key: cord-1005632-6rwny8tr authors: Natalwala, Ibrahim; Bains, Robert; Bourke, Grainne; West, Christopher; Bhat, Waseem title: Major reconstructive surgery and the COVID-19 lockdown – is the dust settling? date: 2020-07-08 journal: Injury DOI: 10.1016/j.injury.2020.07.015 sha: 93a4509a39ab3ae3a7f442335d6ce14850eb5a5a doc_id: 1005632 cord_uid: 6rwny8tr nan The novel Coronavirus SARS-CoV-2 (COVID-19) has had a profound effect on healthcare throughout the world. At the time of writing, there have been almost 10 million confirmed laboratory cases worldwide and 310,250 cases in the United Kingdom (UK) with over 43,000 confirmed deaths [1, 2] . As lockdown came in to affect, our department responded by placing elective surgery on hold, adopting virtual clinics, and minimising inpatients. From the 23 rd March 2020 we had relocated our hand surgery unit and skin cancer lists to a "cold" hospital and began to directly look after medical patients with COVID-19 in what was our plastic surgery ward. As a tertiary centre accepting referrals from a wide geographic area, we had noticed that a significant number of referrals were still requiring tertiary care advice and also transfer for definitive management. All of the peripheral hospitals in our catchment area had reduced their operating capacity substantially, thereby reducing their ability to manage complex reconstructive cases. We performed a retrospective review of our volume of major reconstructive surgery during the period of reduced operating capacity and lockdown (16 th March to 1 st June 2020). Patients included were those requiring ortho-plastic surgery, congenital hand surgery, brachial plexus injuries requiring urgent exploration, non-cancer cases requiring reconstruction of a major nerve or vessel, and any complex trauma requiring revascularisation or replantation. We also analysed the referrals from our online referral system (Patient Pass © [Tomorrow, Salford Quays, UK]) for complex lower limb cases from peripheral hospitals; before and during the lockdown period. A total of 28 patients underwent major reconstructive surgery during our department's lockdown. Of these; 5 had urgent brachial plexus explorations, 5 had debridement and reconstruction for fracture related infections as joint ortho-plastic procedures, 2 required revascularisation, 1 child underwent a foot re-plant, 2 underwent free flaps to the upper limb Table 1 provides a detailed summary of these cases. Figure 1 shows the timeline of when these patients were admitted and had their definitive surgeries. There was a rapid increase in the volume of cases from the 11 th May onwards coinciding with a partial relaxation on the UK lockdown by the government. Data from our pilot referral system Patient Pass © showed that from the 13 th January 2020 up to 15 th March 2020 (9 weeks), we had 13 patients with complex injuries (closed and open) involving the leg, ankle, or foot, referred and transferred to us from peripheral hospitals; 7 (54%) were from units with an ortho-plastic service. From the 16 th March 2020 to the 1 st June 2020 (11 weeks), we had 10 patients referred and transferred; 6 (60%) from units with ortho-plastics. We have previously shown that during the first 5 weeks of lockdown, there was an overall 56% reduction in the total number of hand trauma cases listed for surgery, with a significant increase in hand injuries related to power tool use at home [3] and an increase in deliberate self-harm (DSH) injuries. This trend appears to have continued with more recently one patient requiring revascularisation of her hand and another a free flap reconstruction following DSH. We stress the need for better mental health support in lockdown scenarios. Hampton et al. performed a multi-centre study analysing referrals to the orthopaedic and hand surgery departments during the first two weeks of lockdown and also showed a 54% reduction in trauma admissions. There was no significant difference in the percentage of hip fractures, upper limb injuries, and lower limb injuries pre-lockdown and during lockdown [4] . This is in keeping with our experience that whilst there has been an overall decrease in our non-cancer related major reconstructive surgeries, we have still had a large volume of work throughout the COVID-19 lockdown and it is continuing to increase as lockdown is eased. Despite reduced operating capacity, we received a similar number of referrals and patient transfers from peripheral hospitals for complex lower limb injuries during the lockdown. This experience sets an important precedence in case of future pandemics or when services are significantly rationed; major trauma still occurs to a significant degree and with peripheral hospitals having reduced operating capacity, there is more demand placed on tertiary centres. Appropriate resources must be provisioned to accommodate this continued demand with sufficient ortho-plastic, hand trauma, and major nerve operating lists. Furthermore, on-call scrub teams must continue to have staff trained in microsurgery in case of potential re-plant or revascularisation surgery. Services could also be further centralised during austere conditions so that more patients with complex reconstructive needs can be managed in one place. This could be achieved by better utilisation of the Nightingale hospitals, and more medical patient flow from tertiary to peripheral hospitals. Moreover, the easing of lockdown should be staggered, firstly in the tertiary centres and then the peripheral units. It is also imperative to recognise that a hospital lockdown cannot be at the exact same time as a nationwide lockdown, as preparations to enter and exit lockdown in the hospital must begin at least a week in advance to allow time for workforce to be re-deployed as necessary and physical resources such as equipment and theatres to be re-located. Whilst we have seen a reduction in non-cancer major reconstructive cases throughout lockdown, we have still had a large caseload and as lockdowns ease, the volume of cases continue to rise quickly. We hope this article provides useful information by which other hospitals can organise their resources in a future pandemic or lockdown situation. Figure 1 -Timeline of 28 major reconstructive cases from date of admission to definitive surgery during the COVID-19 lockdown period. World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard 2020 Coronavirus (COVID-19) in the UK 2020 Patterns of Adult and Paediatric Hand Trauma During the COVID-19 Lockdown The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases The authors of this article do not have any conflict of interest nor received any funding for this work.