COVID-19 - ESSKA Guidelines And Recommendations For .
Mouton et al. Journal of Experimental 48-4(2020) 7:28Journal ofExperimental OrthopaedicsREVIEWOpen AccessCOVID-19 - ESSKA guidelines andrecommendations for resuming electivesurgeryCaroline Mouton1,2, Michael T. Hirschmann3, Matthieu Ollivier4, Romain Seil1,2 and Jacques Menetrey5,6*AbstractThe roadmap to elective surgery resumption after this COVID-19 pandemic should be progressive and cautious. Theaim of this paper was to give recommendations and guidelines for resuming elective orthopedic surgery in thesafest environment possible. Elective surgery should be performed in COVID-free facilities and hospital stay shouldbe as short as possible. For matters of safety, patients considered first for surgery should be carefully selectedaccording to COVID infection status/exposure, age, ASA physical status classification system / risk factors, socioprofessional situation and surgical indication. A strategy for resuming elective surgery in four phases is proposed.Preoperative testing for COVID-19 infection is highly recommended. In any cases, COVID symptoms including feverand increased temperature should be constantly monitored until the day of surgery. Elective surgery should bepostponed at the slightest suspicion of a COVID-19 infection. In case of surgery, adapted personal protectiveequipment in terms of gowns, gloves, masks and eye protection is highly recommended and described.IntroductionSince March 2020, hospitals and surgeons have been advised to postpone or cancel elective scheduled operationsuntil the inflection point in the exposure graph has passedso that healthcare infrastructures can support the criticalpatient care needs [1]. Hospital resources have thereforemainly been dedicated to the care of COVID-19 patientsresulting in thousands of orthopedic surgeries being delayed all over the world if they were not considered tocause a significant harm to the patient or outcome.It is commonly agreed that there should be a decreasein incidence of COVID-19 cases for at least 2 weeks before elective surgery is resumed [2]. In Europe, severalcountries will soon reach this goal. Although the sanitarycrisis can be considered to be under control, one shouldkeep in mind that the pandemic is not finished yet.* Correspondence: jacques.menetrey@hirslanden.ch5Centre de Médecine du Sport et de l’Exercice (CMSE), Swiss OlympicMedical Center, Hirslanden Clinique La Colline, Chemin Thury 7A, CH-1206Geneva, Switzerland6Division of Orthopaedic Surgery, University Hospital of Geneva, Geneva,SwitzerlandFull list of author information is available at the end of the articlePremature and sudden lifting of interventions could leadto a second wave of infections [3]. It is thus critical tomaintain regulatory measures within healthcare infrastructures within the next months to assure patient andstaff safety and limit the number of infections. This canonly be achieved by preparing the roadmap to electivesurgery resumption. Unfortunately, there is, to date, nospecific literature concerning the organization of an outpatient clinic and surgical activities [4].The aim of this paper was therefore to provide recommendations and guidelines for resuming elective orthopedic surgery in this period of pandemic in the safestenvironment possible and according to the current stateof knowledge on COVID-19.Surgeries covered by the present guidelineThe American Academy of Orthopaedic surgeons definedfour type of orthopaedics procedures in times of pandemic: A) emergency only, B) urgent types of surgeries, C)urgent/somewhat elective and D) elective (Table 1). Thecurrent guideline only covers categories A and B of thisdefinition. These include all types of surgeries with The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
(2020) 7:28Mouton et al. Journal of Experimental OrthopaedicsPage 2 of 7Table 1 Adapted from AAOS guidelines for elective surgery [5]CategoryABCDDegree of emergencyEmergencyUrgentUrgent/Somewhat electiveElectiveTypes of procedures(non-exhaustive selection)Life- or onsAcute intra- and periarticularligament & tendon conditionsMost traumacases(e.g. ACL tears, meniscusbucket handle tears)Selected trauma casesTotal joint arthroplastyOsteotomiesChronic intra- and periarticularligament & tendon conditionsChronic peripheral nervecompression syndromespredominantly chronic conditions or acute cases wheresurgery generally can be delayed without causing seriousharm to patients. More precisely, the following proceduresare considered: tendinous or ligamentous intra- or periarticular injuries of chronic and acute in nature;deformity-correcting osteotomies; joint arthroplasty procedures; elective shoulder, elbow, hand, hip, knee and footand ankle surgery.The present guideline is essentially based upon a review of sparse literature, interviews of specialist andmostly expert opinion. The content has been reviewedby a scientific committee. It can be useful in conductingnegotiations or for practical implementation at the levelof a hospital or a national specialty society but cannot beimposed as official guidelines. The purpose of this guideline is only to provide the community with possible answers as well as to raise awareness of the complexity ofthe problem.Before resuming surgical activitiesThe main objective before resuming any surgical activityis to assure that all necessary regulatory measures are inplace within the healthcare infrastructure to allow forthe safety of patients, physicians, staff and institutionuntil the end of the pandemic. All decision in theorganizational aspect should naturally be locally baseddecisions, follow legal restrictions and guidelines fromthe relevant health authorities.First, state and hospital regulations should allow for areturn to outpatient clinic and elective surgeries. Theseregulations/rules should be carefully reviewed to identifyany aspect that may impact the ability of the facility toprovide services. The facility’s liability and malpracticeinsurance should also be confirmed for the emergentservices. Ideally, a permanent COVID-negative clinicalpathway should be devoted to elective surgery or urgent,somewhat elective surgery. This could be an isolated institution, a separate COVID free building of the institution or made possible with the creation of additionalspace. Sufficient space should also be available to allowfor social distancing protocols.All collaborators should be tested (COVID-kit test, immune/serology test if possible) before resumption ofclinical practice. According to the development of thepandemic, they should be monitored on a regular (e.g.weekly) basis and their protection be guaranteed (supplies, PPE). Testing of patients should also be organizedbefore any surgery to avoid importing asymptomaticcases within the COVID-negative clinical pathway aswell as to prevent secondary surge. Prescreening of exposed patients is of importance to avoid the planning ofsurgeries during the incubation period of COVID-19and adequate policy should be implemented to avoidperi-operative COVID infection. Finally, care should betaken to operate patients when a standardized and sufficient postoperative follow-up is assured. Nurses, theteam of anesthesiology, physiotherapists should be consulted and aware that elective surgeries will start againto guarantee proper patient care.Preselection of patients eligible for surgeryWhen resuming surgical activities, a careful selection ofpatients should be implemented in order to limit the riskof infections and complications. The selection of prioritized patients should take into account several parameters such as COVID exposure, age, American Society ofAnesthesiologists (ASA) physical status classification system / risk factors and socio-professional situation.According to Fineberg [6], patients should be treatedaccording to their COVID-19 exposure. The author defined five types of patient categories: A patient (1) whois not known to have been exposed or infected, (2) whohas been exposed but is asymptomatic, (3) who has recovered from infection and maybe adequately immune,(4) who is possibly infected (persons with sign andsymptoms consistent with infection who initially testnegative), (5) who is infected.Age and comorbidities are recognized to be negativelyassociated with outcomes of COVID-19. They should betaken into account in evaluating the risk to operate a patient. In the analysis of 44,672 confirmed cases in China,81% of all death after COVID-19 infection occurred in patients above 60 years old [7]. A meta-analysis including 30studies and 53,000 patients revealed that age (above 50),smoking, and any comorbidity were significant predictorsfor disease severity [8]. Other comorbidities to considerinclude high blood pressure, cardiovascular diseases, diabetes, lung diseases, cancer, liver and kidney diseases [9].
Mouton et al. Journal of Experimental Orthopaedics(2020) 7:28Patients with BMI above [10] 30 kg/m2 may also be considered at risk for severe forms of COVID-19. Finally, thesocio-professional situation should be considered withprobably a priority for active workers. Other aspects suchas the presence at home from a person at risk for COVID19 may also be taken into account.To summarize, Table 2 presents the stratification ofthe theoretical risk of infection with respect to patientage, category according to Fineberg [6] and comorbidities. A sixth category of patients was added to take intoaccount the presence of comorbidities. To resume elective surgery, patients with no sign of COVID-19 or whohave recovered from the disease (categories 1, 2, 3)should have the priority. Patients with COVID-19 infection (suspected or confirmed: category 4, 5, 6) shouldhave fully recovered and displayed an adequate immuneresponse before considering surgery. ASA I (normalhealthy patient) and II (patient with a mild systemic disease) should also have the priority. Any risk factor or comorbidity (e.g. age 60 years, obesity, high blood pressure,cardiovascular disease and diabetes) should be disqualifying conditions in the early phase of elective surgeryresumption.Implication of surgical indications in patientselectionIn the early phase, patient selection should also includethe indication for surgery. The viral SARS Cov-2 concentration in articular, periarticular and bony tissues andfluids of infected patients is currently unknown. However, it is reasonable to assume that it is lower in musculoskeletal tissues than in respiratory or digestive tissues.Given these uncertainties, it is recommended to decreasethose types of surgeries which generate a high amountof aerosol like electrocautery, working with oscillatingsaws as well as pulse lavage procedures [12]. In the absence of well-established scientific criteria, minimally invasive and arthroscopic may have the lowest infectionrisk and currently appear to be safer. They should beconsidered a priority if elective surgeries will be resumed. Surgical procedures followed by a hospital stayof no more than two to three days should be initiallyTable 2 Stratification of the theoretical risk of infection withrespect to patient age, category according to Fineberg [11] andcomorbiditiesCategory/Age 4040–6060–7070 1 23 4 5 6 Page 3 of 7favored. Surgeries with a higher degree of invasivenessand blood loss may follow later.Overview of patient selection processCurrently, it appears that patients of categories 1–3(combining the criteria young age, absence of comorbidities, Table 2) and minimally invasive or arthroscopicsurgery may have the lowest risk both for patients andsurgeons. A strategy for resuming elective surgery maythus be foreseen in 4 phases: (1) Mini-invasive surgeriesfor patients under 60 years old, with no comorbidity andan hospital stay of maximum 3 days, (2) Surgeries for allpatients without comorbidities and an hospital stay ofmaximum 3 days, (3) Mini-invasive surgeries for patientsunder 60 years old, with comorbidities or with an hospital stay above 3 days, (4) Surgeries for all patient withcomorbidities (Table 3). Within each of these phases,two scenarios should be considered through a carefulpreoperative screening of patients. Appropriate scheduling should be made according to the COVID status andpatients with no sign of COVID-19 or who have recovered from the disease (categories 1, 2, 3) should be separated from patients with COVID-19 infection (suspectedor confirmed: category 4, 5, 6). The surgery should bedelayed by a minimum of 8 weeks for the latter (untilfull recovery).Pre-operative screeningPatient should be screened preoperatively (e.g. by tele-orvideoconference). A detailed discussion with the patientabout his/her situation may be organized and includesCOVID-19 related questions (symptoms, exposure, previous testing). Patients must understand all aspects of his/her medical care that may change due to the currenthealth emergency situation and also be aware about thelimited but existent risks of COVID-19 infection duringsurgery / hospitalization. Despite all the preventive measures organized by the facilities to avoid COVID-19 infections during surgery and/or hospitalization, the infectionrisk can indeed not be 100% excluded. The patient shouldthus agree to undergo surgery under these conditions aswell as additional preoperative screening. If a suspicion orconfirmation of COVID-19 exists after the preoperativescreening, the surgery should be delayed.In any cases, COVID symptoms including temperatureshould be constantly monitored until the day of surgery.Patients who are not known to have been exposed or infected (category 1) should receive at least receive aCOVID-19-RT-PCR test 48 to 72 h before the operation.Patients who have been exposed but asymptomatic (category 2) should get a COVID-RT-PCR test, and eventually lung CT-scan 48 to 72 h before surgery. Patientswho have recovered from infection and maybe adequately immune (category 3) should get a validated
Mouton et al. Journal of Experimental Orthopaedics(2020) 7:28Page 4 of 7Table 3 Strategy for resuming elective surgery in 4 phases according to patient age, comorbidities, type of surgery and length ofhospital stayPriority1ScenarioABCDEFGHPatient age 60 60All agesAll ages 60 60All agesAll agesSurgeryMini-invasiveMiniinvasiveMini invasive and Mini invasiveopen surgeryand opensurgeryMini-invasiveMiniinvasiveMini invasive and Mini invasiveopen surgeryand opensurgeryLength ofstayMaximum 3 daysMaximum3 daysMaximum 3 daysMaximum 3daysAllAllAllAllComorbidities NoneNoneNoneNoneNone / ExistingNone /ExistingExistingExistingCovid-19Infected /WithsymptomsNo risk detected/ PotentiallyrecoveredInfected /WithsymptomsNo risk detected/ PotentiallyrecoveredInfected /WithsymptomsNo risk detected/ PotentiallyrecoveredInfected /WithsymptomsNo risk detected/ Potentiallyrecovered23immune/serology test if allowed and available 48 to 72 hbefore surgery. Patients presumed to be infected (category 4) should get a repeated COVID-RT-PCR test,and eventually lung CT-scan before considering any surgeries. Finally, surgery of infected patients (categories 5and 6) should be delayed until full recovery (at least 2months) and should get COVID-RT-PCR test, and eventually lung CT-scan 48 to 72 h before surgery.A systematic review reported that 2588 out of 2866(88.2%) patients displayed abnormalities on lung CTscan which places this technique as a good candidate todetect COVID-19 patients [11]. Known features ofCOVID-19 on lung CT-scan mainly include bilateral(87.5%, 435 out of 497 patients), multilobular (78.8%,108 out of 137), ground-glass opacification (GGO; 88%,346 out of 393) with a peripheral (76.0%, 92 out of 121)or posterior distribution (80,4%, 41 out of 51) [13]. Ithas been shown that some patients with a negativeCOVID-RT-PCR test displayed abnormalities on lungCT-scan [14], questioning the sensitivity of the RT-PCRtest. It appears that the combination of RT-PCR andlung CT-scan lead to the highest diagnostic sensitivity[15] (92%) compared to RT-PCR alone (78%), lung CTscan alone (67%) or combination of 2 RT-PCR (86%).Combination of both RT-PCR test and lung CT-scan toexclude COVID-19 patients is thus recommended tolimit the risk to bring infected patient to surgery.Other tests, depending on facility rules, may includestool culture as a meta-analyses reported that viral RNAcould be found in 48,1% of stool samples (95% CI,38.3%–57.9%) [16]. An interesting fact is that 70.3% ofthe positive samples were collected after loss of virus detection from respiratory specimens. Stool culture maytherefore be of interest after COVID-19 infection toinsure that the patient is free from virus.Before surgery, blood samples should be analyzed to detect any abnormalities such as an increased in C-reactiveprotein and modified blood count. A meta-analysis of 194publications [17] showed that common laboratory findingsin COVID-19 patients (observed in more than half ofstudied patients) included: decreased albumin (75,8%; 95%CI: 30,5–100,0), high C-reactive protein (58,3%; 95% CI:21,8–94,7), high lactate dehydrogenase (57,0%; 95% CI: 38,0–76,0), lymphopenia (43,1%; 95% CI: 18,9–67,3).AnesthesiaPrevention of the coronavirus through aerosolization in apotentially infected patient should be the priority [18].Therefore, it appears that local/regional anesthesia shouldbe preferred to invasive airway management wheneverpossible for elective orthopaedic procedures of the upperand lower extremity. Spinal anesthesia is reported to besafe, even in COVID positive patients [19]. If possible, patients should wear surgical masks during the procedure.In case of anesthetic procedures with invasive airway management, surgeons should be aware that aerosolizationthrough exhaled gases may occur. After the procedure,coughing on emergence should be minimized or avoided,as well as postoperative nausea and vomiting. Routinethrombo-prophylaxy should be meticulously prescribedfor the time being between the operation and theauthorization for partial to full weight-bearing.Recommended personal protective equipment(PPE)Balanced recommendations for PPE in operating areafor COVID-19 positive patients or suspected COVID-19patients are found in Table 4 [12]. Sterile surgical gownsare part of the standard protection in the OR. In everysurgery the OR team consisting of the surgeon, the surgical assistants and the scrub nurse wear sterile surgicalgowns in order to reduce intraoperative wound contamination and to minimize the patient’s infection risk. It isalso a personal protection against blood and body fluidswhich often spray in an area of 3–8 m around the operating table. The safety levels of gowns for medical use
Mouton et al. Journal of Experimental Orthopaedics(2020) 7:28Page 5 of 7Table 4 Balanced recommendations for PPE in operating area for COVID-19499 positive patients or suspected COVID-19 patients[12]Health carepersonal (HCP)MasksSurgicalFFP1–3N95–100Patient transport in and from ORPersons involved intransport of patientsXTransfer of patient into OR areaAll HCPIntubation and initiation ofanesthesia in ORAll HCP in ORSurgery including surgical AGPsSurgery including respiratoryAGPsSurgicalgownsEye protectionGloves–Level 1–XX–Level 1XX– FFP2/N95FFP3N99 Level 3X when distance 2mXAll HCP in OR– FFP2/N95FFP3N99 Level 3X when distance 2mX (double gloving)Occupationaldepartmentpersonal (ODP)X Level 3XX FFP2/N95FFP3N99or PAPRaif surgeon needs it Level 3X when distance 2mXAll HCP in OROccupationaldepartmentpersonal (ODP)X– Level 3XXExtubation and ending ofanaesthesia in ORAll HCP in OR– FFP2/N95FFP3N99 Level 3X when distance 2mXCleaning of ORCleaning personal– FFP2/N95FFP3N99 Level 3XXPowered air-purifying respirator, X indicated, not indicatedacan be classified in levels 1–4 [20]. Level 1 gowns shouldbe used in minimal risk environment such as basic careor for visitors. Level 2 gowns should be used in low riskprocedures such as venous blood draw. Level 3 gownsare generally used for moderate risk procedures such asarterial blood draw, or in the ER. Level 4 gowns are preserved for high risk procedures such as surgery or wheninfectious diseases are suspected.Helmets or togas might also be an option for protection against body spray, but only protect against airborne transmission of COVID-19 in combination withrespirator masks. There are three different types of disposable masks available. Single-use face masks, surgicalmasks, and respiratory masks. Single use face masks,which are typically thin and consisting of only one layerare only capable of filtering rather larger particles(3 μm). Surgical masks are generally more effective thansingle use face masks in filtering virus-sized particles. Amedical or surgical mask may be sufficient to preventdroplet transfer but do not offer protection against highrisk AGPs, while a respirator mask is required for airborne infection. Air purifying respirator masks shouldthus be used as they are generally filtering smaller sizedparticles (0.3 μm) than surgical masks. The EuropeanStandard (EN 149:2001) classifies respirator masks intothree different categories: Filtering facepiece 1 (FFP1),FFP2, and FFP3. FFP2 is comparable to US standardN95 [21]. Respiratory AGP require FFP3 masks orpowered air-purifying respirators, whereas surgical AGPonly require FFP-2 masks. The fitting and sizing of themask is of utmost importance. Only a perfect sized andwell fitted mask leads to efficient sealing of the respiratory tract.Eye protection is critical for orthopaedic surgeons asmany procedures such as the use of power tools frequently lead to contamination of every OR personal inthe room and surface contamination in the OR in anarea of up to six meters around the operating table.Post-operative follow-upTo assure a proper post-operative management of electivecases, the country, the region, the city should be partiallyor completely reopened with notably a reopening of physical therapy and outpatient facilities. Postoperative appointments should be planned in the early postoperativephase to detect potential COVID-related complicationsand made, if possible, with the use of videoconferenceand/or telehealthcare to minimize repetitive postoperative visits and therefore limit patient displacement.If telehealthcare cannot be considered for some patients, the facility should organize a specific flow of patients to allow distancing protocol. This can include aminimization of patient number, maintaining a gap between booked appointments, preparing the waiting roomwith enough space for social distancing protocols and
Mouton et al. Journal of Experimental Orthopaedics(2020) 7:28Page 6 of 7organize the patient itinerary to avoid patients to comeacross from each other.Received: 30 April 2020 Accepted: 5 May 2020ConclusionThe roadmap to elective surgery resumption should beprogressive and cautious, especially in area of pandemicfocus. Elective surgery should ideally be strictly performedin a COVID-free facility and hospital stay should be asshort as possible. For matter of safety, patients operatedfirst should be carefully selected according to COVID exposure, age, ASA physical status classification system /risk factors, socio-professional situation and surgical indication. At the slightest suspicion of COVID symptoms,elective surgery should be postponed. In case of surgery,close monitoring of COVID-19 signs and adapted personal protective equipment is highly recommended.References1. American College of Surgeons (ACS). 2020 COVID-19 update: guidance fortriage of non-emergent surgical procedures. iage Accessed 13 Mar 20202. Am. Coll. Surg (2020) Joint statement: roadmap for resuming electivesurgery after COVID-19 pandemic ftercovid-19-pandemic Accessed 17 Apr 20203. Prem K, Liu Y, Russell TW et al (2020) The effect of control strategies toreduce social mixing on outcomes of the COVID-19 epidemic in Wuhan,China: a modelling study. Lancet Public Health. https://doi.org/10.1016/S2468-2667(20)30073-64. de Caro F, Hirschmann TM, Verdonk P (2020) Returning to orthopaedicbusiness as usual after COVID-19: strategies and options. Knee Surg SportsTraumatol Arthrosc. https://doi.org/10.1007/s00167-020-06031-35. AAOS guidelines for elective surgery - American Academy ofOrthopaedic Surgeons. .Accessed 30 Apr 20206. Fineberg HV (2020) Ten weeks to crush the curve. N Engl J Med 382:e377. Hospitalization rates and characteristics of patients hospitalized withlaboratory-confirmed coronavirus disease 2019 — COVID-NET, 14 States,March 1–30, 2020 MMWR8. Zhao X, Zhang B, Li P et al (2020) Incidence, clinical characteristics andprognostic factor of patients with COVID-19: a systematic review and metaanalysis. medRxiv Cold Spring Harbor Laboratory Press, Cold Spring Harbor2020.03.17.200375729. Yang J, Zheng Y, Gou X et al (2020) Prevalence of comorbidities and itseffects in coronavirus disease 2019 patients: a systematic review and metaanalysis. Int J Infect Dis 94:91–9510. Garg S (2020) Hospitalization rates and characteristics of patientshospitalized with laboratory-confirmed coronavirus disease 2019 — COVIDNET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep 6911. Fang Z, Yi F, Wu K et al (2020) Clinical characteristics of coronaviruspneumonia 2019 (COVID-19): an updated systematic review. medRxiv ColdSpring Harbor Laboratory Press, Cold Spring Harbor 2020.03.07.2003257312. Hirschmann MT, Hart A, Henckel J et al (2020) COVID-19 coronavirus:recommended personal protective equipment for the orthopaedic andtrauma surgeon. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-020-06022-413. Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A (2020) Coronavirusdisease 2019 (COVID-19): a systematic review of imaging findings in 919patients. Am J Roentgenol Am Roentgen Ray Soc: 34:1–7. https://doi.org/10.2214/AJR.20.2303414. Xie X, Zhong Z, Zhao W et al (2020) Chest CT for typical 2019-nCoVpneumonia: relationship to negative RT-PCR testing. Radiology. 34:200343. https://doi.org/10.1148/radiol.2020200343 Radiological Societyof North America15. Jiang G, Ren X, Liu Y et al (2020) Application and optimization of RT-PCR indiagnosis of SARS-CoV-2 infection. medRxiv Cold Spring Harbor LaboratoryPress, Cold Spring Harbor 2020.02.25.2002775516. Cheung KS, Hung IF, Chan PP et al (2020) Gastrointestinal manifestations ofSARS-CoV-2 infection and virus load in fecal samples from the Hong Kongcohort and systematic review and meta-analysis. Gastroenterology. https://doi.org/10.1053/j.gastro.2020.03.06517. Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E et al (2020)Clinical, laboratory and imaging features of COVID-19: a systematic reviewand meta-analysis. Travel Med Infect Dis. 34:101623. https://doi.org/10.1016/j.tmaid.2020.10162318. Rajan N, Joshi GP (2020) The COVID-19: role of ambulatory surgery facilitiesin this global pandemic. Anesth Analg. https://doi.org/10.1213/ANE.000000000000484719. Zhong Q, Liu YY, Luo Q et al (2020) Spinal anaesthesia for patients withcoronavirus disease 2019 and possible transmission rates in anaesthetists:retrospective, single-Centre, observational cohort study. Br J 0. ASTM Standards & COVID-19. https://www.astm.org/COVID-19/.Supplementary informationSupplementary information accompanies this paper at nal file 1. Facility checklist to resume elective surgery.Additional file 2. What should I inform my patient about beforeundergoing surgery?Additional file 3. Preoperative screening of patients.Additional file 4. Which patients should you begin with for electiveorthopaedic surgery?AcknowledgementsThe authors would like to thank the following people who participated inthe Review Committee of these guidelines: Philippe Beaufils, James Calder,David Dejour, Michael Hantes, Henrique Jones, Nanne Kort, Giuseppe Milano,Joan C. Monllau, Hélder Pereira, Nicolas Pujol, Pietro Randelli, StefanoZaffagnini.Authors’ contributionsAll authors contributed equally to the study. The author(s) read andapproved the final manuscript.FundingON Foundation.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author detailsSports Clinic, Centre Hospitalier de Luxembourg – Clinique d’Eich, 78, rue d’Eich, 1460 Luxembourg, Luxembourg. 2Luxembourg Institute of Research inOrthopaedics, Sports Medicine and Science, Luxembourg, Luxembourg.3Department of Orthopaedic Surgery and Traumatology, KantonsspitalBaselland (Bruderholz, Liestal, Laufen), CH-4101 Bruderholz, Switzerland.4Department of Orthopedics and Traumatology, Aix Marseille Univ, APHM,CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Marseille,France. 5Centre de Médecine du Sport e
REVIEW Open Access COVID-19 - ESSKA guidelines and recommendations for resuming elective surgery Caroline Mouton1,2, Michael T. Hirschmann3, Matthieu Ollivier4, Romain Seil1,2 and Jacques Menetrey5,6* Abstract The roadmap to elective surgery resumption after t
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