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Review Article
2025
:4;
100552
doi:
10.1016/j.jorep.2025.100552

Should we be concerned about treating mpox patients in orthopaedic surgery? A narrative review

, , , ,
a Chris Hani Baragwanath Academic Hospital, South Africa
b Division of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa

⁎Corresponding author: Collen Sandile Nkosi. drcsnkosi@gmail.com

Received: , Accepted: ,
The Authors
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

The Mpox virus, is a zoonotic viral infection that belongs to the Orthopoxvirus genus and the poxviridae class. Infections caused by the orthopoxvirus can either be local or generalised disease. Once exposed the virus will enter the body through broken skin(cutaneous inoculation), mucous membranes (mouth, eyes) or the respiratory tract. Historically, case fatality rates (CFRs) have been published for each clade; CFRs for Clade I and II have been reported to be >10 % and 1–5%, respectively.

The purpose of this study was to examine the existing literature on Mpox and to consolidate the associated risk factors, causes and orthopaedic management strategies.

Studies done in Nigeria and central Africa highlighted contact with wild life (i.e hunting) as significant risk factor for Mpox.The Mpox has an incubation period of 7–14, that can also range between from 5 to 21 days. The correct use of personal protective equipment (PPE), hand hygiene and patient isolation remain as fundamental ways to prevent pathogen spread. It is highly crucial that all elective orthopaedic procedures should be deferred for patients with suspected or confirmed Mpox until the patient is deemed no longer contagious or typically asymptomatic, and skin lesions have disappeared.

Future research must investigate the correlation between Mpox and orthopaedic surgery. New standardized orthopaedic surgical guidelines should be developed for its treatment.

Keywords

Surgery
Mpox
Orthopaedic
Management
1

1 Introduction

A significant rise of Mpox cases emerged during the coronavirus disease (COVID)-19 pandemic as a new public health concern that might potentially impact people worldwide.1The current Mpox epidemic was declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) in July 2022 due to a notable increase in human Mpox cases in a number of non-endemic nations globally since mid-May 2022.1,2

The neglected pathogen that caused the 2022 MPox outbreak captured the attention of the world.3 Some countries had already witnessed the emergence and endemic nature of this pathogen several decades before this epidemic, unlike most of the world, which was caught off guard.4,5

Mpox is a zoonotic infectious disease.6 The WHO officially renamed monkeypox as Mpox on November 28, 2022.7–9 The etiological agent of Mpox virus, is a double-stranded DNA virus classified under the Orthopoxvirus genus of the Poxviridae family and Chordopoxvirinae subfamily7,10 Within the Orthopoxvirus genus, there are several species, with variola, vaccinia, ectromelia, and cowpox viruses being the most prominent.10,11

Researchers have identified two distinct clades of the human Mpox virus, each originating from different regions in Africa. Despite both causing a smallpox-like disease, the clade I Mpox virus, found in Central Africa, seems to result in more severe illness compared to the clade II Mpox virus, which is found in West Africa.4,8 Genetic variations divide the Clade II Mpox into two subclades, each of which is prevalent in specific regions of West Africa. Clade IIa is found in the western region, while Clade IIb is found in the eastern region of the Dahomey Gap savanna. Clade IIa and IIb Mpox have independently evolved from a common ancestor that originated centuries ago.8,10,12

Historically, CFRs have been published for each clade; CFRs for Clade I and II have been reported to be >10 % and 1–5%, respectively.13 In 1958, Mpox was initially recognized in captive monkeys that exhibited vesicular disease during their transfer from Africa to Copenhagen, Denmark for research.6 Despite the disease being named after this discovery, rodents such as squirrels and giant pouched rats are the primary animal reservoirs for the virus.6 In 1970, Mpox was identified in humans in the Democratic Republic of the Congo (DRC) by researchers.6,14

After that, there have been numerous outbreaks resulting in thousands of cases documented in Africa, particularly in 13 countries within the central and western areas, which are now deemed endemic regions.7 Outside Africa, The USA reported the initial human outbreak in 2003, with prairie dogs suspected to have acquired the infection from imported Gambian pouched rats from Ghana, potentially being the source of the human disease. Additional reports of cases and outbreaks were made in several other nations, including the USA in 2021, Singapore in 2019, and the United Kingdom in 2018–2019. These incidents were generally associated with travel to or the importation of animals from endemic regions.6,7,14,15

Men who engage in sexual activities with other men saw a significant demographic shift in recent outbreaks, becoming a disproportionately impacted group. For example, in the 2022 outbreak, this group reported the bulk of cases outside of endemic regions.16,17 Mpox may also be transmitted (Fig. 1) via intimate contact with contaminated surfaces, bodily fluids, and skin lesions.2,18,19 In a very short amount of time, the growth and evolution of the Mpox disease alongside HIV and genital skin disorders has increased morbidity and mortality worldwide.9 This study aims to review the current literature on Mpox and orthopaedic surgery, including related risk factors, causes, and therapy techniques.

Transmission process of the mpox virus.
Fig. 1 Transmission process of the mpox virus.
Proposed management approach for mpox in the orthopaedic setting.
Fig. 2 Proposed management approach for mpox in the orthopaedic setting.
2

2 Methods

A retrospective analysis of the literature was carried out to identify studies on Mpox patients and orthopaedic surgery. We conducted a comprehensive search for literature in PubMed, MEDLINE, The Cochrane Library, and Google Scholar, covering the period from January 01, 1970 to October 31, 2024. The following Mesh terms were used in the search for the articles: “Mpox” OR “Monkeypox” AND “orthopaedic surgery” OR “orthopaedic management,” and only articles in the English literature were considered.

3

3 Results and discussion

3.1

3.1 Pathophysiology

Infections caused by the orthopoxvirus can either be local or generalised disease.20 Once exposed the virus will enter the body through broken skin(cutaneous inoculation), mucous membranes (mouth, eyes) or the respiratory tract. It replicates at the site of entry.21,22 The virus enters the skin or respiratory system causing subcutaneous inoculation resulting in initial viral replication and spreading to endothelial cells and other cells.21–23 After initial replication the virus will enter the lymphatic system and blood stream causing primary viraemia. The virus will later replicate again in organs in internal organs leading to the development of systemic manifestations due to secondary viraemia.24

3.2

3.2 Risk factors

Studies done in Nigeria and central Africa highlighted contact with wildlife (i.e. hunting) as significant risk factor for Mpox.25 No prior smallpox vaccination was also found to be a risk factor as over 80 % of patients were found to be unvaccinated in Central Africa.26 Human immunodeficiency virus was also identified in patients with severe disease requiring hospitalisation.27 There is also association with high sexual activity.28 Poor socio-economic factors such as crowded settings, lack of access to basic amenities and sharing utensils are also associated with increased risk.29

3.3

3.3 Causes

The Mpox virus, a member of the Orthopoxvirus genus and poxviridae family, is the causative agent of Mpox, a zoonotic viral disease. The virus is a double stranded DNA virus with microscope showing a brick-like virion. The disease is similar to smallpox but generally less severe.30 Mpox is the causative agent. It has two strains, Clade I and Clade II found in different geographical locations in Africa. Clade I has mostly been isolated in Central Africa whereas Clade has been found in parts of West Africa.31,32 The virus is transmissible through contact with infected animals,33 or through human to human transmission directly or indirectly via respiratory droplets, bodily fluids, infected lesions, or formites. Vertical transmission has been described too in parts of DRC.33,34

3.4

3.4 Clinical presentation

The Mpox has an incubation period of 7–14, that can also range between from 5 to 21 days.35,36 Initially, it usual presents with flu-like symptoms which include fever, headache, muscle aches, backache, fatigue and lymphadenopathy, as well as a skin rash which can develop from onset or even up to three days later. Others will have associated proctitis, dysuria or dysphagia.35,37,38 According to WHO, the rash can be painful and itchy. It usually starts as a macule which develops into a papule one to two days later. The papule then develops into a vesicle (lasting for 1–2 days), which further becomes a pustule up to 2 days later, which can last for 5–7 days. The final stage of the rash is scabs which can 7 up to 14 days.35,37 The rash would usually start on the face and spread to the palms and sole. Other sites include the mouth, throat, groin, genitalia and anus. Of note, the patients present differently and some may only exhibit one or two of the mentioned symptoms or signs.37–39

3.5

3.5 Classification

Mpox is a double-stranded DNA virus belonging to the Poxviridae family. Two genetically distinct clades of this virus have been identified: the Congo Basin clade (Central African) and the West African clade.39,40 The Congo Basin clade is more prevalent and has demonstrated human-to-human transmission capabilities.41–43 WHO has identified these two clades of the Orthopoxvirus as Clade I (subclades Ia & Ib) and Clade II (subclades IIa & IIb), and has reported that the Mpox outbreak in 2022–2023 was due to the Clade IIb strain 38.

This self-limiting disease has also been clinically distinguished into two classical phases; the initial invasive period which is manifested as the clinical symptoms mentioned above, and the secondary skin eruption phase which is represented by the typical mucosal and/or skin rash and lesions.40

3.6

3.6 Diagnosis

Mpox is difficult to diagnose due to its similar presentation with other conditions, namely, chickenpox, measles, scabies, herpes, syphilis, sexually transmitted and bacterial skin infections, and medication-associated allergies.38 WHO has described the preferred laboratory test to be the polymerase chain reaction (PCR) to detect the DNA sequence of this virus. Nucleic acid amplification testing using real-time PCR (RT-PCR) or conventional PCR is preferred given its accuracy and sensitivity.36,44Specimens for the test are taken directly from the rash/lesions by swabbing.39 If the patient does not have a rash, throat or anal swabs can be obtained. Blood tests are not recommended as Mpox virus only remains in the blood for a short period.45 Antibody detection methods were also declared not useful by WHO due to their inability to distinguish between the different orthopoxviruses.38

3.7

3.7 Clinical management (Fig. 2)

The correct use of PPE, hand hygiene and patient isolation remain as fundamental ways to prevent pathogen spread.46,47 There is overwhelming evidence that the simple centuries-old practice of hand hygiene is still a principal measure in the prevention of healthcare associated infections.47,48 From the administrative point of view, it is important that facilities allocate enough resources towards infection control.49 This includes consistent supply of personal protective equipment and hand hygiene essentials.49 Additionally, The Centers for Disease Control and Prevention (CDC) also stresses the importance of regular and competency-based training of all staff at health facilities on infection prevention.49

3.8

3.8 Clinic

Clinics offer a unique opportunity for contagious organisms due to the generally confined spaces, high patient turnover and limited ventilation.50 In this setting, careful planning and an efficient scheduling process is important to minimize risk of exposure to both patients visiting the facility and the healthcare workers.51 Despite the structural challenges associated with clinics, facilities should make an attempted to reduce physical contact between individuals visiting the outpatient department. Patients should be screened and triaged during the scheduling process and in the waiting room.50,52 High-risk patients should then be moved to an examination room as soon as possible, to minimize contact with other patients.50 Hand hygiene compliance amongst physicians in the outpatient department is low.53 One study showed an overall compliance rate of 6.48 %, with half of the participants only performing hand hygiene in 3.08 % of their consultations.53

3.9

3.9 Casualty

During the initial assessment patients should be screened and isolation protocols be implemented timeously where it is indicated. The emergency department is a complex environment, often with critically ill patients and overcrowding.54,55 A systematic review found a direct relationship between poor hand hygiene compliance in healthcare workers and an overcrowded casualty.54 In addition, nurses were found to have a higher compliance rate compared to physicians.54 Due to the nature of human-to-human spread of the Mpox virus, the use of PPE and hand hygiene compliance is a crucial method to limit spread when done effectively.47,48 Training and education of healthcare workers, supplemented by posters, live demonstration have proven to be effective interventions to improve compliance.54

3.10

3.10 Ward

Nosocomial infections are the most prevalent adverse event and remain a global issue which needs urgent attention as they complicate management of patients and often prolong hospitalizations.56–58 It is thus important that good infection control practices are always implemented to limit spread during admission. Patients with Mpox should ideally be in an isolation room or have adequate physical distance between them and other patients to limit direct contact.51 During ward rounds, use of the necessary PPE such as gloves is necessary when examining patients.47 It is also paramount that clinicians observe the WHO 5 key moments of hand hygiene whenever conducting ward duties, and this would include during ward rounds.57

3.11

3.11 Vaccines and antiviral drugs

Tecovirimat is effective as both a preventive and therapeutic intervention. It diminishes viral multiplication in the lungs, resulting in expedited viral clearance, and its usually administered oral dosage was 10 mg/kg.59 Cidofovir inhibits viral DNA elongation by obstructing the incorporation of deoxycytidine triphosphate into viral DNA. It serves as an alternative medication to tecovirimat or can be used in conjunction with tecovirimat for patients experiencing severe Mpox.60

Vaccine generations have evolved from the first generation to the current fourth generation. The fourth generation vaccines have undergone trials in animal studies, with further research required in humans. They are believed to be more effective than third generation vaccines.59 Tecovirimat serves as the primary antiviral treatment for the condition, while Third-generation Modified Vaccinia Ankara Bavarian Nordic represents the most effective vaccine for Mpox prevention.59

3.12

3.12 Elective orthopaedic surgery

It is highly crucial that all elective orthopaedic procedures should be deferred for patients with suspected or confirmed Mpox until the patient is deemed no longer contagious or typically asymptomatic, and skin lesions have disappeared.42,61,62 In situations where postponement is not feasible, the procedure should be conducted with fewer healthcare practitioners in the operating theatre.61 This delay also helps mitigate the danger of Mpox transmission to healthcare professionals.45 The skin lesions inconsistent incubation period and prolonged resolution complicate assessment. This entails deferring elective orthopaedic surgery for a minimum of 21 days post-exposure, taking into account the documented incubation time of 4–28 days.45

3.13

3.13 Emergency orthopaedic surgery

A multidisciplinary team approach is recommended for the surgical treatment of Mpox patients. The team should consist of the patient, the patient's family, the surgeon, the physician, the anaesthesiologist, the ward nursing team, the theatre nursing team, the physiotherapist, the occupational therapist, the psychologist, other healthcare professionals, and, in certain instances, the employer in cases of employee exposure.40

Health care workers must recognize risk factors when participating in emergency orthopaedic surgery. These risk factors include patient skin lesions, bedding, clothing, and other types of garments in contact with patients. All equipment in contact with the patient should be isolated to minimize aerosolization of the Mpox particles.45,62 All healthcare personnel in the orthopaedic theatre during an emergency surgical Mpox case must be wearing proper PPE.45,61,62

3.14

3.14 Postoperative orthopaedic surgery

Appropriate personal protective equipment and isolation protocols must be implemented in the management of Mpox patients during transport and postoperative recovery.40,45 Postoperative follow-up should occur at a minimum of three weeks, when the risks for Mpox transmission have decreased. This follow-up should encompass a physical examination, wound assessment, and x-rays.40,63 We could not find any studies in the English literature on fracture-related complications due to Mpox.

3.15

3.15 Complications of mpox

In the event of surgery, every orthopaedic surgeon or physician should get knowledgeable about Mpox complications as part of their preoperative planning. Mpox complications can be classified as either local or systemic. Dermatological complications may encompass secondary bacterial skin infections, including abscesses, boils, septic dermatitis, ulceration, necrotizing soft tissue infections, and diffuse maculopapular rashes. Complications of the respiratory system include bronchopneumonia, pulmonary distress, ulcerative tonsillitis, and retropharyngeal abscess. Other systems that are affected by Mpox include gastrointestinal, ophthalmological, septicaemia, genitourinary, reproductive, myocarditis, and psychological disorders.64

Orthopaedic surgery presents various complications that can be categorized by their nature, including skin and bone issues, as well as their timing, whether early or late, and their phase, either preoperative or postoperative. Recognizing these complications is essential.

4

4 Conclusion

This study represents the inaugural investigation into the relationship between orthopaedic surgery and Mpox. Unfortunately, the study had limitations; we were unable to identify any previous reports addressing Mpox in orthopaedic patients in the English literature. As orthopaedic personnel, it is essential to acquaint ourselves with the disease in order to avoid being unprepared for its care. To understand how to safeguard ourselves against the disease and to provide treatment for patients should we accept an individual with Mpox to our wards.

The musculocutaneous system is a crucial system impacted by Mpox and is a main orthopaedic system of care. New standardized orthopaedic surgical guidelines should be developed for its treatment. We proposed a management strategy for mpox aimed at reducing complications and preventing the spread of the disease within the hospital the setting.

Ethical statement

Not applicable.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Collen Sandile Nkosi: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Yenziwe Sibongokuhle Mbambo: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Lunga Gadala: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Putso Learn Motubatse: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Thabo Leonard Muhango: Conceptualization, Methodology, Writing – original draft, Writing – review & editing.

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