Orthopaedic, trauma surgery, and Covid-2019 pandemic: clinical panorama and future prospective in Europe

Purpose This study investigated the impact of the Covid-19 pandemic in Europe on consultations, surgeries, and traumas in the field of orthopaedic and trauma surgery. Strategies to resume the clinical activities were also discussed. Methods This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. All the comparative studies reporting data on the impact of Covid-19 in the field of orthopaedic and trauma surgery in Europe were accessed. Only comparative clinical studies which investigated the year 2020 versus 2019 were eligible. Results 57 clinical investigations were included in the present study. Eight studies reported a reduction of the orthopaedic consultations, which decreased between 20.9 and 90.1%. Seven studies reported the number of emergency and trauma consultations, which were decreased between 37.7 and 74.2%. Fifteen studies reported information with regard to the reasons for orthopaedic and trauma admissions. The number of polytraumas decreased between 5.6 and 77.1%, fractures between 3.9 and 63.1%. Traffic accidents admissions dropped by up to 88.9%, and sports-related injuries dropped in a range of 59.3% to 100%. The overall reduction of the surgical interventions ranged from 5.4 to 88.8%. Conclusion The overall trend of consultations, surgeries, and rate of traumas and fragility fractures appear to decrease during the 2020 European COVID pandemic compared to the pre-pandemic era. Given the heterogeneities in the clinical evidence, results from the present study should be considered carefully. Level of evidence Level IV, systematic review.


Introduction
The SARS-CoV-2 pandemic made clear that the established administrative structures of the health authorities are generally not prepared to face the immediate challenges of such a major infectious risk or permanent crisis situation. Many national health authorities acted independently and adapted their strategies, evidencing that the countries of the European Union were not able to reach a collective consensus and to adopt common guidelines. The pandemic caused by Covid-19 has been confronting the healthcare landscape with new challenges [1,2]. In addition to the already highly burdened hospitals, the pandemic management required further considerable organizational efforts [3][4][5]. A high degree of flexibility and willingness to improvise for clinical employees and staff responsible for the organization were required [6][7][8]. Often far-reaching process changes, such as the management of patient flows, had to be implemented in everyday clinical practice within a very short period of time [9].
Though orthopaedic and trauma surgery are not disciplines directly involved in the clinical management of Covid-19 patients, the pandemic caused profound changes in patient flow management, impacting the clinical practice and requiring significant management efforts from medical and non-medical personnel [10][11][12]. This study investigated 1 3 the impact of the Covid-19 pandemic in Europe on consultations, surgeries, and traumas in the field of orthopaedic and trauma surgery. Strategies to resume the clinical activities were also discussed.

Eligibility criteria
All clinical investigations reporting data on the impact of Covid-19 in the field of orthopaedic and trauma surgery in Europe were accessed. Studies focusing on consultations and surgeries, sports medicine, fragility fractures, and European trauma registries were included. Study level I to III of evidence, according to Oxford Centre of Evidence-Based Medicine [13], were considered. Given the authors language capabilities, articles in English, German, Italian, French and Spanish were eligible. Comparative studies published in peer reviewed journals were considered. Studies published in grey literature or without full-text were not eligible. Studies which have been conducted in other continents rather than Europe were not suitable. Only comparative studies which investigated the year 2020 versus the pre-COVID era were suitable. Reviews, editorials, comments, and expert opinions were excluded.

Search strategy
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement [14]. The PICOT algorithm was preliminary pointed out to guide the search: In December 2021, the following databases were accessed: Pubmed, Web of Science, Google Scholar, Embase, with no time constrains. The following keywords were used in combination using the Boolean operators AND/OR: Covid, Sars, 2019, 2020, pandemic, Coronavirus, Europe, European, orthopaedic, trauma, traumatology, surgeries, intervention, management, treatment, surgical, consultations, surgeries, sport medicine, fragility fractures, registries.

Selection and data collection
Three authors (FM; HS; GP) independently performed selection and data collection. All the resulting titles were screened and if suitable, the abstract was accessed. The fulltext of the abstracts which matched the topic were accessed. A cross reference of the bibliography of the full-text articles was also performed. Disagreements were debated and the final decision was made by the main author (FM).

Search results
The initial literature search resulted in 19,870 articles. 1154 studies were removed as they were duplicates. Further 18,629 studies were excluded as they did not match the eligibility criteria: not comparative studies (N = 754), not available full text or not published in peer reviewed journals (N = 78), language limitations (N = 21), not in the field of orthopaedic and trauma surgery (N = 4981), not comparing 2020 versus 2019 (N = 4003), not matching the topic (N = 6027), study design (N = 2791). Finally, 57 clinical investigations were included (Fig. 1).
Team sports traumas evidenced a considerable reduction during the pandemic [49][50][51]. The injury rate remains similar in the German Bundesliga and Italian Serie A soccer leagues after the lockdown [52,53]. Paediatric traumas decreased by 50% [54][55][56]. The impact of the pandemic on the incidence of fragility fractures is uncertain. Most studies found no difference in the rate of fragility femoral fractures compared to the same pre pandemic period [57][58][59][60][61][62]. Few studies reported a reduced trend of fractures compared to the pre pandemic period [63,64]. Patients who experienced hip fragility fractures in the 2020 pandemic had a greater mortality compared to the same period of the pre pandemic era [65,66]. The 30-and 90-day mortality in positive patients with fragility hip fractures was greater, as was the time span from injury to surgical treatment, and the hospitalisation [59,[67][68][69][70][71].

Discussion
The Covid-19 pandemic impacted significantly the healthcare landscape worldwide, requiring considerable organizational efforts. According to the main findings of the present study, the overall trend of consultations, surgeries, and the rate of traumas and fragility fractures appear to decrease during the 2020 European COVID pandemic compared to the same period of the pre-pandemic era.
The participation in (team) sports activities was globally limited: several sporting events were suspended as a result of public safety restrictions. The shutdown periods affected training and competition in many sports activities, changing injury rates and patterns, with new implications for sports medicine [43]. However, no increased injury rate was observed in the German Bundesliga after the lockdown [52]. Accordingly, in the Italian Serie A soccer league a  The Covid-19 pandemic raised many important issues, such as the optimal management of patients requiring the treatment of conventional diseases during a pandemic. The flow of patients changes from one area to another during a pandemic and an integrated approach within the same geographical area could be useful to better allocate resources and manage the patients' needs. The preventive measures put in place in Italy seemed to work, but this first experience with Covid-19 crisis highlighted the chronic problems of the Italian health system and the authors believe that all have to "learn the lesson" to be better prepared in the future  Injury Retrospective UK An association between the outbreak of the pandemic and a reduction in referral numbers to our department has been demonstrated. The direct cause of this may be multifactorial but proposing that it is, in part, due to the social distancing measures introduced by the government is certainly conceivable. The patterns of injury would reflect this also with low energy and fragility trauma persisting whilst injuries associated with younger people have reduced. We would suggest that information such as this could be useful in healthcare planning and resource allocation in future pandemic situations   similar injury rate at 1000 game-hours in the pre-and postlockdown period was found [53]. In contrast, when evaluating the impact of the Covid-19 lockdown on fitness in elite handball players, Fikenzer et al. [49] reported a reduced endurance capacity without team training despite a homebased strength and endurance program. The authors suggested a qualified supervision of individual home-based training programs to avoid the implementation of inadequate training concepts [49]. The effect of training restrictions due to Covid-19 associated emotional and physical stress was evaluated in national level Eventing horse-riding athletes [50]. The lockdown decreased performance outcomes of horse-riders in Eventing competitions [50]. Surprisingly, dressage was found to be the most affected discipline, when compared to cross-country and show-jumping. Faulkner et al. [51] evaluated cycling injuries in Scotland during the first Covid-19 lowdown period in a multi-centre study. The study group reported an uptake of cycling and a significant increase in the number of cycling related injuries requiring orthopaedic intervention, particularly with a greater  [40] Wien Klin Wochenschr Retrospective Austria Although trauma of all age groups and severities will continue to occur, the tendency during a lockdown will be a greatly reduced case load. Nevertheless, with no significant drop in major injuries, resources need to remain readily available for any future waves The importance of versatility in managing limited resources has been highlighted, always adapting to an ever-changing situation. This will ensure the highest levels of service are maintained, reducing complications and ultimately improving patient outcomes proportion of female and elderly cyclists compared with similar time periods in 2018 and 2019 [51]. In paediatric sports traumatology, the concept of social distancing, school cancellations, and cessation of organized sports had a major impact on musculoskeletal injuries. Clavicula fractures were diagnosed more frequently compared to 2019. Bolzinger et al. [54] studied the epidemiology of paediatric injuries after the 8-week lockdown in France. The authors found an overall decrease of 50% in paediatric trauma, but an increased rate of domestic accidents (59% vs. 23%) and trampoline accidents (16% vs. 5%) [54]. Clos et al. [55] reported that serious sledding-related injuries increased significantly four-to five-fold in paediatric patients during the winter season of 2020-2021, whereas the number of snowboarding and skiing injuries decreased due to closed ski resorts [55]. Voth et al. [72] reported a rising trend of extremity fractures and sport injuries in children aged 8-12 years; however, their data refer to a prior period in 2018 and, therefore, do not include later effects of the Covid-19 pandemic. Darling et al. [56] analysed the effects of Covid-19 lockdowns on paediatric lower limb trauma. Throughout the lockdown periods, paediatric patients were younger (7 versus 11 years) and they were less likely to be injured as a result of sport [56]. Furthermore, the average rate of referrals and waiting time to receive surgical care dropped significantly. In this context, the role of telemedicine and telehealth is continuing to evolve for both side-line and clinical care of sport-related injuries [73][74][75][76][77]. While the scientific evidence is still evolving, various effects of the Covid-19 pandemic have affected both epidemiology and the clinical care for sports injuries.
The real impact of the COVID pandemic on the incidence of fragility fractures is uncertain. Being more common in outdoor activities, non-hip fragility fractures (e.g., forearm, upper arm, ankle, foot) may have been decreased [78][79][80]. On the other hand, the number of fragility hip fractures, which happen more frequently indoor, should be expected to have increased [81][82][83]. Current evidence is contradictory and within the same country a high variability is also common [84]. In a retrospective cohort study including overall 91,160 elderly people with hip fracture in France, hip fractures decreased by 11% compared to the pre pandemic period [63]. In another retrospective analysis of 236 patients following hip fracture, Ojeda-Thies et al. reported that the trend of hip fractures diminished by up to 26% compared to the previous year before the pandemic [64]. On the other hand, Ogliari et al. [57] evidenced no significant changes in the trend for fragility fractures in the United Kingdom with respect to the pre-pandemic period. In their study, the authors evaluated 6681 outpatients with non-hip fragility fractures and 1752 inpatients admitted for hip fracture [57]. Also Hampton et al. [58] found no difference in the rate of hip and non-hip fragility fractures during the 2020 pandemic compared to the same period of the previous year. Malik-Tabassum et al. [59] performed an observational, retrospective, multicentre study including 6 hospitals in the South East of England (767 patients). Compared to the same period one year before the pandemic, the authors found higher mortality in COVID positive patients, whereas no difference in the incidence of hip fractures was found [59]. The authors found that non-hip fractures were decreased, while there was no change in inpatient admissions for hip fractures [57]. Scott et al. [60] conducted a cohort study including 2876 patients who had been referred to the orthopaedic trauma service in Ireland. Femoral fragility fractures did not change significantly during the pandemic from the pre-pandemic period [60]. Nevertheless, the authors found a relative greater incidence of non-hip fragility fractures during the COVID-19 pandemic compared to the pre-pandemic period [60]. In a recent multicentre study [61] including 580 patients, no difference in the rate of femoral fractures was found alike. However, the authors evidenced a tendency to treat conservatively such fractures, along with a reduced hospitalisation and arthroplasties performed [61]. Similar findings were confirmed by Mazeda et al. [62] in a retrospective observational study involving 162 patients with a negative COVID PCR test. Another aspect to consider which may have an influence on the rate of fragility fractures, is the reduction of the routinely osteoporotic prevention cares. Indeed, the screening for osteoporosis dropped, with only 50% of performed bone density measurements (DXA) in comparison to the pre pandemic situation [85,86]. DXA rates slowly increased to nearly 75% of pre-pandemic counts to the end of 2020 again [87]. Postoperative care also suffered during the pandemic. The incidence of pressure ulcers in patients following surgery for femoral fractures was 21%, a considerable increase when compared to the 10% of the pre pandemic era [88]. Overall, patients who experienced hip fragility fractures in the 2020 pandemic had a greater mortality compared to the same period of the pre-pandemic era [65,66]. COVID infection directly contributed to increase the 30-and 90-day mortality following fragility hip fractures, not explained by patient characteristics [67][68][69][70]. Moreover, a longer time span from injury to surgical treatment and a longer hospitalisation was evidenced in comparison to the preceding year 2019, when the pandemic began [71].
If there are sufficient resources to treat current and potential future Covid-19 patients, elective surgery may be gradually resumed under a continuous monitoring of the infection rate. These resources include adequate intensive care units (ICU) and non-ICU departments, ventilators, personal protection equipment, and workforce projections to manage elective and emergency circumstances, and concurrently the capability to manage Covid-19 patients. If there are not enough resources, clinicians should consider the incubation curve of Covid-19. Previous evidence reported that the maximum estimated incubation for Covid-19 is up to 2 weeks, and 75% of cases develop symptoms within a week [89]. Given these assumptions, surgery should only be planned if there is a sustained reduction in the local infections rate for a period of at least 2 weeks [90,91]. Moreover, given the viral shedding in infected individuals which ranged from 8 to 37 days (median 20) [92], patients who had a previous Covid-19 infection should be also retested within 6 weeks before the rescheduled surgery. Early diagnosis and isolation of positive patients and healthcare workers, and sufficient equipment resources are pivotal to prevent nosocomial transmission [93]. Specific infection rate thresholds should be set by the healthcare facilities to resuspend surgeries [94]. As the prevalence of asymptomatic patients remains unknown [95], rapid testing 3 to 5 days prior to surgery should be set as standard [96][97][98]. The prioritization of orthopaedic and trauma surgical procedures is a multidisciplinary process which involves clinical and non-clinical personnel [99]. This process should follow a standardized decision-making protocol, an equitable and transparent framework to assure efficacy and prevent ethical dilemmas and moral injuries. The Medically Necessary Time-Sensitive (MeNTS) can be used as priority scoring system. Patients are prioritized based on procedure factors, disease factors and patient factors [100][101][102]. Procedure factors include surgical duration, hospitalization length, risk of postoperative ICU, total estimated blood loss, intubation chance, and surgical sites and team. Disease factors embrace the efficacy of conservative management and exposure risk, impact of treatment delay on the outcome, and difficulty or risk of surgery. Patient factors include age, lung and cardiovascular disease, diabetes, immunosuppression, influence symptoms, and contact with positive persons to Covid-19 in the past 2 weeks. For each of these factors a value from 1 to 5 based is assigned on both objective measures and perceived clinical probabilities. Lower values were associated with greater outcome, reduced risk of Covid-19 transmission to the healthcare team, and/or reduced hospital resource use during the pandemic [103,104]. The MeNTS has been also applied with success for difficult decisions on prioritization of surgery in the orthopaedic and trauma surgeries during the pandemic [105]. During the process prioritization of surgical procedures, during the time elapsed since the originally scheduled surgical date, the patient status may have changed and needs to be reassessed prior to surgery. Laboratory and radiological assessment, comorbidities evaluation, symptoms and physical examination should be updated. To reduce the length of the hospitalization, the Enhanced Recovery After Surgery (ERAS) protocol has been introduced in the early 1990s [106][107][108]. The application of ERAS in the orthopaedic and trauma surgery promoted early mobilization, optimizing pain control avoiding the use of opioids, nausea and vomiting prophylaxis, amelioration of the nutritional and hydration status [109][110][111]. The purpose of the ERAS during pandemic is to reduce the risk of Covid-19 transmission and infection, to reduce crowding and improve patient turnover. In a recent meta-analysis involving 20,843 participants, ERAS reduced the incidence of postoperative complications and the 30-day mortality, though the readmission rate within 30 days did not show any statistically significant improvement [112]. One way to reduce crowding and patient turnover is to follow patients who had postponed their surgery by means of telemedicine, to ensure a continuous monitoring. Physicians should thereby be prepared to react to an impending breakdown. Telemedicine is defined as healthcare delivered from a remote location by computer and telecommunications technology replacing face to face modality [113]. Telemedicine is considered a safe and effective means to deliver healthcare. Patients appreciate its convenience due to reduced appointment delays and time off work as well as decreased travelling times and costs [114]. In comparison to other medical disciplines, telemedicine demonstrated limited evolution and application in orthopaedics and trauma surgery before the Covid-2019 pandemic [115,116]. During the first Covid-19 pandemic telemedicine was applied to prevent assemblage and to guarantee access to medical cares. Telemedicine in orthopaedics and trauma surgery had mostly developed for arthroplasty, fracture management, and pre-and postoperative cares [117]. Several clinical studies investigated the application of telemedicine during COVID pandemic, with satisfying results [118][119][120][121][122].
This study has several limitations. Data on clinical evidence on consultations, surgeries, and traumas in the field of orthopaedic and trauma surgery in Europe during 2020 compared to the pre-pandemic era presented a wide range of variation. However, beside such variability in data presentation, the overall trend (increase or decrease) is relatively comparable among the studies. Such variability may arise from the different nature of the health care systems, different levels of care, and the different between-and withincountries heterogeneities in definitions, methodologies, diagnoses, and related management of injuries. Additionally, some between countries anti-COVID regulations allowed the institutions to pursue their surgical activity in a different fashion. These heterogeneities may lie behind the mentioned variability in data presentation, and infer negatively with the reliability of the conclusion of the present study. Therefore, data from the present study should be considered carefully.

Conclusion
The overall trend of consultations, surgeries, and the rate of traumas and fragility fractures appear to decrease during the 2020 European COVID pandemic compared to the same period of the pre-pandemic era. The impact of COVID on morbidity and mortality in orthopaedic and trauma surgery is still unclear. Given the high heterogeneity in the clinical evidence, results from the present study should be considered carefully.
Funding Open Access funding enabled and organized by Projekt DEAL. No external source of funding was used.
Availability of data and materials The data underlying this article are available in the article and in its online supplementary material.

Conflict of interest
The authors declare that they have no conflict of interest.
Ethics approval This study complies with ethical standards.

Consent for publication Not applicable.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.