key: cord-0925592-5sneirso
authors: Heaps, Braiden M.; Ladnier, Karen; Haselman, William T.; Limpisvasti, Orr; Banffy, Michael B.
title: Epidemiologic impact of COVID-19 on a multi-subspecialty orthopaedic practice()
date: 2021-05-06
journal: J Orthop
DOI: 10.1016/j.jor.2021.05.011
sha: 0d590ea744506ee50b3e69d93600f332c5f24d5b
doc_id: 925592
cord_uid: 5sneirso

The purpose of this study is to report the change in surgical case volume and composition encountered by a multi-subspecialty orthopaedic practice due to COVID-19. We reviewed electronic medical records for patients who had surgery at our institution and collected multiple variables including age and the joint that was operated on. In the post-COVID-19 period, we found a significant increase in the percentage of hip procedures, and a significant decrease in the percentage of hand/wrist procedures. Overall, the total surgical volume of our multi-subspecialty orthopaedic practice decreased due to the COVID-19 pandemic, and the composition of surgical cases changed.

J o u r n a l P r e -p r o o f particularly in the United States. As of October 12, 2020, there have been nearly 8 million cases in the 25 US with over 215,000 deaths 1 . The pandemic has brought about widespread changes to routine daily 26 life. These changes include large portions of the American work force now working from home, limited 27 options for entertainment and recreation, cancellation or postponement of many levels of sports, and 28 most impactful, stay at home orders 2,3 . 29

These changes have directly impacted the practice of orthopaedic surgery in the US. In March of 30 2020, due to rapidly increasing cases of COVID-19, the US Surgeon General recommended delay of 31 elective and nonessential medical and surgical procedures. This recommendation was followed by 32 similar recommendations by the Centers for Medicare & Medicaid Services (CMS), American College of 33 Surgeons (ACS) and the American Academy of Orthopaedic Surgeons (AAOS) 4-6 . The AAOS issued 34 guidelines to help surgeons with management and triage of orthopaedic injuries from elective to 35 emergent 5 . Given that a significant portion of orthopaedic surgical procedures are considered elective 36 care, the impact of COVID-19 and these recommendations from governing bodies was immense. 37

Wong and Cheung studied Hong Kong's orthopaedic experience with COVID-19. They reported 38 that during an early part of the pandemic (January 25 to March 27, 2020) orthopaedic procedures 39 performed at all 43 public Hong Kong hospitals decreased by 44.2% with elective joint replacements and 40 J o u r n a l P r e -p r o o f difference between proportions and calculating a Z-score from that by dividing the absolute value of the 73 difference between the pre-and post-COVID-19 proportions by the SE of the difference between the 74 proportions. From that Z-score, we determined a p-value and significance was defined as a p-value < 75 0.05. The statistical analysis above was repeated for the specific diagnoses listed in Table 2. For both  76 analyses, there were enough separate categories to assume independence. 77 78 79

A total of 2, 830 (1917 pre-COVID-19 and 913 post-COVID-19) cases were analyzed within the 81 time frame of the study. When broken down by the joint operated on (Table 1) , we found a significant 82 increase in the percentage of hip procedures performed (+3.5 ± 1.1%, p = 0.002), a significant decrease 83 in the percentage of wrist procedures performed (-2.6 ± 0.8%, p = 0.002), and a significant decrease in 84 the percentage of hand procedures performed (-2.1 ± 1.0%, p = 0.027) between the pre-COVID-19 and 85 post-COVID-19 time frames. Foot, ankle, knee, shoulder, elbow, and back procedures showed no 86 significant change in their respective percentage of total surgeries between the time frames. 87

When the cases were analyzed by diagnosis pre-COVID-19 vs. post-COVID-19 (Table 2) , we found 88 a significant increase in the percentage of adhesive capsulitis procedures (+0.72 ± 0.35%, p = 0.0368), 89 arthritis/osteoarthritis procedures (+3.32 ± 1.40%, p = 0.0174), femoroacetabular impingement (FAI) 90 procedures (+1.50 ± 0.76%, p = 0.0473), removal of loose bodies (+1.26 ± 0.55%, p = 0.0218), and distal 91 biceps repair procedures (+1.30 ± 0.53%, p = 0.0139) performed in the post-COVID time frame. There 92 was also a significant decrease in the percentage of trigger finger procedures (-1.56 ± 0.54%, p = 0.0037) 93

in the post-COVID-19 time frame. Although not significant, there was also a trend towards an increase in 94 the percentage of complete rotator cuff tear repairs (+2.30 ± 1.23%, p = 0.0618) and synovitis debridement procedures (+1.18 ± 0.62%, p = 0.0589) post-COVID-19. There were no other differences in 96 the percentages of any other procedures performed on this population between these time periods. The coronavirus pandemic has changed the epidemiology of orthopaedic pathology requiring 104 surgical intervention. While there is no single explanation for this alteration, several plausible 105 explanations exist. One possible general reason for these changes is a decrease in out of the house 106 work hours and an increase in free time available that would otherwise be occupied by out of the home 107 work obligations due to the pandemic. Pathology specific reasons may also exist. A potential explanation 108 for our observed increase in surgical treatment of FAI, might be due to patients attempting to capitalize 109 on a newly found downtime. The downtime would be newly found time they had away from work or 110 competitive sports participation. This downtime represented an opportunity window where patients 111 could have the surgery they need and have an adequate period away from work or sport obligations to 112 recover with minimal impact on their work life or athletic career. It is also possible many patients 113 suddenly found themselves spending more of their time in a seated position leading to increase in the 114 frequency, and potentially, the severity of their impingement symptoms. Another potential explanation 115 that could account for a portion of the increase in surgically treated FAI is patients finding a new form of 116 exercise. Many regions of the country had public exercise options limited due to closure of swimming 117 pools and fitness centers. It is possible that patients who typically exercise in this setting decided to take 118 symptoms and it has been reported that hip arthroscopy leads to a high return to running rate [17] [18] [19] . It is 120 likely that all these factors contributed in some fashion to our observed increase in treatment for FAI. 121

Our observed increase in removal of loose bodies again potentially could be explained by an increase in 122 patients perceived time available to recover, as they were already not working, working from home, 123 and/or not participating in competitive sports. We speculate a potential explanation for the increase in surgically treated distal biceps repair 145 could be that patients who suddenly found themselves home with more free time chose to spend that 146 free time in pursuit of home improvement projects and/or a new or increased weightlifting program. For 147 many of these patients, who were office or desk workers, this represented a dramatic change in their 148 day-to-day usage of their upper extremities. 149

Regarding the decreased number of trigger finger surgeries performed we have 2 hypotheses. 150

First, patients' day to day lives again significantly changed with the potential that this change in activity 151 lead to a decrease in symptomatic triggering. Second, as trigger finger is considered a minor procedure, 152

we speculate patients who otherwise may have opted for surgical intervention did a personal risk 153 benefit analysis and determined the symptoms of trigger finger did not outweigh the risk of potential 154 COVID-19 exposure and infection therefore they elected to live with the symptoms rather than present 155 to an operative suite. These possible causes however are only hypotheses and the actual causes of 156 these increase warrant further research on the mechanism of injury and why people chose to get 157 surgery. 158

It is also worth noting that in a relatively similar time period, the total post-COVID-19 surgical 159 cases were less than half of the total pre-COVID-19 surgical cases (913 vs. 1,916, respectively). This 160 speaks to the major decrease in volume that our clinic saw during the coronavirus pandemic. While we 161 saw a significant change in the percentage of specific surgical procedures between the two time periods, 162 most of the specific procedures demonstrated an overall decrease in the total number performed during 163 that time, even if the percentage increased. The only exceptions to this that had a significant result were 164 distal biceps repairs which saw 17 cases in the pre-COVID-19 period and 20 in the post-COVID-19 period, 165 loose body removals which saw 20 and 21 cases in the pre-COVID-19 and post-COVID-19 periods, 166 respectively, and adhesive capsulitis procedures which saw 5 and 9 cases in the pre-COVID- respectively. 168 This study could be improved with a larger sample size of patients. This study also only reported 169 on the patients that came to our outpatient clinic in our region, thus our study might not be a 170 representative sample of all orthopaedic procedures performed throughout the country in different 171 settings, such as academic orthopaedic institutions or hospitals, within the time frame of the study. Also, 172 due to the recent nature of the coronavirus pandemic, the post-COVID-19 time frame has a smaller 173 sample size than the pre-COVID-19 time frame so this study would have benefitted from a longer study 174 period for the post-COVID-19 time frame. We also must consider that, because the two groups were 175 split within a single year, that some of the changes in the epidemiology pre-COVID-19 versus post-176 COVID-19 could be explained by normal seasonal changes in activity level and athletic participation. The 177 pre-COVID-19 time period was in the fall and winter, when more indoor sports are played, and the post-178 COVID-19 time period was in the spring and summer, when sports and activities tend to occur outside. 179 180

The total surgical volume of our multi-subspecialty orthopaedic practice decreased as a result of 182 the COVID-19 global pandemic, and the composition of surgical cases changed. There surely is a 183 multitude of explanations for these changes, however we speculate a few major themes largely 184 contributing. We suspect change in lifestyle, time away from competitive athletics and work obligations, 185 time sensitivity of treatments and severity of symptoms were the main contributors. During the COVID-186 19 pandemic patients were forced to weigh the benefits of surgery against the usual surgical risks and 187 the risk of any potential COVID-19 exposure/infection. However, further exploration and research 188 should be performed before a declarative statement can be made attributing these factors as definitive. 

Executive DS of C. California State Executive Order

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