With the novel coronavirus SARS-CoV-2 outbreak being highly contagious, it became clear that health care systems globally would need to evolve, develop strategies, identify new models or rejuvenate old conservative methods of orthopaedic care and thus reduce the risk of disease transmission. Managing trauma and elective surgery in India has been based on strategic recommendations provided by the Indian Orthopaedic Association (IOA) [1] , British Orthopaedic Association (BOA) [2] emergency sub-speciality guidelines and Ministry of Health and Family Welfare, Government of India. However, as and when the pandemic wanes and stabilizes, a surge in orthopaedic patients is expected due to restrictions imposed by the pandemic including situations of trauma conditions which have been managed conservatively along traditional established orthopaedic principles and require a second stage corrective procedure [3] . In India, both the public and private hospitals deliver trauma and orthopaedic services. There is a shortage of orthopaedic surgeons rendering care to people in India [4] with a disproportionate surgeon to patient ratio along with lack of post-operative intensive care bed facilities [3] . However, as we look forward, orthopaedic community and public health systems in India need to consider as to how one can provide the best care for patients in the post-acute stages of COVID-19, patients with trauma who could not have proposed surgery because of non-availability of facilities locally or no possibility of reaching to the higher surgical centres due to national lockdown along with those on current waiting lists for proposed elective orthopaedic surgeries [5, 6] . Currently physiological responses, mortality and morbidity in patients undergoing surgeries during the COVID-19 pandemic are still being published in literature [7, 8] .
The main factors likely to hamper re-introduction of these trauma and orthopaedic surgery would be: a) staff shortages due to sickness and quarantine, b) deficient supply-chain in the surgical materials (consumables, instruments and implants), c) increased expenses to the patients and insurance companies for following elaborate protocols during the surgery, d) availability of suitable operating theatres, e) availability of anaesthetists, f) adequate provision of intensive care unit (ICU) beds and g) prioritize or triage non-emergency surgery according to risk-benefit ratio for the patient and community.
We highlight the challenges and considerations which we anticipate may be encountered in the post COVID-19 scenario in a resource limited public health system like India with lessons learnt which may be applied to other evolving economies.
Challenges and Considerations 1. General Considerations 1.1 Planning-It needs to be dynamic. The planning will be the key logistical challenge and will have to be supported by guidance and observations from other health care organisations like World Health Organisation (WHO), Centres for disease control and prevention (CDC) [9] , Public Health England [10] , American college of surgeons [11] and National bodies of associate branches such as anaesthesia, infection control, and microbiology. These will be continually evolving and the surgeon needs to be frequently in touch with web education and news. [12] . Autonomous government institutions like All India Institute of Medical (AIIMS) will also need a reference document to resume non-emergency surgeries. The MOHFW has and will have an overarching role in regulation of resumption of elective and semi-elective surgery in post-COVID-19 phase in India. They will also have to continually evolve standard operative procedures (SOP) as per feedback from elective surgery patients.
The IOA has a pioneering role in overseeing orthopaedic surgery and education provision in India with a membership of more than 12,000 members associated with the organisation [1] . We are sure IOA will reflect on experiences of orthopaedic health care systems worldwide to provide new, updated guidance on recommendations for resuming safe elective and delayed trauma surgery.
will all need to be tested prior to considering surgery in the post-COVID-19 phase. COVID-19 antigen and antibody testing SARS-CoV real time reverse transcription polymerase chain reaction (rRT-PCR) test [9] can be done to evaluate active contagion or exposure to the virus. The rapid kit tests to check the antibodies are not recommended for use in the surgical patients due to their variable results [13] . testing updates, a logistical challenge is expected with the mobilization of national agencies to oversee and deliver the huge task of wide spread COVID-19 testing is a forethought. Clinical assessment and history of address of stay in a red zone or otherwise will assume more significance.
will have considerable challenges with multiple factors involved in post-COVID-19 recovery. Affordability of surgery, joblessness, economic recession will have significant impact for patients requiring surgery.
Availability of implants due to international and national travel restrictions, production and price hike by implant companies due to more demand and less supply are other confounding factors. Strategies for rural COVID-19 testing facilities will need to be stepped up urgently, to facilitate the detection of Coronavirus, before it is decided to start nonessential services. Morbidity attached to surgery is still based on very little evidence; re-surgence of conservative treatment would be the trend, to balance outcomes.
Mantri Jan ArogyaYojana (AB-PMJAY) or Ayushman Bharat PM-JAY is the world's largest health insurance/ assurance scheme fully financed by the GOI [15] . is available for free under Ayushman Bharat. Till 24th April 2020 about 21,160 hospitals across the India are empanelled with this scheme. This undoubtedly will give some boost to the patients who cannot afford the cost of surgery but will cause more financial burden to the GOI in this dented situation. Orthopaedic surgeons will need to factor in the price of extra tests required, record keeping and Personal Protective Equipment (PPE) and as such the cost for any procedures in hospital is going to rise especially for intended surgeries.
2.1 Timing of resuming orthopaedic surgery-As the incubation period of COVID-19 is reported to be 5-14 days it is recommended that a constant decrease in the rate of new COVID-19 cases for at least 14 days nationally or regionally in the area catered by the hospital is assessed prior to starting of elective or semi-elective procedures [16] . Timing will have to be coincided with availability and appropriate number of supportive equipment requirements e.g. ventilators, PPE and intensive care unit beds for post-operative care following surgery. Any resumption of elective surgeries or reopening of hospital should be approved by the appropriate state health authorities dealing with national COVID management action plan.
The ideal timing of fracture fixation has been the subject of debate for a number of decades.
As we routinely encounter that early fracture fixation is not always possible especially in hemodynamically unstable patients and with comorbidities, this probably will be compounded by the post-COVID-19 situation. In India, a delay in the definitive fixation of several fractures is delayed due to several reasons like lack of operation theatre availability, long waiting list in the public hospitals, and other operational reasons [6] . A late (>21 days) or delayed primary operative fixation of displaced fractures is a viable option for cases that presented late, with predictable, favourable results as described in many studies [17] [18] [19] . A delay to primary fixation of up to three months following injury may be acceptable [20] particularly if the outcomes in delayed surgeries are weighed against the risks of surgeries done during active COVID-19 infection and its associated complications.
orthopaedic elective surgery waiting lists will have to be re-assessed with regards to orthopaedic pathology, fitness for surgery, desire to undergo proposed surgery including revisiting informed consent. We do not know as yet what complications and physiological responses will be encountered in a post COVID-19 scenario. Hence with minimal current literature available on complications, a balanced, pragmatic approach may have to be undertaken. Robust pre-operative assessment to evaluate surgical fitness will be necessary with the aim to reduce the risk of postoperative complications with medical evaluation supported by preoperative assessment, detect asymptomatic carriage of COVID-19 and reduce the demand for post-operative intensive care facilities [11, 21] . It is the need of the hour that orthopaedic fraternity considering its high infectivity rates develop a chronological sequence of surgeries-a) surgeries which if not done in a month or so will cause impairment of limb function or make future surgery dangerous. (b) surgeries to improve lifestyle of patient and for more than one year old conditions can be withheld/deferred as of now unless patient function is seriously impaired that is he/she is bedridden/ cannot walk in house also and (c) a different approach needs to be made for immunocompromised patientsdiabetes mellitus, chronic organic dysfunction, on chemo/radiotherapy. It may be considered to make it mandatory for the patient to isolate himself/herself at home for at least two weeks prior to a major elective orthopaedic surgery like a joint replacement.
Non COVID-19 Care (NCC) zones and COVID-19 care zones will have to be undertaken. There may be a need to identify stand-alone hospitals, separate units on site or wards to facilitate patient admission. The biggest challenge in India will be the availability of resources including masks, gloves and PPE, operation theatre consumables, orthopaedic implants and instruments. Sufficient numbers of ventilators and high flow oxygen masks will also be required as a stand by necessity.
Education of the staff is an essential tool in infection control and needs to be a multi-disciplinary approach. Education, training and change of behaviour of health care workers in accepting and adhering to changes with implementation of standard operating protocol for managing post-COVID-19 conditions will be necessary to prevent recurrence of this viral infection.
2.5 Screening protocols--will have to be established. Television screens, posters on patient warning, disclosure and information need to be displayed and updated. All patients and staff will need to be screened for potential symptoms of COVID-19 prior to entering the NCC facility and staff must be routinely screened for potential symptoms. Isolation prior to surgery will be guided by infection control guidelines. Online patient registration has to be encouraged.
Orthopaedic theatre and staff planning-will require guidance regarding level of PPE used during the surgery and staff training.
Aerosol generating procedures (AGP) including anaesthetic induction and use of orthopaedic power tools would necessitate full PPE adornment [22] . Proper 'donning' and 'doffing' technique will need to be practiced. A separate operative theatre complex should be dedicated for the surgery involving suspected or infected patients of COVID-19 for emergency surgeries. These complexes must have separate access, the other infrastructure, and a separate exit of its own. Rodrigues-Pinto et al [23] have given a detailed account of the surgical team flow for the orthopaedic surgery in a COVID-19 dedicated operating theatre and divided the complex into five zones: i) Entry dressing room, ii) Anteroom, iii) Operating Room, iv) Exit room, and v) Exit dressing room. These protocols must be followed as far as possible. The orthopaedic operation theatre must have a High Efficiency Particulate Air (HEPA) filter/Laminar flow with high frequency and rapid air changes, to reduce viral contamination. Minimum required number of staff and doctors must present during the surgical procedure inside the operating theatre. The orthopaedic tools and procedures which generate aerosols like drills, reamers, saw and electro-cautery must be minimally or not used. The need to have covers for power tools like those currently used for arthroscopy equipment's and how to dispose the irrigating fluid without floor or personnel contamination needs to be worked out .Also the need to shift to un-reamed intramedullary nails and hand reamers and hand drills to reduce the amount of AGP may have to be borne in mind.
The operating team numbers and seniority will need to be judicious.
There has to be a re-enforced established plan for thorough cleaning and [24] . This is essential since usage of power tools e.g drills and saws along with anaesthetic intubation are AGP's. With the difficulties still being encountered in procuring PPE all efforts should be made to innovate them (e.g. intubation teams). Re-use and disposal will keep evolving as the knowledge consolidates in the world. telephone or video consultation), so as to avoid their hospital visit and face-to-face interaction with the doctor and other hospital staff [25] .
Appropriate arrangements will have to be in place to evaluate common complications e.g. surgical site infection assessment and venous thromboembolism pathways probably as one stop visits to either confirm or future follow-up. The follow-up clinic setups should be separate.
Rehabilitation service-Enhanced recovery programmes and discharge planning will play a key role in reducing the length of in-hospital stay.
Application of targeted rehabilitation at home principle identified in the pre-operative assessments may help safe and early discharge home [26] .
Video based rather than direct physical training will be the forward in the future [27] .
Surgical audit of the operated cases-Because of the high risk of getting infection in these operated cases, a strict and regular audit of all the cases must be done on a regular basis, so as to find out the surgical and medical outcome of these patients and it would help to make future planning and decision of going forward with more cases or going backwards, depending on the outcomes.
Second wave preparation-A second wave was seen in both the SARS and Spanish Flu pandemics following relaxation of lockdown and containment methods. We must take lesson from these epidemics that a possible second wave can occur with COVID-19 as well [28] . So therefore we need continued vigilant and prepare for such second wave [29] . A high index of suspicion is needed to detect new cases of COVID 19, in the weeks to months following a slowdown in new cases. We need to strictly follow the policies of disinfection of surfaces and a social distancing in anticipation of a second wave of COVID-19 [30, 31] . 