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Lessons learnt from the impact of COVID-19 on arthroplasty services in Hong Kong: how to prepare for the next pandemic?

Lessons learnt from the impact of COVID-19 on arthroplasty services in Hong Kong: how to prepare... Background: Arthroplasty services worldwide have been significantly disrupted by the pandemic of coronavirus dis- ease 2019 (COVID-19). This retrospective comparative study aimed to characterize its impact on arthroplasty services in Hong Kong. Methods: From January 1 to June 30, 2020, the patients of “COVID-19 cohort” underwent elective total hip or knee replacement in Hong Kong public hospitals. The cohort was compared to the “control cohort” during the same period in 2019. Data analysis was performed to compare the two cohorts’ numbers of operations, hospital admission, ortho- paedic clinic attendances, and waiting time. Results: A total of 33,111 patient episodes were analyzed. During the study period, the elective arthroplasty opera- tions and hospitalizations decreased by 53 and 54%, respectively (P < 0.05). Reductions were most drastic from February to April, with surgical volume declining by 86% (P < 0.05). The primary arthroplasty operations decreased by 91% (P < 0.05), while the revision operations remained similar. Nevertheless, 14 public hospitals continued performing elective arthroplasty for patients with semi-urgent indications, including infection, progressive bone loss, prosthesis loosening, dislocation or mechanical failure of arthroplasty, and tumor. At the institution with the highest arthro- plasty surgical volume, infection (28%) was the primary reason for surgery, followed by prosthesis loosening (22%) and progressive bone loss (17%). The orthopaedic clinic attendances also decreased by 20% (P < 0.05). Increases were observed in waiting time and the total number of patients on the waiting list for elective arthroplasty. Conclusions: Despite the challenges, public hospitals in Hong Kong managed to continue providing elective arthro- plasty services for high-priority patients. Arthroplasty prioritization, infection control measures, and post-pandemic service planning can enhance hospital preparedness to mitigate the impact of current and future pandemics. Keywords: Arthroplasty, Replacement, Total knee arthroplasty, Total hip arthroplasty, COVID-19 handling the challenges of the pandemic. However, since Background most arthroplasties are elective procedures, joint replace- In order to help contain the coronavirus disease 2019 ment services have been significantly disrupted. (COVID-19) outbreak, many hospitals worldwide have The orthopaedic operations were subjected to one of reduced elective operations to redeploy the resources for the greatest relative declines in the normal medical activ- ity in both the United Kingdom (UK) National Health *Correspondence: cpk464@yahoo.com.hk Service and the United States (US) [1, 2]. Although Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong, China there are less abundant data for Asian regions, a major Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Lee et al. Arthroplasty (2021) 3:36 Page 2 of 8 Singapore institution reported a 74% reduction in arthro- cohort” selected during the same period in 2019. We per- plasties compared to the pre-pandemic levels [3], while formed data reconciliation of aggregate and individual a major orthopaedic department in Japan noted over data, followed by statistical analyses using Welch’s t-test. 80 and 50% reductions in hip and knee arthroplasties We assessed whether the differences in continuous out - respectively [4]. Similar patterns were observed in main- comes between the two cohorts were statistically signifi - land China, Malaysia, and South Korea [5, 6]. cant at the 5% significance level. The primary outcomes Hong Kong reported its first confirmed COVID-19 included the number of operations, hospital admission, case on January 23, 2020. The initial outbreak had a rela - and orthopaedic clinic attendances. The secondary out - tively flat epidemic curve. This was followed by a sec - comes included the nature of operations performed, indi- ond and a third wave beginning in March and July 2020, cations for arthroplasty at our institution, and waiting respectively, both related to the imported cases. Hong time for the elective arthroplasty. Kong is currently experiencing its fourth wave, with a cumulative total of 10,710 confirmed cases (including Results 10,022 discharged and 188 deaths) since February 10, We analyzed 33,111 patient episodes, including 3080 2021. The Hong Kong Government’s response level was operations, 3031 hospitalizations, and 27,000 orthopae- raised to “Emergency”–the highest tier–on January 25, dic clinic attendances. 2020, with subsequent public health measures includ- ing school suspension, restricting public gatherings, and Arthroplasty operations postponing non-urgent hospital procedures [7]. The Regarding surgical volume and hospitalizations from Jan- reduction in elective operations has resulted in con- uary 1, 2020 to June 30, 2020, the elective joint replace- siderable disruptions in the local arthroplasty services. ment operations decreased by 53% (from 348 ± 39.6 to In Hong Kong, 30% of the elderly aged over 65  years 165.3 ± 144.6 per month; P = 0.026), compared to the are diagnosed with osteoarthritis, and the knee and hip control cohort (Fig.  1), while the hospital admissions joints are mostly affected [8, 9]. Given the disease preva- fell by 54% (from 345 ± 38.3 to 160.2 ± 145.6 per month; lence and associated morbidity and disability, disruptions P = 0.03). The reductions were most drastic from Febru - in arthroplasty services have important implications on ary to April. This period followed the Hospital Authority patient outcomes and future joint replacement services directives of reprioritizing non-urgent and non-essential when hospitals return to normal surgical schedules. services under the government’s “emergency” response Therefore, this retrospective comparative study aimed level raised on January 25, 2020 [7]. The surgical vol - to review the impact of COVID-19 on the arthroplasty ume and hospital admissions for elective joint replace- services in Hong Kong’s public health care system, to ment declined by 86% (P = 0.004) and 88% (P = 0.003) inform strategies to mitigate the impact of current and respectively (Table 1). This period followed Hong Kong’s future pandemics. first COVID-19 case confirmed on January 23, 2020 and preceded the gradual resumption of elective ser- Methods vices in the public hospitals around May 2020. During The ethics approval was granted by the Institutional this time, reductions in surgical volume varied across Review Board of the University of Hong Kong/Hospital operative categories. Primary arthroplasty operations Authority Hong Kong West Cluster (reference number: decreased by 91% (from 315.3 ± 45.9 to 28 ± 23.1 per UW 20–594). month; P = 0.003), while the number of revision opera- This retrospective cohort study was conducted in Hong tions remained similar (P = 0.21). The ratio of hip to knee Kong, which has a dual-track public and private health- arthroplasties increased from 1:5.3 to 1:1.8. care system for a population of 7.5 million [10]. The pub - Despite massive cutbacks from February to April lic sector provides over 90% of inpatient services in the 2020, 14 public hospitals continued to perform elec- region and handles all suspected and confirmed COVID- tive joint replacement operations. Queen Mary Hospital 19 cases [11]. In our study, we retrospectively analyzed accounted for the majority (26%) of cases, and detailed the data collected from all 43 public hospitals and 122 analysis revealed that infection (28%) was the primary outpatient clinics. Diagnoses and procedures were clas- reason for surgery, followed by implant loosening (22%) sified according to the International Classification of Dis - and bone loss (17%). eases, 9th Edition, Clinical Modification (ICD-9-CM). The “COVID-19 cohort” of patients who underwent Outpatient clinic attendances elective joint replacement surgery (including primary From January 1, 2020 to June 30, 2020, the COVID- and revision total hip and knee arthroplasty) from Janu- 19 cohort had 20% fewer orthopaedic outpatient clinic ary 1 to June 30, 2020 was compared to the “control attendances than the control cohort (reduction from L ee et al. Arthroplasty (2021) 3:36 Page 3 of 8 Fig. 1 Total surgical volume of elective hip and knee arthroplasties in Hong Kong (HK) public hospitals Table 1 Differences in elective arthroplasty services from February to April COVID-19 Cohort (2020) Control Cohort (2019) Change P Value Monthly Mean ± SD Monthly Mean ± SD Operations Total 46.3 ± 16.9 327 ± 45.3 -85.8% 0.004 Revision joint replacement Revision hip arthroplasty 10 ± 4.6 7 ± 2 42.9% 0.382 Revision knee arthroplasty 8.3 ± 4.2 4.7 ± 2.5 78.6% 0.276 Primary joint replacement Total hip arthroplasty 6.7 ± 2.1 45 ± 6.6 -85.2% 0.006 Total knee arthroplasty 21.3 ± 21.0 270.3 ± 43.5 -92.1% 0.003 Hospital admissions 40 ± 19.7 325 ± 44.3 -87.7% 0.003 Orthopaedic clinic attendances 1652.3 ± 143.5 2336.3 ± 200.1 -29.3% 0.011 2,495 ± 243.5 to 2,005 ± 426.5 per month; P = 0.04). The outpatient clinics [13]. It reflected a net increase in total increases were observed in both waiting time and total case load despite fewer new cases at outpatient clinics. number of patients on the waiting list for elective joint replacement surgery. For example, the recent aggregate Discussion data collected from the Hospital Authority showed a COVID-19 profoundly impacts the arthroplasty ser- 14% growth in the arthroplasty waitlist (from 26,547 to vices. Many institutions worldwide have postponed non- 30,342) from March to December 2020 [12], despite an emergent operations to reduce hospital traffic, conserve overall 8% (from 106,472 to 98,153) decline in the past personal protective equipment, and enable manpower 12-month new-case bookings (from the interval between deployment to COVID-19 frontline services. Likewise, April 1, 2019 and March 31, 2020 to the interval between orthopaedic services in Hong Kong have been signifi - January 1, 2020 to December 30, 2020) at the orthopaedic cantly reduced, particularly for joint replacement and Lee et al. Arthroplasty (2021) 3:36 Page 4 of 8 ligamentous reconstruction procedures, as the majority Table 3 US arthroplasty scheduling recommendations, adapted from the American College of Surgeons [16] are elective operations [14]. Apart from the Hospital Authority policies [7], patient Phase II (curtail Phase III (eliminate health-seeking behavior also contributes to those reduc- elective practice) elective practice) tions due to COVID-19 risk. Our institution’s arthro- Proceed Postpone Proceed Postpone plasty prioritization and infection control measures are Acute knee or hip pain ✓ ✓ summarized in Table  2. Specifically, the elective joint Chronic knee or hip pain ✓ ✓ replacement services are maintained primarily for high- Inability to weight bear ✓ ✓ priority patients with increased morbidity and likeli- Knee or hip dislocation ✓ ✓ hood of necessitating more complicated reconstruction Concern for peripros- ✓ ✓ procedures if the operations are delayed [15]. The key thetic joint infection semi-urgent indications for proceeding with elective Acute pain exacerbation ✓ ✓ arthroplasty included (1) infection; (2) progressive bone with prior joint replace- loss; (3) loosening, dislocation, or mechanical failure of ment arthroplasty; and (4) tumor (Table  2). It is in line with Only for acute inability to weight bear the international guidelines proposed by the professional bodies regarding the provision of clinical services during the outbreak, such as the American College of Surgeons “dislocated joints” as priority 1a and “revision surgery guidelines [16] (Table 3) and the clinical guide for ortho- for loosening without impending fracture or recurrent paedic surgical prioritisation established at the request of joint instability” as priority 3 (i.e., arthroplasty should be the UK National Health Service [17] (Table 4). For exam- performed within 3  months). Tumor is listed in the UK ple, infection is one of the essential indications (wound guidelines as priority 2 for “solitary metastasis”. drainage, fever, concern for infection with prior joint The rationale underlying those recommendations takes replacement) for surgery in the American College of Sur- into consideration multiple parameters, including the geons’ guidelines, and the UK guidelines list “infection” immediate risk, the long-term impact of the disease, and and “septic arthritis (natural or prosthetic joint)” as pri- the projected future severity [18]. Since the COVID-19 ority 1a indications, i.e., emergency arthroplasty should situation and resource availability vary by region in Asia, be performed within 24 h. Progressive bone loss is a pri- individual localities will benefit from developing specific ority 2 indication (i.e., a suggested timeframe < 1 month) recommendations on arthroplasty prioritization, to bal- in the UK guidelines as “destructive bone lesion with risk ance between tackling COVID-19 and minimizing the of fracture (e.g., giant cell tumor)”. Loosening, dislocation, service disruption. or mechanical failure of arthroplasty are in accordance Infection control measures are based on the local with American College of Surgeons’ essential indications Hospital Authority guidelines [19]. All inpatients at our of “knee dislocation”, “prior hip or knee replacement with institution (e.g., patients admitted for joint replacement acute pain exacerbation”, while the UK guidelines classify surgery) are screened for COVID-19 at admission. To Table 2 Summary of infection control and arthroplasty service prioritization at our institution Guidelines and measures Patient screening Inpatient admission screening • SARS-CoV-2 RT-PCR test using deep throat saliva self-collected by patient in the presence of a HEPA filter unit Outpatient screening (e.g., preoperative clinic appointments) • Patients are screened for symptoms and signs of COVID-19 using a health declaration form Visiting arrangement • All ward visitations are suspended except for compassionate visit of inpatients for exceptional situations on a case-by-case basis • Visitors are screened for symptoms and signs of COVID-19 using a health declaration form • Visitors are required to wear full personal protective equipment, including face shield, N95 respirator, isolation gown and disposable gloves Arthroplasty prioritisation Proceed with elective arthroplasty for semi-urgent indications, such as: • Joint infection • Loosening, dislocation or mechanical failure of arthroplasty • Bone loss • Tumor Preoperative screening • SARS-CoV-2 RT-PCR test using deep throat saliva self-collected by patient in the presence of a HEPA filter unit L ee et al. Arthroplasty (2021) 3:36 Page 5 of 8 Table 4 National Health Service arthroplasty scheduling recommendations, adapted from the Federation of Specialty Surgical Associations (UK) [17] Priority Surgery timeframe Orthopaedics & traumatology examples 1a < 24 h • Infection: e.g., septic arthritis (natural or prosthetic joint) • Dislocated joints 1b < 72 h • Unstable articular fractures that will result in severe disability without operative fixation 2 < 1 months • Destructive bone lesion with risk of fracture (e.g., giant cell tumour) • Solitary metastasis • Arthroplasty – any site where delay will prejudice outcome 3 < 3 months • Revision surgery for loosening without impending fracture, or recurrent joint instability 4 > 3 months • Arthroplasty/arthrodesis – not otherwise specified minimize the risk of nosocomial transmission, we per- managing previous waves of the outbreak, together with formed a SARS-CoV-2 RT-PCR test for all inpatients the increased availability of infection control equipment using a deep throat saliva sample, and the screening worldwide, results in enhanced outbreak preparedness scheme has now been expanded to patients attending and response measures in public hospitals. Together, day services [19]. Similar to the practices in Japan [4] and the extended efforts of our institution contribute to the South Korea [20], such pre-arthroplasty screening allows timely detection of occult cases and limiting the spread an elective arthroplasty to be continued throughout the of COVID-19, while allowing elective arthroplasty to outbreak. Another strategy recommended by the UK proceed for semi-urgent patients (Table 2). National Health Service is to require patients and their The growing waiting list for elective joint replacement household members to self-isolate for 14  days before reflects a greater impact of the pandemic on the surgi - admission for elective operations [21]. It potentially cal volume than that on the outpatient clinic attend- reduces the risk of transmission in case of insufficient ances. The pent-up demand for elective joint replacement testing capacity. procedures is anticipated to pose significant challenges In addition, patients attending day services at our pre- even after services recover to pre-pandemic full capac- operative assessment clinic are also screened for the signs ity. It is a looming global public health crisis with two and symptoms of COVID-19 and TOCC (travel, occu- major implications. First, a rising number of osteoar- pation, contact, and cluster) history via a patient decla- thritis patients are facing delayed surgical management. ration form. In Hong Kong, although visiting wards has Knee osteoarthritis is the primary reason for disability been suspended in light of the current wave of outbreak, in walking, housekeeping, and stair-climbing among local public hospitals currently allow the compassionate non‐institutionalized individuals aged 50  years or above visit of inpatients for exceptional situations on a case- [22]. A postponed arthroplasty adversely affects patient by-case basis [19]. The visitors are similarly screened for outcomes due to significant deterioration in morbidity the signs and symptoms of COVID-19 before they are during the delay and worse health-related quality of life allowed entry to the wards, and full personal protective outcomes following late arthroplasty [23–26]. Second, equipment is required during the visit. the operation backlog represents a major future burden The rapid return to fully functioning pre-pandemic on the health care system. Estimates showed that if coun- baseline surgical volume by June 2020 reflects adequate tries increased surgical capacity by 20% following the facility readiness to resume normal elective joint replace- pandemic, a median of 45 weeks will be required to work ment services upon dampening of the second wave of through the surgical backlog due to COVID-19 disrup- outbreak. It was supported by the Hospital Authority tions [27]. A May 2020 analysis of elective orthopaedic directives, such as encouraging healthcare departments surgery under the COVID-19 outbreak found that in the to increase weekend clinical service hours under the Spe- optimistic scenario, the US will have a cumulative back- cial Honorarium Scheme from late May to September log of over 1 million surgical cases 2  years following the 2020 to take care of previously postponed cases due to resumption of elective surgeries, and it may take as many COVID-19 restrictions. as 16 months to address 90% of the surgical backlog [28]. Hong Kong subsequently faced its third and fourth Hong Kong has been fortunate to have rapidly returned waves of COVID-19 infection beginning in July and to pre-pandemic service provision levels upon dampen- November 2020, respectively. The experience of ing of previous outbreak waves. Nevertheless, planning Lee et al. Arthroplasty (2021) 3:36 Page 6 of 8 Table 5 Strategies for arthroplasty service planning during the next pandemic Pre-pandemic • Build a consensus among stakeholders for prioritization of arthroplasty services, including inpatient, outpatient and operation, during different degrees of severity of a pandemic • Establish guidelines for infection control measures for patients and health care workers during the pandemic • Establish guidelines for operating on a confirmed infected case during the pandemic • Set up telemedicine infrastructure for preoperative education, outpatient consultation and follow-up, and telerehabilitation • Set up ERAS services for arthroplasty procedures During the pandemic • Adjust clinical services according to the severity of the pandemic • Increase the capacity for supporting ERAS services in arthroplasty to shorten hospital stay and reduce the burden on inpatient care • Provide telemedicine consultations for pre-operative education and postoperative follow-up • Provide telerehabilitation to maintain mobility and knee function; ensure access to drug-refill clinic for patients on waiting list for arthroplasty • Provide telerehabilitation for postoperative rehabilitation after arthroplasty • Develop a post-pandemic arthroplasty resumption plan for the anticipated backlog Post-pandemic • Prepare manpower and hospital capacity for the post-pandemic increase in clinical service (e.g., extend operating room schedules) • Utilize orthopaedic block times for arthroplasty procedures • Enhance mental health support for healthcare workers to cope with the increase in workload during the post-pandemic phase for the anticipated backlog remains critical. Strategies during the dedicated operative time for arthroplasty to for arthroplasty service planning during different stages clear the backlog more quickly and efficiently [37]. Fur - of the pandemic are summarized in Table  5. In addi- thermore, enhancing mental health support for health- tion to guidelines on the resumption of surgical services care workers may help alleviate the anxiety associated published by professional organizations [29, 30], an with the surge of patients during the post-outbreak phase evidence-based three-phase return pathway for elective [38]. orthopaedic operations has been proposed by orthopae- With rapid globalization and rising interconnected- dic surgeons at the Croydon University Hospital London ness between humans and natural environments, there and South West London Elective Orthopaedic Centre is an increasing concern on the emergence of new pan- [31], which suggests stratifying patients into risk groups, demics [39]. The local and global experience during the so as to begin service resumption for low-risk patients COVID-19 pandemic can inform the arthroplasty service with maximum anticipated benefit in quality of life (e.g., planning and post-pandemic recovery to enhance hospi- patients suitable for day case arthroplasty) and gradually tal and community preparedness for current and future expanding to all orthopaedic cases. Developing regional pandemics. post-pandemic arthroplasty resumption guidance for hospitals will not only facilitate the return to normal clin- Conclusions ical services but also avoid creating inequalities in wait- Despite the drastic service reduction, public hospitals in ing time among patients in different hospital catchment Hong Kong continued providing elective joint replace- areas. ment services for high-priority patients. Hong Kong’s Increasing application of Enhanced Recovery After experience in the past few months can inform the ser- Surgery (ERAS) for arthroplasty procedures has deliv- vice planning for post-pandemic recovery and in antici- ered promising results in Singapore and Hong Kong in pation of future crises such as a new wave of COVID-19 terms of reduced hospital length of stay and comparable pandemic. risk of complications [32–34]. The use of telemedicine for outpatient clinic consultations has also been discussed, particularly for postoperative follow-up appointments of Abbreviations suitable patients, in order to reduce hospital traffic while COVID-19: Coronavirus disease 2019; HK: Hong Kong; UK: United Kingdom; US: United States. reaching patients who hesitate to visit hospitals due to concerns regarding the outbreak [35]. Other potential Acknowledgements strategies reported in the literature included extending N/A operating room schedules to increase surgical capac- Authors’ contributions ity [28]; shifting to same-day arthroplasty for carefully LS Lee (study design, data acquisition and analysis, writing of manuscript); PK selected patients at the major arthroplasty centers [36]; Chan (study design, analysis of data, providing revision comments); WC Fung (data acquisition and analysis); A Cheung, VWK Chan, MH Cheung, H Fu, CH and utilizing orthopaedic block times to boost efficiency L ee et al. Arthroplasty (2021) 3:36 Page 7 of 8 Yan and KY Chiu (providing expert advice and revision comments). All authors 11. Hong Kong Food and Health Bureau. Report of the strategic review on read and approved the final manuscript. healthcare manpower planning and professional development. 2017. 12. Hospital Authority. 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Orthopaedic guidelines for the COVID-19 post-outbreak period: experience from Wuhan, People’s Republic of China. J Bone Joint Surg Am. 2020;102(15):e87. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png "Arthroplasty" Springer Journals

Lessons learnt from the impact of COVID-19 on arthroplasty services in Hong Kong: how to prepare for the next pandemic?

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Springer Journals
Copyright
Copyright © The Author(s) 2021
eISSN
2524-7948
DOI
10.1186/s42836-021-00093-5
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Abstract

Background: Arthroplasty services worldwide have been significantly disrupted by the pandemic of coronavirus dis- ease 2019 (COVID-19). This retrospective comparative study aimed to characterize its impact on arthroplasty services in Hong Kong. Methods: From January 1 to June 30, 2020, the patients of “COVID-19 cohort” underwent elective total hip or knee replacement in Hong Kong public hospitals. The cohort was compared to the “control cohort” during the same period in 2019. Data analysis was performed to compare the two cohorts’ numbers of operations, hospital admission, ortho- paedic clinic attendances, and waiting time. Results: A total of 33,111 patient episodes were analyzed. During the study period, the elective arthroplasty opera- tions and hospitalizations decreased by 53 and 54%, respectively (P < 0.05). Reductions were most drastic from February to April, with surgical volume declining by 86% (P < 0.05). The primary arthroplasty operations decreased by 91% (P < 0.05), while the revision operations remained similar. Nevertheless, 14 public hospitals continued performing elective arthroplasty for patients with semi-urgent indications, including infection, progressive bone loss, prosthesis loosening, dislocation or mechanical failure of arthroplasty, and tumor. At the institution with the highest arthro- plasty surgical volume, infection (28%) was the primary reason for surgery, followed by prosthesis loosening (22%) and progressive bone loss (17%). The orthopaedic clinic attendances also decreased by 20% (P < 0.05). Increases were observed in waiting time and the total number of patients on the waiting list for elective arthroplasty. Conclusions: Despite the challenges, public hospitals in Hong Kong managed to continue providing elective arthro- plasty services for high-priority patients. Arthroplasty prioritization, infection control measures, and post-pandemic service planning can enhance hospital preparedness to mitigate the impact of current and future pandemics. Keywords: Arthroplasty, Replacement, Total knee arthroplasty, Total hip arthroplasty, COVID-19 handling the challenges of the pandemic. However, since Background most arthroplasties are elective procedures, joint replace- In order to help contain the coronavirus disease 2019 ment services have been significantly disrupted. (COVID-19) outbreak, many hospitals worldwide have The orthopaedic operations were subjected to one of reduced elective operations to redeploy the resources for the greatest relative declines in the normal medical activ- ity in both the United Kingdom (UK) National Health *Correspondence: cpk464@yahoo.com.hk Service and the United States (US) [1, 2]. Although Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong, China there are less abundant data for Asian regions, a major Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Lee et al. Arthroplasty (2021) 3:36 Page 2 of 8 Singapore institution reported a 74% reduction in arthro- cohort” selected during the same period in 2019. We per- plasties compared to the pre-pandemic levels [3], while formed data reconciliation of aggregate and individual a major orthopaedic department in Japan noted over data, followed by statistical analyses using Welch’s t-test. 80 and 50% reductions in hip and knee arthroplasties We assessed whether the differences in continuous out - respectively [4]. Similar patterns were observed in main- comes between the two cohorts were statistically signifi - land China, Malaysia, and South Korea [5, 6]. cant at the 5% significance level. The primary outcomes Hong Kong reported its first confirmed COVID-19 included the number of operations, hospital admission, case on January 23, 2020. The initial outbreak had a rela - and orthopaedic clinic attendances. The secondary out - tively flat epidemic curve. This was followed by a sec - comes included the nature of operations performed, indi- ond and a third wave beginning in March and July 2020, cations for arthroplasty at our institution, and waiting respectively, both related to the imported cases. Hong time for the elective arthroplasty. Kong is currently experiencing its fourth wave, with a cumulative total of 10,710 confirmed cases (including Results 10,022 discharged and 188 deaths) since February 10, We analyzed 33,111 patient episodes, including 3080 2021. The Hong Kong Government’s response level was operations, 3031 hospitalizations, and 27,000 orthopae- raised to “Emergency”–the highest tier–on January 25, dic clinic attendances. 2020, with subsequent public health measures includ- ing school suspension, restricting public gatherings, and Arthroplasty operations postponing non-urgent hospital procedures [7]. The Regarding surgical volume and hospitalizations from Jan- reduction in elective operations has resulted in con- uary 1, 2020 to June 30, 2020, the elective joint replace- siderable disruptions in the local arthroplasty services. ment operations decreased by 53% (from 348 ± 39.6 to In Hong Kong, 30% of the elderly aged over 65  years 165.3 ± 144.6 per month; P = 0.026), compared to the are diagnosed with osteoarthritis, and the knee and hip control cohort (Fig.  1), while the hospital admissions joints are mostly affected [8, 9]. Given the disease preva- fell by 54% (from 345 ± 38.3 to 160.2 ± 145.6 per month; lence and associated morbidity and disability, disruptions P = 0.03). The reductions were most drastic from Febru - in arthroplasty services have important implications on ary to April. This period followed the Hospital Authority patient outcomes and future joint replacement services directives of reprioritizing non-urgent and non-essential when hospitals return to normal surgical schedules. services under the government’s “emergency” response Therefore, this retrospective comparative study aimed level raised on January 25, 2020 [7]. The surgical vol - to review the impact of COVID-19 on the arthroplasty ume and hospital admissions for elective joint replace- services in Hong Kong’s public health care system, to ment declined by 86% (P = 0.004) and 88% (P = 0.003) inform strategies to mitigate the impact of current and respectively (Table 1). This period followed Hong Kong’s future pandemics. first COVID-19 case confirmed on January 23, 2020 and preceded the gradual resumption of elective ser- Methods vices in the public hospitals around May 2020. During The ethics approval was granted by the Institutional this time, reductions in surgical volume varied across Review Board of the University of Hong Kong/Hospital operative categories. Primary arthroplasty operations Authority Hong Kong West Cluster (reference number: decreased by 91% (from 315.3 ± 45.9 to 28 ± 23.1 per UW 20–594). month; P = 0.003), while the number of revision opera- This retrospective cohort study was conducted in Hong tions remained similar (P = 0.21). The ratio of hip to knee Kong, which has a dual-track public and private health- arthroplasties increased from 1:5.3 to 1:1.8. care system for a population of 7.5 million [10]. The pub - Despite massive cutbacks from February to April lic sector provides over 90% of inpatient services in the 2020, 14 public hospitals continued to perform elec- region and handles all suspected and confirmed COVID- tive joint replacement operations. Queen Mary Hospital 19 cases [11]. In our study, we retrospectively analyzed accounted for the majority (26%) of cases, and detailed the data collected from all 43 public hospitals and 122 analysis revealed that infection (28%) was the primary outpatient clinics. Diagnoses and procedures were clas- reason for surgery, followed by implant loosening (22%) sified according to the International Classification of Dis - and bone loss (17%). eases, 9th Edition, Clinical Modification (ICD-9-CM). The “COVID-19 cohort” of patients who underwent Outpatient clinic attendances elective joint replacement surgery (including primary From January 1, 2020 to June 30, 2020, the COVID- and revision total hip and knee arthroplasty) from Janu- 19 cohort had 20% fewer orthopaedic outpatient clinic ary 1 to June 30, 2020 was compared to the “control attendances than the control cohort (reduction from L ee et al. Arthroplasty (2021) 3:36 Page 3 of 8 Fig. 1 Total surgical volume of elective hip and knee arthroplasties in Hong Kong (HK) public hospitals Table 1 Differences in elective arthroplasty services from February to April COVID-19 Cohort (2020) Control Cohort (2019) Change P Value Monthly Mean ± SD Monthly Mean ± SD Operations Total 46.3 ± 16.9 327 ± 45.3 -85.8% 0.004 Revision joint replacement Revision hip arthroplasty 10 ± 4.6 7 ± 2 42.9% 0.382 Revision knee arthroplasty 8.3 ± 4.2 4.7 ± 2.5 78.6% 0.276 Primary joint replacement Total hip arthroplasty 6.7 ± 2.1 45 ± 6.6 -85.2% 0.006 Total knee arthroplasty 21.3 ± 21.0 270.3 ± 43.5 -92.1% 0.003 Hospital admissions 40 ± 19.7 325 ± 44.3 -87.7% 0.003 Orthopaedic clinic attendances 1652.3 ± 143.5 2336.3 ± 200.1 -29.3% 0.011 2,495 ± 243.5 to 2,005 ± 426.5 per month; P = 0.04). The outpatient clinics [13]. It reflected a net increase in total increases were observed in both waiting time and total case load despite fewer new cases at outpatient clinics. number of patients on the waiting list for elective joint replacement surgery. For example, the recent aggregate Discussion data collected from the Hospital Authority showed a COVID-19 profoundly impacts the arthroplasty ser- 14% growth in the arthroplasty waitlist (from 26,547 to vices. Many institutions worldwide have postponed non- 30,342) from March to December 2020 [12], despite an emergent operations to reduce hospital traffic, conserve overall 8% (from 106,472 to 98,153) decline in the past personal protective equipment, and enable manpower 12-month new-case bookings (from the interval between deployment to COVID-19 frontline services. Likewise, April 1, 2019 and March 31, 2020 to the interval between orthopaedic services in Hong Kong have been signifi - January 1, 2020 to December 30, 2020) at the orthopaedic cantly reduced, particularly for joint replacement and Lee et al. Arthroplasty (2021) 3:36 Page 4 of 8 ligamentous reconstruction procedures, as the majority Table 3 US arthroplasty scheduling recommendations, adapted from the American College of Surgeons [16] are elective operations [14]. Apart from the Hospital Authority policies [7], patient Phase II (curtail Phase III (eliminate health-seeking behavior also contributes to those reduc- elective practice) elective practice) tions due to COVID-19 risk. Our institution’s arthro- Proceed Postpone Proceed Postpone plasty prioritization and infection control measures are Acute knee or hip pain ✓ ✓ summarized in Table  2. Specifically, the elective joint Chronic knee or hip pain ✓ ✓ replacement services are maintained primarily for high- Inability to weight bear ✓ ✓ priority patients with increased morbidity and likeli- Knee or hip dislocation ✓ ✓ hood of necessitating more complicated reconstruction Concern for peripros- ✓ ✓ procedures if the operations are delayed [15]. The key thetic joint infection semi-urgent indications for proceeding with elective Acute pain exacerbation ✓ ✓ arthroplasty included (1) infection; (2) progressive bone with prior joint replace- loss; (3) loosening, dislocation, or mechanical failure of ment arthroplasty; and (4) tumor (Table  2). It is in line with Only for acute inability to weight bear the international guidelines proposed by the professional bodies regarding the provision of clinical services during the outbreak, such as the American College of Surgeons “dislocated joints” as priority 1a and “revision surgery guidelines [16] (Table 3) and the clinical guide for ortho- for loosening without impending fracture or recurrent paedic surgical prioritisation established at the request of joint instability” as priority 3 (i.e., arthroplasty should be the UK National Health Service [17] (Table 4). For exam- performed within 3  months). Tumor is listed in the UK ple, infection is one of the essential indications (wound guidelines as priority 2 for “solitary metastasis”. drainage, fever, concern for infection with prior joint The rationale underlying those recommendations takes replacement) for surgery in the American College of Sur- into consideration multiple parameters, including the geons’ guidelines, and the UK guidelines list “infection” immediate risk, the long-term impact of the disease, and and “septic arthritis (natural or prosthetic joint)” as pri- the projected future severity [18]. Since the COVID-19 ority 1a indications, i.e., emergency arthroplasty should situation and resource availability vary by region in Asia, be performed within 24 h. Progressive bone loss is a pri- individual localities will benefit from developing specific ority 2 indication (i.e., a suggested timeframe < 1 month) recommendations on arthroplasty prioritization, to bal- in the UK guidelines as “destructive bone lesion with risk ance between tackling COVID-19 and minimizing the of fracture (e.g., giant cell tumor)”. Loosening, dislocation, service disruption. or mechanical failure of arthroplasty are in accordance Infection control measures are based on the local with American College of Surgeons’ essential indications Hospital Authority guidelines [19]. All inpatients at our of “knee dislocation”, “prior hip or knee replacement with institution (e.g., patients admitted for joint replacement acute pain exacerbation”, while the UK guidelines classify surgery) are screened for COVID-19 at admission. To Table 2 Summary of infection control and arthroplasty service prioritization at our institution Guidelines and measures Patient screening Inpatient admission screening • SARS-CoV-2 RT-PCR test using deep throat saliva self-collected by patient in the presence of a HEPA filter unit Outpatient screening (e.g., preoperative clinic appointments) • Patients are screened for symptoms and signs of COVID-19 using a health declaration form Visiting arrangement • All ward visitations are suspended except for compassionate visit of inpatients for exceptional situations on a case-by-case basis • Visitors are screened for symptoms and signs of COVID-19 using a health declaration form • Visitors are required to wear full personal protective equipment, including face shield, N95 respirator, isolation gown and disposable gloves Arthroplasty prioritisation Proceed with elective arthroplasty for semi-urgent indications, such as: • Joint infection • Loosening, dislocation or mechanical failure of arthroplasty • Bone loss • Tumor Preoperative screening • SARS-CoV-2 RT-PCR test using deep throat saliva self-collected by patient in the presence of a HEPA filter unit L ee et al. Arthroplasty (2021) 3:36 Page 5 of 8 Table 4 National Health Service arthroplasty scheduling recommendations, adapted from the Federation of Specialty Surgical Associations (UK) [17] Priority Surgery timeframe Orthopaedics & traumatology examples 1a < 24 h • Infection: e.g., septic arthritis (natural or prosthetic joint) • Dislocated joints 1b < 72 h • Unstable articular fractures that will result in severe disability without operative fixation 2 < 1 months • Destructive bone lesion with risk of fracture (e.g., giant cell tumour) • Solitary metastasis • Arthroplasty – any site where delay will prejudice outcome 3 < 3 months • Revision surgery for loosening without impending fracture, or recurrent joint instability 4 > 3 months • Arthroplasty/arthrodesis – not otherwise specified minimize the risk of nosocomial transmission, we per- managing previous waves of the outbreak, together with formed a SARS-CoV-2 RT-PCR test for all inpatients the increased availability of infection control equipment using a deep throat saliva sample, and the screening worldwide, results in enhanced outbreak preparedness scheme has now been expanded to patients attending and response measures in public hospitals. Together, day services [19]. Similar to the practices in Japan [4] and the extended efforts of our institution contribute to the South Korea [20], such pre-arthroplasty screening allows timely detection of occult cases and limiting the spread an elective arthroplasty to be continued throughout the of COVID-19, while allowing elective arthroplasty to outbreak. Another strategy recommended by the UK proceed for semi-urgent patients (Table 2). National Health Service is to require patients and their The growing waiting list for elective joint replacement household members to self-isolate for 14  days before reflects a greater impact of the pandemic on the surgi - admission for elective operations [21]. It potentially cal volume than that on the outpatient clinic attend- reduces the risk of transmission in case of insufficient ances. The pent-up demand for elective joint replacement testing capacity. procedures is anticipated to pose significant challenges In addition, patients attending day services at our pre- even after services recover to pre-pandemic full capac- operative assessment clinic are also screened for the signs ity. It is a looming global public health crisis with two and symptoms of COVID-19 and TOCC (travel, occu- major implications. First, a rising number of osteoar- pation, contact, and cluster) history via a patient decla- thritis patients are facing delayed surgical management. ration form. In Hong Kong, although visiting wards has Knee osteoarthritis is the primary reason for disability been suspended in light of the current wave of outbreak, in walking, housekeeping, and stair-climbing among local public hospitals currently allow the compassionate non‐institutionalized individuals aged 50  years or above visit of inpatients for exceptional situations on a case- [22]. A postponed arthroplasty adversely affects patient by-case basis [19]. The visitors are similarly screened for outcomes due to significant deterioration in morbidity the signs and symptoms of COVID-19 before they are during the delay and worse health-related quality of life allowed entry to the wards, and full personal protective outcomes following late arthroplasty [23–26]. Second, equipment is required during the visit. the operation backlog represents a major future burden The rapid return to fully functioning pre-pandemic on the health care system. Estimates showed that if coun- baseline surgical volume by June 2020 reflects adequate tries increased surgical capacity by 20% following the facility readiness to resume normal elective joint replace- pandemic, a median of 45 weeks will be required to work ment services upon dampening of the second wave of through the surgical backlog due to COVID-19 disrup- outbreak. It was supported by the Hospital Authority tions [27]. A May 2020 analysis of elective orthopaedic directives, such as encouraging healthcare departments surgery under the COVID-19 outbreak found that in the to increase weekend clinical service hours under the Spe- optimistic scenario, the US will have a cumulative back- cial Honorarium Scheme from late May to September log of over 1 million surgical cases 2  years following the 2020 to take care of previously postponed cases due to resumption of elective surgeries, and it may take as many COVID-19 restrictions. as 16 months to address 90% of the surgical backlog [28]. Hong Kong subsequently faced its third and fourth Hong Kong has been fortunate to have rapidly returned waves of COVID-19 infection beginning in July and to pre-pandemic service provision levels upon dampen- November 2020, respectively. The experience of ing of previous outbreak waves. Nevertheless, planning Lee et al. Arthroplasty (2021) 3:36 Page 6 of 8 Table 5 Strategies for arthroplasty service planning during the next pandemic Pre-pandemic • Build a consensus among stakeholders for prioritization of arthroplasty services, including inpatient, outpatient and operation, during different degrees of severity of a pandemic • Establish guidelines for infection control measures for patients and health care workers during the pandemic • Establish guidelines for operating on a confirmed infected case during the pandemic • Set up telemedicine infrastructure for preoperative education, outpatient consultation and follow-up, and telerehabilitation • Set up ERAS services for arthroplasty procedures During the pandemic • Adjust clinical services according to the severity of the pandemic • Increase the capacity for supporting ERAS services in arthroplasty to shorten hospital stay and reduce the burden on inpatient care • Provide telemedicine consultations for pre-operative education and postoperative follow-up • Provide telerehabilitation to maintain mobility and knee function; ensure access to drug-refill clinic for patients on waiting list for arthroplasty • Provide telerehabilitation for postoperative rehabilitation after arthroplasty • Develop a post-pandemic arthroplasty resumption plan for the anticipated backlog Post-pandemic • Prepare manpower and hospital capacity for the post-pandemic increase in clinical service (e.g., extend operating room schedules) • Utilize orthopaedic block times for arthroplasty procedures • Enhance mental health support for healthcare workers to cope with the increase in workload during the post-pandemic phase for the anticipated backlog remains critical. Strategies during the dedicated operative time for arthroplasty to for arthroplasty service planning during different stages clear the backlog more quickly and efficiently [37]. Fur - of the pandemic are summarized in Table  5. In addi- thermore, enhancing mental health support for health- tion to guidelines on the resumption of surgical services care workers may help alleviate the anxiety associated published by professional organizations [29, 30], an with the surge of patients during the post-outbreak phase evidence-based three-phase return pathway for elective [38]. orthopaedic operations has been proposed by orthopae- With rapid globalization and rising interconnected- dic surgeons at the Croydon University Hospital London ness between humans and natural environments, there and South West London Elective Orthopaedic Centre is an increasing concern on the emergence of new pan- [31], which suggests stratifying patients into risk groups, demics [39]. The local and global experience during the so as to begin service resumption for low-risk patients COVID-19 pandemic can inform the arthroplasty service with maximum anticipated benefit in quality of life (e.g., planning and post-pandemic recovery to enhance hospi- patients suitable for day case arthroplasty) and gradually tal and community preparedness for current and future expanding to all orthopaedic cases. Developing regional pandemics. post-pandemic arthroplasty resumption guidance for hospitals will not only facilitate the return to normal clin- Conclusions ical services but also avoid creating inequalities in wait- Despite the drastic service reduction, public hospitals in ing time among patients in different hospital catchment Hong Kong continued providing elective joint replace- areas. ment services for high-priority patients. Hong Kong’s Increasing application of Enhanced Recovery After experience in the past few months can inform the ser- Surgery (ERAS) for arthroplasty procedures has deliv- vice planning for post-pandemic recovery and in antici- ered promising results in Singapore and Hong Kong in pation of future crises such as a new wave of COVID-19 terms of reduced hospital length of stay and comparable pandemic. risk of complications [32–34]. The use of telemedicine for outpatient clinic consultations has also been discussed, particularly for postoperative follow-up appointments of Abbreviations suitable patients, in order to reduce hospital traffic while COVID-19: Coronavirus disease 2019; HK: Hong Kong; UK: United Kingdom; US: United States. reaching patients who hesitate to visit hospitals due to concerns regarding the outbreak [35]. Other potential Acknowledgements strategies reported in the literature included extending N/A operating room schedules to increase surgical capac- Authors’ contributions ity [28]; shifting to same-day arthroplasty for carefully LS Lee (study design, data acquisition and analysis, writing of manuscript); PK selected patients at the major arthroplasty centers [36]; Chan (study design, analysis of data, providing revision comments); WC Fung (data acquisition and analysis); A Cheung, VWK Chan, MH Cheung, H Fu, CH and utilizing orthopaedic block times to boost efficiency L ee et al. Arthroplasty (2021) 3:36 Page 7 of 8 Yan and KY Chiu (providing expert advice and revision comments). All authors 11. Hong Kong Food and Health Bureau. Report of the strategic review on read and approved the final manuscript. healthcare manpower planning and professional development. 2017. 12. Hospital Authority. 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Orthopaedic guidelines for the COVID-19 post-outbreak period: experience from Wuhan, People’s Republic of China. J Bone Joint Surg Am. 2020;102(15):e87. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions

Journal

"Arthroplasty" – Springer Journals

Published: Sep 6, 2021

Keywords: Arthroplasty; Replacement; Total knee arthroplasty; Total hip arthroplasty; COVID-19

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