Shoulder Arthroplasty in the Age of COVID-19

Total shoulder arthroplasty, both anatomic and reverse, can be successful in helping people who suffer from shoulder arthritis reduce, or eliminate, their pain and regain a better quality of life. Traditionally, shoulder replacement has been performed as an inpatient surgery, with one to two nights in the hospital. However, a shift towards outpatient surgery has recently occurred with the right candidates.  

The emergence of COVID-19 has resulted in tremendous demand being placed on health care delivery systems and health care providers throughout the world especially where the virus is ‘surging’.  This has resulted in ‘non-emergency’ orthopedic surgery being halted to preserve operating room and hospital resources.  

Because the shoulder is not a “weight-bearing” joint, some patients end up delaying their shoulder replacement surgery until their symptoms are severe enough to undergo a sizable operation. Therefore, the patient and surgeon should use a shared decision-making model to decide on the optimal timing for their shoulder replacement surgery. In my practice, I advise patients with severe shoulder arthritis to have shoulder replacement surgery when their quality of life has declined due to their symptoms, and non-surgical, conservative measures such as activity modification, medications, and injections fail to provide relief.  

The American College of Surgeons has described a three-tiered system to facilitate decision making during the pandemic.¹  

Low acuity outpatient surgery (where there is no risk to the patient of delaying treatment) is described as Tier 1 and can be safely postponed, or performed at an Ambulatory Surgery Center (ASC).

Tier 2 surgery is intermediate acuity which is not life threatening but has potential for future morbidity to the patient and requires a hospital stay. During COVID-19, these surgeries have been shifted to the ASC (outpatient surgery setting) or performed safely when the COVID-19 cases in a particular area are amenable. 

Tier 3 surgery is urgent and poses an immediate risk to the patient’s well-being if not performed. These surgeries are not typically delayed.  

Shoulder replacement surgery is typically categorized as a tier 2 surgery meaning some delay is acceptable.  However, the progression of disease, increasing symptoms, and worsening shoulder deformity can result in a relative urgency for the surgery to be performed.  There are certain types of shoulder pathology where delaying surgery can actually compromise the results of a future surgery for the patient. 

The European Hip and Knee Societies have published a comprehensive guide to safely resuming joint replacement during the COVID-19 pandemic.² 

To summarize their work, they recommend the following for safe resumption of joint replacement:     

1.   Lockdown should be lifted

2.  COVID-19 cases should be in decline in the corresponding region

3.  The hospital or surgical facility must have the capacity to completely separate non-COVID-19 patients from COVID-19 positive patients

4. The hospital should have adequate personal protective equipment (PPE) and COVID-19 testing capacity to facilitate elective surgery

5. Facility is able to maintain social distancing throughout the process of surgery

At our facility, we have developed a comprehensive reopening plan that’s been in effect since early May 2020. This has enabled us to allow some elective orthopedic surgeries to successfully resume. In fact, many of our patients have stated that the diminished opportunity for work, travel, and leisure activity during the pandemic has actually given them an opportunity to focus on the shoulder replacement surgery during this unique time. Talk to your surgeon to see what their safety plan is for operating during COVID-19.

Just by way of an example, a protocol for reopening elective shoulder replacement safely may include some of the steps below. Your doctor may do things differently. This is simply to give you an idea of what it might include and to help you ask questions around your own safety relative to the pandemic.

General COVID safety

1.  Orthopedic surgery is performed in a stand-alone inpatient/outpatient surgical center geographically distant from COVID-19 care.

2.  Staff is vaccinated and continues to be tested for COVID-19 regularly with a robust testing plan; no staff that interacts with COVID-19 patients will also work in elective orthopedic surgery.

3.  Enhanced screening of all staff and patients for COVID-19 symptoms and fever is conducted upon entry to the facility.

4.  Enhanced sterilization protocols are in place for all patient areas after each procedure in the operating room and after each patient visit in the clinic.

Preoperative (before surgery) COVID safety

1.   Minimal visitors are permitted with patients for preoperative appointments, which also may be conducted virtually if possible.

2.  If a patient vaccination for COVID-19 is imminent, wait 14 days after the final vaccine dose prior to elective orthopedic surgery.

3.  All patients who have surgery at a facility are tested with COVID-19 PCR test 48 hours prior to surgery.  A positive test results in a delay of surgery for at least 21 days post symptom resolution.

Intraoperative (during surgery) COVID safety

1.   Patients are not accompanied by a caregiver to surgery. Enable heightened communication methods with family for frequent updates during surgery since they aren’t able to be present.

2.   Strict masking and social distancing protocols are adhered to throughout the procedure and all phases of care while in the facility.

Postoperative (after surgery) COVID safety

1.   Enhanced recovery protocols are in place to either conduct the shoulder replacement surgery as an outpatient surgery, or shorten any hospital stay to overnight only. Note that all patients aren’t appropriate for outpatient surgery.

2.   Avoid transferring patients to nursing facilities during this time unless absolutely necessary.

3.   Increased use of telemedicine helps patients minimize return trips to the health care facility.

4.   Similarly, rehabilitation protocols have been redesigned so that self-directed physical therapy or telemedicine physical therapy can be utilized.

Again, these are mentioned simply to give you an idea of precautions that can be made for your COVID-related safety. Talk to your doctor about what they do before, during, and after surgery to address COVID safety, as well as the risks of shoulder surgery.

Total shoulder replacement surgery (both reverse and anatomic) can be an essential treatment for a patient with a severe shoulder condition that can provide lasting relief of pain and restoration of function. After a hard shutdown of elective surgery in Mid-March 2020, careful planning, testing, and vigilance is enabling surgery centers and hospitals to provide care while emphasizing patient safety.