How Did the Restrictions Effect the Orthopaedic Trauma Surgery During Covid-19 Pandemic at a Level 1 Tertiary Trauma Hospital?

Background: The aim of the study was to evaluate and compare the demographic characteristics, the trauma mechanism, and fracture types between patients under 20 years of age, 20-65 years of age, and over 65 years of age between the COVID-19 pandemic and the pre-pandemic period.MethodsPatients who were hospitalized and treated for orthopedic treatment between 10 March and 1 June during the pandemic period were retrospectively analyzed. Control group consisted of patients admitted to the hospital in the same time interval in 2019.The patients were divided into three groups, under 20 years of age, between 20-65 years of age, and over 65 years of age. The patients’ data included age, gender, trauma mechanism, fracture type, any COVID-19 radiological or clinical symptoms.ResultsThe number of patients > 65 years old admitted to orthopaedic trauma center were high at pandemic interval compared to pre-pandemic time. When the groups were compared for patients of 20-65 years old;there was a significant difference for the fracture type (p<0.05). Lower extremity fractures were high at pre-pandemic group whereas multiple traumas were high at pandemic group. For sub-group 20-65 ages, low energy traumas were higher at pre-pandemic group whereas high energy traumas were more frequent at pandemic group.ConclusionWe observed a decrease in fracture admission to ortopaedic trauma centers during COVID-19 pandemic for subgroups of < 20 years old and 20-65 years old ages, whereas there was a significant increase for > 65 years old age, most of them related to the osteoporotic hip fractures. So that older age group should be encouraged to mobilized at home and have permission to walk and make physical activity to avoid osteoporosis for a limited time daily.


Abstract Background
The aim of the study was to evaluate and compare the demographic characteristics, the trauma mechanism, and fracture types between patients under 20 years of age, 20-65 years of age, and over 65 years of age between the COVID-19 pandemic and the pre-pandemic period.

Methods
Patients who were hospitalized and treated for orthopedic treatment between 10 March and 1 June during the pandemic period were retrospectively analyzed. Control group consisted of patients admitted to the hospital in the same time interval in 2019.The patients were divided into three groups, under 20 years of age, between 20-65 years of age, and over 65 years of age. The patients' data included age, gender, trauma mechanism, fracture type, any COVID-19 radiological or clinical symptoms.

Results
The number of patients > 65 years old admitted to orthopaedic trauma center were high at pandemic interval compared to pre-pandemic time. When the groups were compared for patients of 20-65 years old; there was a signi cant difference for the fracture type (p<0.05). Lower extremity fractures were high at pre-pandemic group whereas multiple traumas were high at pandemic group. For sub-group 20-65 ages, low energy traumas were higher at pre-pandemic group whereas high energy traumas were more frequent at pandemic group.

Conclusion
We observed a decrease in fracture admission to ortopaedic trauma centers during COVID-19 pandemic for subgroups of < 20 years old and 20-65 years old ages, whereas there was a signi cant increase for > 65 years old age, most of them related to the osteoporotic hip fractures. So that older age group should be encouraged to mobilized at home and have permission to walk and make physical activity to avoid osteoporosis for a limited time daily.

Background
Coronavirus disease (COVID-19) is a severe acute respiratory syndrome determined by the new coronavirus, which was declared a pandemic by the World Health Organization on March 11, 2020 [1]. On March 11, 2020, the rst reports were o cially announced in Turkey, Since March 10, the Turkish Health Ministry assigned all private and public state and university hospitals as pandemic hospitals. By June 1, the normalization was proposed by the government and all organisations were returned to pre pandemic time by care of using masks, hygiene and social distance.
As this was a new kind of virus infection, there was no speci c treatment protocol, vaccine or drug, so most countries formed their own protocols and have implemented strict control measures to limit the ow of people, including city blockades, tra c control, strict access to the community, and self-isolation at home [2]. Su cient evidence has demonstrated higher morbidity and mortality rates in elderly patients infected with COVID-19 [3,4]. The Turkish Ministry of Health took strict nationwide measures to limit the movement and travel of people and strengthened protective measures. The spread of the epidemic was effectively prevented. In Turkey, one of the most popular protective strategies was the restriction of people older than 65 years old and younger than 20 years old. This was due to the high mortality rates in the older age group, and as the younger age group is mostly asymptomatic, they constitute a greater risk when in contact with older individuals [5]. One of the restrictions implemented was to avoid mobility of the population groups aged > 65 years old as the older group tends to have many comorbidities that could be life-threatening in this pandemic. In addition, there is an increased concern that the elderly might be at a higher risk of falls and related fractures, due to the higher prevalence of osteopenia and osteoporosis in the elderly [6,7].
In this retrospective single centre study, the data were analyzed of hospitalized orthopaedic trauma patients who were admitted to our trauma center during the COVID-19 pandemic and compared with the same time interval before pandemic. The primer aim of the study was to compare the demographic characteristics, the trauma mechanism, and fracture types mechanism between pre-pandemic and pandemic restriction time intervals that included groups of younger than < 20 years old, 20-65 years old and older than aged > 65 years old.

Methods
This epidemiological retrospective cohort study was carried out in compliance with the principles outlined in the Declaration of Helsinki and also approved by the Local Ethics Committee of Turkish health directorate (2020-05-11T21-38-53). The pandemic group consisted of patients receiving treatment in the 10-week period from 10 March to June 1 2020. The control cohort named as pre-pandemic group consisted of patients from the same time of year in the past year (from 10 March to June 1 2019). Inclusion criteria of the present study were as follows; 1. Patients diagnosed and hospitalized with a fracture at the same time interval, 2. Patients willing to participate the study. Exclusion criteria were as follows; pathological fractures due to metastatic or primary bone tumors, patients unwilling to participate in the study, old fractures, and patients with incomplete medical data.
The same time interval was used for the comparison of both groups which was 83 days. The data of patients were gathered from the digital archieve. All patient data were collected by an orthopaedic resident, who was not involved in the study. The data included age, gender, trauma mechanism, affected side, fracture location, any COVID-19 radiological or clinical symptoms. The primary outcomes consisted of differences between the pandemic and pre-pandemic groups in terms of fracture type, fracture mechanism, restriction related admissions to orthopaedic trauma center.
Patients were sub-grouped according to age: Group 1; 0-20 years, Group 2; 20-65 years, Group 3; >65 years. The grouping was made on the rationale of the < 20 years and > 65 years age groups being in isolation at home.
The fractures were divided into three groups; upper extremity, lower extremity or multiple trauma. The trauma mechanism was classi ed as low-energy and high-energy. Low-energy trauma is de ned as a simple fall, and high-energy trauma as a fall from height, tra c accident, and rearms injuries. Lower extremity fractures were de ned as proximal femur, diaphyseal femur, distal femur, proximal tibia, tibia diaphysis, distal tibia, foot fractures. Upper extremity fractures were de ned as humerus, radius-ulna and hand fractures. Multiple trauma was de ned as serious injury to two or more regions of the body (head, thorax, abdomen and extremies).

Statistical Analysis
Data obtained in the study were analyzed statistically using IBM SPSS vn. 22.0 software. The Chi-square test and Continuity Correction (Yates) were applied in the evaluation of the data. A value of p < 0.05 was accepted as statistically signi cant.

Results
Evaluation was made of a total of 458 patients included 300 (% 65.5) of pre-pandemic time and 158 (%34.5) of pandemic time of restriction, comprising 267 (58.3%) males and 191 (41.7%) females with a mean age of 44.55 ± 27.61 years (range, 1-102 years) ( Table 1). A statistically signi cant difference was determined between the pre-pandemic and pandemic group in respect of age (p < 0.05). The number of patients younger than < 20 and between 20-65 years old were higher at pre-pandemic time whereas the number of patients > 65 years old were high at pandemic time compared to pre-pandemic time. There was no statistically signi cant difference between the pandemic and pre-pandemic groups with respect to the gender (p > 0.05) ( Table 2). Chi-Square test *p < 0.05 There was no statistically signi cant difference for the fracture type between the pre-pandemic and pandemic groups at patients younger than 20 years old (p > 0.05). When the groups were compared for patients of 20-65 years old; there was a signi cant difference for the fracture type (p < 0.05). Lower extremity fractures were high at pre-pandemic group whereas multiple trauma was high at pandemic group. There was no difference for the upper extremity fractures between the groups (p > 0.05). There was no statistically signi cant difference for the fracture type between the pre-pandemic and pandemic groups at patients older than 65 years old (p > 0.05) ( Table 3). There was no statistically signi cant difference for the mechanism of fracture between the pre-pandemic and pandemic groups at patients younger than 20 years old (p > 0.05). There was a statistically signi cant difference for the mechanism of fracture between the pre-pademic and pandemic groups for patients between 20-65 years old (p < 0.01). Low energy traumas were higher at pre-pandemic group whereas high energy traumas were more frequent at pandemic group. There was no statistically signi cant difference for the mechanism of fracture between the pre-pandemic and pandemic groups for patients older than 65 years old (p > 0.05) ( Table 4). Chi-Square test was used **p < 0.01 A statistically signi cant difference was determined between the age groups in respect of COVID-19 status (p < 0.001). The frequency of COVID-19 positivity was signi cantly higher in the > 65 years age group compared to the other two groups and was higher in the 20-65 years age group than in the 0-20 years group (Table-5).

Discussion
The main nding of the present study was that admissions of patients older than 65 years old to the orthopaedic trauma center were increased although there was a global decrease during the COVID-19 pandemic. Most of the fractures were low extremity fractures, especially pertrochanteric fractures seen in the older age group. Multiple trauma was seen in patients with no restrictions on movement.
When the groups for compared according to the admission to the hospital, there was a signi cant decrease during pandemic time. We believed that this was a result of decreased human mobility outside in order to prevent the spread of virus as recommended by Turgut et al. [8]. The decrease was approximately 52.6% of the pre-pandemic time. Turgut et at. stated that the decrease was one-third of the pre-pandemic time, and in an another study Bram et al. [9] concluded that the pediatric fracture volume had decreased 2.5 fold during the COVID-19 pandemic. The decrease in our study was comparable to the the literature, as we included the patients that were interned for surgical operations, because during pandemic time we only admitted the patients with surgical indications from the area. Our results also con rmed the outcomes of Bram et al. But when the groups were compared with regard to the patients older than 65 years old, there was a signi cant difference, the admission was signi cantly higher at pandemic time (p < 0.05). This can be considered due to osteoporosis, and comorbidities that could result in hypotension in the older age group. Physical activity is a factor as there is ample epidemiological evidence linking inactivity to increased risk of hip fracture [10,11]. Atik et al. [12] stated that osteoporosis was a real burden of older age hip fractures and importance of awareness and diagnosis of the disease was highlighted. The requirement for the > 65 years age groups to stay at home during the pandemic may have increased the rate of osteoporotic hip and pertrochanteric femur fractures. To prevent these fractures, the older age group should be encouraged to be mobile and be physically active at home.
When the fracture types were compared between the groups, there was no signi cant difference between the groups for subgroups of < 20 years old age and > 65 years old age. But when the fracture types of subgroups 20-65 years old age were compared, at pandemic group the mutliple trauma was more signi cant where as lower extremity fractures were more signi cant at pre-pandemic period. Together with the cessation of work and production, the mobility of the population will decrease and there will be an inevitable decrease in fractures resulting from tra c accidents and workplace accidents [13]. We believed that the signi cant increase of the multiple trauma patients were due to the the fact that the surrounding hospitals limited patient acceptance and the fractures requiring surgery and intensive care were directed to our hospital could cause this increase. The number of hospital admissions and surgical procedures for the treatment of lower limbs were higher in pre-pandemic group, whereas this was decreased during COVID-19 pandemic, this was due to the reductions seen across all causes of trauma including sports, tra c, industrial and domestic as recommended by Wong et al [14].
When the sub-groups were compared due to the COVID-19 (+), most of the COVID-19 (+) fractures were in the older age group (> 65 years), which could be attributed to the comorbidities of the elderly, low socioeconomic status living together with more than 5 people or in small ats, and lack of awareness of social distancing. However, there was only one COVID-19 (+) patient in 20-65 age group, who was a polytrauma case. The patients in this age group were all of working age, and were working through the pandemic, and all stated that they used surgical masks, washed their hands frequently, and were careful about social distancing.
When the groups were compared due to the trauma mechanism. There was no signi cant difference for < 20 years old age and > 65 years old age sub-groups at both groups, but high energy traumas were signi cantly higher at pandemic group for 20-65 years old age sub-groups. We believed that this was due to the restricition of outdoor mobility, closing of work areas, restrictions of sportive activity areas, so that this age group whom were at working age could be injuried to higher energy traumas which result in multiple traumas as seen in the present study.
The present study has several limitations. Firstly it was a retrospective designed study, secondly it was from a single centre, nally the outpatient admissions that were treated conservatively were not included in the study due to the lack of datas.

Conclusion
The COVID-19 pandemic has changed the routine of all hospitals. We observed a decrease in fracture admission to orthopaedic trauma centers during COVID-19 pandemic for subgroups of < 20 years old and 20-65 years old ages, whereas there was a signi cant increase for > 65 years old age. So that older age group should be encouraged to mobilized at home and have permission to walk and make physical activity to avoid osteoporosis for a limited time daily.

Abbreviations COVID Coronavirus Disease
Declarations