COVID-19 - ESSKA guidelines and recommendations for resuming elective surgery Caroline Mouton, Michael Hirschmann, Matthieu Ollivier, Romain Seil, Jacques Menetrey To cite this version: Caroline Mouton, Michael Hirschmann, Matthieu Ollivier, Romain Seil, Jacques Menetrey. COVID- 19 - ESSKA guidelines and recommendations for resuming elective surgery. Journal of Experimental Orthopaedics, Springer Verlag, 2020, 7 (1), pp.28. 10.1186/s40634-020-00248-4. hal-03175930 HAL Id: hal-03175930 https://hal.archives-ouvertes.fr/hal-03175930 Submitted on 22 Mar 2021 HAL is a multi-disciplinary open access L’archive ouverte pluridisciplinaire HAL, est archive for the deposit and dissemination of sci- destinée au dépôt et à la diffusion de documents entific research documents, whether they are pub- scientifiques de niveau recherche, publiés ou non, lished or not. The documents may come from émanant des établissements d’enseignement et de teaching and research institutions in France or recherche français ou étrangers, des laboratoires abroad, or from public or private research centers. publics ou privés. Distributed under a Creative Commons Attribution| 4.0 International License Mouton et al. Journal of Experimental Orthopaedics (2020) 7:28 Journal of https://doi.org/10.1186/s40634-020-00248-4 Experimental Orthopaedics REVIEW Open Access COVID-19 - ESSKA guidelines and recommendations for resuming elective surgery Caroline Mouton1,2, Michael T. Hirschmann3, Matthieu Ollivier4, Romain Seil1,2 and Jacques Menetrey5,6* Abstract The roadmap to elective surgery resumption after this COVID-19 pandemic should be progressive and cautious. The aim of this paper was to give recommendations and guidelines for resuming elective orthopedic surgery in the safest environment possible. Elective surgery should be performed in COVID-free facilities and hospital stay should be as short as possible. For matters of safety, patients considered first for surgery should be carefully selected according to COVID infection status/exposure, age, ASA physical status classification system / risk factors, socio- professional situation and surgical indication. A strategy for resuming elective surgery in four phases is proposed. Preoperative testing for COVID-19 infection is highly recommended. In any cases, COVID symptoms including fever and increased temperature should be constantly monitored until the day of surgery. Elective surgery should be postponed at the slightest suspicion of a COVID-19 infection. In case of surgery, adapted personal protective equipment in terms of gowns, gloves, masks and eye protection is highly recommended and described. Introduction Premature and sudden lifting of interventions could lead Since March 2020, hospitals and surgeons have been ad- to a second wave of infections [3]. It is thus critical to vised to postpone or cancel elective scheduled operations maintain regulatory measures within healthcare infra- until the inflection point in the exposure graph has passed structures within the next months to assure patient and so that healthcare infrastructures can support the critical staff safety and limit the number of infections. This can patient care needs [1]. Hospital resources have therefore only be achieved by preparing the roadmap to elective mainly been dedicated to the care of COVID-19 patients surgery resumption. Unfortunately, there is, to date, no resulting in thousands of orthopedic surgeries being de- specific literature concerning the organization of an out- layed all over the world if they were not considered to patient clinic and surgical activities [4]. cause a significant harm to the patient or outcome. The aim of this paper was therefore to provide recom- It is commonly agreed that there should be a decrease mendations and guidelines for resuming elective ortho- in incidence of COVID-19 cases for at least 2 weeks be- pedic surgery in this period of pandemic in the safest fore elective surgery is resumed [2]. In Europe, several environment possible and according to the current state countries will soon reach this goal. Although the sanitary of knowledge on COVID-19. crisis can be considered to be under control, one should keep in mind that the pandemic is not finished yet. Surgeries covered by the present guideline The American Academy of Orthopaedic surgeons defined * Correspondence: [email protected] 5Centre de Médecine du Sport et de l’Exercice (CMSE), Swiss Olympic four type of orthopaedics procedures in times of pan- Medical Center, Hirslanden Clinique La Colline, Chemin Thury 7A, CH-1206 demic: A) emergency only, B) urgent types of surgeries, C) Geneva, Switzerland urgent/somewhat elective and D) elective (Table 1). The 6Division of Orthopaedic Surgery, University Hospital of Geneva, Geneva, Switzerland current guideline only covers categories A and B of this Full list of author information is available at the end of the article definition. These include all types of surgeries with © The Author(s). 2020 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://creativecommons.org/licenses/by/4.0/. Mouton et al. Journal of Experimental Orthopaedics (2020) 7:28 Page 2 of 7 Table 1 Adapted from AAOS guidelines for elective surgery [5] Category A B C D Degree of emergency Emergency Urgent Urgent/ Elective Somewhat elective Types of procedures Life- or limb- Joint/arthroplasty Acute intra- and periarticular Total joint arthroplasty (non-exhaustive selection) threatening infections ligament & tendon conditions Osteotomies conditions Chronic intra- and periarticular Most trauma (e.g. ACL tears, meniscus ligament & tendon conditions cases bucket handle tears) Chronic peripheral nerve Selected trauma cases compression syndromes predominantly chronic conditions or acute cases where pandemic, they should be monitored on a regular (e.g. surgery generally can be delayed without causing serious weekly) basis and their protection be guaranteed (sup- harm to patients. More precisely, the following procedures plies, PPE). Testing of patients should also be organized are considered: tendinous or ligamentous intra- or peri- before any surgery to avoid importing asymptomatic articular injuries of chronic and acute in nature; cases within the COVID-negative clinical pathway as deformity-correcting osteotomies; joint arthroplasty pro- well as to prevent secondary surge. Prescreening of ex- cedures; elective shoulder, elbow, hand, hip, knee and foot posed patients is of importance to avoid the planning of and ankle surgery. surgeries during the incubation period of COVID-19 The present guideline is essentially based upon a re- and adequate policy should be implemented to avoid view of sparse literature, interviews of specialist and peri-operative COVID infection. Finally, care should be mostly expert opinion. The content has been reviewed taken to operate patients when a standardized and suffi- by a scientific committee. It can be useful in conducting cient postoperative follow-up is assured. Nurses, the negotiations or for practical implementation at the level team of anesthesiology, physiotherapists should be con- of a hospital or a national specialty society but cannot be sulted and aware that elective surgeries will start again imposed as official guidelines. The purpose of this guide- to guarantee proper patient care. line is only to provide the community with possible an- swers as well as to raise awareness of the complexity of Preselection of patients eligible for surgery the problem. When resuming surgical activities, a careful selection of patients should be implemented in order to limit the risk Before resuming surgical activities of infections and complications. The selection of priori- The main objective before resuming any surgical activity tized patients should take into account several parame- is to assure that all necessary regulatory measures are in ters such as COVID exposure, age, American Society of place within the healthcare infrastructure to allow for Anesthesiologists (ASA) physical status classification sys- the safety of patients, physicians, staff and institution tem / risk factors and socio-professional situation. until the end of the pandemic. All decision in the According to Fineberg [6], patients should be treated organizational aspect should naturally be locally based according to their COVID-19 exposure. The author de- decisions, follow legal restrictions and guidelines from fined five types of patient categories: A patient (1) who the relevant health authorities. is not known to have been exposed or infected, (2) who First, state and hospital regulations should allow for a has been exposed but is asymptomatic, (3) who has re- return to outpatient clinic and elective surgeries. These covered from infection and maybe adequately immune, regulations/rules