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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 48-50

Ensuring safety from COVID-19 in arthroscopic surgery


Sports Injury Centre, Safdarjung Hospital and Vardhman Mahavir Medical College (VMMC), New Delhi, India

Date of Submission05-Jul-2021
Date of Acceptance30-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Jaswant Kumar
Sports Injury Centre, Safdarjung Hospital and Vardhman Mahavir Medical College (VMMC), New Delhi 110029.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_10_21

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  Abstract 

In the current time of coronavirus disease-2019 (COVID-19) pandemic, orthopedic procedures have been shelved and guidelines to establish the safety of medical professionals and patients are still evolving. Although sports injuries are not life threatening, a spectrum of these injuries requires urgent intervention. To ensure the safety of medical professionals and patients of sports injuries in COVID times, the following guidelines are suggested. Such surgery needs to be performed only in COVID-free facility (green zone). Patients from red zone and containment zone should be avoided. Young, fit individuals without medical comorbidities should be considered. Wherever possible, regional anesthesia should be used. As COVID virus is present in all body fluids, aerosol generation (coughing, sneezing, intubation, use of power instruments, and cautery) should be minimized. Operation theater (OT) should be fumigated on the prior night and ideally between the cases. The number of cases per OT should be kept under three to get adequate time in-between for sterilization. The ventilation setup of OT should be negative pressure in addition to positive pressure. If there are hindrances in setting up negative pressure, a simple exhaust can be added to the existing setup. The ventilation system should ideally provide more than 20 air changes per hour. During surgery, movement of doors of OT and OT personnel should be minimal so as to minimize the air turbulence and eddy current. This will reduce the risk of infection. Surgical team should wear personal protective equipment (PPE) and helmet hood to reduce the chances of respiratory droplet infection. The doffing of helmet and PPE should be done with utmost care and should be discarded in a chloro-derivate solution. The motorized drill used for surgical procedure should be used at low revolution per minute (RPM). Usage of sterile transparent polythene hood while irrigating during drilling and sequential drilling will help in minimizing aerosol generation. Spillage of arthroscopic fluid should be avoided at all times. These basic norms will minimize the chance of accidental spread of COVID.

Keywords: COVID-19, orthopedic procedures, safety of medical professionals, sports injuries


How to cite this article:
Arya R K, Topgia C, Joshi D, Kumar J, Goyal A, Lal H, Sinha S. Ensuring safety from COVID-19 in arthroscopic surgery. J Bone Joint Dis 2021;36:48-50

How to cite this URL:
Arya R K, Topgia C, Joshi D, Kumar J, Goyal A, Lal H, Sinha S. Ensuring safety from COVID-19 in arthroscopic surgery. J Bone Joint Dis [serial online] 2021 [cited 2022 May 25];36:48-50. Available from: http://www.jbjd.in/text.asp?2021/36/3/48/333198



In the current time of coronavirus disease-2019 (COVID-19) pandemic, orthopedic procedures have been shelved due to the diversion of resources in COVID care and also apprehension among medical professionals of catching COVID infection. Guidelines to establish the safety of medical professionals and patients are still evolving.[1]

Although sports injuries are not life threatening, a spectrum of these injuries requires urgent intervention. The recommended time of intervention for acute tendon ruptures (patellar or quadriceps) surgery is <1 week, for dislodged osteochondral fractures surgery is <2 weeks, for multiligament knee injury surgery is 2–4 weeks, for anterior/posterior cruciate ligament avulsion injuries surgery is <3 weeks (<2 weeks for tendinous avulsion), and for meniscus tears surgery is <12 weeks.[2] A locked knee because of bucket handle meniscus tear and any sport injury with neurovascular compromise is an absolute emergency.

COVID virus is present in all body fluids. Hence, aerosol generation (coughing, sneezing, intubation, use of power instruments, and cautery) is a risk factor for spreading COVID in case the patient has COVID.[3],[4],[5]

To ensure the safety of medical professionals and patients of sports injuries, in COVID times the following guidelines are suggested.


  Preoperative Workup Top


Such surgery needs to be performed only in COVID-free facility (green zone). Patients from red zone and containment zone should be avoided.

Young, fit individuals without medical comorbidities should be considered. Wherever possible, regional anesthesia should be used. The surgical team members should remain outside the OT during intubation and extubation procedures of general anaesthesia, so as to minimize the risk of spread of the disease via aerosols.

Clinical history in detail should be taken to rule out recent COVID infection or suspected contact with COVID case. As the majority of cases with COVID infection are asymptomatic, reverse transcription polymerase chain reaction (RT-PCR) test for COVID should be performed within 48–72 h of stipulated surgery. If possible, the patient should be instructed to isolate him or herself to avoid any re-exposure before admission. de Caro et al.[6] recommend high-resolution computed tomography (HRCT) chest for a case who has tested negative for COVID but has symptoms suggestive of COVID and a history of contact. Operating on a patient with COVID-19 can have grave consequences, with approximately 44% requiring intensive care unit (ICU) care after surgery and a mortality rate up to 20%.[7] Therefore, Patient for surgery should be selected very carefully and judiciously.

Patients should be optimized during preoperative assessment by virtual visits to anesthetists and physicians if needed. As short as possible hospital stay is recommended and most arthroscopic surgeries can be performed as daycare procedures. Proper consent in lieu of COVID-19 must be taken in writing.


  Operative Setup Top


OT should be fumigated on the prior night and ideally between the cases. The number of cases per OT should be kept under three to get adequate time in between for sterilization. If fumigation between the cases is not possible, then chloro-derivate solution can be used as surface disinfectant for all surfaces.

The ventilation setup of OT should be negative pressure in addition to positive pressure. If there are hindrances in setting up negative pressure, a simple exhaust can be added to the existing setup. Ventilation system should ideally provide more than 20 air changes per hour.

It should always be ensured that there is minimum manpower in OT. At the time of anesthetic induction, the surgical team should be out of the OT. Instead of patient breathing on room air, a ventimask can be used so as to reduce chances of droplet generation from the patient while breathing, talking, or occasional cough or sneeze. The airway circuit should be sterilized after every case.

During surgery, movement of doors of OT and OT personnel should be minimal so as to minimize the air turbulence and eddy current. This will reduce the risk of infection.

Surgical team should wear personal protective equipment (PPE) and helmet hood to reduce the chances of respiratory droplet infections. The helmet-hood filters cannot filter the particle size of 0.02–1 μm in diameter to ensure the standard for protective respirators, so filter of AAMI class 3 filter over the inlet and AAMI class 4 on the sides of the hood are recommended. If the helmet is not available, a surgical visor and N95 mask can be used. Double surgical masks are less effective than an N95 mask. The helmet must be sterilized after every procedure. A respirator mask can also be used. Respirator masks can filter smaller-sized particles (0.3 μm) in comparison to surgical masks. Use of eye protection is a must if the hood is not being used.

The doffing of helmet and PPE should be done with utmost care even more carefully than donning as the outer surface of these are potentially contaminated. PPE and mask should be discarded in a chloro-derivate solution.

The use of power tools such as drill, saw, and burr are associated with droplet and fine particle generation. In arthroscopy, the power instruments are used in environment containing fluid so aerosol generation is negligible. But drilling in tibia can generate aerosol. To minimize it, the following strategies can be deployed: using drill at low revolutions per minute (RPM), sequential drilling, irrigation while drilling, and drilling under sterile transparent polythene hood. The graft harvest and graft passage should be done in a slow and smooth manner in order to minimize droplets generation.

The patient should be cleaned and draped according to the surgical procedure. Disposable laundry should be preferred over re-usable draping.

Monopolar cautery is to be used sparingly for graft harvest and along with suction of its fumes. The team should always have experienced members so as to reduce operative steps and time. Spillage of arthroscopic fluid should be avoided at all times. If spillage has occurred, floor suction should be deployed expeditiously. Unless contraindicated, the subcuticular buried knots with absorbable sutures should be used for skin closure. This will reduce unnecessary visits to the hospital for suture removal. A transparent dressing should be used after proper closure which will allow wound inspection without the need of unnecessary dressing change.

The OT and its surroundings must be sanitized after every procedure as soon as possible. All the potentially single-use scrubs must be disposed in IRHW (infectious-risk health waste) containers at the dedicated doffing stations. The ventilators and radiological equipment present in the OT must be sanitized with a chloro-derivate solution, rinsed, and dried.

Shifting the cases out of OT complex to ward should be done expeditiously. Usual postoperative care protocol should be used. There are no reports or literatures available with regard to prophylactic use of any antiviral drugs. If resources allow, the paramedics involved in postoperative care should also wear proper PPE kits. Any patients who need longer hospitalization in postoperative ward or patients with longer surgical time should be subjected to two nasopharyngeal swabs within 48 h and HRCT of chest if possible. Any postoperative brace or walking aids, if needed, should be purchased in advance to avoid surface contact spread and the patient or his attendant need to be trained for its proper usage.

Attendant’s visit should be minimized during the postoperative period. The patient’s home caregivers should be identified preoperatively. They should be trained for basic rehabilitation protocols as per the surgery planned.

They should be educated about red flags of arthroscopy management. All attempts should be made to reduce hospital visits by telemedicine. Virtual visits are to be encouraged. Postop physiotherapy by charts and videos should be encouraged. Creating interactive modules including apps and websites with interactive input is advisable.

If these basic norms are followed, then the chance of accidental spread of COVID is minimized and surgical services can resume safely in sports-related injuries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Iyengar KP, Jain VK, Vaish A, Vaishya R, Maini L, Lal H. Post COVID-19: Planning strategies to resume orthopaedic surgery -challenges and considerations. J Clin Orthop Trauma 2020;11:291-5.  Back to cited text no. 1
    
2.
Ding BTK, Decruz J, Kunnasegaran R. Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic. Int Orthop 2020;44:1531-8.  Back to cited text no. 2
    
3.
Heinsohn P, Jewett DL. Exposure to blood-containing aerosols in the operating room: A preliminary study. Am Ind Hyg Assoc J 1993;54:446-53.  Back to cited text no. 3
    
4.
Nogler M, Lass-Flörl C, Wimmer C, Bach C, Kaufmann C, Ogon M. Aerosols produced by high-speed cutters in cervical spine surgery: Extent of environmental contamination. Eur Spine J 2001;10:274-7.  Back to cited text no. 4
    
5.
Nogler M, Lass-Flörl C, Wimmer C, Mayr E, Bach C, Ogon M. Contamination during removal of cement in revision hip arthroplasty: A cadaver study using ultrasound and high-speed cutters. J Bone Joint Surg Br 2003;85:436-9.  Back to cited text no. 5
    
6.
de Caro F, Hirschmann TM, Verdonk P. Returning to orthopaedic business as usual after COVID-19: Strategies and options. Knee Surg Sports Traumatol Arthrosc 2020;28:1699-704.  Back to cited text no. 6
    
7.
Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. Eclinicalmedicine 2020;21:100331.  Back to cited text no. 7
    




 

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