Since the start of the COVID-19 pandemic, thousands of recommended but elective orthopaedic procedures have been delayed. In an article published by The Journal of Bone & Joint Surgery, an expert panel has issued recommendations to guide safe resumption of elective orthopaedic surgery.
“As we resume elective surgical procedures, it is important to understand what practices and protocols should be altered or implemented in order to minimize the risk of pathogen transfer during the severe acute respiratory syndrome (SARS)-CoV-2 pandemic,” said the authors of the guideline statement by the International Consensus Group and the Research Committee of the American Association of Hip & Knee Surgeons.
The guidelines were developed using the Delphi method, including 2 rounds of voting on recommendations gleaned from the literature, said Prof. Bill Walter of Royal North Shore Hospital in Sydney, Australia, a senior author on the study. Following this method, the consensus guidelines were approved by an international panel of 77 expert physicians and scientists in orthopaedic surgery, infectious disease, microbiology and virology, and anesthesia.
The authors of the guidelines note that the recommendations “are based on the available scientific evidence, albeit scant,” and will likely change with the rapidly evolving understanding of COVID-19. The guidelines present 30 recommendations in 4 categories: general, preoperative, intraoperative, and postoperative.
The guidelines include criteria for when hospitals and surgical centers can resume elective procedures, based on factors such as local trends in COVID-19 cases and availability of personal protective equipment and testing supplies. “The prevalence of COVID-19 in the local community will have a big impact on how these recommendations are implemented,” Prof. Walter said.
“Patients who are currently infected with COVID-19 should not undergo elective surgery,” the expert panel said. The guidelines also state that for older patients (75 years or older) and those with comorbidities that put them at a high risk for COVID-19, surgery should be “possibly deferred in the early phases” of resuming elective procedures.
Several added steps in the preadmission process are recommended, including:
- Screening for symptoms of COVID-19
- Wearing masks
- Practicing social distancing
- Limiting family members and visitors in the hospital
In areas with a high prevalence of SARS-CoV-2, mandatory diagnostic testing is recommended before elective surgery. There is currently no evidence to recommend SARS-CoV-2 antibody testing before surgery.
“It is critical for patients undergoing elective surgery to be educated on the protocols that are in place to minimize SARS-CoV-2 transmission to themselves, family members, other patients, and hospital personnel,” the expert panel said.
The intraoperative section addresses the surgical environment, with recommendations for operating room ventilation systems, necessary personal protective equipment (PPE), precautions to take during the procedure, and cleaning of the operating room between surgeries.
For example, there is a strong recommendation for use of the lowest-possible setting on high-power tools, or, as an alternative, using a Gigli saw, sharp osteotomes, and manual reaming. In addition, the guidelines strongly recommend that surgeons keep equipment to a minimum to avoid extra surfaces that could be contaminated by the COVID-19 virus.
The guidelines suggest considering regional anesthesia, when possible, to avoid aerosolization and the increased risk of virus transmission that may occur with intubation during general anesthesia.
Other recommendations include limiting the number of personnel in the operating room and reducing the number of times the operating room door is opened, following standard recommendations for cleaning and sterilizing of instruments, and using absorbable sutures or skin glue and occlusive dressings to reduce the need for patients to return to the office in the early postoperative period.
Postoperative recommendations include safeguards following surgery, such as:
- Staff in the post-anesthesia care unit should wear appropriate masks at all times and keep their patients at least 6 feet (2 meters) from each other.
- Length of stay in the hospital should be minimized and as many patients as possible should be discharged to their home instead of a rehabilitation facility.
- Telemedicine should be used for early postoperative follow-up visits when possible. Only patients with a suspected complication, such as wound-healing issues, fracture, or stiffness, should be seen in the office.
“We realize that the situation is evolving on a daily basis and that some of the recommendations in the present report may need to be altered as new evidence emerges,” the guideline authors said. “In addition, we are aware that the infection-prevention measures described in the present report will highly depend on the prevalence of COVID-19 in the affected areas and the ability to implement the recommended diagnostic tests to properly rule out COVID-19 prior to surgery.
“We will continue to monitor the literature and update this document as needed.”
The full report can be found here.
Parvizi J, Gehrke T, Krueger CA, et al. Resuming elective orthopaedic surgery during the COVID-19 pandemic: guidelines developed by the International Consensus Group. J Bone Joint Surg Am. 2020;102(14):1205-12. doi: 10.2106/JBJS.20.00844.