Did COVID-19 related delays in surgical management lead to patient morbidity in the orthopaedic oncological population?

Abstract

Aims: The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA.

Methods: A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity.

Results: Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19.

Conclusion: COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236-242.

Keywords: COVID-19; Cancer; Coronavirus; Orthopaedic oncology; SARS-CoV-2.

Fig. 1

Morbidities due to COVID-19 related delays. The most common morbidity was prolonged pain/disability (52%). The second most common morbidity was a delay in diagnosis (40%).

Fig. 2

76-year-old female with poorly differentiated metastatic lung carcinoma to bone, prioritized as level III. Anteroposterior (AP), external rotation, and internal rotation radiographs of the left humerus, a) and b) 11 February 2020 and c) and d) 24 April 2020. e) Postoperative AP view, 2 May 2020. Extensive progressive interval osseous destruction with extraosseous soft tissue mass involving the left proximal humerus to mid-shaft diaphysis with associated pathological fracture. Due to COVID-19 related delays, this patient experienced prolonged pain and disability, unplanned radiation, and local tumour progression resulting in markedly increased surgical complexity.

Fig. 3

64-year-old male with undifferentiated pleomorphic sarcoma of the right arm, prioritized as level III. a) Coronal and b) axial MRI of the right humerus demonstrating a 2.1 × 2.2 × 3.3 cm well-defined lateral subcutaneous lesion at the level of the distal humeral diaphysis, 25 March 2020. c) Coronal and d) axial MRI of the right humerus demonstrating significant interval enlargement of an enhancing lobulated mass of the right arm, 7.8 × 4.8 × 4.6 cm, 8 July 2020. Due to COVID-19 related delays, this patient experienced a delay in diagnosis and marked local tumour progression, leading to a substantial increase in surgical complexity with a resulting wider required resection.

Fig. 4

31-year-old male with high-grade malignant melanoma of the left long finger, prioritized as level III. a) Gross image, 16 March 2020. b) Preoperative coronal positron emission tomography scan, negative for systemic pathological fluorodeoxyglucose uptake, 25 March 2020. c) Lymphoscintigraphy on the day of surgery (20 May 2020), demonstrating left axillary and pectoral nodal accumulation of radiopharmaceutical material. d) Postoperative gross image. Final pathology of the axillary lymph node was positive for malignant melanoma. Due to COVID-19 related delays, this patient may have experienced increased systemic tumour progression.