**5.2 Asia**

A multi-center study in India revealed that the total number of traumas during lockdown period was significantly reduced by 1266 cases, a reduction of 62.7% (p < 0.01). Road traffic accident is the main cause of trauma in all age groups except the elderly, and a 77.9% reduction in cases was found during the lockdown period (n = 1343 vs. n = 298) [17].

A study in Hong Kong showed orthopedic surgery decreased by 44.2%, from a weekly average of 795 ± 115.1 to 443.6 ± 25.8 (p < 0.001), and the ratio of emergency surgery to elective surgery increased from 1.27:1 to 3.78:1. Surgery for treatment of upper and lower limb fractures was reduced by 23% (from 98.5 ± 14 to 75.9 ± 15.2 per week; p < 0.001) and 20% (from 210.6 ± 29.5 to 168.4 ± 16.9 per week) 16.9 times; p < 0.001), while elective joint replacement and ligament reconstruction surgery decreased by 74–84% (p < 0.001). The number of hospitalizations decreased by 41.2% (from 2365 ± 243 to 1391 ± 53 per week; p < 0.001), while the number of clinical outpatient visits decreased by 29.4% (from 11,693 ± 2240 to 8261 ± 1104 per week; p < 0.001, 30).

A study in Taiwan showed that the COVID-19 pandemic resulted in a 22%−29% and 20%−26% reduction in outpatients, 22%−27% and 25%−37% reduction in inpatients, and 26%−35% and 18%−34% reduction in orthopedic operations [55]. Taiwan successfully prevented the spread of COVID-19 without lockdown and adopted many prevention strategies effectively, such as the use of masks in the public [59].

**Figure 1.** *Reduction percentage of all surgeries.*

*Perspective Chapter: Impact of the COVID-19 Pandemic on the Field of Orthopedics DOI: http://dx.doi.org/10.5772/intechopen.102847*

#### **5.3 North and South America**

A study focused on multi-subspecialty in the United States analyzed a total of 2830 (1917 pre-COVID-19 and 913 post-COVID-19) cases. A significant increase in the percentage of hip procedures performed (+3.5 ± 1.1%, p = 0.002), a significant decrease in the percentage of wrist procedures performed (−2.6 ± 0.8%, p = 0.002), and a significant decrease in the percentage of hand procedures performed (−2.1 ± 1.0%, p = 0.027). Foot, ankle, knee, shoulder, elbow, and back procedures showed no significant change [39].

A study in Chile revealed that the number of orthopedic surgeries fell by 22.8%. All surgical procedures were adversely affected, with fracture/traumatic surgery being the least affected. Knee replacement (−64%) had the greatest adverse impact, followed by hip replacement (−41%) and knee ligament reconstruction (−44%). The number of orthopedic surgeries was slightly correlated with the number of COVID-19 cases per month (p = 0.08) and strongly correlated with the country's mobility (p = 0.0001) [32].

#### **5.4 Australia**

A study in Australia during lockdown revealed the total number of emergency operations performed decreased by 15.6% compared to the same period in 2019. The number of orthopedic hospitalizations decreased by 30.8%. Road trauma accounts for a similar proportion of overall cases; however, bicycle-related

**Figure 2.** *Maximal reduction percentage of the elective surgeries.*

accidents have increased significantly, accounting for 11% of presentations. During the pandemic, sports injuries, work-related injuries, and multiple injuries have decreased [49].

#### **5.5 Comparable reduction percentage of all surgeries and elective surgeries**

The reduction percentage in various countries was one of the few parameters that can be compared. However, the data may not be available from some countries. The reduction percentage of the volume of all surgeries was 49.4% in Germany [14], 44.2% in Hong Kong [30], 35% in Taiwan [55], 33% and 26% in the United Kingdom [19, 21], 22.8% in Chile [32], and 15.6% in Australia (**Figure 1**, [49]). Surprisingly, even though there were few COVID-19 cases in the first wave and no serious lockdowns or restrictions in Hong Kong and Taiwan, they still experienced a substantial impact on the number of surgeries. This may be attributable to psychological factors caused by a large flow of people to and from China due to proximity to China.

The maximal reduction percentage of the elective surgery was 100% in the United Kingdom [42], 84% in Hong Kong [30], 83% in Portugal [53], 64% in Chile [32], and 43.5% in Taiwan (**Figure 2**, [55]). The relatively smaller reduction percentage in Taiwan may be attributable to the lack of restrictions or lockdowns [59]. Taiwan prevented the spread of COVID-19 successfully by adopting effective preventive strategies, such as mandatory mask use in public [60].

## **6. Workload impact**

Service volume impact represents the entire department or hospital, the workload impact represents individuals. Three studies [19, 21, 26] focused on the impact of personal workload during the pandemic in the UK. A study on the workload in the UK revealed the average number of weekly referrals to the service decreased by 33% (p < 0.0001). The number of operations performed each week was reduced by 26% (p = 0.001). The number of referrals related to domestic abuse or non-accidental injury had not changed. In addition, the number of hip fractures, periprosthetic fractures, and prosthetic joint dislocations did not change. The number of referrals for simple fractures, natural joint dislocations, wounds, and soft tissue injuries had been significantly reduced. Similarly, in the pediatric population, the reduction in referrals for simple fractures had also been demonstrated [19]. Another study on the workload in UK showed acute trauma referrals decreased almost 50%, with similar distribution between pediatric and adult patients, but the required hospital admissions increased significantly by 19% (RR 1.3, OR 2.6, p = 0.003). During the COVID-19 outbreak, the total number of surgical cases fell by a third. The usage of aerosol-generating anesthesia technique was reduced by 14% (RR 0.85, OR 0.20, p = 0.006) [21]. A study on pediatric trauma in UK during lockdown revealed that acute pediatric trauma referrals were reduced by two-thirds compared with 2019 (n = 302 vs. 97, RR 0.55, OR 0.43) (p = 0.002). Outpatient telemedicine was used more, virtual fracture clinics were used more (OR 97, RR 84, p < 0.001), and fewer patients received consultation and face-to-face follow-up (OR 0.55, RR 0.05) (P < 0.001) [26]. Although for individuals, the reduction in clinical workload during this period may bring more rest time, and the extra free time can also be used for writing, reading or personal research, this also means that the economic income will inevitably decrease accordingly.
