Back to the operating room: Resuming elective surgery amid COVID-19 pandemic

July - Since the start of the COVID-19 pandemic, thousands of patients have had to delay recommended but elective surgical procedures including orthopedic procedures such as joint replacement surgery or knee arthroscopy.

Now an expert panel has issued recommendations to guide safe resumption of elective surgery. The guidelines appear in the July 15, 2020 issue of The Journal of Bone & Joint Surgery, published in the Lippincott portfolio in partnership with Wolters Kluwer.

"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," according to the guideline statement by the International Consensus Group and Research Committee of the American Association of Hip and Knee Surgeons. The lead author is Javad Parvizi, MD, FRCS, of the Rothman Institute, Philadelphia.

The recommendations were developed using the Delphi method, including two rounds of voting on the gleaned recommendations from the literature, explains Prof. Bill Walter of Royal North Shore Hospital, Sydney, another senior author on the study. Following this method, the consensus guidelines were approved by an international panel of 77 expert physicians and scientists in orthopedic surgery, infectious disease, microbiology and virology, and anesthesia.

Coronavirus Spurs Changes in Managing Elective Orthopedic Surgery The guidelines "are based on the available scientific evidence, albeit scant," and will likely change with the rapidly evolving understanding of COVID-19. The guideline statement presents a set of 30 recommendations in four categories:

General. 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," said Prof. Walter.

"Patients who are currently infected with COVID-19 should not undergo elective surgery," the expert panel writes. They also state that surgery should be "possibly deferred in the early phases" in elderly patients (75 years or older) and those with health problems that put them at a high risk for COVID-19.

Preoperative. Several added steps in the preadmission process are recommended, including screening for symptoms of COVID-19, wearing masks, practicing social distancing, and 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. Currently, there is 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 writes.

Intraoperative. The intraoperative section includes recommendations for carrying out surgery-addressing factors like operating room ventilation systems, necessary personal protective equipment, cleaning of the operating room between procedures, and more. The guidelines suggest considering regional anesthesia, when possible, to avoid aerosolizations and the increased risk of virus transmission that may occur with intubation during general anesthesia. Other recommendations include the use of absorbable sutures or skin glue, occlusive dressing and so on, all aimed at reducing the need for patients' return to the office in the early postoperative period.

Postoperative. Postoperative recommendations include safeguards in the post-anesthesia care unit, such as wearing masks and putting distance between patients. Length of hospital stay should be minimized, and follow-up visits should be carried out via telemedicine, when possible.

The expert panel hopes their recommendations will be helpful in resuming recommended elective surgical procedures in patients with painful, potentially disabling orthopedic conditions. The task force emphasizes: "Each hospital and health system should consider their unique situation in terms of SARS-CoV-2 prevalence, staffing capabilities, personal protection equipment supply, and so on when determining how and when to implement these recommendations."