Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology

A Longitudinal Evaluation of Coronavirus Disease 2019 and Its Effects on Spinal Decompressions With or Without Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The objectives were to (1) compare the safety of spine surgery before and after the emergence of coronavirus disease 2019 (COVID-19) and (2) determine whether patients with a history of COVID-19 were at increased risk of adverse events.

SUMMARY AND BACKGROUND DATA

The COVID-19 pandemic had a tremendous impact on several health care services. In spine surgery, elective cases were canceled and patients received delayed care due to the uncertainty of disease transmission and surgical outcomes. As new coronavirus variants arise, health care systems require guidance on how to provide optimal patient care to all those in need of our services.

PATIENTS AND METHODS

A retrospective review of patients undergoing spine surgery between January 1, 2019 and June 30, 2021 was performed. Patients were split into pre-COVID or post-COVID cohorts based on local government guidelines. Inpatient complications, 90-day readmission, and 90-day mortality were compared between groups. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome.

RESULTS

A total of 2976 patients were included for analysis with 1701 patients designated as pre-COVID and 1275 as post-COVID. The pre-COVID cohort had fewer patients undergoing revision surgery (16.8% vs 21.9%, P < 0.001) and a lower home discharge rate (84.5% vs 88.2%, P = 0.008). Inpatient complication (9.9% vs 9.2%, P = 0.562), inpatient mortality (0.1% vs 0.2%, P = 0.193), 90-day readmission (3.4% vs 3.2%, P = 0.828), and 90-day mortality rates (0.8% vs 0.8%, P = 0.902) were similar between groups. Patients with positive COVID-19 tests before surgery had similar complication rates (7.7% vs 6.1%, P = 1.000) as those without a positive test documented.

CONCLUSIONS

After the emergence of COVID-19, patients undergoing spine surgery had a greater number of medical comorbidities, but similar rates of inpatient complications, readmission, and mortality. Prior COVID-19 infection was not associated with an increased risk of postsurgical complications or mortality.

LEVEL OF EVIDENCE

Level III.

Mortality Rate and Outcomes of Omicron Variant Positive Patients with Osteoporotic Fractures: A Retrospective Study

BACKGROUND

During the lockdown period associated with the coronavirus disease 2019 (COVID-19) pandemic, increased mortality rates among patients with COVID-19 have been reported. This study aimed to analyze the mortality rate of osteoporotic hip fractures in patients who were COVID-19-positive after the lockdown during the Omicron period.

METHODS

A retrospective study was performed with 194 patients who were aged 70 years or more and diagnosed with osteoporotic hip fracture. The patients were divided into two groups according to their COVID-19 diagnoses. Surgery was performed within 10 days of diagnosis. Age, sex, past medical history, time until surgery, postoperative complications, and the primary outcome of mortality rate at 30 and 90 days were analyzed.

RESULTS

Among the 194 patients, 13 and 181 were in the COVID-19-positive and negative group, respectively. The total, 30-day, and 90-day mortality rates in the control and COVID-positive group were 11% and 0% (P=0.368), 1.7% and 0% (P=1.000), and 5.0% and 0% (P=1.000), respectively. No significant differences were observed in age, sex, history, time to surgery, postoperative complications, or postoperative mortality. In 1:1 propensity score matching, the time to surgery was 5.34 days in patients who were COVID-19-positive, and 3.00 days in patients who were COVID-19 negative, with no statistical significance (P=0.09). Age, sex, medical history, postoperative complications, and postoperative mortality were not significantly different between the groups.

CONCLUSIONS

Regardless of the COVID-19 diagnosis, surgical treatment without delay is believed to result in positive outcomes in older patients with osteoporotic hip fractures, as no significant differences in mortality rate and respiratory complications were observed between patients who were COVID-19-positive and those who were COVID-19 negative.

The Effects of COVID-19 Pandemic on the Recovery of Hip Fracture Patients

Purpose

To figure out how complete control of family visits to prevent infection of coronavirus disease 2019 (COVID-19) affected the activity recovery of hip fracture patients admitted to nursing hospitals.

Materials and Methods

Eighty-one patients with hip surgery in the two years prior to COVID-19 pandemic were classified as Group A, and 103 patients in the next two years were designated as Group B. The subjects' walking ability was evaluated by using the modified Koval index (MKI). In order to analyze the impact of the family visit control to the subjects, each group was classified into two different groups: (1) inpatients group who admitted to nursing hospitals and (2) home-treated patients. Additionally, statistical elements were processed in consideration of other factors that may affect the results of the experiment.

Results

The MKI evaluated at 6 months postoperative was 3.31±1.79 in Group A and 2.77±1.91 in Group B, and it was meaningfully low after the pandemic (P=0.04). There was significantly low among both of Group A 2.74±1.76 and Group B 1.93±1.81 after the pandemic (P=0.03) among those treated at the nursing hospital. The rate of deterioration of the MKI was 35 (43.2%) in Group A and 57 (55.3%) in Group B, which increased by 12.1% after the pandemic.

Conclusion

The pandemic had a negative effect on the recovery of postoperative activities of elderly hip fracture patients who admitted to nursing hospitals when family access was completely restricted to prevent infection.

Clinical outcomes of non-COVID-19 orthopaedic patients admitted during the COVID-19 pandemic: a multi-centre interrupted time series analysis across hospitals in six different countries

OBJECTIVES

To assess across seven hospitals from six different countries the extent to which the COVID-19 pandemic affected the volumes of orthopaedic hospital admissions and patient outcomes for non-COVID-19 patients admitted for orthopaedic care.

DESIGN

A multi-centre interrupted time series (ITS) analysis.

SETTING

Seven hospitals from six countries who collaborated within the Global Health Data@Work collaborative.

PARTICIPANTS

Non-COVID-19 patients admitted for orthopaedic care during the pre-pandemic (January/2018-February/2020) and COVID-19 pandemic (March/2020-June/2021) period. Admissions were categorised as: (1) acute admissions (lower limb fractures/neck of femur fractures/pathological fractures/joint dislocations/upper limb fractures); (2) subacute admissions (bone cancer); (3) elective admissions (osteoarthritis).

OUTCOME MEASURES

Monthly observed versus expected ratios (O/E) were calculated for in-hospital mortality, long (upper-decile) length-of-stay and hospital readmissions, with expected rates calculated based on case-mix. An ITS design was used to estimate the change in level and/or trend of the monthly O/E ratio by comparing the COVID-19 pandemic with the pre-pandemic period.

RESULTS

69 221 (pre-pandemic) and 22 940 (COVID-19 pandemic) non-COVID-19 orthopaedic patient admissions were included. Admission volumes were reduced during the COVID-19 pandemic for all admission categories (range: 33%-45%), with more complex patients treated as shown by higher percentages of patients admitted with ≥1 comorbidity (53.8% versus 49.8%, p<0.001). The COVID-19 pandemic was not associated with significant changes in patient outcomes for most diagnostic groups. Only for patients diagnosed with pathological fractures (pre-pandemic n=1671 and pandemic n=749), the COVID-19 pandemic was significantly associated with an immediate mortality reduction (level change of -77.7%, 95% CI -127.9% to -25.7%) and for lower limb fracture patients (pre-pandemic n=9898 and pandemic n=3307) with a significantly reduced trend in readmissions (trend change of -6.3% per month, 95% CI -11.0% to -1.6%).

CONCLUSIONS

Acute, subacute, as well as elective orthopaedic hospital admissions volumes were reduced in all global participating hospitals during the COVID-19 pandemic, while overall patient outcomes for most admitted non-COVID-19 patients remained the same despite the strain caused by the surge of COVID-19 patients.

Impact of COVID-19 pandemic at a level 1 trauma center

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic commonly called COVID-19 brought new changes to healthcare delivery in the US. The purpose of this study is to identify the impact of COVID-19 on the delivery of acute surgical care for patients at a Level 1 trauma center during the lockdown period of the pandemic from March 13-May 1 2020.

Methods

All trauma admission to the University Medical Center Level 1 Trauma Center from March 13 to May 13, 2020, were retrospectively abstracted and compared to the same period during 2019. Analysis focused on the lockdown period of March 13-May 1, 2020, and compared to the same dates in 2019. Abstracted data included demographics, care timeframes, length of stay, and mortality. The data were analyzed using Chi-Square, Fisher Exact, and the Mann-Whitney U test.

Results

A total of 305 (2019) vs. 220 (2020) procedures were analyzed. No significant differences were seen in mean BMI, Injury Severity Score, American Society of Anesthesia Score, and Charlson Comorbidity Index between the two groups. Diagnosis time, interval to surgery, anesthesia time, surgical preparation time, operation time, transit time, mean hospital stay, and mortality were similar.

Conclusion

The results of this study demonstrate that the lockdown period of the COVID-19 pandemic did not significantly affect the trauma surgery service line, aside from case volume, at a Level 1 trauma center in West Texas during the lockdown period. Despite changes to healthcare delivery during the pandemic, care of surgical patients was conserved as timely and of high quality.

The total number of patients with any of four major fragility fractures decreased during the first wave of the COVID-19 epidemic in Japan, commencing before the state of emergency declaration, which was not as enforceable as lockdown

Durin g the first wave of the COVID-19 epidemic, the total number of patients with any of the four major fragility fractures, including both inpatients and first-visit outpatients, began to decline shortly before the state of emergency was declared, rather than immediately after it was declared.

PURPOSE

This study aimed to investigate the impact of public health measures in the first wave of the COVID-19 epidemic on the occurrence of major fragility fractures (MFFs).

METHODS

Patients aged 50 years or older who were hospitalized or had an initial visit as an outpatient for an MFF, defined as a proximal femoral fracture (PFF), vertebral fragility fracture (VFF), distal radius fracture (DRF), or a proximal humeral fracture (PHF), were included in this study. Three-phase interrupted time-series analyses were performed to evaluate the impact of the voluntary event cancellation request in late February 2020 and the emergency declaration in early April 2020 on changes in the total number of patients, including inpatients and first-visit outpatients.

RESULTS

A total of 166,560 patients with MFFs were included (92,767 PFFs, 26,158 VFFs, 33,869 DRFs, and 13,766 PHFs). From the end of February, in seven prefectures with high proportions of urbanization, decreasing trends were estimated for level changes and slope changes in the total number of patients with any of the four MFFs (level change: PFF; point estimate; - 13.5 (95% CI; - 43.4, 16.5), VFF; - 15.3 (- 32.2, 1.5), DRF; - 16.1 (- 39.9, 7.6), PHF; - 1.9 (- 13.6, 9.8), slope change: PFF; - 4.8 (- 14.0, 4.4), VFF; - 3.0 (- 8.1, 2.2), DRF; - 0.6 (- 7.9, 6.7), PHF; - 2.4 (- 6.0, 1.2)).

CONCLUSION

The findings suggested that the total number of patients with any of the four MFFs did not begin to decline from early April 2020 after the state of emergency was declared but earlier, in late February 2020.

Analysis of the Effects of COVID-19 on Hip Fractures in Korea Without Lockdown: Interrupted Time Series Analysis Using a Nationwide Cohort

BACKGROUND

The purpose of this study was to investigate the change in the incidence rate, length of hospital stay (LOS), in-hospital mortality rate, and surgical method of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic in South Korea where lockdown restrictions were not implemented.

METHODS

We calculated the expected values of the incidence of hip fractures, in-hospital mortality and LOS of hip fracture patients in 2020 (COVID period) based hip fracture database of the Korean National Health Insurance Review and Assessment (HIRA) during a 9-year period from 2011 to 2019 (pre-COVID period). A generalized estimating equation model with Poisson distribution and logarithmic link function was used to estimate adjusted annual percent change (PC) of incidence rate and 95% confidence intervals (CIs). Then, we compared the annual incidence, in-hospital mortality rate and LOS in 2020 with the expected values.

RESULTS

The overall incidence rate of hip fracture in 2020 was not significantly different from the expected value (PC, -5%; 95% CI, -13 to 4; P = 0.280). In women, the incidence rate of hip fracture in age groups over 70 years was smaller than the predicted value (P < 0.001). The in-hospital mortality rate was not significantly different from the expected value (PC, 5%; 95% CI, -8 to 19; P = 0.461). The mean LOS was larger than the expected value by 2% (PC, 2%; 95% CI, 1 to 3; P < 0.001). In intertrochanteric fracture, the proportion of internal fixation was smaller than the predicted value by 2% (PC, -2%; 95% CI, -3 to -1; P < 0.001), and that of hemiarthroplasty was larger than the predicted value by 8% (PC, 8%; 95% CI, 4 to 14; P < 0.001).

CONCLUSIONS

In 2020, the incidence rate of hip fracture did not significantly decrease, and in-hospital mortality rate did not significantly increase compared to the expected rates, which were projected based on the HIRA hip fracture data from 2011 to 2019. Only LOS increased slightly.

A Demographic Survey of Pertrochanteric Fractures Based on the Revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) Classification Using 3D CT Scan Images

Introduction A demographic survey of femoral pertrochanteric fractures provides several important information for the healthcare system of a country since this fracture is commonly seen in the elderly and has a poor postoperative functional prognosis that is a burden on society. The importance of accurately classifying pertrochanteric fractures as stable or unstable cannot be understated. However, the use of plain radiograph images alone is known to underestimate fracture severity with low inter- or intra-observer agreement. Computed tomography (CT) images offer information for a more accurate classification of pertrochanteric fractures. With this three-dimensional (3D) CT-based study using the revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification, the purpose of this study is to elucidate the epidemiological demography of patients with pertrochanteric fractures. Material and methods We retrospectively collected 808 patients from five hospitals, classified into two groups: stable (A1) or unstable (A2). Age, gender, fracture laterality, and surgery timing were identified as epidemiological variables. Patients with both preoperative plain radiographs and 3D CT scans were included in the study. The exclusion criteria were AO/OTA A3 type fractures, pathological fractures, previous ipsilateral surgery, 60 years old or younger, and conservatively treated patients. The primary outcome involved detailing the total number of fractures based on classification (A1 or A2) and variables. The secondary outcome involved a comparison between the A1 and A2 groups. Results The mean age of patients at the time of surgery was 85 years (range: 61-103 years). There were 637 female and 171 male patients. There were 463 left-sided fractures and 345 right-sided fractures. Of the 808 patients, 371 (45.9%) were classified to have A1 fractures, and 437 (54.1%) had A2 fractures. The age at surgery, gender, fracture laterality, and surgery timing between the A1 and A2 groups were compared. The mean and standard deviation of the age at surgery for patients in the A1 and A2 groups were 84.9±7.7 and 86.9±6.8, respectively. The number of patients for each age distribution of 61-69, 70-74, 75-79, 80-84, 85-89, 90-94, and 95 or older for the A1 and A2 groups was 18 and 7, 18 and 12, 43 and 44, 76 and 82, 107 and 132, 79 and 110, and 30 and 50, respectively, showing that the difference in categorial distribution was statistically significant (p=0.002). Overall, 278 females and 93 males were classified to have A1 fractures compared with 359 females and 78 males with A2 fractures (p=0.01). There were 166 right-sided and 205 left-sided stable A1 fractures and 179 right-sided and 258 left-sided A2 fractures (not significant (NS)). Among the total number of A1 and A2 surgeries by month, the most were in December with 77 surgeries (37 and 40, respectively), and the least was in June with 37 (18 and 19, respectively). The seasonal classification for A1 and A2 surgeries is as follows: spring with 172 (74 and 98, respectively), summer with 150 (70 and 80, respectively), autumn with 193 (90 and 103, respectively), and winter with 208 (97 and 111, respectively) (NS). Conclusion In this demographic study of 808 patients with pertrochanteric fractures classified by 3D CT images, 371 had A1 fractures and 437 had A2 fractures. A2 fractures were significantly more in females with an age peak of 85-89 years.

Decreasing incidence rates of osteoporotic hip fractures in Ecuador during the COVID-19 pandemic

We aimed at comparing the incidence of hip fractures in older adults from Ecuador before and during the COVID-19 pandemic. There was a significant reduction in the number of hip fractures, with no change in the length of hospital stay, mortality, and case-fatality rate, during the period of social isolation.

INTRODUCTION

The impact that the COVID-19 pandemic has had on fragility fractures is being recently evaluated in the literature. Despite this, data from Latin America in this regard is scarce.

PURPOSE

This study aims to compare the incidence rate of hip fractures before and during the COVID-19 pandemic in older adults who received care in the public and private health system of Ecuador.

METHODS

This was a descriptive and retrospective study that analyzed data of individuals aged 60 years and older who had hip fractures before and during the COVID-19 pandemic. The information was obtained from the National Hospital Discharge Yearbook. We calculated the incidence, average length of hospital stay, mortality, and case-fatality rate associated with hip fractures.

RESULTS

There was a significant reduction in the incidence of hip fractures in adults 60 or older during the period of social isolation due to COVID-19. Between March and December 2019, there was an incidence of 152 hip fractures per 100,000 inhabitants, whereas during the same period but in 2020 in the incidence was 110 per 100,000 inhabitants (p < 0.0001). The main decrease was observed in women aged 80 or more. The average length of hospital stay did not show significant changes. Mortality displayed a non-significant decrease (p = 0.14), although this decrease was significant among women (p = 0.02). Case-fatality rate showed a non-significant increase for the whole group (p = 0.68) and for men (p = 0.09).

CONCLUSION

Hip fracture rates decreased significantly in adults aged 60 and older in 2020 compared to 2019. This decrease of hip fracture incidence rates was mainly due to the reductions observed in older people and women. The average length of hospital stay, mortality, and case-fatality rate associated with hip fractures did not show significant changes during the pandemic.

Impact of COVID-19 on Timing of Hip-Fracture Surgeries: An Interrupted Time-Series Analysis of the Pre/Post-Quarantine Period in Northern Italy

BACKGROUND

To assess whether the imposition of the coronavirus disease 2019 (COVID-19) national quarantine (March 10, 2020) resulted in a shift in the proportion of patients operated for hip fracture on the day of admission, the following day and two days after admission in the region of Piedmont, northern Italy.

METHODS

Interrupted time-series analysis (ITSA) comparing hospitalization rate and timing of hip-fracture surgeries between pre- and post-quarantine period. The same data observed in Piedmont the year before were included as a control time series with no "intervention" (quarantine) in the middle of the observation period.

RESULTS

We found that 70.3% and 69.4% of hip-fracture patients received surgery within 2 days of hospital admission in the 16 weeks before and after the national quarantine, respectively. One-day surgery went from 46.0% to 46.5%, and same-day surgery from 13.3% to 12.4%. Unchanged trends were confirmed by ITSA after controlling for the 32-week time-series observed the year before. In the second week of March 2020, there was a borderline significant decrease in weekly hospital admissions for hip fractures as compared with that of the same week of March 2019 (-1.95 per 100 000, 95% CI = -4.10 to 0.21, P value = .075), followed by a weekly significant increase in the hospitalization rate (+0.14 per 100 000, 95% CI = 0.01 to 0.27, P value = .039), although the difference-in-differences of slopes failed to achieve statistical significance (0.19 per 100 000, 95% CI = -0.03 to 0.41, P value = .090).

CONCLUSION

Our study shows that the timing of hip-fracture surgery was unchanged during the lockdown period. This suggests that the healthcare systems can be resilient and able to guarantee a high-quality and safe healthcare to hip-fracture patients, even in the most challenging working conditions.

Surgical treatment for fragility hip fractures during the COVID-19 pandemic resulted in lower short-term postoperative functional outcome and a higher complication rate compared to the pre-pandemic period

The COVID-19 pandemic adversely affected the functional outcomes of fragility hip fracture patients. This study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among patients treated during the pandemic. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods.

INTRODUCTION

This study aims to investigate the in-hospital complication rate and short-term postoperative functional outcomes of fragility hip fracture (FHF) patients compared between during the COVID-19 pandemic and the same 14-month time period 1 year prior to the pandemic.

METHODS

Using data from the Siriraj Fracture Liaison Service registry, FHF patients treated during the COVID-19 pandemic (1 March 2020 to 30 April 2021) were time-matched with FHF patients treated during the pre-pandemic period (1 March 2018 to 30 April 2019). We collected the rate of in-hospital postoperative complications and the postoperative functional outcomes at discharge and 3 months as measured by the Barthel Index (BI) and EuroQol visual analog scale (EQ-VAS). Functional outcome measures were compared between the pre-pandemic and pandemic periods.

RESULTS

There were 197 and 287 patients in the pre-pandemic and pandemic groups, respectively. At the 3-month postoperative follow-up, the mean postoperative BI score and change in BI score were both significantly lower in the pandemic group indicating poorer postoperative function. Moreover, FHF patients treated during the pandemic had significantly more in-hospital complications (36.6% vs. 22.8%, p = 0.002). There was no significant difference in the 3-month EQ-VAS or change in the EQ-VAS between groups.

CONCLUSION

The results of this study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among FHF patients treated during the COVID-19 pandemic compared to the pre-pandemic period. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods.

Comparative Outcomes and Surgical Timing for Operative Fragility Hip Fracture Patients during the COVID-19 Pandemic: A Retrospective Cohort Study

The COVID-19 pandemic had wide-reaching effects on healthcare delivery, including care for hip fractures, a common injury among older adults. This study characterized factors related to surgical timing and outcomes, length-of-stay, and discharge disposition among patients treated for operative hip fractures during the first wave of the COVID-19 pandemic, compared to historical controls. A retrospective, observational cohort study was conducted from 16 March-20 May 2020 with a consecutive series of 64 operative fragility hip fracture patients at three tertiary academic medical centers. Historical controls were matched based on sex, surgical procedure, age, and comorbidities. Primary outcomes included 30-day mortality and time-to-surgery. Secondary outcomes included 30-day postoperative complications, length-of-stay, discharge disposition, and time to obtain a COVID-19 test result. There was no difference in 30-day mortality, complication rates, length-of-stay, anesthesia type, or time-to-surgery, despite a mean time to obtain a final preoperative COVID-19 test result of 17.6 h in the study group. Notably, 23.8% of patients were discharged to home during the COVID-19 pandemic, compared to 4.8% among controls (p = 0.003). On average, patients received surgical care within 48 h of arrival during the COVID-19 pandemic. More patients were discharged to home rather than a facility with no change in complications, suggesting an opportunity for increased discharge to home.

The Impact of COVID-19 on SARSCoV-2-Negative Elderly Patients with Hip Fractures: A Single-Center Retrospective Study from Shanghai, China

Purpose

Coronavirus disease 2019 (COVID-19) has brought an unprecedented change in wellbeing globally. The spread of the pandemic reportedly reduced the incidence of activity-related trauma, while that of fragility fractures remained stable. Here, we aimed to identify the risk factors associated with the prognosis of SARS-CoV-2 negative elderly patients with hip fractures.

Patients and Methods

This retrospective study included elderly patients with hip fractures between 1st January and 9th May during the COVID-19 pandemic (Experiment group) and the same period from 2017 to 2019 (Control group). Perioperative mortality, complications, and functional recovery were compared between two groups of different time frame in the total cohort and patients who received surgical treatment. Multiple linear regression was carried out to identify the risk factors influencing the prognosis of COVID-negative elderly patients with hip fractures.

Results

The proportion of patients with admission time less than 24 hours and the 6-month postoperative Parker score were significantly decreased during COVID-19 compared with the pre-COVID-19 period (p < 0.001). Multiple linear regression demonstrated that TTA (defined as time from injury to admission), rehabilitation after discharge and outpatient follow-up were associated with the 6-month Parker score in the total population (p < 0.001) and in patients who received surgical treatment (p < 0.001).

Conclusion

Elderly patients with hip fractures had a poorer prognosis in epidemic period despite being COVID-19 negative. Factors including timely admission, postoperative follow-up, and rehabilitation could optimize safety and significantly improve the prognosis of elderly COVID-19 negative patients with hip fractures, even during a pandemic.

Non-COVID outcomes associated with the coronavirus disease-2019 (COVID-19) pandemic effects study (COPES): A systematic review and meta-analysis

BACKGROUND

As the Coronavirus Disease-2019 (COVID-19) pandemic continues, healthcare providers struggle to manage both COVID-19 and non-COVID patients while still providing high-quality care. We conducted a systematic review/meta-analysis to describe the effects of the COVID-19 pandemic on patients with non-COVID illness and on healthcare systems compared to non-pandemic epochs.

METHODS

We searched Ovid MEDLINE/EMBASE/Cochrane Database of Systematic Reviews/CENTRAL/CINAHL (inception to December 31, 2020). All study types with COVID-pandemic time period (after December 31, 2019) with comparative non-pandemic time periods (prior to December 31, 2019). Data regarding study characteristics/case-mix/interventions/comparators/ outcomes (primary: mortality; secondary: morbidity/hospitalizations/disruptions-to-care. Paired reviewers conducted screening and abstraction, with conflicts resolved by discussion. Effect sizes for specific therapies were pooled using random-effects models. Risk of bias was assessed by Newcastle-Ottawa Scale, with evidence rating using GRADE methodology.

RESULTS

Of 11,581 citations, 167 studies met eligibility. Our meta-analysis showed an increased mortality of 16% during the COVID pandemic for non-COVID illness compared with 11% mortality during the pre-pandemic period (RR 1.38, 95% CI: 1.28-1.50; absolute risk difference: 5% [95% CI: 4-6%], p<0.00001, very low certainty evidence). Twenty-eight studies (17%) reported significant changes in morbidity (where 93% reported increases), while 30 studies (18%) reported no significant change (very low certainty). Thirty-nine studies (23%) reported significant changes in hospitalizations (97% reporting decreases), while 111 studies (66%) reported no significant change (very low certainty). Sixty-two studies (37%) reported significant disruptions in standards-to-care (73% reporting increases), while 62 studies (37%) reported no significant change (very low certainty).

CONCLUSIONS

There was a significant increase in mortality during the COVID pandemic compared to pre-pandemic times for non-COVID illnesses. When significant changes were reported, there was increased morbidity, decreased hospitalizations and increased disruptions in standards-of-care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020201256 (Sept 2, 2020).

Effect of Ultrasound-Guided Fascia Iliac Compartment Block on Serum NLRP3 and Inflammatory Factors in Patients with Femoral Intertrochanteric Fracture

Objective

To investigate the effects of ultrasound-guided fascia iliac compartment block (FICB) on patients' postoperative pain and inflammatory factors as well as nucleotide-binding domain and leucine-rich repeat (NLR) family, pyrin domain-containing 3 (NLRP3) in femoral intertrochanteric fracture.

Methods

This single-blind randomized controlled study included 231 patients with femoral intertrochanteric fracture treated in our hospital from January 2017 to December 2020. All patients were randomized into two groups, the FICB group (n = 116) and the general anesthesia group (control group, n = 115). The serum NLRP3 levels and inflammatory factors were evaluated. The heart rate (HR), mean arterial pressure (MAP), and SpO₂ values were recorded. Pain condition was measured by the visual analogue scale (VAS) score. Harris score was performed for positive hip function.

Results

The values of HR and MAP were significantly lower after anesthesia induction in FICB groups compared with the control group. However, no significant difference was found for SpO₂. Compared with the control group, the VAS scores within 72 h after surgery were all markedly lower in the FICB group than in the control group and showed no significant difference at 1 week after surgery. The levels of NLRP3 and interleukin 6 (IL-6) were significantly lower in FICB patients at 1 h, 6 h, 24 h, 48 h, and 72 h after surgery compared with the control group. Tumor necrosis factor-α (TNF-α) showed a significant lower level in the FICB group at 1 h and 6 h after surgery, and significant lower levels of C-reactive protein (CRP) were found at 1 h and 24 h after surgery compared with the control group. Positive correlation was found between NLRP3 and IL-6, as well as CRP and VAS scores after 1 h of the surgery. No significant difference was found for both Harris score and postoperative complications between the two groups.

Conclusion

Fascia iliac compartment block could reduce the postoperative pain, which might be associated with the decrease of the serum levels of NLRP3, CRP, IL-6, and TNF-α in femoral intertrochanteric fracture patients.

Trends in Lower Extremity Injuries Presenting to Emergency Departments During the COVID-19 Pandemic

Background

During the emergence of the SARS-CoV-2 (COVID-19) pandemic, there were substantial changes in U.S. emergency department (ED) volumes and acuity of patient presentation compared with more recent years. Objectives: The purpose of this study was to characterize the incidence of specific lower extremity (LE) injuries presenting to U.S. EDs during the COVID-19 pandemic and to analyze trends across age groups and rates of hospital admission compared with previous years.

Methods

The National Electronic Injury Surveillance System database was queried to identify patients who presented to U.S. EDs for a LE orthopedic injury between 2016 and 2020.

Results

These queries returned 252,656 cases, representing a total estimate of 9,740,514 injuries presenting to EDs across the United States. The mean incidence of LE orthopedic injuries was 596.8 injuries per 100,000 person-years (95% confidence interval [CI] 594.9–598.7), with the greatest annual decrease in incidence occurring between 2019 and 2020 (24.96%). The largest number of estimated hospital admissions occurred in 2020, with a total 181,671 admissions (95% CI 178,032–185,311), a 25.74% increase from the average number of admissions between 2016 and 2019.

Conclusion

The COVID-19 pandemic has placed immense stress on both emergency medical services and hospital systems around the United States. While there were decreased rates of ED utilization for LE orthopedic complaints during the first year of the pandemic, there was a concomitant increase in both the number and proportion of these injuries admitted to the hospital from the ED. This places an additional burden on already stressed emergency medicine services and overall hospital systems that could slow down the management of medical emergencies.

Increasing hip fracture volume following repeated lockdowns: an Irish multicentre study of periods pre-Covid, during Covid lockdown and following vaccination

Background

Older age groups were identified as a high-risk cohort for Covid-19 and thus were a focus of lockdown measures enacted internationally. Resultant decreased social mobility and physical activity levels are associated with sarcopenia, which may lead to increased risk of hip fracture upon resuming social integration and physical activities after easing of lockdown restrictions.

Aims

Our aim was to compare the incidence of hip fractures during the period following vaccination with subsequent relaxation of restrictions, to those prior to and during the Covid pandemic.

Methods

A multicentre retrospective cohort study was performed consisting of all patients presenting with a “hip” fracture to 3 regional trauma units over the relevant time periods in 2019, 2020 and 2021. Tallaght, Galway and Waterford University Hospitals are large academic teaching hospitals with a combined mixed urban and rural catchment of over 1 million people.

Findings

Four-hundred-fourteen patients in total were included in the final analysis, with 133 eligible hip fractures observed proceeding to operative treatment across the study period in 2019, 132 in 2020 and 149 in 2021, representing a 12.88% increase. Demographic data revealed similar patient cohorts with respect to age and gender, fracture pattern and treatment.

Conclusions

An increase in hip fracture volume was observed during the period post vaccination with subsequent relaxation of restrictions and increased social mobility, compared to those prior to and during the Covid pandemic. These findings have implications for hospital planning and orthopaedic resourcing as we navigate our way forward past the Covid-19 Pandemic.

Hüftfrakturinzidenz und Lockdown: Gibt es Zusammenhänge?

Zur Eindämmung der COVID-19-Pandemie wurde in Österreich bereits mehrfach ein Lockdown verhängt. Durch die häusliche Isolation und dadurch reduzierte physische Aktivität könnte die Frakturhäufigkeit initial positiv beeinflusst werden, aber mittel- bis langfristig aufgrund eines reduzierten Trainingsstatus und verringerter Koordinationsfähigkeit, welche zu einem erhöhten Sturz- und damit Frakturrisiko führen, steigen. Basierend auf Daten der österreichischen Allgemeinen Unfallversicherungsanstalt (AUVA) zeigte sich die Häufigkeit von Hüftfrakturen im Zeitraum des ersten Lockdowns (16. März bis 31. Mai 2020) unverändert im Vergleich zu den gleichen Zeiträumen der Jahre zuvor, jedoch ergab eine Subanalyse eine reduzierte Frakturrate bei Frauen in der Altersgruppe 50-69 Jahre während des ersten Lockdowns verglichen mit dem gleichen Zeitraum des Jahres 2018.

Incidence of hip fractures during the COVID-19 pandemic in the Brazilian public health care system

This study compared the incidence of hip fractures before and during the COVID-19 pandemic in Brazil, aged ≥ 60 years excluding all fractures related to any trauma. There was a significant reduction in the number of hip fractures and the length of hospital stay during the period of social isolation.

PURPOSE

To compare the incidence of hip fractures before and during the COVID-19 pandemic in Brazil and in the main regions of the country in patients covered by the Brazilian public health care system (SUS). As far as we are aware, no studies have evaluated the impact of COVID-19 pandemic on hip fractures in Brazil.

METHODS

Descriptive, cross-sectional study in individuals aged ≥ 60 years who presented with a hip fracture before and during the COVID-19 pandemic and received treatment covered by the SUS. The data were collected from the DATASUS electronic database. We calculated the incidence, mortality, lethality, duration of hospitalization, and average reimbursement associated with the treatment of the fractures.

RESULTS

There was a significant reduction in the incidence of hip fractures among individuals aged ≥ 60 years in Brazil during the period of social isolation due to COVID-19. The observed incidence was 15.58/10,000 inhabitants between March and December 2020 and 16.07/10,000 inhabitants in the same period of 2019 (p < 0.005; main decline observed in the age groups > 70 years). The average length of hospital stay reduced from 8.35 days in 2019 to 7.33 days in 2020, following a similar pattern of reduction across all regions. The Southeast was the only region with a significant reduction in mortality during the pandemic (relative risk 0.90, 95% confidence interval 0.84-0.97, p < 0.005).

CONCLUSION

During the COVID-19 pandemic in Brazil, the incidence rate of hip fractures and the associated duration of hospital stay decreased among patients aged ≥ 60 years.

Variations of the quality of care during the COVID-19 pandemic affected the mortality rate of non-COVID-19 patients with hip fracture

Introduction

As COVID-19 roared through the world, governments worldwide enforced containment measures that affected various treatment pathways, including those for hip fractures (HFs). This study aimed to measure process and outcome indicators related to the quality of care provided to non-COVID-19 elderly patients affected by HF in Emilia-Romagna, a region of Italy severely hit by the pandemic.

Methods

We collected the hospital discharge records of all patients admitted to the hospitals of Emilia-Romagna with a diagnosis of HF from January to May in the years 2019 (pre-pandemic period) and 2020 (pandemic period). We analyzed surgery rate, surgery delays, length of hospital stay, timely rehabilitation, and 30-day mortality for each HF patient. We evaluated monthly data (2020 vs. 2019) with the chi-square and t-test, where appropriate. Logistic regression was used to investigate the differences in 30-day mortality.

Results

Our study included 5379 patients with HF. In April and May 2020, there was a significant increase in the proportion of HF patients that did not undergo timely surgery. In March 2020, we found a significant increase in mortality (OR = 2.22). Male sex (OR = 1.92), age ≥90 years (OR = 4.33), surgery after 48 hours (OR = 3.08) and not receiving surgery (OR = 6.19) were significantly associated with increased mortality. After adjusting for the aforementioned factors, patients hospitalized in March 2020 still suffered higher mortality (OR = 2.21).

Conclusions

There was a reduction in the overall quality of care provided to non-COVID-19 elderly patients affected by HF, whose mortality increased in March 2020. Patients’ characteristics and variations in processes of care partially explained this increase. Policymakers and professionals involved in the management of COVID-19 patients should be aware of the needs of patients with other health needs, which should be carefully investigated and included in future emergency preparedness and response plans.

Decrease in incidence of proximal femur fractures in the elderly population during the Covid-19 pandemic: a case-control study

Background

The World Health Organization classified Covid-19 as a pandemic during the first months of 2020 as lockdown measures were implemented globally to mitigate the increasing incidence of Covid-19-related morbidity and mortality. The purpose of this study was to evaluate the effect of national lockdown measures on proximal femur fracture epidemiology. Our hypothesis was that due to the prolonged period of stay-at-home orders, we would observe a decrease in the incidence of proximal femur fractures during the years 2020–21.

Methods

A retrospective case–control study of 2784 hip fractures admitted to the emergency department at one hospital between January 1, 2010, and March 31, 2021, was conducted. Cases were stratified weekly, and an analysis was conducted comparing cases occurring during government-imposed lockdown periods of 2020–21 to corresponding periods during 2010–2019. Furthermore, the trend of cases throughout the year of 2020 was observed.

Results

Of all proximal femur fracture cases included, 2522 occurred between 2010–2019 and 261 during the Covid-19 period. There was no significant difference in age (81.95 vs. 82.09; P = 0.78) or gender (P = 0.12). There was a total decrease of 21.64% in proximal femur fracture per week during the entirety of the Covid-19 pandemic period compared to the previous years (3.64 ± 1.99 vs. 4.76 ± 0.83; P = 0.001). During all three lockdown periods, there was a significant decrease in proximal femur fracture cases per week (3.55 ± 2.60 vs. 4.87 ± 0.95; P = 0.04), and the most pronounced decrease occurred during the third lockdown period (2.89 ± 1.96 vs. 5.23 ± 1.18; P = 0.01).

Conclusion

We observed a total decrease in the number of proximal femur fractures occurring during the Covid-19 era compared to previous years and specifically a decrease of cases occurring during the government-imposed lockdown periods. The decrease in cases was more pronounced during the second and third lockdown periods.

Natural language processing of radiology reports to investigate the effects of the COVID-19 pandemic on the incidence and age distribution of fractures

OBJECTIVE

During the COVID-19 pandemic, the number of patients presenting in hospitals because of emergency conditions decreased. Radiology is thus confronted with the effects of the pandemic. The aim of this study was to use natural language processing (NLP) to automatically analyze the number and distribution of fractures during the pandemic and in the 5 years before the pandemic.

MATERIALS AND METHODS

We used a pre-trained commercially available NLP engine to automatically categorize 5397 radiological reports of radiographs (hand/wrist, elbow, shoulder, ankle, knee, pelvis/hip) within a 6-week period from March to April in 2015-2020 into "fracture affirmed" or "fracture not affirmed." The NLP engine achieved an F₁ score of 0.81 compared to human annotators.

RESULTS

In 2020, we found a significant decrease of fractures in general (p < 0.001); the average number of fractures in 2015-2019 was 295, whereas it was 233 in 2020. In children and adolescents (p < 0.001), and in adults up to 65 years (p = 0.006), significantly fewer fractures were reported in 2020. The number of fractures in the elderly did not change (p = 0.15). The number of hand/wrist fractures (p < 0.001) and fractures of the elbow (p < 0.001) was significantly lower in 2020 compared with the average in the years 2015-2019.

CONCLUSION

NLP can be used to identify relevant changes in the number of pathologies as shown here for the use case fracture detection. This may trigger root cause analysis and enable automated real-time monitoring in radiology.

Hip fracture care during the COVID-19 pandemic: retrospective cohort and literature review

Objectives:

The goal of this study was to investigate whether the COVID-19 pandemic has affected hip fracture care at a Level I Trauma hospital. The secondary goal was to summarize the published hip fracture reports during the pandemic.

Design:

A retrospective cohort study.

Setting:

Level I Trauma Center.

Patients/Participants:

Eighty-six operatively treated hip fracture patients age ≥65 years, occurring from January 17 to July 2, 2020.

Intervention (if any):

N/A.

Main Outcome Measurements:

We defined 3 phases of healthcare system response: pre-COVID-19 (period A), acute phase (period B), and subacute phase (period C). The primary outcome was 30-day mortality. Clinical outcomes including time to surgery (TTS) and length of stay (LOS) were extracted from the electronic medical record.

Results:

Twenty-seven patients from Period A, 27 patients from Period B, and 32 patients from Period C were included. The 30-day mortality was not statistically different. The mean TTS was 20.0 +/− 14.3 hours and was the longest in Period C (22.1 +/− 9.8 hours), but the difference was not statistically significant. The mean LOS was 113.0 +/− 66.2 hours and was longest in Period B (120.9 +/− 100.6 hours). However, the difference was not statistically significant.

Conclusions:

The 30-day mortality, TTS, and LOS were not statistically different across multiple phases of pandemic at a level 1 trauma center. Our results suggest that we successfully adapted new protocol changes and continued to provide evidence-based care for hip fracture patients. Our results were comparable with that of other authors around the world.

Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions

BACKGROUND

There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery.

METHODS

A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported.

RESULTS

The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome.

CONCLUSIONS

There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores.

CLINICAL RELEVANCE

Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

Increased Comorbidity Burden Among Hip Fracture Patients During the COVID-19 Pandemic in New York City

Background

The coronavirus disease 19 (COVID-19) pandemic had a devastating effect on New York City in the spring of 2020. Several global reports suggested worse early outcomes among COVID-positive patients with hip fractures. However, there is limited data comparing baseline comorbidities among patients treated during the pandemic relative to those treated in non-pandemic conditions.

Materials and Methods

A multicenter retrospective cohort study was performed at two Level 1 Trauma centers and one orthopedic specialty hospital to assess demographics, comorbidities, and outcomes among 67 hip fracture patients treated (OTA/AO 31, 32.1) during the peak of the COVID-19 pandemic in New York City (March 20, 2020 to April 24, 2020), including 9 who were diagnosed with COVID-19. These patients were compared to a cohort of 76 hip fracture patients treated 1 year prior (March 20, 2019 to April 24, 2019). Baseline demographics, comorbidities, treatment characteristics, and respiratory symptomatology were evaluated. The primary outcome was inpatient mortality.

Results

Relative to patients treated in 2019, patients with hip fractures during the pandemic had worse Charlson Comorbidity Indices (median 5.0 vs 6.0, P = .03) and American Society of Anesthesiologists (ASA) scores (mean 2.4 vs 2.7, P = .04). Patients during the COVID-19 pandemic were more likely to have decreased ambulatory status (P<.01) and a smoking history (P = .04). Patients in 2020 had longer inpatient stays (median 5 vs 7 days, P = .01), and were more likely to be discharged home (61% vs 9%, P<.01). Inpatient mortality was significantly increased during the COVID-19 pandemic (12% vs 0%, P = .002).

Conclusions

Patients with hip fractures during the COVID-19 pandemic had worse comorbidity profiles and decreased functional status compared to patients treated the year prior. This information may be relevant in negotiations regarding reimbursement for cost of care of hip fracture patients with COVID-19, as these patients may require more expensive care.

Paediatric orthopaedic surgery during the SARS-CoV-2 pandemic. A safe and pragmatic approach to service provision

The SARS-COV-2 pandemic has brought unparalleled challenges to healthcare provision. Being a newly discovered virus, there is a lack of previous experience and published evidence to guide healthcare providers on how to deliver services. We would like to share our approach to service delivery in a newly open children's hospital in the United Arab Emirates with a particular focus on paediatric orthopaedic services.

Coronavirus disease 2019 pandemic, restriction, and orthopedic trauma: Retrospective observational study

In 2019, the Coronavirus disease 2019 (Covid-19) was reported in Wuhan, China. Governments in various countries had taken many safeguards. This study investigated the incidence of orthopedic trauma in a rural region epidemiologically and guided source distribution and medical professionals to sustain healthcare systems.Between December 2019 and August 2020, 1651 patients admitted to orthopedics and traumatology clinics with trauma were evaluated in this study. Patients were grouped into 3 groups: pre-covid, restriction, and permitted groups. Age, sex, and fracture types of patients were recorded.The number of patients in the pre-covid period was 629 (38.1%), those were 334 (20.2%) in the restriction period, and 688 (41.7%) patients were admitted in the permitted period. A total of 1203 (72.9%) patients with upper extremity fractures, 383 (23.2%) patients with lower extremity fractures, and 65 (3.9%) patients with axial skeleton and pelvic ring fractures were included in the study. The lowest rates were found in the restriction period when all fractures were evaluated according to the admission periods. There were significant differences between admission dates and the fractures (P < .001).In this study, a decrease in orthopedic trauma rates was observed by half in the restriction period compared with the other 2 periods. Public health precautions had led to a reduction in the incidence of orthopedic trauma in all age groups.

Management of proximal femur fractures in the elderly: current concepts and treatment options

As one of the leading causes of elderly patients’ hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients’ outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

The Procoagulant Effect of COVID-19 on the Thrombotic Risk of Patients with Hip Fractures Due to Enhanced Clot Strength and Fibrinolysis Shutdown

Introduction: Coronavirus disease 2019 (COVID-19) in patients with hip fractures is associated with increased incidence of venous thromboembolism (VTE). The purpose of this study was to evaluate the hemostatic alterations of COVID-19 that are associated with a higher thrombotic risk using rotational thromboelastometry (ROTEM). Methods: A retrospective observational study was performed including 20 COVID-19 patients with hip fractures. To compare the coagulopathy of patients with mild COVID-19 and hip fractures with the coagulopathy associated with each of these two conditions separately, we used two previously recruited groups of patients; 198 hip fracture patients without COVID-19 and 21 COVID-19 patients without hip fractures. The demographics, clinical parameters, conventional coagulation parameters and ROTEM findings of the three groups were analyzed and compared. Results: COVID-19 hip fracture patients had higher amplitude of clot firmness at 10 min (p < 0.001), higher alpha angle (p < 0.001), higher lysis index at 60 min (p < 0.001), and shorter clot formation time (p < 0.001) than non-COVID-19 hip fracture patients, indicating increased clot strength and impaired fibrinolysis due to COVID-19. The value of lysis index at 60 min (99%) in COVID-19 patients with hip fractures was consistent with fibrinolysis shut down. Multivariable linear regression analysis further confirmed that COVID-19 resulted in increased amplitude of clot firmness at 10 min (p < 0.001), increased maximum clot firmness (p < 0.001), increased lysis index at 60 min (p < 0.001) and increased alpha angle (p < 0.001), but significantly shortened clot formation time (p < 0.001). Discussion: The higher thrombotic risk in COVID-19 patients with hip fractures is characterized by increased clot strength and fibrinolysis shutdown, as shown by ROTEM findings. Further prospective studies are warranted to evaluate the need for modification of thromboprophylaxis to balance the hemostatic derangements of COVID-19 patients with hip fractures.

Is performing joint arthroplasty surgery during the COVID-19 pandemic safe?: A retrospective, cohort analysis from a tertiary centre in NCR, Delhi, India

PURPOSE

Resuming joint replacement arthroplasty amidst the COVID-19 pandemic and lockdown has come with various challenges that had to be dealt with utmost caution. Patients with severe arthritis experiencing a state of intolerable pain, could not be left unaddressed. Guidelines published by surgical associations, collaborative surgical author groups including public health organisations had to be modified to suit the Indian scenario and obtain optimal functional outcomes in these patients.

METHODS

A retrospective cohort analysis of 147 patients who underwent arthroplasty during the pandemic (March 2020 to April 2021), for either primary or secondary arthritis, was performed. We assess the efficacy and safety of the newly established Institutional surgical peri-operative protocol at our tertiary care centre in the National Capital Region, India in response to COVID-19 guidelines. The primary outcome measures appraised was 30-day mortality and the secondary outcome measures included length of stay, peri-operative complications and COVID-19 infection.

RESULT

The most common indication for arthroplasty during the pandemic was neglected trauma. One patient died, due to myocardial infarction during the follow-up period. About 67% of patients were discharged to their usual residence within 7 days of admission. Two patients tested positive for COVID-19 postoperatively, but none required Intensive Care Unit admission.

CONCLUSION

Joint replacement arthroplasty can be undertaken safely with diligent patient selection, application of a stringent COVID appropriate behaviour and a 'ring-fenced' peri-operative pathway.

Hip Fractures in the Elderly During the COVID-19 Pandemic: A Latin-American Perspective With a Minimum 90-Day Follow-Up

Introduction:

Hip fracture patients have been severely affected by the COVID-19 pandemic; however, the sub acute effects of a concomitant SARS-CoV-2 infection and the outcomes in highly exposed developing countries are still unknown. Our objective is to describe the morbidity and mortality of elderly patients admitted for a hip fracture during the COVID-19 pandemic in Chile, with a minimum 90-day follow-up. Also, to elucidate predictors for mortality and to compare mortality results with the pre-pandemic era.

Material and Methods:

Multicentric retrospective review of patients admitted for a fragility hip fracture in 3 hospitals during the COVID-19 pandemic, and during the same time in 2019. All clinical information and images were recorded, and patients were followed for a minimum of 90-days. Morbidity and mortality were the primary outcomes. Uni/multivariable models were performed to elucidate predictors for mortality utilizing the Weibull’s regression.

Results:

Three hundred ninety-one cases were included. From the 2020 cohort (162 patients), 24 (15%) had a concomitant SARS-CoV-2 infection. Fourteen patients (58%) tested positive after admission. The COVID-19(+) group had a higher risk of in-hospital, 30-day, and 90-day mortality (p < 0.001). They also had a prolonged hospital stay and presented with more complications and readmissions (p < 0.05). Only COVID-19(+) status and older age were independent predictors for mortality with a HR = 6.5 (p = < 0.001) and 1.09 (p = 0.001), respectively. The 2020 cohort had twice the risk of mortality with a HR = 2.04 (p = 0.002) compared to the 2019 cohort. However, comparing only the COVID-19 (-) patients, there was no difference in mortality risk, with a HR = 1.30 (p = 0.343).

Discussion:

The COVID-19 pandemic has significantly affected healthcare systems and elderly patients.

Conclusions:

Hip fracture patients with a concomitant SARS-CoV-2 virus infection were associated with increased morbidity and mortality throughout the first 3 months. COVID-19 status and older age were significant predictors for mortality. Efforts should be directed into nosocomial infection reduction and prompt surgical management.

Level of evidence:

Level III

Mortality escalates in patients of proximal femoral fractures with COVID-19: A systematic review and meta-analysis of 35 studies on 4255 patients

BACKGROUND

Concerns have been raised about the escalated mortality in patients of proximal femoral fractures (PPFs) with COVID-19. A meta-analysis to evaluate the mortality in patients with PPFs managed during the current COVID-19 pandemic was conducted.

METHODS

A systematic review and meta-analysis of all published studies were conducted with a search on PubMed, Scopus, Web of Science, and Cochrane Library databases using appropriate keywords from January 01, 2020 to January 29, 2021.

RESULTS

35 relevant studies reporting 4255 patients with hip fracture in the current ongoing pandemic, out of which 692 patients were COVID-19 positive. Twenty studies reported mortality and other relevant statistics on hip fracture patients with and without COVID-19 (4123 hip fracture patients in the year 2020-21, out of which 560 had or were suspected of having COVID -19). A meta-analysis of mortality statistics in patients with and without COVID revealed increased odds of mortality among COVID patients [odds ratio (OR) 6.31, 95% confidence interval (CI) [5.09, 7.83] and meta-analysis on the subgroup of surgically treated patients also showed markedly increased mortality risk among those with COVID-19 (OR) 5.99, 95% CI [3.88,9.24].

CONCLUSION

The mortality risk is markedly increased in hip fracture with concomitant COVID-19 as compared to those without it. This increased risk persisted in those managed surgically. It could be due to the inflammation induced by the fracture or surgery for fracture fixation, further exacerbating inflammation, leading to cytokine storm. It is imperative that such patients are informed regarding increased mortality risk during the consent and shared decision-making process.

Bee honey and exercise for improving physical performance, reducing fatigue, and promoting an active lifestyle during COVID-19

Active lifestyle has enormous health benefits. However, physical activity has globally decreased since the beginning of the current coronavirus disease 2019 (COVID-19) outbreak because of social distancing measures. Older adults and people with age-related diseases (e.g., diabetes, obesity, cancer, cardiovascular disorders, etc.) are widely affected by COVID-19 and its grave adverse effects because of their baseline poor immune function. Although they are in intense need for the therapeutic benefits of exercise, they may express a low capacity for exercising due to skeletal muscle dysfunction and low motivation. Honey is a natural energy-rich, low glycemic index food with a variety of biological activities. It is reported to correct muscle pathology in diseased conditions. Because skeletal muscle is the key structure involved in exercise, we explored the literature for the exercise-promoting potential of natural honey. Bee honey improves physical performance at moderate levels of activity, and it reduces the production of inflammatory cytokines and biomarkers of fatigue following strenuous exercise among athletes. Supplementing ischemic heart disease patients with honey combined with floral pollen improved patients' tolerance for physical loads and corrected metabolism. Therefore, the therapeutic use of honey may have implications for to increasing the capacity for exercise in aged and diseased individuals. Soundly designed studies are needed to evaluate such possibility.

Impact of the COVID-19 pandemic on orthopedic fracture characteristics in three hospitals in Turkey: A multi-center epidemiological study

Objectives

In this study, we present the use of case specific three- dimensional (3D) printed plastic models and custom-made acetabular implants in orthopedic surgery.

Materials and methods

Between March 2018 and September 2020, surgeries were simulated using plastic models manufactured by 3D printers on the two patients with pilon fractures. Also, custom-made acetabular implants were used on two patients with an acetabular bone defect for the revision of total hip arthroplasty (THA).

Results

More comfortable surgeries were experienced in pilon fractures using preoperative plastic models. Similarly, during the follow-up period, the patients that applied custom-made acetabular implants showed a fixed and well-positioning in radiographic examination. These patients did not experience any surgical complications and achieved an excellent recovery.

Conclusion

Preoperative surgical simulation with 3D printed models can increase the comfort of fracture surgeries. Also, custom-made 3D printed acetabular implants can perform an important task in patients treated with revision THA surgery due to severe acetabular defects.

Impact of the COVID-19 pandemic on orthopedic fracture characteristics in three hospitals in Turkey: A multi-center epidemiological study

Objectives

The aim of this study was to evaluate the impact of novel coronavirus-2019 (COVID-19) on the epidemiological characteristics of orthopedic fractures.

Patients and methods

A total of 2,960 patients (1,755 males, 1,205 females; mean age: 39.6 years; range, 1 to 98 years) with orthopedic fractures were included in the study: 552 patients during the pandemic period (March 10th and July 1st, 2020) and 1,158 control patients in the same period 2019 and 1,250 control patients in 2018. Epidemiological characteristics, injury mechanisms, fracture locations and treatment details of the patients were analyzed and compared between 2018, 2019 and 2020 for adult and pediatric populations.

Results

Of a total of 552 patients, 485 were adults and 67 were pediatric patients. In the control groups, of 1,158 patients (2019), 770 were adults and 378 were pediatric patients and, of 1,250 patients (2018), 857 were adults and 393 were pediatric patients. The proportion of proximal femur and hand fractures significantly increased during the pandemic period (p=0.025 and p=0.038, respectively). The most frequent surgical indication in the pandemic period was proximal femoral fracture. The proportion of home accidents as an injury mechanism significantly increased in the pandemic period compared to 2018 and 2019 (48.5% vs. 18.6% and 20.6%, respectively; p=0.000). The proportion of female pediatric patients significantly increased during the pandemic period compared to 2018 and 2019 (44.8% vs. 25.4% and 27.2%, respectively, p=0.004). The proportion of forearm fractures (p=0.001) also increased, and the proportion of tibia-fibula fractures (p=0.03) decreased. The most frequent surgical indication in pediatric patients was distal humeral fracture in both groups.

Conclusion

During the pandemic period, proximal femoral fractures in the elderly remained a concern. In-home preventative strategies may be beneficial to reduce the incidence of hip fractures in the elderly.

Meta-analysis and metaregression of risk factors associated with mortality in hip fracture patients during the COVID-19 pandemic

Incidence of hip fractures has remained unchanged during the pandemic with overlapping vulnerabilities observed in patients with hip fractures and those infected with COVID-19. We aimed to investigate the independent impact of COVID-19 infection on the mortality of these patients. Healthcare databases were systematically searched over 2-weeks from 1st-14th November 2020 to identify eligible studies assessing the impact of COVID-19 on hip fracture patients. Meta-analysis of proportion was performed to obtain pooled values of prevalence, incidence and case fatality rate of hip fracture patients with COVID-19 infection. 30-day mortality, excess mortality and all-cause mortality were analysed using a mixed-effects model. 22 studies reporting 4015 patients were identified out of which 2651 (66%) were assessed during the pandemic. An excess mortality of 10% was seen for hip fractures treated during the pandemic (OR 2.00, p = 0.007), in comparison to the pre-pandemic controls (5%). Estimated mortality of COVID-19 positive hip fracture patients was four-fold (RR 4.59, p < 0.0001) and 30-day mortality was 38.0% (HR 4.73, p < 0.0001). The case fatality rate for COVID-19 positive patients was 34.74%. Between-study heterogeneity for the pooled analysis was minimal (I2 = 0.00) whereas, random effects metaregression identified subgroup heterogeneity for male gender (p < 0.001), diabetes (p = 0.002), dementia (p = 0.001) and extracapsular fractures (p = 0.01) increased risk of mortality in COVID-19 positive patients.

Epidemiologic impact of COVID-19 on a multi-subspecialty orthopaedic practice

The purpose of this study is to report the change in surgical case volume and composition encountered by a multi-subspecialty orthopaedic practice due to COVID-19. We reviewed electronic medical records for patients who had surgery at our institution and collected multiple variables including age and the joint that was operated on.

In the post-COVID-19 period, we found a significant increase in the percentage of hip procedures, and a significant decrease in the percentage of hand/wrist procedures. Overall, the total surgical volume of our multi-subspecialty orthopaedic practice decreased due to the COVID-19 pandemic, and the composition of surgical cases changed.

Hip fracture characteristics and outcomes during COVID-19: a large retrospective national database review

Background

The COVID-19 pandemic has impacted healthcare in various vulnerable patient subpopulations. However, data are lacking on the impact of COVID-19 on hip fractures, seen mainly in older patients. Using national claims data, we aimed to describe the epidemiology during the first COVID-19 wave in the USA.

Methods

We compared patients admitted for hip fractures during March and April of 2020 with those admitted in 2019 in terms of patient and healthcare characteristics, COVID-19 diagnosis, and outcomes. An additional comparison was made between COVID-19-positive and -negative patients. Outcomes included length of hospital stay (LOS), admission to an ICU, ICU LOS, use of mechanical ventilation, 30-day readmission, discharge disposition, and a composite variable of postoperative complications.

Results

Overall, 16 068 hip fractures were observed in 2019 compared with 7498 in 2020. Patients with hip fractures in 2020 (compared with 2019) experienced earlier hospital discharge and were less likely to be admitted to ICU, but more likely to be admitted to home. Amongst 83 patients with hip fractures with concomitant COVID-19 diagnosis, we specifically observed more non-surgical treatments, almost doubled LOS, a more than 10-fold increased mortality rate, and higher complication rates compared with COVID-19-negative patients.

Conclusions

The COVID-19 pandemic significantly impacted not only volume of hip fractures, but also patterns in care and outcomes. These results may inform policymakers in future outbreaks and how this may affect vulnerable patient populations, such as those experiencing a hip fracture.

Delayed hospital admission for traumatic hip fractures during the COVID-19 pandemic

BACKGROUND

Concerns of contracting the highly contagious disease COVID-19 have led to a reluctance in seeking medical attention, which may contribute to delayed hospital arrival among traumatic patients. The study objective was to describe differences in time from injury to arrival for patients with traumatic hip fractures admitted during the pandemic to pre-pandemic patients.

MATERIALS AND METHODS

This retrospective cohort study at six level I trauma centers included patients with traumatic hip fractures. Patients with a non-fall mechanism and those who were transferred in were excluded. Patients admitted 16 March 2019-30 June 2019 were in the "pre-pandemic" group, patients were admitted 16 March 2020-30 June 2020 were in the "pandemic" group. The primary outcome was time from injury to arrival. Secondary outcomes were time from arrival to surgical intervention, hospital length of stay (HLOS), and mortality.

RESULTS

There were 703 patients, 352 (50.1%) pre-pandemic and 351 (49.9%) during the pandemic. Overall, 66.5% were female and the median age was 82 years old. Patients were similar in age, race, gender, and injury severity score. The median time from injury to hospital arrival was statistically shorter for pre-pandemic patients when compared to pandemic patients, 79.5 (56, 194.5) min vs. 91 (59, 420), p = 0.04. The time from arrival to surgical intervention (p = 0.64) was statistically similar between groups. For both groups, the median HLOS was 5 days, p = 0.45. In-hospital mortality was significantly higher during the pandemic, 1.1% vs 3.4%, p = 0.04.

CONCLUSIONS

While time from injury to hospital arrival was statistically longer during the pandemic, the difference may not be clinically important. Time from arrival to surgical intervention remained similar, despite changes made to prevent COVID-19 transmission.

Approaches to Nutritional Screening in Patients with Coronavirus Disease 2019 (COVID-19)

Malnutrition is common among severe patients with coronavirus disease 2019 (COVID-19), mainly elderly adults and patients with comorbidities. It is also associated with atypical presentation of the disease. Despite the possible contribution of malnutrition to the acquisition and severity of COVID-19, it is not clear which nutritional screening measures may best diagnose malnutrition in these patients at early stages. This is of crucial importance given the urgency and rapid progression of the disease in vulnerable groups. Accordingly, this review examines the available literature for different nutritional screening approaches implemented among COVID-19 patients, with a special focus on elderly adults. After a literature search, we selected and scrutinized 14 studies assessing malnutrition among COVID-19 patients. The Nutrition Risk Screening 2002 (NRS-2002) has demonstrated superior sensitivity to other traditional screening measures. The controlling nutritional status (CONUT) score, which comprises serum albumin level, cholesterol level, and lymphocytes count, as well as a combined CONUT-lactate dehydrogenase-C-reactive protein score expressed a predictive capacity even superior to that of NRS-2002 (0.81% and 0.92% vs. 0.79%) in midlife and elder COVID-19 patients. Therefore, simple measures based on routinely conducted laboratory investigations such as the CONUT score may be timely, cheap, and valuable alternatives for identifying COVID-19 patients with high nutritional risk. Mini Nutritional Assessment (MNA) was the only measure used to detect residual malnutrition and high malnutrition risk in remitting patients-MNA scores correlated with hypoalbuminemia, hypercytokinemia, and weight loss. Older males with severe inflammation, gastrointestinal symptoms, and pre-existing comorbidities (diabetes, obesity, or hypertension) are more prone to malnutrition and subsequently poor COVID-19 prognosis both during the acute phase and during convalescence. Thus, they are in need of frequent nutritional monitoring and support while detecting and treating malnutrition in the general public might be necessary to increase resilience against COVID-19.

Twenty-one Days of Solitude

As the world is now gradually coming out of the "lockdown" phase, one can expect a change in the demographics and epidemiology of trauma. With traffic back on roads and shifting life again towards "normalcy", it is imperative to carry out introspection and see how we can stop trauma from reaching its pre-COVID levels. How to cite this article: Prabhakar H. Twenty-one Days of Solitude. Indian J Crit Care Med 2021;25(3):249-250.

Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods: A systematic review and meta-analysis

BACKGROUND

Timely intervention in hip fracture is essential to decrease the risks of perioperative morbidity and mortality. However, limitations of the resources, risk of disease transmission and redirection of medical attention to a more severe infective health problem during coronavirus disease 2019 (COVID-19) pandemic period have affected the quality of care even in a surgical emergency.

AIM

To compare the 30-d mortality rate and complications of hip fracture patients treated during COVID-19 pandemic and pre-pandemic times.

METHODS

The search of electronic databases on 1^st August 2020 revealed 45 studies related to mortality of hip fracture during the COVID-19 pandemic and pre-pandemic times. After careful screening, eight studies were eligible for quantitative and qualitative analysis of data.

RESULTS

The pooled data of eight studies (n = 1586) revealed no significant difference in 30-d mortality rate between the hip fracture patients treated during the pandemic and pre-pandemic periods [9.63% vs 6.33%; odds ratio (OR), 0.62; 95%CI, 0.33, 1.17; P = 0.14]. Even the 30-d mortality rate was not different between COVID-19 non-infected patients who were treated during the pandemic time, and all hip fracture patients treated during the pre-pandemic period (OR, 1.03; 95%CI, 0.61, 1.75; P = 0.91). A significant difference in mortality rate was observed between COVID-19 positive and COVID-19 negative patients (OR, 6.99; 95%CI, 3.45, 14.16; P < 0.00001). There was no difference in the duration of hospital stay (OR, -1.52, 95%CI, -3.85, 0.81; P = 0.20), overall complications (OR, 1.62; P = 0.15) and incidence of pulmonary complications (OR, 1.46; P = 0.38) in these two-time frames. Nevertheless, the preoperative morbidity was more severe, and there was less use of general anesthesia during the pandemic time.

CONCLUSION

There was no difference in 30-d mortality rate between hip fracture patients treated during the pandemic and pre-pandemic periods. However, the mortality risk was higher in COVID-19 positive patients compared to COVID-19 negative patients. There was no difference in time to surgery, complications and hospitalization time between these two time periods.

Epidemiological pattern of orthopaedic fracture during the COVID-19 pandemic: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed evaluate the 30-day mortality, number and site of fracture, mechanism of injury, and location where injury was sustained during the pandemic compared to pre-pandemic.

METHODS

We performed a systematic literature search from PubMed and Embase on original articles, research letters, and short reports which have data about the number of fractures, site of fracture, mechanism of injury, location where injury was sustained, percentage of operative intervention, mortality during the pandemic compared to a specified period of time before the pandemic. The search was finalized in October 14, 2020.

RESULTS

A total of 11,936 participants from 16 studies were included in our study. The pooled analysis indicated a higher 30-days mortality associated with fractures during the pandemic (9% vs 4%, OR 1.86 [1.05, 3.27], p = 0.03; I²: 36%, p = 0.15). The number of fractures presenting to hospitals has declined 43% (35-50%) compared to pre-pandemic. Hand fracture was fewer during the pandemic (18% vs 23%, OR 0.75 [0.58, 0.97], p = 0.03; I²: 69%, p = 0.002). Work-related traumas, high-energy falls, and domestic accidents were more common during the pandemic, while sports-related traumas were found to be less. Injuries that occurred in the sports area were lower than before the pandemic.

CONCLUSION

The present meta-analysis showed that during the COVID-19 pandemic, the number of fractures has decreased, but there is a higher mortality rate associated with fractures.