In recent months, the SARS-CoV-2 pandemic (COVID-19) has evolved rapidly in Europe, disrupting the personal, social, economic and professional lives of health professionals on a large scale. The overall goal of most governments in Europe has been to flatten the curve of infected SARS-CoV-2 patients and prevent a collapse of national health systems. The April 2020 SARS-CoV-2 survey completed by EHS and EKA members in Europe has confirmed the impact of SARS-CoV-2: this pandemic has resulted in a tremendous reduction in primary hip and knee arthroplasty procedures as shown in the survey. A broad consensus is needed about the factors that need to be in place before restarting such procedures.

Delaying hip and knee arthroplasty in patients with severe osteoarthritis (OA) may lead to increased opioid use. It is associated with lower clinical results and increased readmission rates after the index procedure. Moreover, when access to hip and knee arthroplasty is limited, as it is now in the wake of the COVID-19 sanitary measures, the direct and indirect costs for our health care and social systems are enormous. Many patients suffering from OA have to prolong their absence from work, request temporary unemployment benefits, and burden the public welfare system.

We are now entering a new phase in most European countries, where we can consider restarting elective hip and knee arthroplasty in a “post-pandemic” period. To date, the scientific basis for the existing guidelines is not robust; there is much room for an exchange of ideas between surgeons. The current concern is to map out the optimal trajectory for starting up elective hip and knee arthroplasties. As a result, the European Hip Society (EHS) and the European Knee Association (EKA) formed a panel of experts that have produced a consensus on how the safe re-introduction of elective arthroplasty should be undertaken. They have provided recommendations based on the available evidence [1]. This survey aimed to validate the recommendations by involving arthroplasty surgeons from a wide geographical area to promote then the recommendations for a safe return to elective joint arthroplasty across Europe and elsewhere.

Materials and method

A prospective online survey was done online using SurveyMonkey (Portland, USA: among members of European Hip Society (EHS) and European Knee Associates (EKA). A link to the survey was sent by email to all members of the EHS and the EKA and affiliated arthroplasty surgeons. The online survey was launched on 23rd May 2020 and concluded on 6th June 2020.

The survey consisted of 27 questions. It includes basic information on demographics and details the participant’s agreement with each recommendation. The participant could choose among three options (agree, disagree, abstain). The recommendations focus on three time periods; pre-operative, per-operative, and post-operative (Table 1).

Table 1 Questions and Statements from recommendations used in the survey

This survey did not require formal ethical approval with a practice dedicated to adult reconstruction.


A total of 681 arthroplasty surgeons participated in the survey, with 479 fully completing the survey. The geographical spread of this survey included surgeons from 44 different countries in 6 continents (Fig. 1). The EHS and EKA had a 22.1% and 20.9% response rate, respectively. The mean time in practice for all participants was 20 years (min 1 year–max 46 years).

Fig. 1
figure 1

Geographical distribution of survey participants

The detailed results are shown in Table 2.

Table 2 Results of the survey


The survey has shown good-to-excellent agreement by the participants to the Statements made in the Recommendations for the safe return to elective arthroplasty following the COVID-19 pandemic. Although the response rate from both the EHS and EKA membership was low, at around 20%, it is notable that the mean time in elective arthroplasty of the participants was 20 years. This means that very experienced surgeons gave their opinions. Coupled with the global coverage of the survey, the mean time in elective arthroplasty is a proper validation for the recommendations.


The survey has shown good-to-excellent agreement of the participants with regards to the statements made in the recommendations for the safe return to elective arthroplasty following the first wave of the COVID-19 pandemic.