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SA Orthopaedic Journal

versión On-line ISSN 2309-8309
versión impresa ISSN 1681-150X

SA orthop. j. vol.20 no.2 Centurion  2021




Here we go again: is this our new normal?



Lipalo Mokete

Orthopaedic surgeon and lecturer; Incoming President of the South African Arthroplasty Society




As I write this piece, we are in the throes of working through the logistical consequences of cancelling the 2021 Biennial South African Arthroplasty Society (SAAS) Conference. In May last year, even as the first wave of Covid-19 engulfed South Africa, we were confident of holding a successful congress in 2021. September came, Covid-19 cases receded, elective surgery resumed, and our lives started to take on a semblance of normality. This state of affairs lulled us into believing that we were on track to a relatively Covid-19-free 2021. The 2021 conference would be one way of reclaiming normality in our orthopaedic lives. However, we have now had to make the painful but inevitable decision to postpone the SAAS conference to 2022 as the Covid-19 pandemic has continued to be the chief disruptor in our lives for the second year running.

George Bernard Shaw is credited with the saying 'if history repeats itself, and the unexpected always happens, how incapable must Man be of learning from experience'. A quick Google search of the word 'pandemic' brings up the 1918 influenza pandemic which was the most widespread lethal pandemic in recent memory. According to the Centers for Disease Control and Prevention (CDC) in the US, an estimated 500 million people or one-third of the world's population became infected with the 1918 strain of the flu virus, and 50 million people succumbed.1 The 1918 pandemic had multiple waves, with the second wave being much more deadly than the first and third waves. One hundred years later and just over a year since the declaration of SARS-CoV-2 as a pandemic, we have been transported back in time. As implausible as it may seem given the significant advances in medicine and technology that we have witnessed in the last 100 years, 'we are much more vulnerable today to a catastrophic influenza pandemic than we were in 1918'.2 These are the words Dr Osterholm (Director of the Center for Infectious Disease Research and Policy at the University of Minnesota) intimated during the centennial of the 1918 flu epidemic in 2018, a full two years before the current pandemic. As we slowly get to grips with a new normal following the recent second Covid-19 wave, we should heed the warnings from the experts and prepare for a third wave. Vaccines offer a welcome respite from the misery we have endured but they have been late in coming to South Africa and they are unlikely to substantially change our course towards the inevitable third Covid-19 wave.

The social cost of the pandemic has been immense. There is not a single orthopaedic surgeon in South Africa who has not been affected by the pandemic. We bear deep personal scars having lost family members and colleagues to the pandemic. The effect on orthopaedic private practices has been brutal, with elective orthopaedics bearing the brunt. Elective joint arthroplasty has arguably suffered the most of all orthopaedic disciplines. We observed with trepidation as the first reports of the impact of the pandemic on elective orthopaedics started emerging from the northern hemisphere. Governments rightfully mandated the complete cessation of elective surgical operations.3 And soon we were living the same shared reality.

Fortunately, the South African Covid-19 surges and peaks have lagged the northern hemisphere and we can take valuable lessons from their experience. During the aftermath of the first wave in Europe, Oussedik et al. suggested reinstating elective orthopaedic surgery by operating on patients with a low risk of morbidity from Covid-19 with short duration of surgery first then progressing to include low-risk patients with longer duration of surgery or hospital stay.4 The vast majority of lower limb arthroplasty patients are at high risk for Covid-19 because of their advanced age and comorbidities. Furthermore, their surgery is high risk because of prolonged theatre time and hospital stay. Chang et al. showed that elective orthopaedic surgery could be done safely with a designated Covid-19-free pathway.5 As we emerged from the first wave, into an unfamiliar new normal, we recognised that there would likely be pent-up demand for elective joint arthroplasty and many of us armed with fresh Covid-19-safe treatment protocols started making plans accordingly. Private hospitals quickly ramped up capacity to handle elective surgery to make up for lost revenue. But patients have not returned in anticipated numbers. The green shoots that we experienced towards the end of 2020 were soon quashed by the advent of the second wave. Patients remain concerned and fearful of contracting Covid-19 in hospital settings. Our experience is certainly not unique as it mirrors that of other countries where arthroplasty surgical and outpatient volumes have failed to recover to pre-pandemic levels.6

The South African Orthopaedic Association has been supportive in mitigating the financial pain, but now more than ever, efforts need to be intensified to ensure the survival of orthopaedic private practices. Established practices will likely weather the storm because of their financial reserves; however, new practices will battle to survive the pandemic. The young, recently qualified orthopaedic surgeon, without the financial security of a government job, is facing a precarious financial future, certainly in the short term. Special efforts should be devoted to ensuring the survival of our young colleagues as South Africa can ill afford to lose orthopaedic surgeons. Admittedly, there is no financial blueprint regarding how to survive this once-in-a-lifetime event. There are a lot of knowledgeable individuals, but no experts!

As orthopaedic surgeons we need the collective wisdom and fraternity of our peers to navigate these unprecedented times. Our representative bodies have to be more aligned towards alleviating our common plight and serving our interests. As individuals we must keep adapting and learn to embrace the ever-evolving new normal.



1. Centers for Disease Control and Prevention [Internet]. 1918 Pandemic (H1N1 virus). Available from: [Accessed 03 March 2021].         [ Links ]

2. Voelker R. Vulnerability to the flu pandemic could be greater today than a century ago. JAMA. 2018;320(16):1523-25.         [ Links ]

3. Remuzzi A, Remuzzi G. Covid-19 and Italy: what next? Lancet. 2020;395(10231):1225-28.         [ Links ]

4. Oussedik S, Zagra L, Shin GY, D'Apolito R, Haddad FS. Reinstating elective orthopaedic surgery in the age of Covid-19. Bone Joint J. 2020;102-B(7):807-10.         [ Links ]

5. Chang JS, Wignadasan W, Pradhan R, et al. Elective orthopaedic surgery with a designated Covid-19-free pathway results in low perioperative viral transmission rates. Bone Joint Open. 2020;1-9:562-67.         [ Links ]

6. Tan YN, Vandekerckhove PJ, Verdonk P. The long road to recovery: at six months since the first Covid-19 wave, elective orthopedic care has not fully recovered in Belgium. J Exp Orthop. 2020;7:99.         [ Links ]



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