The findings of this study demonstrate that the COVID-19 pandemic had a significant impact on both elective and emergency orthopaedic procedure volumes in our tertiary hospital. Specifically, elective orthopaedic procedures such as arthroplasty, arthroscopy, nailing, and orthopaedic implant removal saw a reduction, while paediatric fracture fixation with K-wires and anterior cervical discectomy and fusion (ACDF)/laminectomy procedures experienced an increase in volumes. These findings are consistent with global trends reported in the literature and highlight the pandemic’s selective impact on different types of orthopaedic procedures. This was in part postulated to be due to increased access to private facilities by holders of the government’s health insurance fund, a measure undertaken by the Kenyan government in response to the crisis, anecdotally to ease the pressure on public sector hospitals. Additionally the spine surgery team pushed for daycare surgery which was attractive to worried patients and reduced costs further. By 2022, the numbers of operations had returned to pre-covid levels with the exception of arthroscopy numbers which had increased, which could be explained by the possible backlog of patients who didn’t have their surgery in the pandemic period or by increased uptake of sporting activities after the pandemic.

The reduction in elective orthopaedic surgeries, including arthroplasty, arthroscopy, and orthopaedic implant removals, aligns with other studies that have documented the widespread deferral of non-urgent surgeries during the pandemic. In many healthcare settings, elective procedures were intentionally delayed to conserve hospital resources, such as ICU beds, ventilators, and personal protective equipment, and to minimise the risk of viral transmission (Pronk, 2021, Al-Jabir, 2020). Arthroplasty procedures, which are typically performed to address chronic degenerative conditions such as osteoarthritis, were particularly affected, as they were classified as non-emergent surgeries during the height of the pandemic (Megaloikonomos, 2020). The decrease in arthroscopy and implant removal procedures can similarly be attributed to their elective nature, where delays would not result in immediate harm to patients (Bram, 2020).

Looking at trauma, there was a reduction in the number of fracture fixations/nailings and manipulations by 14% and 46% respectively during the covid period, which may have been explained by the effect of the curfew that limited night driving, cross country travelling and the restrictions that reduced sports participation. Fixation/nailing in the post covid period had increased by 26% compared to baseline, which could be explained by a resumption of travelling, sports and socialising while manipulations had reduced by 61% compared to the 2019 baseline, perhaps a reflection of perceived end of health austerity measures which had encouraged more conservative practices from the clinicians.

The observed increase in paediatric fracture fixation procedures, particularly using K-wires, reflects a trend seen in some regions where paediatric trauma volumes either remained steady or increased during the pandemic (Jain, 2021,Mahmood, 2021). The likely explanation for this increase lies in the changing patterns of physical activity among children during lockdowns and post-lockdown periods. While organised sports and school activities were restricted, children often engaged in unsupervised play, which may have contributed to an increase in fractures (Wong 2021). In addition, as paediatric fractures are often considered time-sensitive emergencies, the management of these injuries continued with little disruption, in contrast to elective procedures.

One of the most surprising findings of the study was the increase in ACDF/laminectomies and K-wiring during the Covid period compared to the previous year. As was explained earlier, there are various factors which drive healthcare seeking habits, and in our private hospital setting, cost is a major one. Having affordable access to healthcare was the major reason for the spike in ACDF/laminectomy numbers, and is an indirect representation of the effect of cost on health seeking behaviour with patients timing need for intervention with availability of financial resources. These procedures are often performed to address acute spinal conditions, such as cervical myelopathy or disc herniations, that can result in severe pain or neurological compromise if not treated in a timely manner (McCormick, 2020). As a result, these cases were likely prioritized despite the pandemic’s restrictions on elective procedures, as delaying surgery could result in serious functional impairment. This also highlights that even in LMIC, insurance companies and the private sector can play a role in shaping and improving much needed surgical services. Clinician awareness of sensitivity to the general economic climate may have driven the more cost effective K-wires as opposed to other means of fixation (5) and this too represents an interesting area of surgeon influence in the overall cost of healthcare.

We expected that during the pandemic induced lockdown, with reduced travel, sports, socialising and alcohol consumption, there would be a drop in injuries, driving balance of procedures towards elective operating, but the data collected did not reflect this. According to the Kenya national Bureau of statistics data (6), the number of road traffic accidents rose during 2020 with an increase in all categories including, pedestrians, motorcyclists and cyclists. The number of casualties in motorcyclists rose 58% compared to 2019. There was a 17.3% increase in serious injuries involving drivers and an 8% increase in pedestrian casualties. This, however, was not the experience in our tertiary referral hospital where the overall numbers of patients requiring surgery dropped as observed. One possible explanation may have been due to the fact the lockdown restrictions ensured surgical attention was administered in regional facilities with a reduction in transfers to often distant tertiary referral centres.

In a 2021 paper examining the effects of the pandemic on surgical practice, there was found to be a reduction in elective cases and prioritisation of cancer and emergency surgery, and an overall drop in patient volumes, with a rate of cancellations of surgical procedures in the range of 74 to 81% (7). This reduction in elective volumes was in keeping with our findings, as the uncertainty caused by the pandemic may have led patients who had non-urgent conditions to wait until it was deemed safe to return to hospital. Third quarter analysis was used as this was the period that the effect of the pandemic was most felt in the country. With the first case of COVID-19 diagnosed in March 2020 in Kenya, the government put a series of curfews, lockdowns, and movement restrictions in place which had fully taken hold by July 2020. An evaluation of orthopaedic services in other centres around the world showed a reduction as high as 61% in the total number of cases in the second quarter of 2020 compared to the second quarter of the previous year (8). Though their time periods were not precisely the same as ours, there is evidence that although the number of orthopaedics cases performed at our tertiary referral centre followed the general global trend, the consequence was not as profound comparatively.

The emergence of the pandemic highlighted the importance of anticipating such a global crisis. It led to a “mini-revolution” in healthcare with a greater appreciation of the role of technology, i.e., teleconsultation and telerehabilitation. (9). As such, with the trends noted at our unit, we believe that this and similar studies in different settings would be useful in the projection of resource allocation in future similar crises.

Limitations of the study include seasonal variation in clinical workload that was not captured. It would have been valuable to statistically test the difference between the numbers analysed but with no known expected change, comparison groups, or knowledge of numbers who were actually eligible for surgery rather than only those who underwent it, this was not possible. Another potential confounder includes change in surgical personnel over the study period which would have altered the numbers.

Being a cross-sectional retrospective study, confounding factors to the outcomes were not assessed. The study had low external validity as the findings are from a single centre. Ideally, a large multicentre review is needed to fully assess the lasting effects of this pandemic.