Introduction

The COVID-19 pandemic poses unprecedented challenges for patients, clinicians and healthcare systems. During the pandemic clinicians of every discipline have been forced to modify patient care, to minimise exposure for patients and health care workers, and to preserve and reallocate resources to COVID-19 patients [16]. There has been a drastic cutback of arthroplasty services [3] and other orthopaedic procedures [8] due to COVID-19, with procedures being cancelled or postponed not only in Europe [14], but all over the world [2]. Surgeons have been forced to triage arthroplasty patients during the COVID-19 pandemic using their expertise because of a lack of guidelines or published data. Therefore, the risks of disease progression and compromised outcomes for patients had to be weighed against viral exposure of patients and staff [5, 15], taking into consideration each individual’s comorbidities and age to predict the risk of mortality from COVID-19. As arthroplasty procedures have now resumed to some extent worldwide, increased demand for hip and knee arthroplasty, coupled with limited hospital resources [11], will force surgeons to select which patients will receive hip and knee arthroplasties sooner than others [6, 10]. This will entail employing objective, transparent criteria in prioritising patient selection [7] to identify those patients most in need, who also have lower risk factors for disease transmission and post-operative complications. Unfortunately, these factors frequently conflict with high-risk patients who may need major surgery such as revision arthroplasty, implant removal or reimplantation due to infection. Some guidelines are available for prioritising patients undergoing elective surgery. The MeNTS Score (Medically Necessary Time-Sensitive Procedures Score) [13] is a scoring system that takes procedural factors, disease factors and patient factors into account. The final score ranges from 21 to 105, and higher scores represent poorer patient outcomes and increased risk of SARS-CoV-2 transmission. The MeNTS Score is not widely available and is not specific to arthroplasty patients. The International Consensus Meeting and the AAHKS (American Association of Hip and Knee Surgeons (AAHKS) Research Committee recommend priority surgery for impending fracture and exposed implants, hip dislocation, knee dislocation, periprosthetic fracture, and acute pain exacerbation [12]. However, no exact ranking of such procedures was provided. The spread of the COVID-19 infection is still increasing, and many healthcare systems fear a second wave.

The objective of this survey was to prioritise patient scenarios by the urgency of treatment and to make treatment recommendations based on these priorities. These recommendations can be used by those countries which are still in a reinstatement period following an acute outbreak of COVID-19, for countries facing a COVID-19s-wave, and in the case of a further, future pandemic.

Material and methods

The study design was a prospective online survey sent to orthopaedic surgeons (expert opinion). All participants were members of the European Hip Society (EHS), of the European Knee Associates (EKA) or affiliated surgeons by invitation. Approval of an institutional review board was deemed unnecessary because no patient data were involved.

The survey was created with LimeSurvey (http://www.limesurvey.org/Hamburg/Germany), an online data collection program. The survey included 17 indications for arthroplasty surgeries. The indications were selected based on the findings of Thaler et al. and Liebensteiner et al. [8, 14]. Tables 1 and 2 show the indications, which were selected by the participants. Participants were asked to rank their top ten priority indications for adult hip and knee arthroplasty.

Table 1 List of procedures in relative percentages with weighted average and weighted standard deviation
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Table 2 List of ranked procedures in absolute percentages (explanation for repeats in the text)
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A link to the survey was then sent out on the 23rd of May 2020, and the survey was finally closed on 6th of June. Participants had to choose ten indications out of 17, and the ranks 1 to 10 were given to the 10 selected indications. Those indications which were not ranked by the individual were finally summarised as “not applicable”.

In the ranking calculation we set the given points in descending order, rank one equalled 10 points, and rank 10 equalled 1 point. For the evaluation of the statistics, the weighted average and the weighted standard deviation of the relative points were calculated. The corresponding points included the summarised “not applicable” data. Weighted average takes into account the varying degrees of importance of the indication. Therefore, each rank in our data set was multiplied by the rank number and divided by its sum to make the final calculation. The weighted standard deviation showed the relative significance to each value in our number of responses. To summarise the overall ranks we also calculated the absolute percentages by excluding the value for “not applicable”. Some indications might be ranked twice in absolute percentages because the surgeons ranked them differently.

Results

439 arthroplasty surgeons participated in the online survey. The geographical spread of this survey included surgeons from 44 different countries on six continents (Fig. 1). The EHS and EKA had a 43% response rate of members, respectively. The mean ‘time in practice’ for all participants was 20 years (min 1 year–max 46 years). The calculated weighted average shows the averaged ranks from 1 to 10 (Table 2).

Fig. 1
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Participants from 6 different continents

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In absolute percentages ‘acute fractures requiring arthroplasty (Periprosthetic fractures, THA/Hemi-arthroplasty for femoral neck fractures)’ ranked as number 1 (83.3%). The other indications were listed differently by individuals and therefore appeared on different ranks in absolute percentages (Table 2).

Discussion

The most important finding of our survey is that the majority of survey respondents prioritised fractures (periprosthetic fractures, THA/Hemi-arthroplasty for femoral neck fractures) and surgery for acute PJI (periprosthetic joint infection), like first-stage explantations and one-stage revisions. Most of these cases were never completely halted even during the peak of the outbreak due to the recognised emergency features of such cases [14, 16]. The historic cutback of arthroplasty service worldwide has forced surgeons to triage arthroplasty patients according to their indications, in particular in the early reinstatement period. Protection of patients, surgical staff, limited availability of beds in intensive care units and hospital wards, and COVID-19 restrictions by the authorities, have created the need for an evidence-based prioritization of the patient undergoing arthroplasty. Many patients requiring arthroplasty are older and may have associated comorbidities, and therefore a higher risk of morbidity and mortality following COVID-19 transmission [4, 17]. On the other hand, these ‘more fragile’ patients may require revision for implant failure for any reason or suffer from rapidly disruptive osteoarthritis. Pain and walking capability can quickly be compromised, with various consequences on general health status in such cases when autonomy is lost. Pain control may require opioids with the risk of developing subsequent dependency. All these factors, as well as ethical implications [7], have to be considered in the decision-making process of patient prioritisation. The American College of Surgeons has published a guideline for elective surgical procedures and recommended as priority indications for hip and knee arthroplasty surgery the following; hip dislocation, knee dislocation, periprosthetic fracture, acute pain exacerbation in prior joint arthroplasty, inability to bear weight on the extremity, wound drainage, fever and concern about periprosthetic infection [1]. However, this guideline is very general and hence challenging to apply in daily clinical routine, when surgeons have to decide whether to treat a patient suffering from a periprosthetic fracture or a patient with fever and a TJA [9]. Our results provide a more detailed prioritisation list with different indications. Our prioritisation ranking can easily be applied to most arthroplasty cases in daily clinical routine. They can also form the basis for discussion with patients and relatives for shared decision-making and well informed consent for the procedure.

The present study has several limitations. First, the findings from the participants (n = 439 arthroplasty surgeons) cannot be fully extrapolated to all surgeons and all health care systems. Nevertheless, surgeons from 44 countries and six continents participated, and to the best of our knowledge, this is the most extensive survey on this topic as well as the most recent one initiated by two important scientific societies. Other limitations are related to the fact that it was an Internet-based survey with a response rate of 21%. However, those who responded had an average of 20 years experience in arthroplasty practice. Therefore the survey can be considered to state an expert recommendation that covers multiple healthcare systems on patient prioritisation in a pandemic. In addition, we were not able to discriminate among prioritisation surgery in COVID-19 negative, positive or post-positive cases. Nevertheless, it can be a useful tool for surgeons when a decision about prioritisation must be taken for patients with no signs of COVID-19 and negative tests.

The results of this survey could be used to organise a process of structured decision-making for the care of patients undergoing arthroplasty surgery during reinstatement or a possible second wave of the COVID-19 pandemic or another pandemic. However, as the current pandemic is still rapidly evolving, we are increasingly learning about the disease and its impact on the arthroplasty service; thus, our prioritisation recommendations may change over time and place.

Conclusions

There is an agreement that femoral neck fractures, periprosthetic fractures and acute infections should be prioritised in the setting of the COVID-19 pandemic and cannot be postponed. As arthroplasty surgery is now being resumed, there has also been a relaxation of the lockdown rules in most countries, which may lead to a second wave of the pandemic. The results of the current study represent a proposal by experts as to which arthroplasty procedures should be prioritised in all phases of a pandemic.