Postoperative Outcomes in Patients Undergoing Orthopedic Surgery Within 90 Days of Coronavirus Disease 2019.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic with several hundred million infections worldwide. COVID-19 causes systemic complications that last beyond the initial infection. It is not known whether patients who undergo elective orthopaedic surgeries after COVID-19 are at increased risk of complications. The purpose of this study was to evaluate whether patients who undergo orthopaedic procedures after recent COVID-19 diagnosis are at increased risk of complications compared with those who have not had a recent COVID-19 diagnosis. METHODS: The TriNetX Research Network database was queried for patients undergoing elective orthopaedic surgeries from April 2020 to January 2022 in the following subspecialties: arthroscopic surgery, total joint arthroplasty, lumbar fusion, upper extremity surgery, foot and ankle (FA) surgery. Cohorts were defined by patients undergoing surgery with a diagnosis of COVID-19 from 7 to 90 days before surgery and those with no COVID-19 diagnosis 0 to 90 days before surgery. These cohorts were propensity-score matched based on differences in demographics and comorbidities. The matched cohorts were evaluated using measures of association analysis for complications, emergency department (ER) visits, and readmissions occurring 90 days postoperatively. RESULTS: Patients undergoing arthroscopic surgery were more likely to experience venous thromboembolism (VTE) (P = 0.006), myocardial infarction (P = 0.001), and ER visits (P = 0.001). Patients undergoing total joint arthroplasty were more likely to experience VTE (P < 0.001), myocardial infarction (P < 0.001), pneumonia (P< 0.001), and ER visits (P = 0.037). Patients undergoing lumbar fusion were more likely to experience VTE (P = 0.016), infection (P < 0.001), pneumonia (P < 0.001), and readmission (P = 0.006). Patients undergoing upper extremity surgery were more likely to experience VTE (P = 0.001) and pneumonia (P = 0.015). Patients undergoing foot and ankle surgery were more likely to experience VTE (P < 0.001) and pneumonia (P < 0.001). CONCLUSION: There is an increased risk of complications in patients undergoing orthopaedic surgery after COVID-19 infection; all cohorts were at increased risk of VTE and most at increased risk of pneumonia. Additional investigation is needed to stratify the risk for individual patients.

Development of a Low-Resource Operating Room and a Wide-Awake Orthopedic Surgery Program During the COVID-19 Pandemic.

Introduction. The COVID-19 pandemic resulted in significant medication, supply and equipment, and provider shortages, limiting the resources available for provision of surgical care. In response to mandates restricting surgery to high-acuity procedures during this period, our institution developed a multidisciplinary Low-Resource Operating Room (LROR) Taskforce in April 2020. This study describes our institutional experience developing an LROR to maintain access to urgent surgical procedures during the peak of the COVID-19 pandemic. Methods. A delineation of available resources and resource replacement strategies was conducted, and a final institution-wide plan for operationalizing the LROR was formed. Specialty-specific subgroups then convened to determine best practices and opportunities for LROR utilization. Orthopedic surgery performed in the LROR using wide-awake local anesthesia no tourniquet (WALANT) is presented as a use case. Results. Overall, 19 limited resources were identified, spanning across the domains of physical space, drugs, devices and equipment, and personnel. Based on the assessment, the decision to proceed with creation of an LROR was made. Sixteen urgent orthopedic surgeries were successfully performed using WALANT without conversion to general anesthesia. Conclusion. In response to the COVID-19 pandemic, a LROR was successfully designed and operationalized. The process for development of a LROR and recommended strategies for operating in a resource-constrained environment may serve as a model for other institutions and facilitate rapid implementation of this care model should the need arise in future pandemic or disaster situations.

Maintaining Access to Orthopaedic Surgery During Periods of Operating Room Resource Constraint: Expanded Use of Wide-Awake Surgery During the COVID-19 Pandemic.

INTRODUCTION: Wide-awake local anesthesia no tourniquet (WALANT) presents a nonstandard anesthetic approach initially described for use in hand surgery that has gained interest and utilization across a variety of orthopaedic procedures. In response to operating room resource constraints imposed by the COVID-19 pandemic, our orthopaedic service rapidly adopted and expanded its use of WALANT. METHODS: A retrospective review of 16 consecutive cases performed by 7 surgeons was conducted. Patient demographics, surgical details, and perioperative outcomes were assessed. The primary end point was WALANT failure, defined as intraoperative conversion to general anesthesia. RESULTS: No instances of WALANT failure requiring conversion to general anesthesia occurred. In recovery, one patient (6%) required narcotics for pain control, and the average postoperative pain numeric rating scale was 0.6. The maximum pain score experienced was 4 in the patient requiring postoperative narcotics. The average time in recovery was 42 minutes and ranged from 8 to 118 minutes. CONCLUSION: The WALANT technique was safely and effectively used in 16 cases across multiple orthopaedic subspecialties, including three procedures not previously described in the literature. WALANT techniques hold promise for use in future disaster scenarios and should be evaluated for potential incorporation into routine orthopaedic surgical care.

Risk factors for severe illness in hospitalized Covid-19 patients at a regional hospital.

BACKGROUND: The Covid-19 pandemic threatens to overwhelm scarce clinical resources. Risk factors for severe illness must be identified to make efficient resource allocations. OBJECTIVE: To evaluate risk factors for severe illness. DESIGN: Retrospective, observational case series. SETTING: Single-institution. PARTICIPANTS: First 117 consecutive patients hospitalized for Covid-19 from March 1 to April 12, 2020. EXPOSURE: None. MAIN OUTCOMES AND MEASURES: Intensive care unit admission or death. RESULTS: In-hospital mortality was 24.8% and average total length of stay was 11.82 days (95% CI: 10.01 to 13.63 days). 30.8% of patients required intensive care unit admission and 29.1% required mechanical ventilation. Multivariate regression identified the amount of supplemental oxygen required at admission (OR: 1.208, 95% CI: 1.011-1.443, p = .037), sputum production (OR: 6.734, 95% CI: 1.630-27.812, p = .008), insulin dependent diabetes mellitus (OR: 11.873, 95% CI: 2.218-63.555, p = .004) and chronic kidney disease (OR: 4.793, 95% CI: 1.528-15.037, p = .007) as significant risk factors for intensive care unit admission or death. Of the 48 patients who were admitted to the intensive care unit or died, this occurred within 3 days of arrival in 42%, within 6 days in 71%, and within 9 days in 88% of patients. CONCLUSIONS: At our regional medical center, patients with Covid-19 had an average length of stay just under 12 days, required ICU care in 31% of cases, and had a 25% mortality rate. Patients with increased sputum production and higher supplemental oxygen requirements at admission, and insulin dependent diabetes or chronic kidney disease may be at increased risk for severe illness. A model for predicting intensive care unit admission or death with excellent discrimination was created that may aid in treatment decisions and resource allocation. Early identification of patients at increased risk for severe illness may lead to improved outcomes in patients hospitalized with Covid-19.