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

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. Cite this article: Bone Joint Open 2020;1-9:562–567.

National operating volume for primary hip and knee arthroplasty in the COVID-19 era: a study utilizing the Scottish arthroplasty project dataset

“…23 Adopting a ‘COVID-19-free’ or ‘green’ pathway has since shown promise in providing elective services in a safe and efficient manner. 24 - 26 …”

The rate of patient deferral and barriers to going forward with elective orthopaedic surgery during the COVID-19 pandemic

“…Zahra et al 3 described their “green” COVID-19 free elective orthopaedic pathway which demonstrated a high rate of patient satisfaction and a low rate of postoperative COVID-19, with only one of their 100 patients developing asymptomatic SARS-CoV-2 infection. A similar study by Chang et al 2 also described their COVID-19 free elective orthopaedic pathway for 121 patients, whom had isolated 14 days prior to surgery, of which only one patient had a suspected but not confirmed COVID-19 infection with symptoms of anosmia. A secondary effect of these new COVID-19 free elective pathways is a decrease in the capacity due to theatre and ward work flows and social distancing.…”

“… 11 However, this was during a period when there was no preoperative screening or hospital precautions for COVID-19 and this risk may be lower with green COVID-19 free pathways. 2 The next question a patient may ask might be : “what is my mortality risk should I be one of 264 patients that develop COVID-19 postoperatively?” Mortality data from the COVIDSurg group suggests the 30-day mortality was 19% (n = 53/278) for patients undergoing all elective surgical procedures, although only 20 of these were elective orthopaedic procedures. 4 Therefore, from this data, it could be hypothesized that the risk of dying from COVID-19 after an elective orthopaedic procedure may be approximately one in 1,000.…”

“…However, the mortality rate may be lower than this with the adoption of new patient COVID-19-free pathways and may also be related to the individual patient’s own background mortality risk that should be taken in account when informing them of the potential risks of surgery. 2 , 3 , 11 …”

“… 16 This requires continuous and flexible planning. Inpatient stay is associated with risk and there is an argument for focusing on day case work or healthy American Society of Anesthesiologists (ASA) grade 17 1 patient mix, 2 but this may be to the detriment of older, less healthy individuals and does not account for the socioeconomic impact of providing continued nonoperative care for long-term treatable surgical conditions, which can lead to worsening comorbidity. 18 , 19 …”