The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period. Cite this article: Bone Joint Open 2020;1-6:222–228

Introduction. Patient reported outcome measures (PROMs) are increasingly used as quality benchmarks in total joint arthroplasty (TJA). The objective of this study was to investigate whether PROMs correlate with patient satisfaction, which is arguably the most important and desired outcome. Methods. An institutional joint database was queried for patients who underwent primary, elective, unilateral TJA. Eligible patients were asked to complete a satisfaction survey at final follow-up. Correlation coefficients (R) were calculated to quantify the relationship between patient satisfaction and prospectively collected PROMs. We explored a wide range of PROMs including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); Short Form-12 (SF-12), Oxford Hip Score (OHS), Knee Society Clinical Rating Score (KSCRS), Single Assessment Numerical Evaluation (SANE), and University of California Los Angeles activity level rating (UCLA). Results. In general, there was only weak to moderate correlation between patient satisfaction and PROMs. Querying the absolute postoperative scores had higher correlation with patient satisfaction compared to either preoperative scores or net changes in scores. The correlation was higher with disease-specific PROMs (WOMAC, OHS, KSCRS) compared to general health (SF-12), activity level (UCLA), or perception of normalcy (SANE). Within disease-specific PROMs, the pain domain consistently carried the highest correlation with patient satisfaction (WOMAC pain subscale, R = 0.45, p <0.001; KSCRS pain subscale, R = 0.49, p <0.001). Conclusion. There is only weak to moderate correlation between PROMs and patient satisfaction. PROMs alone are not the optimal way to evaluate patient satisfaction. We recommend directly querying patients about satisfaction and using shorter PROMs, particularly disease-specific PROMs that assess pain perception to better gauge patient satisfaction. For figures, tables, or references, please contact authors directly

Statement of clinical significance: Gait Analysis (GA) is a valuable technique for investigating functional limitations in children with gait abnormalities. Because GA generates such a large quantity of data, it could be more useful to have a single parameter derived from kinematic and kinetic GA data. For this reason, Schutte proposed the use of a global index (Normalcy Index – NI) that is derived from 16 selected gait variables and measures the distance between the patient’s gait data and that of a control population with no pathology. The first aim of this study is the classification of children with gait abnormalities such as “clumsy” children, idiopathic Toe-walkers and children affected by Cerebral Palsy using NI and the second aim is to verify the usefulness of the NI in the characterisation of these subjects’ gait.

Material and methods: The GA trials were carried out at the “Gait Analysis Lab”, Children Hospital “V.Buzzi”, Milan, Italy by using an ELITE system (8 TVC working at 100 Hz) and two force platforms (Kistler, CH). 25 subjects with no known gait pathology (mean age 14, range: 7– 28 years) underwent GA and formed the group needed in order to define the parameters of normal gait. The subjects with gait abnormalities were 7 clumsy children (mean age: 7 years, range: 5-10 years), 17 idiopathic Toe-walkers (mean age: 6 years, range: 5-8 years) and 166 subjects affected by Cerebral Palsy (mean age: 10 years, range: 3-24 years) divided in two groups: Independent Walkers (33 hemiplegics, 106 diplegics and 7 quadriplegics) and Dependent Walkers (13 diplegics and 7 quadriplegics). The mean NI over the available trials was calculated for each subject. For all the subjects the left and right side NI values were pooled. Group means and standard errors were then calculated.

Results: For clumsy children and for idiopathic Toe-walkers we obtained mean NI values higher than mean NI value found for healthy subjects, but they are smaller than the mean NI values calculated for subjects affected by Cerebral Palsy. Moreover for children affected by Cerebral palsy, we found that higher degrees of severity of CP induced impairment were associated with higher NI values, in accordance with the findings of Schutte et al. The division of the Cerebral Palsy subjects into Independent and Dependent Walkers shows that the use of aids results in a locomotor pattern that is totally incomparable with that of “normal gait”.

Conclusions: The NI is easy to understand and to apply in order to summarize GA data. It is a useful element in the classification of the locomotor pattern of subjects with motor abnormalities. The NI is able to distinguish normal subjects from clumsy children and idiopathic Toe-walkers, patients with only minor abnormalities and by using NI it’s possible to classify different levels of functional impairments in group of subjects affected by Cerebral Palsy.