Orthopedic Telemedicine Encounter During The COVID-19 .

Journal Pre-proofOrthopedic telemedicine encounter during the COVID-19pandemic: A cautionary taleEric M. Bluman, Matthew S. Fury, John E. Ready, Jason L.Hornick, Michael J. /10.1016/j.tcr.2020.100323Reference:TCR 100323To appear in:Trauma Case ReportsAccepted date:26 June 2020Please cite this article as: E.M. Bluman, M.S. Fury, J.E. Ready, et al., Orthopedictelemedicine encounter during the COVID-19 pandemic: A cautionary tale, Trauma CaseReports (2020), https://doi.org/10.1016/j.tcr.2020.100323This is a PDF file of an article that has undergone enhancements after acceptance, suchas the addition of a cover page and metadata, and formatting for readability, but it isnot yet the definitive version of record. This version will undergo additional copyediting,typesetting and review before it is published in its final form, but we are providing thisversion to give early visibility of the article. Please note that, during the productionprocess, errors may be discovered which could affect the content, and all legal disclaimersthat apply to the journal pertain. 2020 Published by Elsevier.

Journal Pre-proofOrthopedic Telemedicine Encounter During the COVID-19 Pandemic:A Cautionary TaleEric M. Bluman MD PhD, Matthew S. Fury MD, John E. Ready MD,re-proofJason L. Hornick, MD PhD and Michael J. Weaver, MDlPEric M. Bluman MD PhD (ebluman@bwh.harvard.edu)naMatthew S. Fury MD (MFURY@mgh.harvard.edu)John E. Ready MD (jready@bwh.harvard.edu)urMichael J. Weaver, MD (MJWEAVER@PARTNERS.ORG)Brigham HealthJoDept. of Orthopedic Surgery75 Francis St., Boston, MAJason L. Hornick, MD PhD ( jhornick@bwh.harvard.edu)Dept. of PathologyBrigham Health75 Francis St., Boston, MA

JournalPre-proofJournal Pre-proof

Journal Pre-proofOrthopedic Telemedicine Encounter During the COVID-19 Pandemic:JournalPre-proofA Cautionary Tale

Journal Pre-proofSummaryThe COVID-19 pandemic has necessitated increased use of telemedicine for diagnosis andmanagement of musculoskeletal disorders. We describe the initial virtual/telemedicine encounterand management of a patient with knee pain initially diagnosed as gonarthrosis but that actuallyresulted from an impending pathologic fracture of the femur. Definitive diagnosis and treatmentofoccurred only after completion of the impending fracture. The multiple factors makingrotelemedicine encounters challenging which contributed to this outcome are highlighted.-pOrthopedists need awareness of these challenges and must take steps to mitigate the risk ofrecomplications possible with continued increased utilization of telemedicine during this pandemiclPand beyond.naKeywords: coronavirus, telemedicine, orthopedic surgery, delayed diagnosis, impending fractureurIntroJoTelemedicine or virtual visits (VVs) refers to the treatment of various medical conditions withoutseeing the patient in person. Encounters conducted over the phone without video imaging toconduct evaluation and management visits are termed telephonic E&M visits. eVisits, like EMRmessaging or e-mail, utilize internet-based forms of communication,1 however eVisits mustinclude history taking, diagnosis and intervention.2 eVisits commonly incorporate both audioand video transmission.

Journal Pre-proofThe COVID-19 pandemic has transformed VVs from a technically demanding and rarely-usedoption into a necessity used by a large proportion of physicians around the world. Our healthcare system averaged 17 VVs/day prior to the WHO declaration of the pandemic. Since thattime, we completed on average 1,440 VVs/day ( 65,000 cumulative VVs). During this sameperiod our department averaged over 100 VVs/day.ofTelemedicine visits have enabled us to continue to evaluate patients while maintaining socialrodistancing and minimizing patient visits to the hospital. However, these technologies are notre-pwithout risk, as this case illustrates.Case ReportlPA 65-year-old Spanish-speaking-only female presented to the orthopedic surgery clinic on 01naApr 2020 for increasing right knee pain. She had been seen by her PCP who obtainedurradiographs and referred her to the clinic for evaluation of presumed gonarthrosis.JoAn eVisit (with audio and video interaction) to the orthopedic clinic was planned. However, thepatient was not able to engage the video component and it was converted to a telephonic-onlyvisit. No Spanish-interpreter was available, so the patient’s children, who were fluent in bothEnglish and Spanish, were enlisted to provide translation. The patient reported a history ofdifficulty with ambulation and pain in her right lower extremity necessitating use of a cane. Shecouldn’t describe the exact nature of the pain, but localized it to the knee and thigh for threemonths prior to presentation. Her past medical history was significant for morbid obesity(BMI 45) and a remote history of thyroid cancer treated with complete thyroid resection.

Journal Pre-proofNo physical examination was possible because of the virtual nature of the encounter. Three nonweight bearing radiographs of her right knee were evaluated as part of the encounter (Figure 1).These demonstrated mild arthritic changes of the patellofemoral joint. No appreciable deformitywas noted. A diagnosis of mild right knee arthritis was made. Non-operative managementincluding weight loss, NSAIDs and physical therapy to include a home exercise program wasroofdecided upon.-pOn 13 Apr 2020, the patient twisted her body while at home with a resultant fall, pain in her rightrethigh, and inability to stand. She was transported to our hospital by emergency services. In theemergency department, her right lower extremity was shortened and her thigh was tender tolPpalpation but her integument and neurovascular exam were intact. Radiographs of her rightnafemur revealed a displaced, oblique subtrochanteric fracture through a lytic lesion (Figure 2).Further history revealed that her prior thyroid cancer had metastasized to a rib that requiredurresection. Standard lab testing for patients with known skeletal metastases was initiated. SheJowas admitted and a bone scan and skeletal survey was performed to ensure there were no othersites of impending fracture and to identify possible targets for radiation therapy.The patient underwent reduction and placement of a cephalomedullary device for fixation of theright femur (Figure 3). The surgery was un-eventful, and she tolerated it well. During theprocedure, a biopsy of the contents of the lytic lesion within the right femur was performed andsent to surgical pathology for gross and microscopic histologic evaluation. This analysisconfirmed the diagnosis of metastatic thyroid carcinoma (Figure 4).

Journal Pre-proofRadiation oncology was consulted to provide post-operative radiation therapy and medicaloncology was consulted for consideration of postoperative chemotherapy. She was mobilizedwith physical therapy, and was able to walk with the aid of a walker at the time of discharge.DiscussionofIn this case report, we illustrate numerous factors associated with a telemedicine visit thatroresulted in the delayed diagnosis of a skeletal metastasis. This case highlights many of there-ppitfalls possible with orthopeadic surgeons’ use of this type of encounter.One obvious drawback to using telemedicine visits is the limitation placed in conducting alPphysical examination. Telephonic-only visits are the most limited. These types of visits cannadetect certain components of the examination (e.g. affect) the patient’s verbal communication. InJocrepitus).ursome unusual circumstances, the physician may be able to evaluate audible findings (e.g. tendonPhysical examinations through the video component of eVisits are also limited, albeit less sothan with telephonic encounters. eVisits with orthopeadic encounters can certainly providegreater information but still prevent adequate examination of tissue character, temperature,sensory function, motor strength, differentiation of pain intensity and certain types ofcoordination.

Journal Pre-proofWith both isolated telephonic encounters and eVisits, there is a very limited ability to obtainsynchronous supplemental imaging. For these visits, patients ideally obtain imaging just beforethe visit itself (e.g. one or a few days before) to allow accurate radiographic diagnosis. Whenpatients are seen in-person in the orthopeadic clinic, they are easily sent back to radiology forrepeat imaging for those studies that were inadequate or for supplementary studies to showexpanded fields of view or non-standard views. In most cases, this option is not available foroftelephonic or eVisits. Some locales have services that provide mobile imaging at the home ofrothe patient.3–5 Where available, these services can help improve the quality of the care.-pHowever, the imaging equipment such companies are able to bring to the patient’s home isrelimited; specialized studies are not able to be performed. This limits the improvement inlPdiagnostic capabilities.naAll patients are not able to use eVisit technology. While smart phones are extremely common,the expertise to conduct a eVisit is not universal. We have found that many geriatric patientsurhave difficulty with eVisit technology. In our case, had an eVisit been possible, it may haveJotipped-off the treating surgeon to the true nature of the problem. In the hospital, when describingher “knee pain,” she grabbed her thigh. This observation during an eVisit may have led to furtherquestioning or radiographs.While we have in-person or virtual interpreter services for all in-person patient visits, during thepandemic this has not been possible. This deficit is related to the quick adoption of the eVisittechnology as well as the lack of a formal “check-in” where the need for interpreter services istypically ascertained. Although this patient’s family spoke fluent English and Spanish, it is likely

Journal Pre-proofthat communication issues stemming from the lack of professional interpreter servicescontributed to the delay in diagnosis.A different outcome would not have been assured if an in-person visit had been conducted.However, the surgeon who conducted the VV is fellowship trained in arthroplasty andmusculoskeletal oncology, with over 30 years of experience in practice. We believe it unlikelyofthat this diagnosis would have been initially missed if the clinic encounter had been conducted-proin-person with a dedicated professional interpreter.reMany practices are embracing both virtual visits and telemedicine to continue to treat patientswith musculoskeletal problems while maintaining social distancing during the COVID-19lPpandemic. It is important to note the limitations of the technology and take steps to mitigateJournathese problems.

Journal Pre-proofReferences1.AAFP Blog. A virtual visit algorithm: how to differentiate and code telehealth visits, evisits, and virtual inpractice/entry/telehealth algorithm.html.Accessed April 25, 2020.Mehrotra A, Paone S, Martich GD, Albert SM, Shevchik GJ. Characteristics of Patientsof2.roWho Seek Care via eVisits Instead of Office Visits. Telemed J e-Health. 2013;19(7):515-Ricauda NA, Tibaldi V, Bertone P, et al. The RAD-HOME Project: A pilot study of homere3.-p519. doi:10.1089/tmj.2012.0221delivery of radiology services. Arch Intern Med. 2011;171(18):1678-1680.Gaitan D. Portable X-ray services becoming more common - rtable-x-ray-services-becoming-AARP. Mobile X Ray Services Amy Goyer Vlog.Jo5.urmore-common-idUSKBN0KW1ZN20150123. Accessed April 25, 2020.https://www.youtube.com/watch?v 3ge8llElOgk. Accessed April 25, 2020.