Trauma and orthopaedics in the COVID-19 pandemic: breaking every wave.

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has placed the whole world and the medical profession in an unprecedented situation. Each medical specialty has had to develop protocols within the local context to cope with this crisis. We aimed to provide a commentary on the evolving situation in orthopaedic departments in Singapore and share insights and recommendations for the consideration of orthopaedic surgeons worldwide. The COVID-19 threat in Singapore can be classified into ‘waves’, which started with the confirmation of the first COVID-19-positive patient in Singapore on 23 January 2020. The first wave of cases was traced to travel or contact with travellers to and from the Chinese city of Wuhan, Hubei.(1) This progressed to more cases from North Asian cities in February 2020, with few cases from Europe or North America. As Singapore braced itself for community spread, the national disease threat level was stepped up from Disease Outbreak Response System Condition (DORSCON) Yellow to Orange on 7 February 2020.(2-4) By early March, the number of COVID-19-positive cases in Europe and North America had increased exponentially with a high number of fatalities, signalling a global pandemic. The second wave of cases in Singapore, many of whom were returning students and Singaporeans working abroad, was traced to previous travel to Europe, North America and other cities in Asia. Unlike many countries that imposed a lockdown to limit local community spread, Singapore maintained a strategy of testing and isolation of infected individuals, and quarantine of all close contacts of infected individuals. This aggressive public health strategy allowed most Singaporeans to continue work and school with limited restrictions in February and March 2020. The policy of ‘social distancing’ was additionally promoted to mitigate local transmission. The end of March 2020 saw multiple new local clusters and increased numbers of local unlinked COVID-19-positive cases. This heralded the start of the third wave of patients from significant local case transmission.(5) Over this period, the resources of the local medical community – community practice, government restructured hospitals and the National Centre for Infectious Diseases (NCID) – were strained and further put to the test. The significant rise of new local unlinked cases necessitated a national ‘circuit breaker’ period that commenced on 7 April 2020 for one month (i.e. two COVID-19 incubation cycles). During this time, only essential services were permitted to continue. A nationwide school and non-essential workplace closure took effect in order to create a period of enhanced social distancing and reduced human traffic in Singapore. Trauma and orthopaedics encompass both non-elective and elective work. Trauma involves the management of fractures that are categorised as urgent and semi-urgent. Elective orthopaedic surgery covers soft tissue repair and reconstruction, joint replacement in the shoulder, knee, ankle and hip joints, and spine surgery. Musculoskeletal oncology surgery and certain aspects of spine surgery such as spinal cord decompressions are generally considered urgent and semi-urgent. During this pandemic, orthopaedic departments in Singapore have to frequently calibrate and recalibrate their organisational structure and clinical operations as the crisis evolves.