Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.
Clin Orthop Relat Res. 2021 Aug 1;479(8):1691-1699. doi: 10.1097/CORR.0000000000001697.
Many patients with coronavirus disease 2019 (COVID-19) are asymptomatic. The prevalence of COVID-19 in orthopaedic populations will vary depending on the time and place where the sampling is performed. The idea that asymptomatic carriers play a role is generalizable but has not been studied in large populations of patients undergoing elective orthopaedic surgery. We therefore evaluated this topic in one large, metropolitan city in a state that had the ninth-most infections in the United States at the time this study was completed (June 2020). This work was based on a screening and testing protocol that required all patients to be tested for COVID-19 preoperatively.
QUESTIONS/PURPOSES: (1) What is the prevalence of asymptomatic COVID-19 infection in patients planning to undergo orthopaedic surgery in one major city, in order to provide other surgeons with a framework for assessing COVID-19 rates in their healthcare system? (2) How did patients with positive test results for COVID-19 differ in terms of age, sex, and orthopaedic conditions? (3) What proportion of patients had complications treated, and how many patients had a symptomatic COVID-19 infection within 30 days of surgery (recognizing that some may have been missed and so our estimates of event rates will necessarily underestimate the frequency of this event)?
All adult patients scheduled for surgery at four facilities (two tertiary care hospitals, one orthopaedic specialty hospital, and one ambulatory surgery center) at a single institution in the Philadelphia metropolitan area from April 27, 2020 to June 12, 2020 were included in this study. A total of 1295 patients were screened for symptoms, exposure, temperature, and oxygen saturation via a standardized protocol before surgical scheduling; 1.5% (19 of 1295) were excluded because they had COVID-19 symptoms, exposure, or recent travel based on the initial screening questionnaire, leaving 98.5% (1276 of 1295) who underwent testing for COVID-19 preoperatively. All 1276 patients who passed the initial screening test underwent nasopharyngeal swabbing for COVID-19 via reverse transcription polymerase chain reaction before surgery. The mean age at the time of testing was 56 ± 16 years, and 53% (672 of 1276) were men. Eighty-seven percent (1106), 8% (103), and 5% (67) were tested via the Roche, Abbott, and Cepheid assays, respectively. All patients undergoing elective surgery were tested via the Roche assay, while those undergoing nonelective surgery received either the Abbott or Cepheid assay, based on availability. Patients with positive test results undergoing elective surgery had their procedures rescheduled, while patients scheduled for nonelective surgery underwent surgery regardless of their test results. Additionally, we reviewed the records of all patients at 30 days postoperatively for emergency room visits, readmissions, and COVID-19-related complications via electronic medical records and surgeon-reported complications. However, we had no method for definitively determining how many patients had complications, emergency department visits, or readmissions outside our system, so our event rate estimates for these endpoints are necessarily best-case estimates.
A total of 0.5% (7 of 1276) of the patients tested positive for COVID-19: five via the Roche assay and two via the Abbott assay. Patients with positive test results were younger than those with negative results (39 ± 12 years versus 56 ± 16 years; p = 0.01). With the numbers available, we found no difference in the proportion of patients with positive test results for COVID-19 based on subspecialty area (examining the lowest and highest point estimates, respectively, we observed: trauma surgery [3%; 2 of 68 patients] versus hip and knee [0.3%; 1 of 401 patients], OR 12 [95% CI 1-135]; p = 0.06). No patients with negative preoperative test results for COVID-19 developed a symptomatic COVID-19 infection within 30 days postoperatively. Within 30 days of surgery, 0.9% (11 of 1276) of the patients presented to the emergency room, and 1.3% (16 of 1276) were readmitted for non-COVID-19-related complications. None of the patients with positive test results for COVID-19 preoperatively experienced complications. However, because some were likely treated outside our healthcare system, the actual percentages may be higher.
Because younger patients are more likely to be asymptomatic carriers of disease, surgeons should emphasize the importance of taking proper precautions to prevent virus exposure preoperatively. Because the rates of COVID-19 infection differ based on city and time, surgeons should monitor the local prevalence of disease to properly advise patients on the risk of COVID-19 exposure. Further investigation is required to assess the prevalence in the orthopaedic population in cities with larger COVID-19 burdens.
Level III, therapeutic study.
许多 COVID-19 患者无症状。COVID-19 在骨科人群中的流行率将取决于采样的时间和地点。无症状携带者起作用的观点是普遍的，但尚未在接受择期骨科手术的大量患者中进行研究。因此，我们在一个大城市评估了这一主题，该城市所在的州是当时全美感染人数第九多的州（2020 年 6 月）。这项工作是基于一项筛查和检测方案进行的，该方案要求所有患者在术前接受 COVID-19 检测。
问题/目的：（1）在一个主要城市，计划接受骨科手术的患者中无症状 COVID-19 感染的流行率是多少，以便为其他外科医生提供评估其医疗系统 COVID-19 发生率的框架？（2）COVID-19 检测结果为阳性的患者在年龄、性别和骨科疾病方面有何不同？（3）接受治疗的并发症比例是多少，术后 30 天内有多少患者出现有症状的 COVID-19 感染（因为有些可能已被漏诊，因此我们对事件发生率的估计必然低估了这种事件的频率）？
在费城大都市区的一家机构的四个设施（两个三级保健医院、一个骨科专科医院和一个门诊手术中心），从 2020 年 4 月 27 日至 6 月 12 日期间，所有计划手术的成年患者都接受了症状、暴露、体温和血氧饱和度的标准化方案筛查；根据初始筛查问卷，1.5%（19/1295）因 COVID-19 症状、暴露或近期旅行而被排除在外，其余 98.5%（1276/1295）在术前接受 COVID-19 检测。所有通过初始筛查测试的 1276 名患者在手术前都接受了鼻咽拭子 COVID-19 逆转录聚合酶链反应检测。检测时的平均年龄为 56±16 岁，53%（672/1276）为男性。87%（1106）、8%（103）和 5%（67）分别接受了罗氏、雅培和 Cepheid 检测。所有接受择期手术的患者均接受罗氏检测，而接受非择期手术的患者则根据检测结果分别接受雅培或 Cepheid 检测。接受择期手术且检测结果为阳性的患者将重新安排手术，而接受非择期手术的患者则无论检测结果如何都将接受手术。此外，我们还通过电子病历和外科医生报告的并发症，回顾了所有患者在术后 30 天内的急诊就诊、再入院和 COVID-19 相关并发症的记录。然而，我们没有确定有多少患者发生并发症、急诊就诊或再入院的方法，因此我们对这些终点的事件发生率估计只是最乐观的估计。
7 名（0.5%）患者的 COVID-19 检测结果呈阳性：5 名患者罗氏检测阳性，2 名雅培检测阳性。检测结果阳性的患者比检测结果阴性的患者年轻（39±12 岁比 56±16 岁；p=0.01）。根据可用数据，我们发现 COVID-19 检测结果阳性的患者在亚专科领域的比例没有差异（观察到的最低和最高点估计值分别为：创伤外科[3%；68 名患者中的 2 名]与髋膝科[0.3%；401 名患者中的 1 名]，比值比为 12[95%CI 1-135]；p=0.06）。在术前 COVID-19 检测结果阴性的患者中，没有 1 人在术后 30 天内出现有症状的 COVID-19 感染。术后 30 天内，11 名（0.9%）患者到急诊就诊，16 名（1.3%）患者因非 COVID-19 相关并发症再入院。术前 COVID-19 检测结果阳性的患者均未发生并发症。然而，因为有些可能在我们的医疗系统之外得到了治疗，实际的百分比可能更高。
由于年轻患者更有可能成为无症状疾病携带者，外科医生应强调术前采取适当预防措施预防病毒暴露的重要性。由于 COVID-19 感染率因城市和时间而异，外科医生应监测当地疾病的流行率，以便就 COVID-19 暴露风险向患者提供适当建议。需要进一步调查以评估在 COVID-19 负担较大的城市中的骨科人群中的流行率。
III 级，治疗性研究。
