**5. Global service impact**

Through major publications in different regions, we can understand the real impact of COVID-19 on the volume of clinical services. Generally, the service volume was inevitably reduced in all aspects, except for a few specific items. Even in a country where there was no lockdowns or restrictions, there was still a small reduction, which may also be influenced by psychological factors.

#### **5.1 Europe**

A study in Italy during lockdown revealed the average age of the COVID-19 group is 51.9 +/− 24.8 years, which is significantly higher than the pre-COVID-19 group (41.4 +/− 25.7) (p < 0.0001). The most common injury was fracture (45.1% in 2019; 62.7% in 2020) (p < 0.0001). The most severely injured anatomical location during COVID-19 lockdown was the hand (14.2%), while in the pre-COVID-19 group, the most common type of injury was multiple injuries (22.8%) [4]. Another study in Italy focused on orthopedic oncology and spine had a unique result. During the lockdown period, by managing urgent and non-delayable spinal diseases with a low COVID-19 infection rate (3.9%), surgical activities have increased instead [12]. The other study in Italy showed a reduction of emergency room visits (−18.0%). The increase in the number of deaths in the emergency room was equal to +220%. The orthopedic pathway dropped by −26.8%. Trauma at home increased (+19.1%) [16].

A nationwide questionnaire survey in Germany showed only 7 respondents (13.7%) fully agreed or quite agreed with the authorities' support for orthopedics and trauma surgery. Major financial and personnel changes had taken place, resulting in an average reduction in operating room capacity of 49.4% and an estimated loss of income of 29.3%. In addition, 14.7% of doctors were redistributed [14]. Another study in Germany focused on emergency departments during the 35-day lockdown. The daily total number of patient cases (lockdown and control, 106.94 and 167.54) and orthopedic trauma cases (lockdown and control, 30.91 and 52.06) declined with an increase in the incidence of home injuries, bicycle accidents, domestic violence, and acute/conventional drug abuse [44].

A study in the UK focused on orthopedic emergencies, during lockdown, showed that patient visits had a decrease of 58.6%. The orthopedic presentations in 2020 and 2019 were 736 (37.2%) and 1729 (36.2%), a decrease of 57.4% [11]. An orthopedic team in the UK set up a 7-day "One-Stop" clinic for minor injuries/ ambulatory patients. Approximately 700 patients who were supposed to be treated in the emergency room changed to minor injuries unit, reducing the pressure on the emergency room. Seventy-one percent of patients were discharged after the

initial appointment, and only 9 patients (1%) needed to make an appointment for a fracture clinic within 72 hours. A total of 15 patients (2%) revisited the clinic with concern, and only 4 of them required additional intervention [40].
