Hidroxichloroquine trials are being
have been studied for COVID-19 done 12,13.
Treatment with no success compared Philippe Gautret; et. Al. from IHU-
to regular protective measures, so it is Méditerranée Infection, Marseille
disregarded 6. France reported in a small sample viral
count disminution using
Hydroxichloroquine with
Comorbidities: Azythromycin.

Michael Roth, et. Al.; published a Prognosis:

correspondence where ACE2
polimorphisms, their which is expressed Older age, higher SOFA score, and
by epithelial cells of the lung, intestine, elevated d-dimer at admission were
kidney, and blood vessels; proposing risk factors for death of adult patients
the probability of increasing the risk of
with COVID-19. 10
virus attachment to the cells in
patients using ACE inhibitors 7. Like
Younger Patients present a better
Hipertensive patients, Chronic Disease
prognosis 3 , than older patients 7,10,
Orthopedic Patients, etc.

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 COVID-19 in Orthopedics

Morbidity and mortality are worse in So pharmacological options must be

older patients that suffer chronic studied to replace ACE inhibitors use
disease 10. until further data and new treatments
are created 7.
Discusion: Together with general preventative
This finding makes a clear statement of measures as the ones popularly known
the multisystemic morbidity of the virus of hand wash, no physical contact
which lead to lung, liver, kidney and with people, N-95 use, we also suggest
intestinal morbidity, the last three to clean orthopedic devises every
organs are related to the 1,25- time they are used to go in and out
Dihydroxicolecalciferol, and calcium from public places with alcohol
metabolism, affecting bone tissue in devices, chloride or ammonia for
ways not determined yet 7. further protection of the most sensitive
Together with the virus capability from population that use this devices 8.
it´s capsule for survival and adherence Emergency Room and Outpatient
to metal, plastic, surfaces 1, leads the consultation of Orthopedic patients
way for future studies to determine if must get this revision in their treatment
the virus is capable of surviving inside for their protection, and in post
and in between the metal implants by infected and recuperated patients
forming viral biofilms, Biofilms are the follow up and protection must
largely studied for Bacteria 11 for viruses include this measures. Postop
this is not. Like prosthesis in patients inpatients, tests must include Dimer-D,
with Arthroplastic Surgery in the hip, Il-6, Troponin 1 10 .
polyethylene insertos 1,11 and
acetabular component, knee femoro- Conclusion:
tibial polyethilene inserto, in the
locking mechanisms of the Orthopedics may see as a specialty
transpedicular screws 1,11 and far from the pulmonary disease
intersomatic bars, among other pandemic, but in a closer look
implants. Giving the way for research orthopedic patients with Chronic
regarding if this patients when Articular diseases and Spine surgery
immunosuppressed or when started need further care and preventative
on treatment with ACE inhibitors may measures to prevent and treat SARS-
have a SARS-CoV-2 clinical relapse in Cov-2 , for risk of increased morbidity,
the future, or simply won´t be able to mortality and relapse, all of this
get rid of the virus secondary to the aspects will need future research.
inability of fresh blood to get in to this
mechanical spaces 11.

Patients with arthroplasty 11 are

patients in fragile age for this disease,
and most have Hypertension,
diabetes, and chronic disease
comorbidities 10 .

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 COVID-19 in Orthopedics

March 11, 2020;

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