EVALUATION OF THE EPIDEMIOLOGY OF EXPOSED FRACTURES BEFORE AND DURING THE COVID-19 PANDEMIC

ABSTRACT Objective: To assess the impact of the COVID-19 pandemic on the epidemiology and clinical outcomes of open fractures considering the periods before and during the pandemic. Methods: An observational and retrospective study, which included patients aged over 18 years, admitted to the Orthopedics and Traumatology Ward of Hospital São Paulo, of the Federal University of São Paulo (UNIFESP). Data was collected in two moments: pre-pandemic (March 1, 2019, to February 29, 2020) and during the pandemic (March 1, 2020, to February 28, 2021). Results: In total, 183 patients were evaluated with a mean age of 36 years ± 14 years. In the pre-pandemic period, 94 patients underwent surgery, 81 men (85.37%) and 13 women (14.2%), with a mean age of 36 ± 3 years. During the pandemic period, 89 patients were subjected to surgery, 77 men (86.6%) and 12 women (13.4%), with a mean age of 38 ± 3 years. Conclusion: During the pandemic, open fractures were still more common in men. Regarding hospital indicators, the prevalence of infections in the surgical wound and the length of stay of patients with open fractures increased, however, with little significance. Fractures classified as Gustilo IIIA were the most common, while the most common according to the AO classification were 33, 34, 42, 43, 2R3, and 2R3 + 2U2. The frequency of run overs during the pandemic decreased. However, firearm projectile injuries and falls and occupational injuries increased. Level of Evidence III, Retrospective Comparative Study.


INTRODUCTION
According to a World Health Organization study, COVID-19 has affected over 216 countries, with 194,080,019 confirmed cases and 4,162,304 deaths as of the termination of this study. 1 The transmission of the SARS-cov-2 disease can easily occur by airways infection and can lead to many clinical situations, ranging from a common cold to more severe respiratory syndromes. 2 The new scenario set by the COVID-19 pandemic has created enormous pressure on health systems worldwide. This scenario deeply impacted the management of fractures on the locomotor system, which are the main circumstances responsible for admissions to emergency rooms. 3 Thus, the continuous provision of care in trauma services are a great challenge. 4 Many orthopedic surgeons have been instructed to postpone or cancel elective surgeries without urgency to delay the transmission of the disease and conserve health resources. 5 The new standard of living during the pandemic has had a significant impact on epidemiology and prevalence, especially in cases of orthopedic trauma, including fractures. 6 The increase in social isolation due to the pandemic and the length of stay at home have affected the number of hospital visits and the distribution of patients with fractures who are admitted to the emergency room. 3 Recent studies such as those by Murphy, Akehurst, and Mutimer 7 and by Lima et al. 8 reported a reduction in the number of cases of fractures at the beginning of the pandemic, which probably occurred due to the decrease in patient demand for health services justified by the fear of contamination and the possibility of sequelae from COVID-19 infection. 7,8 However, we also found studies showing an increase in mortality rates [9][10][11] and complications 12,13 in patients with fractures treated during the pandemic. In this way, our research group decided to carry out this study.
Therefore, this study aimed to evaluate the impact of the pandemic on patients with fractures considering the epidemiological elements.
Moreover, we aimed to analyze the clinical outcome of open fractures in the periods before and during the COVID-19 pandemic.

METHODS
This study was submitted to evaluation and approved by the Statistical significance was considered when p-values were equal to or lower than 0.05, both for the results from the t-test, and for those from the proportional difference tests, allowing to verify the existence of significant differences between the parameters before and during the COVID-19 pandemic. P-values higher than 0.05 indicate that the period is insignificant for the measures analyzed. Table 1 shows data regarding hospital indicators, length of hospital stay, ICU admission, number of surgical procedures, and Gustilo classification. Table 2 shows the results based on the test of difference of proportions, involving the qualitative variables related to the surgical processes in both periods evaluated. Table 3 shows the diversity of fracture classifications, their frequencies, and proportional comparisons. Table 4 shows the data on the incidence of complications, as well as their proportional differences.    There was a statistically significant difference in the prevalence of men in both periods (p < 0.02). However, we found no difference in age groups between the periods analyzed (p > 0.07).

RESULTS
Regarding hospital indicators, we found a slight statistical difference in the length of stay during the pandemic, as well as in the classifications of Gustilo I, II, and IIIA (Table 1). In the evaluation of risk factors, we highlight the reduction in the frequency of run overs during the pandemic, the increase in firearm projectile injuries (FPI) and falls and occupational injuries, epidemiological situations involved with measures to restrict activities during the pandemic. Amputations slightly increased, however, at levels very close to statistical insignificance. On the other hand, accidents involving motor vehicles, such as motorcycles and automobiles, did not present statistically significant differences between the periods. When verifying the incidences and classifications of fractures, not all of them could be compared due to the differences of incidence. Those that occurred simultaneously between the groups and that showed statistically significant differences between the periods were 33, 34, 42, 43, 2R3, and 2R3 + 2U2.
Post-surgical complications were the same before and during the pandemic, except for surgical wound infection. Notably, the absence of post-surgical complications maintained stable percentages and without differences between the two periods evaluated.

DISCUSSION
Both public and private healthcare services have needed significant adaptations to handle the large influx of patients during the COVID-19 pandemic. There has been a new level of redeployment of surgical and anesthetic teams of all grades to manage the vast workload related to the pandemic, which has greatly impacted service delivery, with the complete suspension of elective orthopedic surgeries and significant changes in the way trauma care is provided. 17 Considering the risks to which patients and medical staff were exposed in the pandemic, the Department of Orthopedics and Traumatology of the Federal University of São Paulo (UNIFESP) created three protocols in the service that were applied during the pandemic. Thus, the application of these protocols aimed to reduce the risk of infection of patients and healthcare professionals and adapt work, academic, and scientific activities, and orthopedic treatment in the face of the pandemic. 8 The impact on trauma services was especially related to the need to balance optimal treatment of patients' injuries with safety and clinical resources. The need to reduce hospitalizations and elective surgeries was reinforced, as well as accepting that conventional surgical decision-making would have to change, with an increase in cases of late reconstruction. However, major orthopedic injuries, including open fractures, had to continue their treatment in emergency cases. Open fractures are complex injuries associated with high rates of complications, including infection and neurological and vascular impairment. 17 Thus, this study aimed to understand the impact of the pandemic on the reduction or increase in the prevalence of hospital visits, the waiting time for hospitalizations, treatment options, and clinical outcomes of patients with open fractures, comparing the rates obtained in our service before and during the COVID-19 pandemic, to provide information that can improve patient management.
Our results showed a higher prevalence of fractures in men for both periods. This finding is similar to that observed by Tian et al., 18 who evaluated 111 studies involving 41,429 individuals by a systematic review of the literature, to identify factors involved with the occurrence and resolution of fractures, including those involved with the formation of pseudarthrosis in tibial fractures. According to the authors, many factors significantly influenced the outcomes, including being aged over 60 years old and being a man, occurrence of open fracture, IIIB or IIIC fractures according to the Gustilo classification, among others. 18 These results are very similar to those identified in this survey. We observed fewer run overs and more firearm projectile injury and domestic accidents during the COVID-19 pandemic. According to Sephton et al., 19 the confinement led to a decrease in emergency orthopedic emergency referrals and the number of procedures, as well as resulting in a shift in the injury mechanisms, which became characterized by domestic accidents and some situations of violence, justifying the change in the profile of the trauma mechanism observed in this study. During the pandemic, the prevalence of surgical wound infections increased. Moreover, the length of stay of patients with open fractures was slightly longer during the pandemic. Although our findings were significant, we had some limitations since this is single-center study and the sample size is relatively small. However, all patients treated at our tertiary health care institution were compiled for the analyses.

CONCLUSION
During the pandemic, open fractures maintained their occurrence, which had a higher frequency in men. Regarding hospital indicators, the prevalence of infections in the surgical wound and the length of stay of patients with open fractures increased, however, they were not significant. The fractures classified as Gustilo IIIA were the most prevalent and, according to the AO classification, the most common types were 33, 34, 42, 43, 2R3, and 2R3 + 2U2. Furthermore, during the pandemic, the frequency of run overs decreased, however, FPI and falls and occupational injuries increased.