What is the Impact of Novel Coronavirus Disease 2019 Pandemic on Orthopedic Surgeons?: Experience from a Single Institution of South Korea

Background: This study aimed to investigate the cancellation rate and trend of orthopedic surgery at the main institution in Daegu, Korean epicenter of novel coronavirus disease 19 (COVID-19), and to analyze the psychologic status of the healthcare workers in the orthopedic division during the COVID-19 pandemic. Moreover, we sought to assess the outcomes of the preventive surgeries underwent in patients suspected to have COVID-19. Methods: Cancellation rates of elective surgeries over three months since the rst conrmed COVID-19 case in South Korea on January 20, 2020 were investigated. Moreover, the number of elective surgeries conducted in the same period over the last two years was compared. Four different questionnaires were used to investigate psychologic impact among health care workers in the orthopedic department. The surveyed outcomes according to occupation and type of work were compared. Urgent preventive surgeries underwent in patients who could not wait for the results of the COVID-19 diagnosis were also investigated. Results: During the pandemic, spine and hip surgery had relatively lower cancellation rates, and elective surgeries were signicantly reduced compared to the same period in the last two years. The surveyed outcomes of the psychological questionnaires were within the normal range and there were no signicant differences between groups. After preventive surgeries, the virus did not spread to all medical staff involved. Conclusions: During the COVID-19 pandemic, the cancellation rate of orthopedic elective surgeries was signicantly higher than in the same period of the previous year, and was different for each subdivision depending on the degree of pain or disability experienced by the patient. Health care workers in the orthopedic division did not seem to have signicant psychological distress; rather, a decrease in workload appears to be a positive factor in their mental health. Preventive surgery performed in specialized facilities did not spread the virus to involved medical staff.


Background
Since the initial report of the novel coronavirus disease (COVID- 19) from Wuhan, China in December 2019, the spread of pandemic continues to explode worldwide [1]. Health care workers, including clinicians and nurses from around the world, are struggling to manage the many COVID-19 patients. Since their rst con rmed case in January 20 2020, South Korea has been severely burdened with COVID-19, showing a rapid increase in case numbers over the last few months [2,3]. Particularly, the epicenter of Daegu, located in southeastern South Korea, has experienced a rapid spread of COVID-19 that has been attributed to a con rmed case on February 19, 2020, which was related to subsequent super spreading at a church service [2,4,5].
A challenging crisis such as the COVID-19 can cause psychological issues including fright, anxiety, uncertainty, and loneliness that affects not only infected patients, but also the health care workers who treat them [6,7]. During this national disaster, assessing the psychological status of health care workers associated with diagnosis, treatment, and care for COVID-19 patients, as well as considering optimal support for these workers, are issues of top priority [8,9]. Furthermore, the relationship between the type of COVID-19 services provided by a health care worker and degree of psychological stress have not been fully understood. Some studies showed that non-frontline workers have less psychological stress in comparison with frontline workers [10,11], but vice versa in other studies [12,13]. Particularly, in order to minimize the risk and negative in uence of this disaster in orthopedic health care, it is necessary to acknowledge the effect of COVID-19 on surgeons' work and mental status; however, no studies have yet reported an impact of COVID-19 on orthopedic surgeons.
In a pandemic such as COVID-19, orthopedic surgery is not a priority, and thus, appears to be less relevant during this urgent situation. In most countries, elective orthopedic procedures are recommended to be delayed [12,14,15]. Moreover, the demand for orthopedic care has decreased due regulations such as social distancing and home isolation that prevent the transmission of COVID-19. Nevertheless, some orthopedic emergent surgeries have no choice but to be performed, and in such situations, the preliminary settings or strategies of the operation room (OR) should take extreme measures to reduce the risk of viral transmission [16,17]. However, most countries still have not provided guidance regarding the continuation of orthopedic procedures during the COVID-19 pandemic. Furthermore, to date, there has been a paucity of literature on orthopedic surgery related to COVID-19.
Therefore, the purpose of this study is to investigate the cancellation rate and trend of orthopedic surgery at the main institute in Daegu, the Korean epicenter of COVID-19, and to analyze the psychologic status of the healthcare workers in the orthopedic division during the COVID-19 pandemic. Moreover, we sought to assess the outcomes of the preventive surgeries underwent in patients suspected to have COVID-19.

Methods
Source of data Data were collected from a single institution at Daegu, the epicenter of COVID-19 in South Korea, for three months since January 20, 2020, when the rst case was con rmed in South Korea. This study was approved by the institutional review board of our hospital, and written informed consent was provided by all survey participants prior to their enrollment. All information was retrieved from the institution's medical records, including detailed information such as primary diagnosis, surgical procedure, use of specialized facilities (including negative pressure environments), whether the operation was performed, and if COVID-19 was diagnosed. During the COVID-19 pandemic, our institution established a guideline to routinely perform a COVID-19 diagnostic test in all patients requiring surgery from the outpatient clinic or emergency room. (Table 1). Patients requiring urgent procedures that could not wait for COVID-19 results and diagnosis underwent surgical treatment with preventive measures, such as employing a temporary negative pressure room and a mobile negative pressure tent for patient transport in a speci c OR complex with special facilities (Fig. 1). These patients were relocated to wards based on the results of the COVID-19 diagnosis after surgery. 2. Always! Con rmation of COVID-19 screening in all patients undergoing elective surgeries: even in asymptomatic patients 3. COVID-19 screening is included in the pre-operative evaluation, and is prescribed and paid in outpatient clinic. 4. After payment, a screening test label is obtained from a laboratory. 5. The day before hospitalization, the patient should visit the Drive-thru screening room in our hospital and wait after collecting a sample, until con rming it.
6. After con rming the COVID-19 negative, the patient can proceed with the admission procedure.
7. If symptoms are suspected, the operation should be postponed until a negative result is con rmed.
8. Always! If the diagnostic test is positive, the operation must be postponed until a negative result is con rmed and symptoms improve.
*If the samples are received by 10 a.m., the results can be noti ed by 3 p.m. on the same day. In uence on elective surgeries "Elective surgery" is de ned as a pre-planned procedure that provides medically unnecessary or non-emergent surgery which, if delayed, does not place a patient's immediate health, safety, or wellbeing at risk, or contribute to the worsening of a lifethreatening medical condition [12,15]. During events such as a pandemic, cancellation rates of elective surgeries for each orthopedic subdivision were compared. In addition, the difference in the number of surgeries in each subdivision during the same period over the past two years was also compared.

Outcomes of preventive surgeries
Generally, elective surgeries on non-COVID-19 patients in our institution were assigned to the main OR complex. Patients suspected to have COVID-19 underwent preventive surgery in a speci c OR complex separated from the main complex with facilities such as negative pressure environments and personal protective equipment ( Fig. 1) [12,16]. Additionally, patients in need of urgent procedures who could not wait for COVID-19 results and diagnosis underwent preventive surgery in a separate OR complex. During the study period, we investigated the details of preventive surgeries and the presence of postoperative COVID-19 transmission of operation-related staffs.

Statistical methods
Data analysis was performed using IBM SPSS software (version 23; IBM, Armonk, NY), and continuous data were expressed as means with ranges. The Kolmogorov-Smirnov test was utilized to evaluate all dependent variables for normality of distribution and equality of variance. Moreover, data was also analyzed using nonparametric tests based on normality. Between the groups, continuous variables were compared by Mann-Whitney U test and Kruskal-Wallis test depending on the normality of distribution. Categorical variables were compared using Chi square or Fisher's exact test. A p-value < 0.05 was considered statistically signi cant.

Results
Cancellation of elective surgery and changes of surgery conducted Among a total of 151 elective surgeries during a reference period of January 20, 2020 -April 20, 2020, 84 cases (55.6%) were delayed due to COVID-19 and the remaining 67 (44.4%) were conducted as scheduled (Table 2). During the COVID-19 pandemic period compared to the same period in the past two years, elective surgeries at the institution signi cantly decreased (p = 0.003) (Fig. 2).

Psychological impact on health care workers in orthopedic division
In total, 48 health care workers in the orthopedic division (16 men and 32 women) answered the questionnaire. The average age was 35.9 years (range, 22 -60 years). All physicians participating in the survey were men, and all nurses were women. Although IES-R showed mild distress, most of psychological outcomes were within the normal range and there were no signi cant differences between the groups according to occupation or type of work (Table 3).  During the study period, a total of 47 preventive surgeries were performed at the hospital. The majority of preventive surgeries (19 cases) were performed in the orthopedic surgery unit, followed by general surgery and other units ( Table 4). All patients had a fever of 37.7 -38.7 ℃, and nine patients had respiratory symptoms such as cough or sputum. Among these, only one patient suffering from a diabetic foot was con rmed as COVID-19-positive after surgery; however, all medical staff involved in the operation tested negative. Discussion most notable ndings in the current study indicate that the cancellation rate of elective procedures in the orthopedic department was signi cantly higher during the COVID-19 pandemic compared to the same period of the previous year or before the outbreak of this virus. Furthermore, the discontinuation of elective procedures was signi cantly different for each subdivision. During the same period, the mental health status of health care workers in the orthopedic division did degrade signi cantly according to the outcomes of the psychological questionnaires. Additionally, there were no signi cant differences in psychological outcomes according to occupation or type of work. Although there was one postoperative patient that tested positive for COVID-19, the virus was not transmitted to health care workers who were involved in the operation, including surgeons.
To date, the cancellation rate of elective surgery in orthopedic divisions during viral epidemic outbreaks such as COVID-19 has not been reported. The cancellation may be due to the public health awareness or individual patient needs. There have been no established guidelines regarding cancellation of orthopedic procedures in South Korea during the COVID-19 pandemic. Since some cases are ambiguous, the guidelines and decision-making often depend on the individual hospital system or surgeon.
Meanwhile, several states in the United States have recommended the minimizing, delay, or cancellation of non-essential elective surgical, endoscopic, dental, and orthopedic procedures as much as possible [12,22,23]. In the current study, the cancellation rate in the spine subdivision was the lowest, which is likely due to the high degree of pain and disability of patients, compared to those suffering from knee, foot, or ankle injuries.
Several previous studies have reported on the mental health status of health care workers during viral epidemic outbreaks such as COVID-19, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS) [6,7,24,25]. During this period, medical staff in direct contact with infected patients consistently have a fear of infection. Accordingly, such outbreaks of epidemics may cause severe emotional distress, anxiety, depression, and post-traumatic stress among health care workers [6,26]. Particularly, it has been reported that clinicians may have more fundamental psychological distress from such epidemics compared to other health care professionals [11,27]. However, in the current study, health care workers in the orthopedic division did not demonstrate severe mental health issues according to the conducted surveys. Moreover, although some studies reported psychological differences according to type or level of work [10,11], there were no signi cant differences in the current study. It is thought that health care workers in orthopedic surgery, who are non-frontline workers that rarely directly treat COVID-19 patients, may not have severe emotional distress. Additionally, the reduction in demand for orthopedic care due to the COVID-19 pandemic seems to bene t orthopedic health care workers in regard to mental health. A recent study reported some advantages for orthopedic surgeons during this calamity, including more time for personal stress relief, time away from the radiation exposure, the opportunity to nish pending research, and more time with their family [28].
When performing surgery on patients suspected of having COVID-19, specialized facilities such as isolation OR, negative pressure mechanisms, and personal protective equipment are essential (Fig. 1) [16]. These measures can optimize the quality of care provided to patients infected with COVID-19 and minimize the risk of viral transmission to other patients or health care workers. We performed preventive surgery in patients who were suspected of having COVID-19 without con rming the results of the diagnosis due to a time-sensitive urgency for surgery. Although one patient was con rmed positive after surgery, the virus was not transmitted to the medical staff involved.
This study has some limitations. First, the scope of the study is limited. This study collected data related to orthopedic surgery at the main medical institution in Daegu. Therefore, it may be di cult to generalize the results of the current study to all regions of South Korea or Asia. Nevertheless, data from Daegu, the epicenter of South Korea, a representative country of the early COVID-19 outbreak, can be a good reference for medical staff in other regions. Second, since the study was based on three months of data since the rst con rmation of COVID-19, it lacks long-term follow-up results. Although the current mental health status of orthopedic surgeons is reported to have no major problems, it is possible that health care workers may experience a severe deterioration in psychological state as the pandemic continues. Therefore, follow-up of long-term psychological symptoms for these subjects is needed.
Nevertheless, this study suggests some valuable information for many health care workers, including orthopedists, during the COVID-19 pandemic. (1) To date, this study is the rst to report the cancellation rate of elective procedures in orthopedic division during the COVID-19 pandemic; (2) Health care workers, such as orthopedic surgeons, who rarely treat patients infected with COVID-19 directly, report to have less psychologic stress. Furthermore, it showed that the pandemic may be a positive factor in mental health for orthopedic health care workers, as their overall workload was reduced; and (3) In patients suspected of having COVID-19, performing preventive surgery in special facilities equipped with negative pressure environments or personal protective equipment could prevent the transmission to involved health care workers.

Conclusions
During the COVID-19 pandemic, the cancellation rate of orthopedic elective surgeries was signi cantly higher than in the same period of the previous year, and differed for each subdivision depending on the degree of pain or disability reported by patients. Health care workers in the orthopedic division did not report signi cant psychological distress; rather, subjects reported a decreased workload to be a positive factor in their mental health. Preventive surgery performed in specialized facilities prevented the spread of virus to involved medical staff.  Comparison of the number of elective surgeries conducted in the same period over the last two years in our institution (p=0.003) (Fig. 2).