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Nuñez, MD, Lledó Batalla, MD, Martin Plomer, MD, Kushal Lakhani, MD, PhD, Josep Massons, PhD PII: S1058-2746(20)30472-9 DOI: https://doi.org/10.1016/j.jse.2020.06.001 Reference: YMSE 5219 To appear in: Journal of Shoulder and Elbow Surgery Received Date: 15 May 2020 Accepted Date: 8 June 2020 Please cite this article as: Garcia-Portabella M, Nuñez JH, Batalla L, Plomer M, Lakhani K, Massons J, Patient outcomes after humeral fracture surgery during the COVID-19 outbreak in Spain, Journal of Shoulder and Elbow Surgery (2020), doi: https://doi.org/10.1016/j.jse.2020.06.001. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not 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 this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. 1 Patient outcomes after humeral fracture surgery during the COVID-19 outbreak in Spain 2 3 Running head: Humeral Fractures in COVID-19 4 5 Authors: M.D. Montserrat Garcia-Portabella, MD1, Jorge H. Nuñez, MD1, M.D. Lledó Batalla, MD1, 6 Martin Plomer, MD1, Kushal Lakhani, MD1, PhD; Josep Massons, PhD1. 7 8 9 Institutional affiliation: 10 1. Shoulder and Elbow Unit, Traumatology and Orthopaedic Surgery Department, Universitat Autónoma 11 de Barcelona, Vall d’Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035 12 Barcelona, Spain 13 14 Corresponding author: 15 Jorge Hassán Nuñez Camarena, MD 16 Shoulder and Elbow Unit. Traumatology and Orthopaedic Surgery Department, Vall d’Hebron University 17 Hospital, Universitat Autónoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, 18 Spain 19 E-mail: j.nuñez@vhebron.net, hassan2803med@gmail.com 20 Telephone number: +34 727770739 21 22 Disclaimer: None. 23 24 Institutional review board approval was not required for this report. 1 Humeral Fractures in COVID-19 1 Patient outcomes after humeral fracture surgery during the COVID-19 outbreak in 2 Spain 3 4 Abstract 5 Background: The global spread of the 2019 novel coronavirus (COVID-19) has profoundly 6 affected the way we conduct our healthcare practices. The goal of this paper is to report the 7 outcomes of 11 patients who underwent humeral fracture surgery in the first few weeks of 8 the COVID-19 outbreak in Spain. 9 10 Methods: This was a retrospective case series of 11 patients who underwent humeral 11 fracture surgery during the first weeks of the COVID-19 outbreak in Spain, between 10 12 March and 25 April 2020. The clinical outcomes of these operative patients were monitored 13 up to 12 May 2020, the final date of follow-up, a minimum of 15 days after all patients 14 were discharged from the hospital. COVID-19 infection, mortality, demographic, clinical, 15 and laboratory data were analyzed. 16 17 Results: Thirty-six humeral fractures were recorded between 10 March and 25 April 2020. 18 During this period, humeral fracture fixation was the third most common surgery for 19 fracture in our institution after hip fracture and ankle fracture surgery. Eleven patients 20 underwent surgery (30.5%), of which seven were women (63.3%). The mean age was 64.8 21 years (SD 13.5). Nine operated cases had a proximal humerus fracture and 2 had a humeral 22 shaft fracture. One of the 11 patients was positive for SARS-CoV-2 on the basis of 23 quantitative reverse transcription polymerase chain reaction (RT-PCR) of throat swab 1 Humeral Fractures in COVID-19 24 samples. The overall median surgical time was 101.2 minutes (SD 28.4). The overall 25 median hospital length stays for the patient discharged was 2.2 days (range 1-4). No 26 COVID-19 nosocomial intrahospital infection occurred, no patient reported COVID-19 27 infection during the 15 days after hospital discharge. No intrahospital mortality was 28 recorded. Furthermore, no COVID-19 infection was reported in the shoulder surgeons that 29 performed the surgeries. 30 31 Conclusions: Although humeral fractures were not the most frequent fracture during this 32 outbreak, some required surgery. With good preoperative management that included RT- 33 PCR for COVID-19 and chest radiographs, protective measurements for the surgical team, 34 and rapid discharge of the patients, we were able to operate on 11 humeral fractures with no 35 COVID-19 nosocomial intrahospital infection in the patients or in the shoulder surgeons 36 that performed the surgeries. 37 38 Level of Evidence: Level IV, Retrospective Case Series 39 40 Keywords: shoulder; humerus; fracture; coronavirus; pandemic 1 Humeral Fractures in COVID-19 41 The global spread of the 2019 novel coronavirus (COVID-19) has profoundly affected the 42 way we conduct our healthcare practices 1. On 11 March 2020, the World Health 43 Organization (WHO) declared COVID-19 a pandemic. As of early June 2020, more than 44 7,000,000 people across all countries, territories, and regions have been infected by this 45 virus, and over 400,000 people have died 17. 46 47 Hospitals’ work regimes have been re-prioritized. However, even though coronavirus 48 infection must be a priority, this pandemic does not cause other health injuries, including 49 shoulder fractures, to disappear13. Although most surgeons are not fighting on the front 50 line, we must continue treatment for surgical patients and in the meantime, protect 51 healthcare workers and patients from COVID-19 infection14. Current guidelines, based on 52 expert opinion, suggest operating may be done on select closed shoulder fractures, that if 53 left untreated for more than 30 days, may lead to loss of function, permanent disability, 16 54 and/or irreducible dislocation of major joints . However, outcomes reported during the 55 pandemic have been less than optimal. Lei et al, retrospective analyzed 34 operative 56 patients who underwent elective surgeries during the incubation of COVID-19 in Wuhan, 57 they reported that all patients developed COVID-19, 44% required intensive care unit 58 (ICU) admission, and 7 died after admission to the ICU. Aminian et al, reported 4 surgical 59 patients (cholecystectomy, hernia repair, gastric bypass, and hysterectomy) who developed 60 perioperative complications in the first few weeks of COVID-19 outbreak in Tehran, Iran, 61 with a mortality of 75%2. Mi et al, reported 7 cases of osteoporotic hip fractures with an 62 intrahospital mortality of 42.9%, (3 of 7) and the other 4 remained in the hospital, with no 63 one discharged home8. Although many questions remain unanswered about COVID-19 and 1 Humeral Fractures in COVID-19 64 surgical practice, surgical teams should appropriately respond to this worldwide public 65 health crisis to improve patient outcomes and minimize the burden on the health care 66 systems and global society. 67 68 Despite shoulder fractures not being the most common fracture during this outbreak, most 69 shoulder fractures occurred in the home, so the implementation of stringent lockdown 70 measures for the population may not affect their incidence. Zhu et al, in a retrospective 71 multi-centre study of the epidemiologic characteristics of traumatic fractures in elderly 72 patients during the outbreak of coronavirus disease 2019 in China found that shoulder 73 fractures were the third most common fracture after hip fractures and spine fractures19. The 74 goal of this paper is to report the outcomes of 11 patients who underwent humeral fracture 75 surgery in the first weeks of the COVID-19 outbreak in Spain. Furthermore, we discuss our 76 personal protective equipment (PPE) and recommendations in these cases. 77 78 1 Humeral Fractures in COVID-19 79 Material and methods 80 Our experience comes from our work at a hospital within the Spanish National Health 81 System, which is one of the orthopedic and trauma referral centers in Spain. This was a 82 retrospective review of all humeral fractures between 10 March and 25 April 2020. We also 83 analyzed a retrospective case series of all patients who underwent humeral fracture surgery. 84 We monitored the clinical outcomes of these operative patients up to 12 May 2020, the 85 final date of follow-up, a minimum of 15 days after all patients were discharged from 86 hospital. 87 88 Surgery Protection Measures 89 A description of our personal protective equipment (PPE) is in table 1, and is also shown in 90 Figure 1. In our institution, two different surgical areas were created, each on a different 91 floor: one a COVID-positive surgical area and the other a COVID-negative surgical area. 92 Reverse transcription polymerase chain reaction (RT-PCR) tests for COVID-19 and chest 93 radiographs were performed before the patients underwent surgery. 94 95 In the operating room, general anesthesia with endotracheal intubation was performed, with 96 only the anesthesiologist and one surgical nurse in the room at that time. Only one surgeon 97 performed patient positioning in the beach-chair. In draping the surgical field, we started by 98 draping and covering the head, instead of starting at the axilla, for further protection of the 99 healthcare providers. A maximum of three surgeons was allowed during surgery, although 100 most of the surgeries were performed by only two surgeons. 101 1 Humeral Fractures in COVID-19 102 Follow-up and outcome measures 103 Primary data included demographics, clinical characteristics, laboratory findings, evidence 104 of COVID-19 infection or lack thereof, surgical treatment, and clinical outcome. Data 105 collected included: patient’s age, gender, injury mechanism, ASA (American Society of 106 Anesthesiologists) score, fracture type (Shoulder fracture using the AO classification), and 107 complications. We also recorded the surgical duration and time from hospital admission to 108 discharge. We monitored the status of any COVID-19 positive patients, to know if it was 109 reasonable to operate on patients with fractures during this pandemic. A COVID-19 110 nosocomial infection was defined as one that was acquired in the hospital. We reviewed the 111 electronic medical record to note if any symptoms of fever, dyspnea or COVID-19 112 infection (RT-PCR for COVID-19 and chest radiographs) occurred up until 12 May 2020, a 113 minimum of 15 days after surgery. We also directly communicated with the patients and 114 their families for any missing information. 115 116 Statistical Analysis 117 The results are presented as descriptive statistics, describing the categorical variables by 118 absolute values and percentages. Quantitative variables were presented by their measures of 119 central tendency (mean and standard deviation [SD]). We used SPSS software (version 120 23.0; IBM, Armonk, NY, USA) for statistical analysis of the data. 121 122 1 Humeral Fractures in COVID-19 123 Results 124 Thirty-six humeral fractures presented between 10 March and 25 April 2020, of which 26 125 (72.2%) were female. The mean patient age was 71.4 years (standard deviation (SD) 15.2). 126 Of these patients, 11 underwent surgery (30.5%) (Table 2), of which 7 (63.6%) were 127 women. The age range on surgical patients was 43-86, with a mean age of 64.8 years old 128 (SD 13.5). A fall from standing height caused 10 (90.9%) of the fractures. One younger 129 patient was involved in a high-velocity (traffic) accident, which caused his humeral fracture 130 and also a thoracic vertebral fracture that required surgery and débridement. 131 132 Nine operated cases had a proximal humerus fracture and two had a humeral shaft fracture. 133 The patients included in this study underwent 3 different surgical procedures. Eight 134 underwent open reduction and internal fixation (ORIF) of a proximal humeral fracture with 135 a proximal humeral plate, two underwent ORIF of a humeral shaft fracture with a humeral 136 nail, and one underwent a reverse total shoulder arthroplasty. 137 138 At the time of surgery, one of the 11 patients was positive for SARS-CoV-2 on the basis of 139 quantitative RT-PCR of throat swab samples. The overall median time between fracture 140 and surgery was 9 days (SD 8.7). All patients had an ASA score of II. The overall median 141 surgical time was 101.2 minutes (SD 28.4), and the overall median hospital stay until 142 discharge was 2.2 days (range 1- 4). No COVID-19 nosocomial intrahospital infections 143 occurred, and no patient reported COVID-19 infection during the 15 days after hospital 144 discharge. No intrahospital mortality was recorded. The 10 COVID-19 free patients, were 145 discharged, nine to home and one to a nursing home. The COVID-19 patient remained in 1 Humeral Fractures in COVID-19 146 the hospital for complications related to his spine surgery, but as of 19 April 2020 was 147 asymptomatic with a negative RT-PCR for COVID-19. Furthermore, no COVID-19 148 infection occurred in the shoulder surgeons that performed the surgeries. 149 150 Discussion 151 This report, to the best of our knowledge, is the first retrospective cohort study to describe 152 the clinical characteristics and outcomes of shoulder surgery patients during the COVID-19 153 pandemic. Shoulder fractures are not the most frequent fracture during this outbreak, but 154 their incidence is relatively constant despite the implementation of stringent lockdown 155 measures for the population because, as with hip fractures, most shoulder fractures occurr 156 at home11. Proximal humeral fractures account for 4% to 5% of all fractures, with only hip 157 and distal radial fractures being more common in the elderly3. In our study, humeral 158 fracture fixation was the third most common fracture surgery at our institution after hip and 159 ankle fractures (Figure 2). Using all the protective measurements described, we had no 160 COVID-19 nosocomial intrahospital infection in the patients nor shoulder surgeons that 161 performed the surgeries. 162 163 Unfortunately, this pandemic does not mean other medical emergencies disappear, 164 including shoulder fractures requiring surgery. We recommend only operating when it is 165 essential, and realize that we put both ourselves and our team, which includes 166 anesthesiologists and nurses, at risk. We must remember that intubation is considered one 167 of the highest-risk procedures when dealing with COVID-19 patients12. The majority of 168 proximal humerus fractures and humerus shaft fractures can be treated non-operatively. In a 1 Humeral Fractures in COVID-19 169 study evaluating the surgical management of proximal humerus fractures it was found that 170 the percentage of patients with proximal humerus fractures who underwent surgery ranged 171 from 0% to 68%3. A randomized clinical trial also found that in 2 years of follow-up, no 172 significant differences were seen in patient-reported outcomes between surgical and non- 173 surgical management of displaced proximal humeral fractures of the surgical neck. 174 Although in that study, the patients who underwent non-operative management underwent 175 guided physiotherapy15. In our study only 30.5% of humerus fracture required surgery and 176 was indicated only in complex and displaced fractures. Three cases were fracture- 177 dislocations of the proximal humerus, 6 cases were three and four-part proximal humeral 178 fractures, and the 2 humeral shaft fractures were severely displaced. 179 180 We note that in comparison with other studies, our patients had good outcomes with respect 181 to COVID-19 infection or respiratory complications. Fifteen days after discharge no patient 182 was noted to have COVID-19 infection. We assessed the patients after 15 days because it 183 has been estimated that 97.5% of COVID-19 infected cases will show symptoms within 184 11.5 days (95% CI, 8.2 to 15.6 days) 6. 185 186 One of the most important problems during the pandemic outbreak has been nosocomial 187 COVID-19 infections. In our hospital, as of 2 April 2020, 707 COVID-19 patients had been 188 admitted, of whom 165 were considered critical, requiring intensive care unit (ICU) (Figure 189 3)5. 190 1 Humeral Fractures in COVID-19 191 One point that differs from other studies is that we did surgery on the day of the admission 192 in 81.1% of our cases. Only 2 cases had a hospital admission prior to our surgery, one 193 because of polytrauma in the COVID-19 positive patient, and the other one due to a 194 concomitant proximal femur fracture. The overall mean hospital length stay was 2.2 days 195 (range 1-4), although we excluded the polytrauma patient, because he was COVID-19 196 positive before surgery and stayed to the date of this paper due to his spinal surgery. 197 198 In the Spanish HIP-COVID Investigation Group study, the mean delay from presentation to 199 the surgical procedure was 2.4 days. They did not report the overall median hospital length. 200 In that study of 62 patients who were tested for COVID-19, 23 patients were positive10. In a 201 study of 305 patients admitted to gastrointestinal surgery services, Luong-Nguyen et al7 had 202 15 patients (4.9%) develop a nosocomial infection with SARS-Cov-2. In 12 patients (80%), 203 the diagnosis was made after a hospital stay of more than 14 days (15-63 days)7. A report of 204 138 hospitalized patients from a single institution in Wuhan indicated that hospital-acquired 205 transmission accounted for 41.3% of these admitted patients, thus implicating the hospital 206 environment as a source of spread of the virus. Among those discharged alive, the median 207 hospital stay was 10 days (IQR, 7.0-14.0)18. 208 209 From an epidemiological perspective, nosocomial infection is a time-dependent event, 210 although other factors can contribute to nosocomial infection4. However, in our study with 211 a mean hospital stay of 2.2 days, we had excellent outcomes with respect to COVID-19 212 nosocomial infection. No COVID-19 infection was reported in the shoulder surgeons that 213 performed the surgeries. 1 Humeral Fractures in COVID-19 214 215 It is known that COVID-19 has forced 1000s of healthcare workers out of action in 216 Europe9. As of 25 April 2020, more than 35,000 healthcare workers were infected in Spain 16 217 . Every possible effort is important to create a feeling of healthcare provider protection. In 218 our study, 3 patients had abnormal laboratory data with an increase in white blood-cell 219 count and D-dimer, despite having a negative RT-PCR for COVID-19 and normal chest 220 radiographs. 221 222 We recommend that surgical draping start by covering the head, instead of starting at the 223 axilla. With our protocol, no surgical wound infection developed in our patients at an early 224 follow-up. Also, depending on the severity of the epidemic and available resources, the risk 225 and benefits of performing shoulder surgical procedures should be carefully assessed. In 226 locations with widespread infections and limited resources, the risk of shoulder surgical 227 procedures for the patient and the community may outweigh the benefit. Hospital beds, 228 surgical masks, and other PPE are in enormous demand around the world. 229 230 Our study has several notable limitations. The sample size of the present study was small 231 with a short follow-up. However, this is understandable because all surgeries around the 232 world have decreased because the COVID-19 pandemic. Additionally, only 7 patients had 233 RT-PCR for COVID-19 before surgery, however, none developed SARS-CoV-2 infection 234 after surgery, and no respiratory symptoms were recorded during follow-up. 235 236 Conclusion 1 Humeral Fractures in COVID-19 237 With good preoperative management that included RT-PCR for COVID-19 and chest 238 radiographs, protective measures for the surgical team, and rapid patient discharge, we 239 were able to operate on 11 humeral fractures with no COVID-19 nosocomial intrahospital 240 infection in the patients or the shoulder surgeons who performed the surgeries. 1 Humeral Fractures in COVID-19 241 References 242 1. Acter T, Uddin N, Das J, Akhter A, Choudhury TR, Kim S. Evolution of severe 243 acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as coronavirus disease 244 2019 (COVID-19) pandemic: A global health emergency. Sci Total Env. 2020 Apr 245 30 [Epub ahead of print]. doi: 10.1016/j.scitotenv.2020.138996. 246 2. Aminian A, Safari S, Razeghian-Jahromi A, Ghorbani M, Delaney CP. COVID-19 247 Outbreak and Surgical Practice. Ann. Surg. 2020 Mar 26 [Epub ahead of print]. 248 doi:10.1097/sla.0000000000003925 249 3. Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, Tosteson 250 AN. Trends and variation in incidence, surgical treatment, and repeat surgery of 251 proximal humeral fractures in the elderly. J Bone Joint Surg Am. 2011;93(2):121– 252 131. doi:10.2106/JBJS.I.01505 253 4. Beyersmann J, Kneib T, Schumacher M, Gastmeier P. Nosocomial Infection, Length 254 of Stay, and Time-Dependent Bias. Infect Control Hosp Epidemiol. 2009;30(3):273– 255 276. doi:10.1086/596020 256 5. Hospital Universitario Vall d' Hebron. Dades actualització situació COVID-19 - 257 Evolució Ingressos i Altes Hospitalització. 2020 258 https://hospital.vallhebron.com/es/enfermedades/coronavirus-sars-cov-2 (12 May 259 2020, date last accessed) 260 6. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The Incubation 261 Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported 1 Humeral Fractures in COVID-19 262 Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 Mar 20 [Epub 263 ahead of print]. doi:10.7326/M20-0504 264 7. Luong-Nguyen M, Hermand H, Abdalla S, Cabrit N, Hobeika C, Brouquet A, et al. 265 Nosocomial infection with SARS-Cov-2 within Departments of Digestive Surgery. J 266 Visc Surg. 2020 April 24 [Epub ahead of print]. doi:10.1016/j.jviscsurg.2020.04.016 267 8. Mi B, Chen L, Xiong Y, Xue H, Zhou W, Liu G. Characteristics and Early Prognosis 268 of COVID-19 Infection in Fracture Patients. J Bone Joint Surg Am. 2020 Apr 1 269 [Epub ahead of print]. doi:10.2106/jbjs.20.00390 270 9. Minder R. Virus Knocks Thousands of Health Workers Out of Action in Europe. 271 The New York Times. 272 https://www.nytimes.com/2020/03/24/world/europe/coronavirus-europe-covid- 273 19.html (Accessed 17 March 2020) 274 10. Muñoz Vives JM, Jornet-Gibert M, Cámara-Cabrera J, Esteban PL, Brunet L, 275 Delgado-Flores L, et al. Mortality Rates of Patients with Proximal Femoral Fracture 276 in a Worldwide Pandemic Preliminary Results of the Spanish HIP-COVID 277 Observational Study. J Bone Joint Surg Am. 2020 May 6 [Epub ahead of print]. 278 doi:10.2106/JBJS.20.00686 279 11. Nuñez JH, Sallent A, Lakhani K, Guerra-Farfan E, Vidal N, Ekhtiari S, Minguell J. 280 Impact of the COVID-19 Pandemic on an Emergency Traumatology Service: 281 Experience at a Tertiary Trauma Centre in Spain. Injury. 2020 May 12 [Epub ahead 282 of print]. doi:10.1016/j.injury.2020.05.016 1 Humeral Fractures in COVID-19 283 12. Orser BA. Recommendations for Endotracheal Intubation of COVID-19 Patients. 284 Anesth Analg. 2020;130(5):1109–1110. doi:10.1213/ANE.0000000000004803 285 13. Prada C, Chang Y, Poolman R, Johal H, Bhandari M. Best Practice for Surgeons. 286 COVID-19 Evidence-Based Scoping Review A Unifying Report of Global 287 Recommendations. https://myorthoevidence.com/covid19 (12 April 2020, date last 288 accessed) 289 14. Ramanathan K, Antognini D, Combes A, Paden M, Zakhary B, Ogino M, et al. 290 Health-care Development Planning and provision of ECMO services for severe 291 ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious 292 diseases. Lancet Respir. 2020;8(5):518-526. doi:10.1016/S2213-2600(20)30121-1 293 15. Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, et al. Surgical 294 vs nonsurgical treatment of adults with displaced fractures of the proximal humerus 295 the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037–1047. 296 doi:10.1001/jama.2015.1629 297 16. Urra S. Spain ranks first for Covid-19 infections among healthcare workers. El País. 298 https://english.elpais.com/spanish_news/2020-04-25/spain-ranks-first-for-covid-19- 299 infections-among-healthcare-workers.html (25 April 2020, date last accessed) 300 17. World Health Organization (WHO). https://ourworldindata.org/coronavirus. (8 June 301 2020, date last accessed) 302 18. Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 Transmission in Patients with 303 Cancer at a Tertiary Care Hospital in Wuhan, China. JAMA Oncol. 2020 Mar 25 1 Humeral Fractures in COVID-19 304 [Epub ahead of print]. doi:10.1001/jamaoncol.2020.0980 305 19. Zhu Y, Chen W, Xin X, Yin Y, Hu J, Lv H, et al. Epidemiologic characteristics of 306 traumatic fractures in elderly patients during the outbreak of coronavirus disease 307 2019 in China. Int. Orthop. 2020 Apr 29 [Epub ahead of print]. doi:10.1007/s00264- 308 020-04575-0 1 Humeral Fractures in COVID-19 309 Tables 310 Table 1. Description of persona+l protective equipment (PPE). 311 312 Table 2. Demographic, Clinical and Laboratory Data for Patients who underwent surgery 313 in our study. 314 315 Figure Legends 316 Figure 1: Photographs of our personal protective equipment (PPE) 317 318 Figure 2: Fracture surgery performed in our institution between 10 March and 25 April 319 2020. Humeral fracture fixation was the third most common surgery for fracture in our 320 institution after hip fracture and ankle fractures during this period. 321 322 Figure 3: Number of COVID-19 patients admitted in our hospital per day and the day of 323 surgery of the 11th patient. 1 1 Tables 2 Table 1. Description of personal protective equipment (PPE). 3 Description of personal protective equipment (PPE) 1. Waterproof gown 2. Mask. The conventional surgical mask does not offer protection if aerosols exist. The type of mask that is required includes the N95 and FFP2/FFP3 masks (which filter 96 and 99% of organisms, respectively). It is preferable to use masks without valves, since masks with valves do not protect patients from our microorganisms. We recommend wearing a surgical mask over a N95 or FFP2/FFP3 mask. 3. Glasses. Because of the power tools, aerosols are produced during procedures, so that complete ocular screen coverage is essential. 4. Full face coverage screen. This does not protect from aerosols, but is necessary when there is a risk of splashing (blood, vomiting or other biological fluids). 5. Sterile gloves (2 pairs) 6. Cap. It is a good idea for all staff with long hair to have it fully tied up in a low bun and properly restrained. 7. Exclusive footwear for the area of activity, without perforations. We recommend long boots for arthroscopy. Once the PPE is in place, surgical scrubbing with an alcohol gel will be performed on the surgical gloves, and sterile equipment necessary for the surgical intervention (gown and sterile gloves) will be placed on the PPE. 4 %: Percentage, PPE: Personal protective equipment 1 1 Tables 2 Table 2. Demographic, Clinical and Laboratory Data for Patients who underwent surgery in our study. 3 Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 Case 11 Sex Female Female Female Female Male Male Female Female Male Female Male Age (years) 86 74 64 58 55 43 84 73 50 60 66 ASA score II II II II II II II II II II II Comorbidity HBP, DLP, HBP DLP Fibromyalgia Diabetes, Polytrauma Diabetes, Asthma, HBP HBP HBP A-fib DLP, BPH with Thoracic Hypothyroidism, DLP, PFF vertebral DLP fracture, pelvis fracture, PFF Orthopaedic Proximal Humerus Proximal Proximal Proximal Proximal Humerus Proximal Proximal Proximal Proximal Diagnosis Humerus Shaft Humerus Humerus Humerus Humerus Shaft Humerus Humerus Humerus Humerus Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Fracture Orthopaedic rTSA ORIF with ORIF with ORIF with ORIF with ORIF with ORIF with ORIF with ORIF with ORIF with ORIF with Procedure humeral proximal proximal proximal proximal humeral nail and proximal proximal proximal proximal nail and humeral humeral humeral plate humeral plate cerclages humeral plate humeral plate humeral plate humeral plate cerclages plate plate Date of Fracture March 04, March 13, March 14, March 15, March February 28, April 02, April 21, April 22, April 25, April 22, 2020 2020 2020 2020 21,2020 2020 2020 2020 2020 2020 2020 Date of March 13, March 17, March March March February 28, April 22, April 21, April 29, April 29, April 29, Admission 2020 2020 18,2020 18,2020 25,2020 2020 2020 2020 2020 2020 2020 Orthopaedic March 13, March 17, March 18, March 18, March 25, March 27, April 22, April 24, April 29, April 29, April 29, Operation 2020 2020 2020 2020 2020 2020 2020 2020 2020 2020 2020 Date of March 16, March 20, March 19, March March 27, Remained in April0 25, April 26, April0 30, May 1, 2020 May 7, 2020 Discharge 2020 2020 2020 20,2020 2020 hospital 2020 2020 2020 Surgical 80 110 84 80 75 150 100 90 95 160 90 duration (minutes) Hospital Length 3 3 1 2 2 Remained in 3 5 1 3 1 1 Stay (days) hospital Laboratory test results Hemoglobin 12.9 11.9 13 14.6 14 12 13.2 15.2 13.1 13.7 14.1 (g/dL) White blood- 17.2 12.2 10.62 6.97 15.63 10.78 5.79 13.2 10.9 17.66 7.4 cell count (x109/L) Neutrophil 14.4 7.9 6.9 4.1 12.3 8.2 3.4 9.4 8 15.6 5.6 count (x109/L) Lymphocyte 1.8 2.9 2.2 2 1.3 1.6 1.8 2.8 1.8 0.8 1.2 count (x109/L) Monocyte count 0.9 1.1 1.5 0.7 1.5 0.6 0.5 0.7 1 1.3 0.5 (x109/L) Platelet count 264 256 288 253 189 647 249 269 298 258 250 (x109/L) aPTT (s) 26 26.4 31.1 27.8 26.6 28.3 28.8 22.9 34.3 29.7 30.1 PT (s) 16.1 11.9 11.3 10.9 12.8 14.6 13.1 11.5 12.2 13.1 13.1 Albumin (g/L) 3.3 3.7 3.2 3.7 3.7 2.7 4.1 NA 3.8 NA 4.7 ALT (U/L) 10 17 22 24 62 95 10 15 11 13 35 AST (U/L) 22 18 31 24 73 27 15 24 18 19 26 Total bilirubin NA 0.75 0.77 0.67 0.78 0.42 NA 0.68 NA 0.48 NA (mg/dL) Blood urea 56 47 44 51 32 28 33 54 15 35 46 nitrogen (mg/dL) Creatinine 1.44 0.88 0.54 0.59 1.08 0.37 0.7 0.72 0.49 0.64 0.84 (mg/dL) C-reactive 0.70 1.45 0.75 0.39 1.41 2.76 0.24 0.27 0.75 0.24 0.39 protein (mg/dL) IL-6 NA NA NA NA NA 17.1 NA 72.7 NA 25.23 NA 2 (pg/mL) D-dimer NA NA NA NA NA 710 NA 7780 NA 4743 NA (ng/mL) SARS-CoV-2 NA NA NA NA NEGATIVE POSITIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE quantitative RT- PCR Chest X-ray Lungs and Lungs and Lungs and Lungs and Lungs and Unilateral Lungs and Lungs and Lungs and Lungs and Lungs and pleural pleural pleural pleural pleural spaces patchy pleural spaces pleural spaces pleural spaces pleural spaces pleural spaces spaces were spaces were spaces spaces were were clear consolidation were clear were clear were clear were clear were clear clear clear were clear clear 4 HBP: high blood pressure; DLP: Dyslipidemia; A-fib: Atrial fibrillation; BHP: Benign prostatic hyperplasia; PFF: Proximal Femoral Fracture; rTSA: Reverser 5 Total Shoulder Arthroplasty; aPTT: activated partial thromboplastin time; PT: prothrombin time; ALT: alanine aminotransferase; AST: aspartate 6 aminotransferase; IL: interleukin; RT-PCR: Reverse transcription polymerase chain reaction. 7 3