most notable findings in the current study indicate that the cancellation rate of elective procedures in the orthopedic department was significantly 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 significantly different for each subdivision. During the same period, the mental health status of health care workers in the orthopedic division did degrade significantly according to the outcomes of the psychological questionnaires. Additionally, there were no significant 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 significant 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 benefit 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 finish 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 confirming the results of the diagnosis due to a time-sensitive urgency for surgery. Although one patient was confirmed 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 difficult 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 first confirmation 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 first 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.