Acta Ortop Bras aob Acta Ortopédica Brasileira Acta Ortop. Bras. 1413-7852 1809-4406 Sociedade Brasileira de Ortopedia e Traumatologia, Brazil Resumo Objetivo: Avaliar o impacto da COVID-19 em cirurgias eletivas e emergenciais de mão e punho realizadas em um centro ortopédico privado. Métodos: Foi realizado um estudo retrospectivo que incluiu cirurgias de mão e punho em um centro ortopédico privado. Todas as cirurgias foram computadas e classificadas como eletivas ou de emergência. Os números foram analisados por mês, trimestre e ano antes e depois da pandemia (março de 2020). Resultados: Foram incluídas 843 cirurgias de março de 2018 a fevereiro de 2022. A média de casos mensais dos 12 meses iniciais da pandemia (15,3) foi estatisticamente igual aos períodos anteriores (17,3 e 17,2), mas o período de março de 2021 a fevereiro de 2022 apresentou um aumento (20,5; p = 0,037). Os primeiros quatro meses da pandemia tiveram uma média (8,3) menor do que o período anterior (14,0; p = 0,002), entretanto, logo houve um aumento significativo nos quatro meses seguintes (19,3; p = 0,002). Como um padrão histórico, as cirurgias eletivas foram maiores do que as emergenciais nessa instituição. Ainda assim, nos dois primeiros trimestres da pandemia, houve uma redução nos casos eletivos, igualando-se à emergência. Conclusão: Um impacto importante, mas relativamente curto, no volume cirúrgico foi observado nas cirurgias de mão e punho durante a COVID-19. Uma redução significativa nos casos eletivos ocorreu no início da pandemia, seguida de uma rápida recuperação após quatro meses. Nível de Evidência II; Estudo Retrospectivo. INTRODUCTION The coronavirus pandemic (COVID-19) has disrupted health services worldwide, testing service’s physical and administrative infrastructure, especially in developing countries.1 Orthopedic services, in particular, were obliged to reorganize themselves at all levels of activity, from adopting new safety protocols and use of personal and collective protective equipment to restructuring the flows and processes of all wards of clinics and hospitals, passing through emergency rooms to infirmaries and intensive care units.2,3,4 The demand for orthopedic care during COVID-19 generally decreased during the stricter restriction, but trauma and orthopedic involvement continued to demand attention from services.5,6 This reduction in cases mainly affected the elective surgeries rate.3 Emergency surgeries, such as fractures and infection, continued to occur, but with a reduced number.7 The reduction in surgeries also influenced resident physician’s and subspecialist’s training. As a result, school hospitals responsible for education and training had to create alternative ways to meet this lack of demand, such as electronic teaching and telemedicine.8,9 The objective of this study is to evaluate the impact of COVID-19 on elective and emergency hand and wrist surgeries performed by the Hand Surgery and Microsurgery group in a private orthopedic center in São Paulo – Brazil. MATERIAL AND METHODS A cross-sectional study was performed, with retrospective data collection from the medical records of patients treated at a large private orthopedic service in São Paulo – Brazil, submitted to elective or emergency surgery by the Hand and Microsurgery group from March 2018 to February 2022. This study was evaluated and approved by the Institution Research Ethics Committee (CAAE: 67277423.6.0000.5474). The number of surgeries performed during COVID-19 (March 2020 to February 2022) was compared with those in the previous two years (March 2018 to February 2020), a period without interference from the pandemic. The data used was age, gender, and date of the procedures performed (elective and emergency) and were analyzed through electronic medical records. The variables evaluated were presented in tables with absolute and relative frequency distribution. The descriptive analysis was performed in addition to means between the two groups and was compared using the Student’s t-test. A specific three-month moving mean was calculated by the mean number of surgeries from the previous two months and the corresponding month. This mitigates the data by creating a constantly updated mean number and mitigates the impacts of short-term random fluctuations. The significance level adopted was 95%, and the tests were performed in the SPSS software. RESULTS From March 2018 to February 2020 (pre-pandemic period), the total elective surgery was 284, and emergency was 130, totaling 414. Between March 2020 and February 2022 (during the pandemic), the elective surgery was 312, and emergency was 117, totaling 429. Throughout the period (2018–2022), the mean age of the operated patients was 45 years, and 49% were women. Figure 1 shows the monthly distribution of operated cases, and Figure 2 shows the distribution of surgeries classified as elective or emergency. The qualitative analysis of surgeries throughout the period shows that historically there has been an oscillation in surgeries over the months, but it shows two periods of most considerable reduction, both during the pandemic, between December 2019 and June 2020, and March 2021 and June 2021. The cumulative numbers of surgery performed 12 months before (March 2019 – February 2020) and 12 months after the pandemic (March 2020 – February 2021) show a similarity of elective surgeries (130 vs. 134, respectively) but a reduction in emergency surgeries (76 vs. 50, respectively). Figure 1 Total number of surgeries performed in different quarters two years before and two years after the onset of COVID-19. The bars represent the number of surgeries, and the dotted line represents the 3-month moving mean. Figure 2 Number of surgeries performed in different quarters two years before and two years after the onset of COVID-19 divided into elective surgeries (dark bars) and emergency surgeries (light bars). The mean monthly surgeries during the entire period evaluated was 17.6. There was no statistical difference (p = 0.348) between the mean monthly surgeries two years before the pandemic (March 2018 – February 2020), with 11.8 surgeries per month, compared to two years during the pandemic (March 2020 – February 2022), with 13 surgeries per month (Table 1). The month with the lowest number of surgeries was March 2020, with six surgeries. The month with the highest number of surgeries was November 2021, with 27 surgeries. The discriminative analysis between emergency vs. elective surgeries (Figure 2) demonstrated that the elective surgeries was historically higher than emergency, except for November 2018 (9 vs. 11), July 2019 (8 to 8), December 2019 (7 to 7), January 2020 (6 to 6), and May 2020 (4 to 6). Table 1 Comparison between surgeries performed in different periods of four months, one year, and two years, two years before and two years after the onset of COVID-19. Mean ± SD p-value vs. Mar20 – Jun20 p-value vs. Mar20 –Feb21 p-value vs. Previous period Period of 4 months Mar18 – Jun18 12.5 ± 4.4 0.062 na na Jul18 – Oct18 19.5 ± 1.9 < 0.001 na 0.014 Nov18 – Feb19 20.0 ± 4.3 0.001 na 0.420 Mar19 – Jun19 19.5 ± 4.4 0.001 na 0.438 Jul19 – Oct19 18.0 ± 2.2 < 0.001 na 0.280 Nov19 – Feb20 14.0 ± 2.2 0.002 na 0.003 Mar20 – Jun20 8.3 ± 1.7 - na 0.020 Jul20 – Oct20 19.3 ± 4.8 0.002 na 0.002 Nov20 – Fen21 18.5 ± 5.7 0.007 na 0.423 Mar21 – Jun21 13.8 ± 2.6 0.006 na 0.090 Jul21 – Oct21 22.8 ± 5.4 0.001 na 0.012 Nov21 – Feb22 25.0 ± 6.6 0.001 na 0.309 Period of 1 year Mar18 – Feb19 17.3 ± 4.9 na 0.204 na Mar19 – Feb20 17.2 ± 3.7 na 0.205 0.463 Mar20 – Feb21 15.3 ± 6.6 na na 0.205 Mar21 – Feb22 20.5 ± 6.9 na 0.037 0.037 Period of 2 years Mar18 – Feb20 11.8 ± 3.7 na na na Mar20 – Feb22 13.0 ± 5.6 na na 0.348 SD: Standard deviation The quarterly analysis of the mean number of surgeries (Table 1) showed that the most critical period in relation to the reduction in surgical volume was the first four months of the pandemic (between March 2020 and June 2020), with a mean of 8.3 surgeries, with a statistical difference (p < 0.05) with all other 4-month periods, except the beginning of 2018 (March 2018 – June 2018, p = 0.062) The analysis of the mean annual surgeries per month (Table 1) showed a tendency to maintain the mean in 2018 (17.3), 2019 (17.2), and 2020 (15.3), with a subsequent increase in 2021, which had a mean monthly of 20.5 surgeries (p = 0.037). The comparison between the number of elective and emergency surgeries performed in different periods of four months, one year, and two years before and two years after the beginning of COVID-19 is shown in Table 2. All comparisons in the 4-month periods had significant differences, except for November 2019 to February 2020 (p = 0.552), March 2020 to June 2020 (0.144), and November 2021 to February 2022 (p = 0.060). The comparisons year by year and every two years (period before and during COVID-19) were also statistically significant. Table 2 Comparison between the number of elective vs. emergency surgeries performed in different periods of four months, one year, and two years, two years before and two years after the onset of COVID-19. Electives Mean ± SD Urgency Mean ± SD p-value Period of 4 months Mar18 – Jun18 10.3 ± 2.5 2.3 ± 2.6 0.005 Jul18 – Oct18 14.0 ± 2.6 5.5 ± 1.9 0.002 Nov18 – Feb19 14.3 ± 5.0 5.8 ± 3.8 0.037 Mar19 – Jun19 13.5 ± 2.6 6.0 ± 2.2 0.005 Jul19 – Oct19 11.8 ± 3.0 6.3 ± 1.3 0.027 Nov19 – Feb20 7.3 ± 1.3 6.8 ± 1.0 0.552 Mar20 – Jun20 5.3 ± 1.5 3.0 ± 2.2 0.144 Jul20 – Oct20 16.0 ± 4.0 3.3 ± 1.7 0.004 Nov20 – Fen21 12.3 ± 3.4 6.3 ± 2.9 0.037 Mar21 – Jun21 11.0 ± 2.8 2.8 ± 0.5 0.009 Jul21 – Oct21 16.5 ± 5.2 6.3 ± 3.9 0.022 Nov21 – Feb22 17.0 ± 6.2 8.0 ± 0.8 0.060 Period of 1 year Mar18 – Feb19 12.8 ± 3.7 4.5 ± 3.1 < 0.001 Mar19 – Feb20 10.8 ± 3.5 6.3 ± 1.4 0.001 Mar20 – Feb21 11.2 ± 5.5 4.2 ± 2.6 0.001 Mar21 – Feb22 14.8 ± 5.3 5.7 ± 3.1 < 0.001 Period of 2 years Mar18 – Feb20 11.8 ± 3.7 5.4 ± 2.5 < 0.001 Mar20 – Feb22 13.0 ± 5.6 4.9 ± 2.9 < 0.001 SD: Standard deviation DISCUSSION COVID-19 interfered with health systems worldwide by prioritizing the treatment of large numbers of patients with often severe clinical respiratory demands and by generating greater attention to prevention measures regarding respiratory isolation in the general population. Consequently, medical services in surgical areas initially significantly reduced admissions and the volume of surgeries in adults and children in several countries.10,11 This need for a higher attention to the respiratory condition may have also decreased the number of orthopedic surgeries. Blum et al.,6 in a systematic review, also concluded that there was a reduction not only in consultations or elective and emergency visits but also in the general trauma surgeries (around 21.2% to 66.7%) and even more in elective surgeries (33.3% to 100%) during the pandemic period. In Brazil, the reduction in surgical volume during the highest period of the pandemic occurred mainly in the Unified Health System (SUS). In nine months there was a reduction of about 46% in elective surgeries attributed to COVID-19.12 As demonstrated in our study, during the first two years of COVID-19 in Brazil, considering the reality of the service in question, there was an important change in the flow of surgeries in the hand surgery subspecialty, but only occasionally, in the first four months following the decree of the World Health Organization that confirmed that we were facing a pandemic. Certainly, the reasons for certain services to present a more or less significant reduction in the surgical volume were diverse and heterogeneous. However, we can draw a parallel between the surgical volume curve and the epidemiological situation experienced in the city where the work was performed (Figure 3). This analysis suggests an inversely proportional relationship between the periods of lower volume of surgeries with the period of stricter restriction. Figure 3 COVID-19 timeline in the state where work was performed. The reduction in the mean monthly surgeries in the first four months of the pandemic was similar to other studies.5,6 However, in our study, this tendency did not continue in the subsequent months, including a demand similar to the two pre-pandemic years. Possibly, the fact that our institution did not directly serve patients with respiratory demand, combined with the effectiveness of organizational measures and administrative flows, made it possible that the reduction in surgical volume did not occur sustainably. In addition, the type of health service may have had a great influence on the rapid recovery of these numbers since it may have been seen as a place of safety for patients with orthopedic demand who did not want to be exposed to hospitals that were treating cases of COVID-19.2 The higher period of surgeries in the institution among the four years evaluated was after July 2021. We can also contextualize with the local health scenario, which at that time was experiencing a gradual reopening and was heading for a vaccination rate (1st dose) of 50% of the eligible population, which occur in August 2021, reaching the mark of 80% of the country’s population at the end of December 2021. The timeline shown in Figure 3 illustrates the epidemiological scenario of COVID-19 in the state where this study was performed, the first and most affected by the pandemic in the country. The limitations of this study start with the specificity of the study in a single center, so we must be careful in extrapolating these results. Still, we must remember that the occasional fluctuation in the number of cases can also occur due to other factors, population vacation periods, and habitual seasonality of certain pathologies, among others. CONCLUSION Our study showed a significant reduction in surgeries at the beginning of the pandemic, with elective surgeries most affected. 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