Trends in Orthopedics: COVID-19 Impact on Q2

As of this writing, any news has been displaced by speculation on COVID-19—its progression, its lethality, the impact of mitigation measures as well as comorbid conditions. Paralleling the public health speculation is the discussion on businesses—small businesses, unemployment, tourism and travel, as well as hospitals and healthcare organizations.

Most of the impact on healthcare organizations has been the financial reporting from publicly traded companies or surveys of hospitals and surgeons on their willingness or ability to increase procedure volumes. Publicly traded companies have reported 2nd quarter (April-June 2020) declines of between 30% and 37% for the spinal implant sales at NuVasive, SpineGuard, DePuy Synthes Spine, Medicrea and Implanet. Reconstructive surgery sales were reported to have similar declines during the same period.

While none of us can predict the future, what we can report on is selective statistics on hospital purchases of critical components. While the data that we often receive is less than reliable for this type of speculation, we have focused on two integrated delivery networks (IDNs) whose data has been consistently accurate for this type of reporting. One IDN (IDN 1) comprises 86 hospitals and included over 80,000 reconstructive surgery and spinal fusion procedures between January 2019 and June 2020, and the second IDN included over 14,000 cases in this time period and included 6 hospitals. While IDN 1 included more cases, it did not include trauma procedures. IDN 2 included trauma procedures but had limited spine procedures from 2020.

The data systems that we use to collect this information is highly integrated with the purchasing systems. Therefore, the notorious weaknesses in purchasing systems are reflected in these statistics. These weaknesses include the disparity between the number of procedures and the volume of purchases, the inability of purchasing systems to identify specific procedures, and the tendency to “add-on” purchases after procedures have been completed.

Having said that, the purchasing systems often can be used as an index into the number of surgeries—the number of femoral stems can often be used as a proxy for the number of hip replacement surgeries, the number of femoral components for knee implants can be used to estimate the number of knee procedures, since neither are likely to be purchased for something other than the procedure they were designed for.

The “index” components examined here are coated femoral stems as a proxy for hip procedures, knee femurs as a proxy for knee procedures, shoulder humeral heads or glenospheres for total or reverse shoulder procedures, lumbar pedicle screws for lumbar fusions, cervical plates for cervical fusions, cephalomedullary nails for estimates of hip fracture repairs, wrist plates for wrist fracture repairs, fixation plates and screws for fractures of other bones, and soft tissue attachments as a proxy for sports medicine procedures.

The common wisdom has been that COVID-19 has impacted elective surgical procedures—namely reconstructive joint replacements (hips, knees, and shoulders), spinal fusions, and sports medicine procedures. Although trauma procedures have also declined somewhat because of reduced driving and sports activities, they would not be affected as much as the elective procedures.

To calculate the number of procedures, the average number of key components was calculated between January 2019 and June 2020, and an index representing the multiple of this average was calculated for each of the IDNs for each month between January 2019 and 2020, and then graphed.

The first three graphs display the index by month between January 2019 and June 2020 for reconstructive procedures for IDN 1 and IDN 2. As can be seen, an almost identical pattern shows the extremely low dip in procedures in April 2020 when elective surgical procedures were largely abandoned in the United States followed by increases in both May and June. Note also that IDN 2 shows extreme seasonality in these procedures in the summer months of 2019, typically correspond to summer vacations when fewer procedures are performed.

The trend in lumbar pedicle screws and spinal plates at IDN 1 show a similar dip in April 2020, although it was not as deep as it was for joint replacements. IDN 2 did not report spine procedures for April 2020 through June 2020, so it is not possible to report their changes.

The fracture fixation trends are displayed at right for IDN 2. Although there are differences between the months and a decrease in April 2020 compared to other months, they are not as pronounced and dramatic as those displayed for joint replacements. Finally, the sports medicine trends display a similar to that of reconstructive surgeries with dramatic declines in April followed by an increase in May and June.

While the impact of the resurgence of COVID-19 in July 2020 in the US is not reflected here, nor are any predictions possible on the future of the virus, the underlying data from these sources support the narrative that elective procedures showed dramatic drops earlier in 2020 while the number of trauma procedures, although impacted, was less dramatic.

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