COVID-19 FAQs for surgeons

This depends on the indications for X-ray. If a fracture fixation is being performed, then it is best practice for the radiographer to be in theatre throughout the procedure. However, if a check X-ray is required at the end of the operation such as after a total hip or knee replacement, then the radiographer can enter theatre wearing appropriate PPE once the designated period (usually 20 minutes for an AGP) at the conclusion of the operation has passed. Although this is time consuming, performing a check X-ray in this way avoids the patient having to be transported out of a ‘Green Zone’ to the imaging department and potentially being exposed to infection.

PPE use should follow the guidance from the public health bodies across the UK. High speed power tools used in T&O surgery can produce aerosolisation (e.g. of blood, bone marrow or soft tissue fluid) and the national guidance is that all scrub staff should use FFP3 masks in this situation. This applies to all patients who are ‘possible or confirmed’ COVID-19 and at present all patients are treated in this category. (For reference see guidance here).

The BOA advises that a ‘Recovery Planning Team’ should be set up in each hospital to oversee the re-start of scheduled surgery as there are so many interdependent issues that will need to be addressed. The understandable desire to start Category 4 arthroplasty work should not interfere with the need to ensure trauma services are maintained and more urgent Category 2 and 3 cases are given priority. The BOA guidance document provides detailed advice on the steps required before considering progressing to the provision of a routine joint replacement service, see here.

The BOA is deeply concerned by the evidence that staff from BAME backgrounds are at increased risk from COVID-19. We are aware that NHSE and PHE are monitoring and analysing the data and have developed appropriate advice. As new evidence emerges their advice will be updated further.  

All Trusts should already have updated risk assessments prepared and a policy in place so that staff who have concerns about their own safety can discuss them with their manager, and if necessary can also get individual advice from their local Occupational Health department. Managers should also have support from their HR and Occupational Health departments to enable them to provide relevant information and up to date advice.

Further information on this issue can be obtained using the following links:

• NHS England page on ‘Addressing impact of COVID-19 on BAME staff in the NHS’.
• NHS Employers page on ‘Risk assessments for staff’.

We are aware that there is a significant number of surgeons who fall into the shielding category because of a pre-existing medical condition. They are able to support the department by home working such as doing video follow-up consultations or running the virtual fracture clinic. At present there is no advice on when or how they may return to the workplace. They will need to follow national guidance that applies to this group as it changes during the course of the pandemic and any return to work will need to be in consultation with the Trust Occupational Health department.

The preparation of patients who will undergo surgery in the Green zone should reduce the chances of them carrying the coronavirus but it cannot ensure they are not developing COVID-19. The patient or other members of the household may not have fully complied with isolation or shielding and there is a known false negative rate for antigen screening using present PCR techniques. As a consequence, we advise that the requirement should remain that for the type of surgery being performed for a ‘suspected case’ and if that includes an AGP, then full PPE with an FFP3 mask must be used.

Ideally, we would like to see regular testing of all staff but despite the increased availability of testing, the resources to do this are still not in place in the majority of hospitals. The procedural details required for staff to enter and work in a Green zone will need to be agreed within the Trust as they will depend on many factors such as the physical separation of Green and Blue (COVID-19 managed) pathways and the availability of staff. At a minimum, all staff should be screened with a questionnaire and have temperature checks before entering a Green zone and should work there for a whole day. No staff should transfer from a Blue to a Green zone during the same day. If possible, staff should be dedicated to either the Green or Blue zones for several days to avoid the transmission of coronavirus into the Green zone. Whatever arrangements can be put in place, it is vital that the highest standards of infection prevention and control are maintained.

More information can be found at:

• BOA guidance here.
• NHS England Operating Principles here. 

Many units have had a system of clinics set aside for obtaining signed consent. During the pandemic, the fundamental principle is to keep the number of attendances to a minimum. Informed consent has never been more important and considerable time must be set aside to discuss surgery, the risks and benefits, alternative options and the outcome of not intervening or delaying treatment. This information could be given at a telephone or video consultation supported by written documentation. For patients who will then be managed in a Green zone, written consent can be combined with pre-operative assessment at the hospital at least 14 days before planned surgery so they can fully isolate for that period prior to surgery.

A locked knee due to a meniscal tear is given a priority level 2 meaning it should be operated on within four weeks. It is most likely that this can be achieved using an ambulatory trauma pathway with testing 72 to 48 hours before surgery, screening on admission, performing surgery using a ‘Blue’ COVID-19 managed pathway and guided remote rehabilitation. It may be best to perform surgery using a short acting spinal anaesthetic rather than a GA. Informed consent will have to include the altered pathway of management and a realistic appraisal of the risks of COVID-19 infection.