IMPACT-Scot 2 report on COVID-19 in hip fracture patients

[Excess mortality of patients who negative for COVID-19 with proximal femoral fractures during the pandemic : What can we learn for future pandemics?]

BACKGROUND

The global COVID-19 pandemic led to excess mortality, especially for vulnerable older patients with simultaneous comorbidities. Patients with proximal femoral fractures already have a high mortality risk of up to 30% during the first postoperative year. The purpose of this study was not only to investigate the impact of COVID-19 on the mortality of patients tested positive but also of negatively tested patients with proximal femoral fractures.

METHODS

A single center cohort study of 2186 patients (mean age 79.8 years) who were surgically treated for a proximal femoral fracture at a level I trauma center was retrospectively carried out. The mortality and complication rates before the COVID-19 pandemic (January 2016-February 2020) and during the pandemic (March 2020-October 2021) were compared. A standardized treatment protocol was carried out during the total observational period. Orthogeriatric co-management was negatively impaired by the pandemic. Patient data, COVID-19 infections, surgical procedure, time from admission to surgery, postoperative complications and mortality were analyzed.

RESULTS

The pandemic group included 596 patients with an average age of 79.7 years. During the pandemic 26 patients were tested positive for COVID-19 (18 women, 8 men, average age 81.4 years, minimum 63 years, maximum 99 years, SD 9 years). Patients who tested positive for COVID-19 had more comorbidities than COVID-19 negative patients during the same period (Charlson comorbidity index, CCI 6.26 vs.5.25 points p < 0.037). The prepandemic control group consisted of 1590 patients with an average age of 79.9 years and a mean CCI of 5.86 points. Patients tested positive had a much longer hospitalization and a longer duration on the intensive care unit (p < 0.001) and a complication rate of 62.5%, especially due to the occurrence of pneumonia (p < 0.001). The mortality rate during the pandemic did not differ between patients tested positive or patients tested negative but was significantly higher for both groups in comparison to the period before the pandemic (pandemic 14% vs. 15.4%, before the pandemic 3.1%).

CONCLUSION

Patients suffering from COVID-19 infection and proximal femoral fractures have a high risk of complications and a high mortality. The total increase in mortality for all patients with critical injuries, such as hip fractures during the pandemic emphasizes the importance of early mobilization and orthogeriatric co-management, which was discontinued during the pandemic and the lockdown.

Pre-hospital and Hospital Trauma Care during the Covid-19 Lockdown - Experience in a Metropolitan European Level 1 Trauma Centre

BACKGROUND

Trauma case load is said to have declined during the Covid-19 pandemic, especially during the national lockdowns. Due to the altered frequency and changes in daily life, pre-hospital care (altered personal protective measurements) as well as mechanisms of trauma and initial trauma treatment may have changed. The purpose of this study was to assess differences in pre-hospital as well as initial treatment of trauma victims and trauma mechanisms during a national lockdown compared to the year before.

MATERIAL AND METHODS

Pre-hospital as well as clinical data from all trauma patients admitted to our metropolitan level 1 trauma center resuscitation room during the hard lockdown in Switzerland (March 17 to April 26, 2020) and the same time period in 2019 were analyzed retrospectively.

RESULTS

In total, we assessed 91 patients (51 lockdown cohort, 40 control cohort) with a mean age of 50.7 years. Significantly more trauma was sustained in the household environment during the lockdown (p = 0.015). Pre-hospital treatment remained similar between the two assessed groups. No difference was found in length of stay or mortality. In severely injured patients (ISS > 15), we found significantly fewer motor vehicle accidents (p = 0.018) and fewer horizontal decelerations (p = 0.006), but insignificantly more falls (p = 0.092) in the lockdown cohort. None of the patients in the lockdown cohort had a positive PCR test for Covid-19 on admission.

CONCLUSION

Trauma systems seem not to have changed during hard lockdowns in terms of pre-hospital treatment. Fewer severely injured patients due to motor vehicle accidents and horizontal decelerations, but more household-related injuries were seen in the lockdown cohort than in the control cohort. A qualitative analysis of treatment during the hard lockdown is needed to gain further insights into the effect of the pandemic on trauma care.

Vaccination against COVID-19 reduced the mortality risk of COVID-positive hip fracture patients to baseline levels: the nationwide data-linked IMPACT Protect study

This nationwide study used data-linked records to assess the effect of COVID-19 vaccination among hip fracture patients. Vaccination was associated with a lower risk of contracting COVID-19 and, among COVID-positive patients, it reduced the mortality risk to that of COVID-negative patients. This provides essential data for future communicable disease outbreaks.

PURPOSE

COVID-19 confers a three-fold increased mortality risk among hip fracture patients. The aims were to investigate whether vaccination was associated with: i) lower mortality risk, and ii) lower likelihood of contracting COVID-19 within 30 days of fracture.

METHODS

This nationwide cohort study included all patients aged > 50 years that sustained a hip fracture in Scotland between 01/03/20-31/12/21. Data from the Scottish Hip Fracture Audit were collected and included: demographics, injury and management variables, discharge destination, and 30-day mortality status. These variables were linked to government-managed population level records of COVID-19 vaccination and laboratory testing.

RESULTS

There were 13,345 patients with a median age of 82.0 years (IQR 74.0-88.0), and 9329/13345 (69.9%) were female. Of 3022/13345 (22.6%) patients diagnosed with COVID-19, 606/13345 (4.5%) were COVID-positive within 30 days of fracture. Multivariable logistic regression demonstrated that vaccinated patients were less likely to be COVID-positive (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.34-0.48, p < 0.001) than unvaccinated patients. 30-day mortality rate was higher for COVID-positive than COVID-negative patients (15.8% vs 7.9%, p < 0.001). Controlling for confounders (age, sex, comorbidity, deprivation, pre-fracture residence), unvaccinated patients with COVID-19 had a greater mortality risk than COVID-negative patients (OR 2.77, CI 2.12-3.62, p < 0.001), but vaccinated COVID19-positive patients were not at increased risk of death (OR 0.93, CI 0.53-1.60, p = 0.783).

CONCLUSION

Vaccination was associated with lower COVID-19 infection risk. Vaccinated COVID-positive patients had a similar mortality risk to COVID-negative patients, suggesting a reduced severity of infection. This study demonstrates the efficacy of vaccination in this vulnerable patient group, and presents data that will be valid in the management of future outbreaks.

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.

Completion of the Emergency Department "Big 6" in Patients with an Acute Hip Fracture Is Associated with a Lower Mortality Risk and Shorter Length of Hospital Stay

The aims of this study were to assess whether completion of the emergency department (ED) Big 6 interventions (provision of pain relief, screening for delirium, early warning score (EWS) system, full blood investigation and electrocardiogram, intravenous fluids therapy, and pressure area care) in those presenting with an acute hip fracture were associated with mortality risk and length of acute hospital stay. A retrospective cohort study was undertaken. All patients aged ≥50 years that were admitted with a hip fracture via the ED at a single centre during a 42-month period were included. A total of 3613 patients (mean age 80.9; 71% female) were included. The mean follow up was 607 (range 240 to 1542) days. A total of 1180 (32.7%) patients had all six components completed. Pain relief (90.8%) was the most frequently completed component and pressure area assessment (57.6%) was the least. Completion of each of the individual Big 6 components, except for pressure areas assessment, were associated with a significantly (p ≤ 0.041) lower mortality risk at the 90-days, one-year and final follow-up. The completion of all components of the Big 6 was associated with a significantly (2.4 hours, p = 0.002) shorter time to theatre. Increasing number of Big 6 components completed were independently associated with a lower mortality risk: when all six were completed, the hazard ratio was 0.64 (95% CI 0.52 to 0.78, p < 0.001). Completion of an increasing number of Big 6 components was independently associated with shorter length of hospital stay and completion of all six was associated with a 2.3 (95% CI 0.9 to 3.8)-day shorter acute stay. The findings provide an evidence base to support the ongoing use of the Big 6 in the ED.

Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study

OBJECTIVE

To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications.

DESIGN

Retrospective chart review.

SETTING

Eleven Level I trauma centers.

PATIENTS

From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included.

INTERVENTION

Reamed IMN.

MAIN OUTCOME MEASURES

Incidence of postoperative thromboembolic and respiratory complications.

RESULTS

Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days.

CONCLUSION

In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries.

LEVELS OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip Fracture Surgery in Trinidad and Tobago During the COVID-19 Pandemic: An Analysis of Two Patients Treated in the Parallel Healthcare System

The rapid spread of the deadly coronavirus disease 2019 (COVID-19) pandemic has fundamentally affected healthcare delivery globally. As governments struggled to preserve life, several approaches to healthcare delivery have emerged. Central to limiting viral transmission is the separation of patients based on their COVID-19 status. Studies have shown that a geographically separate dual-site service is preferable, contingent upon the local infrastructure and circumstances. Despite the restrictions on free movement, most studies indicate that low-energy hip fractures in elderly patients have remained relatively constant throughout the pandemic. Arguably these patients represent the most vulnerable subgroup in society and are susceptible to developing severe COVID-19 respiratory disease.

In keeping with global recommendations, the government of Trinidad and Tobago devised a parallel healthcare system to limit the spread of disease. All regional health authorities under the Ministry of Health were at liberty to implement the system in a manner best suited for their particular infrastructure leading to highly variable practices among institutions. This report describes the clinical course of two hip fracture patients treated within the parallel healthcare system at different regional health authorities. Analysis of these cases provides an understanding of the potential risks to patients entering the parallel healthcare system and an insight into preventative measures to improve clinical outcomes.

The impact of COVID-19 on mortality after hip fracture : a population cohort study from England

AIMS

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

METHODS

We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.

RESULTS

Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days.

CONCLUSION

COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival.Cite this article: Bone Joint J 2022;104-B(10):1156-1167.

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.

Developing a minimum common dataset for hip fracture audit to help countries set up national audits that can support international comparisons

AIMS

The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

METHODS

We compared all ten established national hip fracture registries: England, Wales, and Northern Ireland; Scotland; Australia and New Zealand; Republic of Ireland; Germany; the Netherlands; Sweden; Norway; Denmark; and Spain. We tabulated all questions included in each registry, and cross-referenced them against the 32 questions of the MCD dataset. Having identified those questions consistently used in the majority of national audits, and which additional fields were used less commonly, we then used consensus methods to establish a revised MCD.

RESULTS

A total of 215 unique questions were used across the ten registries. Only 72 (34%) were used in more than one national audit, and only 32 (15%) by more than half of audits. Only one registry used all 32 questions from the 2014 MCD, and five questions were only collected by a single registry. Only 21 of the 32 questions in the MCD were used in the majority of national audits. Only three fields (anaesthetic grade, operation, and date/time of surgery) were used by all ten established audits. We presented these findings at the Asia-Pacific FFN meeting, and used an online questionnaire to capture feedback from expert clinicians from different countries. A draft revision of the MCD was then presented to all 95 nations represented at the Global FFN conference in September 2021, with online feedback again used to finalize the revised MCD.

CONCLUSION

The revised MCD will help aspirant nations establish new registry programmes, facilitate the integration of novel analytic techniques and greater multinational collaboration, and serve as an internationally-accepted standard for monitoring and improving hip fracture services. Cite this article: Bone Joint J 2022;104-B(6):721-728.

The IMPACT of COVID-19 on trauma & orthopaedic surgery provides lessons for future communicable disease outbreaks : minimum reporting standards, risk scores, fragility trauma services, and global collaboration

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies.

Cite this article: Bone Joint Res 2022;11(6):342–345.

The safe resumption of elective orthopaedic services following the first wave of the COVID-19 pandemic : a review of 2,316 consecutive cases and implications for recovery following further waves

Aims

There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019.

Methods

A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019.

Results

A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery.

Conclusion

Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery.

Level of evidence: III

Cite this article: Bone Jt Open 2022;3(1):42–53.

Hip and distal femur fracture outcomes over three successive UK lockdown periods during the COVID-19 pandemic: what have we learnt? : a single-centre retrospective cohort study

Aims

This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year.

Methods

A single-centre retrospective cohort study was performed at an acute NHS Trust. Hip and distal femur fracture patients admitted within the first month from each of the three starting dates of each national lockdown were included and compared to a control group in March 2019. Data were collected as per the best practice tariff outcomes including additional outcomes as required. Data collection included COVID-19 status, time to theatre, 30-day mortality, presence of acute kidney injury (AKI) and pneumonia, and do not attempt cardiopulmonary resuscitation (DNACPR) status. Data were analyzed using an independent-samples t-test or chi-squared test with Fisher’s exact test where applicable. A p-value of < 0.05 was considered statistically significant.

Results

A total of 95 patients during the pandemic were included and 20 were COVID-positive. Patients experienced a statistically significant increase in time to theatre in Lockdown 1 compared to 2019 (p = 0.039) with a decrease with successive lockdown periods by Lockdown 3. The 30-day mortality increased from 8.8% in 2019 to 10.0% to 14.8% in all lockdown periods. COVID-positive patient mortality was 30.0% (p = 0.063, odds ratio (OR) = 4.43 vs 2019). The rates of AKI and pneumonia experienced were higher for patients during the pandemic. The highest rates were experienced in COVID-positive patients, with 45.0% of patients with AKI versus 27.0% in 2019 (p = 0.38, OR = 1.80), and 50.0% of patients diagnosed with pneumonia versus 16.2% in 2019 (p = 0.0012, OR = 5.17). The percentage of patients with a DNACPR increased from 30.0% in 2019 to 60.7% by Lockdown 3 (p = 0.034, OR = 3.61).

Conclusion

COVID-positive hip and distal femur fracture patients are at a higher risk of mortality due to AKI and pneumonia. Patient outcomes have improved with successive lockdowns to pre-pandemic levels.

Cite this article: Bone Jt Open 2021;2(12):1017–1026.

Multidisciplinary rehabilitation for older people with hip fractures

BACKGROUND

Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009.

OBJECTIVES

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.

MAIN RESULTS

The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months.

AUTHORS' CONCLUSIONS

In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

COVID-19 and Proximal Femur Fracture in Older Adults-A Lethal Combination? An Analysis of the Registry for Geriatric Trauma (ATR-DGU)

Objectives

COVID-19 can be a life-threatening illness, especially for older patients. The COVID-19 outbreak created a dramatic organizational challenge in treating infected patients requiring surgical treatment, like those suffering a proximal femur fracture, in a pandemic setting. We investigate the impact of a COVID-19 infection in patients with a proximal femur fracture not only on mortality but also on quality of life (QoL), length of stay, and discharge target.

Design

Retrospective cohort analysis from July 1, 2020, to December 31, 2020. The Registry for Geriatric Trauma collected the data prospectively. Patient groups with and without COVID-19 infection were compared using linear and logistic regression models.

Setting and Participants

Retrospective multicenter registry study including patients aged ≥70 years with proximal femur fracture requiring surgery from 107 certified Centers for Geriatric Trauma in Germany, Austria, and Switzerland.

Measures

The occurrence and impact of COVID-19 infection in patients suffering a proximal femur fracture were measured regarding in-house mortality, length of stay, and discharge location. Moreover, QoL was measured by the validated EQ-5D-3L questionnaire.

Results

A total of 3733 patients were included in our study. Of them, 123 patients tested COVID-19 positive at admission. A COVID-19 infection resulted in a 5.95-fold higher mortality risk (odds ratio 5.95, P < .001], a length of stay prolonged by 4.21 days [regression coefficient (β) 4.21, P < .001], a reduced QoL (β −0.13, P = .001), and a change in discharge target, more likely to their home instead of another inpatient facility like a rehabilitation clinic (P = .013).

Conclusions and Implications

The impact of a COVID-19 infection in patients suffering a proximal femur fracture is tremendous. The infected patients presented a dramatic rise in mortality rate, were significantly less likely to be discharged to a rehabilitation facility, had a longer in-hospital stay, and a reduced QoL.

Unexpected details regarding nosocomial transmission revealed by whole-genome sequencing of severe acute respiratory coronavirus virus 2 (SARS-CoV-2)

OBJECTIVE

Effective infection prevention and control (IPC) measures are key for protecting patients from nosocomial infections and require knowledge of transmission mechanisms in different settings. We performed a detailed outbreak analysis of the transmission and outcome of coronavirus disease 2019 (COVID-19) in a geriatric ward by combining whole-genome sequencing (WGS) with epidemiological data.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care hospital.

PARTICIPANTS

Patients and healthcare workers (HCWs) from the ward with a nasopharyngeal sample (NPS) positive for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) RNA during the outbreak period.

METHODS

Patient data regarding clinical characteristics, exposure and outcome were collected retrospectively from medical records. Stored NPSs from 32 patients and 15 HCWs were selected for WGS and phylogenetic analysis.

RESULTS

The median patient age was 84 years and 17 (53%) of 32 were male. Also, 14 patients (44%) died within 30 days of sampling. Viral loads were significantly higher among the deceased. WGS was successful in 28 (88%) of 32 patient samples and 14 (93%) of 15 HCW samples. Moreover, 3 separate viral clades were identified: 1 clade and 2 subclades among both patient and HCW samples. Integrated epidemiological and genetic analyses revealed 6 probable transmission events between patients and supported hospital-acquired COVID-19 among 25 of 32 patients.

CONCLUSIONS

WGS provided an insight into the outbreak dynamics and true extent of nosocomial COVID-19. The extensive transmission between patients and HCWs indicated that current IPC measures were insufficient. We recommend increased use of WGS in outbreak investigations to identify otherwise unknown transmission links and to evaluate IPC measures.

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

IMPACT of COVID-19 on hip fracture services: A global survey by the International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics

Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic resulted in major disruption to hip fracture services. This frail patient group requires specialist care, and disruption to services is likely to result in increases in morbidity, mortality and long-term healthcare costs.

Aims

To assess disruption to hip fracture services during the COVID-19 pandemic.

Methods

A questionnaire was designed for completion by a senior clinician or service manager in each participating unit between April–September 2020. The survey was incorporated into existing national-level audits in Germany (n = 71), Scotland (n = 16), and Ireland (n = 16). Responses from a further 82 units in 11 nations were obtained via an online survey.

Results

There were 185 units from 14 countries that returned the survey. 102/160 (63.7%) units reported a worsening of overall service quality, which was attributed predominantly to staff redistribution, reallocation of inpatient areas, and reduced access to surgical facilities. There was a high rate of redeployment of staff to other services: two thirds lost specialist orthopaedic nurses, a third lost orthogeriatrics services, and a quarter lost physiotherapists. Reallocation of inpatient areas resulted in patients being managed by non-specialised teams in generic wards, which increased transit of patients and staff between clinical areas. There was reduced operating department access, with 74/160 (46.2%) centres reporting a >50% reduction. Reduced theatre efficiency was reported by 135/160 (84.4%) and was attributed to staff and resource redistribution, longer anaesthetic and transfer times, and delays for preoperative COVID-19 testing and using personal protective equipment (PPE).

Conclusion

Hip fracture services were disrupted during the COVID-19 pandemic and this may have a sustained impact on health and social care. Protection of hip fracture services is essential to ensure satisfactory outcomes for this vulnerable patient group.

Higher 90-Day Mortality after Surgery for Hip Fractures in Patients with COVID-19: A Case-Control Study from a Single Center in Italy

The mortality of hip fracture (HF) patients is increased by concomitant COVID-19; however, evidence is limited to only short follow-up. A retrospective matched case-control study was designed with the aim to report the 90-day mortality and determine the hazard ratio (HR) of concomitant HF and COVID-19 infection. Cases were patients hospitalized for HF and diagnosed with COVID-19. Controls were patients hospitalized for HF not meeting the criteria for COVID-19 diagnosis and were individually matched with each case through a case-control (1:3) matching algorithm. A total of 89 HF patients were treated during the study period, and 14 of them were diagnosed as COVID-19 positive (overall 15.7%). Patients' demographic, clinical, and surgical characteristics were similar between case and control groups. At 90 days after surgery, 5 deaths were registered among the 14 COVID-19 cases (35.7%) and 4 among the 42 HF controls (9.5%). COVID-19-positive cases had a higher risk of mortality at 30 days (HR = 4.51; p = 0.0490) and 90 days (HR = 4.50; p = 0.025) with respect to controls. Patients with concomitant HF and COVID-19 exhibit high perioperative mortality, which reaches a plateau of nearly 30-35% after 30 to 45 days and is stable up to 90 days. The mortality risk is more than four-fold higher in patients with COVID-19.

The rate of COVID-19 and associated mortality after elective hip and knee arthroplasty prior to cessation of elective services in UK

AIMS

The primary aim was to assess the rate of postoperative COVID-19 following hip and knee arthroplasty performed in March 2020 in the UK. The secondary aims were to assess whether there were clinical factors associated with COVID-19 status, the mortality rate of patients with COVID-19, and the rate of potential COVID-19 in patients not presenting to healthcare services.

METHODS

A multicentre retrospective study was conducted of patients undergoing hip or knee arthroplasty during the first wave of the COVID-19 pandemic (1 March 2020 to 31 March 2020) with a minimum of 60 days follow-up. Patient demographics, American Society of Anesthesiologists grade, procedure type, primary or revision, length of stay (LOS), COVID-19 test status, and postoperative mortality were recorded. A subgroup of patients (n = 211) who had not presented to healthcare services after discharge were contacted and questioned as to whether they had symptoms of COVID-19.

RESULTS

Five (0.5%) of 1,073 patients who underwent hip or knee arthroplasty tested positive for SARS-CoV-2 postoperatively. When adjusting for confounding factors, increasing LOS (p = 0.022) was the only significant factor associated with developing COVID-19 following surgery and a stay greater than three days was a reliable predictor with an area under the curve of 81% (p = 0.018). There were three (0.3%) deaths in the study cohort and the overall mortality rate attributable to COVID-19 was 0.09% (n = 1/1,073), with one (20%) of the five patients with COVID-19 dying postoperatively. Of the 211 patients contacted, two had symptoms within two to 14 days postoperatively with a positive predictive value of 31% and it was therefore estimated that one patient may have had undiagnosed COVID-19.

CONCLUSION

The rate of postoperative COVID-19 was 0.5% and may have been as high as 1% when accounting for those patients not presenting to healthcare services, which was similar to the estimated population prevalence during the study period. The overall mortality rate secondary to COVID-19 was low (0.09%), however the mortality rate for those patients developing COVID-19 was 20%. Cite this article: Bone Joint J 2021;103-B(4):681-688.