key: cord-0758757-8nrev34j
authors: Chen, Aaron Z.; Shen, Tony S.; Bovonratwet, Patawut; Pain, Kevin J.; Murphy, Alexander I.; Su, Edwin P.
title: Total Joint Arthroplasty during the COVID-19 Pandemic: A Scoping Review with Implications for Future Practice
date: 2021-01-06
journal: Arthroplast Today
DOI: 10.1016/j.artd.2020.12.028
sha: 9180b6c1c368a20f16c7de6f93aa0452ad84546e
doc_id: 758757
cord_uid: 8nrev34j

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 CEBM level of evidence. The identified relevant studies were grouped into six 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. Further, virtual technologies are a promising area of future focus that may ultimately improve upon previous existing inefficiencies in the education and clinical environments.

During the pandemic caused by , the number of elective surgeries has 49 significantly decreased around the world in order to control the spread of the disease, conserve 50 personal protective equipment (PPE), and decrease strain on health care systems [1, 2] . Total 51 joint arthroplasty has been among the surgical procedures that has seen its volume drastically 52 reduced [1] . Projections have estimated that up to 30,000 primary and 3,000 revision hip and 53 knee arthroplasty procedures were cancelled every week that restrictions for elective surgery 54 were in place, leading to the progression of patient symptoms and significant financial losses for 55 both hospitals and individual providers [3] [4] [5] . 56

In addition to being redeployed to the front lines of the pandemic, orthopedic surgeons have 58 encountered significant changes to their practice, including the adoption of strict COVID-19 59 screening protocols, the alteration of teaching responsibilities, and the implementation of virtual 60 health care visits for patients [5] [6] [7] . Further, orthopedic surgeons have documented these 61 substantial alterations in the literature, resulting in an explosion of publications related to 62 COVID-19 [8, 9] . Recently, as the initial wave of the pandemic has slowed down and many 63

institutions have begun to resume elective surgery, guidelines from expert panels and individual 64 physicians have been published, offering their recommendations on how to safely and effectively 65 resume elective orthopedic surgery [10, 11] . Due to the high volume of scientific publications 66 related to COVID-19, Gazendam et al. highlighted the role of a review article in synthesizing the 67 plethora of information into relevant data to guide policy and decision making [9] . However, no 68 study has performed a comprehensive literature review to provide future recommendations 69 specific for arthroplasty surgeons in the COVID-19 era. Thus, the aims of the present study are 70 J o u r n a l P r e -p r o o f to perform a scoping review of the literature in order to 1) summarize the high volume of 71 information about the impact of COVID-19 on total joint arthroplasty and 2) compile 72 recommendations for arthroplasty surgeons as they resume their orthopedic practices during the 73 pandemic. 74

A scoping review of the literature was performed to identify articles that pertained to the effects 77 of the COVID-19 pandemic on total joint arthroplasty. In June 2020, a library research specialist 78 performed searches of PubMed, Embase (Ovid), Cochrane Library (Wiley), Scopus, LitCovid, 79 CINAHL, and the pre-print servers medRxiv and bioRxiv, using both controlled vocabulary and 80 keywords (see supplementary document for specific database strategies). All references were 81 exported to Covidence, an online tool for managing the review. Two independent reviewers 82 screened articles for inclusion, first at the title/abstract stage and then at the full-text stage. A 83 third reviewer resolved cases of screener conflict. 84

The inclusion criteria for the present review were studies pertaining to COVID-19 describing 86 future implications and recommendations for joint arthroplasty, or studies pertaining to COVID-87 19 describing future implications and recommendations for general orthopedics that could be 88 applied to joint arthroplasty. Exclusion criteria were review articles that involved a literature 89 search, non-English publications, studies with a primary focus of another orthopedic specialty, 90

and studies with a primary focus of documenting initial changes to orthopedic practice due to 91 COVID-19. Initial changes were excluded due to the focus of the review on providing surgeons 92 forward-looking information as practices resume amid the pandemic. 93 of COVID-19 symptoms, the assumption that all patients will be a carrier for the virus, and the 117 possibility for reinfection. Developed in conjunction with 77 leading international physicians, 118

Parvizi et al. extensively documented the preoperative screening considerations of resuming 119 elective surgery in the COVID-19 era [11] . Further, Gruskay et al. noted that a positive chest x-120 ray did not significantly improve the negative predictive value of symptom screening [26] . 121

Eleven studies documented the importance of risk stratification of patients undergoing 122 orthopedic surgery [4-7, 10, 11, 18, 22, 29, 44, 45] . Due to poorer surgical outcomes of patients 123 with comorbidities, these authors noted that potential complications would result in excessive 124 consumption of additional hospital resources postoperatively. Further, they argued that the initial 125 resumption of elective surgery should prioritize those without comorbidities. 126

Thirteen studies considered intraoperative considerations during orthopedic surgery during the 128 COVID-19 era [6, 7, 10, 11, 15, 18, 19, 24, 29, 32, 38, 41, 50] . Themes discussed included the 129 recommendation of negative pressure operating rooms or the presence of a high efficiency 130 particulate air (HEPA) filter if operating in a positive pressure operating room (OR), separate 131 OR's for COVID-19 positive patients, adequate PPE and low setting power tools during aerosol 132 generating procedures, the utilization of regional over general anesthesia, and thorough 133 decontamination following operation. 134

Eight studies discussed the importance of outpatient orthopedic surgery practice in the COVID-136 19 era [4, 5, 19, 22, 35, 37, 38, 49] In total, eleven studies addressed the effect of COVID-19 on the education of orthopedic surgery 149 residents and fellows (Table 2) [5-7, 13, 14, 16, 20, 40, 46, 48, 51] Seven studies commented on the current and future use of virtual learning in orthopedic and 159 arthroplasty education [5-7, 13, 16, 40, 46] . Recommendations included the importance of virtual 160 teaching for residents in formats such as online conferences, case presentations, webinars, 161 journal clubs, and readings. Further, four studies documented the potential for technological 162 technology platforms, and arthroscopic simulators [6, 16, 40, 46] . Further, two studies suggested 164 that future national and international meetings take place partly in a virtual format [40, 46] . 165

Stambough et al. suggested that these virtual meetings would result in a lower overall cost, 166

improve the ability to attend poster sessions that were scheduled at similar times, and improve 167 networking among different institutions [46] . Six studies noted the adverse economic effects of the COVID-19 pandemic, which could lead to 185 significant financial consequences and gaps in insurance coverage for patients [3-5, 29, 33, 38] psychological stressors and to support their patients during these times [15] . 210 211

Twelve studies detailed the effects of COVID-19 pandemic on personal implications for 213 orthopedic and arthroplasty surgeons ( Table 2) [3-6, 14, 20, 23, 24, 27, 33, 48, 49] . (Table 2) [4-7, 11, 14-16, 25, 28, 29, 32-34, 36, 38, 39, 42, 43, 45, 47, 49] . 255 Two studies reported cross-sectional data on the usage of telemedicine, noting that the vast 256 majority of providers had adopted the technology, but that there were differences in adoption by 257 country and associations of adoption with the presence of a COVID-19 hotspot location [14, 39] . 258

Five studies addressed their institution's experience with the establishment of telehealth during 259 the COVID-19 pandemic [6, 7, 25, 34, 38, 49] . Gilbert et al. noted that satisfaction in using 260 telehealth for both physicians and patients was high, but ultimately determined that telehealth patients [4-7, 11, 15, 16, 29, 32, 42, 45, 47] Four studies described the future considerations that practices would need to consider in order to 282 effectively implement telehealth during and after the COVID-19 pandemic [28, 33, 36, 43] . In total, twelve studies addressed the effect of COVID-19 on orthopedic and arthroplasty surgical 295 volume (Table 2) [1, 4, 5, 7, 10, 21, 31, 37, 38, 48, 52] . Of these, six studies addressed the 296 specific number of cases that were cancelled or projected to be cancelled due to 7, 297 14, 21, 48, 52] . Two studies, in comparing their hospital's orthopedic surgical volume from 2020 298 to the same time period in 2019, both noted a 70% reduction in surgical volume [21, 52] . Two 299 J o u r n a l P r e -p r o o f studies used a cross sectional survey among their arthroplasty societies to determine the 300 significant reduction in volume of cases caused by 48] to project the number of months required to achieve a 90% pre-pandemic volume of surgery 316

[31]. They noted that 7 months would be required to achieve this volume in their optimistic 317 scenario, 12 months would be required in their ambivalent scenario, and 16 months would be 318 required in their pessimistic scenario. Even with their optimistic scenario, they projected that 319 over 1 million orthopedic surgery cases would be backlogged at 2 years in the United States 320 (Table 3) in the future [6, 16, 40] . Furthermore, while current national and international conferences are 354 often hindered by the conference hall location, the timing of presentation, and the individual cost 355

for participants, virtual meetings may facilitate learning, networking, and decrease the cost of 356 participation [40, 46] . 357

In addition, these virtual technologies have significant implications for patient care and may have 359 a role in arthroplasty practice after the pandemic. Notably, the COVID-19 pandemic has 360 challenged providers to rapidly adopt and implement telehealth practices when previously, they 361 may not have had the same urgency [25, 34, 39] . In their department, Loeb et al. highlighted that 362 only one out of thirty six physicians were trained to use video technologies before the pandemic, 363 but that they were able to see successfully 25% of normal clinic volume within one week of 364 implementation [34]. Further, Parisien et al. determined that 63% of orthopedic residency 365 programs in the United States are now currently using telehealth in their practices, and for the 366 majority, the primary reason for this adoption was . This experience with 367 telehealth, initially driven by necessity, will be instrumental in the future as administrative and 368 telehealth is largely in place, and that significant investments have already been made into the 370 sector [16] . Previous studies have indicated that telemedicine can provide comparable quality as 371 in-person visits, but significant cost-savings [36, 58] . In a randomized control trial prior to the 372 pandemic, Bettger et al. noted that a virtual physical therapy program after total knee 373 arthroplasty decreased 3-month associated health care related costs and provided comparable 374 clinical outcomes with traditional in-person physical therapy [58] . Furthermore, many 375 postoperative visits for patients following total joint arthroplasty can be performed virtually, 376 leading to potential cost and time savings for patients and providers [36] . 377

There are several limitations to the present study. First, the COVID-19 pandemic is ongoing and 379 is subject to rapid changes. While this review captured the literature in early June 2020, 380 guidelines and management are certainly evolving, and published articles after this date were 381 notably excluded. However, the majority of the included articles for this present study were from 382

April 2020, and as the initial wave of the pandemic has subsided, it is likely that this review has 383 captured the most important guidelines and recommendations. Of course, there is much to be 384 Using a Monte-Carlo simulation-based analysis, the time it will take for the healthcare system to perform 90% of pre-pandemic forecasted volume of surgery:

• Optimistic scenario: 7 months • Ambivalent scenario: 12 months • Pessimistic scenario: 16 months

• Deferment of cases will cause a lasting impact on the healthcare system • Strategies to combat this deferment include the utilization of telemedicine, increased operating room schedules, dedicated orthopedic anesthesia and nursing teams, utilization of ambulatory surgery centers, and amplification of care coordination resources • Suggest prioritizing certain surgical patients with the limitation that it may worsen existing health care disparities J o u r n a l P r e -p r o o f 

COVID-19

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hip or knee or joint) adj2 (replac* or reconstruct* or repair*)).tw. 7. (arthroplast* or orthopedic* or orthopaedic*)

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June 6, 2020 S11 S9 AND S10 S10TX "COVID-19" OR "COVID19" OR COVID-19OR "2019-nCoV" OR "2019nCoV" OR "HCoV-19" OR "HCoV19" OR "SARS-CoV-2" OR "SARS-CoV2" OR "coronavirus" OR "corona virus" OR "2019 ncos" OR "severe acute respiratory syndrome coronavirus 2" OR "nCov 2019" S9 S3 OR S8 S8 S4 OR S5 OR S6 OR S7 S7TX "joint replacement" OR "joint reconstruction" OR "joint repair" S6 TX "knee replacement" OR "knee reconstruction" OR "knee repair" S5 TX "hip replacement" OR "hip reconstruction" OR "hip repair" S4 TX arthroplast* OR orthopedic* OR orthopaedics S3 S1 OR S2 S2(MH "Orthopedics") S1(MH "Orthopedic Surgery+") medRxiv & bioRxiv June 6, 2020 Separate keyword searches combining the following two sets of terms: 1) arthroplasty, orthopedics, orthopaedics, hip/knee/joint replacement/reconstruction/repair and 2) COVID-19, COVID19, 2019-nCoV, 2019nCoV, HCoV-19, HCoV19, SARS-CoV-2, SARS-CoV2, coronavirus, corona virus, 2019 ncos, severe acute respiratory syndrome coronavirus 2, nCov 2019