Universal Testing for COVID-19 in Essential Orthopaedic Surgery Reveals a High Percentage of Asymptomatic Infections

J Bone Joint Surg Am. 2020 Aug 19;102(16):1379-1388. doi: 10.2106/JBJS.20.01053.


Background: The long incubation period and asymptomatic spread of COVID-19 present considerable challenges for health-care institutions. The identification of infected individuals is vital to prevent the spread of illness to staff and other patients as well as to identify those who may be at risk for disease-related complications. This is particularly relevant with the resumption of elective orthopaedic surgery around the world. We report the results of a universal testing protocol for COVID-19 in patients undergoing orthopaedic surgery during the coronavirus pandemic and to describe the postoperative course of asymptomatic patients who were positive for COVID-19.

Methods: A retrospective review of adult operative cases between March 25, 2020, and April 24, 2020, at an orthopaedic specialty hospital in New York City was performed. Initially, a screening questionnaire consisting of relevant signs and symptoms (e.g., fever, cough, shortness of breath) or exposure dictated the need for nasopharyngeal swab real-time quantitative polymerase chain reaction (RT-PCR) testing for all admitted patients. An institutional policy change occurred on April 5, 2020, that indicated nasopharyngeal swab RT-PCR testing for all orthopaedic admissions. Screening and testing data for COVID-19 as well as relevant imaging, laboratory values, and postoperative complications were reviewed for all patients.

Results: From April 5, 2020, to April 24, 2020, 99 patients underwent routine nasopharyngeal swab testing for COVID-19 prior to their planned orthopaedic surgical procedure. Of the 12.1% of patients who tested positive for COVID-19, 58.3% were asymptomatic. Three asymptomatic patients developed postoperative hypoxia, with 2 requiring intubation. The negative predictive value of using the signs and symptoms of disease to predict a negative test result was 91.4% (95% confidence interval [CI], 81.0% to 97.1%). Including a positive chest radiographic finding as a screening criterion did not improve the negative predictive value of screening (92.5% [95% CI, 81.8% to 97.9%]).

Conclusions: A protocol for universal testing of all orthopaedic surgery admissions at 1 hospital in New York City during a 3-week period revealed a high rate of COVID-19 infections. Importantly, the majority of these patients were asymptomatic. Using chest radiography did not significantly improve the negative predictive value of screening. These results have important implications as hospitals anticipate the resumption of elective surgical procedures.

Level of evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Asymptomatic Infections / epidemiology*
  • Betacoronavirus*
  • COVID-19
  • COVID-19 Testing
  • COVID-19 Vaccines
  • Clinical Laboratory Techniques*
  • Clinical Protocols
  • Coronavirus Infections / complications
  • Coronavirus Infections / diagnosis*
  • Coronavirus Infections / epidemiology*
  • Female
  • Hospitalization
  • Humans
  • Male
  • Middle Aged
  • New York City
  • Orthopedic Procedures*
  • Pandemics
  • Pneumonia, Viral / complications
  • Pneumonia, Viral / diagnosis*
  • Pneumonia, Viral / epidemiology*
  • Postoperative Complications / epidemiology
  • Retrospective Studies
  • SARS-CoV-2
  • Symptom Assessment