Unexpected positive cultures in revision total knee arthroplasty after unicompartmental knee arthroplasty.

PURPOSE: Unexpected positive cultures are defined as a single positive culture in intraoperative samples taken during revision surgery after prosthetic joint infection was preoperatively ruled out. This study aims to determine the prevalence of unexpected positive cultures (UPC) in revision total knee arthroplasty (TKA) after unicompartmental knee arthroplasty (UKA). As a secondary objective, this study aims to compare the re-intervention rate in this specific group, between UPC and non-UPC patients. The hypothesis is that the UPC prevalence in patients who undergo a revision TKA after UKA is not higher than in other TKA revision cases and this does not increase the risk of re-intervention. METHODS: This is a retrospective study where all patients who underwent a UKA revision from January 2016 to February 2023 in a high-volume arthroplasty centre, were analyzed. Unexpected positive culture prevalence in this group of patients was obtained. RESULTS: During the included period, 270 UKA revision surgeries were performed. Eight cases had at least two positive cultures and were therefore excluded. The final analysis included 262 patients. Of these, 8 (3.05%) patients presented UPCs and the isolated microorganisms were low-virulence organisms. None of the UPC patients received any treatment. No statistical differences were found between UPC and non-UPC groups in the analyzed variables. CONCLUSION: The prevalence of unexpected positive cultures in patients following revision of unicompartmental knee arthroplasty is lower than in patients who undergo a revision of total knee arthroplasty. In UKA patients a UPC does not seem to increase the risk of a re-intervention, so it can be safely ignored if ICM criteria are not met.

Cemented vs cementless stems for revision arthroplasties due to Vancouver B2 periprosthetic hip fracture.

PURPOSE: According to Vancouver classification, B2 type fractures are most often treated with removal of the loose stem and implantation of a long stem that bypasses the fracture site. However, there is a controversy about the stem fixation that should be used: cemented or cementless. Hence, this study aims to compare cemented and cementless stems in prosthetic revision due to Vancouver B2 (VB2) periprosthetic hip fracture. METHODS: A retrospective study was done including all the patients treated with stem exchange due to VB2 periprosthetic hip fracture in a tertiary hospital between 2015 and 2022. Patients were divided into two groups according to the stem fixation used: cemented or cementless. Functional outcomes, hospital stay, surgical time, complication rate, and mortality were compared between the two groups of patients. RESULTS: Of the 30 included patients, 13 (43.4%) were treated with cementless stems and 17 (56.7%) with cemented stems. There were no statistically significant differences in age, gender, anesthesia risk scale (ASA) or functional capacity prior to the intervention. Patients treated with cementless stems had a higher complication and reintervention rate than those treated with cemented stems: 62 and 45% versus 34 and 6% (p = 0.035; p = 0.010), respectively. Furthermore, in the group of cementless stems a higher proportion of non-union was found (53.8% vs. 17.6%; p = 0.037). Also, the hospital stay (33 vs. 24 days; p = 0.037) and the time to full weight-bearing (21 days vs. 9 days; p < 0.001) were longer in the cementless stem group. CONCLUSION: Cemented fixation in stem revision due to Vancouver B2 periprosthetic hip fracture could be an optimal option with faster recovery which could decrease the rate of complications and reintervention, without compromising the fracture healing and patient mortality. Thus, this option can be considered when an anatomical reduction can be obtained, especially in elderly patients with multiple comorbidities in which a less aggressive surgical option should be considered.

Fused hip conversion to total hip arthroplasty with the direct anterior approach: surgical technique on a regular surgical table under fluoroscopic guidance.

PURPOSE: Conversion of a fused hip to a total hip arthroplasty (THA) is technically challenging due to the loss of anatomical references. Here, a reproducible technique using the direct anterior approach (DAA) with a regular surgical table under fluoroscopic guidance is described, which has several advantages over traditional such as lateral or posterior approaches. METHODS: There were reported 11 cases of ankylosis hip that were converted to THA using the same surgical technique protocol. Clinical and radiographic outcomes were recorded at 3.2 years of follow-up. A detailed preoperative evaluation was performed, including a pelvis radiological evaluation and magnetic resonance image (MRI) to assess the integrity of the periarticular soft tissue and flexor muscles. RESULTS: The DAA has considerable advantages, such as allowing more precise targeting during surgery, avoiding the risk of pseudoarthrosis due to the absence of a trochanteric osteotomy, preserving the abductors, and allowing an easier-to-use of intraoperative fluoroscopy due to the supine position. Besides, the use of a standard table reduces surgical time and allows assessment of limb length, hip stability, and impingement in all planes in an intraoperative dynamic range, which decreases postoperative complications. CONCLUSION: Conversion from hip fusion to THA is a rare and complex procedure. The use of DAA with a standard table and fluoroscopy helps to avoid high complications since it allows a dynamic intra-operative examination of the range of motion to rule out impingements, reduces the risk of dislocation, and allows leg lengthening verification.

Vancouver B2 periprosthetic hip fractures treatment: fix or replace? A retrospective study comparing both techniques.

INTRODUCTION: Vancouver B2 periprosthetic hip fractures involve stem stability and they have been classically treated with revision surgery. Crucial factors such as age, clinical comorbidities and functional status are often neglected. The current study aims to compare clinical outcomes between patients treated with open reduction and internal fixation (ORIF) or femoral stem exchange. METHODS: This is a retrospective study that includes all Vancouver B2 periprosthetic hip fractures in a tertiary referral hospital from 2016 to 2020. Patients were divided into two groups: Group 1. Patients treated with an ORIF and Group 2. Patients treated with stem replacement. The outcomes that were compared between groups included demographic data, functional capacity, complications and mortality. RESULTS: 29 periprosthetic Vancouver B2 fractures were finally analyzed. 11 (37.9%) were treated with ORIF (Group 1) and 18 (62.1%) by stem replacement (Group 2). Surgery time (143 vs. 160 min), hemoglobin drop (1.8 vs. 2.5 g/dL) and hospital stance (25.5 vs. 29.6 days) were shorter in Group 1. According to complications, 18.2% of patients in the ORIF group had orthopedic complications compared with 44.4% in the revision group. In the revision group, 3 cases needed a two-stage revision and one of these revisions ended up with a resection arthroplasty (Girdlestone). The first-year mortality rate was 27% in Group 1 and 11% in Group 2. DISCUSSION: ORIF treatment seems to be a less aggressive and complex procedure which can lead to a faster general recovery. Revision surgery can imply a higher risk of orthopedic complications which can be severe and may require further aggressive solutions. The ORIF group mortality was similar to the proximal femur fracture rate (20-30%). In conclusion, ORIF treatment seems to be a good option especially in fragile patients with low functional demand when anatomical reduction is possible.

Unexpected positive cultures in patients with arthrofibrosis following total hip and total knee arthroplasty.

PURPOSE: It has been suggested that low-grade infections could be the cause of arthrofibrosis. However, this hypothesis has not been conclusively proven. The aim of this study is to assess the incidence of unexpected positive cultures (UPC) in patients undergoing revision total joint arthroplasty for a diagnosis of arthrofibrosis. METHODS: A retrospective single-centre review was performed. All patients who underwent an aseptic revision due to histologically confirmed arthrofibrosis (based on the synovial-like interface membrane (SLIM) criteria) were included. The incidence of UPC was then calculated. RESULTS: A total of 147 patients were included. Of these, 100 underwent a total knee arthroplasty (TKA) procedure and 46 a total hip arthroplasty (THA) surgery. One patient had a periprosthetic joint infection and was therefore excluded. Of the 146 included patients, 6 had confirmed UPC (4.08%). The following bacteria were identified: Anaerococcus octavius, Staphylococcus epidermidis, Enterobacter cloacae, Staphylococcus hominis, Streptococcus pluranimalium, Staphylococcus pettenkoferi. CONCLUSIONS: Our results suggest that the incidence of UPC in patients with arthrofibrosis is low. It is lower than that of UPC in patients that undergo a revision for other causes. There is no proven relationship between histologically confirmed arthrofibrosis following total joint arthroplasty and prosthetic joint infection.

Staged treatment of bicondylar tibial plateau fractures: influence of frame configuration and quality of reduction on outcomes.

PURPOSE: Despite evolving treatment, the surgical management of high-energy tibial plateau fractures (TPF) remains challenging, associating high rates of complications. In recent decades, staged management has emerged as an encouraging option. The main goal of our study was to evaluate the influence of bridging external fixation (EF) frame configuration and the resultant quality of reduction (QOR) on outcomes after staged-treatment of bicondylar TPF. METHODS: A retrospective review was conducted of patients with bicondylar TPF treated at our level-I trauma center using a staged-treatment protocol from January 2010 to January 2020. Data on baseline characteristics, injuries, treatments, and clinical/radiological results were collected. The QOR was evaluated on CT images after EF and on plain films after ORIF. RESULTS: Sixty-eight patients were eligible for analysis. By our criteria, QOR was good in 57.4% and 70.6% after EF and ORIF, respectively. A squared EF configuration was associated with superior EF QOR (p = 0.032), while better EF QOR was linked to improved ORIF QOR (p = 0.016). No relationship between ORIF delay and ORIF QOR was identified. Postoperative complications were documented in 19 patients. Average ROM at one-year follow-up was 114.9 ± 12.6°, and non-influenced by anterior femoral pin placement. CONCLUSIONS: Staged management of bicondylar TPF resulted in a reasonable rate of complications. A direct relationship between QORs obtained with EF and after ORIF was found. Squared frames were associated with faster and better reductions, regardless of the surgeon's background. Considering our results, we advocate for the wider use of squared EF configurations in these patients.

Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. / Riesgo de tromboembolismo venoso en la tromboprofilaxis entre aspirina y heparinas de bajo peso molecular tras una artroplastia total de cadera o artroplastia total de rodilla. Revisión sistemática y metaanálisis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Antimicrobials in polymethylmethacrylate: from prevention to prosthetic joint infection treatment: basic principles and risk of resistance.

BACKGROUND: Excellent revisions about antibiotic-loaded bone cement (ALBC) have been recently published. In the present article, we review the principles and limitations of local antibiotic delivery in the context of recent advances in the pathogenesis of prosthetic joint infections (PJI), with particular attention paid to the potential association between ALBC and antimicrobial resistance. MAIN BODY: Recalcitrance of PJI is related to the ability of pathogens to adapt to particular environments present in bone tissue and protect themselves from host immunity in different ways. Accordingly, delivery of high local antimicrobial concentrations using ALBC is needed. Most relevant clinical data showing the efficacy of ALBC for PJI prophylaxis and treatment are reviewed, and we dissected the limitations on the basis of the recent findings from animal models and suggested that aminoglycosides, in particular, could not be the best option. One of the major concerns associated with ALBC is the emergence of resistance because of theoretical prolonged exposure to low antibiotic concentrations. We summarize the mechanisms for the selection of resistant microorganisms, and we critically reviewed the evidence from animal models and clinical data from observational and registry studies and concluded that there is no evidence to support this association. CONCLUSION: While waiting for better evidence from well-designed clinical trials, ALBC shows a beneficial effect as a prophylaxis in arthroplasty, and to avoid the colonization of spacers used for two-stage revision in patients with PJI. Experimental models and clinical evidence suggest the need to achieve high local antimicrobial concentrations to obtain the highest prophylactic and therapeutic effect. The current evidence does not support the risk of increasing resistance with use of ALBC. In the future, it is necessary to evaluate new carriers and different antimicrobials to improve clinical outcomes.

Clinical practice guidelines: The good, the bad, and the ugly.

Clinical practices guidelines (CPGs) play a fundamental role in improving healthcare and patients' outcomes by helping clinicians make the best evidence-based decisions for their patients in a time-efficient manner. By following the available methods and criteria to create trustworthy CPGs, panel members can develop high-quality guidelines. However, despite the improvements over the years, CPGs are still subjected to biases and limitations, with conflicts of interest being the ugliest problem GCPs must face. In this review, we discuss the main characteristics of clinical practice guidelines, their pros and cons, and the future challenges they need to overcome.

Salvage hip replacement after cut-out failure of cephalomedullary nail fixation for proximal femur fractures: a case series describing the technique and results.

BACKGROUND: Cut-out failure following proximal femoral fracture fixation is a compromising complication warranting surgical treatment. We describe 24 patients with cut-out failure after cephalomedullary nail fixation managed with salvage hip replacement. METHODS: Twenty-four consecutive patients who had sustained a proximal femoral fracture from December 2009 to December 2019, were managed with cephalomedullary nail fixation and experienced a cut-out failure were reviewed retrospectively. Data on demographics, comorbidities, injury characteristics, treatment, and post-operative course were analysed. RESULTS: Among 2802 proximal femoral fractures assessed, 28 fixations failed due to cut-out, with 24/28 patients subsequently undergoing salvage hip replacement. Intertrochanteric fractures (66.7%) managed with short nails predominated (79.2%). The median tip-to-apex distance (TAD) was 19 mm, but only two fractures had a good quality of reduction. Inverse correlations were identified between patient age and the time from fixation to cut-out (r = - 0.57; p = 0.02), and between the time of nailing to failure among patients with a greater TAD (r = - 0.43; p = 0.04). Most patients were managed via cemented hemiarthroplasty (66.7%). Surgical time was longer for total hip replacements (175.4 vs. 136.8 min; p < 0.01), but no bleeding or blood transfusion requirement differences were found. Two patients had orthopaedic complications, and three patients died within the first follow-up year. CONCLUSION: In our series, 1% of the proximal femoral fractures managed with a cephalomedullary nail failed due to cut-out. Salvage hip replacement appeared to be a relatively safe and reliable procedure for managing this challenging complication in patients who typically are elderly and physically frail.

Direct anterior approach provides better functional outcomes when compared to direct lateral approach in hip hemiarthroplasty following femoral neck fracture.

PURPOSE: This study aims to compare the differences between direct anterior approach (DAA) and direct lateral approach (DLA) in hip hemiarthroplasty (HHA) after displaced femoral neck fracture (FNF) in early functional outcome, hospital length of stay, morbidity and mortality rates. METHODS: This non-interventional retrospective study, carried out at a tertiary trauma centre within the Spanish National Health System, included all patients who underwent a bipolar HHA between 1st January 2018 and 31st December 2019 performed by 2 of our hip unit surgeons. RESULTS: A total of 94 patients were included (40 in DAA group and 54 in DLA group). Median follow-up was 19.2 months (range 8-30.8 months). Postoperative degree of mobilisation showed statistically significant differences in favour of DAA group, where 35% of patients were able to walk with no assistance after surgery. DAA group had 1 day less of hospitalisation in contrast with DLA group overall (8 days vs 9 days, respectively, p < 0.05). Statistically significant differences were not detected in comparing postoperative complications, re-operations rates or 6-months mortality rate. CONCLUSION: Our study highlights the benefits of DAA for HHA after displaced FNF in terms of postoperative mobilisation degree and hospitalisation length of stay when compared to DLA.

How COVID-19 has affected emergent visits to a Latin-American trauma department: Experience at a Peruvian national trauma referral center.

INTRODUCTION: By May 2020, Peru was the country with the third most COVID-19 cases in the Americas. The current study's overall aim was to examine the impact of the current COVID-19 outbreak on the number of non-COVID-related patient presentations to a major national emergency traumatology/orthopedics referral center in Latin America. METHODS: An observational study was performed at one of Peru's main tertiary trauma referral centers, during the current COVID-19 pandemic. Numbers of non-follow-up patients presenting to the traumatology/ orthopedics service were counted and compared between January through April 2019 and January through April 2020; and between the month immediately prior to the Peruvian government's implementation of national lock-down measures (Feb 16-Mar 15; Period 1) and the month immediately following (Mar 16-Apr 15; Period 2). The number of surgery service hospitalizations also was compared pre- versus post lockdown initiation (Period 1 vs. 2), as were patient characteristics and outcomes, like age, sex, discharge disposition, mortality, indications for hospital admission, and COVID-19 status. RESULT: Comparing 2019 and 2020, no appreciable differences were detected in the number of patients seen in either January or February. However, relative to March and April 2019, the numbers of patients seen in March and April 2020 (the two months after the first Peruvian case of COVID-19 was detected) were reduced by 55.8 and 88.6%, respectively. Comparing the months immediately pre and post lockdown, the number of service patients declined by 79.9% in April, while the number of hospitalizations declined by 30.9%. The number of admissions for various surgical indications either remained stable or declined in parallel with the overall decline in admissions for all indications except for osteoporotic hip fractures and diabetic foot ulcers (both of which increased proportional to the overall number of admissions) and for hand and foot fractures, both of which decreased. CONCLUSION: At our hospital, not all indications for traumatology/orthopedics service utilization declined despite the national government's directive to reduce non-COVID-related consultations and admissions. Some disorders presented with even greater frequency, which must be considered when developing contingencies for the reallocation of healthcare resources during a pandemic.

Rethinking Trauma Hospital Services in one of Spain's Largest University Hospitals during the COVID-19 pandemic. How can we organize and help? Our experience.

INTRODUCTION: The severe disruptions caused by the SARS-CoV-2 coronavirus have necessitated a redistribution of resources to meet hospitals' current service needs during this pandemic. The aim is to share our experiences and outcomes during the first month of the Covid-19 pandemic, based on the strategies recommended and strategies we have implemented. METHODS: Our experience comes from our work at a referral hospital within the Spanish National Health System. Changes to clinical practice have largely been guided by the current evidence and four main principles: (1) patient and health-care worker protection, (2) uninterrupted necessary care, (3) conservation of health-care resources, (4) uninterrupted formation for residents. Based on these principles, changes in the service organization, elective clinical visits, emergency visits, surgical procedures, and inpatient and outpatient care were made. RESULTS: Using the guidance of experts, we were able to help the hospital address the demands of the Covid-19 outbreak. We reduced to a third of our orthopaedics and trauma hospital beds, provided coverage for general emergency services, and five ICUs, all continuing to provide care for our patients, in the form of 102 trauma surgeries, 6413 phone interviews and 520 emergency clinic visits. Also in the third week, we were able to restart morning meetings via telematics, and teaching sessions for our residents. On the other hand, eight of the healthcare personnel on our service (10.8%) became infected with Covid-19. CONCLUSIONS: As priorities and resources increasingly shift towards the COVID-19 pandemic, it is possible to maintain the high standard and quality of care necessary for trauma and orthopaedics patients while the pandemic persists. We must be prepared to organize our healthcare workers in such a way that the needs of both inpatients and outpatients are met. It is still possible to operate on those patients who need it. Unfortunately, some healthcare workers will become infected. It is essential that we protect those most susceptible to severer consequences of Covid-19. Also crucial are optimized protective measures.

What Predicts Health-Related Quality of Life for Patients With Displaced Femoral Neck Fractures Managed With Arthroplasty? A Secondary Analysis of the HEALTH Trial.

BACKGROUND: Total hip arthroplasty (THA) has been argued to improve health-related quality of life (HRQoL) and function in femoral neck fracture patients compared with hemiarthroplasty (HA). The HEALTH trial showed no clinically important functional advantages of THA over HA. The current analysis explores factors associated with HRQoL and function in this population. METHODS: Using repeated measures regression, we estimated the association between HRQoL and function [Short Form-12 (SF-12) physical component score (PCS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score] and 23 variables. RESULTS: THA as compared to monopolar HA, but not bipolar HA, was more likely to improve PCS scores (adjusted mean difference [AMD] 1.88 points, P = 0.02), whereas higher American Society of Anesthesiologists score (AMD -2.64, P < 0.01), preoperative use of an aid (AMD -2.66, P < 0.01), and partial weight-bearing status postoperatively (AMD -1.38, P = 0.04) demonstrated less improvement of PCS scores over time. THA improved WOMAC function scores over time compared with monopolar HA (but not bipolar HA) (AMD -2.40, P < 0.01), whereas higher American Society of Anesthesiologists classification (AMD 1.99, P = 0.01) and preoperative use of an aid (AMD 5.39, P < 0.01) were associated with lower WOMAC function scores. Preoperative treatment for depression was associated with lower functional scores (AMD 7.73, P < 0.01). CONCLUSION: Patients receiving THA are likely to receive small and clinically unimportant improvements in health utility and function compared with those receiving monopolar HA and little improvement compared with those receiving bipolar HA. Patient-specific characteristics seem to play a larger role in predicting functional improvement among femoral neck fracture patients. LEVEL OF EVIDENCE: Prognostic Level II.

Correction to: Cluster identification, selection, and description in Cluster randomized crossover trials: the PREP-IT trials.

An amendment to this paper has been published and can be accessed via the original article.

Nosocomial infection with SARS-CoV-2 and main outcomes after surgery within an orthopaedic surgery department in a tertiary trauma centre in Spain.

AIMS: The purpose of the present study is to analyse clinical data of a series of cases who developed nosocomial infection with SARS-CoV-2 in an orthopaedic and traumatology department. PATIENTS AND METHODS: In this non-interventional retrospective study, carried out at a tertiary hospital within the Spanish National Health System, all adult patients who were admitted in the Orthopaedic Surgery and Traumatology Department between March 9th and May 4th, 2020, were included. Clinical, biological and radiological data, as well as mortality rates, were collected from hospital medical records. RESULTS: A total of 293 periods of hospitalization were analysed in 288 patients. Mean age was 66.1 years old and 57.3% were females. Nineteen patients (6.48%) met the inclusion criteria to be categorized as a nosocomial infection with SARS-CoV-2. In a comparison between patients with and without nosocomial infection, age, mortality and hospital length of stay were statistically significant (p < 0.05). The median time from admission to diagnosis of SARS-CoV-2 infection in our cohort was 16 days (6-86 days). No statistically significant differences were found in sex, living situation, reason of admission or period of admission (even if we observed that most of the nosocomial infections (78.9%) occurred in March). CONCLUSION: We have found a 6.48% of nosocomial infection with SARS-CoV-2, but with an important reduction of it after undergoing preventing protocols that included screening RT-PCR test for COVID-19. Age and hospital length stay were statistically significant risk factors for nosocomial infection with SARS-CoV-2. For the progressive restoration of the surgical activity, we recommend to correctly select the patients in elective surgery and to encourage fast-track programs and early discharge of patients with fractures.

Usefulness of PCR Screening in the Initial Triage of Trauma Patients During COVID-19 Pandemic.

BACKGROUND: Hospitals worldwide have postponed all nonessential surgery during the COVID-19 pandemic, but non-COVID-19 patients are still in urgent need of care. Uncertainty about a patient's COVID-19 status risks infecting health care workers and non-COVID-19 inpatients. We evaluated the use of quantitative reverse transcription polymerase chain reaction (RT-qPCR) screening for COVID-19 on admission for all patients with fractures. METHODS: We conducted a retrospective cohort study of patients older than 18 years admitted with low-energy fractures who were tested by RT-qPCR for SARS-CoV-2 at any time during hospitalization. Two periods based on the applied testing protocol were defined. During the first period, patients were only tested because of epidemiological criteria or clinical suspicion based on fever, respiratory symptoms, or radiological findings. In the second period, all patients admitted for fracture treatment were screened by RT-qPCR. RESULTS: We identified 15 patients in the first period and 42 in the second. In total, 9 (15.8%) patients without clinical or radiological findings tested positive at any moment. Five (33.3%) patients tested positive postoperatively in the first period and 3 (7.1%) in the second period (P = 0.02). For clinically unsuspected patients, postoperative positive detection went from 3 of 15 (20%) during the first period to 2 of 42 (4.8%) in the second (P = 0.11). Clinical symptoms demonstrated high specificity (92.1%) but poor sensitivity (52.6%) for infection detection. CONCLUSIONS: Symptom-based screening for COVID-19 has shown to be specific but not sensitive. Negative clinical symptoms do not rule out infection. Protocols and separated areas are necessary to treat infected patients. RT-qPCR testing on admission helps minimize the risk of nosocomial and occupational infection. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.