Major reconstructive surgery and the COVID-19 lockdown – is the dust settling?

Dear Editor,

The novel Coronavirus SARS-CoV-2 (COVID-19) has had a profound effect on healthcare throughout the world. At the time of writing, there have been almost 10 million confirmed laboratory cases worldwide and 310,250 cases in the United Kingdom (UK) with over 43,000 confirmed deaths [1, 2]. As lockdown came in to affect, our department responded by placing elective surgery on hold, adopting virtual clinics, and minimising inpatients. From the 23rd March 2020 we had relocated our hand surgery unit and skin cancer lists to a “cold” hospital and began to directly look after medical patients with COVID-19 in what was our plastic surgery ward.

As a tertiary centre accepting referrals from a wide geographic area, we had noticed that a significant number of referrals were still requiring tertiary care advice and also transfer for definitive management. All of the peripheral hospitals in our catchment area had reduced their operating capacity substantially, thereby reducing their ability to manage complex reconstructive cases.

We performed a retrospective review of our volume of major reconstructive surgery during the period of reduced operating capacity and lockdown (16th March to 1st June 2020). Patients included were those requiring ortho-plastic surgery, congenital hand surgery, brachial plexus injuries requiring urgent exploration, non-cancer cases requiring reconstruction of a major nerve or vessel, and any complex trauma requiring revascularisation or replantation. We also analysed the referrals from our online referral system (Patient Pass © [Tomorrow, Salford Quays, UK]) for complex lower limb cases from peripheral hospitals; before and during the lockdown period.

A total of 28 patients underwent major reconstructive surgery during our department's lockdown. Of these; 5 had urgent brachial plexus explorations, 5 had debridement and reconstruction for fracture related infections as joint ortho-plastic procedures, 2 required re-vascularisation, 1 child underwent a foot re-plant, 2 underwent free flaps to the upper limb for trauma (1 free groin and 1 free lateral arm flap), 6 had free flaps for lower limb open fractures (all contralateral gracilis), 2 local flaps for lower limb open fractures (1 gastroc and 1 keystone flap), 3 had skin grafts for upper and lower limb open fractures, 1 had 1st stage reconstruction of complex bilateral syndactyly, and 1 child had local flap coverage for a complex spinal wound. Table 1 provides a detailed summary of these cases. Fig. 1 shows the timeline of when these patients were admitted and had their definitive surgeries. There was a rapid increase in the volume of cases from the 11th May onwards coinciding with a partial relaxation on the UK lockdown by the government.

Table 1.

Summary of major reconstructive cases performed during the period of reduced operating capacity and COVID-19 lockdown.

Patient	Age	Gender	Referral From	Procedure
1	26	Male	ED	Debridement of left tibial osteomyelitis and free flap, exchange of nail, and local fasciocutaneous flap
2	58	Male	Peripheral hospital	Free gracilis flap for left open tibial fracture and Ilizarov frame
3	0	Female	Paediatric plastics clinic	Release of complex bilateral syndactyly for Apert's Syndrome + skin grafting (1st Stage) due to recurrent infections
4	81	Female	Orthopaedic clinic	Removal of right fibular plate, debridement of osteomyelitis, and peroneus brevis flap
5	36	Male	ED	Revascularisation of 4 fingers to right hand, fracture fixation, repair of nerves and tendons
6	2	Male	ED	Right foot replant
7	50	Male	ED	Right above knee amputation and free gracilis for left open tibial fracture
8	15	Male	Orthopaedic clinic	Debridement and removal of plate right tibia, refashion free ALT flap
9	35	Male	Peripheral hospital	Keystone flap for left open tibial fracture and IM nail
10	0	Female	MNI clinic	Exploration left brachial plexus, spinal accessory nerve to suprascapular nerve transfer and x3 intercostal nerves to musculocutaneous nerve transfers
11	0	Female	MNI clinic	Exploration of left brachial plexus and multiple sural nerve grafts
12	39	Female	ED	DSH to left wrist with repair of all flexors, radial artery, radial nerve, median nerve, ulnar nerve, and ulnar artery
13	38	Female	Peripheral hospital	Free gracilis to right open tibial fracture and ORIF
14	65	Female	ED	Free gracilis to right open tibial fracture and Ilizarov frame
15	60	Female	Orthopaedic clinic	Exploration right brachial plexus
16	76	Female	Peripheral hospital	Gastrocnemius flap for right open tibial fracture and IM nail
17	8	Female	Spinal surgeons	Spinal wound debridement, repair of dural defect, closure via mobilisation of bilateral latissimus dorsi flaps
18	19	Male	ED	Left distal radius and ulna fractures leading to compartment syndrome, fasciotomies, followed by definitive fixation and skin grafting
19	40	Male	Ortho-plastic clinic	Removal of plate right fibulafibula, debridement, and reconstruction with peroneus brevis muscle flap
20	43	Male	Peripheral hospital	Free gracilis for right open tibial fracture and ORIF
21	0	Male	MNI clinic	Exploration right brachial plexus, sural nerve grafting, spinal accessory to suprascapular nerve, Oberlin I, and Oberlin II transfers
22	37	Male	ED	Skin grafting to large de-gloving injury left leg, Ilizarov frame, and Achilles tendon repair
23	42	Male	ED	Debridement of left foot de-gloving injury and skin grafting, K-wire fixation of open meta-tarsal fractures
24	20	Male	Peripheral hospital	Free groin flap for de-gloving injury dorsum left hand
25	41	Male	Mental health hospital	Free lateral arm flap right volar forearm and ulnar nerve to median nerve distal transfers for DSH injury
26	33	Male	Peripheral hospital	Free gracilis for right open tibial fracture and Ilizarov frame
27	54	Male	Orthopaedic clinic	Debridement of sinus right elbow, remove metalwork, cement spacer, re-fashion free ALT flap
28	29	Female	MNI clinic	Exploration brachial plexus, Oberlin I, Oberlin II, and Somsack transfers

Key: MNI – Major Nerve Clinic, ED – Emergency Department, ALT – Anterolateral thigh, DSH – Deliberate self-harm, IM – Intramedullary, ORIF – Open reduction and internal fixation.

Fig. 1.

Timeline of 28 major reconstructive cases from date of admission to definitive surgery during the period of reduced operating capacity and COVID-19 lockdown.

Data from our pilot referral system Patient Pass © showed that from the 13th January 2020 up to 15th March 2020 (9 weeks), we had 13 patients with complex injuries (closed and open) involving the leg, ankle, or foot, referred and transferred to us from peripheral hospitals; 7 (54%) were from units with an ortho-plastic service. From the 16th March 2020 to the 1st June 2020 (11 weeks), we had 10 patients referred and transferred; 6 (60%) from units with ortho-plastics.

We have previously shown that during the first 5 weeks of lockdown, there was an overall 56% reduction in the total number of hand trauma cases listed for surgery, with a significant increase in hand injuries related to power tool use at home [3] and an increase in deliberate self-harm (DSH) injuries. This trend appears to have continued with more recently one patient requiring revascularisation of her hand and another a free flap reconstruction following DSH. We stress the need for better mental health support in lockdown scenarios.

Hampton et al. performed a multi-centre study analysing referrals to the orthopaedic and hand surgery departments during the first two weeks of lockdown and also showed a 54% reduction in trauma admissions. There was no significant difference in the percentage of hip fractures, upper limb injuries, and lower limb injuries pre-lockdown and during lockdown [4]. This is in keeping with our experience that whilst there has been an overall decrease in our non-cancer related major reconstructive surgeries, we have still had a large volume of work throughout the COVID-19 lockdown and it is continuing to increase as lockdown is eased. Despite reduced operating capacity, we received a similar number of referrals and patient transfers from peripheral hospitals for complex lower limb injuries during the lockdown.

This experience sets an important precedence in case of future pandemics or when services are significantly rationed; major trauma still occurs to a significant degree and with peripheral hospitals having reduced operating capacity, there is more demand placed on tertiary centres. Appropriate resources must be provisioned to accommodate this continued demand with sufficient ortho-plastic, hand trauma, and major nerve operating lists. Furthermore, on-call scrub teams must continue to have staff trained in microsurgery in case of potential re-plant or revascularisation surgery.

Services could also be further centralised during austere conditions so that more patients with complex reconstructive needs can be managed in one place. This could be achieved by better utilisation of the Nightingale hospitals, and more medical patient flow from tertiary to peripheral hospitals. Moreover, the easing of lockdown should be staggered, firstly in the tertiary centres and then the peripheral units. It is also imperative to recognise that a hospital lockdown cannot be at the exact same time as a nationwide lockdown, as preparations to enter and exit lockdown in the hospital must begin at least a week in advance to allow time for workforce to be re-deployed as necessary and physical resources such as equipment and theatres to be re-located.

Whilst we have seen a reduction in non-cancer major reconstructive cases throughout lockdown, we have still had a large caseload and as lockdowns ease, the volume of cases continue to rise quickly. We hope this article provides useful information by which other hospitals can organise their resources in a future pandemic or lockdown situation.

Declaration of Competing Interest

The authors of this article do not have any conflict of interest nor received any funding for this work.