In December 2019, a novel form of a coronavirus (COVID-19) was identified in Wuhan, China, which spread rapidly among human beings across the globe1. Currently infecting over 2,310,500 people worldwide in 185 countries, the death of over 158,600 people has been attributed to COVID-192. It is so quickly transmitted via human-to-human contact that the number of affected individuals is estimated to double every 7 days, and in response, many governments have issued so-called “shelter in place” orders.3
Because many countries have directed hospitals to limit elective surgery in the face of the persisting COVID-19 pandemic, many institutions will also be forced to implement protocols to safely perform emergent surgical procedures on patients who are suspected of or confirmed to have COVID-19 in addition to other pathological processes4. We present the case of a 64-year-old man admitted with fever, new cough, and also cauda equina symptoms who was diagnosed with COVID-19 and concomitant bacteremia, bacterial meningitis, and an acute left knee periprosthetic joint infection (PJI).
The patient was informed that data concerning the case would be submitted for publication, and he provided consent.
The patient is a previously healthy 64-year-old man who presented to the emergency department (ED) on March 21, 2020, with 1 week of fever, cough, and progressive acute on chronic low back pain that was now exacerbated by 12 hours of urinary retention and suprapubic pain. He had a medical history of left lower extremity radiculopathy but now noted bilateral lower extremity weakness in addition to back pain. His surgical history was also pertinent for bilateral simultaneous total knee arthroplasties (TKAs) performed in 2014 that had been previously well functioning.
In the ED, the patient was febrile to 102.1°F and thus was indicated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing per the protocol and a lumbar spine magnetic resonance imaging (MRI) based on his symptoms. His lumbar spine MRI revealed diffuse leptomeningeal enhancement at the conus medullaris and the cauda equina concerning for infection, and a lumbar puncture was planned. He was then admitted by the Internal Medicine team to a negative pressure room in the hospital's Special Pathogen Unit (SPU) for further treatment. During his first hospital day, the patient's SARS-CoV-2 PCR testing returned positive, and blood cultures were noted to be growing Staphylococcus aureus. Intravenous vancomycin was started initially before the patient was transitioned to nafcillin once bacterial sensitivities became available to treat methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. On hospital day 2, a lumbar puncture was performed and MSSA was also identified in the spinal fluid confirming the diagnosis of bacterial meningitis.
Orthopaedic surgery was also consulted on hospital day 2 for worsening left knee pain that was reported to be coincident with his other presenting symptoms. His clinical examination revealed a well-healed incision without erythema, a large effusion, and global tenderness limiting the range of motion. Radiographs revealed well-placed arthroplasty components with a moderate effusion (Fig. 1), and serum laboratory evaluation demonstrated an ESR of 119 mm/h and C-reactive protein (CRP) of >300 mg/L. Arthrocentesis was performed and revealed a large volume of turbid fluid with a total nucleated cell count of 36,000 with 84% neutrophils. The patient was diagnosed with a late acute PJI according to the Musculoskeletal Infection Society criteria5 and was taken to the operating room (OR) for an irrigation and debridement with polyethylene component exchange using the following perioperative protocol to safeguard our healthcare team.
Figs. 1-A and 1-B Anteroposterior (AP) (Fig. 1-A) and lateral (Fig. 1-B) images of left knee demonstrating a moderate effusion and well-fixed components.
All invasive preoperative procedures, such as joint aspirations and lumbar puncture, were performed in private patient rooms of the limited access SPU. Practitioners were limited to essential personnel, and personal protective equipment (PPE) included shoe covers, disposable gown and gloves, N95 respirator masks, and long face shields. A dedicated assistant was ready outside the door to assist with additional supplies, and this limited entry and exits to the room. All sample vials were sanitized before exiting the room and placed into clean bags using no touch technique. Doffing of PPE with meticulous care and repetitive change of gloves and hand sanitization was also performed.
Surgery was conducted in a negative pressure OR, which was physically separated from the routine orthopaedic OR pod and other ORs. This required extensive preoperative planning to ensure that all required instrumentation and equipment was available to minimize traffic and avoid repeatedly opening the OR doors and exposing surrounding staff. The surrounding OR wing was blocked to limit surrounding traffic and potential exposure.
An extended preoperative huddle was performed with all involved staff before the arrival of the patient. The patient had been fit with a standard surgical mask before being transported to the OR. All surgical staff had pre-emptively donned PPE, meeting the current Centers for Disease Control and Prevention (CDC) recommendations in anticipation of the patient's arrival. Donning of PPE occurred after staff watched a proprietary training video demonstrating our OR policy and was then performed in a supervised fashion with designated staff ensuring adherence to protocol. An N95 mask, covered by a standard surgical mask to avoid gross contamination, along with surgical eyeglasses and a full face shield were worn by all OR personnel in addition to a full surgical hood with the otherwise normal gown, gloves, and boot covers. Minimal intraoperative staffing was used with 2 surgeons, 2 anesthesiologists, one OR nurse, and one surgical technician to minimize potential exposure.
Anesthesia was induced, and a mandatory 30-minute pause was observed after induction. Surgery was carried out expeditiously in the standard fashion without compromised care, but cysto tubing was used to deliver irrigation instead of the typical pulse lavage system to minimize airborne droplets in the room and contamination of PPE. Communication between intraoperative staff members and supporting staff outside of the OR was by telephone, although this may be more effectively arranged via intercom or handheld radio to avoid additive unnecessary noise to the OR environment.
Postoperatively, the patient was transported back to the SPU from the OR with the aid of a dedicated team using appropriate PPE. The surgical team then followed a supervised doffing sequence, with boot covers removed, followed by outer gloves. Hand sanitizer was then applied to the inner gloves, and the face shield was removed, followed by the surgical hood. Hand sanitizer was again applied, and the surgical gown was removed with care not to touch the outer layer. Surgical personnel then left the OR, removed their gloves, used hand sanitizer, and placed new gloves. Disposable surgical eye shields were then removed, followed by the surgical mask, and N95 mask. Hand sanitizer was used over the gloves, and the outer hair bouffant was removed. Gloves were then removed, and the hand sanitizer was used one final time.
The patient recovered uneventfully in the SPU, and the infectious disease service provided consultation throughout his hospitalization with a planned prolonged course of intravenous Penicillin G.
Our understanding of COVID-19 and its treatment strategies are evolving rapidly. At this time, supportive care remains the mainstay treatment and there is no formal role for surgical intervention6. However, the sheer volume of patients who will contract this infection at an exponential rate, along with the fact that patients remain contagious for approximately 2 weeks after becoming infected, means that hospital systems must expect and prepare to perform essential surgical procedures on COVID-19-positive patients.
The CDC has published recommendations for infection prevention strategies in healthcare settings for the care of suspected or confirmed patients with COVID-194. However, the authors are not aware of any uniform guidelines currently for the management of these patients in an OR environment or regarding perioperative care. Accomplishing safe and effective surgical care is an evolving and location-specific endeavor to minimize risks to hospital personnel. We reported on strategies here that we used and hope that others can build on them for future improvement.
In conclusion, we present a case of concurrent COVID-19 and acute TKA PJI that was treated with irrigation and debridement and polyethylene component exchange. We described our hospital protocol used with concomitant precautions in the care of this COVID-19-positive surgical patient. We present our perioperative process knowing that our collective understanding in the treatment algorithm of COVID-19 continues to evolve but hope that this serves as a platform for further discussion based on our management early in the wave of patients with COVID-19. Our described experience is not limited only to the treatment of PJI or even orthopaedics as a specialty but is likely applicable to the care of all patients with surgical pathology and COVID-19 and will likely be an unfortunate reality for many hospital systems in the near future.
1. Li JY, You Z, Wang Q, Zhou ZJ, Qiu Y, Luo R, Ge XY. The epidemic of 2019-novel-coronavirus (2019-nCoV) pneumonia and insights for emerging infectious diseases in the future. Microbes Infect. 2020;22(2):80-5.
2. Johns Hopkins University. Coronavirus Resource Center. Available at: https://coronavirus.jhu.edu
. Accessed April 18, 2020.
3. Chan JF, Yuan S, Kok KH, To KK, Chu H, Yang J, Xing F, Liu J, Yip CC, Poon RW, Tsoi HW, Lo SK, Chan KH, Poon VK, Chan WM, Ip JD, Cai JP, Cheng VC, Chen H, Hui CK, Yuen KY. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;395(10223):514-23.
4. Centers for Disease Control and Protection. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Available at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommenda-tions.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html
. Accessed March 26, 2020.
5. Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11):2992-4.
6. Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, Tan KS, Wang DY, Yan Y. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak—an update on the status. Mil Med Res. 2020;7(11):1-10.