The Persistent Effects of the COVID-19 Pandemic on Total Joint Arthroplasty Changes in Practice Patterns in the United States From 2020 to 2021.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has dramatically disrupted orthopaedic surgery practice patterns. This study aimed to examine differences between patients who underwent total joint arthroplasty (TJA) before the pandemic compared to 2020 and 2021. METHODS: A retrospective cohort study was performed on all patients who underwent elective inpatient TJA from January 2017 to December 2021 using a national large database. Descriptive statistics were utilized to trend length of stay (LOS) and patient age. Patient demographics, discharge destinations, and rates of medical comorbidities were assessed for patients undergoing TJA in 2020 and 2021 compared to patients from prepandemic years (2017 to 2019). Overall, 1,173,366 TJAs were identified (2017 to 2019: 810,268 TJAs, average 270,089 cases/year; 2020: 175,185 TJAs; 2021: 187,627 TJAs). There was a 35.3% and 30.5% decrease in 2020 and 2021, respectively, when compared to the prepandemic annual average. RESULTS: Average LOS decreased from 1.6 days in January 2020 to 0.9 days by December 2021. Same-day discharges increased from 6.2% of cases in 2019 to 30.5% in 2021. Discharge to skilled nursing facilities (SNF) reduced from 11.3% in 2017 to 2019 to 4.3% and 4.5% in 2020 and 2021, respectively. Patients ≥70 years old undergoing elective TJA decreased from 39.6% in 2017 to 2019 to 29.2% in April 2020. CONCLUSION: In response to the COVID-19 pandemic, same-day discharges following primary elective TJA increased markedly, the average LOS decreased, discharges to SNFs decreased, and a preferential shift toward younger patients was observed. LEVEL OF EVIDENCE: Therapeutic Level III.

Total Hip Replacement in Severe Haemophilia A: Challenges and Feasibility.

The management of haemophilic patients is complicated due to multiple comorbidities. A dedicated haemophilia treatment centre with a multidisciplinary team can plan and execute elective orthopaedic surgery in such haemophilic individuals. A cementless total hip arthroplasty (THA) was performed in a 26-year-old male patient with haemophilic arthropathy of the right hip under factor VIII replacement therapy based on activated partial thromboplastin time levels. The patient received a preoperative dose of recombinant anti-haemophilic factor. Venous thromboembolic event prophylaxis was not given. Postoperative radiographs demonstrated successful prosthesis placement. The patient could bear weight and walk unassisted two weeks after surgery. THA in patients with haemophilia leads to significant improvement in joint function with a relatively low incidence of complications with modern techniques and haematological management.

Effect of the COVID-19 Pandemic on Rates of Ninety-Day Peri-Prosthetic Joint and Surgical Site Infections after Primary Total Joint Arthroplasty: A Multicenter, Retrospective Study.

Background: The impact of the coronavirus 2019 (COVID-19) pandemic on the rate of primary total joint arthroplasty (TJA) peri-prosthetic joint infection (PJI) and superficial surgical site infections (SSI) is currently unknown. The purpose of this multicenter study was to evaluate any changes in the rates of 90-day PJI or 30-day SSI, including trends in microbiology of the infections, during the COVID-19 pandemic compared to the three years prior. Patients and Methods: An Institutional Review Board-approved, multicenter, retrospective study was conducted with five participating academic institutions across two healthcare systems in the northeastern United States. Primary TJA patients from the years 2017-2019 were grouped as a pre-COVID-19 pandemic cohort and patients from the year 2020 were grouped as a COVID-19 pandemic cohort. Differences in patient demographics, PJI, SSI, and microbiology between the two cohorts were assessed. Results: A total of 14,844 TJAs in the pre-COVID-19 pandemic cohort and 5,453 TJAs in the COVID-19 pandemic cohort were evaluated. There were no substantial differences of the combined 90-day PJI and 30-day superficial SSI rates between the pre-COVID-19 pandemic cohort (0.35%) compared with the COVID-19 pandemic cohort (0.26%; p = 0.303). Conclusions: This study did not find any change in the rates of 90-day PJI or 30-day superficial SSI in patients undergoing primary TJA between a pre-COVID-19 pandemic and COVID-19 pandemic cohort. Larger national database studies may identify small but substantial differences in 90-day PJI and 30-day superficial SSI rates between these two time periods. Our data may support continued efforts to maintain high compliance with hand hygiene, use of personal protective equipment, and limited hospital visitation whenever possible.

Italian Translation, Adaptation, and Validation of the Novel Satisfaction Measure Assessment after Primary Total Joint Arthroplasty: The Goodman Score Questionnaire.

Patient satisfaction after total joint arthroplasties (TJA) represents a key element for the evaluation of surgery success in relation to subjects' needs and expectations. The assessment tools are applied inconsistently throughout the literature, and thus, it is difficult to compare results among different studies. Goodman et al. proposed a standardized questionnaire with strong psychometric properties for the assessment of satisfaction. The present study aims to translate, adapt, and validate the Goodman questionnaire for the Italian population. After translation and back translation, the questionnaire was administrated to 50 patients. Internal consistency, test-retest reliability, floor and ceiling effects, and construct validity were evaluated (correlation with KOOS/HOOS, SF-12 PCS/MCS, EQ-5D). Responsiveness was evaluated with respect to SF-12 PCS improvements. The Italian version of the Goodman score questionnaire demonstrated psychometric properties similar to those of the original version. The translated questionnaire showed good internal consistency (Cronbach's alpha = 0.836) and test-retest reliability (ICC: 0.507). Moderate/strong correlations were observed between the Italian version of the Goodman score and other scores. The score significantly discriminated patients who improved from those who did not improve in SF-12 PCS after treatment. This study provides an adapted and validated Italian version of the Goodman score questionnaire, with psychometric properties similar to those of its original counterpart.

Comparison of total joint arthroplasty care patterns prior to the Covid-19 pandemic and after resumption of elective surgery during the Covid-19 Outbreak: A retrospective, large urban academic center study.

BACKGROUND: After the suspension of elective surgeries was lifted in June 2020 in New York State, challenges remained regarding coordination of total joint arthroplasty (TJA) cases. Using the experience from a high-volume health system in New York City, we aimed to describe patterns of care after resumption of elective TJA. METHODS: We retrospectively assessed 7,699 TJAs performed before and during the COVID-19 pandemic. Perioperative characteristics and clinical outcomes were compared between TJAs based on time period of performance: 1) pre-pandemic (PP, June 8th-December 8th, 2019), 2) initial period post-resumption of elective surgeries (IR, June 8th-September 8th, 2020), and 3) later period post-resumption (LR, September 9th-December 8th, 2020). RESULTS: LOS > 2 days (83%, 67%, 70% for PP, IR, LR periods respectively) and discharge rates to post-acute care (PAC) facilities were lower during the pandemic periods (ORIR vs. PP: 0.48, 95% CI: 0.40-0.59, p < 0.001; ORLR vs. PP: 0.63, 95% CI: 0.53-0.75, p < 0.001). Compared to the pre-pandemic period, the risk for 30-day readmission was lower during the IR period (OR: 0.62, 95% CI: 0.40-0.98, p = 0.041) and similar during the LR period (OR: 0.96, 95% CI: 0.65-1.41, p = 0.832). CONCLUSIONS: Despite decreased LOS and discharge to PAC for TJAs performed during the pandemic, 30-day readmissions did not increase. Given the increased costs and lack of superior functional outcomes associated with discharge to PAC, these findings suggest that discharge to PAC facilities need not return to pre-pandemic levels.

Resumption of Elective Orthopaedic Surgery in the US Epicenter of COVID-19: Overcoming the Continuous Challenges.

On 1 March 2020, New York State confirmed its first case of COVID-19. An explosive progression of hospitalizations ensued, and all elective surgeries were cancelled between 23 March and 13 May 2020 per federal and state mandate. Upon return to elective surgery in May, 2020, the hospital found itself navigating uncharted territory. The unpredictability of the post-pandemic environment has required the healthcare team to constantly reassess and revise processes to ensure optimal patient outcomes, as well as safe practices for staff providing perioperative care. Health care professionals must continue to remain adaptable and amenable to constant change.

Disruption of joint arthroplasty services in Europe during the COVID-19 pandemic: an online survey within the European Hip Society (EHS) and the European Knee Associates (EKA).

PURPOSE: The aim of the present study was to evaluate the impact of the coronavirus (COVID-19) pandemic on joint arthroplasty service in Europe by conducting an online survey of arthroplasty surgeons. METHODS: The survey was conducted in the European Hip Society (EHS) and the European Knee Associates (EKA). The survey consisted of 20 questions (single, multiple choice, ranked). Four topics were addressed: (1) origin and surgical experience of the participant (four questions); (2) potential disruption of arthroplasty surgeries (12 questions); (3) influence of the COVID-19 pandemic on the particular arthroplasty surgeon (four questions); (4) a matrix provided 14 different arthroplasty surgeries and the participant was asked to state whether dedicated surgery was stopped, delayed or cancelled. RESULTS: Two-hundred and seventy-two surgeons (217 EHS, 55 EKA) from 40 different countries participated. Of the respondents, 25.7% stated that all surgeries were cancelled in their departments, while 68.4% responded that elective inpatient procedures were no longer being performed. With regard to the specific surgical procedures, nearly all primary TJA were cancelled (92.6%) as well as aseptic revisions (94.7%). In most hospitals, periprosthetic fractures (87.2%), hip arthroplasty for femoral neck fractures and septic revisions for acute infections (75.8%) were still being performed. CONCLUSION: During the current 2020 COVID-19 pandemic, we are experiencing a near-total shutdown of TJA. A massive cutback was observed for primary TJA and revision TJA, even in massively failed TJA with collapse, dislocation, component failure or imminent dislocation. Only life-threatening pathologies like periprosthetic fractures and acute septic TJA are currently undergoing surgical treatment. LEVEL OF EVIDENCE: V.

Telemedicine Hip and Knee Arthroplasty Experience During COVID-19.

BACKGROUND: Although telemedicine visits were essential and adopted by providers and patients alike, few studies have been conducted evaluating orthopedic patient perception of the care delivered during these visits. To our knowledge, no study has evaluated specific factors that affected patient satisfaction with telemedicine and the receptiveness to continue virtual visits post COVID-19 in total joint arthroplasty (TJA) patients. Thus, the purposes of our study are to determine the following: (1) patient satisfaction with using TJA telemedicine services, (2) whether patient characteristics might be associated with satisfaction, and (3) whether virtual clinic visits may be used post-COVID-19. METHODS: A prospective, cross-sectional survey study was completed by 126 TJA patients who participated in telemedicine visits with TJA surgeons from May 1, 2020 to August 31, 2020. The survey consisted of questions regarding demographics, satisfaction, and telemedicine experiences. RESULTS: One hundred one (80.2%) patients were satisfied with their telemedicine visit, with patients <80 years old (P = .008) and those with a longer commute time (P = .01) being more satisfied P = .01. There was a significant preference for in-person visits when meeting arthroplasty surgeons for the first time (P < .001), but patients were equally amenable to follow-up telemedicine visits once there was an established relationship with the surgeon. CONCLUSION: Younger patients, patients with longer commute distances, and patients who had established relationships with their provider expressed higher satisfaction with telemedicine arthroplasty visits. Although >80% of patients were satisfied with their telemedicine visit, an established patient-provider relationship may be integral to the success of an arthroplasty telemedicine practice.

COVID-19 Infection After Total Joint Arthroplasty Is Associated With Increased Complications.

BACKGROUND: The impact of a postoperative diagnosis of COVID-19 in patients undergoing total joint arthroplasty (TJA) remains unknown. The objective of this study is to characterize the effect of COVID-19 infection following TJA on perioperative complication rates. METHODS: The Mariner database was queried for patients undergoing total hip and total knee arthroplasty from January 2018 to April 2020. TJA patients who were diagnosed with COVID-19 within 90 days postoperatively were matched in a 1:3 fashion based on age, gender, iron deficiency anemia, payer status, and Charlson Comorbidity Index with patients who were not diagnosed with COVID-19. Preoperative comorbidity profiles and complications within 3 months of surgery were compared. Statistical analysis included chi-squared tests and multivariate logistic regression with outcomes considered significant at P < .05. RESULTS: Of the 239 COVID-19 positive patients, 132 (55.2%) underwent total hip arthroplasty. On multivariate analysis, COVID-19 diagnosis was associated with increased odds of deep vein thrombosis (odds ratio [OR] 4.86, 95% confidence interval [CI] 2.10-11.81, P < .001), pulmonary embolism (OR 6.27, 95% CI 2.57-16.71, P < .001), and all complications (OR 3.36, 95% CI 2.47-4.59, P < .001). Incidence of deep vein thrombosis/pulmonary embolism was greater the closer in time the COVID-19 diagnosis was to the surgical procedure (10.24 times at 1 month, 7.87 times at 2 months, and 1.42 times at 3 months; P < .001). A similar relationship was observed with all complications. CONCLUSION: Postoperative COVID-19 infection is associated with higher rates of cardiopulmonary complications, thromboembolic disease, renal injury, and urinary tract infections in patients undergoing hip and knee arthroplasty. COVID-19 infection earlier in the postoperative period is associated with a higher risk of complications.

Unit Sales Trends of Hip Arthroplasty Procedures Performed in Ontario in 2020.

BACKGROUND: In March 2020, an emergency was declared in the province of Ontario owing to the COVID-19 pandemic. From March 19 to May 26, all elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures were deferred. The purpose of this study was to review the unit sales data of THA and TKA procedures in Ontario over this time period to identify any trends in surgical activity. METHODS: Unit sales data for all THA and TKA procedures performed in Ontario between January 2019 and December 2020 were reviewed. All orthopedic companies contributed to the data set. Femoral stems were considered an indicator of THA procedures, while primary femurs were considered an indicator of TKA procedures. Data were analyzed to determine trends in THA and TKA procedures during the deferral period and the relative change in THA and TKA activity following resumption. RESULTS: There was a 53% reduction in THA activity between March and May of 2020 when compared to the same interval in 2019. From June to September of 2019, THA sales activity was 87.3% that of TKA. From June to September of 2020, THA sales activity was 122.8% that of TKA. CONCLUSION: Provincial directives aimed at controlling the outbreak of COVID-19 contributed to a substantial reduction in THA and TKA activity in 2020. Compared to 2019, there was a disproportionate increase in THA compared to TKA activity in 2020 following resumption of surgical services. These data have implications in recovery planning for the surgical backlog of THA in Ontario.

History of COVID-19 Was Not Associated With Length of Stay or In-Hospital Complications After Elective Lower Extremity Joint Replacement.

BACKGROUND: The impact of previous SARS-CoV-2 infection on the morbidity of elective total joint arthroplasty (TJA) is not fully understood. This study reports on the association between previous COVID-19 disease, hospital length of stay (LOS), and in-hospital complications after elective primary TJA. METHODS: Demographics, comorbidities, LOS, and in-hospital complications of consecutive 340 patients with a history of COVID-19 were compared with those of 5014 patients without a history of COVID-19 undergoing TJA. History of COVID-19 was defined as a positive IgG antibody test for SARS-CoV-2 before surgery. All patients were given both antibody and polymerase chain reaction tests before surgery. RESULTS: Patients with a history of COVID-19 were more likely to be obese (43.8% vs 32.4%, P < .001), Black (15.6% vs 6.8%, P < .001), or Hispanic (8.5% vs 5.4%, P = .028) than patients without a history of COVID-19. COVID-19 treatment was reported by 6.8% of patients with a history of COVID-19. Patients with a history of COVID-19 did not have a significantly longer median LOS after controlling for other factors (for hip replacements, median 2.9 h longer, 95% confidence interval = -2.0 to 7.8, P = .240; for knee replacements, median 4.1 h longer, 95% confidence interval = -2.4 to 10.5, P = .214), but a higher percentage were discharged to a post-acute care facility (4.7% vs 1.9%, P = .001). There was no significant difference in in-hospital complication rates between the 2 groups (0/340 = 0.0% vs 22/5014 = 0.44%, P = .221). CONCLUSIONS: We do not find differences in LOS or in-hospital complications between the 2 groups. However, more work is needed to confirm these findings, particularly for patients with a history of more severe COVID-19. LEVEL OF EVIDENCE: II.

COVID-19 (SARS-CoV-2) lymphocyte responses are associated with inflammatory biomarkers in total joint replacement surgery candidates pre-operatively.

BACKGROUND: Recent studies indicate that, in addition to antibody production, lymphocyte responses to SARS-CoV-2 may play an important role in protective immunity to COVID-19 and a percentage of the general population may exhibit lymphocyte memory due to unknown/asymptomatic exposure to SARS-CoV-2 or cross-reactivity to other more common coronaviruses pre-vaccination. Total joint replacement (TJR) candidates returning to elective surgeries (median age 68 years) may exhibit similar lymphocyte and/or antibody protection to COVID-19 prior to vaccination METHODS: In this retrospective study, we analyzed antibody titters, lymphocyte memory, and inflammatory biomarkers specific for the Spike and Nucleocapsid proteins of the SARS-CoV-2 virus in a cohort of n=73 returning TJR candidates (knees and/or hips) pre-operatively. RESULTS: Peripheral blood serum of TJR candidate patients exhibited a positivity rate of 18.4% and 4% for IgG antibodies specific for SARS-CoV-2 nucleocapsid and spike proteins, respectively. 13.5% of TJR candidates exhibited positive lymphocyte reactivity (SI > 2) to the SARS-CoV-2 nucleocapsid protein and 38% to the spike protein. SARS-CoV-2 reactive lymphocytes exhibited a higher production of inflammatory biomarkers (i.e., IL-1ß, IL-6, TNFα, and IL-1RA) compared to non-reactive lymphocytes. CONCLUSIONS: A percentage of TJR candidates returning for elective surgeries exhibit pre-vaccination positive SARS-CoV-2 antibodies and T cell memory responses with associated pro-inflammatory biomarkers. This is an important parameter for understanding immunity, risk profiles, and may aid pre-operative planning. TRIAL REGISTRATION: Retrospectively registered.

A COVID-19 Pivot Plan to Resume Elective Surgeries at the Hartford Healthcare Connecticut Orthopaedic Institute.

Background The Connecticut Orthopaedic Institute (COI) conceptualized a Pivot Plan during an elective surgery moratorium at the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic with the goal of planning and executing orthopedic procedures safely. With the resumption of elective surgeries and the continued planning of surgical recovery over the months (and possibly years) to follow, facilities must brace themselves for repeat waves of COVID-19. Thereby, herein we share the Pivot Plan, its implementation process, evaluation of patient safety, and program performance during a pandemic. This could inform the efforts of other institutions seeking to restart non-emergent surgeries during similarly trying times in the future.  Methods The COI formed a multidisciplinary team of leaders that met weekly to design a Pivot Plan and a dashboard to guide the resumption of surgeries and assess the performance of the Pivot Plan. The plan revolved around four domains: safety, space, staff, and supplies. It was implemented in two COI-affiliated facilities: MidState Medical Center (MMC) and St. Vincent's Medical Center (SVMC). Monthly metrics from May to November 2020 were compared to the six-month averages for the pre-pandemic baseline period from September 2019 to February 2020. Results The total number (N) of elective orthopaedic cases prior to the pandemic pre-COVID averaged 372 cases per month for MMC and 197 cases for SVMC. During the pandemic post-COVID, N averaging at 361 for MMC and 243 for SVMC illustrates COI was able to perform elective surgeries amid a worsening pandemic. Same-day (SD) discharge rates for total joint arthroplasty (TJA) pre-COVID averaged 8% for MMC and 3% for SVMC. Post-COVID, the SD average was 16.7% for MMC and 11.4% for SVMC. This data indicates that orthopaedic providers were cognizant of length of stay in order to reduce the risk of in-hospital exposure to COVID-19. The 30-day readmission (30R) rate for TJA pre-COVID averaged 1.4% for MMC and 2.7% for SVMC. A high level of care and follow-up is reflected in a lower average 30R post-COVID, 1.1% for both MMC and SVMC. Transitions for TJA patients to their home settings after surgery also reflect the quality of care and the efficiency of the patient throughput process with necessary precautions in place. Post-COVID, the patient transition to home (T) averaged 98.1% for MMC and 97.5% for SVMC compared to T = 96.8% for MMC and 88% for SVMC pre-COVID. No patients experienced deep vein thrombosis or pulmonary embolism during the time period of the project. Positive COVID-19 diagnosis 23 days after discharge was 0% at MMC and 0.2% at SVMC. Conclusion The COI Pivot Plan was successfully implemented at two different hospitals offering elective orthopaedic surgeries to a varied patient population. The precautions taken by COI were effective in controlling the spread of the SARS-CoV-2 virus while returning to elective orthopaedic surgery. Furthermore, data collected before and after the onset of the COVID-19 pandemic indicated that program performance and quality improved.

COVID-19 and elective joint arthroplasty: Patient perspectives and considerations.

This study gauged patient perspectives regarding elective joint arthroplasty during the COVID-19 pandemic. Eligible patients undergoing consultation for primary hip or knee arthroplasty received a survey with questions regarding opinions towards COVID-19 and on undergoing elective procedures during the pandemic. Of the 112 respondents, 78% believed that their condition warranted surgery despite COVID-19 circumstances. There were no differences in desire for surgery based on age, smoking history or comorbidities. Patients older than 65 years were significantly more concerned with skilled nursing facility placement. This survey suggests that the majority of patients are comfortable pursuing elective joint arthroplasty despite the pandemic.

Pain and function deteriorate in patients awaiting total joint arthroplasty that has been postponed due to the COVID-19 pandemic.

BACKGROUND: Elective total joint arthroplasty (TJA) procedures have been postponed as part of the coronavirus disease 2019 (COVID-19) response to avert healthcare system collapse. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures comprise the highest volume of elective procedures performed at health care facilities worldwide. AIM: To determine the demand for TJA despite the pandemic and the impact of surgery postponement on physical and mental health. METHODS: We conducted a prospective cross-sectional telephonic interview-based study on patients awaiting THA and TKA at an academic institution in South Africa. The questionnaire consisted of four sections. The first section recorded baseline demographic data and medical co-morbidities, the length of time spent awaiting TJA, and the patients' desire to undergo elective surgery despite the COVID-19 pandemic. Section 2 and Section 3 assessed the patients' current physical and mental health, respectively, as a consequence of deferred surgical intervention. The last section established the patients' perception of the healthcare system's response to the COVID-19 pandemic and necessity to postpone elective surgery. Patients received counseling and education on the current state of surgery during the COVID-19 pandemic and associated risks. Thereafter, patients were once again asked about their desire to undergo TJA during the COVID-19 pandemic. RESULTS: We included 185 patients (65.95% female; mean age: 50.28 years) awaiting TJA for a mean of 26.42 ± 30.1 mo. Overall, 88.65% of patients wanted TJA despite the COVID-19 pandemic. Patients awaiting TJA for 1-3 years were 3.3-fold more likely to want surgery than those waiting < 1 year (P < 0.000). Patients with comorbidities were 8.4-fold less likely to want TJA than those with no comorbidities (P = 0.013). After receiving education, the patients wanting TJA decreased to 54.05%. Patients who changed their opinion after education had less insight on the increased morbidity (P = 0.046) and mortality (P = 0.001) associated with COVID-19. Despite awaiting TJA for shorter period (24.7 ± 20.38 mo), patients who continued to demand TJA had greater pain (P < 0.000) and decreased function (P = 0.043) since TJA postponement. CONCLUSION: There is deterioration in health for patients, who have had elective procedures postponed during the COVID-19 pandemic. Waiting lists should be prioritized for urgency with the re-initiation of elective surgery.

Perioperative Medical and Surgical Coronavirus Disease 2019 Issues: Keeping Surgeons, Operating Room Teams, and Patients Safe.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has infected over 22 million people in the United States (US) and has had a devastating impact on the US economy and healthcare system. In order to help slow the spread of the virus and save hospital resources, nonessential businesses were forced to close and elective surgeries have been postponed. METHODS: As we reach the peak of the pandemic and the COVID-19 vaccine gets distributed, healthcare systems must develop plans to safely resume elective surgeries. This article outlines a single center academic medical center's perioperative COVID-19 protocol to help keep surgeons, operating room teams, and patients safe. RESULTS: While testing protocols can help minimize the transmission of the virus, there is still the potential for COVID+ patients to undergo surgery undetected, due to potential false negative tests and the long incubation period before seroconversion and symptom development. CONCLUSIONS: An effective institutional strategy not only includes clear perioperative testing protocols, but also education regarding clinical manifestations and exposure control.

Resumption of Elective Orthopaedic Surgery in the US Epicenter of COVID-19.

On March 1, 2020, New York State confirmed its first case of COVID-19. This state has had the largest initial mortality in the United States with more than 479,000 confirmed cases and over 25,000 deaths as of October 10, 2020. All elective surgeries in New York State were suspended on March 23, 2020, due to the national state of emergency. Syosset Hospital is a 75-bed community hospital dedicated primarily to elective surgery. During the COVID-19 surge, the hospital was converted to provide needed beds for the treatment of COVID-19 illness. In anticipation of the resumption of urgent elective procedures, this hospital became one of the two designated sites within the Northwell Health system to be "non-COVID." Once the hospital was emptied of all inpatients, a complete and thorough cleaning and disinfection was performed on the entire building. All equipment was thoroughly decontaminated following Centers for Disease Control and Prevention (CDC) guidelines. In anticipation of the resumption of elective surgery, each surgeon evaluated their cancelled case list to determine patient priority, based on a scale of 1 (elective, non-urgent), 2 (semi-urgent), 3 (urgent), to 4 (highly urgent). Site-specific disaster credentialing was expedited so that emergent surgeries could be performed by surgeons located at other Northwell sites. To ensure a structured and informative onboarding process, each visiting surgeon received a "welcome" email which requested pertinent information to facilitate the surgical process. Presurgical, surgical, and postoperative protocols were revised based on federal and local guidance and regulations. Resumption of elective surgery post COVID-19 placed the hospital into uncharted territory.

Total Joint Arthroplasty During the COVID-19 Pandemic: A Scoping Review with Implications for Future Practice.

BACKGROUND: Recent studies have examined the impact of the COVID-19 pandemic on the practice of total joint arthroplasty. A scoping review of the literature with compiled recommendations is a useful tool for arthroplasty surgeons as they resume their orthopedic practices during the pandemic. METHODS: In June 2020, PubMed, Embase (Ovid), Cochrane Library (Wiley), Scopus, LitCovid, CINAHL, medRxiv, and bioRxiv were queried for articles using controlled vocabulary and keywords pertaining to COVID-19 and total joint arthroplasty. Studies were characterized by their region of origin, design, and Center of Evidence Based Medicine level of evidence. The identified relevant studies were grouped into 6 categories: changes to future clinical workflow, education, impact on patients, impact on surgeons, technology, and surgical volume. RESULTS: The COVID-19 pandemic has had a significant impact on arthroplasty practice, including the disruption of the clinical teaching environment, personal and financial consequences for patients and physicians, and the drastic reduction in surgical volume. New pathways for clinical workflow have emerged, along with novel technologies with applications for both patients and trainees. CONCLUSIONS: The COVID-19 pandemic emphasizes the recent trend in arthroplasty toward risk stratification and outpatient surgery, which may result in improved clinical outcomes and significant cost-savings. Furthermore, virtual technologies are a promising area of future focus that may ultimately improve upon previous existing inefficiencies in the education and clinical environments.

Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols.

BACKGROUND: Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged 2 or 3 days postoperatively (later). METHODS: In total, 530 aseptic rTJAs performed at a single tertiary care referral center (December 5, 2011 to December 30, 2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, American Society of Anesthesiologists physical status classification, age, and body mass index. All patients were optimized using modern perioperative protocols. The rate of 90-day emergency department (ED) visits and hospital admissions was compared between groups. RESULTS: In total, 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. Sixty-two percent of the sample was female, with an overall average age and body mass index of 63 ± 9.9 (range: 18-92) years and 32 ± 6.9 (range: 18-58) kg/m2. There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (P = .214). Ninety-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) discharges did not differ (P = .545). CONCLUSION: Using modern perioperative protocols with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may safely discharge home the same or next day to preserve hospital beds and resources for more critical illness.

Rapid Decline in Online Search Queries for Hip and Knee Arthroplasties Concurrent With the COVID-19 Pandemic.

BACKGROUND: In response to the coronavirus disease 2019 (COVID-19) pandemic, US hospitals have canceled elective surgeries. This decline in total joint arthroplasty (TJA) revenue may place financial strain on hospitals. Our goal was to quantify the impact of COVID-19 on the public interest in elective TJA. METHODS: The Google Search Volume Index (GSVI) identified the terms "knee replacement," "hip replacement," and "orthopedic surgeon" as the most common to describe TJA. The term "elective surgery cancellation" was also analyzed. Weekly GSVI data were extracted between 04-01-2015 and 04-04-2020. Time series analysis was conducted and state GSVI values were compared with COVID-19 prevalence and unemployment claims. RESULTS: The relative public interest in elective TJA has sharply declined since the WHO declaration of COVID-19 as a global pandemic. Between 03-01-2020 and 03-29-2020, the popularity of searches for "knee replacement", "hip replacement," and "orthopedic surgeon" dropped by 62.1%, 52.1%, and 44.3%, respectively. A concurrent spike was observed for the term "elective surgery cancellation." California, New Hampshire, Maine, and Nevada showed a low relative rate for TJA searches, and the highest increase in unemployment claims. CONCLUSION: The onset of COVID-19 correlates with declining relative popularity of searches related to elective TJA. Higher volume of COVID-19 cases in certain states may correspond with lower relative search popularity, although this correlation remains unclear. These results portend the possibility of a decline in elective TJA case volume, further straining hospitals. Further research is required to inform stakeholders how best to proceed and determine any sustained effects from the current diminished relative interest in TJA. LEVEL OF EVIDENCE: Level III.