An Imminent Return to Elective Orthopaedic Surgeries

Professor David Barrett, NHS Southampton consultant orthopaedic surgeon, and Torbjorn Skold, Vice President of EMEA DePuy Synthes Joint Reconstruction, discuss how elective orthopaedic surgeries have been affected by the Covid-19 pandemic and the most efficient solutions to navigating their successful restart.

Over the last year, many hospitals were forced to postpone elective surgeries to make room for critical care related to the Covid-19 pandemic. As of February, 4.7 million people were still awaiting their routine surgical procedures in England alone. Of these patients, NHS England reported that 388,000 had been waiting for more than one year to have their non-urgent surgical procedures performed – a figure that had totalled only 1,600 prior to the start of the pandemic. 

This situation has put many orthopaedic patients in the same boat. For example, 100,000 people in the UK had their joint replacement procedures cancelled during the first wave of the pandemic, leaving them with untreated mobility and pain challenges. 

Of those waiting for a Total Knee Arthroplasty (TKA) or a Total Hip Arthroplasty (THA), over one-third of them described their state of being as “worse than death” in a UK nation-wide survey. Furthermore, the study correlated each additional month on a surgical waiting list with a decreasing quality of life. If we extend this disturbing phenomenon across the whole of Europe, it becomes easy to see that health care systems and surgeons everywhere now face a growing caseload of both urgent and elective arthroplasty and arthroscopy procedures.  

Critical orthopaedic procedures have been ignored for far too long 

Osteoarthritis (OA), a degenerative joint condition that affects approximately 250 million people worldwide, is one of the most frequent diseases leading to the need for joint replacement. Sadly, we also know that this condition often afflicts older individuals, who are also deemed by the Centres for Disease Control and Prevention (CDC) to be at the highest risk for hospitalization from Covid-19. Individuals over the age of 65 have a 35 times higher risk of hospitalization and an 1100 times higher risk of death from complications related to the virus,4 so it’s easy to understand why many put off their elective procedures due to fear of contracting the illness. 

Compounding the issue, OA is on the rise due to demographic changes like an aging population. According to a paper using a comprehensive set of nationwide data from Germany, researchers projected a growth of approximately 143 per cent in the incidence rate of Total Knee Replacement (TKR) procedures between 2020 and 2050.  

While many countries in Europe continue to face lockdowns and restrictions, many elective wards remain occupied by Covid-19 patients. Nurses find themselves pulled into other wards or diverted to vaccination hubs while hospitals face lower staffing levels than ever before. At the end of the spectrum, many operating rooms have closed completely. 

Medical professionals face huge challenges in addressing the mounting quantity of cases  

The Covid-19 vaccine, which has typically been made available to older people first, is slowly making it possible for orthopaedic patients to venture out of their cocoons of safety and into the operating room (OR) and outpatient clinics. Now that people are becoming increasingly eager to return to their pre-covid-19 lifestyles and activities, the time for a full return to elective surgeries will soon be upon us.  

Value-Based Healthcare means everything these days 

There’s no quick fix and it could take years to train more hospital staff to help with the burden. As soon as hospitals are well-positioned to start resuming elective procedures, our goal is to allow them to achieve and maintain a high throughput of patients and return to performing orthopaedic procedures more efficiently and effectively.  

Since it’s unrealistic to think that hospitals can double the number of surgeons in order to catch up, we offer solutions intended to help educate and equip surgeons to deal more effectively with the backlog. Our focus on delivering value-based healthcare products and services will help us increase patient turnover once the restrictions start to disappear.  

Focus on helping to increase patient throughput 

Once the clinics can start operating again, one major goal will be to reduce the waiting lists. This need can be addressed by simplifying the time requirements related to diagnostics, scheduling, procedural efficiency, and follow-up care. In fact, patient throughput is a function of three factors: length of stay, OR time and reduction in complications.  

Shorten length of stay 

Reducing the length of stay is usually a concern of the patient more than the practitioner, but with the onset of Covid-19, things certainly changed. With fewer nurses available, reducing a patient’s length of stay helps alleviate overall pressure on the system. Our ATTUNETM Knee System has been associated with length of stay reductions. In one study, generalized estimating equation models led to the conclusion that the adjusted mean length of stay of patients who received our ATTUNE gradually reducing radius knee were “significantly shorter” than those who received a single radius knee.  

Reduce Operating Room time 

One of the biggest constraints that hospitals face is in the OR. Cementless solutions have been shown to save about 11.6 minutes per surgery compared to cemented solutions. Knee replacement surgery duration varies by surgeon but the mean operative time for cemented TKA equates to about 93.7 minutes. Therefore, an 11-minute boost per procedure could potentially allow time for the surgeon to see an extra patient per day – perhaps with a smaller treatment, like an arthroscopy.  Especially during the pandemic, this outcome can be viewed as a win-win for surgeons, patients and health systems.  

Reduce rate of complications 

High quality implants can result in fewer complications, and the occurrence of fewer complications can translate directly into shorter hospital stays and bypassing rehabilitation centres. When patients proceed faster through the mobilization scheme, they reach their discharge criteria earlier. Right after surgery, it’s all about mobilizing the patient. We often say that ATTUNE is a knee that can help your patients “get back sooner”, a motto supported by study results showing that 85 per centof ATTUNE Knee patients were able to be discharged in 3 days or less.

Moving forward – together  

The pandemic may have stalled a sizable number of surgeries, but our solutions and spirit have continued to evolve in new and exciting ways to help health care systems navigate a successful journey toward a post-Covid-19 surgical world. Helping surgeons build a strong provider-to-patient connection may enable a more positive patient experience, and we therefore see it as our mission to help them do this both in person and over a digital medium.