Pandemic Lockdown Does Not Flatten the Curve of Complex Foot Ankle Injuries.

Few would have expected the massive implications to the world population, economics and health care system following the first COVID-19 case from Wuhan China early December 2019. The first case in the Netherlands was seen on 27 February 2020. First a part of the Netherlands was on high alert, but on March 23, 2020, the entire country was put in what was called an intelligent lockdown. Compared to other countries this was not a complete lockdown, people were allowed to leave their houses, but several strict rules (stay at home as much as possible, work from home as much as possible, no shaking hands, keep 1.5 m distance) were set to flatten the curve and prevent mass spread of the virus, especially to the elderly and frail patients. As of this week ( May 11, 2020) 5456 people lost their lives from the corona virus in the Netherlands, fortunately the number of people dying per day is steadily declining. Starting from this day several measures and restrictions of the intelligent lockdown are eased, for example schools are partially opened.

At our Level-1 trauma-centre, the same rules were set. Elective care and surgery were postponed until further notice (gradual restarting on May 4, 2020). Only acute care was performed. The emergency department and ICU where overwhelmed with COVID-19 cases, putting enormous strains on all other health care disciplines. Several departments in the hospital were closed and restructured to become COVID departments, for suspected patients and for proven positive patients separately. Outpatient clinics were shut down for about 4 weeks and most appointments were rescheduled to phone-call or video-calling appointments, if necessary. The amount of work put in by many of the nurses and doctors has been breath-taking. Not only due to the enormous increase in work-load and due to the increased stress surrounding the care for positively tested patients, but also because many chose to help in departments outside of their comfort-zones.

From a trauma point of view, the number of severely injured polytrauma patients dropped in the first weeks of the lockdown. However, the number of cases seen with complex foot and ankle injuries did not. In between the 7 weeks of start of the lockdown (March 23) and relieve of some of the restrictions (May 11), a total of 21 complex foot-ankle cases were operated. A total of 4 procedures were orthopaedic emergencies (external fixator placement in 3 complex ankle/pilon fractures and one closed reduction of a locked fracture dislocation [subtalar dislocation] of the calcaneus). The others were definitive surgery in the three pilon/ankle fractures, 1 talar fracture dislocation, 3 Lisfranc/Chopart midfoot injuries, and 11 intra-articular calcaneal fractures (of which 1 was the definitive surgery following the closed reduction of the subtalar dislocation). When taking a closer look at the 11 calcaneal fractures, 5 were work related (fall from ladder or scaffold), 2 occurred at home, a bilateral fracture was due to a jump from height during a psychosis, and 2 were sports-related accidents. Compared to the same time-period in previous years, the number of calcaneal fractures treated surgically increased (2016: 5, 2017: 8, 2018: 8, 2019: 2), but the distribution of injury mechanism remained the same (about 50% work related). On average 3.1 calcaneal fractures are treated surgically at our hospital per month (1). All patients were screened prior to their surgery using viral testing, and in the acute patients a CT chest was obtained to rule out infection as much as possible to lower the risks for staff and spreading.

Please take note this is not meant as a scientific paper. It is merely an observation from one Level-1 hospital (out of 11 Level-1 trauma-centres in the Netherlands, on a total of 71 hospital organisations with 120 locations serving a population of 17.4 million). It does however show that even in a pandemic (intelligent) lockdown not all non-COVID care comes at a full stop nor should it be neglected, due to the risks of increased morbidity and lower patient satisfaction in complex foot ankle injuries if treated too late or inadequately (2). Of course one should outweigh these risks against the risks related to the virus to care-providers and patients. And finally, we should take good care of ourselves, our loved-once, and our fellow-men (including foot-ankle patients).