COVID-19 Resource Center
COVID-19 Resource Center
Source/Disclosures
Disclosures: Barrett reports he is a consultant for DePuy Synthes and he receives royalties from DePuy Synthes as a result of his transfer of intellectual property for the development of hip and knee systems. Bray reports he is a non-paid consultant for Ampersand Intelligence and a major owner of DISC Sports & Spine. Denti reports he is an employee of Johnson & Johnson.
July 27, 2020
6 min read
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Controlled environment makes elective orthopedic surgery safer in COVID-19 pandemic

Source/Disclosures
Disclosures: Barrett reports he is a consultant for DePuy Synthes and he receives royalties from DePuy Synthes as a result of his transfer of intellectual property for the development of hip and knee systems. Bray reports he is a non-paid consultant for Ampersand Intelligence and a major owner of DISC Sports & Spine. Denti reports he is an employee of Johnson & Johnson.
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Except for states that have had to cease performing elective surgery due to a recent surge in COVID-19 cases, elective orthopedic surgery has resumed, for the most part, nationwide.

To keep those procedures safe for patients and orthopedic surgery teams now, and into the future, orthopedic surgeons and companies have taken steps to reduce the type of contact that might transmit COVID-19, better plan surgical steps and tap into technology that supports safer and more efficient procedures, sources told Healio Orthopedics.

At the most basic level, unsafe surgery and surgical practices occur when health care providers and facilities ignore what is going on in the world with regard to the COVID-19 pandemic, according to Robert S. Bray Jr., MD.

Robert S. Bray Jr.
Robert S. Bray Jr.

“What we need to develop at the centers is protocol-driven isolation, testing and then care that is following these enforced protocols,” he told Healio Orthopedics.

Bray, who is a neurological spine surgeon at DISC Sports & Spine Center in Newport Beach, California, told Healio Orthopedics he has encountered patients who are fearful of undergoing an elective orthopedic procedure now because of the COVID-19 pandemic.

From that standpoint, the possible risk situations patients face today differ greatly from infection and other complications of orthopedic surgery that may more typically occur in the perioperative time frame.

“We’re creating environments that are much safer than being in the public,” so patients can get the care they need and return to their normal lifestyles, Bray said. “It’s now a matter of controlling our environments.”

William P. Barrett
William P. Barrett

Fortunately, the hip and knee arthritis that William P. Barrett, MD, of Renton, Washington, treats is not life threatening. However, he said it can be debilitating if the condition is not managed in a timely fashion.

“One option is always not to do surgery. People will still live,” Barrett, who performs more than 500 joint replacement procedures each year, told Healio Orthopedics.

However, once a patient’s total hip replacement or total knee replacement is scheduled, “Everything we do is about mitigating risk for the patient, mitigating risk for the staff to contract coronavirus during the pandemic,” he said.

Among the steps Barrett took when elective surgery resumed was educating patients on the measures the surgical team has taken to safely prepare for the reopening.

Reduce contacts preoperatively

New patients who would normally see an orthopedic physician assistant (PA) for an initial examination now complete that initial “visit” to Barrett’s practice via telehealth, an approach Barrett said he adopted only a couple weeks after elective surgery in Washington was discontinued in mid-March due to the pandemic.

Once scheduled for surgery, patients who once saw the PA about 2 weeks preoperatively to review everything now do that with telehealth, according to Barrett, who noted the first postoperative visit to the PA at about 10 to 14 days following THR or TKR is also conducted via telehealth.

“There has been a change as far as the introduction of technology into orthopedics, particularly adult reconstructive practices, as far as the preoperative and postoperative to minimize the contact with the patient, for the safety of the patient,” he said.

Preoperatively, Barrett’s patients who are scheduled for THR or TKR get a COVID-19 test at the hospital 72 hours prior to their procedure to ensure they are negative. They are then asked to self-quarantine between the test and the time of their surgery.

DISC Sports & Spine Center uses a Clinical Laboratory Improvement Amendment (CLIA)-certified laboratory for 1-hour COVID-19 test results. This provides the information the surgical team needs to proceed — or cancel the case — close to the time of admission, and sometimes patients undergo CLIA-certified COVID-19 testing the same day as surgery.

“We’ve highly adapted to telemedicine to connect with the patients as much as possible for both pre-evaluation and review of tests,” Bray said. “You get down, at some point, to still examining the patients, so it has to happen. However, much of the process can be done with telemedicine. We also put in place a constant testing program. We are monitoring every patient that comes in the door preoperatively. We are not letting any family member in who’s not been tested, as well.”

In addition, staff members at DISC Sports & Spine Center regularly undergo temperature monitoring, as well as COVID-19 testing with polymerase chain reaction for antibodies.

Bray said, “We are at zero transmission of any active case to any staff member or any personnel at our facility and, with numbers going up, you’ve just got to have a way to deal with it.”

In addition to testing protocols followed at Barrett’s hospital, everyone must wear a face mask.

Aldo Denti
Aldo Denti

Aldo Denti, company group chair of DePuy Synthes, part of Johnson & Johnson Medical Devices Companies, said with the explosion in telehealth use in orthopedic surgery, “DePuy Synthes is working to arm our surgeons with information that is built into the telemedicine solution so that when they are having a conversation with the patient, they actually have the ability to pull up materials” that explain what THR and TKR looks like. These materials are all built into the protocol of that patient’s journey preoperatively, he told Healio Orthopedics.

Intraoperative steps

Safety issues should be addressed long before a case goes to the OR and not arise during orthopedic surgery in the COVID-19 pandemic, particularly if all the established protocols and safety measures are put in place, according to Bray.

He mentioned there were a few instances during the COVID-19 pandemic of a manufacturer’s representative trying to enter the facility wearing scrubs from the outside or not wearing a mask.

Intraoperatively, if a break in the safety protocols and practices occurs, “you resolve the break as quickly as possible, asses whether it has done any damage and make your choice, but we‘ve rarely had to stop a procedure,” he said. “Most of the intraoperative complications are other things that we have dealt with for years.”

Sources said artificial intelligence (AI) technology may play a role in making the OR more efficient during the COVID-19 pandemic and possibly reduce the number of people in the OR.

“It absolutely has a role, and we are going to see the whole format of our ORs change rapidly,” Bray said, noting there are helpful apps available to perform the preoperative assessments for the surgeon.

Furthermore, today’s information analytics support data collection and sharing, he said.

Concerning robotics in spine surgery, Bray said a new robot, the Walter Lorenz Surgical Assist Arm (Zimmer Biomet), assists with the retraction step of the procedure.

“You can reduce a contact in the operating field just by having assisted retraction guidance,” he said.

Progress in postoperative safety

Barrett has adopted automated and digital surgery technology to increase OR efficiency.

DePuy Synthes is also working on the postoperative aspect of a patient’s surgical journey, Denti said, “to see whether we can maximize the ways we can engage or help our surgeons engage with the patients.”

This might include, for example, a novel process by which the surgeon or PA can view the patient’s surgical scar via telehealth in a way that is more streamlined and simpler than having the patient show the physician the scar using their phone or computer camera.

“That is an area that we are actually investing in as we speak,” Denti said.

Optimizing the patient’s surgical pathway is another area on which DePuy Synthes is heavily focused. Among the preoperative, intraoperative and postoperative aspects of the DePuy Synthes VELYS Digital Surgery Platform, digitally mapping the surgical steps patients go through can enhance procedural safety, he said.

Patient optimization and calculating a patient’s risk for certain orthopedic surgery complications, which was done manually before, is also being digitized through risk calculators, sources said.

“[The risk calculator] basically takes data from the patient’s electronic medical record, puts it through a process and comes up with a score,” Barrett said.

The score can then be compared to scores of similar patients in a database who underwent the same procedure. The resultant information, such as the patient being at a 20% greater risk of infection or having another medical complication based on the data, can be discussed with the patient during shared decision-making.

“It streamlines the conversation,” Barrett said.

“Patients are smart. They get this,” he added.

Bray agreed that AI and the integration of information all need to, and will, play a role in safe orthopedic surgical practices during the COVID-19 pandemic and beyond.

The COVID-19 pandemic continues to be a learning experience for all, according to Bray. For example, determining which authority to listen to and how to effectively monitor the critical guidelines for safe elective surgery, from local and state agencies to the American Academy of Orthopaedic Surgeons and the CDC, has been challenging, he said.

“Our industry needs a better way of communication and information sharing during an event,” Bray said.