THE IMPACT OF COVID-19 ON THE ORTHOPAEDIC PATIENT IN SLOVENIA:  
HIP AND KNEE REPLACEMENT SURGERY, 90-DAY MORTALITY,  
OUTPATIENT VISITS AND WAITING TIMES
Vesna LEVAŠIČ1*, Denia SAVARIN1, Simon KOVAČ1,2
1Valdoltra Orthopaedic Hospital, Research Department, Jadranska cesta 31, 6280 Ankaran, Slovenia
2University of Maribor, Faculty of Medicine, Taborska ulica 8, 2000 Maribor, Slovenia
Received: Aug 2, 2021
Accepted: May 16, 2022
Original scientific article
*Corresponding author: Tel. + 386 56 696 130; E-mail: vesna.levasic@ob-valdoltra.si
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162
155
VPLIV PANDEMIJE COVID-19 NA ORTOPEDSKEGA PACIENTA V SLOVENIJI: 
NA OPERACIJE ZAMENJAVE KOLKA IN KOLENA, SMRTNOST 90 DNI 
PO OPERACIJI, AMBULANTNE PREGLEDE IN ČAKALNE VRSTE
© National Institute of Public Health, Slovenia. 
Levašič V, Savarin D, Kovač S. The impact of COVID-19 on the orthopaedic patient in Slovenia: hip and knee replacement surgery, 90-day mortality, outpatient visits and waiting times.  
Zdr Varst. 2022;61(3):155-162. doi: 10.2478/sjph-2022-0021.
ABSTRACT
Keywords: 
COVID-19, hip 
replacements, knee 
replacements, 90-day 
mortality, outpatient 
clinics, waiting times
IZVLEČEK
Ključne besede: 
COVID-19, endoproteze 
kolka, endoproteze 
kolena, smrtnost v 
90 dneh, ambulantna 
dejavnost, 
čakalne dobe
Introduction: The purpose of the study was to analyse the impact of the COVID-19 pandemic on the healthcare 
of the orthopaedic patient, i.e. numbers of hip and knee replacement surgeries, 90-day mortality, waiting 
times and outpatient clinic visits.
Methods: The Hip (HR) and Knee Replacement (KR) records from The National Arthroplasty Registry of Slovenia 
in the pandemic year 2020 were compared to the year 2019. To compare reasons for revision and 90-day 
mortality the Chi-square test was used. The median values of the number of operations and waiting times 
were compared with the 95% confidence intervals. The number of outpatient clinic visits was tested with the 
Wilcoxon Signed Ranked test.
Results: All operations fell by 19%, from 7825 to 6335. The number of Primary Total HR declined from 3530 to 
2792 (21%) and the number of Primary KR from 3191 to 2423 (24%). The number of hip revisions declined by 10% 
and knee revisions by 25%. We did not find differences in 90-day mortality (p=0.408). Outpatient clinic visits fell 
from 228682 to 196582 (14%) per year. Waiting times increased by 15% for HR and by 12% for KR.
Conclusion: There was an inevitable drop in the number of surgeries and outpatient clinic visits in the spring 
and autumn lockdown. With the reorganisation of the orthopaedic service in Slovenia, the number of KR and 
HR stayed at a relatively high level despite the pandemic. An epidemiological model and mechanisms for the 
reduction of waiting times could overcome the impact of the epidemic.
Uvod: Namen študije je bil analizirati vpliv pandemije COVID-19 na ortopedskega pacienta in sicer na dostopnost 
operacij zamenjave kolka in kolena, smrtnost v 90 dneh po operaciji, čakalne dobe na te posege in obiske 
ortopedskih ambulant v Sloveniji.
Metode: Primerjali smo podatke bolnikov iz Registra endoprotetike Slovenije (RES), ki so imeli v pandemičnem 
letu 2020 opravljeno zamenjavo kolka in kolena v primerjavi s predhodnim letom 2019. Vzroke revizij in 
smrtnost v 90 dneh po operaciji smo primerjali s testom Hi-kvadrat, vrednosti števila operacij in čakalnih dob 
pa s primerjavo medianih vrednosti s 95-odstotnim intervalom zaupanja. Obiske ambulant smo primerjali z 
neparametričnim testom za odvisne vzorce – testom Wilcoxon Signed Ranked.
Rezultati: Število vseh operacij kolka in kolena, vključno s parcialnimi kolčnimi artroplastikami, se je zmanjšalo 
za 19 %, s 7.825 na 6.335. Število elektivnih primarnih totalnih kolčnih artroplastik se je zmanjšalo za 21 %, s 
3.530 na 2.792. Število primarnih kolenskih artroplastik je padlo za 24 %, s 3.191 na 2.423. Število revizij kolčnih 
se je zmanjšalo za 10 %, revizij kolenskih endoprotez pa za 25 %. Razlik v 90-dnevni smrtnosti po operaciji 
nismo našli (p = 0,408). Obiski ambulant so se zmanjšali za 14 % z 228.682 na 196.582 letno. Čakalne dobe so se 
podaljšale za 56 dni (15 %) za artroplastiko kolka in 54 (12 %) za artroplastiko kolena.
Zaključek: Spomladi in jeseni se je število operacij in obiskov v ambulantah zaradi epidemije neizogibno 
zmanjšalo. Vendar smo z reorganizacijo ortopedske službe v Sloveniji v letu 2020 kljub pandemiji omogočili 
ohranitev števila kolčnih in kolenskih endoprotez na dokaj visoki ravni. Epidemiološki model, telemedicina 
in spodbujevalni mehanizmi za skrajševanje čakalnih dob bi lahko pomagali premagati vpliv epidemije na 
elektivne posege.
1 INTRODUCTION
Coronavirus epidemics started in March 2020 and had a 
huge effect on elective surgery during the first wave, hip 
and knee arthroplasty included (1). Slovenia was one of the 
countries least affected in the first wave and most affected 
in the second wave of the epidemics (2). The health system 
had to prepare for high numbers of hospitalized COVID-19 
patients. One of the measures was a reorganization of 
orthopaedic wards into COVID-19 treatment units in most 
general and both University Hospitals. At the same time, 
the public hospital specialized exclusively in orthopaedics 
remained open for most of the urgent revisions and other 
urgent orthopaedic cases as a referral hospital. A drop 
in elective surgeries, which we followed in The National 
Arthroplasty Registry of Slovenia (RES), i.e. hip and knee 
replacements, was inevitable. 
Slovenia is a central European country with approximately 
two million inhabitants. The health system provides near-
universal coverage paid by The Health Insurance Institute 
of Slovenia; co-payments are covered by private health 
insurance (3). They apply to most health services but 
not for infectious diseases, cancer, diabetes, congenital 
anomalies and neuromuscular diseases. In 2017, health 
expenditure accounted for 8.2% of GDP (4).
The first confirmed COVID-19 infection was reported on 
4 March 2020 followed by the first lockdown on 12 March 
2020. The country was successful in the control of the 
first wave in less than two months. The approach taken 
enabled the country to be the first in the EU to declare 
the end of the epidemic on 31 May 2020 (5). But after the 
summer holiday season the numbers started to increase 
very rapidly, so the declaration of the second wave and 
lockdown on 19 October 2020 was inevitable (2). 
After the first wave, orthopaedic programmes were re-
established as soon as the legal causes were eliminated 
(elective programmes were banned by a government 
decree) and the organizational issues of individual hospitals 
were resolved. In both lockdowns, the Minister of Health 
implemented strict control measures, all schools and 
educational institutions were closed, all public transport 
services stopped and all non-essential services shut. All 
non-essential outpatient visits and surgery appointments 
were put on hold with the exception of oncological 
services. This resulted in the cancellation of most elective 
surgeries. In the first lockdown, the recommendation 
was based on concerns about the quantity of personal 
protective equipment and blood components available at 
the time (6). 
In May 2020 a study by the European Hip Society and 
European Knee Associates from 40 different countries 
stated that nearly all primary total joint arthroplasties 
were cancelled (92.6%), as well as aseptic revisions 
(94.7%). Urgent procedures (periprosthetic fractures, hip 
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162
156
arthroplasty for femoral neck fractures and septic revisions 
for acute infection) were still being performed (7).
During the second lockdown, all general and university 
hospitals in Slovenia recruited all resources for COVID-19 
patients’ treatment. The two University Medical Centres 
and general hospitals had to reorganize because of 
the massive input of COVID-19 patients. Orthopaedic 
departments were converted into COVID-19 departments 
and a part of the medical staff was transferred from 
surgery to COVID-19 departments (8).
Nevertheless, between the spring wave (March-May 2020) 
and the autumn wave of epidemics (October-December 
2020), the registry recorded an increased number of 
elective arthroplasty surgeries.
The study aimed to analyse what the impact was of the 
COVID-19 pandemic on the healthcare of the orthopaedic 
patient, i.e. access to primary and revision hip and knee 
replacement surgery, change in 90-day mortality, waiting 
times and outpatient clinic visits in Slovenia.
2 METHODS
A retrospective study analysing data routinely collected 
from the RES registry, which had 92% and nearly 100% 
completeness in 2019 for hip and knee replacements, 
respectively, has been made (9, 10). The calculation of 
completeness was made regarding the comparison of the 
forms gathered in the registry and the data of procedures 
paid by The Health Insurance Institute of Slovenia (11). The 
publicly available data on waiting times and outpatient 
clinic visits, comparing the years 2019 and 2020, stratified 
by month, has been studied.
2.1 Description of patients in registry study
The characteristics of the patients involved in our study 
are described in Table 1.
The number of all operations in the RES registry was 
7825 in 2019 and 6335 in 2020 (9, 10). To evaluate the 
influence on elective operations we excluded partial HR 
since they are done for hip fractures. So we analysed 
in total 6322 records of Primary Total Hip Replacement 
(THR) and 5614 records of Primary Unicondylar and Total 
Knee Replacements (KR) in the period from 1 January 
2019 to 31 December 2020 from the RES registry. We 
compared Primary THR in 2019 (N°=3530) to those made 
in 2020 (N°=2792) and Primary Partial and Total KR in 2019 
(N°=3191) to 2020 (N°=2423), stratified by month. 
The same analysis was made on 669 hip and 372 knee 
revision operations, separately. We also compared them 
for reason for revision. 
For 90-days mortality analysis after the procedure in 
the non-COVID-19 (2019) and COVID-19 year (2020), we 
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162
157
reviewed the data on the vital status of patients in the 
RES registry from the Population Registration Division at 
the Slovenian Ministry of the Interior. 
We compared the waiting times for primary HR and KR 
from The National Institute of Public Health (NIJZ) data 
service. Waiting periods for the surgery are evaluated on 
the first day of every month. In the article, the median 
change is presented.
We looked at the number of outpatient clinic visits in 2019 
and 2020. The data are published on the website of The 
Health Insurance Institute of Slovenia (ZZZS), which covers 
all public services provided in Slovenia (11).
2.2 Statistics
The normality and homogeneity of variance were tested 
using the Kolmogorov–Smirnov test. The reasons for 
revision and 90-day mortality were analysed with a 
Chi-square test with a p-value of <0.05 as statistically 
significant. Median values of the number of operations and 
waiting times were analysed with 95% confidence intervals 
(CI). To check for statistically significant differences 
in the number of outpatient clinic visits per clinic, the 
nonparametric Wilcoxon Signed Ranked test for paired 
samples was used.
2.3 Technical information
The programme IBM SPSS Statistics for Windows, version 
26.0 was used for statistical analysis.
3 RESULTS
3.1 Primary hip replacement
Comparing the pandemic year 2020 to the non-pandemic 
year 2019, we noticed an evident drop in all operations, 
including partial HR, of 19% from 7825 to 6335. To see more 
clearly the impact on elective hip surgery, we compared 
Primary THR. They fell 21% from 3530 operations in 2019 
to 2792 in 2020 (9). 
The two waves had an impact on Primary THR, which 
decreased by 84% in April 2020, compared to the value in 
April 2019, and increased by 99% in August 2020, compared 
to the same month in 2019, and then dropped again by 86% 
in November 2020 compared to November 2019 (Figure 1).
Primary THR
Primary Total and Partial KR
Revision HR
Revision KR
Sum of THR and KR
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Type of operation Gender 2019
Age at operation 
(±SD)
Age at operation 
(±SD)
N° N°% %
2020
1610
1920
1157
2034
168
184
84
129
3019
4267
1269
1523
929
1494
123
194
65
94
2386
3305
46%
54%
36%
64%
48%
52%
39%
61%
41%
59%
45%
55%
38%
62%
39%
61%
41%
59%
42%
58%
66.64 (±10.26)
69.18 (±10.24)
67.80 (±8.54)
70.12 (±8.38)
69.28 (±11.13)
73.99 (±9.23)
68.13 (±9.74)
69.83 (±10.01)
67.96 (±9.92)
70.78 (±9.47)
66.14 (±10.87)
69.71 (±10.50)
67.97 (±8.84)
70.19 (±8.67)
69.84 (±11.99)
75.03 (±10.52)
68.40 (±7.84)
71.53 (±8.80)
68.09 (±9.89)
71.62 (±9.62)
Table 1.
Figure 1.
Demographics of patients in 2019 and 2020.
Comparison of surgery volumes of THR in 2019 
and 2020 per month.
Comparing the 95% CI of THR performed monthly in 2019 
and 2020, the difference was not statistically significant. 
The median in 2019 was 304 operations per month, 95% 
CI 289 to 335. The Median in 2020 was 264 operations per 
month, 95% CI 105 to 336 (Figure 2).
158
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162
Figure 2. Figure 4.
Figure 3.
Simple Error Bar comparing 95% CI of two medians 
of THR per month in 2019 and 2020.
Simple Error Bar comparing 95% CI of two medians 
of KR per month in 2019 and 2020.
Comparison of surgery volumes of KR in 2019 and 
2020 per month.
3.2 Primary knee replacement
Primary KR has fallen from 3191 to 2423 (24%) operations 
from 2019 to 2020 (10). 
The number of KR surgeries decreased by 91% in April 2020 
below the levels in April 2019. The volume then increased 
during the summer, reaching a 59% higher level in August 
2020 compared to the same month in 2019, but reaching 
the bottom again in November 2020 with 90% fewer KRs 
compared to November 2019 (Figure 3).
Comparing the 95% CI of KR performed monthly in 2019 
and 2020, the difference was not statistically significant. 
The median in 2019 was 263 operations per month, 95% CI 
210 to 295. The median in 2020 was 218.5 operations per 
month, 95% CI 81 to 302 (Figure 4).
3.3 Revision procedures
There were 35 fewer (10%) hip revisions and 54 fewer 
(25%) knee revisions in 2020 compared to 2019. Comparing 
the 95% CI of the two years for Hip Revisions, stratified by 
month, the difference was not statistically significant. The 
median in 2019 was 27.5 operations per month, 95% CI 26 
to 34. The median in 2020 was 26.5 operations per month, 
95% CI 19 to 36. The difference was also not statistically 
significant in Knee Revisions stratified by month. The 
median in 2019 was 18 operations per month, 95% CI 15 
to 19. The median in 2020 was 15.5 operations per month, 
95% CI 5 to 19. 
We analysed also the influence of the pandemic on reasons 
for revision in 2020 compared to 2019. The Chi-square value 
was statistically significant at the 0.05 level (p=0.025) for 
reasons for HR revisions, but when comparing a single 
reason, only pain (p=0.001) was statistically significant. 
The Chi-square value was not statistically significant at 
the 0.05 level for reasons for KR revisions (p=0.073), so 
we did not find differences in reasons for KR revisions 
between 2019 and 2020, except for pain as the reason 
(p=0.036) (Table 2). 
3.4 Mortality
The 90-day mortality after HR and KR is presented in 
Table 3. The table contains numbers of operated patients 
by type of operation and the number and percentage of 
deaths in 90 days after operation in two time periods 
(2019 and 2020). 
With the numbers available we cannot support the notion 
that there was a difference in 90-days mortality between 
2019 and 2020 (p=0.408) for all types of operations. The 
Chi-square test for 90-days mortality after each type of 
operation separately in 2019 compared to 2020 showed no 
statistically significant difference either.
159
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162
2-stage revision  
Aseptic loosening
Deep infection
Dislocation
Broken Implant 
Malalignment
Other
Pain
Periprosthetic fracture
Chi-square test
Primary THR
Primary Total and Partial KR
Revision HR
Revision KR
x² df(3)
Reason for revision
Type of operation
20202020
N°
N° of deaths 
in 90-days
N°
N° of deaths 
in 90-days
x² df(1)
p-value
x² df(1)
p-value
% of 
deaths
p-value
% of 
deaths
20192019
N°
N° of 
operations
N°
N° of 
operations
Knees
2020 x² df(1)
Hips
2019
22
34
82
0
0
21
29
20
5
3436
2423
317
159
20
117
42
37
12
0
41
10
73
3691
3191
352
213
p=0.408
x² df(7) p=0.025 x² df(6) p=0.073
21
32
50
0
0
21
19
6
10
14
8
14
2
22
99
48
21
9
0
28
27
63
15
4
11
5
0.390
0.298
0.160
NA
NA
0.313
0.636
0.036
0.056
0.4
0.3
4.4
1.3
0.994
0.100
0.379
0.444
0.503
0.579
0.224
0.074
0.673
NA
0.232
0.001
0.781
0.4
0.1
3.1
2.4
Table 2.
Table 3.
Reasons for revision for hip and knee replacements.
90-day mortality after primary and revision HR and KR.
x²=Chi-square test; df= degrees of freedom; NA= not applicable
x²=Chi square test; df= degrees of freedom
3.5 Waiting times
There were on average 56 days (15%) of increased waiting 
times for hip surgery and 54 (12%) for knee surgery in 2020 
compared to 2019, stratified by month. The median in 
2019 for HR was 393 days, 95% CI 349 to 397; in 2020 it was 
472 days, 95% CI 393 to 499. The median in 2019 for KR was 
496 days, 95% CI 370 to 534. The median in 2020 was 572 
days, 95% CI 511 to 582. The difference in waiting times 
was still not statistically significant.
3.6 Outpatient orthopaedic visits
The number of outpatient clinic visits has fallen by 32100 
(14%), from 228682 in 2019 to 196582 in 2020. To check 
for statistically significant differences in the number of 
outpatient clinic visits per clinic between 2019 and 2020, 
the Wilcoxon Signed Ranked test for paired samples was 
used. The result (z=-4.076, p<0.01) confirms the hypothesis 
that there were statistically significant fewer outpatient 
clinic visits in 2020 compared to 2019. 
4 DISCUSSION
The first wave of COVID-19 had a large impact on elective 
hip and knee primary replacements in Slovenia (84% and 
92% decrease in April 2020, respectively), in the summer 
period the numbers mostly recovered up until the 
second wave when we noticed an 86% and 90% decline 
in November 2020, respectively. Very similar results 
were observed in Milan, Italy, where elective surgery 
in the first wave declined rapidly, going close to zero, 
outpatient admissions were restricted to cases that 
cannot be postponed, while emergencies increased due to 
the role played by the hospital as a referral orthopaedic 
centre during the pandemic (1). The history of pandemics 
suggests that there is no predictable temporal pattern for 
major pandemics, so the next waves of epidemics seemed 
inevitable (12). In the post-acute phase, a normal surgical 
programme can be resumed step-by-step, taking into 
account clear hygiene regulations, the occupancy of the 
ward and the operating room adjusted accordingly (13, 14). 
However, a quick return to the normal volume of surgeries 
160
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162
can be obstructed by the fact that many patients refuse to 
undergo rescheduled surgery (15). We managed to increase 
the number of surgeries in the summer months, between 
two lockdowns, substantially. Accepting rescheduled 
surgery was not a problem in our population of patients. 
The specialized orthopaedic hospital as a referral hospital 
took the main role in regaining the numbers between the 
two waves.
Despite the temporary increase, the number of HR and 
KR in 2020 was 19% lower than in 2019. Nevertheless, the 
difference was not as prominent as we expected. Within 
these numbers, we did not find the drop to be statistically 
significant. The number of surgeries did not decrease 
significantly, however it was lower than the year before 
COVID-19. But, if we take into account a steady yearly 
increase in the number of surgeries by approximately 5% 
per year before the pandemic (16), then the decrease in 
surgeries is even more obvious.
The COVID-19 epidemics and their consequences were 
associated with higher all-cause mortality compared to 
previous years. There were more than 530000 additional 
deaths from January to December 2020, against the 
average number of deaths during the same period 
between 2016 and 2019 in the EU and in Iceland, Norway, 
Liechtenstein and Switzerland (17). The data from Italy 
showed increased 7-week mortality after surgery, which 
was 1.2% in 2020 compared to 0% in 2019 (18). According to 
the Population Registration Division in Slovenia, there were 
3648 (17%) additional deaths in 2020 compared with the 
average between 2015 and 2019 (2). The highest increase 
in mortality was in November 2020, at 89.5% compared to 
2019. The age group over 72 represents 72% and the age 
group 62 -71 years an additional 16% of all excess deaths 
(2). Since the mean age of orthopaedic patients at surgery 
is 68 years for primary THR and 83 years for primary 
Partial HR, we expected increased 90-day mortality after 
the hip and knee arthroplasty (9, 10). But our data did 
not support that. The answer is perhaps in the selection 
of patients for elective surgery. They are all screened for 
other illnesses (in the COVID-19 era they are tested also 
for this disease). The patients who underwent hip or knee 
replacement have also better relative survival compared 
to the Slovenian population (19). Other outcome indicators 
such as Patient Related Outcome Measures (PROMs) should 
be analysed to see the change in the quality of life, but we 
did not have access to routinely gathered data.
Accessibility to healthcare can be limited for several 
reasons, including cost, distance to the closest health 
facility and waiting times, and this may result in poorer 
health for people forgoing care (20). Nevertheless, 
hospital-related factors are more important than patient 
characteristics as explanations of variations in waiting 
times for orthopaedic surgery (21). The effect of the 
COVID-19 pandemic on waiting times for KR and HR in 
Slovenia showed 15% days per month higher waiting time 
on average for hip surgery and 12% for knee surgery in 
2020 compared to 2019, which was less than we expected. 
In an OECD report, median waiting times for HR in 2019 
ranged from 35 in Denmark to 250 days in Estonia. 
Slovenia with 393 days was at the tail end. The long 
waiting times are partly explained by the limited volume 
of specialist consultations reimbursed by public health 
insurance. According to the OECD report of 2018, Slovenia 
has the feature of no large differences in unmet needs 
for medical examination between high and low-income 
populations (20). The pattern is generally the same for 
knee replacement, where Slovenian patients have to wait 
496 days for KR (20). In the UK, up until November 2020 
the waiting list remained approximately double the size of 
the pre- COVID-19 waiting list (22). This was not the case 
in Slovenia, where the increase was 15% for HR and 12% 
for KR. However, with already long waiting times, even a 
relatively small increase can have a pronounced impact on 
patients’ health.
Analysis of the impact on outpatient visits of Medicare 
data showed overall outpatient visits decreased by 
30.0% in the first half of 2020 (23). Cardiovascular 
visits conducted in the first 15 weeks of the COVID-19 
pandemic decreased by 33.1% compared with the same 
period in 2019 (24). Interestingly, in our study outpatient 
orthopaedic visits dropped by only 14% in 2020 compared 
to 2019. The cause was in the disruption of services on 
the primary level as well as on the secondary level. This 
drop could be partially replaced by telemedicine solutions 
such as the telemonitoring, provision of healthcare 
services by remotely connecting patients with healthcare 
professionals and remote cooperation for the patient’s 
treatment between healthcare professionals who are 
physically at different locations (25). The experts in 
epidemiology, data science and statistics should make an 
epidemiological model that simulates different scenarios 
of the dynamics of the disease (26).
There are limitations to our study. When comparing the 
number of THR and KR in Slovenia one year before the 
pandemic (2019) and in the first year of the pandemic 
(2020), only the difference between outpatient clinics was 
statistically significant. The reason that other differences 
did not show a significant result could be because the 
reorganisation of planned surgeries during the summer of 
2020 resulted in large month-to-month variations, and also 
that just two years were taken into consideration. Since the 
collection of data for The National Arthroplasty Registry 
started in 2019, there were no prior data available.
161
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162
5 CONCLUSION
Based on the results, we can conclude that there was 
an inevitable loss of elective surgery and outpatient 
clinic visits in 2020, with an impact on orthopaedic 
patients’ needs. During the lockdowns, urgent surgeries 
were performed in a few hospitals with strictly divided 
departments and in a specialized orthopaedic hospital, 
which remained open for orthopaedic emergencies only 
and was all the time predominantly a COVID-19 “free” 
institution. A positive impact of the public system was 
that it enabled the circulation of patients between 
hospitals. So the majority of urgent revisions (KR and HR) 
during the first lockdown were made in the specialized 
orthopaedic hospital that served as a referral hospital. 
The same hospital was the first to resume a normal pre-
pandemic volume of surgeries, followed by orthopaedic 
departments in general and university hospitals. This 
reorganization of the orthopaedic service in Slovenia and 
increasing volume of surgeries in COVID-19 “free” months 
have been an example of good practice to maintain the 
number of KR and HR at a fairly high level in 2020, so 
it should be taken as a recommendation for dealing with 
epidemic work conditions in orthopaedics. 
In Slovenia, the cap on the number of surgeries per 
hospital can limit the yearly number of total HR and KR 
surgeries in public institutions (3). For the reduction of 
waiting times, it requires a range of policy initiatives, 
including higher spending, waiting-times target schemes, 
and other incentive mechanisms (27). Nevertheless, 
further investigations of lower health expenditure due to 
the outage of orthopaedic treatments are needed.
ACKNOWLEDGMENT
We thank Assist. Prof. Eva Podovšovnik, PhD for providing 
statistical help, and David Breznikar from NIJZ for 
providing data on waiting times.
CONFLICTS OF INTEREST
The author SK declared the following potential conflicts 
of interest concerning the research, authorship, and/
or publication of this article: Personal fees from De Puy 
for lectures during the last 36 months. The other authors 
declare that no conflicts of interest exist. 
FUNDING 
The study had no funding.
ETHICAL APPROVAL 
This is a retrospective cohort study analysing data 
routinely collected from the national registry and publicly 
available data for audit and research. Upon the advice of 
the Institutional Ethical Board, we did not attempt to seek 
ethical approval.
REFERENCES
1. Zagra L, Faraldi M, Pregliasco F, Vinci A, Lombardi G, Ottaiano I, et al. 
Changes of clinical activities in an orthopaedic institute in North Italy 
during the spread of COVID-19 pandemic: a seven-week observational 
analysis. Int Orthop. 2020;44(8):1591–8. doi: 10.1007/s00264-020-
04590-1.
2. Covid-19 sledilnik.org. Accessed March 13th, 2021 at: https://covid-19.
sledilnik.org/sl/stats/.
3. Albreht T, Pribakovic Brinovec R, Josar D, Poldrugovac M, Kostnapfel 
T, Zaletel M, et al. Slovenia: health system review. Health Syst Transit. 
2016;18(3):1-207. 
4. OECD, European observatory on health systems and policies. Slovenija: 
Zdravstveni profil leta 2017. Accessed January 11st, 2021 at: https://
doi.org/10.1787/9789264285422-sl.
5. Leskovar M, Cizelj L, Beović B. Successful containment of the first 
wave of COVID-19 in Slovenia: a short assessment. Accessed November 
19th, 2020 at: https://www.researchgate.net/publication/342397534. 
doi: 10.2139/ssrn.3619766.
6. Zadnik V, Mihor A, Tomsic S, Zagar T, Bric N, Lokar K, et al. Impact 
of COVID-19 on cancer diagnosis and management in Slovenia – 
preliminary results. Radiol Oncol. 2020;54(3):329–34. doi: 10.2478/
raon-2020-0048.
7. Thaler M, Khosravi I, Hirschmann MT, Kort NP, Zagra L, Epinette JA, 
et al. Disruption of joint arthroplasty services in Europe during the 
COVID-19 pandemic: an online survey within the European Hip Society 
(EHS) and the European Knee Associates (EKA). Knee Surg Sports 
Traumatol Arthrosc. 2020;28(6):1712–9. doi: 10.1007/s00167-020-
06033-1.
8. Komadina R, Crnjac A, Sojar V, Gasparini M, Potrč S, Pšenica J, et al. 
The impact of COVID-19 on the organisation of surgical activity. Zdrav 
Vestn. 2020;89(11–12):650–7. doi: 10.6016/ZdravVestn.3080.
9. Levašič V, Savarin D, Kovač S. 1st RES annual report - hip replacement. 
Accessed March 12th, 2020 at: https://www.ob-valdoltra.si/sl/
international.
10. Levašič V, Savarin D, Kovač S. 1st RES annual report - knee 
replacement. Accessed March 12th, 2021 at: https://www.ob-
valdoltra.si/sl/international.
11. ZZZS. Plan in realizacija programa po posameznih dejavnostih - 
Q86.220. Accessed March 13th, 2021 at: https://api.zzzs.si/zzzs/pao/
izvajalci.nsf/ZbirniPlanRealizacija?openview&count=1000 
12. Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Projecting 
the transmission dynamics of SARS-CoV-2 through the postpandemic 
period. Science. 2020;368(6493):860-8. doi: 10.1126/science.abb5793.
13. Müller M, Stöckle U, Trampuz A, Felix S, Kramer A, Wassilew G. 
Coronavirus pandemic - SARS-CoV-2 in orthopedics and trauma 
surgery. Z Orthop Unfall. 2021;159(1):25-31. doi: 10.1055/a-1208-0182.
14. Zeegen EN, Yates AJ, Jevsevar DS. After the COVID-19 pandemic: 
returning to normalcy or returning to a new normal? J Arthroplasty. 
2020;35(7S):S37-41. doi: 10.1016/j.arth.2020.04.040.
15. Hernigou J, Valcarenghi J, Safar A, Ferchichi MA, Chahidi E, Jennart 
H, et al. Post-COVID-19 return to elective orthopaedic surgery - is 
rescheduling just a reboot process? Which timing for tests? Is chest 
CT scan still useful? Safety of the first hundred elective cases? How 
to explain the “new normality health organization” to patients? Int 
Orthop. 2020;44(10):1905–13. doi: 10.1007/s00264-020-04728-1.
16. ZZZS. O ZZZS: Letno poročilo. Accessed April 8th, 2022 at:  https://
www.zzzs.si/o-zzzs/letno-poslovno-porocilo/.
17. Eurostat Group. Eurostat statistics explained. Accessed March 13th, 
2021 at: https://ec.europa.eu/eurostat/statistics-explained/index.
php?title=Weekly_death_statistics.
18. D’Apolito R, Faraldi M, Ottaiano I, Zagra L. Disruption of arthroplasty 
practice in an orthopedic center in northern Italy during the 
coronavirus disease 2019 pandemic. J Arthroplasty. 2020;35(7S):S6-9. 
doi: 10.1016/j.arth.2020.04.057.
19. Levašič V. The evaluation of cancer incidence after total hip or knee 
arthroplasty: doctoral thesis. Ljubljana: University of Ljubljana; 2019. 
Accessed July 22nd, 2021 at: https://repozitorij.uni-lj.si/IzpisGradiva.
php?lang=slv&id=106040.
20. OECD. Health at a glance: Europe 2020: state of health in the EU cycle. 
Acccessed Jan 11st, 2021 at: https://doi.org/10.1787/82129230-en. 
21. Löfvendahl S, Eckerlund I, Hansagi H, Malmqvist B, Resch S, Hanning 
M. Waiting for orthopaedic surgery: factors associated with waiting 
times and patients’ opinion. Int J Qual Health Care. 2005;17(2):133-40. 
doi: 10.1093/intqhc/mzi012. 
22. Oussedik S, MacIntyre S, Gray J, McMeekin P, Clement ND, Deehan 
DJ. Elective orthopaedic cancellations due to the COVID-19 pandemic: 
where are we now, and where are we heading? Bone Jt Open. 
2021;2(2):103–10. doi: 10.1302/2633-1462.22.BJO-2020-0161.R1.
23. Patel SY, Mehrotra A, Huskamp HA, Uscher-Pines L, Ganguli I, Barnett 
ML. Trends in outpatient care delivery and telemedicine during the 
COVID-19 pandemic in the US. JAMA Intern Med. 2021;181(3):388-91. 
doi: 10.1001/jamainternmed.2020.5928.
24. Wosik J, Clowse MEB, Overton R, Adagarla B, Economou-Zavlanos 
N, Cavalier J, et al. Impact of the COVID-19 pandemic on patterns 
of outpatient cardiovascular care. Am Heart J. 2021;231:1-5. doi: 
10.1016/j.ahj.2020.10.074.
25. Rant Ž. Telemedicine in Slovenia. In: 34th Bled eConference digital 
support from crisis to progressive change. Maribor: University of 
Maribor Press; 2021:87–96. Accessed July 22nd, 2021 at: https://press.
um.si/index.php/ump/catalog/book/581.
26. Eržen I, Kamenšek T, Fošnarič M, Žibert J. Key challenges in modelling 
an epidemic - what have we learned from the COVID-19 epidemic so 
far. Zdr Varst. 2020;59(3):117-9. doi: 10.2478/sjph-2020-0015. 
27. Siciliani L, Moran V, Borowitz M. Measuring and comparing health care 
waiting times in OECD countries. Health Policy. 2014;118(3):292-303. 
doi: 10.1016/j.healthpol.2014.08.011.
162
10.2478/sjph-2022-0021 Zdr Varst. 2022;61(3):155-162