COVID-19: Initial experience of hand surgeons in Northern Italy.

We are grateful to Ducournau et al. for sharing how an international group of hand surgeons managed surgery during the COVID-19 pandemic [1]. This event has severely affected many countries worldwide [2]. After the first Italian death due to COVID-19 in Vò, the Italian healthcare system managed to limit the diffusion and deadliness of the virus [3].

Our facility is a hand trauma referral center in Northern Italy that sees more than 700 trauma cases/year. We agree with the need for an international consensus and we would like to report our initial experience. Our healthcare facility created an internal study group called Plastic Surgeons Against COVID-19 (PSAC) to deal with specific issues related to the pandemic [4].

Preventive measures are needed to ensure the safety of patients and healthcare workers, to provide emergency treatment during the peak of the pandemic, and to schedule non-emergent procedures in the next months. Respecting social distancing, limiting meeting time and using personal protective equipment (PPE) allowed all of our unit's surgeons and staff to avoid SARS-CoV-2 infection, as confirmed by the more than 100 negative swabs tested [4].

An analysis of the cases treated in one month from the beginning of the lockdown (9th March–9th April 2020) confirmed the impact of COVID-19 in hand surgery and dictated the need for precise screening to limit the spread of the infection (Table 1 ). To our surprise, the number of hand injuries was similar to the same period over the prior three years, despite the suspension of many work activities and millions of people being forced to stay home. In fact, we witnessed a slight relative increase in home-related injuries in 2020.

Table 1

Hand surgical cases at our facility from 9 March to 9 April in the years 2017 to 2020.

	2017		2018		2019		2020
	Home	Work	Home	Work	Home	Work	Home	Work
Minor procedurea/No immediate treatment needed	46	12	35	14	41	15	38	11
Major injuries requiring hospitalization/No immediate treatment needed	11	5	6	2	2	2	11	2
Revascularization or replantation	4	2	4	2	5	5	4	2
Total trauma cases	61	19	45	18	48	22	53	15
Elective hand surgeryb	40		52		47		0

Tendon repair, nerve repair, bone fixation, soft tissue reconstruction, infection drainage.

Carpal tunnel release, trigger finger, ganglion cyst removal, collagenase injection or fasciectomy for Dupuytren's disease.

All elective hand surgeries (**see Table 1) were cancelled except for non-emergent posttraumatic and oncologic procedures. Outpatient office visits were reduced to only posttraumatic and oncologic preoperative cases and essential follow-up. Fortunately, postoperative physiotherapy counseling has always been available.

According to our data, hand injuries remain a major healthcare issue during a pandemic. Also, sooner or later, we will have to deal with all the postponed elective patients. We agree that hand surgery units need to share COVID-19 preventive protocols to allow elective and non-elective procedures to continue safely. We believe that all patients should ideally undergo a screening test for the virus, and we advocate for wider test availability and faster results [5]. In the middle of this crisis, we developed a screening protocol for safe and systematic organization of the required activities (Fig. 1 ).

Fig. 1

Screening protocol for all patients undergoing hand surgery. *Minor procedures: tendon repair, nerve repair, bone fixation, soft tissue reconstruction, infection drainage; ** COVID-19 risk pattern interview: fever, cough, conjunctivitis, shortness of breath, diarrhea and temperature monitoring; *** PPE: personal protective equipment consisting of gown, glasses and N95 masks; §: In case of a positive swab test or while waiting for the test result, patients are treated in a dedicated COVID operating room.

Given their role in such important period, hand surgery units should share their protocols and their know-how to develop an international consensus in face of the current pandemic. Besides, we should be prepared to gradually restore the pre-COVID surgical regimen while doing all we can to limit the second wave of contagions expected once the lockdown is over.

Disclosure of interest

The authors declare that they have no competing interest.