Triaging Total Hip Arthroplasty During the COVID-19 Pandemic

Abstract

Purpose of Review The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic. Recent Findings SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting "elective" surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely "elective" procedure, versus an "urgent" procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into "elective" versus "urgent" categories. Summary In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one's peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.

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

“…Following the initial title/abstract screen, 78 articles were assessed for eligibility in the full-text phase. Ultimately, 48 studies met the inclusion and exclusion criteria and were included for analysis [ 1 , 3 , 4 , 5 , 6 , 7 , 10 , 11 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 ]. All of these studies were categorized as level IV or level V Evidence, representing low-quality studies ( Table 1 ).…”

“…Twenty-five studies documented the impact of COVID-19 on future clinical or operational workflow ( Table 2 ) [ 4 , 5 , 6 , 7 , 10 , 11 , 15 , 18 , 19 , 22 , 24 , 26 , 29 , 30 , 32 , 33 , 35 , 37 , 38 , 41 , 44 , 45 , 49 , 50 ]. Of these, fourteen studies detailed the importance of establishment and updating of an effective COVID-19 screening protocol [ 5 , 6 , 10 , 11 , 18 , 19 , 22 , 24 , 26 , 29 , 32 , 33 , 37 , 38 ].…”

“…Further, Gruskay et al noted that a positive chest x-ray did not significantly improve the negative predictive value of symptom screening [ 26 ]. Eleven studies documented the importance of risk stratification of patients undergoing orthopedic surgery [ 4 , 5 , 6 , 7 , 10 , 11 , 18 , 22 , 29 , 44 , 45 ]. Due to poorer surgical outcomes of patients with comorbidities, these authors noted that potential complications would result in excessive consumption of additional hospital resources postoperatively.…”

Elective Orthopaedic Surgeries During Coronavirus Disease 2019 Pandemic

“…Otherwise, Rizkalla et al [3] establish an algorithm that classifies urgent arthroplasties and arthroplasties that can be postponed without problems. The decision to perform hip arthroplasty is based on the damage caused by not performing the procedure and the risk of contagion if the surgery is performed.…”

Response to Letter to the Editor on “Elective Orthopaedic Surgeries During Coronavirus Disease 2019 Pandemic”

“…We agree with the authors that the risks and harms of coronavirus disease 2019 (COVID-19) in our patient were greater than the additional risks of delayed surgery. According to criteria put forward by Rizkalla et al [2], our case differs from an elective total joint arthroplasty (TJA), as we presented a critically ill, decompensated patient with active COVID-19 disease and an acute femoral neck fracture. As concluded by Collins et al [3] and Rodriguespinto et al [4], with implementation of safe surgical practices (ie, proper personal protective equipment [PPE], dedicated COVID-19 operating room, communication with anesthesia team, etc.)…”