European Journal of Cardiovascular Medicine

cCOVID -19 pandemic had a great impact on the day to day life of people and healthcare, including orthopaedic clinical practice.1 The World Health Organization declared COVID-19 as a pandemic on 11 March 2020.2 The first case of COVID- 19 was reported from Kerala on 30 January 2020.3 In Jammu, the confirmed positive case was detected on 9 march 2020 having travel history.4 To control the pandemic, the Government of India announced a nationwide lockdown from 25 March 2020 so as to promote social distancing, stopping unnecessary movement of people, quarantine, tracing contacts, and use of masks, Personal Protective Equipments(PPE), testing facilities, notification of COVID designated hospitals. From orthopaedic healthcare in hospitals point of view, COVID-19 and the lockdown significantly affected the access to healthcare practices and delivery of the orthopaedic facilities including devices , equipments, modes of treatment.1,5 The medical symptoms like fever, cough, chest discomfort, flu like symptoms, associated with the orthopaedic problems affected the patient care.13 It also resulted in decrease of professional income of surgeons and hospitals.6,7 Due to this pandemic, not only in India but also in the western countries a lot of confusion in patient management and decision making took place.8 The Indian Orthopaedic Association (IOA) and British Orthopaedic Association (BOA) had published guidelines on the management of the orthopaedic patients requiring trauma and other orthopaedic related urgent care during the COVID-19 pandemic.9,10 Arksey and O’ Malley described rapid review as a type of knowledge synthesis in which the components of the systemic review process are simplified or omitted to produce information in a short period of time.11

The aim of our study is to aware the healthcare personnel including orthopaedic surgeons, postgraduate students, paramedics, and other staff about the pandemic situation of any kind if happens in future, the whole healthcare team gets prepared well on time by learning the experiences of the COVID-19 pandemic and the literature studies so that the future pandemic like situations, can be managed effectively well on time, in a coordinated way , following all safety measures, minimizing the associated risks, and appropriate decision making to decrease the negative impacts of similar pandemics in clinical orthopaedic practice for better patient care in future.

This was a retrospective observational study in design conducted in the Post graduate Department of Orthopaedics in a tertiary care hospital in Government Medical College and Hospital Jammu. The study was approved by the Institutional Ethics Committee GMC Jammu vide notice no: IEC/GMJ/2022/1053/ regd: C-297. The data was collected from the Medical Records Department for the year 2019 and 2020 which was analysed. It was aimed to compare the impact of COVID-19 pandemic on orthopaedic practice with the previous year. The effects of COVID -19 pandemic on various clinical parameters like outpatient numbers, indoor patient admissions, management options conservative and surgery were noted. The data was divided into two groups. In the first group, April 2019 to December 2019; and in the second group from April 2020 to December 2020. The effect of Pandemic on conservative treatments like plaster application, and the effect on surgical treatments categories like arthroplasty, arthroscopy, trauma, spine and other surgeries, and other changes in patient management at our set up was studied. The effect of pandemic on Surgeons, mental stress among doctors, postgraduate students and patient was studied.

Triage: The American College of Orthopaedic Surgeons had recommended an appropriate triage plan for surgical treatment of orthopaedic patients.¹² The patients reporting to the orthopaedic emergency hospital were screened for fever. The COVID -19 test using nasopharyngeal swab was also done.

In the present study, the number of patients attending the orthopaedics department was decreased, including OPD, admission and surgery, follow up in the year 2020 in the pandemic.

Total cases in 2019 = 29700

Total cases in 2020 = 6500

Difference in the cases = 29700-6500 =23200

Difference in cases in April and May was 6600-850 = 5750

In the present study, the OPD cases were reduced by 78.11%. The maximum reduction was seen in the lockdown period of 2 months April 2020 and May 2020 (lockdown period) which was 87.12%.

Total admissions in 2019 = 2690

Total admissions in 2020 = 855

Difference in admissions = 2690 – 855 = 1835

Difference in admissions in April and May 2020 was 400 – 105 = 295

The admission of the orthopaedic trauma cases was reduced by     68.21%. The maximum reduction was seen in the lockdown period of 2 months April 2020 and May 2020 (lockdown period) which was 73.8%.

Total surgeries in 2019 = 1660

Total surgeries in 2020 = 483 Difference in surgeries = 1177

Difference in surgeries in April and May 2020 was 390 – 48= 342

The number of orthopaedic surgeries done in the time period of 2019 and 2020 were 1660 and 483 respectively. The surgical procedures were reduced in the year 2020 by 70.90%. Maximum reduction was seen in the lockdown period which was 87.7%.

Table1:ShowingreductioninOPDcases,admissionsandsurgery.

Table2:Showingvarioussurgicalprocedures.

Figure5:DiagramshowingnumberofArthroplasty,Arthroscopy,SpineSurgeriesin2019and2020.

In the present study, the outdoor patients were reduced by 78.11%. The maximum reduction was seen in the lockdown period of 2 months April 2020 and May 2020 (lockdown period) which was 87.12%. The admission of the orthopaedic trauma cases was reduced by 68.21%. The maximum reduction was seen in the lockdown period of 2 months April 2020 and May 2020 (lockdown period) which was 73.8%. The number of orthopaedic surgeries done in the time period of 2019 and 2020 were 1660 and 483 respectively. The surgical procedures were reduced in the year 2020 by 70.90%. Maximum reduction was seen in the lockdown period which was 87.7%. According to various studies, a significant reduction in the orthopaedic related workload was seen. There was reduction in the orthopaedic and trauma cases as the people were forced to stay indoors due to lockdown, outdoor services were given with prior appointment. Also, telemedicine services were started by the administration to reduce the risk of exposure. The hospital staff, residents, doctors were mobilised to provide COVID-19 services irrespective of the speciality.

A study was conducted in Italy during lockdown which showed that the mean age of the COVID-19 patients was 51.9 years which was higher than the previous year 2019 (p < 0.0001).¹⁴ Another study done in Italy showed a decrease in emergency visits by 18%. Orthopaedic road accidents cases were reduced by 26.8% while trauma cases at home were increased by 19.1%.¹⁵ A study was done in Germany which revealed that the total orthopaedic trauma patients were decreased , and the incidence of domestic violence, home injuries, bicycle accidents and drug abuse was increased as per patients history reporting the orthopaedic emergency.¹⁶ During the initial stage of the pandemic, orthopaedic surgeons a lot of mental stress in dealing with the patients.⁹ Similar trends were shown by our studies. Battiato et al. observed a significant reduction in the elective surgery to 50%, during pandemic in Central Italy.¹⁷ Bedard et al. also noted a significant impact of COVID-19 in the USA.¹⁸ Best et al. in their study showed that all the elective orthopaedic surgeries were significantly reduced in the USA.¹⁹ The results of the literature were similar to our study.

Table 3: Studies showing trend in COVID-19 orthopaedic trauma and practice.

The present study showed that COVID -19 had shifted the management in patients from surgical to conservative side. Many patients with trauma were treated conservatively, like humerus fractures, isolated forearm fractures, proximal humeral fractures, tibia shaft fractures, femur fractures, distal tibia fractures, malleolar fractures by using casts, braces splints. The elderly patients not fit were treated using conservative methods. Results were similar as given by Iyengar et al. ²³.In the present study, the follow up of the patients was missed which led to non union, delayed unions, stiffness due lack of rehabilitation which were later managed after the pandemic period was over. In the present study, loss to follow up was 58%. Study by Stone et al. and Sajid Ansari et al. reported that loss to follow up was 69% and 57% respectively^24,25 The negative impact of COVID- 19 was also seen on the orthopaedic resident clinical practical teaching which was similar to studies given by Chatterji et al.²⁶ and Haider et al.²⁷

LIMITATION OF THE STUDY

The present study was a generalized study not focussing much on a particular issue, the type and outcome of a particular study. The study was more of epidemiological in type and retrospective.

Conflict of Interest: No

The World Health Organization declared COVID-19 as a pandemic on 11 March 2020. The study concluded that during Pandemic and disaster like situation decision making is an important step. Conservative treatment should be done as much as possible. Elective surgeries postponed and emergency surgeries be continued by keeping all safety measures. The aim of our study is to aware the healthcare personnel including faculty, orthopaedic surgeons, postgraduate students, paramedics, and other staff about the pandemic situation in future by providing the literature studies so that the orthopaedic patient care during such pandemics do not suffer.

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