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Telemedicine in orthopaedics and trauma surgery during the first year of COVID pandemic: a systematic review

Abstract

Purpose

Prior to the COVID-19 pandemic, telemedicine in orthopaedics and trauma surgery had mostly developed for joint arthroplasty, fracture management, and general pre- and postoperative care including teleradiology. With the corona-outbreak, telemedicine was applied on a broad scale to prevent assemblage and to guarantee access to medical care protecting critical areas. The purpose of the present study was to give an overview of the spectrum of clinical applications and the efficacy of telemedicine in orthopaedic and trauma surgery as published in times of the COVID-19 pandemic.

Methods

All published studies investigating the application of telemedicine related to orthopaedics and trauma during the COVID-19 pandemic were accessed and screened for suitability. The primary outcome of interest was the efficacy of telemedicine in various clinical applications. The secondary outcome of interest was the spectrum of different applications in which telemedicine applications were investigated.

Results

The literature search resulted in 1047 articles. After the removal of duplicates, 894 articles were screened of which 31 finally met the inclusion criteria. Dimensions that were described by studies in the literature to have positive effects were preoperative patient optimisation, the usefulness of telemedicine to correctly diagnose a condition, conservative treatment, willingness to and feasibility for telemedicine in patients and doctors, and postoperative/post-trauma care improvement. The efficacy of telemedicine applications or interventions thereby strongly varied and seemed to depend on the exact study design and the research question addressed.

Conclusion

Various successful applications of telemedicine have already been reported in orthopaedics and trauma surgery, with a strong increase in scientific output during the COVID-19 years 2020–2021. Whether the advantages of such an approach will lead to a relevant implementation of telemedicine in everyday clinical practice should be monitored after the COVID-19 pandemic.

Peer Review reports

Introduction

Telemedicine is defined as healthcare delivered from a remote location by means of telecommunications technology replacing face-to-face contact [1]. Telemedicine was mostly considered helpful to provide access to modern medicine in areas with great distances to cover to see the next specialist [2]. In the US, before an expansion of telehealth with the 1135 waiver on March 2020, Medicare refunded only patients in designated rural areas [3]. Telemedicine is safe and effective to deliver and it is used in many medical specialities [4]. Patients appreciate its convenience, shortened appointment delay, reduced travelling times, costs, and time off work [5]. In comparison to other medical disciplines, telemedicine demonstrated limited evolution and application in the field of orthopaedics and trauma surgery before the COVID-19 pandemic [6]. Telemedicine in orthopaedics and trauma surgery had mostly developed for joint arthroplasty, fracture management, and general pre- and postoperative care including teleradiology [7]. With the first corona wave on the rise, telemedicine was applied on a global scale to prevent assemblage and to guarantee access to medical care [8, 9]. With a general boost in online services during the pandemic, institutionalised services were re-organised, re-adapted, and made available for patients and medical staff, with easy to use interfaces and tutorials. Technologies broadly used during the COVID-19 pandemic were daily life domains, with artificial intelligence, video-based communication platforms, and remote computerised topographies affordable to everyone [10]. In this context, it can be hypothesised that also telemedicine developed and gained popularity. Hence, several clinical investigations on telemedicine have emerged in the past years [11,12,13,14,15].

The purpose of the present systematic review was to investigate the development of telemedicine during the first year of the COVID-19 pandemic in orthopaedic and trauma surgery, exploring its clinical application and efficacy. It was hypothesised that the use of telemedicine during the first year of the COVID-19 pandemic gained popularity and efficacy, providing an alternative to face-to-face consultation and reducing within hospital patient turnover and assembly.

Material and methods

Search strategy

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement [16]. The following algorithm was preliminarily established:

  • Population: orthopaedic and trauma patients;

  • Intervention: telemedicine application;

  • Outcomes: development, clinical application, and efficacy;

  • Timing: during COVID pandemic.

In February 2022, PubMed, Web of Science, Google Scholar, and Embase were accessed restraining the search to articles published from January 1, 2020, until December 31, 2021. The following keywords were used in combination using the Boolean operator AND/OR: telemedicine(ALL FIELDS) AND orthopaedics(ALL FIELDS) OR trauma(ALL FIELDS) OR traumatology(ALL FIELDS). No additional filters were set for the literature search. Two authors (UKH; MM) independently performed the database search. All the resulting titles were screened per hand and, if suitable, the abstract was accessed. The full text of the abstracts which matched the topic was accessed. A cross reference of the bibliography of the full-text articles was also screened for inclusion. Disagreements were debated and settled by consensus.

Eligibility criteria

All published studies investigating the application of telemedicine during the COVID pandemic were accessed. Only articles available in English were eligible. Original studies with a level of evidence of I to IV according to the Oxford Centre of Evidence-Based Medicine [17] were considered. Reviews, opinions, letters, and editorials were not considered. Animal studies, in vitro-, biomechanical, computational, and cadaveric studies were not eligible. Only studies published during the period 2020–2021 were included. Only studies related to orthopaedics and trauma surgery were eligible.

Data collection and outcome of interest

The objective of the present systematic review was to provide an overview of the development of telemedicine during the COVID-19 pandemic in orthopaedic and trauma surgery, exploring its clinical application and efficacy. The following data were extracted and retrieved in a Microsoft Office Excel Version 16.69 (Microsoft Corporation, Redmond, US): name of the first author, year and journal of publication, level of evidence, study design, country of the study, purposes and main findings.

Results

Study selection

The literature search resulted in 1047 articles. After the removal of duplicates, 694 articles were screened. Of them, 353 studies did not focus on telemedicine applications in the field of orthopaedic and trauma surgery during the COVID-19 pandemic. A further 310 studies were excluded for the following reasons: language limitation (n = 33), not clinical studies (n = 171), and not being published during the period 2020–2021 (n = 106). Finally, 31 publications met the inclusion criteria and were included in the present systematic review (Fig. 1).

Fig. 1
figure 1

Flow chart of the literature search

Study characteristics and results of individual studies

Key interests in the published works were preoperative patient optimisation, the efficacy of telemedicine in diagnosis, follow-up of conservative and surgical treatments, willingness to and feasibility for telemedicine in patients and medical staff, and postoperative/post-trauma care improvement. Two studies found a positive impact of telemedicine in preoperative patient optimisation [18, 19]. Four studies evaluated the willingness to and feasibility of performing telemedicine in patients and doctors [20,21,22,23], and one study investigated its application in diagnoses [24]. Two studies evaluated the implementation of telemedicine for conservative treatments, including rotator cuff ailments [25, 26]. For chronic musculoskeletal spinal conditions, results were unambiguous and warrant further investigations [25]. Most studies in the field of orthopaedics investigated the efficacy of telemedicine in postoperative care [27,28,29,30,31,32]. In the field of trauma, the success of prevention programs was evaluated in two studies [33, 34], pre-treatment optimisation in one study [35], and conservative treatment/outpatient care in four studies [36,37,38,39]. One further study described the necessity to use high quality photographs to correctly formulate diagnoses via telemedicine [40]. The majority of studies deal with postoperative or post-trauma care improvements [41,42,43,44,45,46,47]. Generalities, purposes, and main findings of the studies which investigated the application of telemedicine during the COVID-19 pandemic in orthopaedics and trauma surgery are reported in Tables 1 and 2, respectively.

Table 1 Clinical studies from the field of orthopaedics reporting on telemedicine from 2020 and 2021
Table 2 Clinical studies from the field of trauma surgery reporting on telemedicine from 2020 and 2021

Discussion

Various applications of telemedicine have been reported in orthopaedics and trauma surgery, with a strong increase in scientific output during the years 2020–2021. Whether the advantages of such an approach will lead to a relevant implementation of telemedicine in everyday clinical practice should be monitored after the COVID-19 pandemic. A broad range of different clinical applications of telemedicine was investigated during the first year of the pandemic.

The efficacy of telemedicine applications or interventions thereby strongly varied and seemed to depend on the exact study design and the research question addressed. Classen et al. [20] for example compared the effect of an educational teleintervention (eHealth tool) to the usual elective consultation in patients with osteoarthritis of the knee or hip in a randomised controlled trial involving 286 patients. The authors concluded that an educational teleintervention does not improve patient satisfaction with the consultation, but it increases cognition about osteoarthritis [20].

Functional recovery was investigated by Ortiz-Piña et al. [47], who evaluated the influence of a multidisciplinary telerehabilitation program on functional recovery in elderly patients following surgical management for hip fracture in a single-blinded, non-randomised clinical trial. Twelve weeks of telerehabilitation program (35 patients) were compared to a control group receiving usual care (35 patients) [47]. Participants who used the telerehabilitation program had higher Functional Independence Measure scores and better performance in the Timed Up and Go Test compared with the control group, but no difference in the Short Physical Performance Battery [47]. Also in pain management, positive data were published: Pronk et al. [32] performed a randomised clinical trial to evaluate the introduction of a mobile application to manage pain in 71 patients following total knee arthroplasty during the first two weeks postoperatively. The authors stated that this method is effective to manage pain and that it reduces opioid consumption [32]. Teot et al. [39] conducted a randomised controlled trial comparing the efficacy of complex wound management. In their study, the authors evaluated complex wound management performed by untrained staff guided by an off-site wound care expert via telemedicine (89 wounds) versus professional staff at home (59 wounds) versus professional staff in the clinic (35 wounds) [39]. The authors found no difference between the three modalities, stating that telemedicine may represent a reliable alternative [39]. Similar results could be obtained by Westley et al. [49] when comparing the accuracy of virtual versus face-to-face assessment in hand trauma: there were no significant differences [49]. Another important issue is patient satisfaction, as it is crucial for compliance. Several studies are available all of them showing high patient and physician satisfaction, however not equal to face-to-face examination [21, 50,51,52]. Especially older patients show lower acceptance rates [22, 53]. Looking into a third-party perspective, Ariza-Vega et al. [41] investigated 44 family caregivers who had an older family member with a previous hip fracture. The authors stated that telemedicine should also address the family caregivers, who represent an essential component of recovery after hip fracture by providing emotional and physical support [41].

While previously being used only in a limited way in the context of mostly pre- and postoperative care, the use of telemedicine appears to have strongly increased during the COVID-19 pandemic. This is also reflected in the number of articles in PubMed resulting from “telemedicine AND orthopaedics”. Indeed, in 2018 and 2019 only 62 and 65 articles were retrieved, this number increased to 233 and 273 articles in 2020 and 2021, respectively. The same applies to the search terms “telemedicine AND trauma”: from 141 and 128 articles in 2018 and 2019 to 322 and 270 in 2020 and 2021, respectively. The evident problem of telemedicine in orthopaedics and trauma is the high relevance of manual clinical examination. Nevertheless, several applications are successful, such as postoperative telerehabilitation after total knee arthroplasty [54], or post-operative telemedicine encounters following rotator cuff repair [30]. Especially follow-up appointments are favourable for telemedicine since the patient-physician-connection is already stable and laboratory or surgery results can be discussed virtually as well [21, 51, 55]. In addition, single parameters such as the range of motion can be reliably evaluated by telemedicine in various joints [56,57,58]. First studies evaluating patient and surgeon satisfaction after online consultations showed promising results, with patient satisfaction exceedingly clearly that of surgeons [21, 50,51,52, 59]. Of note, satisfaction is a subjective outcome parameter and does not reflect the actual quality provided by telemedicine. With still further improving digital infrastructure the role of telemedicine is likely to increase in the coming years, especially if conditions like the COVID-19 pandemic turn up again. In addition, the still increasing specialisation in the field might lead to higher use of online services including virtual reality. To define, however, conditions and circumstances where to adequately apply telemedicine is still a challenge to face.

The present study has several limitations. While the present study highlights the findings of those studies published in the context of telemedicine during the COVID-19 pandemic, it does not selectively display information on changes directly measured in the context of the pandemic itself. It thus only provides a current picture of the general use of telemedicine, its possibilities and weaknesses. It neither analyses its suitability per-se to replace direct patient-doctor contact nor does it describe actual changes in use as a result of the pandemic. These articles are likely to emerge in the upcoming months and shall then be analysed accordingly.

Conclusion

The use of telemedicine increased during the COVID-19 years 2020–2021 in orthopaedics and trauma surgery. Key interests in the published works were preoperative patient optimisation, the efficacy of telemedicine in diagnosis, follow-up of conservative and surgical treatments, willingness to and feasibility for telemedicine in patients and doctors, and postoperative/post-trauma care improvement. Whether the advantages of telemedicine will lead to its relevant implementation in everyday clinical practice should be monitored after the COVID-19 pandemic. New digital possibilities, including artificial intelligence and virtual reality, should also be implemented and carefully evaluated.

Availability of data and materials

The datasets generated during and/or analysed during the current study are available throughout the manuscript.

Abbreviations

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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UKH conception and design, drafting; MM: supervision, literature search revision; FH: supervision; FM: conception, design, analysis, and interpretation of the data, drafting. All authors have agreed to the final version to be published and agree to be accountable for all aspects of the work.

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Hofmann, U.K., Hildebrand, F., Mederake, M. et al. Telemedicine in orthopaedics and trauma surgery during the first year of COVID pandemic: a systematic review. BMC Musculoskelet Disord 24, 101 (2023). https://doi.org/10.1186/s12891-023-06194-3

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