The female sex distribution is the majority in this study, possibly because women find it more difficult to save themselves when an earthquake occurs, but in the largest age distribution for adults this is a concern because the most affected group is the productive age group, so this has an impact on wheels people's economy. It is estimated that the total economic loss is IDR 7.7 trillion (528 million dollars) and 431,416 people have lost their homes. This study has a similar result from the epidemiological study conducted by Prabowo et al earthquake in Palu-Indonesia September 2018, the largest distribution age is adult. But the sex distribution is more common male (52,6) than female (47,4).38,46
The most common location of the injury is the lower limb, this is probably due to injuries while rescuing themselves and this exacerbates the economic and social burden of the affected community because the patient becomes unable to walk and returns to work as usual. Based on Indonesia central bureaus report (BPS) 2018–2019 of statistics that the majority of the population of North Lombok and West Lombok region are farmers and traders with general level of education is graduated from elementary school and junior high school (low education level).49
In this study, we found the total infection rate was 12 cases or 16.2%, the results showed that most infections were found in post-ORIF treatment patients at RSUDP NTB (Regional General Hospital of West Nusa Tenggara) as many as 4 cases (33%) and the second was found in post-ORIF action patients at KRI Hospital Dr. Soeharso (Indonesia warship floating hospital) has as many as 3 cases (25%). In an epidemiological study conducted by Prabowo et al in the 2018 Palu earthquake found that the highest incidence of orthopedic cases was lower limb fracture (64.5%) and the most common procedure performed were debridement (43.3%) and then ORIF (33.3%) but debridement and external fixation was only 3.3%. A systematic review study conducted by McKenzie et al on epidemiological studies and management of orthopedic injuries after earthquake disasters in developing countries found that 59% of the injuries that occurred were lower limb fractures and the most common procedure performed was debridement (33%). The high incidence of infection occurred in both hospitals (RSUDP NTB Hospital and KRI dr. Soeharso Hospital) maybe due to the lack of sterilization equipment, limited resources for wound treatment and aggressive methods of treatment to perform definitive treatment in acute phase disaster period in lombok.8,46
Relationship between risk factors and clinical & radiological outcomes
The highest infection cases occurred in cases of open fracture lower limb (42.1%). This is consistent with the literature because open fracture injuries of the lower extremities are prone to infection leading to chronic osteomyelitis. in the risk factors group ORIF / Non-ORIF, there was a significant difference in the incidence of infection (P = 0.011). The population group that received ORIF procedure, cases of infection was 23.5% and in the population group that did not receive ORIF procedure, cases of infection were 0%. This suggests that the ORIF procedure is a major risk factor for causing infection. This is in accordance with the guidelines issued by the AO and WHO that in a disaster emergency condition, if an area cannot be ascertained, the availability of a referral hospital for optimal orthopedic surgery, adequate surgical and nursing teams, complete sterile equipment and adequate postoperative care recommended only external fixation debridement for open fractures, casting with plaster of Paris and skin / skeletal traction for closed fractures. 21, 37
A guideline issued by the AO-ICRC and WHO states that all cases of closed fracture are closed reduction to minimize complications, especially infection, even though this management results in prolonged management of the patient. Articular and periarticular fractures where ORIF action is required are proven to be more profitable to be postponed in disaster conditions and should only be done in good health facilities and adequate sterility. The use of internal fixation in limited health facilities causes high infection rates. Therefore, ORIF procedure should only be carried out in good health facilities, good and safe clean water facilities, sterile equipment, orthopaedic surgery teams, sound nursing teams and physiotherapist and postoperative care teams. For open fracture cases, the guidelines expressly prohibit primary initial management with internal fixation at any level of health care facilities, because the principle of open fracture management in a disaster condition is to stabilize the fracture so that it has a safe environment for wound care, wound healing and closure. primer from the wound in the easiest and safest way.9,21,37
The experience of Médecins Sans Frontières in the 2010 Haiti earthquake stated that external fixation in a sudden onset disaster can be the definitive therapy and is best adapted in the context of a major disaster in 1–2 weeks of the initial phase of the disaster. In the initial phase of a disaster, definitive operation with internal fixation is not recommended because in that phase there can be a collapse of both the structural facilities and functional human resources, facilities and infrastructure for health services as well as the management of human resources for medical personnel who deal with the injured victims of the earthquake which jumped at one time causing fatigue and can reduce post-traumatic patient care. In the case of natural disasters due to earthquakes, we cannot predict how long aftershocks will last and experts estimate that two weeks after the initial earthquake is a critical time for stabilization of the patient's condition, both with conservative plaster of Paris, external fixation and Sskeletal traction. In the third weeks, definitive surgery can be done with the condition that qualified health facilities, a team of doctors, a team of nurses and the availability of complete sterile equipment to adequate postoperative care and rehabilitation. If these facilities cannot be reached in the area either with a field hospital or a floating/emergency hospital, it is advisable to evacuate outside the area where the referral hospital for orthopedic and trauma service centers is available.21,36,37
On the other hand, we know that almost all type B referral hospitals in Lombok regions have suffered serious damage and the main referral hospital, namely the West Nusa Tenggara regional general hospital, serves orthopedic trauma cases with excess capacity and treatment in the hallway and hospital parking lot, when the service lasts the third day. After the initial earthquake, suddenly a large aftershock occurred which caused the hospital management to stop surgical services in the operating room at that time. The systematic review research conducted by McKenzie et al. states that it is unrealistic to treat definitive internal fixation in conditions immediately after an earthquake / acute onset disaster. The focus of action on the surgical team that is initially present at the disaster site is to carry out disaster triage, control bleeding, debridement of wounds, stabilization of soft tissue, so that the Damage Control Orthopaedic surgery protocol in disaster conditions is the treatment of choice and the key to management of orthopedic case treatment in acute onset disaster setting.8, This has been proven in the experience of the IDF medical team in handling the earthquake in Pakistan in 2005 and Haiti in 2010 installing external fixation follow-up 2 weeks after the action showed no sign of infection and the team from the Israel defense force waited 2 weeks after the initial disaster and waited until the preparations were made. A sufficient number of medical teams, nurses, equipment, sterilization and new wound care then perform definitive action with internal fixation, the initial team that comes only performs external fixation, plaster of Paris (casting) and amputation.8,44,45
The patient group with ORIF had lower SF-36 in general health and health change values than the non-ORIF group, and in the previous discussion, it had been proven that action ORIF increases the risk of postoperative infection. For cases of spinal cord injury, both in the injury location category and the diagnosis was found to have a low value on the SF-36 physical function, role limitations due to emotional problems and social functioning, and all spinal cases in this study were post-posterior stabilization surgery and decompression in the first two weeks following the earthquake. Research conducted by Sudaryo et al. Prospective cohort study on the quality of life of patients who experienced the 2009 Padang earthquake showed a significant reduction in quality of life with QLA scores in the earthquake-injured group and the most common injured group were limb fractures and dislocations47. the probable causative of the lower score of SF-36 in ORIF group than the non-ORIF group is due to the general effect of the earthquake injury in this study. Orthopaedic injury affects mostly productive age and from Indonesia Central Bureau of Statistics (badan pusat statistik) 2018–2019 data stated that in north Lombok region majority the employee of people is peasant, farmer and merchant, and this brings about loss of job due to orthopaedic injury. This result is similar to the result from study Stroebe et al about chronic disaster impact in the Netherlands that stated that earthquakes can have negative health consequences for inhabitants over time, especially people that experience repeated damage or earthquake. Another study conducted by Gallardo et al about systematic review and meta-analysis data of Medium- and long-term health effects of earthquakes in high-income countries found an increased mortality rate for all causes, myocardial infarction and stroke from the first month to up to 3 years after an earthquake. Our theory that the effect of the Lombok earthquake that quadruplet type (four big attacks of earthquake) still persists for at least 3–4 years afterward.49,50,51
Referring to the results of the analysis above, the researcher suggests definitive measures for spinal cord injuries that require immediate surgery in the acute phase of a disaster, so it is better to evacuate victims to a referral center for qualified orthopedic services, having standard spine surgery and ICU wards, both in terms of facilities and human resources for orthopedic medical rehabilitation specialists and a team of orthopedic nurses. In an analysis of the 2005 earthquake in Pakistan, as many as 194 spinal cord injury patients were treated at one time at the Rawalpindi medical college and its allied hospital, the majority of injuries to the lumbar area were 61.85% and as many as 41% of patients had paraplegia, many victims did not receive treatment and rehabilitation accordingly so that there were several cases of paraplegic patients with large decubitus ulcers in the sacral area (20%), so they underline from the experience of the 2005 Pakistan earthquake that the management of the spine should be comprehensive. So that the establishment of a spinal injury management center at a referral hospital in the earthquake disaster area or evacuation to the nearest hospital outside the earthquake-hit area whose services and human resources are not affected by the earthquake disaster and ICU services and post-operative handling and proper rehabilitation is an inevitability for acute earthquake disaster conditions.48
Research implications and follow-up research plans
In conclusion, the risk factors that influence the union rate status, infection and SF-36 functional score are age, diagnosis, location of injury and ORIF action. Direct ORIF action in the initial phase of a disaster is a risk factor that can be intervened to reduce the morbidity that will occur due to infection, infection causing new problems and causing the need for repeated operations in patients, then by the AO-ICRC-WHO in its management guide, in the initial acute disaster phase is conservative management of closed fractures (POP, scalp traction etc.) and external fixation for open fractures.9,21,37.
This research implies that the government, in this case, the Ministry of Health of the Republic of Indonesia, National Disaster Management Authority Indonesia and association organizations, in this case, the Indonesian Orthopedic Association, should make guidelines for the management of actions for orthopedic cases in disaster conditions, given the high number of natural disasters that occur annually in Indonesia (earthquake) which are namely earth, landslides, floods) and manmade disasters such as victims of bombs, terrorist attacks, collapsed buildings. This management guide follows adaptations or references from the management guidelines previously prepared by AO-ICRC-WHO and other textbooks specializing in disasters, and adapting to local wisdom, culture, culture and characteristics of the Indonesian society, therefore the researcher recommends the need for research on post-earthquake clinical outcomes in other locations such as the Aceh tsunami earthquake, the Yogyakarta earthquake, the Palu earthquake and the Banten tsunami earthquake. Researchers saw that there was no comprehensive research on follow-up clinical and radiological outcomes after orthopedic action in acute disaster conditions and the importance of developing management guidelines together with other surgical colleges regarding initial and advanced management in conditions of mass disasters.