During the initial surge of COVID-19, symptomatic patients were thought to be mainly responsible for spreading the virus, and guidelines therefore focused on identifying and isolating patients with fever, cough, or shortness of breath. However, as the asymptomatic spread became better understood, the need for more widespread, consistent molecular testing protocols became evident—and this is especially important now that elective orthopaedic surgery has resumed. Performing a surgical procedure on an asymptomatic patient with COVID-19 could lead to contamination of the operating room and other hospital zones, possibly infecting staff and other patients.
In the latest JBJS fast-track article related to COVID-19, Gruskay et al. describe a protocol for universal PCR swab testing of all orthopaedic surgery admissions at their New York City hospital during the 3 weeks between April 5, 2020 and April 24, 2020. At that time, only urgent orthopaedic procedures were being performed. Swab testing of 99 patients revealed a high rate of COVID-19 infections—the majority of which were in patients with no symptoms. With these published findings, the authors “hope to… make a case for nasopharyngeal testing of all preoperative patients.”
During those 3 weeks in April, 7 (58.3%) of the 12 patients who tested positive for COVID-19 had no symptoms consistent with the infection on presentation, and only 1 of those patients had pneumonia that appeared on a preoperative chest radiograph. Three asymptomatic patients who tested positive developed postoperative hypoxia, with 2 requiring intubation.
In recommending routine preoperative PCR testing for orthopaedic patients, the authors acknowledge the high specificity but only moderate sensitivity of the swab test, “but few other practical options exist,” they say. Evidence suggests that CT evaluation is the most accurate diagnostic test for COVID-19 pneumonia, but its use for screening is impractical. Chest radiography is more widely available, faster, and cheaper and emits less radiation than CT, but the sensitivity for diagnosing COVID-19 pneumonia with radiographs is reported as only 70%.