VOL. 1, NO. 9, SEPTEMBER 2020 562
Freely available online
Follow us @BoneJointOpen
J. S. Chang,
F. S. Haddad
From University College
London, London, UK
Correspondence should be sent to
Justin S Chang; email:
justin. chang@ mail. utoronto. ca
Bone Joint Open 2020;1-9:562–
Elective orthopaedic surgery with a
designated COVID-19- free pathway
results in low perioperative viral
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.
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
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.
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
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
Question asked Answer
Have you experienced a high temperature since the date of
Have you developed a new cough since the date of your
Have you experienced any shortness of breath since the date
of your operation?
Have you noticed any loss of smell since the date of your
Have you noticed any change in taste since the date of your
Have you had a COVID-19 swab since being discharged from
Have you developed any other concerning symptoms since
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
aected 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
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 eectiveness
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.
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
Table II. Baseline patient characteristics.
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
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
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.
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-
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) (TableII). 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
TableIII. 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.
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.
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
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-
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
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
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
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 eective 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.
Follow J. S. Chang @j_chang8
Follow F. S. Haddad @bjjeditor
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J. S. Chang, MBBS, MRCS, FRCSC, Senior Clinical Fellow
W. Wignadasan, MBBS, BSC (Hons), MRCS, Specialist Registrar in Trauma and
R. Pradhan, MBBS, BSC (Hons), Foundation Doctor in Trauma and Orthopaedics
C. Kontoghiorghe, MBBS, BSC (Hons), MRCS, Specialist Registrar in Trauma and
Department of Trauma and Orthopaedic Surgery, University College London,
B. Kayani, MBBS, BSC (Hons), MRCS, Specialist Registrar in Trauma and
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.
J. S. Chang: Generated the hypothesis, Prepared the manuscript, Interpreted the
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.
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.