Limited Effect of Generalized Systematic Lockdown on Urgent Orthopedic and Limb Trauma Surgery in a Geographical Area Mildly Affected by the First of SARS-CoV-2 Pandemic: A Multicentric Study (Limited Effect of Lockdown in an Area Mildly affected by the Pandemic)

Introduction

The second quarter of 2020 saw the Covid-19 epidemic spread across Europe, causing an unprecedented healthcare, social, and economic crisis. At the beginning of autumn, the epidemic is still going on and rules limiting meetings and sometimes local lockdowns are maintained.

This new infectious disease, caused by the pathogen SARS-CoV-2, appeared at the end of 2019 in mainland China (Wuhan district) [1, 2]. The World Health Organization (WHO) declared a Covid-19 pandemic on 11 March 2020.

In response to this pandemic, health systems had to adapt, which included rescheduling all non-urgent medical and surgical care [3, 4] to reallocate resources (beds, care staff, etc.) to the emergency, infectiology and resuscitation services, which were in greatest need. In parallel, governments and their departments in each country took measures, of which the most emblematic one was the stay-at-home order or ‘lockdown’ [3]. In restricting the non- essential professional activities and also private activities of its population (ex. limitation of displacement for one hour and less than one-kilometer far from home) this measure sought to both curb the propagation of the virus within the country and relieve the national healthcare system. No data were then available to gage the true impact of a measure such as generalized systematic lockdown on urgent orthopedic and trauma surgery. First Chinese then European teams published figures soon after lockdown that showed marked reductions of such surgery, of at least 30% [5, 6, 7, 8, 9, 10, 11]. However, all these series were recorded in geographical areas with high population densities where the epidemic was especially active.

The present study set out to determine (i) the number of surgical operations in orthopedics and limb traumatology carried out during the first lockdown in a region of metropolitan France mildly affected by the SARS-CoV-2 epidemic, and (ii) the types of emergency surgery (main characteristics) performed during that period.

The hypothesis was that the decrease in surgical activity during lockdown would be less than 30% in this area.

Materials and Methods

A retrospective, comparative, observational, multi- centric study of emergency surgery in orthopedics and limb traumatology was conducted over the three months encompassing the health crisis due to the SARS-CoV-2 pandemic.

Three care centers took part in this study: two public teaching hospitals and one private hospital offering an ‘SOS hand injury’ service (French Federation of Emergency Hand Injury Services, FESUM). Together they serve two administrative districts with a total population of 1.03 million. They are reference centers for orthopedics and traumatology (‘trauma centers’) in their administrative regions (population about 2.1 million) [12].

These two administrative districts were mildly affected by the SARS-CoV-2 epidemic (Figure 1). The first cases found in this geographical area were detected on 5 March 2020. The total number of deaths recorded over the study period was 67 (3.5 per 100,000 inhabitants). By comparison, the Covid-19 death rate in the whole of France was 43 per 100,000 inhabitants (28,833 deaths) over the same period.

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The medical records of all the patients undergoing surgery between 1 March and 1 June 2020 in these centers were analyzed anonymously. The following data were collected: date of surgery, patient’s age and sex, their main place of residence, the principal standardized descriptor categorizing the anatomic location of the condition (French CCAM code), namely proximal femur, pelvis, femoral and tibial diaphysis, knee, ankle, shoulder/humerus, distal radius, hand/wrist (soft tissue/bone), the context in which the injury occurred (sport accident, occupational accident, accident in everyday life, DIY/gardening accident, road traffic accident, infection, cancer), and lastly SARS-CoV-2 PCR status. The reference period for the data comparison was the same successive weeks in 2019. The data about the SARS-CoV-2 pandemic (rate of death) were obtained from French Public Health and www.coronavirus-statistiques.com (Eficiens) websites.

Results

Volume of Activity

In the three care centers included in the study, 1098 patients underwent surgery during the lockdown against 1266 over the same period in 2019, a non-significant difference of −13.3% (p = 0.11). This trend in activity was superimposable in the three centers (p = 0.27).

The period of least activity was Week 13 (5 days after the start of lockdown) with a significant decrease in activity of 39.2% (103 patients versus 173 in 2019) (p = 0.02). Conversely, in the last week of lockdown (Week 19), activity increased non-significantly by 7.6% relative to 2019 (127 versus 118 patients) (p = 0.16). In all, three weeks out of the eight weeks that the lockdown lasted (Weeks 13, 14 and 15) showed an activity below 75% of that for the same period in 2019 (375 versus 505 patients) (Figure 2) (p = 0.04).

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Discussion

In a geographical area mildly affected by the SARS-CoV-2 epidemic, this multi-centric comparative study showed that lockdown produced a limited decrease in emergency surgery in orthopedics and limb traumatology (−13.3%, p = 0.11).

In March 2020 numerous guidelines were published [13] to organize care provision for patients in orthopedics and traumatology during the pandemic so as to relieve pressure on the care system and free resources to deal with the SARS- CoV-2 epidemic. However, evidence that would help predict the volume of activity in this new context was lacking, with a consequent risk of mismatch between means and needs in patient care.

The results of our work are original in that they report a much lower decrease in surgical activity in an area mildly affected by the SARS-CoV-2 pandemic than in one where it was especially serious (Table 2). In the region studied, lockdown had a modest and temporary effect on the volume of emergency surgery. A decrease exceeding 15% was observed only for three weeks (Weeks 13–15), with a maximum decrease of 39.2% in Week 13. This period immediately followed the unprecedented political decision to order total national lockdown and when daily media coverage of the pandemic was intense [14]. However, in early April the epidemic affected our study region only mildly, the government issued some rules to relax lockdown for certain occupational groups and an end to lockdown was envisioned [15]. The combination of these different factors probably helped to reassure the local population, allowing a gradual resumption of activities. In parallel, we observed changes in the characteristics of the emergency surgery during this period. Restricted travel and gatherings resulted in a decrease in sport accidents (−80.0%) and road accident trauma (−41.8%), explaining a decrease in injuries to the femoral and tibial diaphysis (−29.6%) and ankle (−40.5%). Conversely, the locked down population was freer to indulge in DIY/gardening activities, with a correspondingly steady volume of hand and wrist injuries (−10.6% and +13.3%, p = 0.07). Among elderly persons (both in their own home and in care homes), lockdown induced social isolation and less stimulation, sometimes with loss of familiar bearings, conducting to a potential risk of fall which can explain a tendential rise in proximal femur factures (+6.4%, p = 0.12). These trends have been systematically reported in all the studies on the topic [5, 6, 8, 9, 10, 11, 13, 16].

This study presents some biases and limits. It is a retrospective study with a risk of selection bias by data omission. To ensure good representativeness of the results, it was decided to include all the patients undergoing surgery identified by a national code specific to each procedure. This option can be criticized because the manually assigned descriptors may not have been exhaustive and not precisely fit the conditions treated, but it can be considered as sufficiently representative because the assignment of this code determines the remuneration of care centers and surgeons and underpins epidemiological surveys of surgical practice [17, 18, 19]. Lastly, despite the multicentric design and more than 1000 patients included (largest series on the topic concerning surgery patients), some of the results are non- significant, suggesting insufficient power.

Conclusion

In a region where the SARS-CoV-2 epidemic was mildly active, generalized systematic lockdown moderately and temporarily decreased the volume of emergency surgery in orthopedics and limb traumatology, and the anatomical distribution of emergency types was changed.

These findings are an example which argues that health policies to lockdown a population and to decide for the staffing, equipment, and operating facilities needed to ensure continuity of vital care during a health crisis should be adapted to local conditions rather than be applied nationally. They should allow for both the lockdown measures and the real intensity of the epidemic in the geographical area affected.

STROBE Guidelines for Authors of OTSR

To be used by authors of all observational clinical studies published in OTSR. For this purpose a cohort study (the term used by STROBE) is considered a longitudinal study typically reporting outcomes of treatment in one or more cohorts; a case-control study is one identifying factors in outcomes; a cross-sectional study is one to identify the prevalence of factors or characteristics in a population at a single point in time.

This checklist table is modified from The STROBE Initiative, www.strobe-statement.org and should be filled and submitted within the electronic submission.

Participants 13*

(a) Report numbers of individuals at each stage of study—eg, numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analyzed ok (b) Give reasons for nonparticipation at each stage ok (a) Give characteristics of study participants (eg, demographic, clinical, social) and information on other treatments and potential confounders Ok (b) Indicate number of participants with missing data for each variable of interest Ok (c) Cohort study—Summarize follow-up time (eg, average and total amount) Ok Outcome data 15* Report numbers of outcome events or summary measures over time Ok (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included Main results 16 Ok (b) Report category boundaries when continuous variables were categorized Ok (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Ok Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses Ok Discussion Key results 18 Summarise key results with reference to study objectives Ok Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias Ok Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence ok Generalisability 21 Discuss the generalisability (external validity) of the study results ok Other information Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based ok *Give information separately for cases and controls. Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. Information on the STROBE Initiative is available at http://www.strobe-statement.org.