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Ensuring Responsible Care

Effective May 4, 2020

As the spread of the coronavirus continues to dissipate, we are returning to our core mission of providing the best musculoskeletal care in the world. We remain ever mindful of the fact that resumption of surgical care needs to be balanced by rigorous safety measures. 

Learn more about how we are maintaining our commitment to safe and responsible care as we emerge from this crisis. 

Safety protocols

Our famously rigorous infection control protocols were proactively expanded to minimize risk of exposure to the coronavirus, including:

  • Pre-screening of all patients, visitors and staff
  • Pre-testing for the coronavirus of all patients scheduled for surgery, and rescheduling of those who tested positive
  • Limitations on visitors and vendors
  • Requirement that all staff wear appropriate personal protective equipment (PPE) at all HSS locations
  • Social distancing protocols and reminders at all HSS locations 

The process of expanding surgical care began with ensuring the safety of our facilities, including extensive cleaning. That process took approximately one week for each floor and included: 

  • the application of approved disinfectants upon all high-touch surfaces followed by the repeat electrostatic disinfection spray
  • the use of portable high-efficiency particulate air (HEPA) filter scrubbers, after which all rooms were sealed and underwent third-party testing to ensure cleanliness and suitability for patient use

All common areas including nursing stations were subject to similar cleaning protocols. Additionally, the entire heating, ventilation and cooling (HVAC) system, including all ductwork and fans, underwent an extensive sanitization process along with the changing out of all air filters. 

Learn more about what to expect if you have an upcoming visit at HSS.

Emergent and urgent surgeries

Back in March, physician leadership of each sub-specialty area at HSS came together and systematically defined essential procedures. This team of experts defined four categories — Emergent, Urgent, Priority and Elective.

Categories of injuries and conditions

Emergent
Any orthopedic injury or condition resulting in the need for immediate care, that if delayed will be life or limb threatening, or result in long-term functional disability.

Urgent
Any orthopedic condition that if not treated in a timely fashion will result in sub-optimal outcome, aggravation of underlying medical condition, or chronic opioid dependence.

Priority
Any orthopedic condition that if not treated in a timely fashion will result in a sub-optimal outcome for a variety of medical or socioeconomic factors.

Elective
Any procedure that is performed to improve a patient's function but does not have a time constraint placed on its optimal outcome

 


Our plans for May include the expansion of our services to allow urgent surgeries and procedures in addition to emergent cases.  As we seek to identify those patients who are most in need of treatment, the specifics for each orthopedic service line were developed by each service chief with input from members of the service.

View listing of emergent and urgent surgeries

Listed below are emergent and urgent procedures applicable to all service lines, followed by additional procedures specific to individual service lines.

Master list

Emergent

  • Any infection, chronic or acute, requiring surgical intervention
  • Any surgical wounds requiring surgical intervention
  • Compartment syndrome
  • Dislocation of native or prosthetic joint requiring reduction in the OR
  • Malignant or benign tumors with impending fracture or neurovascular compromise
  • Fractures (periprosthetic or native bone)
  • Tendon injuries requiring surgical intervention
  • Any loose body in the joint or displaced cartilage causing a locked joint
  • Any injury to the lower extremity where the patient has an inability to bear weight or walk
  • Any vascular or neurologic injuries
  • Any injury where prompt intervention significantly improves outcomes

Urgent 

  • Intractable pain or severe functional status limitation

Adult Reconstruction and Joint Replacement

Emergent

  • PPF for ORIF/revision
  • Fracture
  • Hip/knee relocation 
  • Infection
  • Evacuation of hematoma
  • Open reduction of hip dislocation

Urgent 

  • Reimplantation
  • Revision for recurrent dislocation
  • Pending fracture in a failed implant
  • Severe untreatable pain with justifiable imaging (subchondral fractures, collapsed AVN, severe bone loss, etc)
  • COVID(-) only patients

Spine

Emergent

  • Progressive weakness on physical exam or weakness with active denervation on EMG
  • Myelopathy with cord at risk
  • Novel Infection requiring surgical debridement or decompression
  • Postoperative wound infection or dehiscence
  • Fracture or trauma with spinal instability
  • Cauda Equina Syndrome

Urgent 

  • Intractable or incapacitating pain with neurologic compression that has failed non operative care including injections
  • Neurogenic claudication with walking tolerance less than 200 feet or walking/standing tolerance less than 5 minutes
  • Rapidly progressive deformity

Sports Medicine

Emergent

  • Peri-articular and avulsion fractures

Urgent 

  • Recurrent shoulder or knee instability that affects ADLs
  • Knee and shoulder joint manipulations

Pediatrics

Emergent

  • Pin removal (post fracture or osteotomy)
  • Frame removal
  • Clubfoot tenotomy
  • Guided growth plate removal
  • Poorly compensated non-unions (e.g. those that effect the ability to perform ADL’s and/or ambulation)

Urgent 

  • Risser casting for early onset scoliosis (Outpatient Only)
  • Closed/open reduction of congenital hip dislocation 
  • Percutaneous heelcord release for club foot deformity (Outpatient Only)
  • Growth modulation for angular deformities of lower extremities along with removal of implants as needed (Outpatient Only)
  • Acute Sports Medicine procedures 

Trauma

Emergent

  • Poorly compensated nonunions (e.g. those that effect the ability to perform ADLs and/or ambulation)

Urgent 

  • Nonunions (unqualified)
  • Malunions
  • Treatment of other debilitating conditions

Limb Lengthening and Complex Reconstruction

Emergent

  • Nerve decompression in setting of compromised neurologic exam
  • Removal of external fixation
  • Bone grafting of bone transport docking sites
  • Stabilization and correction of unstable limb with deformity

Urgent 

  • Osteotomy to correct limb deformity with joint compromise
  • Nonunion or delayed union repair
  • Ankle joint arthrodesis for pain and deformity
  • Knee joint arthrodesis for pain and deformity
  • Osteotomy to correct asymmetry and inequality
  • Ankle distraction joint preservation
  • Revision amputation reconstruction
  • Removal of painful hardware

Foot and Ankle

Emergent

  • Same as Master List

Urgent 

  • Achilles insertional tendinosis with undersurface tearing
  • Impending lesser MTP dislocation
  • Rapidly progressive flatfoot deformity
  • Grossly loose or migrated ankle arthroplasty implant
  • Rapidly progressive ankle and hindfoot arthritis with articular surface collapse 
  • Avascular necrosis of the talus with collapse

Hand and Upper Extremity

Emergent

  • Lacerations with critical injury to tendons, nerves, arteries
  • Ligament tears where timely treatment is necessary
  • Brachial plexus or other significant nerve injury or problem

Urgent 

  • Nerve decompression surgery (carpal tunnel release, cubital tunnel release) with motor loss
  • Grossly loose, migrated total joint implants of elbow, wrist, hand
  • Ruptured tendons of the hand, wrist, elbow

Special Procedures:

Urgent special procedures are defined as epidural steroid injections and peripheral joint injections for cases that meet two or more of the following criteria:

  • Pain level >= 7 out of 10
  • Oral steroid course is not appropriate or ineffective
  • Oral pain medications are maximized, optimized, or not appropriate 
  • Response to the injection may influence short-term decision making for surgical procedure
 

HSS Physician leadership has developed guidelines to be considered when a patient with an urgent orthopedic condition is identified as a candidate for surgery. As with most guidelines, they are not strict rules but provide a framework for balancing the need for surgery with the risk to the individual patient.

HSS has also established a multidisciplinary Surgical Oversight Committee to review surgical cases to ensure they prioritize patient safety and outcomes.

View additional safety guidelines for identifying urgent surgical candidates

  • COVID negative by PCR and no history of a prior COVID diagnosis
  • No Chest x-ray suggestive of active or prior COVID infection
  • RA O2 saturation ≥ 94%
  • Age ≤ 70, unless healthy
  • ASA Class 1 or 2
  • BMI ≤ 35
  • Nonsmoker
  • If history of CAD, no active ischemia
  • No a-fib
  • If history of CHF, well managed at present (echo within year and EF ≥ 45%)
  • No obstructive sleep apnea or STOP BANG score ≥ 5
  • No O2 dependency, asthma with frequent use of inhalers, COPD with frequent exacerbations, significant ILD
  • If DM Hgb A1c ≤ 7.0
  • If CKD, stage 1 or 2 (GFR ≥ 60)
  • Not expected to need blood transfusion
  • Not immunosuppressed
  • Low risk for complex pain management challenges
  • Narcotic use < 6 months
  • No history of substance use disorder 
  • No history of of current or past illicit substance abuse
  • No intrathecal pump
  • No history of buprenorphine use
  • Not expected to need chronic pain consult
  • Expected LOS ≤ 48 hrs.
  • Expected discharge to home (i.e. RAPT ≥ 9)
  • Independent Functional status preop
  • Ability to participate in remote/tele PT
 

Expansion of services

Emergent and urgent surgeries are performed at the following locations:

Elective surgeries are performed at the HSS Palm Beach ASC in HSS Florida.

Outpatient services available at our locations are listed below.