key: cord-1009917-oycyn192 authors: Sadigale, Omkar; Bagaria, Vaibhav; Vaishya, Raju title: Resuming arthroplasty: A well aligned and a balanced approach in the COVID-19 era date: 2020-06-17 journal: J Clin Orthop Trauma DOI: 10.1016/j.jcot.2020.06.024 sha: a97d9af4a2f7de3959962d49b441b01883133d4a doc_id: 1009917 cord_uid: oycyn192 Returning to Arthroplasty amidst the COVID-19 pandemic requires a well aligned and a balanced approach. Following a set protocol and staged measures are the need of the hour. This article details the specifics for resumption of arthroplasty in the era of COVID19. While formulating the policy for resumption, it is necessary that we consider the following factors: patient's general health status, follow strict guidelines issued by the government, alter and enhance our operating room discipline and last but not the least, leverage technology for optimal patient care and enhanced outcome. to ascertain and scientifically answer some very pertinent questions regarding resuming arthroplasty, some evidence-based information is being provided in form of this monograph, which should help to guide surgeons. We did extensive literature review considering the following points, related specifically to Arthroplasty on the: • Clarity of protocol and commitment to successful execution The review of EBP suggests the following guidelines to use for the Arthroplasty surgeons: • Elective arthroplasty surgeries should be performed only in COVID free facility • Hospital stay must be as short as possible. • Judicious patient selection based on COVID exposure, age (<60 years old), ASA grading, socio-economic-professional situation and surgical indication. [1] • Determine patient demand and willingness for Arthroplasty after the Pandemic • Assess patient's demand by asking those who had cancellations for their elective Arthroplasty, to see if they want to reschedule it immediately. • Unilateral procedures must be preferred to bilateral simultaneous arthroplasty. • The positive pressure ventilation should be avoided, ideally turned off or a negative pressure is recommended if it can be reliably installed. [2] • Use of ventilation system with minimum 20 air changes per hour. • It is preferable that the surgical team members to remain outside the OT during intubation and extubation procedures. • Maintain unidirectional flow of people, with minimum door openings. • These systems are ineffective in preventing the respiratory droplet or aerosol mediated contamination as seen in SARS cases. [3] • The helmet-hood filters are inefficient to contain the particles of 0.02-1 μm in diameter to meet the standard for protective respirators. • However, we recommend the use of AAMI class 3 filter over the top of the inlet and AAMI class 4 filter on the sides of the hood. • The use of N95 masks is must under the hoods. In absence of helmets, a visor or googles along with double masking is recommended. • The helmet must be sterilized after every procedure. • The doffing should be done carefully. • The OT and its surroundings must be sanitized after every procedure as soon as possible. • All the potentially single use scrubs must be disposed in IRHW containers at the dedicated doffing stations. • The ventilators, radiological equipment must be sanitized with chloro-derivate solution, rinsed and dried. and Not more than 8) • The use of power tools like drill, saw and burr are associated with droplet and fine particle generation and their use must be minimized as much as possible. • The procedures where reaming of the medullary canal is done, extra precaution is needed as it disrupts the laminar flow, transmitting and disseminating the infectious particles in the OT. • The monopolar cautery should be used minimally and that too with sucking its fumes. • All the procedures must be done by senior experienced surgeon to avoid repetition of steps • The use of pulsed lavage systems must be avoided as it may increase the risk of transmission by generating the fine particles from the surgical wound. [8] 6. Closure and dressing • Unless contraindicated the subcuticular buried knots with absorbable sutures. • Consider Negative Pressure Wound therapy (NPWT) that can reduce need for frequent dressing changes. Based on the current available information, a staged return is probably the best way forward. All the patients planned for surgery must be screened and tested negative for COVID-19-rt-PCR 48 to 72 hours prior to surgery. This return can be described in three stages: • Targeted to who will have maximum benefit and those are mentally conditioned to undergo the same in the times of pandemic. • Relatively younger patients between 50-60 years, ASA grade I (normal healthy patients and ASA grade II (with mild systemic disease), BMI < 30kg/m 2 must be considered. (Risk factors -smoking and comorbidities cardiovascular diseases, hypertension, diabetes, lung disease, cancer, liver and kidney diseases). • Patients fit for Day care Arthroplasty are preferred in Stage I • Avoid bilateral cases in Stage 1 • Patient tested negative for COVID -19 • All the patients to be optimised for surgeries on virtual visits by a multidisciplinary team of anaesthetist, physicians orthopaedic surgeons • Focussed on the patients with low to moderate risks depending on the age, patient`s demographics and COVID-19 local profile (green zone). • Shorter inpatient stay (overnight or 48hrs) • The focus in this stage would be to resume all arthroplasty procedures • Reaching the stage will depend on epidemiological assessment of the prevalence of the herd immunity in the community • Healthcare facilities should be relatively free and be amenable to take elective and planned post operative intensive care admissions • To assert that the dedicated multidisciplinary team is available is available all the time in ongoing pandemic without compromising the pandemic needs. [10] The summary of recommendations is listed in table 1. • Closure: with Absorbable subcuticular preferred. NPWT in obese and vulnerable groups. • Follow up: Virtual Consults and where available home care program for physio/ nursing care can be instituted. As the number of COVID cases rises, the possibility of arthroplasty returning to normalcy seems a distant dream today. The truth about what the future holds is -"We have absolutely no idea what's going to happen; your guess is as good as ours". One thing however is certain that we need to restart it at some point soon. However, this has to be done with meticulous planning to safeguard our patients, our staff, and all stake holders including ourselves. Surgery in COVID-19 patients: operational directives COVID-19 -Evidence-Based Best Practice Guidelines Specific to Orthopaedic Surgeons Surgical helmets and SARS infection Helmet Modification to PPE With 3D Printing During the COVID-19 Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement regarding COVID Economic recovery after the COVID-19 pandemic: resuming elective orthopedic surgery and total joint arthroplasty Infection Prevention Measures for Surgical Procedures during a Middle East Respiratory Syndrome Outbreak in a Tertiary Care Hospital in South Korea