Discussion
In view of the current health crisis due to COVID-19, the suspension of elective surgery and all non-urgent activities is a fundamental measure both to limit the spread of the infection and to relocate medical and nursing staff to COVID-19-dedicated departments [18]. Other fundamental measures are the drafting of precise national and intra-hospital protocols, the training of personnel, and the supply of all necessary PPE. Nonetheless, there are still significant differences between protocols in different countries regarding the organization of departments, patient management, and rules for healthcare professionals [19].
Orthopaedic surgeons are at the forefront of this emergency, and numerous cases of SARS-CoV-2 infection have been recorded among them; a Chinese study showed an incidence of COVID-19 between 1.5 and 20.7% in eight hospitals in Wuhan. The most suspected places for exposure to the virus were the wards, public places in hospitals, operating rooms, intensive care units, and outpatient clinics. A quarter of the infected orthopaedic surgeons passed on the virus to other people, including family members, friends, colleagues, and patients. Severe fatigue has proven to be a risk factor for COVID-19, so an optimal organization of health workers’ shifts is of crucial importance [20].
In Italy we are experiencing a high number of COVID-19 deaths among doctors. Many surgeons feel exposed to a high risk of contagion, and the supply of PPE is not always adequate in all hospitals [21]. Thanks to the organization and protocols described above, the health workers of our unit are provided with all the necessary PPE. In addition, since we enabled these measures, we have not recorded new cases of infection among doctors and nurses in orthopedic wards and operating rooms.
In recent months, due to national measures to contain the infection, road accidents have decreased in Italy, and most of the fractures occur in elderly patients with significant comorbidities. These patients are also those most severely affected by COVID-19 [22]. Considering the high risk of rapid deterioration of their health conditions [23], it is necessary to carefully evaluate these patients to decide whether or not to undergo surgery for the treatment of fractures. The flow chart created by our anaesthesiology team (Fig. 2) is currently guiding us in the management of these patients; the measures we have adopted for our surgical activity are in accordance with the latest indications of the scientific literature [24, 25]. Although we do not yet have the numbers to demonstrate the effectiveness of this system, we are recording the data for further analysis.

Limitations
We have been adapting to a rapidly changing environment. These strategies proved to be practical and feasible. Having a well thought plan helps to provide for the most robust response possible. However, this strategy has several important limitations. First, we have not yet been able to study the effectiveness of our proposed strategies. Second, our contingency plan is a temporary emergency plan that could not resist long-scale outbreak. This plan was rapidly developed and continues to be modified and updated at “Spedali Civili” Hospital in Brescia. Finally, the isolation OR workflow and clinical care guidelines are institution- and department-specific; hence, our recommendations may not be applicable to all healthcare facilities. Nonetheless, we thought that it would be useful to share our early experience to help other institutions conducting and adapting such strategies more quickly.