Changes in trends of orthopedic services due to the COVID-19 pandemic: A review

Table 1 Description of studies collected for the review

Title	Author	Country	Study during lockdown?	Extremity injured	Patient outcomes	Article impact index
Lower extremity fractures
The COVID-19 Pandemic: The effect on open lower limb fractures in a London major trauma centre - a plastic surgery perspective	Campbell et al[3]	England	Yes	Lower extremity fractures	Despite a 64% reduction in ER attendance and 50% decrease in traffic, RTA were the most common mechanism of injury and oLLFs were reduced from 22 to 18; there was a rise in oLLFs in those with mental health diagnoses	1
Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective	Egol et al[4]	United States	Yes	Hip fractures	Rates of mortality in hip fracture patients in COVID-positive, suspected COVID, and COVID-negative groups were 35.3%, 7.1%, and 0.9%, respectively	28
Hip fracture care and mortality among patients treated in dedicated COVID-19 and non-COVID-19 circuits	Ojeda-Thies et al[5]	Spain	Yes	Hip fractures	COVID-negative patients were able to receive timely and adequate care; COVID-positive patients also received adequate care but there were delays in surgeries; separating COVID-positive and negative patients helped efficiently treat patients	1
Effect of Covid-19 on best practice care of hip fracture patients: An analysis from the National Hip Fracture Database (NHFD)	Tyas et al[6]	UK	Yes	Hip fractures	COVID-19 led to a significant reduction in best practice tariff with decreases in timely surgery, postoperative delirium, 20-d mortality, length of stay, and timely orthogeriatric review	0
Rehabilitation guidance for hip fracture patients during the COVID-19 pandemic using chat software: A new model	Gao et al[7]	China	Yes	Hip fractures	Complications and mortality were higher in the group that did not use WeChat; complications included UTIs, deep vein thrombosis, dislocation, and infections	1
Hip Fracture Outcomes During the COVID-19 Pandemic: Early Results From New York	Lebrun et al[8]	United States	Yes	Hip fractures	Mortality was 56% amongst COVID-19 patients and were at higher risk for pneumonia and hyperinflammation	19
IMPACT-Scot report on COVID-19 and hip fractures	Hall et al[9]	Scotland	Yes	Hip fractures	Low platelet count was an indicator for an increased risk of COVID-19 infection and COVID-19 was related with an increased risk of 30-d mortality	27.5
Hip fracture care during Covid-19: a regional trauma centre's experience	Crozier-Shaw et al[10]	Ireland	Yes	Hip fractures	Though there was a 20% reduction in hip fractures, the 30-d mortality rate increased from 2.2% to 8.3% and having COVID-19 also increased mortality rates	2
Clinical Characteristics and Perioperative Complication Profiles of COVID-19-Positive Patients Undergoing Hip Fracture Surgery	Galivanche et al[11]	United States	Yes	Hip fractures	COVID-positive patients presented with more comorbidities which resulted in a higher incidence of adverse events perioperatively	0
Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy	Catellani et al[12]	Italy	Yes	Femur fractures	Surgery is required for positive outcomes, but respiratory stabilization is crucial to ensure survival, comfort, and stability	30
Influence of coronavirus disease 2019 pandemic state of emergency in orthopaedic fracture surgical treatment	Mitkovic et al[13]	Serbia	Yes	All	Overall number of fractures decreased, female patients were observed more for femoral neck fractures	2.5
The effect of COVID-19 pandemic on the care of fragility hip fracture patients in the United Kingdom	Orfanos et al[14]	United Kingdom	Yes	Hip fractures	Early intervention resulted in better outcomes, higher mortality rates amongst COVID-positive patients	0
How SARS-CoV-2 Pandemic Changed Traumatology and Hospital Setting: An Analysis of 498 Fractured Patients	Brayda-Bruno et al[15]	Italy	Yes	All	More femoral fractures during COVID era, average injury age increased to 69, separating COVID-negative and positive patients allowed patients to remain negative, faster diagnoses to discharge times	0
Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study	Zagra et al[16]	Italy	Yes	All	Delays in surgery, hip fractures were associated with higher mortality rates, 60% of orthopedic patients were at risk of developing perioperative complications	0
Perioperative management of patients with hip fractures and COVID-19: A single institution's early experiences	Muse et al[17]	United States	Yes	Femur fractures	Early intervention improved patient outcomes in COVID-positive patients; spinal anesthesia was used to prevent viral aerosolization; treatment plans should be altered based on severity of infection	1.5
Foot and ankle trauma management during the COVID-19 pandemic: Experiences from a major trauma unit	Shah et al[18]	England	Yes	Foot and ankle fractures	Telemedicine aided in reducing patient-provider contact and eased the burden of follow-up	1
Effect of the COVID-19 pandemic on foot surgeries	Kuliński et al[19]	Poland	Yes	Foot fractures	Total orthopedic surgeries declined by 55% and elective surgeries were not eliminated. The length of stay was decreased by 2.5 d for adults and 1.7 d for children	0
Outcomes of orthopaedic trauma surgery in COVID-19 positive patients	Al-Humadi et al[20]	United States	Yes	Lower Extremity	Operations in COVID-positive patients were accomplished with anticoagulation and hematologic and pulmonary management; complications and mortality still occurred	0
Upper extremity fractures
Patient care modifications and hospital regulations during the COVID-19 crisis created inequality and functional hazard for patients with orthopaedic trauma	Dunkerley et al[21]	United Kingdom	Yes	Upper extremity fractures	The increase in use of telemedicine services resulted in 12% of patients discharged with potentially unstable fractures with a danger of mal-union	1.5
A Call to Arms: Emergency Hand and Upper-Extremity Operations During the COVID-19 Pandemic	Diamond et al[22]	United States	Yes	Hand and upper extremity	A 40% increase in volume injuries attributed to high risk behaviors such as lawlessness, assault, and high-speed auto accidents; lack of social and physical impacted and aggravated injuries	2
Upper extremity emergencies during SARS-COV-2 pandemic: Turnout trends	Fyllos et al[23]	Greece	Yes	Upper extremity fractures	The mechanisms for which emergency upper extremity and hand and wrist injuries occurred were mostly from domestic accidents such as new hobbies	0
The impact of COVID-19 on shoulder and elbow trauma in a skeletally immature population: an Italian survey	Gumina et al[24]	Italy	Yes	Shoulder and elbow	Pediatric cases decreased by 84.6%, shoulder and elbow traumas were caused by domestic accidents	1.5
Other fractures
Outcomes of Orthopaedic Trauma Services at a UK Major Trauma Centre During a National Lockdown and Pandemic: The Need for Continuing the Provision of Services	Donovan et al[25]	United Kingdom	Yes	All	Theater time increased by 14 min due to new PPE requirements. Complication and mortality rates remained unchanged and there was not a higher risk of transmitting COVID-19 in the hospital	0.5
Proximal femur fractures in COVID-19 emergency: the experience of two Orthopedics and Traumatology Departments in the first eight weeks of the Italian epidemic	Maniscalco et al[26]	Italy	Yes	Femur fractures	There was a decrease of emergency ortho cases by 26.8%; femur fractures decreased, and other fracture types increased; school traumas were 0%, sports injuries decreased by 75.3%, work injuries decreased by 42.2%	0
Evaluation of containment measures' effect on orthopaedic trauma surgery during the COVID-19 pandemic: a retrospective comparison between 2019 and 2020	Druel et al[27]	France	Yes	Upper extremity, lower extremity, hand fractures	Work-related accidents, RTAs, and altercations decreased, but domestic accidents increased. Rates of infection decreased; overall there was a 28.7% decrease in trauma surgery patients	3
Impact of the COVID-19 pandemic on the trauma and orthopaedic department at level one Major Trauma Centre in the republic of Ireland	Elbardesy et al[28]	Ireland	Yes	All	Adult distal radius fractures increased by 88% and pediatric elbow fractures decreased by 13%. Fractures were mostly caused by independent outdoor activities	0
The impact of COVID-19 on orthopaedic trauma: A retrospective comparative study from a single university hospital in Italy	Andreozzi et al[29]	Italy	Yes	All	Average age of patients increased, 67% of injuries occurred in the home, and the most commonly injured body part was the hand	0
Effects of COVID-19 pandemic curfew on orthopedic trauma in a tertiary care hospital in Turkey	Kalem et al[30]	Turkey	Yes	All	Center saw a 65% decrease in upper extremity injuries. Overall human movement has decreased by about 40% which is correlated to the decrease in admissions	0
Elective surgeries
COVID-19 consent and return to elective orthopaedic surgery: allowing a true patient choice?	Clough et al[31]	England	Yes	All	Rates of COVID-19 were lower at elective surgery compared to trauma sites	1
Practice patterns
The Effect of COVID-19 on Orthopedic Practices and Surgeons in Louisiana	Kale et al[32]	United States	No	All	COVID-19 restructuring led to delays in care, injuries not properly healed, and increase in pain.	2
A clinical pathway for pre-operative screening of COVID-19 and its influence on clinical outcome in patients with traumatic fractures	Meng et al[33]	China	Yes	All	Average wait time to surgery increased by 4.1 d, resulting in complications such as pneumonia, fever, venous thromboembolism, and cardiovascular complications	7.5
Lessons Learnt from Managing Orthopaedic Trauma During the First Wave of the COVID-19 Pandemic at a UK District General Hospital	Patel et al[34]	United Kingdom	Yes	All	Delays to surgery were doubled and postoperative complications were more present but were not directly associated with COVID-19 status	1
Effect of COVID-19 on surgical management of open fractures and infection rates: A tertiary care experience in Indian set-up	Gupta et al[35]	India	Yes	All- open fractures	Even though this center saw a decrease of cases, there was a delay of patient presentation to the ER, delay in administering antibiotics, and an increase of emergency temporary fixations, infection rates, and readmissions	0.5
Pooling of neglected and delayed trauma patients - Consequences of 'lockdown' and 'Unlock' phases of COVID-19 pandemic- A retrospective cohort analysis from a tertiary centre	Saini et al[36]	India	Yes	Upper and lower extremity fractures	Complications (blood loss, requirement for bone grafts) rates increased, delays to surgery significantly increased from an average of 8.23 d to 21.38 d	0
Miscellaneous
Mortality risk of surgically managing orthopaedic trauma during the COVID-19 pandemic	Balakumar et al[37]	United Kingdom	Yes	Femur fractures	The risk of contracting COVID-19 perioperatively was 11%, separating COVID-negative and -positive patients did not improve patient outcomes	0
Effect of COVID-19 on Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers	Paul et al[38]	United States	No	Ulnar Collateral Ligament	Decreased movement had an impact on ulnar collateral ligament reconstruction rates when sporting practices resumed	0
The patterns and management of fracture patients under COVID-19 outbreak in China	Yu et al[39]	China	Yes	Upper and lower extremity fractures	Delays in surgery, decrease in total number of patients but increase in forearm, thigh, hand, and foot fractures. Hip fractures most prevalent	2