key: cord-0816871-fp8qcsv0 authors: North, Trevor; Bullock, Matthew W.; Danoff, Jonathan R.; Saxena, Arjun; Fischer, Stuart J.; Stronach, Ben M.; Levine, Brett R. title: Arthroplasty During the COVID-19 Pandemic date: 2020-05-19 journal: Arthroplast Today DOI: 10.1016/j.artd.2020.05.011 sha: be3912e643e6b0acd227595144b2a5b4d3c5ba33 doc_id: 816871 cord_uid: fp8qcsv0 This article aims to give a brief outline of the pathogenesis and transmission of SARS-CoV-2 and how to safely navigate an arthroplasty practice during and after the pandemic. The coronavirus disease caused by the SARS coronavirus 2 (SARS-CoV-2) has 3 brought professional life to a standstill for many orthopaedic surgeons around the world. 4 Although some will be given roles to work on the front lines or take on leadership positions 5 during this crisis, many surgeons will act in a supportive or reserve role. This article aims to give 6 a brief outline of the pathogenesis and transmission of SARS-CoV-2 and how to safely navigate 7 your practice during and after the pandemic. We will outline recommendations of how to 8 resume clinical operations when restrictions are lifted. 9 Presentation and Incubation 11 As of writing of this manuscript there are over 3 million global confirmed positive 12 COVID-19 cases with over 215,000 deaths; however, the true number of cases has been and will 13 continue to be difficult to ascertain due to the varying nature of how the viral illness presents 14 [1] . Early presenting symptoms of the virus frequently include fever, non-productive cough and 15 fatigue and occasionally gastrointestinal symptoms and anosmia [2] [3] [4] . A well-characterized 16 subset of the population contracts the infection with indiscernible symptoms. The average 17 incubation period has been reported to last 14 days, with a median presentation of five days 18 [5, 6] . There have been some reports of patients remaining infectious for over 20 days from 19 symptom onset [5] . Without widespread testing, quantification of this asymptomatic group in 20 the pandemic is nearly impossible to determine [6] . Premature studies have suggested hydroxychloroquine, best known for its role in 46 malaria prophylaxis and rheumatoid arthritis maintenance therapy, and remdesivir, an antiviral 47 that gained popularity during the Ebola epidemic, could be effective in managing the COVID-19 48 disease [10] [11] [12] . While no current randomized controlled trials exist, both medications are 49 currently being investigated in several large clinical trials. Meanwhile, plasma infusion therapy 50 using the separated blood products containing antibodies against COVID-19 from patients who 51 have recovered is a strategy reserved for the most serious of cases [13] . Several vaccine trials 52 are on the horizon with hopes of mass production within the next 12-18 months to promote 53 long term immunity, but further research is still required. their anesthesia colleagues in regards to general or regional anesthesia for infected patients. 153 It is important to remain vigilant during this time of increased infectivity, especially in 154 high-risk environments such as the operating room and intensive care unit (ICU). According to 155 manufacturers, orthopaedic surgical hoods alone are not protective against this virus [13, 19] . 156 All surgeons and operative staff should maintain universal precautions at all times and use N95 157 masks when operating on suspected or confirmed 13, 20] . Covering the 158 N95 with a level 1 approved mask may help to prevent soilage, which then requires mask 159 disposal [13, 19] . Otherwise the N95 can be decontaminated by a variety of methods and then 160 re-used. for our patients. The ability to consistently and promptly identify SARS-CoV-2 carriers will 173 further help to navigate this pandemic. Routine serologic testing for SARS-CoV-2 for all patients, 174 and in some circumstances, healthcare staff, is being considered by public health officials. A timeframe for a normal elective arthroplasty schedule is still being debated. Initially 178 there will need to be a balance between surgical volume to address case backlogs and ensuring 179 orchestration of appropriate hospital support for patients regarding staff and supplies. In 180 addition, availability of operating room PPE and a reliable central processing system are keys to 181 operative consistency. Regular open communication with immediate team members, nursing 182 managers, and hospital administrators will facilitate a safe return to elective cases. 183 The surgeon also needs to facilitate discussions between device manufacturers and 184 hospitals to ensure essential equipment is available. This is of particular importance because 185 many supply chains have been disrupted; implant companies may need additional time to 186 ensure equipment and implants are readily available. During the early return to elective cases, 187 surgeons must remain flexible with operative schedules knowing that case mix may vary for an 188 extended period of time in comparison to previous practice routine. 189 Social distancing practices will likely persist for quite some time after elective cases 190 resume. Patient social support systems will be impacted as we expect most facilities will limit 191 visitors at office encounters and around the perioperative period for an underdetermined 192 period of time as we continue to navigate the viral pandemic. Surgeons should be prepared for 193 the possibility that a patient's family member or support person may not be allowed to enter 194 the facility and their comfort level without a "coach" may lead to delay or cancellation of the 195 surgery. These considerations will likely impact the surgeon's normal schedule. Re-opening 196 schedules for elective cases will likely include some additional challenges. guidance on these issues. 216 Lastly, procedures and regulations will vary across different regions of the country and 217 community settings. Areas with lower viral density are more likely to see a faster "return to 218 normal" than harder hit regions. By the same token, hospitals and surgery centers in smaller 219 cities that are more remote from larger urban areas may be faster to ramp up their elective 220 schedules. 221 14 An evolution in healthcare is upon us as we learn to navigate this pandemic. Expect the 222 time to resume normal schedules and procedures to be gradual over the next several months. 223 Advances in telecommunication enable surgeons and therapists an avenue to provide 224 individualized patient care from a safe distance. Above all, communication remains essential to 225 meet patient needs and expectations. If a patient requires a face-to-face encounter, 226 appropriate precautions have been outlined to ensure the office visit is safe for all parties 227 involved. Because this respiratory disease is spread via droplet transmission, hand hygiene is 228 the most critical step to slow the spread of the COVID-19 virus. Patience is paramount as we 229 adapt our orthopaedic practices to safely meet the future needs of our patients. Worldometer Clinical Characteristics of Coronavirus Disease 2019 in China Survey of COVID-19 Disease Among Orthopaedic Surgeons in 240 People's Republic of China Clinical Course and Risk Factors for Mortality of Adult Inpatients with 244 China: A Retrospective Cohort Study The Incubation Period of Coronavirus Disease From Publicly Reported Confirmed Cases: Estimation and Application Clinical Outcome of 55 Asymptomatic Cases at the Time of 252 Hospital Admission Infected with SARS-Coronavirus-2 in Shenzhen, China Are Patients with Hypertension and Diabetes Mellitus at Increased Risk 256 for COVID-19 Infection Receptor Recognition by the Novel Coronavirus from Wuhan: An 260 Analysis Based on Decade-Long Structural Studies of SARS Coronavirus Modes of Transmission of Virus Causing COVID-19: 264 Implications for IPC Precaution Recommendations Use of Hydroxychloroquine and Chloroquine 270 During the COVID-19 Pandemic: What Every Clinician Should Know NIH Clinical Trial of Hydroxychloroquine, a Potential 274 Therapy for COVID-19, Begins COVID-19, Begins Department of Health & Human Services Preparing to Perform Trauma and Orthopaedic Surgery 306 on Patients with COVID-19 ACGME Resident/Fellow 310 Education and Training Considerations Related to Coronavirus (COVID-19) Resident/Fellow Education and Training Considerations Related to Coronavirus (COVID-19) Resident-Fellow-Education-and-Training-Considerations-related-to-Coronavirus-COVID-19 Laminar Air Flow Handling Systems in the Operating 316 Clinical Characteristics and Outcomes of Patients Undergoing 319 Surgeries during the Incubation Period of COVID-19 Infection 323 Information and Resources around Physical Therapy and COVID-19 Continue to Develop We would like to thank Denise Smith Rodd (Communications Department -American Association of Hip and Knee Surgeons) for her help collating and proofreading this manuscript.There were no funding sources for this manuscript All authors have contributed to the writing of this manuscript. BRL currently serves as Depuy Editor for Arthroplasty Today. He has recused himself from the communication, editorial, and peer review process for this submission.In addition, JRD and MWB currently serve on the Arthroplasty Today editorial board -They have been excluded from the peer review and editorial process for this manuscript.