Impact of COVID-19 Pandemic on Patients' Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States.
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2021-04
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Abstract
Background
With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient's willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision.Methods
Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient's decisions.Results
A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%).Conclusion
COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic.Level of evidence
Level III.Type
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Chan, Jimmy J, Kevin K Chen, Peter Choi, Edward O Rojas, Oliver N Schipper, Amiethab Aiyer, Cesar de Cesar Netto, Amgad M Haleem, et al. (2021). Impact of COVID-19 Pandemic on Patients' Perceptions of Safety and Need for Elective Foot and Ankle Surgery in the United States. Foot & ankle orthopaedics, 6(2). p. 24730114211013788. 10.1177/24730114211013788 Retrieved from https://hdl.handle.net/10161/27429.
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Cesar de Cesar Netto
Cesar de Cesar Netto, MD, PhD, is an Associate Professor of Orthopaedic Surgery at Duke University School of Medicine, where he practices in the Division of Foot and Ankle Surgery. At Duke he serves as Head of Clinical Research for the Foot and Ankle Division and Program Director of the Foot and Ankle Fellowship. He is also Director of Foot and Ankle for the FIFA Medical Centre of Excellence at Duke and Director of the Duke GRAV-ET Laboratory (Global Research for Advanced Visualization and Enabling Technologies). He joined the Duke faculty in May 2023.
A native of Brazil, Dr. de Cesar Netto earned his medical degree from the University of São Paulo School of Medicine in 2006. He completed his residency in orthopaedic surgery and a fellowship in foot and ankle surgery at the same institution, where he also served as Chief of Residents. He later completed his PhD at the University of São Paulo in 2017. Early in his career he was Chief of the Foot and Ankle Service at Vila Nova Cachoeirinha Hospital and a team physician for Sport Club Corinthians Paulista, one of Brazil's leading professional soccer clubs.
He moved to the United States in 2014 for a research fellowship at MedStar Union Memorial Hospital in Baltimore, where he went on to work as a clinical research coordinator. He then completed three clinical foot and ankle fellowships: at the University of Alabama at Birmingham, at the Hospital for Special Surgery in New York, and at MedStar Union Memorial Hospital. In 2019 he joined the University of Iowa as an Assistant Professor in the Department of Orthopedics and Rehabilitation. There he co-directed the orthopaedic foot and ankle fellowship and built a research program that drew trainees from around the world, before moving to Duke in 2023.
Dr. de Cesar Netto's research centers on weight-bearing CT, three-dimensional imaging, and enabling technologies for the diagnosis and surgical planning of foot and ankle deformity. His group developed three-dimensional distance and coverage mapping techniques that measure joint alignment and subluxation under physiologic load. This work has helped redefine progressive collapsing foot deformity, the condition formerly known as adult-acquired flatfoot deformity. He chaired the international expert consensus group that introduced the progressive collapsing foot deformity classification in 2019 and reconvened it in 2025. His broader research covers hallux valgus and first ray instability, cavovarus deformity, syndesmotic and multiligament ankle instability, post-traumatic ankle osteoarthritis, and total ankle arthroplasty. It spans clinical outcomes, cadaveric biomechanics, and computational modeling.
He has authored more than 310 peer-reviewed publications and 12 book chapters. He co-edited the first textbook dedicated to weight-bearing CT in foot and ankle surgery (Springer, 2020) and the volume Forefoot Disorders: Basic Considerations and Treatment Strategies (Karger, 2024). He has given more than 400 podium and poster presentations and over 140 invited lectures across the Americas, Europe, and Asia. He has held visiting professorships and grand rounds lectureships at Harvard University, Northwestern University (Hampar Kelikian Memorial Lecture), the Rizzoli Orthopaedic Institute at the University of Bologna, the University of Maryland, Georgetown University, McGill University, and the University of São Paulo. He also delivered the James Nunley Visiting Professorship lecture at Duke. His research has been supported by the American Orthopaedic Foot & Ankle Society (AOFAS), the Arthritis Foundation, the Orthopaedic Research and Education Foundation, and industry partners.
His work has received numerous honors, including the following:
• the AOFAS J. Leonard Goldner Award (2026)
• the AOFAS Robert Anderson Award for sports medicine research (2026)
• the Orthopaedic Research Society New Investigator Recognition Award (2022 and 2026)
• the American Academy of Orthopaedic Surgeons Top Paper in Foot and Ankle (2023)
• the International Federation of Foot and Ankle Societies (IFFAS) President's Prize (2022)
• the European Foot and Ankle Society Distinguished Research recognition (2018)
• the IFFAS Takakura Prize (2017)
He has also received the American Orthopaedic Foot & Ankle Society Traveling Fellowship (2022) and the AOFAS and European Foot and Ankle Society Exchange Traveling Fellowship (2025).
Dr. de Cesar Netto has been Editor-in-Chief of Foot and Ankle Clinics since 2021. He serves as Associate Editor of the Journal of the Foot & Ankle and Scientific Reports (Nature), and reviews for the leading journals in the specialty. He is a founding board member of the International Weight Bearing CT Society, where he has served as Secretary, Treasurer, Vice President, and President. He is Secretary-Treasurer of the Orthopaedic Foot Club and a member of the Association of Bone and Joint Surgeons. Within the AOFAS, he chaired the Young Physicians Committee and serves on the Fellowship Committee. He has also served on the Education Committee of the American Academy of Orthopaedic Surgeons and on the board of the Brazilian Foot and Ankle Society. He regularly chairs international courses and consensus meetings, including the International Bone Research Association foot and ankle courses.
Mentorship is central to his academic work. He has mentored more than 70 clinical and research fellows, residents, and medical and undergraduate students. His mentees have won national and international research awards and now hold academic and clinical positions in the United States, Europe, South America, and Asia. At Iowa he was recognized three times as Outstanding Mentor in Translational Research by the Carver College of Medicine.
Clinically, Dr. de Cesar Netto treats a wide range of foot and ankle conditions. His practice focuses on complex reconstruction for progressive collapsing foot deformity and cavovarus deformity, hallux valgus and forefoot disorders, chronic ankle instability and syndesmotic injuries, sports and soccer injuries, and total ankle arthroplasty. He routinely uses weight-bearing CT and three-dimensional planning to tailor surgical correction to each patient.
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