Ranjith R. Kuzhupilly

Introduction Coronavirus disease 2019 (COVID-19) resulted in postponing non-emergency elective surgeries beginning in April 2020. Our hospital successfully restarted elective orthopaedic surgery during the pandemic to help improve the quality of life of patients with chronic disabilities. This study describes the development of local protocols and pathways to allow for a safe restart of elective orthopaedic surgery in a COVID-19-free ‘green’ site. It includes the morbidity and mortality outcomes of those patients who underwent non-emergency orthopaedic operations during this time. Methods This is a prospective cohort study over an eight-week period evaluating 104 patients undergoing non-emergency orthopaedic procedures through a COVID-19-free surgical pathway. The primary outcome measure was 14-day postoperative mortality. The main secondary outcome measures were the development of a COVID-19 infection in the hospital and 14 days postoperatively as well as the need for intensive care unit admissions. Results No patients developed a COVID-19 infection. There were no intensive care unit admissions or postoperative deaths during our study time frame. There was no statistical difference seen for age (< 70 or > 70), gender, body mass index, or American Society of Anesthesiologists (ASA) grades in the development of postoperative complications. Conclusions This study describes a roadmap to setting up a protocolised elective operating service for orthopaedic surgery. It has shown that standardised protocols in a COVID-19-free ‘green’ site, preoperative COVID-19 testing, and adherence to national guidelines on self-isolation can help prevent developing COVID-19 infection postoperatively and reduce the risk of postoperative mortality.

Although there is agreement that flexion and extension spaces should be symmetrical and that rotation of the femoral component impacts outcome in a knee replacement, there is dispute over what is the ‘correct’ rotation and how best to achieve it (Akagi et al., Clin Orthop Relat Res 366:155–163, 1999; Anouchi et al., Clin Orthop Relat Res 287:170–177, 1993; Barrack et al., Clin Orthop Relat Res 392:46–55, 2001; Berger et al., Clin Orthop Relat Res 356:144–153, 1998; Jenny and Boeri, Acta Orthop Scand 75(1):74–77, 2004; Poilvache et al., Clin Orthop Relat Res 331:35–46, 1996; Siston et al., J Bone Joint Surg Am 87(10):2276–2280, 2005). Insall and Scuderi recommended placing a tensor in flexion and rotating the femoral cutting block so that its posterior edge is parallel to the cut tibia (Insall, Surgery of the knee, vol 2, 2nd edn., Churchill Livingstone, New York, 1993; Scuderi and Insall, Orthop Clin N Am 20:71–78, 1989). We feel Equiflex instrumentation will reliably achieve Insall and Scuderi’s recommendation. To evaluate early results and lateral retinacular release rates using Equiflex instrumentation for TKR, we evaluated 209 consecutive knees (31 valgus, 178 varus) using this technique from 4 April 2005 until 19 September 2006. Pre and postop American Knee Society and Oxford scores, deformity, ROM, lateral retinacular release rates and complications were recorded. We could correct alignment and achieve our technical goals in 99% of cases. A lateral retinacular release was required in only five knees (2.4%). The complications are comparable to published data. The Equiflex instrumentation does help in equalising flexion-extension gaps, improves patellar tracking and reduces the incidence of lateral retinacular release.