A Role for ASCs During the COVID-19 Pandemic?

The last JBJS fast-track article cited the need for clearer definitions of “elective” orthopaedic surgery amid the COVID-19 pandemic. As if in response to that, the newest JBJS fast-track article by DePhillipo et al. further explores the moving-target distinction between elective and necessary orthopaedic surgery. The authors also delineate the possible role of ambulatory surgical centers (ASCs) in handling outpatient surgical procedures that were previously scheduled for inpatient facilities.

Absent clear recommendations about which procedures should be considered important enough to be performed in ASCs, DePhillipo et al. offer the following general suggestions:

  • Acute and/or disabling injuries to health-care workers, first responders, and members of the military and police and fire departments
  • Osseous fractures and/or irreducible joint dislocations
  • Wound/joint infections or postoperative wound dehiscence
  • Pathologies that could lead to long-term disability and chronic pain if acute surgical management is delayed

The most specific and valuable information in this article is a table that lists, joint-by-joint, acute orthopaedic injuries that the authors deem “surgically necessary” or “elective-urgent procedures,” along with justifications for each. The authors note that the list is far from “a medical directive or standard of care,” but they propose an interesting rationale for fewer restrictions on elective procedures for low-risk individuals: those who are currently restricted from work or unemployed would have the opportunity to have and recover from surgery and be ready to reenter the work force when the time comes.

Finally, the authors offer best-practice guidance for ASCs in the current climate:

  • Limit visitors to all but minor patients, the mentally/physically disabled, and elderly patients who require assistance.
  • Administer appropriate screening of patients and staff for signs of illness or other risk factors.
  • Ensure that all who are present during intubation and extubation have access to appropriate personal protective equipment, including N95 masks.

More Pre-op Bone Health Evaluations Needed

“We believe that bone health screening should be considered in all orthopaedic surgical candidates who are ≥50 years of age.” So proclaim Kadri et al., based on results of their study of 124 patients who were referred by orthopaedic surgeons for preoperative bone health optimization. The study appeared in the April 1, 2020 issue of The Journal of Bone & Joint Surgery.

The importance of identifying poor bone health before reconstructive orthopaedic surgery is well known but poorly implemented. The bone health evaluation in this cohort consisted of a physical examination, structured history-taking focused on prior fracture, and collection of Fracture Risk Assessment Tool (FRAX) data. Most (122 patients) also underwent dual X-ray absorptiometry (DXA), and more than two-thirds were evaluated with a trabecular bone score. Incidental CT scans were available for and evaluated in 43 patients. Based on these data, Kadri et al. found the following:

  • >90% of the cohort met National Osteoporosis Foundation criteria for osteoporosis treatment.
  • A high FRAX risk (major osteoporotic fracture ≥20% or hip ≥3%) was present in 82% of the patients.
  • Osteoporosis, as defined by T scores of ≤─2.5 points, was present in 45% of the women and 20% of the men.
  • Trabecular bone scores identified 34% of patients as having degraded bone microarchitecture.

As a result of these findings, 75% of the cohort were prescribed treatment for osteoporosis; 45% were prescribed anabolic agents and 30% were prescribed antiresorptive therapy.

For patients with clinical risk factors for osteoporosis and high FRAX risk, Kadri et al. recommend bone health optimization strategies for a minimum of 3 months prior to any planned orthopaedic surgery. “It has been our experience that patients are generally satisfied and are grateful to undergo bone health optimization despite a delay in the surgical procedure,” they write.

Although postsurgical outcomes among these patients were not analyzed, the authors intuitively point out that bone health optimization probably reduces the likelihood of postoperative complications and revisions and therefore would lead to improved outcomes and lower costs. Preoperative bone health optimization could also help surgeons select the most effective surgical technique and/or implant, they say.

Amid COVID-19, What Does “Elective” Mean?

As Sarac et al. note in the latest JBJS fast-tracked article, the phrase “elective procedure” is ambiguous, even though it is supposed to identify procedures that are being postponed to help hospitals cope with the COVID-19 pandemic. Guidelines from the Centers for Disease Control and Prevention (CDC) say that operations for “most cancers” and “highly symptomatic patients” should continue, but that leaves much of the ambiguity unresolved. What constitutes an elective procedure in orthopaedics at this unusual time remains unclear.

To help clarify the situation, the authors summarize guidance issued by states and describe the guidelines currently in use for orthopaedic surgery at their institution, The Ohio State University College of Medicine.

Here are the state-related data collected by Sarac et al., as of March 24, 2020:

  • 30 states have published guidance regarding discontinuation of elective procedures; 16 of those states provide a definition of “elective” or offer guidance for determining which procedures should continue to be performed.
  • 5 states provide guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly permit trauma-related procedures, and 4 states recommend against performing arthroplasty.
  • 10 states provide guidelines permitting the continuation of oncological procedures.

In the Buckeye State, the Ohio Hospital Association asked each hospital and surgery center to cancel procedures that do not meet any of the following criteria:

  • Threat to a patient’s life if procedure is not performed
  • Threat of permanent dysfunction of an extremity or organ system
  • Risk of cancer metastasis or progression of staging
  • Risk of rapid worsening to severe symptoms

Mindful of those criteria, individual surgical and procedural division directors at the authors’ university developed a list of specific procedures that should continue to be performed. Respective department chairs approved the lists, which were then sent to the hospital chief clinical officer for signoff.

The authors tabulate the orthopaedic procedures that continue to be performed at their institution as of March 25, 2020, but they are quick to add that even this list is not without ambiguity. For example, surgery should continue on “select closed fractures that if left untreated for >30 days may lead to loss of function or permanent disability,” but that requires surgeons to judge, in these uncertain and fluid times, which fractures necessitate fixation in the short term.

Sarac et al. emphasize that such lists, however specific they are today, are likely to change as demands on hospitals shift. They suggest that as the pandemic evolves, a further classification of procedures into 2 time-based categories might be helpful: (1) those that need to be performed within 2 weeks and (2) those that need to be performed within 4 weeks. Sarac et al. also remind orthopaedic surgeons to provide patients waiting for surgery that has been postponed with information regarding safe and effective methods of managing their pain.

Prepping for Surgery on Patients with COVID-19

JBJS has already fast-tracked an article by Mi et al. about the best way to manage patients who have a bone fracture as well as COVID-19. The latest fast-tracked COVID-19 article from JBJS comes from Portuguese authors Rodrigues-Pinto et al. It provides an exquisitely detailed protocol for operating room set-ups and staff workflows when treating surgical patients who are COVID-19-positive, with an emphasis on the specifics required for trauma and orthopaedic surgery.

The authors describe a 5-zone operative complex, as shown in the Figure above. Most of the details from Rodrigues-Pinto et al. explain precautionary procedures to be taken in Zones 1 and 2 and Zones 3 and 4, areas preceding and following the operating room.

For Zone 3, the OR itself, the authors recommend a portable HEPA filtration system with a high frequency of air changes to rapidly reduce the viral load within the OR. Another in-the-OR tip for trauma and orthopaedic surgical procedures is to use power tools (such as electrocautery, bone saws, reamers, and drills) sparingly, and to set their power levels as low as possible. That’s because such tools release aerosols, which increase the risk of virus spread. Suction devices to remove smoke and aerosols should also be used during surgical procedures on COVID-19 patients.

What’s Important? Togetherness

At a time when the general public is being encouraged to isolate and maintain physical distance, healthcare professionals are coming together as never before. This unprecedented level and type of collaboration and teamwork is the theme of 2 JBJS fast-track “What’s Important” articles related to the COVID-19 pandemic.

In the first, Mohamad Halawi, MD and colleagues from Baylor University College of Medicine in Houston say that this extraordinary event calls for physician leadership and unity. The authors encourage the orthopaedic community to “focus on supporting our medical colleagues” and for all healthcare professionals to demonstrate “resilience, vigilance, and common resolve.”

For Boston orthopaedists George S.M. Dyer, MD and Mitchel B Harris, MD “things are changing so quickly around us that every day feels like a week,” and “fear appears to be the new ingredient.” Faced with feelings of anxiety and vulnerability, these authors sought advice from three quarters: a group of military veterans affiliated with their medical school, several orthopaedic surgeons who currently serve in the military, and patients who are police officers and firefighters.

The collective wisdom in their advice boils down to this:

  • Remind yourself why you became a doctor; it’s a privilege to be able to help.
  • Take care of yourselves and of each other.
  • Buddy up and stay close to your teammates.
  • Keep lines of communication open; in times of stress, unfettered communication is essential.
  • Remember that you are capable and resilient.
  • Don’t force yourself into “heroism”; volunteer to support and assist in any way you feel comfortable.

Does Computer-Assisted Surgery Drive Better TKA Outcomes?

Computer-assisted surgery (CAS) for total knee arthroplasty (TKA) has become popular largely based on claims that the technology improves accuracy of component positioning and alignment. Theoretically, that leads to superior patient-reported outcomes. However, the use of CSA has not reliably yielded improvements in implant survival or clinical outcomes. A large registry study by Roberts et al. in the April 1, 2020 issue of The Journal sheds additional light on this perplexing question.

An earlier study by the same author group used data from the same New Zealand Joint Registry and showed no difference in functional outcomes or implant survival between TKAs performed with and without CAS.1 However, that study did not account for the potential bias introduced by surgeons who use CAS only for complex cases.

In this study, Roberts et al. analyzed data from 2 carefully selected groups of surgeons: those who used CAS in 90% of their TKAs (“routine CAS” surgeons) and those who used CAS in <10% of their TKAs (“routine conventional” surgeons). Further limiting their analysis to surgeons with >50 TKAs recorded in the registry between 2006 and 2018, Roberts et al. identified 25 “routine CAS” surgeons and 22 “routine conventional” surgeons. This allowed a comparison between 9,501 TKAs performed by routine CAS surgeons and 7,672 TKAs performed by routine conventional surgeons.  While analyzing revision rates and Oxford Knee Scores (OKS) at 6 months, 5 years, and 10 years, the authors also controlled for confounding variables such as age, body-mass index, and implant type.

With a mean follow-up of 4.5 years, the authors found a revision rate per 100 component-years of 0.437 in the group operated on by routine CAS surgeons, compared to a mean 4.9-year revision rate of 0.440 in the group operated on by routine conventional surgeons (p=0.724).  When stratifying outcomes of patients <65 years old, the authors again found no statistical difference in revision rates. They also found no between-group differences in OKS within the full and <65 cohorts at 6 months, 5 years, or 10 years.

The findings prompt the authors (and I) to wonder whether continually improving design and durability of modern implants make it difficult to discern any advantage from computer assistance in implant positioning.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

Reference

  1. Roberts TD, Clatworthy MG, Frampton CM, Young SW. Does computer assisted navigation improve functional outcomes and implant survivability after total knee arthroplasty? J Arthroplasty. 2015 Sep; 30(9)Suppl: 59-63.

Subtalar Joint Compensation after Ankle Fusion

Ankle fusion continues to be a predictable treatment for degenerative tibiotalar arthritis. It improves both pain and function from primary osteoarthritis and degeneration related to chronic instability or trauma. JBJS has published several recent studies demonstrating that the outcomes of fusion compare favorably with those of total ankle replacement, particularly in higher-demand patients. (See, for example, Effectiveness and Safety of Ankle Arthrodesis Versus Arthroplasty and Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis.)

Many clinicians have wondered why outcomes after ankle arthrodesis are typically so much better than those after arthrodesis of other mobile joints. In the April 1, 2020 issue of The Journal, Lenz et al. provide an answer. Using dual fluoroscopy integrated with 3-D CT, the authors compared the subtalar motion of the surgically fused ankle in 10 patients with the motion of the untreated, asymptomatic side. The findings strongly suggest that compensatory increased plantar flexion of the subtalar joint allows improved function following successful arthrodesis. The authors found that this increased motion occurred during both normal plantigrade ambulation and bilateral heel raises.

Clinicians can use this important information to explain to patients who are deciding between ankle arthrodesis and arthroplasty how fusion can not only improve pain, but can also result in good functional range of motion. On the other hand, the authors surmise that the compensatory increase in subtalar joint plantar flexion may explain the reported increased risk of future subtalar osteoarthritis in surgically fused ankles. However, to answer that question, we’ll need larger, longitudinal clinical studies that evaluate the relationship between the compensatory post-fusion subtalar kinematics discovered by Lenz et al. and radiographic findings and patient-reported pain and function.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Learnings from Orthopaedists Infected with COVID-19

One serious challenge in responding to COVID-19 is how to better protect healthcare workers and prevent nosocomial infection. A fast-track JBJS Orthopaedic Forum article by Guo et al. provides instructive data about this challenge from 24 orthopaedic surgeons in Wuhan, China who contracted the illness. Orthopaedic surgeons generally don’t work on the front lines of infectious-disease pandemics, but these cases help us understand the overall infection situation of healthcare workers.

Twenty-six orthopaedic surgeons from 8 of 24 investigated hospitals in Wuhan were identified as having COVID-19, and 24 of them completed a self-administered questionnaire. From that information, the authors found that the peak date of onset of orthopaedic surgeons’ infection was 8 days earlier than the peak of the public epidemic, indicating that these surgeons were probably exposed to COVID-19 in the hospitals, rather than in the community. Fifteen surgeons were admitted to the hospital for treatment, and 9 surgeons self-isolated at home or hotels with medicine for at least 2 weeks. All 24 surgeons recovered after treatment.

According to questionnaire responses, the suspected in-hospital sites of exposure were general wards (79.2%), public places in the hospital (20.8%), operating rooms (12.5%), the intensive care unit (4.2%), and the outpatient clinic (4.2%). Three surgeons were exposed during operations on patients who were diagnosed as having COVID-19 several days after the surgical procedures.

This and other findings underscore an already-known but worrisome feature of this disease: many asymptomatic patients with COVID-19 are shedding the virus and unwittingly exposing other people—inside and outside of hospitals—to the risk of infection.

Also worrisome: these 24 orthopaedists infected others in 25% of cases, with a 20.8% transmission rate to family members. The authors therefore recommend that orthopaedic surgeons who work in hospital settings during the COVID-19 pandemic period avoid close contact with family members at home.

Risk Factors for Infection
The authors also conducted a 1:2 matched case-control study to explore possible risk factors for COVID-19 infection. The controls were selected from uninfected orthopaedic surgeons who worked in the same department as the case(s) at each hospital.

Severe fatigue of orthopaedic surgeons during the 2 months before the outbreak was found to be a risk factor for COVID-19 infection. (Fatigue from overwork, less sleep, and mental stress are issues for orthopaedic surgeons under many “normal” circumstances.)

Real-time training in infection-prevention measures was found to have a protective effect against COVID-19, as was wearing respirators or masks all the time. More specifically, not wearing an N95 respirator was found to be a risk factor.

Generally, Guo et al. conclude that orthopaedic surgeons must be highly vigilant to avoid infection with COVID-19. They recommend the following approaches:

  • Work with medical and orthopaedic associations to provide real-time infection-control training and to address any shortages of personal protective equipment.
  • Minimize, postpone, or cancel elective operations. Test patients for COVID-19 before any operation if resources allow. Place face masks on all patients.
  • Wear N95 respirators all the time while in a hospital during the pandemic.
  • If you are exposed to the virus by patients with confirmed or suspected COVID-19, avoid close contact with family members at home and maintain physical distance in other situations.
  • If possible, avoid long-term overwork and fatigue, which could compromise immunity against COVID-19.

What Is a “High-Priority” Knee Replacement?

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

The coronavirus epidemic has caused all of us to “rethink” many things. Several days ago, a radiologist asked me whether 3 of my requested imaging studies were high priority in light of the pandemic. My response was, “God bless you. No, none of those is urgent.”

I am 79 years old and think back to my first year of orthopaedic residency, 1968. In 2020, the expectation among many patients is for immediate relief, and many orthopaedists try to deliver that. Whatever “new normal” emerges after the COVID-19 surge subsides, how will patients and physicians work together to arrive at a decision when to proceed to a knee replacement? Although knee replacement can result in pain and function salvation for patients with end-stage knee osteoarthritis, as many as 20% of patients report “unsatisfactory” results.

A recent “appropriateness” analysis of data from 2 multicenter cohort studies classified 3,417 potential knee replacements as follows:

  • Timely—total knee replacement took place within 2 years after the procedure had met “potentially appropriate” criteria
  • Potentially Appropriate but Not Replaced (for >2 years after the procedure had met appropriateness criteria)
  • Premature—a replacement that the authors deemed inappropriate but was performed anyway.

The authors found that surgery for 9% of the knees for which replacement was potentially appropriate took place in a “timely” manner. But overall, there was a high prevalence of both delayed and premature surgery. Specifically, 91% of the knees for which replacement was potentially appropriate were not replaced, and 26% of the 1,114 total knee replacements that were performed were considered to be “likely inappropriate” and therefore “premature.”

The likelihood of a knee being classified as potentially appropriate but not undergoing replacement was greater among black patients, and the likelihood of having premature total knee replacement was lower among participants with a body mass index of >25 kg/m2 and those with depression.

In a Commentary on this study, Michael G. Zywiel, MD noted that the Escobar appropriateness criteria used in the analysis focuses predominantly on physician-assessed rather than patient-assessed factors. This all begs the question: Now that we have joint-replacement tools that we could not even dream of in 1968, how do we as responsible surgeons help guide our patients in deciding when the time is right to use them?

Managing Fractures in Patients with COVID-19

As JBJS Editor-in-Chief Marc Swiontkowski, MD observed in a recent editorial, some musculoskeletal health professionals “have been set aside to some degree” during the COVID-19 pandemic. However, Dr. Swiontkowski also emphasized that “emergency/urgent procedures [still] need to be carried out.” Which leads to the question: What are the best medical practices for patients who have both fracture and COVID-19 infection.

To help answer that question, JBJS fast-tracked the publication of an article by Mi et al., which retrospectively reviewed the medical records of 10 patients from 8 hospitals in China who had both a bone fracture and COVID-19 infection.

Presenting Symptoms
All of the fractures were caused by accidents, most of them low-velocity. Flu-like symptoms of patients with a fracture and COVID-19 disease were diverse, as follows:

  • 7 patients (70%) reported fever, cough, and fatigue.
  • 4 (40%) had a sore throat.
  • 5 (50%) presented with dyspnea.
  • 3 (30%) reported dizziness.
  • 1 patient (10%) reported chest pain, nasal congestion, and headache.
  • 1 patient (10%) reported abdominal pain and vomiting.

Imaging and Lab Results
Six of the 10 patients were positive for SARSCoV-2 based on quantitative reverse transcription polymerase chain reaction (qRT-PCR) of throat-swab samples. All patients ultimately showed evidence of viral pneumonia on computed tomography (CT) scans, but on admission 3 patients did not exhibit severe symptoms or have obvious evidence of COVID-19 on CT scans, and they therefore underwent a surgical procedure. Fever and fatigue signs were observed in these 3 patients after the operation.

The overall results of laboratory tests were as follows:

  • 6 patients had lymphopenia (<1.0 x 109 cells/L)
  • 9 patients had a high level of C-reactive protein.
  • 9 patients had D-dimer levels that exceeded upper normal limits. The authors suggest that this finding “could represent the special laboratory characteristics of fractures in patients with COVID-19.”

Management
Three of the 10 patients underwent surgery; the others were managed nonoperatively due to their compromised status.

All patients received antiviral therapy and antibacterial therapy, and 9 patients were managed with supplemental oxygen. None of the patients received invasive mechanical ventilation or extracorporeal membrane oxygenation because of local limitations in medical technology.

Outcomes
Four patients died in the hospital. Among those who died, surgery had been performed on 1. The clinical outcomes for the 6 surviving patients have not yet been determined.

Conclusions
Because 7 of the 10 patients were determined to have developed a nosocomial infection, the authors emphasize the need “to adopt strict infection-control measures…Doctors, nurses, patients, and families should be wearing protective devices such as an N95 respirator and goggles.”

Mi et al. propose the following 3 additional strategies for patients with a fracture and COVID-19 pneumonia:

  • Consider nonoperative treatment for older patients with fractures, such as distal radial fractures, in endemic areas.
  • Give patients with a fracture and COVID-19 pneumonia more intensive surveillance and treatment.
  • Perform surgery on patients with a fracture and COVID-19 pneumonia in a negative-pressure operating room.