ArticlePDF Available

Elective orthopaedic surgery with a designated COVID-19-free pathway results in low perioperative viral transmission rates

Authors:

Abstract

Aims The safe resumption of elective orthopaedic surgery following the peak of the COVID-19 pandemic remains a significant challenge. A number of institutions have developed a COVID-free pathway for elective surgery patients in order to minimize the risk of viral transmission. The aim of this study is to identify the perioperative viral transmission rate in elective orthopaedic patients following the restart of elective surgery. Methods This is a prospective study of 121 patients who underwent elective orthopaedic procedures through a COVID-free pathway. All patients underwent a 14-day period of self-isolation, had a negative COVID-19 test within 72 hours of surgery, and underwent surgery at a COVID-free site. Baseline patient characteristics were recorded including age, American Society of Anaesthesiologists (ASA) grade, body mass index (BMI), procedure, and admission type. Patients were contacted 14 days following discharge to determine if they had had a positive COVID-19 test (COVID-confirmed) or developed symptoms consistent with COVID-19 (COVID-19-presumed). Results The study included 74 females (61.2%) and 47 males (38.8%) with a mean age of 52.3 years ± 17.6 years (18 to 83 years). The ASA grade was grade I in 26 patients (21.5%), grade II in 70 patients (57.9%), grade III in 24 patients (19.8%), and grade IV in one patient (0.8%). A total of 18 patients (14.9%) had underlying cardiovascular disease, 17 (14.0%) had pulmonary disease, and eight (6.6%) had diabetes mellitus. No patients (0%) had a positive COVID-19 test in the postoperative period. One patient (0.8%) developed anosmia postoperatively without respiratory symptoms or a fever. The patient did not undergo a COVID-19 test and self-isolated for seven days. Her symptoms resolved within a few days. Conclusion The development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. While both surgeons and patients should remain vigilant, elective surgery can be safely restarted using dedicated pathways and procedures.
VOL. 1, NO. 9, SEPTEMBER 2020 562
Freely available online
Follow us @BoneJointOpen
BJO
J. S. Chang,
W. Wignadasan,
R. Pradhan,
C. Kontoghiorghe,
B. Kayani,
F. S. Haddad
From University College
London, London, UK
Correspondence should be sent to
Justin S Chang; email:
justin. chang@ mail. utoronto. ca
doi: 10.1302/2633-1462.19.BJO-
2020-0110.R1
Bone Joint Open 2020;1-9:562–
56 7.
GENERAL ORTHOPAEDICS
Elective orthopaedic surgery with a
designated COVID-19- free pathway
results in low perioperative viral
transmissionrates
Aims
The safe resumption of elective orthopaedic surgery following the peak of the COVID-19
pandemic remains a significant challenge. A number of institutions have developed a COVID-
free pathway for elective surgery patients in order to minimize the risk of viral transmission.
The aim of this study is to identify the perioperative viral transmission rate in elective ortho-
paedic patients following the restart of elective surgery.
Methods
This is a prospective study of 121 patients who underwent elective orthopaedic procedures
through a COVID- free pathway. All patients underwent a 14- day period of self- isolation, had
a negative COVID-19 test within 72 hours of surgery, and underwent surgery at a COVID-
free site. Baseline patient characteristics were recorded including age, American Society of
Anaesthesiologists (ASA) grade, body mass index (BMI), procedure, and admission type.
Patients were contacted 14 days following discharge to determine if they had had a posi-
tive COVID-19 test (COVID- confirmed) or developed symptoms consistent with COVID-19
(COVID-19- presumed).
Results
The study included 74 females (61.2%) and 47 males (38.8%) with a mean age of 52.3 years
± 17.6 years (18 to 83 years). The ASA grade was grade I in 26 patients (21.5%), grade II in 70
patients (57.9%), grade III in 24 patients (19.8%), and grade IV in one patient (0.8%). A total
of 18 patients (14.9%) had underlying cardiovascular disease, 17 (14.0%) had pulmonary
disease, and eight (6.6%) had diabetes mellitus. No patients (0%) had a positive COVID-19
test in the postoperative period. One patient (0.8%) developed anosmia postoperatively
without respiratory symptoms or a fever. The patient did not undergo a COVID-19 test and
self- isolated for seven days. Her symptoms resolved within a few days.
Conclusion
The development of a COVID- free pathway for elective orthopaedic patients results in very
low viral transmission rates. While both surgeons and patients should remain vigilant, elec-
tive surgery can be safely restarted using dedicated pathways and procedures.
Cite this article: Bone Joint Open 2020;1-9:562–567.
Keywords: COVID-19, Elective orthopaedic surgery, COVID-19- free pathway, Restarting elective surgery
Introduction
COVID-19 was declared a pandemic by the
World Health Organization (WHO) on 11
March 2020.1 Globally, healthcare systems
faced the enormous challenge of managing
the peak of the pandemic while limiting the
number of lives lost. The initial response to the
pandemic included the cessation of routine
services including elective orthopaedic surger y.
Many orthopaedic sta were redeployed to the
intensive therapy unit (ITU), formed “proning”
teams, and managed minor injury units in the
emergency department.2,3 However, as the
peak of the pandemic passes, the challenge
shifts to the safe resumption of routine medical
services including elective orthopaedic surger y.
VOL. 1, NO. 9, SEPTEMBER 2020
ELECTIVE ORTHOPAEDIC SURGERY WITH A DESIGNATED COVID-19- FREE PATHWAY RESULTS IN LOW PERIOPERATIVE VIRAL TRANSMISSION RATES 563
Table I. Questionnaire derived from the NHS diagnosis criteria for
COVID-19.8
Question asked Answer
Have you experienced a high temperature since the date of
your operation?
Yes/No
Have you developed a new cough since the date of your
operation?
Yes/No
Have you experienced any shortness of breath since the date
of your operation?
Yes/No
Have you noticed any loss of smell since the date of your
operation?
Yes/No
Have you noticed any change in taste since the date of your
operation?
Yes/No
Have you had a COVID-19 swab since being discharged from
the hospital?
Yes/No
Have you developed any other concerning symptoms since
your operation?
Yes/No
NHS, National Health Service
There is apprehension among both surgeons and
patients about restarting elective surgical services. A
recent study suggested that only 56.8% of patients
previously booked for surgery wanted to undergo their
planned procedure once elective services resumed.4 The
high mortality rate in perioperative patients who contract
COVID-19 is of particular concern. One study reported
a 30- day mortality rate of 23.8% in patients who had
contracted COVID-19 in the perioperative period.5 In
addition, London, UK, has become one of the worst
aected cities globally; as of 17 June 2020, there were
27,354 confirmed cases and 6,079 deaths in patients with
COVID-19 in London hospitals alone.6 This highlights the
dilemma faced by healthcare systems in restarting elec-
tive surgical services while trying to minimize potential
COVID-19 transmission, particularly in an epicentre such
as London.
A designated COVID-19- free pathway was developed
in our institution to minimize the risk of COVID-19 trans-
mission in elective surgical patients. The hospital was
separated into two separate “zones” including a “green
COVID-19- free zone and a “blue” potential COVID-19
zone. Additionally, two independent private hospitals
were converted into COVID-19- free sites for National
Health Service (NHS) use. All patients undergoing elec-
tive surgery are required to self- isolate for a period of
14 days and test negative for COVID-19 within 72 hours
prior to their surgery. In addition, these patients are all
admitted through the COVID- free pathway in order to
minimize viral transmission risk. In contrast, all patients
admitted through the emergency department (ED),
including all trauma patients, are admitted under the
“blue” COVID-19 pathway due to uncertain COVID-19
exposure and status.
The aim of this study is to assess the eectiveness
of a designated COVID-19- free pathway in minimizing
viral transmission rates in elective orthopaedic patients.
Our hypothesis is that a preoperative 14- day period of
self- isolation, negative COVID-19 test within 72 hours
of surgery, and admission through a COVID-19- free
pathway results in low transmission rates of the virus.
Methods
Study design. This is a prospective study of 121 consec-
utive patients who underwent an elective orthopaedic
procedure in the first four weeks following the resump-
tion of elective operating services during the COVID-19
pandemic. The study dates are from 26 May 2020 to 19
June 2020. Patients were included if they self- isolated 14
days prior to surgery, had a negative COVID-19 test with-
in 72 hours of surgery, and were admitted through the
COVID-19- free pathway. Patients who underwent emer-
gency procedures and trauma operations were excluded.
Ethical approval was not required as this was considered
a necessary evaluation of service.
Outcomes. Baseline characteristics including sex, age,
American Society of Anaesthesiologists (ASA) grade, body
mass index (BMI), comorbidities, surgical procedure, and
admission type were recorded. The primary outcome
was transmission of COVID-19 infection in the periop-
erative period following elective orthopaedic surgery.
Patients were considered COVID-19- positive for the virus
if they had a positive COVID-19 laboratory test, irrespec-
tive of symptoms experienced (COVID-19 confirmed).7
Patients were also considered COVID-19- positive if they
experienced any of the main criteria described by the
NHS including a high temperature, a new or continuous
cough, and/or a loss or change in sense of smell or taste.
Patients were designated as COVID-19 presumed if they
did not undergo a confirmatory laboratory test or had
an inconclusive test.8 All patients were contacted by a
member of the orthopaedic team 14 days after discharge
and were asked questions from a pre- designed question-
naire derived from the diagnostic criteria by NHS England
(Table I).8 This included determining whether patients
had a confirmed positive test or experienced symptoms
of COVID-19 within 14 days of hospital discharge.
COVID-free pathway for elective orthopaedic patients. The
British Orthopaedic Association (BOA) and the NHS have
released guidelines for the safe resumption of elective
surgical services.9,1 0 These guidelines include a period of
self- isolation prior to surgery, a preoperative COVID-19
test, and surgery in a designated COVID-19- free zone.
At our institution, a central London tertiary centre, the
hospital was divided into a COVID-19- free zone and a
“possible” COVID-19 zone. Each zone had designated en-
trances, wards, operating theatres, and sta. Patients in
the COVID-19- free pathway used a separate entrance to
the hospital, designated elevators, and were admitted to
COVID-19- free wards. In addition, hospital sta are divid-
ed into separate teams that cannot cross pathways within
the same 24- hour period in order to minimize the risk of
viral transmission. Two independent hospitals were also
BONE & JOINT OPEN
J. S. CHANG, W. WIGNADASAN, R. PRADHAN, C. KONTOGHIORGHE, B. KAYANI, F. S. HADDAD
564
Table II. Baseline patient characteristics.
Characteristic Variable
Overall, n 121
Age yrs, mean (range) 52.3 ± 17.6 (18 to 83)
Sex, n (%)
Female 74 (61.2)
Male 47 (38.8)
ASA grade, n (%)
I 26 (21.5)
II 70 (57.9)
III 24 (19.8)
IV 1 (0.8)
Comorbidities, n (%)
Cardiovascular disease 18 (14.9)
Pulmonary disease 17 (14.0)
Diabetes 8 (6.6)
Admission type, n (%)
Day case 58 (47.9)
Inpatient 63 (52.1)
ASA, American Society of Anaesthesiologists.
designated as COVID-19- free areas for NHS use; the risk
of cross- contamination at these sites is likely reduced
further.
Patients with clinically urgent procedures and who
were deemed low risk for COVID-19- related complica-
tions were prioritized. However, urgent procedures in
higher- risk patients were also undertaken. All elective
surgical patients, and their respective households, were
instructed to self- isolate for a period of 14 days prior to
surgery. A self- isolation period of 14 days was selected
on evidence that 99% of patients will develop symptoms
within 14 days of exposure to the virus.11 Pre- assessment
clinics were carried out in a face- to- face manner approx-
imately 15 days prior to the scheduled procedure before
the self- isolation period. In addition, all patients under-
went a reverse transcription polymerase chain reaction
(RT- PCR) COVID-19 test within 72 hours of their sched-
uled operation date. Only patients with a negative test
were allowed to proceed with surgery. Patients were
tested at a “drive- through” facility to enable easy and
rapid testing with appointments staggered to maintain
social distancing and reduce the risk of viral transmission.
Patients were also advised to avoid taking public trans-
port to the hospital both for their COVID-19 test and for
their operation.
Once admitted to hospital, social distancing measures
were observed and patients were allocated private rooms
where possible. All patients and hospital sta wore
surgical masks in the hospital and full personal protec-
tive equipment (PPE), including FFP3 masks, protective
visors, gloves, and gowns for any aerosol- generating
procedures. Prior to surgery, all patients were specifically
consented for the risk of COVID-19 transmission in the
perioperative period. The potential complications asso-
ciated with the disease including intensive therapy unit
(ITU) admission and an increased perioperative mortality
rate of up to 23.5% were discussed. Postoperatively, all
patients were admitted to a COVID- free ward. Only sta
assigned to the COVID-19- free pathway were able to care
for the patients while they remained in hospital in order
to minimize the risk of viral transmission.
Results
A total of 125 elective orthopaedic cases were sched-
uled from 26 May 2020 to 19 June 2020. Four of these
procedures (3.2%) were cancelled: two patients (1.6%)
postponed their operations at the last minute due to fear
of COVID-19 contraction; and two patients (1.6%) were
deemed not fit for surgery after being seen in the pre-
assessment clinic.
Overall, 121 patients underwent elective orthopaedic
procedures in the study period. The study included 74
females (61.2%) and 47 males (38.8%) with a mean age
of 52.3 ± 17.6 years (18 to 83) (TableII). The ASA grade
was classified as grade I in 26 patients (21.5%), grade II
in 70 patients (57.9%), grade III in 24 patients (19.8%),
and grade IV in one patient (0.8%). The BMI was 28.0
± 6.3 (19.2 to 50.6). A total of 18 patients (14.9%) had
a history of cardiovascular issues, 17 patients (14.0%)
had a history of pulmonary disease, such as asthma and
chronic obstructive pulmonary disease (COPD), and
eight patients (6.6%) had underlying diabetes mellitus.
The various surgical procedures performed are listed in
TableIII. There were 58 day- case procedures (47.9%) and
63 inpatient procedures (52.1%).
One patient (0.8%) developed anosmia 12 days post-
operatively and was designated as COVID-19 presumed.
However, this patient did not develop a fever or other
respiratory symptoms; fortunately, the symptoms
resolved within a few days. The patient did not undergo
a COVID-19 test and self- isolated for seven days after
developing symptoms. None of the other patients in our
cohort experienced any positive symptoms of COVID-19
and, as a result, did not warrant a COVID-19 test.
Discussion
The resumption of routine medical and surgical services
after the peak of the COVID-19 pandemic poses a great
challenge to healthcare systems globally. There is
increasing debate over the safest time to resume routine
services, including elective orthopaedic services. While
the concern of hospital- acquired COVID-19 transmis-
sion is significant, the true risk is uncertain.12
Our study demonstrates that elective orthopaedic
surgery can be safely restarted following a designated
COVID-19- free pathway. At our institution, no patients
tested positive for COVID-19 postoperatively and one
patient was classified as a presumed COVID-19 case due
to the development of anosmia 12 days after surgery.
VOL. 1, NO. 9, SEPTEMBER 2020
ELECTIVE ORTHOPAEDIC SURGERY WITH A DESIGNATED COVID-19- FREE PATHWAY RESULTS IN LOW PERIOPERATIVE VIRAL TRANSMISSION RATES 565
Table III. Elective orthopaedic procedures performed.
Procedure Number
Overall 121
Primary knee arthroplasty 14
Primary hip arthroplasty 32
Revision knee arthroplasty 1
Revision hip arthroplasty 4
Knee arthroscopy (including meniscectomy/meniscal repair) 8
Knee ligament reconstruction 6
Hand and wrist procedures 16
Removal of metalwork 8
Unicompartmental/patellofemoral knee arthroplasty 4
Primary shoulder arthroplasty 1
Revision shoulder arthroplasty 1
Shoulder arthroscopic procedures 5
Foot and ankle procedures 4
All other procedures 17
That patient did not undergo a confirmatory test after
the onset of her symptoms. Fortunately, this patient did
not develop a fever or cough and the symptoms resolved
within a few days. It is also possible that her symptoms
were not related to her perioperative care as the patient
did not self- isolate following hospital discharge and the
onset of symptoms was late. While our institution is still
in the early phases of restarting elective surgery, there
is growing confidence that elective procedures can be
performed in a safe environment that greatly minimizes
the risk of COVID-19 transmission and its associated
complications.
A significant concern for restarting elective surgery
includes reports of high mortality rates in patients who
contract COVID-19 in the perioperative period. An inter-
national cohort study involving 1,128 patients reported
a 30- day perioperative mortality of 23.8% among
COVID-19- positive patients.3 Additionally, another early
COVID-19 study from Wuhan, China, reports a high
complication rate and 20% mortality rate associated with
patients who contracted COVID-19 in the early postoper-
ative period.13
Despite these concerns, a significant proportion of
patients want to proceed with their scheduled opera-
tions. A recent study suggested that 56.8% of patients
who were previously listed for surgery wanted to
proceed with their operations at the earliest opportu-
nity. These patients were willing to self- isolate for 14
days and to be tested for COVID-19 within 72 hours
prior to surgery.4
Elective orthopaedic procedures are typically
performed to improve quality of life and physical func-
tion.14,15 Primary joint arthroplasty is one of the most
successful procedures in terms of improving quality
of life, and patients are often in significant pain and
severely debilitated prior to surgery.16-18 Furthermore,
a significant deterioration in patients’ physical and
mental health can arise with a delay in surgery. One
study reported that 19% of patients waiting for a total
hip arthroplasty (THA) and 12% of those waiting for
a total knee arthroplasty (TKA) are in a ‘worse than
death’ state, based on the EuroQol five- dimension (EQ-
5D) questionnaire, where pain is a key factor.19
Strategies to reinstate elective surgery have focused
on patient risk assessment, surgical procedure and
comorbidities.20,21 An international collaborative study
reported an association between COVID-19 mortality
with ASA grade and advanced age.5 In addition, age > 50
years, history of smoking, and the presence of comor-
bidities are all associated with a higher risk of mortality
following COVID-19 infection.22 At our institution, low-
risk patients with urgent procedures were prioritized
for surgery. In our study, 79.3% of patients operated
on were classified as ASA grade I or II. Initially, in the
first week following resumption of elective services, all
procedures were day cases, however, planned inpa-
tient procedures were restarted the following week. In
addition, high- risk patients who required urgent proce-
dures also underwent surgery. As more complex elec-
tive procedures in higher- risk patients are performed,
both surgeons and patients must remain alert in order
to minimize virus transmission.
Our study has some limitations. At our institution,
low- risk patients with urgent procedures were priori-
tized, with 96 patients (79.3%) classified as ASA grades
I and II. This population is more likely to develop
asymptomatic disease which may not be reflected in
our results. As more complex procedures in higher-
risk patients are performed, patients with more severe
symptoms may be observed. Also, major surgery can
have an impact on the immune system for a period
that is greater than 14 days.23 While performing the
study 14 days post- discharge captures the periopera-
tive transmission rate in hospital, patients may still be
more vulnerable to viral transmission post- discharge in
the community. However, as the incidence of COVID-19
continues to decrease in the UK, there is confidence that
viral transmission rates and subsequent complications
will follow. Another limitation is that not all patients
were formally tested for COVID-19 in the postopera-
tive period; it is possible that there is a percentage of
asymptomatic COVID- positive patients in our group.
At the time of this study, widespread testing of post-
operative patients for COVID-19 was not feasible as
tests were reserved for symptomatic patients. Future
studies formally testing all postoperative patients
for COVID-19 would likely provide a more accurate
perioperative transmission rate. Multiple studies have
described symptoms that have been associated with
COVID-19.24,25 Clemency et al reported positive likeli-
hood ratios (PLR) for certain COVID-19 symptoms in
BONE & JOINT OPEN
J. S. CHANG, W. WIGNADASAN, R. PRADHAN, C. KONTOGHIORGHE, B. KAYANI, F. S. HADDAD
566
a study involving 961 healthcare workers.26 The study
found that the loss of smell and taste had the greatest
PLR (3.33, 95% confidence interval (CI) 2.60 to 4.06),
followed by fever (1.79, 95% CI 1.56 to 2.03). No other
symptom had a significant PLR.26 These findings can
be used to aid in the determination of who should be
tested.
In addition, our institution is currently able to utilize
the independent sector hospitals for NHS operating
lists, where providing a COVID-19- free pathway is more
straightforward. It may not be possible to replicate this
type of arrangement in other healthcare systems. As
care begins to shift from the independent sector, hospi-
tals will need to continue to ensure that clearly desig-
nated COVID- free pathways exist in order to minimize
transmission rates.
Restarting elective surgery during the COVID-19
pandemic remains a significant global challenge. While
it is impossible to completely eliminate the risk of viral
transmission, the development of a designated COVID-
free pathway is an eective way to safely resume elec-
tive surgery. As elective operating returns to a “new
normal”, surgeons must remain alert in order to mini-
mize virus transmission and continue to provide appro-
priate and safe orthopaedic surgical care.
Take home message
- Elective orthopaedic surgery can be safely resumed with a
designated COVID- free pathway.
- A designated COVID- free pathway results in low
perioperative viral transmission rates.
- Surgeons must remain alert in order to minimize virus transmission
and continue to provide safe orthopaedic surgical care.
Twitter
Follow J. S. Chang @j_chang8
Follow F. S. Haddad @bjjeditor
References
1. No authors listed. Rolling updates on coronavirus disease (COVID-19). World
Health Organization (WHO). 2020. https://www. who. int/ emergencies/ diseases/
novel- coronavirus- 2019/ events- as- they- happen (date last accessed 1 September
2020).
2. Hourston GJM. The impact of despecialisation and redeployment on surgical
training in the midst of the COVID-19 pandemic. Int J Surg. 2020;78:1–2.
3. Oussedik S, Zagra L, Shin GY, D'Apolito R, Haddad FS. Reinstating elective
orthopaedic surgery in the age of COVID-19. Bone Joint J. 2020;102- B(7):807–810.
4. Chang J, Wignadasan W, Kontoghiorghe C, etal. Restarting elective orthopaedic
services during the COVID-19 pandemic. Bone Joint Open. 2020;1(6):267–271.
5. COVIDSurg Collaborative. Mortality and pulmonary complications in patients
undergoing surgery with perioperative SARS- CoV-2 infection: an international cohort
study. Lancet. 2020;396(10243):27-38.
6. No authors listed. Coronavirus numbers in London. London. gov. uk. 2020. https://
www. london. gov. uk/ coronavirus/ coronavirus- numbers- london (date last accessed 1
September 2020).
7. No authors listed. Global surveillance for COVID-19 caused by human infection
with COVID-19 virus: interim guidance, 20 March 2020. World Health Organization
(WHO). 2020. https:// apps. who. int/ iris/ handle/ 10665/ 331506 (date last accessed 1
September 2020).
8. No authors listed. Check if you or your child has coronavirus symptoms. National
Health Service (NHS). 2020. https://www. nhs. uk/ conditions/ coronavirus- covid- 19/
symptoms/ (date last accessed 1 September 2020).
9. No authors listed. Re- starting non- urgent trauma and orthopaedic care: full
guidance. British orthopaedic association (BOA). 2020. https://www. boa. ac. uk/
resources/ boa- guidance- for- restart--- full- doc--- final2- pdf. html (date last accessed 1
September 2020).
10. No authors listed. Operating framework for urgent and planned services in
hospital settings during COVID-19. National Health Service (NHS). 2020. https://
www. england. nhs. uk/ coronavirus/ wp- content/ uploads/ sites/ 52/ 2020/ 05/ Operating-
framework- for- urgent- and- planned- services- within- hospitals. pdf (date last accessed
2 September 2020).
11. Lauer SA, Grantz KH, Bi Q, etal. The incubation period of coronavirus disease 2019
(COVID-19) from publicly reported confirmed cases: estimation and application. Ann
Intern Med. 2020;172(9):577–582.
12. BMJ. Only reliable data on hospital- acquired covid-19 will give people confidence
that hospitals are safe. 2020. https:// blogs. bmj. com/ bmj/ 2020/ 05/ 20/ we- need-
reliable- data- on- hospital- acquired- covid- 19/ (date last accessed 1 September 2020).
13. Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients
undergoing surgeries during the incubation period of COVID-19 infection.
EClinicalMedicine. 2020;21:100331.
14. Kayani B, Konan S, Thakrar RR, Huq SS, Haddad FS. Assuring the long- term total
joint arthroplasty: a triad of variables. Bone Joint J. 2019;101- B(1_Supple_A):11–18.
15. Amstutz HC, Le Duff MJ. Effects of physical activity on long- term survivorship after
metal- on- metal hip resurfacing arthroplasty: is it safe to return to sports? Bone Joint
J. 2019;101- B(10):1186–1191.
16. Zhang L, Lix LM, Ayilara O, Sawatzky R, Bohm ER. The effect of multimorbidity
on changes in health- related quality of life following hip and knee arthroplasty. Bone
Joint J. 2018;100- B(9):1168–1174.
17. Thewlis D, Bahl JS, Fraysse F, et al. Objectively measured 24- hour activity
profiles before and after total hip arthroplasty. Bone Joint J. 2019;101- B(4):415–425.
18. Scott CEH, Turnbull GS, Powell- Bowns MFR, MacDonald DJ, Breusch SJ.
Activity levels and return to work after revision total hip and knee arthroplasty in
patients under 65 years of age. Bone Joint J. 2018;100- B(8):1043–1053.
19. Scott CEH, MacDonald DJ, Howie CR. 'Worse than death' and waiting for a joint
arthroplasty. Bone Joint J. 2019;101- B(8):941–950.
20. Mouton C, Hirschmann MT, Ollivier M, Seil R, Menetrey J. COVID-19 - ESSKA
guidelines and recommendations for resuming elective surgery. J Exp Orthop.
2020;7(1):28.
21. Al- Omar K, Bakkar S, Khasawneh L, Donatini G, Miccoli P. Resuming elective
surgery in the time of COVID-19: a safe and comprehensive strategy. Updates Surg.
2020;72(2):291–295.
22. Zhao X, Zhang B, Li P, etal. Incidence, clinical characteristics and prognostic factor
of patients with COVID-19: a systematic review and meta- analysis. Medrxiv. 2020.
23. Dąbrowska AM, Słotwiński R. The immune response to surgery and infection.
Cent Eur J Immunol. 2014;39(4):532–537.
24. Vaira LA, Salzano G, Deiana G, De Riu G. Anosmia and Ageusia: Common
Findings in COVID-19 Patients. Laryngoscope. 2020;130(7):1787.
25. Wang D, Hu B, Hu C, etal. Clinical characteristics of 138 hospitalized patients
with 2019 novel coronavirus- infected pneumonia in Wuhan, China. JAMA.
2020;323(11):1061–1069.
26. Clemency BM, Varughese R, Scheafer DK, etal. Symptom Criteria for COVID-19
Testing of Heath Care Workers. Acad Emerg Med. 2020;27(6):469–474.
Author information:
J. S. Chang, MBBS, MRCS, FRCSC, Senior Clinical Fellow
W. Wignadasan, MBBS, BSC (Hons), MRCS, Specialist Registrar in Trauma and
Orthopaedics
R. Pradhan, MBBS, BSC (Hons), Foundation Doctor in Trauma and Orthopaedics
C. Kontoghiorghe, MBBS, BSC (Hons), MRCS, Specialist Registrar in Trauma and
Orthopaedics
Department of Trauma and Orthopaedic Surgery, University College London,
London, UK.
B. Kayani, MBBS, BSC (Hons), MRCS, Specialist Registrar in Trauma and
Orthopaedics
F. S. Haddad, BSc MD (Res), FRCS (Orth), Professor of Orthopaedic Surgery
Department of Trauma and Orthopaedic Surgery, University College London,
London, UK; The Princess Grace Hospital, London, UK.
Author contributions:
J. S. Chang: Generated the hypothesis, Prepared the manuscript, Interpreted the
data.
W. Wignadasan: Collected the data, Prepared the manuscript.
R. Pradhan: Collected the data, Prepared the manuscript.
C. Kontoghiorghe: Prepared the manuscript.
B. Kayani: Interpreted the data, Prepared the manuscript.
F. S. Haddad: Generated the hypothesis, Prepared the manuscript.
VOL. 1, NO. 9, SEPTEMBER 2020
ELECTIVE ORTHOPAEDIC SURGERY WITH A DESIGNATED COVID-19- FREE PATHWAY RESULTS IN LOW PERIOPERATIVE VIRAL TRANSMISSION RATES 567
J. S. Chang and W. Wignadasan are joint first authors.
Funding statement:
This research did not receive any specific grant from funding agencies in the public,
commercial, or not- for- profit sectors.
ICMJE COI statement:
J. S. Chang, W. Wignadasan, R. Pradhan, C. Kontoghiorghe, and B. Kayani did not
receive any financial support and do not have any conflicts of interest. F. S. Haddad
reports board membership of The Bone & Joint Journal and the Annals of the Royal
College of Surgeons; consultancy for Smith & Nephew, Corin, MatOrtho and Stryker;
payment for lectures including service on speakers’ bureaus for Smith & Nephew
and Stryker; royalties paid by Smith & Nephew, MatOrtho, Corin and Stryker, all of
which are outside the submitted work.
Ethical review statement:
Ethics committee approval was not required as this study was considered a necessary
review of service.
© 2020 Author(s) et al. This is an open- access article distributed under the terms of
the Creative Commons Attributions licence (CC- BY- NC- ND), which permits unrestricted
use, distribution, and reproduction in any medium, but not for commercial gain, pro-
vided the original author and source are credited.
... Other methods include conducting preoperative RT-PCR tests, restricting visitors, maintaining physical distance, washing hands, as well as wearing masks by inpatients and workers. [4][5][6] Ulin Hospital Banjarmasin is a third-level referral hospital that provides health services to COVID-19 patients. Prior to the pandemic in 2019, it had performed a total of 3,720 elective surgeries. ...
... 15 Several COVID-19-free pathways use preoperative isolation for 14 days on patients scheduled for surgery to prevent the spread of SARS-CoV-2 from the community. 5,11 However, the pathway at the study hospital did not use this method, but patients were quarantined on admission for RT-PCR test until the day of surgery. Negative RT-PCR results were declared valid up to 48 hours before the procedure, hence, the maximum quarantine period was two days. ...
... 11 The use of two separate zones, each of which has special entry access and its HCWs, is required in health facilities with infected and uninfected patients. 5,10 A study conducted at Columbia University Irving medical center shows that the incidence of nosocomial transmission after dividing the wards was 0-2%. 12 In the early stages of the pandemic, several studies showed that people infected with SARS-CoV-2 who underwent surgery experienced increased morbidity and mortality. ...
Article
Full-text available
Background. Elective surgery during the COVID-19 pandemic must continue to prevent a backlog of surgical cases. Several institutions are implementing a COVID-19-free surgical pathway to minimize the risk of SARS-CoV-2 transmission. This study aimed to assess the safety of patients undergoing surgery against hospital-acquired SARS-CoV-2 infections by implementing a COVID-19-free pathway. Methods. This study is cross-sectional of 572 patients who underwent elective surgery with a COVID-19-free pathway. All patients underwent two days of quarantine in the hospital for RT-PCR testing. A negative COVID-19 test result is valid within 48 hours before surgery, and all surgeries were performed in a non-COVID-19 operating room. Age, gender, ASA classification, type of anesthesia, surgery criteria, length of stay, and ICU admission were the baseline characteristics of the patients in this study. The outcome in this study was hospital-acquired SARS-CoV-2 infections after the patient underwent surgery based on COVID-19 symptoms during hospitalization and 14 days after discharge. Results. This study involved 303 males (53%) and 269 females (47%) with a mean age of 40.16 years ± 11.35 years (12 days–84 years). According to the ASA classification, 44 patients (7.7%) ASA I, 450 (78.7%) ASA II, 77 (13.4%) ASA III and 1 (0.2%) ASA 4. Major or complex surgery criteria accounted for 48% (277) of all surgeries. One hundred and fifty-seven patients (27,4%) underwent postoperative hospitalization for 0-3 days, 190 (33.3%) 4-7 days, and 225 (39.3%) had a length of stay ≥ 8 days. None of the patients showed postoperative COVID-19 symptoms. Three patients died postoperatively, but their deaths were not COVID-19 related. Fourteen days after discharge, eight patients (3%) had fever and cough but did not perform the RT-PCR test. These eight patients experienced clinical improvement and recovery. Conclusion. Implementing a COVID-19-free pathway provides safety for patients from hospital-acquired SARS-CoV-2 infections.
... Despite this, published results on COVID-19 safe pathways have been limited. To date, one large multicentre study and three small single centre studies have reported on the apparent success of COVID-19 safe pathways [7][8][9][10][11]. ...
... Guidelines instituted by the UK national governing bodies on the formation of green pathways did not occur until after the first UK national lockdown [4,5]. Prior to this time, hospitals arranged "green" pathways based on local policies and availability of resources as reported in a number of small studies [7][8][9]. A number of authors concluded that the use of "COVID-19 free" pathways (green pathways) were key to the resumption of elective services [7,8,10]. ...
... Prior to this time, hospitals arranged "green" pathways based on local policies and availability of resources as reported in a number of small studies [7][8][9]. A number of authors concluded that the use of "COVID-19 free" pathways (green pathways) were key to the resumption of elective services [7,8,10]. In the first phase of our study, we did not find significant differences in COVID-19 infection rate between pathways. ...
Article
Full-text available
Objectives: The primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second UK national lockdowns. Setting: This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020. Participants: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection). Results: 10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (Odd’s Ratio 0.077, p < .001). There was no significant difference in COVID-19 related mortality between pathways. Conclusions: There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.
... Recommendations for safe surgery during the pandemic include routine preoperative reverse-transcriptase polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 and/or preoperative self -isolation for variable time durations [7][8][9][10][11]. Studies from cancer surgery further suggest that a negative preoperative RT-PCR or operating in hospitals that have "coronavirus disease (COVID-19) free" surgical pathways (complete segregation of the operating theatre, critical care, and inpatient ward areas) is associated with a lower rate of postoperative pulmonary complications [12,13]. ...
... It is important to keep in mind that, compared to the nCOV-19 rates after elective surgeries in the literature, our infection rate is much higher (21.4%). The reason for this is that the studies in the literature generally consider the diagnosis of infection in the early postoperative period (12,16,18) whereas, in our study, postoperative nCOV-19 rates were evaluated after an average of 294.59 days (range: 205-523 days) of follow-up. It is not possible to consider all high-risk actions of patients during this period and to determine all risk factors accordingly. ...
Article
Full-text available
Objective: To investigate the effect of the postponement of elective surgeries on the quality of life of the patients and to examine the post-operative COVID-19 rates of patients who underwent elective surgery and investigate the associated risk factors. Methods: In this retrospective study, 187 patients who underwent elective surgery between June and July 2020 and between January and May 2021 were examined. Age, gender, occupation, comorbidity, time of surgical delay, type of surgery, hospitalization, and follow-up periods were recorded. Surgeries were categorized under four headings; knee arthroscopy, arthroplasty, rotator cuff repair/impingement, and minor surgery. To examine the quality of life of all operated patients, a validated Turkish version of EQ-5D-3L was used. All patients were questioned on phone to identify the risk factors for transmission. Statistical analyzes were performed using SPSS 26.0 version. Results: Among the 187 patients evaluated in the study, 40 patients (21.4%) were diagnosed nCOV-19 during the postoperative period. Regardless of the type of surgery performed, mobility, pain/discomfort, and anxiety/depression scores were increased significantly postoperatively (p<0.05 for each). A significant relationship was found between younger age, surgery type, shorter hospitalization period, a greater number of visits to the outpatient clinic, longer follow-up period, history of nCOV-19 preoperatively, diagnosis of nCOV-19 among relatives and the diagnosis of nCOV-19 after surgery (p<0.05 for each). Conclusion: By taking all possible precautions and avoiding identifiable risk factors, thus eliminating the risk of COVID-19 transmission as much as possible, and then performing elective surgeries will significantly increase the quality of life of the patients.
... 2 Previous investigations have identified that only between 27 and 56.8% of patients would be willing to undergo an elective procedure at the earliest available time. 3,4 With patient hesitancy to obtain elective surgery, there was a potential for delayed care for rotator cuff pathology, a risk factor that has been linked to worse outcomes. 5,6 There is a risk for increased tear size, progression of muscle atrophy, and increased risk of revision surgery with delayed treatment of rotator cuff tears. ...
Article
Full-text available
Resumo Objetivo O reparo do manguito rotador (RMR) é um dos procedimentos artroscópicos mais comuns. Nossa pesquisa visa quantificar o impacto da pandemia de COVID-19 sobre o RMR, especificamente em pacientes com lesões agudas e traumáticas. Métodos Os prontuários institucionais foram consultados para identificação de pacientes submetidos ao RMR artroscópico entre 1° de março e 31 de outubro de 2019 e de 2020. Dados demográficos, pré-operatórios, perioperatórios e pós-operatórios dos pacientes foram coletados de prontuários eletrônicos. Os dados foram analisados por estatística inferencial. Resultados Totais de 72 e de 60 pacientes foram identificados em 2019 e 2020, respectivamente. Os pacientes de 2019 apresentaram menor intervalo entre a ressonância magnética (RM) e a cirurgia (62,7 ± 70,5 dias versus 115,7 ± 151,0 dias; p = 0,01). Os exames de RM mostraram menor grau médio de retração em 2019 (2,1 ± 1,3 cm versus 2,6 ± 1,2 cm; p = 0,05), mas nenhuma diferença foi observada na extensão anteroposterior da laceração entre os anos (1,6 ± 1,0 cm versus 1,8 ± 1,0 cm; p = 0,17). Em 2019, o número de pacientes atendidos por seus cirurgiões em consultas pós-operatórias por telemedicina foi menor em comparação com 2020 (0,0% versus 10,0%; p = 0,009). Não foram observadas alterações significativas nas taxas de complicação (0,0% versus 0,0%; p > 0,999), de readmissão (0,0% versus 0,0%; p > 0,999) ou de revisão (5,6% versus 0,0%; p = 0,13). Conclusão Não houve diferenças significativas nos dados demográficos dos pacientes ou nas principais comorbidades entre 2019 e 2020. Nossos dados sugerem que, embora o intervalo entre a RM e a cirurgia tenha sido maior em 2020 e tenha havido necessidade de consultas por telemedicina, o RMR ainda foi realizado em tempo hábil e sem alterações significativas nas complicações precoces. Nível de Evidência III.
... operative AMT were largely comparable between the cohorts ( Table 2). The rate of admission of hip fractures were similar across the three time periods (Fig. 3), with a seven-day median admission rate of 16 ...
Article
Aims and objectives The Covid-19 pandemic has had an unprecedented effect on surgical practice and healthcare delivery globally. We compared the impact of the care pathways which segregate Covid-19 Positive and Negative patients into two geographically separate sites, on hip fracture patients in our high-volume trauma center in 3 distinct eras - the pre-pandemic period, against the first Covid-19 wave with dual-site service design, as well as the subsequent surge with single-site service delivery. In addition, we sought to invoke similar experiences of centres worldwide through a scoping literature review on the current evidence on “Dual site” reconfigurations in response to Covid-19 pandemic. Methods We prospectively reviewed our hip fracture patients throughout the two peaks of the pandemic, with different service designs for each, and compared the outcomes with a historic service provision. Further, a comprehensive literature search was conducted using several databases for articles discussing Dual-site service redesign. Results In our in-house study, there was no statistically significant difference in mortality of hip fracture patients between the 3 periods, as well as their discharge destinations. With dual-site reconfiguration, patients took longer to reach theatre. However, there was much more nosocomial transmission with single-site service, and patients stayed in the hospital longer. 24 articles pertaining to the topic were selected for the scoping review. Most studies favour dual-site service reorganization, and reported beneficial outcomes from the detached care pathways. Conclusion It is safe to continue urgent as well as non-emergency surgery during the Covid-19 pandemic in a separate, geographically isolated site.
Article
Background Total shoulder arthroplasty (TSA) is one of the fastest growing procedures in terms of volume performed in hospitals in the United States. In 2020, elective surgery was suspended nationwide as a result of the SARS-CoV-2 (COVID-19) pandemic, and the utilization trends in the wake of the pandemic have yet to be evaluated substantially. Nationwide case volume reduction for TSA is unknown, therefore the aim of this study is to compare patient demographics, complications, and temporal trends in case volume of elective total shoulder arthroplasty (TSA) in the calendar year 2019 (pre-pandemic) to 2020 in the United States. Methods Utilizing a multicenter, nationwide representative sample from 2019 to 2020, a retrospective query was conducted for all patients undergoing elective TSA. Patients undergoing surgery Pre-COVID (2019 and 2020 Q1) were compared to those during COVID (2020 Q2-Q4). Temporal trends in case volumes were compared between timeframes. TSA utilization, patient demographics, complications, and length of stay (LOS) were compared between years. Linear regression was used to evaluate for changes in the case volume over the study period. A statistical significance threshold of p<0.05 was used. Results In total, 9667 patients underwent elective TSA in 2019 (N=5342) and 2020 (N=4325). The proportion of patients who underwent outpatient TSA in 2020 was significantly greater than the year prior (20.6% vs 13.9%; p<0.001). Overall, elective TSA case volume declined by 19.0% from 2019 to 2020. There was no significant difference in the volume of cases in 2019Q1 (N=1401) through 2020Q1 (N=1296) (p = .216). However, elective TSA volumes declined by 54.6% in 2020Q2. Elective TSA case volumes recovered to pre-pandemic baseline in 2020Q3 and 2020Q4. The average length of stay was comparable in 2020 vs 2019 (1.29 vs 1.32 days; p= .371), with the proportion of same day discharge increasing per quarter from 2019 to 2020 (from 11.8% to 26.8% of annual cases). There was no significant difference in the total complication rates in 2019 (4.6%) vs 2020 (4.9%); p = .441. Conclusion Using a nationwide sample, elective TSA precipitously declined during the second quarter of 2020. Patient demographics of those undergoing elective TSA in 2020 were similar in comorbidity burden. A large proportion of surgeries were transitioned to the outpatient setting with rates of same day discharge doubling over the study period, despite no change in overall complication rates.
Article
Introduction Maintaining timely and safe delivery of major elective surgery during the COVID-19 pandemic is essential to manage cancer and time-critical surgical conditions. Our NHS Trust established a COVID-secure elective site with a level 2 Post Anaesthetic Care Unit (PACU) facility. Patients requiring level 3 Intensive Care Unit admission were transferred to a non-COVID-secure site. We investigated the relationship between perioperative anaesthetic care and outcomes. Materials and methods All consecutive patients undergoing major surgery at the COVID-secure site between June and November 2020 were included. Patient demographics, operative interventions and 30-day outcomes were recorded. Multivariate logistic regression was used to determine the odds ratio of outcomes according to PACU length of stay and the use of spinal or epidural anaesthesia, with age, sex, malignancy status and American Society of Anesthesiologists grade as independent co-variables. Results There were 280 patients. PACU length of stay >23h was associated with increased 30-day complications. Epidural anaesthesia was associated with PACU length of stay >23h, increased total length of stay, increase hospital transfer and 30-day complications. Two patients acquired nosocomial COVID-19 following hospital transfer. Discussion Establishing a separate COVID-secure site has facilitated delivery of major elective surgery during the COVID-19 pandemic. Choice of perioperative anaesthesia and utilisation of PACU appear likely to affect the risk of adverse outcomes.
Article
Full-text available
Introduction Patients undergoing lower limb arthroplasty who are SARS-CoV-2 positive at the time of surgery have a high-risk of mortality. The National Institute for Health and Clinical Care Excellence and the British Orthopaedic Association advise self-isolation for 14-days pre-operatively in patients at high-risk of adverse outcomes due to COVID-19. The aim of the study is to assess whether pre-operative PCR for SARS-CoV-2 could be performed at between 48 and-72 hours pre-operatively with specific advice about minimising the risk of SARS-CoV-2 restricted to between PCR and admission. Methods A multi-centre, international, observational cohort study of 1000 lower limb arthroplasty cases was performed. The dual primary outcomes were thirty-day conversion to SARS-CoV-2 positive and thirty-day SARS-CoV-2 mortality. Secondary outcomes included thirty-day SARS-CoV-2 morbidity. Results Of the 1000 cases, 935 (94%) had a PCR between 48 and 72-hours pre-operatively. All cases were admitted to, and had surgery through a COVID-free pathway. Primary knee arthroplasty was performed in 41% of cases, primary hip arthroplasty in 40%, revision knee arthroplasty in 11% and revision hip arthroplasty in 9%. Six-percent of operations were emergency operations. No cases of SARS-CoV-2 were identified within the first thirty-days. Conclusion Pre-operative SARS-CoV-2 PCR test between 48 and 72-hours pre-operatively with advice about minimising the risk of SARS-CoV-2 restricted to between PCR and admission in conjunction with a COVID-free pathway is safe for patients undergoing primary and revision hip and knee arthroplasty. Pre-operative SARS-CoV-2 PCR test alone may be safe but further, adequately powered studies are required. This information is important for shared decision making with patients during the current pandemic.
Article
Full-text available
Aims As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment. Methods This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery. Results Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p = 0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p = 0.03). Conclusion Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services. Cite this article: Bone Joint Open 2020;1-6:267–271.
Article
Full-text available
Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
Article
Full-text available
The roadmap to elective surgery resumption after this COVID-19 pandemic should be progressive and cautious. The aim of this paper was to give recommendations and guidelines for resuming elective orthopedic surgery in the safest environment possible. Elective surgery should be performed in COVID-free facilities and hospital stay should be as short as possible. For matters of safety, patients considered first for surgery should be carefully selected according to COVID infection status/exposure, age, ASA physical status classification system / risk factors, socio-professional situation and surgical indication. A strategy for resuming elective surgery in four phases is proposed. Preoperative testing for COVID-19 infection is highly recommended. In any cases, COVID symptoms including fever and increased temperature should be constantly monitored until the day of surgery. Elective surgery should be postponed at the slightest suspicion of a COVID-19 infection. In case of surgery, adapted personal protective equipment in terms of gowns, gloves, masks and eye protection is highly recommended and described.
Article
Full-text available
Background The outbreak of 2019 novel coronavirus disease (COVID-19) in Wuhan, China, has spread rapidly worldwide. In the early stage, we encountered a small but meaningful number of patients who were unintentionally scheduled for elective surgeries during the incubation period of COVID-19. We intended to describe their clinical characteristics and outcomes. Methods We retrospectively analyzed the clinical data of 34 patients underwent elective surgeries during the incubation period of COVID-19 at Renmin Hospital, Zhongnan Hospital, Tongji Hospital and Central Hospital in Wuhan, from January 1 to February 5, 2020. Findings Of the 34 operative patients, the median age was 55 years (IQR, 43–63), and 20 (58·8%) patients were women. All patients developed COVID-19 pneumonia shortly after surgery with abnormal findings on chest computed tomographic scans. Common symptoms included fever (31 [91·2%]), fatigue (25 [73·5%]) and dry cough (18 [52·9%]). 15 (44·1%) patients required admission to intensive care unit (ICU) during disease progression, and 7 patients (20·5%) died after admission to ICU. Compared with non-ICU patients, ICU patients were older, were more likely to have underlying comorbidities, underwent more difficult surgeries, as well as more severe laboratory abnormalities (eg, hyperleukocytemia, lymphopenia). The most common complications in non-survivors included ARDS, shock, arrhythmia and acute cardiac injury. Interpretation In this retrospective cohort study of 34 operative patients with confirmed COVID-19, 15 (44·1%) patients needed ICU care, and the mortality rate was 20·5%. Funding National Natural Science Foundation of China.
Article
Full-text available
In a not negligible number of patients affected by COVID‐19, especially if paucisymptomatic, ageusia and anosmia can represent the first or only symptomatology present. This article is protected by copyright. All rights reserved.
Article
Aims As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment. Methods This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee procedure during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery. Results Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p = 0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p = 0.03). Conclusion Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services. Cite this article: Bone Joint Open 2020;1-6:267–271.
Article
The 2019 novel corona virus and the disease it causes (COVID-19) is a public health crisis that has profoundly modified the way medical and surgical care is delivered. Countries around the globe had a variable initial response to the COVID-19 pandemic from imposing massive lock downs and quarantine to surrendering to herd immunity. However, healthcare bodies worldwide recognized early on that a triumph against COVID-19 could only be achieved by maintaining the infrastructure of healthcare systems and their capacity to accommodate a potentially overwhelming increase in critical patient care needs. Therefore, they reacted by restricting medical care to emergency cases and postponing elective surgical procedures in all disciplines. The priority was made for treatment of COVID-19 patients and emergency cases. Nevertheless, the battle against the COVID-19 pandemic is still ongoing. In the absence of vaccines or effective drug treatments, its timeline remains uncertain and it cannot be forecast how long healthcare systems will need to cope with it in managing inpatient and outpatient services. Accordingly, extreme measures and restriction may become a recipe for a disaster in the context of the potential adverse health implications imposed by delaying timely medical and surgical care. Therefore, restrictive measures should be substituted with a comprehensive surgical and medical care strategy. One that provides a safe balance between the prevention of COVID-19 and the delivery of essential surgical care. This article provides an overview on how to safely deliver essential surgical care in the time of COIVD-19.
Article
The transition from shutdown of elective orthopaedic services to the resumption of pre-COVID-19 activity presents many challenges. These include concerns about patient safety, staff safety, and the viability of health economies. Careful planning is necessary to allow patients to benefit from orthopaedic care in a safe and sustainable manner. Cite this article: Bone Joint J 2020;102-B(7):1–4.
Article
Background Limitations on testing availability has been a challenge during the COVID‐19 pandemic. An evidence based symptom criteria for identifying heath care workers (HCW) for testing, based on the probability of positive COVID‐19 test results, would allow for a more appropriate use of testing resources. Methods This was an observational study of outpatient COVID‐19 testing of HCW. Prior to testing, HCW were asked about the presence of 10 symptoms. Their responses were then compared to their subsequent pharyngeal swab COVID‐19 Polymerase Chain Reaction test results. These data were used to derive and evaluate a symptom based testing criteria. Results 961 HCW were included in the analysis, of which 225 (23%) had positive test results. Loss of taste or smell was the symptom with the largest positive likelihood ratio (3.33). Dry cough, regardless of the presence or absence of other symptoms, was the most sensitive (74%) and the least specific (32%) symptom. The existing testing criteria consisting of any combination of one or more of three symptoms (fever, shortness of breath, dry cough) was 93% sensitive and 9% specific (AUC = 0.63, 95% CI: 0.59 – 0.67). The derived testing criteria consisting of any combination of one or more of two symptoms (fever, loss of taste or smell) was 89% sensitive and 48% specific (AUC = 0.75, 95% CI: 0.71 – 0.78). The hybrid testing criteria consisting of any combination of one or more of four symptoms (fever, shortness of breath, dry cough, loss of taste or smell) was 98% sensitive and 8% specific (AUC = 0.77, 95% CI: 0.73 – 0.80). Conclusion An evidence based approach to COVID‐19 testing which at least includes fever and loss of taste or smell should be utilized when determining which HCW should be tested.