Daniel K. Guy, MD, FAAOS; Joseph A. Bosco III, MD, FAAOS; and Felix H. Savoie III, MD, FAAOS
April 2, 2020
In these uncertain times, we all need to be considerate of the population. AAOS’ guidelines on elective surgery during the COVID-19 pandemic should be applied judiciously depending on your location, where your area/institution happens to be situated relative to the curve of the disease, and the availability, or scarcity, of your resources, including personal protective equipment (PPE), intensive care unit (ICU) beds, respirators, and personnel.
The Centers for Medicare & Medicaid Services (CMS) and the American College of Surgeons (ACS) have provided a rough framework for the analysis of elective surgery in the face of disease and limited resources. Board of Specialty Societies member Todd Schmidt, MD, of Georgia, has graciously shared a flow diagram of decision making that has been in use at his hospital system. AAOS Board of Directors member James R. Ficke, MD, FAAOS, of Johns Hopkins Hospital, has also shared the method his facility is using to try to preserve PPE and personnel during the crisis.
- ACS’s COVID-19 guidelines for triage of orthopaedic patients
- CMS’s recommendations for adult elective surgery and procedures
- A treatment algorithm currently in use by the Georgia Surgeons in the Piedmont Healthcare System
- A Journal of Bone & Joint Surgery article on early experiences from Singapore that outlines their method of surgical triage,
- An AAOS letter from AAOS Past President Kristy L. Weber, MD, FAAOS, to Vice President Mike Pence from March 26, regarding AAOS and the COVID-19 pandemic
Patients for whom surgery is deemed “elective” are those with chronic problems whose surgery can certainly be delayed without significant harm to the patient or eventual outcome. Although an argument can be made for the need for surgery in some individuals due to pain or functional impairment, the determining principle is that delaying treatment will not significantly alter the eventual outcome. Such surgeries include total joint replacements, spine fusion, chronic joint conditions (e.g., atraumatic, chronic rotator cuff tears; posterior cruciate ligament injuries; and degenerative meniscal tears) and other conditions that although painful will not be altered by delay in treatment (e.g., elbow tendonitis and carpal tunnel surgery).
Urgent, Somewhat Elective, Surgery (Tier 2)
As the virus becomes more prevalent and resources become of more paramount importance, the option for surgery becomes much more limited. In addition, the availability of ICU beds,ventilators, and PPE should be considered. Under urgent-only conditions, injuries in which immediate surgical intervention would prevent significant impairment of function should be considered, including fracture dislocations, pilon fractures, distal biceps ruptures, etc., as well as fractures where failure to repair the injury would result in increased morbidity (e.g., intertrochanteric fractures, pelvic fractures, femur fracture, etc.). This category of injuries would typically not include humerus or tibia fractures but would include both bone forearm fractures.
(See method from Dr. Ficke and Johns Hopkins Hospital)
In this situation, the hospital and ICU are full and a critical shortage of resources is the prevailing circumstance. Surgery cannot be safely performed without considerable expenditure of scarce resources. In this situation, only true life- or limb-threatening injures should be taken to surgery with the goal of minimizing the need for ventilator support, even if this is outside the usual standard of care (e.g., use of spinals for surgery).