Change in Orthopedic Trauma Practice under Strict Lockdown due to COVID-19 Pandemic
Authors: A.R. Altamimi Anas , Al-Omari Ali A. , Al-Naser Saeed , Al-Dabouby Firas , Al-Balas Mahmoud , Masarweh Odai 
Published: April 2021

Introduction:
The COVID-19 pandemic has led to remarkable changes in several aspects of medical practice. Elective surgeries, including orthopedic surgery, were deferred worldwide, allowing hospitals to accommodate higher numbers of COVID-19 patients and reduce the possible risk of infection among healthcare workers. However, healthcare systems aimed to continue providing emergency services at similar standards. In this study, we aim to highlight the impact of lockdowns secondary to the pandemic on orthopedic trauma practice in a country that was described to have one of the strictest lockdowns worldwide. We aim to examine the trends of change in number and type of orthopedic trauma cases and the changes to decision making and patient care among orthopedic surgeons.

Methods:
This cross-sectional study is based on a survey that was designed and delivered to orthopedic surgeons from different health sectors i.e. governmental, military, private and university hospitals. The questionnaire was distributed through the official Jordan orthopedic association WhatsApp group by the end of the 4th week of strict lockdown. A total of 256 orthopedic surgeons were invited to participate and responses were limited to one per participant. 147 replies were received with a response rate of 57.4%. Data were analyzed using the Statistical Package for the Social Sciences Version 23 (SPSS Inc., Chicago, IL) statistical software.

Results:
A total of 147 surgeons participated in the study with a response rate of 57.4%. The mean age of the participants was 39.8 years, with the majority being between 30 and 40 years (n=70; 48%). There was a significant decline in the number of trauma cases admitted to the Emergency Departments (ER), especially cases with polytrauma. During this period, the most common reported fractures were proximal femur fractures (47.6%) followed by distal radius fracture (17%). 30% of participants used to perform more than 10 trauma operations per week. This percentage dropped to 7.5% during the pandemic lockdown. 25% did not operate at all during the lockdown period. Outpatients practice was significantly affected with almost 40% of orthopedic surgeons not managing any single patient. Regarding the use of Personal Protective Equipment (PPE), 85% of the surgeons used face masks and gloves only during their patient's encounter. Inside the operating room, only 9.5% of surgeons used fully protective PPEs. Regarding the changes in practice, 62% of surgeons reported an increased tendency toward non-operative management with a significant delay in follow up of patients. The use of telemedicine was effective in the management of less than 50% of patient encounters, according to our participants. Private practice respondents reported more than 50% drop in their income during the lockdown.

Conclusion:
Strict lockdown in Jordan led to significant changes to orthopedic trauma practice in terms of the number and type of cases. Emergency and outpatient services were similarly affected. Orthopedic surgeons developed a tendency towards more conservative management and less surgical treatment. There is a need for stricter implementation of guidelines regarding the use of PPE especially in the operating theatre. Telemedicine use in management and follow up of trauma patients needs further assessment in terms of its efficacy and efficiency to patients and to healthcare professionalswith regards to its medico-legal aspects.