The theoretical mortality risk of an asymptomatic patient with a negative SARS-CoV-2 test developing COVID-19 following elective orthopaedic surgery

Kader, Nardeen; Clement, Nick D; Patel, Vipul; Caplan, Nick; Banaszkiewicz, Paul A.; Kader, Deiary F.

doi:10.1302/0301-620x.102b9.bjj-2020-1147.r1

Cited by 46 publications

(39 citation statements)

References 24 publications

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“…3 Routine swabbing may have a false negative rate of around 30%, meaning that at times it may falsely reassure, while as prevalence falls the proportion of positive tests that are true positives becomes increasingly minuscule. 17 The data from this study support performing day case upper limb surgery not requiring GA without routine SARS-CoV-2 testing in healthcare settings in which patient groups can be kept physically separate. This would enable those patients being treated under local or regional anaesthetic to remain distant from other patients in whom the potential implications of contracting SARS-CoV-2 would be likely to be more serious, for example, this may be via the use of a dedicated minor operations facility.…”

Section: Discussionsupporting

confidence: 56%

Mortality and pulmonary complications in patients undergoing upper extremity surgery at the peak of the SARS-CoV-2 pandemic in the UK: a national cohort study

Dean

2020

BMJ Qual Saf

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IntroductionThis study reports the 30-day mortality, SARS-CoV-2 complication rate and SARS-CoV-2-related hospital processes at the peak of the first wave of the pandemic in the UK.MethodsThis national, multicentre, cohort study at 74 centres in the UK included all patients undergoing any surgery below the elbow at the peak of the UK pandemic. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The secondary outcomes were SARS-CoV-2 complication rates and overall complication rates. A clinician survey relating to SARS-CoV-2 safety processes was carried out for each participating centre.ResultsThis analysis includes 1093 patients who underwent upper limb surgery from the 1 to 14 April 2020 inclusively. The overall 30-day mortality was 0.09% (1 pre-existing SARS-CoV-2 pneumonia) and the mortality of day case surgery was zero. Most centres (96%) screened patients for symptoms prior to admission, only 22% routinely tested for SARS-CoV-2 prior to admission. The SARS-CoV-2 complication rate was 0.18% (2 pneumonias) and the overall complication rate was 6.6% (72 patients). Both SARS-CoV-2-related complications occurred in patients who had been hospitalised for a prolonged period before their surgery and a total of 19 patients (1.7%) were SARS-CoV-2 positive.ConclusionsThe SARS-CoV-2-related complication rate for upper limb surgery even at the peak of the UK pandemic was low at 0.18% and the mortality was zero for patients admitted on the day of surgery. Urgent surgery should not be delayed pending the results of SARS-CoV-2 testing. Routine SARS-CoV-2 testing for day case upper limb surgery not requiring general anaesthesia may be excessive and have unintended negative impacts.

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Section: Discussionsupporting

confidence: 56%

Mortality and pulmonary complications in patients undergoing upper extremity surgery at the peak of the SARS-CoV-2 pandemic in the UK: a national cohort study

Dean

2020

BMJ Qual Saf

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“…As lockdown measures in the UK and globally eases and the incidence of trauma returns to pre-lockdown trends, it is imperative that we understand the true increased risk of mortality in the acute trauma patient during the COVID-19 era. A recent publication by Kader et al 16 has suggested that the rate of mortality from COVID-19 for elective Orthopaedic patients is low; yet this is the first nationwide study to quantify mortality risk for trauma patients. Trauma procedures due to the nature of the injuries are necessary and time-critical, and nobody can afford to postpone trauma care even during a global pandemic 17 .…”

Section: Discussionmentioning

confidence: 99%

The impact of COVID-19 on acute Trauma and Orthopaedic referrals and surgery in the UK: the ‘golden peak weeks’ of the first national multi-centre observational study: The COVid-Emergency Related Trauma and orthopaedics (COVERT) Collaborative

Sugand

Collaborative

2020

Preprint

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Objectives: This is the first national study observing the impact of the COVID-19 pandemic on orthopaedic trauma with respect to referrals, operative caseload and mortality during the first six weeks (namely the "golden peak weeks") following the introduction of the national social distancing and lockdown measures from mid-March 2020. Design: A longitudinal, national, multi-centre, retrospective, observational, cohort study was conducted for the first six weeks from March 17, 2020 from start of the national social distancing and then lockdown compared to the same period in 2019 as a comparative baseline. Setting: Hospitals from seven major urban cities were recruited around the UK, including London, representing a comprehensive national picture of the impact of COVID-19 pandemic and its lockdown at its peak. Participants: A total of 4840 clinical encounters were initially recorded. Exclusion criterion consisted of spinal pathology only. Post-exclusion, 4668 clinical encounters were recorded and analysed within the two timeframes. Main outcome measures: Primary outcomes included the number of acute trauma referrals and those undergoing operative intervention, patient demographics, mortality rates, and the proportion of patients contracting COVID-19. Secondary outcomes consisted of the mechanism of injury, type of operative intervention and proportion of aerosolising-generating anaesthesia utilised. Demographics for each patient was recorded along with underlying medical co-morbidities. Sub-group analysis compared mortalities between both cohorts. Statistical analyses included mean (+/-SD), risk and odds ratios, as well as Fisher's exact test to calculate the statistical significance (p = 0.05). Results: During the COVID-19 period there was a 34% reduction in acute orthopaedic trauma referrals compared to 2019 (1792 down to 1183 referrals), and 29.5% less surgical interventions (993 down to 700 operations). The mortality rate significantly (both statistically and clinically) more than doubled for both risk and odds ratios during the COVID period in all referrals (1.3% vs 3.8%, p=0.0005) and in those undergoing operative intervention (2.2% vs 4.9%, p=0.004). Moreover, mortality due to COVID-related complications (versus non-COVID causes) had greater odds by a factor of at least 20 times. The odds ratios of road traffic accidents, sporting injuries, infection, and lower limb injuries were significantly less (by a third to a half) during the COVID period; albeit, the odds of sustaining neck of femur fractures and having falls <1.5m increased by more than 50%. For the operative cohorts, there was a greater odds of aerosolising-generating anaesthesia (including those with superimposed regional blocks) by three-quarters as well as doubling of the odds of a Consultant acting as the primary surgeon. Nevertheless, the odds of open reduction and internal fixation reduced by a quarter whereas removal of metalwork or foreign bodies reduced by three-quarters. Six-week Kaplan-Meier survival probability analysis confirmed those patients with neck of femur fracture and pre-existing cardiovascular and cerebrovascular disease were most at risk of mortality during the COVID-19 era. Conclusion: Although there was a reduction of acute trauma referrals and those undergoing operative intervention, the mortality rate still more than doubled in odds during the peak of the pandemic compared to the same time interval one year ago. Elderly patients with neck of femur fractures and existing cardiovascular and cerebrovascular comorbidities were at the highest risk stratification for mortality. This was the first national study to assess impact of COVID-19 pandemic on acute Orthopaedic trauma and it will aid clinicians in counselling trauma patients of the increased risk of mortality during the era of COVID-19 as well as acting as a risk-prediction tool influencing policymaking as the pandemic continues with potential subsequent waves. Further studies after the lifting of the lockdown are also required to observe for return of standard practice.

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“…In the worst-case scenario, asymptomatic but infected patients could become super spreaders, which may generate infection clusters in the hospital. In a recent calculation in the United Kingdom, the risk of patients with an undetected SARS-CoV-2 infection being inadvertently admitted for elective orthopaedic surgery was relatively low (0.07%, 1 in 1400) [21]; however, the best efforts should be taken to decrease this possibility. The self-quarantine programme is beneficial in decreasing the possibility of infection in patients scheduled to undergo elective surgery if all patients strictly obey the rules.…”

Section: Discussionmentioning

confidence: 99%

Self-quarantine programme and pre-operative SARS-CoV-2 PCR screening for orthopaedic elective surgery: experience from Japan

Nishitani

Nagao

Matsuda

2021

International Orthopaedics (SICOT)

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Purpose This study aimed to evaluate the acceptability of 14 days of self-quarantine and the positivity rate of pre-operative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) screening for patients undergoing elective orthopaedic surgery. Methods The self-quarantine programme and pre-operative SARS-CoV-2 PCR screening were initiated for patients who were scheduled for admission later than 7 May 2020 for elective orthopaedic surgery on admission. On the day of admission, the patients declared compliance with self-quarantine regulations. The admission was refused in cases of non-compliance. After admission, the patients underwent SARS-CoV-2 PCR screening. If PCR results were negative, isolation was terminated. If PCR results were positive, the surgery was postponed. If the patients had symptoms suspicious of coronavirus disease (COVID-19) after surgery, the PCR test was repeated. Results Overall, 308 patients (age: 63.2 ± 18.8 years, 197 female and 111 male) were scheduled for elective orthopaedic surgery. Two patients did not agree with the requirements of self-quarantine, and two other procedures were cancelled. No non-compliance was reported; thus, the completion rate of the self-quarantine programme was 304/308 (98.7%). Finally, 304 patients underwent PCR testing, and there were no positive PCR results. After cancellations of four operations due to reasons other than COVID-19, 300 surgical procedures were performed. No patients developed COVID-19 during hospitalisation. Conclusions Although this system is based on trusting the good behaviour of patients, accompanied by PCR screening, we believe that the results showed the efficacy of the system in safely performing orthopaedic surgery during the COVID-19 pandemic.

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The theoretical mortality risk of an asymptomatic patient with a negative SARS-CoV-2 test developing COVID-19 following elective orthopaedic surgery

Cited by 46 publications

References 24 publications

Mortality and pulmonary complications in patients undergoing upper extremity surgery at the peak of the SARS-CoV-2 pandemic in the UK: a national cohort study

Mortality and pulmonary complications in patients undergoing upper extremity surgery at the peak of the SARS-CoV-2 pandemic in the UK: a national cohort study

The impact of COVID-19 on acute Trauma and Orthopaedic referrals and surgery in the UK: the ‘golden peak weeks’ of the first national multi-centre observational study: The COVid-Emergency Related Trauma and orthopaedics (COVERT) Collaborative

Self-quarantine programme and pre-operative SARS-CoV-2 PCR screening for orthopaedic elective surgery: experience from Japan

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