COVID-19: An update on elective orthopaedic knee surgery
Due to the surge in COVID-19 cases, elective surgery has been restricted to Category 1 cases from 10 January 2022 until further notice.
What does this mean for patients?
Many patients in public and private hospitals will have their surgery postponed to decrease the hospital admission rate and accommodate the upcoming increase in COVID hospital admissions.
Are you still consulting on patients?
Yes, I still see patients in my rooms and perform telehealth consultations where appropriate. We ask that patients come by themselves and comply with our face mask and hand hygiene practices.
What is considered a Category 1 case?
For general orthopaedics, the following conditions are Category 1:
Septic arthritis
Infected joint replacements
Joint dislocations
Fractures
Compartment syndrome
For my elective knee practice, I would consider the following conditions as being Category 1:
Infected total knee replacement
Septic arthritis of the knee
Quadriceps or patellar tendon rupture
Locked knee due to a bucket-handle meniscal tear, loose osteochondral fragment or loose body
Elective joint replacements, ACL reconstructions, non-obstructive meniscal lesions and patella stabilisation surgery are unable to be performed at the time being.
Should I wait until the surge is over before seeing Dr Pai?
In most circumstances, you should not postpone your healthcare despite the restrictions on elective surgery as interim management plans can be instituted.
Often, various non-operative modalities can be trialled for patients to improve their symptoms significantly. Not all patients will require surgery, and usually, patients will require pre-operative optimisation before surgery.
Case 1: Younger patient with an ACL rupture
A good example is a younger patient who has sustained an ACL rupture and wants to return to pivoting sport. They often present with a significant knee effusion and a stiff, painful knee. Typically in this scenario, performing surgery before the swelling and stiffness have resolved can lead to a poor outcome as patients can develop excessive scar tissue post-operatively (arthrofibrosis).
My usual practice is encouraging simple analgesia (paracetamol, anti-inflammatories), weight-bearing, range of motion exercises, and a physiotherapist referral. It typically takes 3-4 weeks for the swelling and stiffness to settle down to a point where surgery is appropriate. In this period, the patient can work on quadriceps and hamstring strengthening exercises to make post-operative rehabilitation easier.
Case 2: Elderly patient with knee osteoarthritis
Another example is a patient with knee osteoarthritis and has not responded well to standard non-operative measures. These patients may be appropriate for knee replacement surgery. I often find that patients with osteoarthritis with a structured pre-operative rehabilitation program tend to recover quicker post-operatively. Even if surgery is deemed appropriate, I usually get my patients to participate in a GLA:D program to manage the symptoms of osteoarthritis. This is a physiotherapy led 6-week program educating patients on the management of knee osteoarthritis and improving their muscle strength to help with the symptoms of arthritis. Another aspect is optimising the patient’s nutrition and blood sugar control. If they have an HbA1c greater than 7.5%, the risk of periprosthetic infection is higher, and I would suggest postponing surgery until it can be improved.
What about injections for osteoarthritis? A corticosteroid and hyaluronic acid intra-articular injection can often improve symptoms temporarily in osteoarthritis. The more severe the osteoarthritis, the less likely it will provide long-lasting relief. Just be aware that having an intra-articular injection of corticosteroid within three months of joint replacement surgery will increase the risk of infection. If surgery is being planned within this period, avoid this.
There has been a recent randomised control trial published from Melbourne that shows that a PRP injection did not significantly improve knee pain or prevent disease progression. Read more about this study here.
I have been referred to the public system and have not been seen yet. What can I do?
Given the COVID outbreak, many public hospitals have had resource constraints concerning staffing clinics. It is common practice to divide large surgical teams into two sub-units to prevent staff furloughing if someone is in close contact or contracts COVID. At my institution, there was an on-site team and off-site time that varied from week to week. Due to such changes, clinic spaces for new patients are more limited, and waiting times have increased during the pandemic.
If you have an urgent condition and have not been contacted in an appropriate time frame, please get in touch with your GP so they can contact the relevant orthopaedic unit at the public hospital to reconsider the priority of the referral.
What are the waiting times like for surgery in a public hospital?
This is difficult to answer as it varies by hospital and surgeon. Due to recurrent lockdowns and cessation of elective surgery, the public system waiting lists have increased significantly. There will likely be initiatives that should take place once the pandemic has subsided and elective surgery resumes. This includes extra public hospital theatre lists and having funding for a long-wait time for public patients to have their surgery in a private hospital. Unfortunately, it will likely be a slow recovery till we reach pre-COVID waiting times. Ultimately, any urgent orthopaedic knee surgery will always be performed promptly without compromising patient care and outcomes.
What are my options if my patient doesn’t want to wait for surgery in public?
One option is to have self-funded surgery in a private hospital. For conditions like an arthroscopic partial meniscectomy or ACL reconstruction, this may be a financially viable option for some patients. For knee replacement surgery, the cost of the prosthetic components may be prohibitive. To find out more about self-funded surgery, read this article.
Another option for patients who need a knee replacement or any other procedure is to take out private insurance and undergo the waiting period. This is typically 12 months, and then the patient is covered for their pre-existing conditions. If this option is viable for your patients, it would likely be quicker than waiting on the public waiting list. People are often unaware that private health insurers can cover pre-existing conditions if they wait an appropriate amount of time with their health insurance policy.