Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy

COVID-19 and Mortality in the Global Surgical Population: A Systematic Review and Meta-Analysis

INTRODUCTION

To date, no systematic review or meta-analysis has comprehensively estimated the risk of mortality by surgery type on an international scale. We aim to delineate the risk of mortality in patients with COVID-19 who undergo surgery.

METHODS

PubMed (MEDLINE), Scopus, OVID, the World Health Organization Global Literature on Coronavirus Disease, and Corona-Central databases were searched from December 2019 through January 2022. Studies providing data on mortality in patients undergoing surgery were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for abstracting data were followed and performed independently by two reviewers. The main outcome was mortality in patients with COVID-19.

RESULTS

Of a total of 4023 studies identified, 46 studies with 80,015 patients met our inclusion criteria. The mean age was 67 y; 57% were male. Surgery types included general (14.9%), orthopedic (23.4%), vascular (6.4%), thoracic (10.6%), and urologic (8.5%). Patients undergoing surgery with COVID-19 elicited a nine-fold increased risk of mortality (relative risk [RR] 8.99, 95% confidence interval [CI] 4.96-16.32) over those without COVID-19. In low-income and middle-income countries (RR: 16.04, 95% CI: 4.59-56.12), the mortality risk was twice as high compared to high-income countries (RR: 7.50, 95% CI: 4.30-13.09).

CONCLUSIONS

Mortality risk in surgical patients with COVID-19 compared to those without is increased almost 10-fold. The risk was highest in low-income and middle-income countries compared to high-income countries, suggesting a disproportionate effect of the pandemic on resource-constrained regions.

Preoperative COVID-19 infection status negatively impacts postoperative outcomes of geriatric hip fracture surgery

OBJECTIVES

Compare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

Retrospective propensity score matched cohort.

METHODS

Patients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts.

RESULTS

After matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 - 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 - 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 - 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 - 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 - 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 - 3.06).

CONCLUSIONS

Active COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population.

LEVEL OF EVIDENCE

III.

COVID-19 hip fracture outcomes: The role of Ct values and D-dimer levels?

Introduction

The COVID-19 pandemic has caused high mortality rates in hip fracture patients, but data for Asian patients are lacking. Whilst Cycle threshold (Ct) values and D-dimer have been reported as predictors of mortality in COVID-19 patients, their prognostic roles in those with concomitant hip fracture remain unknown. The objectives of this study were to i) assess the clinical outcomes of COVID-19 hip fractures patients in the Chinese population, ii) identify risk factors of mortality and complications, and iii) determine the prognostic roles of Ct values and D-dimer levels.

Methodology

This cohort study was conducted during the 5th wave of the COVID-19 pandemic. Inclusion criteria were 1) hip fracture 2) ​≥ ​60 years old 3) low-energy trauma. Outcomes were 90-day all-cause mortality, complications, length of stay, discharge destination and mobility status. Logistic regression analysis was performed to identify risk factors for mortality and complications. Subgroup analysis was performed for patients with Ct ​< ​30 and Ct ​> ​30, comparing their outcomes of operations performed within 48 ​h vs beyond 48 ​h.

Results

159 hip fracture patients were included, 42 patients were COVID-19 positive. COVID-19 group had significantly higher 90-day mortality rates (21.4% vs 9.4%), complication rates (45.2% vs 28.2%) and longer length of stay (17.06 vs 10.84 nights). COVID-19 was an independent risk factor for mortality and complications. Amongst the COVID-19 group, risk factors for poor outcomes were advanced age, steroids use, conservative treatment and American Society of Anaesthesiologists (ASA) score ≥ 3. Conservative treatment was associated with higher mortality (OR ​= ​16.00; p ​= ​0.025) in COVID-19 hip fracture patients. There was no significant difference between Ct values ​< ​30 and >30 regarding mortality and complication rate. D-dimer and timing to operation did not affect outcomes.

Conclusions

Patients with concomitant COVID-19 and hip fracture are at high risk of mortality and complications. Ct values and D-dimer levels have no prognostic roles for hip fracture outcomes. Early operative treatment is recommended as soon as patients are medically fit.

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates

BACKGROUND

This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19.

METHODS

A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]).

RESULTS

Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately.

CONCLUSION

Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.

Risk factors for hypoxaemia following hip fracture surgery in elderly patients who recovered from COVID-19: a multicentre retrospective study

Objectives

To explore the risk factors associated with postoperative hypoxaemia in elderly patients who have recovered from coronavirus disease (COVID-19) and underwent hip fracture surgery in the short term.

Design

Multicentre retrospective study.

Setting

The study was performed in three first 3A-grade hospitals in China.

Participants

A sequential sampling method was applied to select study participants. Medical records of 392 patients aged ≥65 years who had recovered from COVID-19 and underwent hip fracture surgery at three hospitals in China between 1 November, 2022, and 15 February, 2023, were reviewed.

Interventions

Patients were assigned to hypoxaemia or non-hypoxaemia groups, according to whether hypoxaemia occurred after surgery. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for postoperative hypoxaemia.

Results

The incidence of postoperative hypoxaemia was 38.01%. Statistically significant differences were found between the two groups in terms of age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, presence of expectoration symptoms, preoperative hypoxaemia, chronic obstructive pulmonary disease, pulmonary inflammation, time between recovery from COVID-19 and surgery, anaesthetic mode, surgical procedure, intraoperative blood loss, intraoperative infusion, duration of surgery, and length of hospital stay (p < 0.05). Furthermore, patients with BMI ≥28.0 kg/m², expectoration symptoms, presence of preoperative hypoxaemia, ASA classification III, time between recovery from COVID-19 and surgery ≤2 weeks, and general anaesthesia were potential risk factors for postoperative hypoxaemia.

Conclusion

Obesity, expectoration symptoms, preoperative hypoxaemia, ASA classification III, time between recovery from COVID-19 and surgery ≤2 weeks, and general anaesthesia were potential risk factors for postoperative hypoxaemia in elderly patients who recovered from COVID-19 and underwent hip fracture surgery in the short term.

Impact of COVID-19 Pandemic on Fragility Fractures of the Hip: An Interrupted Time-Series Analysis of the Lockdown Periods in Western Greece and Review of the Literature

Since December 2019, the COVID-19 pandemic has had a significant impact on healthcare systems worldwide, prompting policymakers to implement measures of isolation and eventually adopt strict national lockdowns, which affected mobility, healthcare-seeking behavior, and services, in an unprecedented manner. This study aimed to analyze the effects of these lockdowns on hip-fracture epidemiology and care services, compared to nonpandemic periods in previous years. We retrospectively collected data from electronic patient records of two major hospitals in Western Greece and included patients who suffered a fragility hip fracture and were admitted during the two 5-week lockdown periods in 2020, compared to time-matched patients from 2017-2019. The results showed a drop in hip-fracture incidence, which varied among hospitals and lockdown periods, and conflicting impacts on time to surgery, time to discharge after surgery, and total hospitalization time. The study also found that differences between the two differently organized units were exaggerated during the COVID-19 lockdown periods, highlighting the impact of compliance with social-distancing measures and the reallocation of resources on the quality of healthcare services. Further research is needed to fully understand the specific variations and patterns of geriatric hip-fracture care during emergency health crises characterized by limited resources and behavioral changes.

Postoperative mortality in the COVID-positive hip fracture patient, a systematic review and meta-analysis

PURPOSE

The extent to which concomitant COVID-19 infection increases short-term mortality following hip fracture is not fully understood. A systemic review and meta-analysis of COVID-19 positive hip fracture patients (CPHFPs) undergoing surgery was conducted to explore the association of COVID-19 with short-term mortality.

METHODS

Review of the literature identified reports of short-term 30-day postoperative mortality in CPHFPs. For studies including a contemporary control group of COVID-19 negative patients, odds ratios of the association between COVID-19 infection and short-term mortality were calculated. Short-term mortality and the association between COVID-19 infection and short-term mortality were meta-analyzed and stratified by hospital screening type using random effects models.

RESULTS

Seventeen reports were identified. The short-term mortality in CPHFPs was 34% (95% C.I., 30-39%). Short-term mortality differed slightly across studies that screened all patients, 30% (95% C.I., 22-39%), compared to studies that conditionally screened patients, 36% (95% C.I., 31-42%), (P = 0.22). The association between COVID-19 infection and short-term mortality produced an odds ratio of 7.16 (95% C.I., 4.99-10.27), and this was lower for studies that screened all patients, 4.08 (95% C.I., 2.31-7.22), compared to studies that conditionally screened patients, 8.32 (95% C.I., 5.68-12.18), (P = 0.04).

CONCLUSION

CPHFPs have a short-term mortality rate of 34%. The odds ratio of short-term mortality was significantly higher in studies that screened patients conditionally than in studies that screened all hip fracture patients. This suggests mortality prognostication should consider how COVID-19 infection was identified as asymptomatic patients may fare slightly better.

Perioperative mortality and morbidity of hip fractures among COVID-19 infected and non-infected patients: A systematic review and meta-analysis

PURPOSE

Hip fractures among elderly patients are surgical emergencies. During COVID-19 pandemic time, many such patients could not be operated at early time because of the limitation of the medical resources, the risk of infection and redirection of medical attention to a severe infective health problem.

METHODS

A search of electronic databases (PubMed, Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials) with the keywords "COVID", "COVID-19″, "SARS-COV-2", "Corona", "pandemic", "hip fracture", "trochanteric fracture" and "neck femur fracture" revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time. The 30-day mortality rate, inpatient mortality rate, critical care/special care need, readmission rate and complications rate in both groups were evaluated. Data were analyzed using Review Manager (RevMan) V.5.3.

RESULTS

After screening, 7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected (COVID-19 +) and non-infected (COVID-19 -) patients. There were significantly increased risks of 30-day mortality (32.23% COVID-19 + death vs. 8.85% COVID-19 - death) and inpatient mortality (29.33% vs. 2.62%) among COVID-19 + patients with odds ratio (OR) of 4.84 (95% CI: 3.13 - 7.47, p < 0.001) and 15.12 (95% CI: 6.12 - 37.37, p < 0.001), respectively. The COVID-19 + patients needed more critical care admission (OR = 5.08, 95% CI: 1.49 - 17.30, p < 0.009) and they remain admitted for a longer time in hospital (mean difference = 3.6, 95% CI: 1.74 - 5.45, p < 0.001); but there was no difference in readmission rate between these 2 groups. The risks of overall complications (OR = 17.22), development of pneumonia (OR = 22.25), and acute respiratory distress syndrome/acute respiratory failure (OR = 32.96) were significantly high among COVID-19 + patients compared to COVID-19 - patients.

CONCLUSIONS

There are increased risks of the 30-day mortality, inpatient mortality and critical care admission among hip fracture patients who are COVID-19 +. The chances of developing pneumonia and acute respiratory failure are more in COVID-19 + patients than in COVID-19 ‒ patients.

Milder impact of the COVID-19 pandemic on the practice of orthopaedic surgery in Greece and Cyprus than other European countries

PURPOSE

The aim of this study was to highlight the impact of the COVID-19 pandemic on the practice of orthopaedics in Greece and Cyprus.

METHODS

The survey used the online questionnaire from AGA (Gesellschaft für Arthroskopie und Gelenkchirurgie; Society for Arthroscopy and Joint Surgery) to facilitate the comparison between different European countries. The questionnaire was distributed online to members of the HAOST (Hellenic Association of Orthopaedic Surgery and Trauma), the ΟΤΑΜΑΤ (Orthopaedic and Trauma Association of Macedonia and Thrace) and the CAOST (Cypriot Association of Orthopaedic Surgery and Trauma). The questionnaire consisted of 29 questions, which included demographic data, questions on the impact of the pandemic on the practice of orthopaedic surgery and questions on the impact on the personal and family life of orthopaedic surgeons.

RESULTS

The questionnaire was sent to 1350 orthopaedic surgeons in Greece and Cyprus, 303 of whom responded (response rate 22.44%). 11.2% of the participants reported cancellation of overall orthopaedic procedures. According to 35.6-49.8% of the participants, arthroscopic procedures were continued. As regards elective primary arthroplasties, 35.3% of the participants reported that these continued to be performed at their hospitals. Post-operative follow-ups as well as physiotherapy were affected by the pandemic, and changes were also observed in the habits of orthopaedic surgeons in their personal and family lives.

CONCLUSION

The orthopaedic service in Greece and Cyprus decreased during the first wave of the COVID-19 pandemic. Arthroscopic procedures and total joint replacements decreased significantly, but not to the same extent as in other countries. Health systems were not fully prepared for the first wave of the pandemic and the various countries took social measures at different times and to different extents. Thus, studying the impact of the pandemic on the practice of orthopaedic surgery in different countries can help health systems to better prepare for future pandemics; public health can then be shielded and hospitals can continue to provide high-quality orthopaedic care.

LEVEL OF EVIDENCE

Level V.

Changes in trends of orthopedic services due to the COVID-19 pandemic: A review

As of June 10, 2022, the World Health Organization has recorded over 532 million documented coronavirus disease 2019 (COVID-19) [(Coronavirus) SARS-CoV-2] cases and almost 6.3 million deaths worldwide, which has caused strain on medical specialties globally. The aim of this review is to explore the impact that COVID-19 has had on orthopedic practices. Providers observed a rapid decline in the number of orthopedic patients’ admissions due to cancellation of elective procedures; however, emergent cases still required treatment. Various observational studies, case reports, and clinical trials were collected through a PubMed database search. Additional sources were found through Google. The search was refined to publications in English and between the years of 2019 and 2021. The keywords used were “COVID-19” and/or “Orthopedic Injuries”. Thirty-seven studies were retained. The pandemic brought on significant changes to the mechanism of injury, number of admissions, type of injuries, and patient outcomes. Mortality rates significantly increased particularly amongst patients with hip fractures and COVID-19. Road traffic injuries remained a common cause of injury and domestic injuries became more prevalent with lockdown. Social isolation negatively affected mental health resulting in several orthopedic injuries. Telehealth services and separation for COVID-positive and COVID-negative patients benefited both patients and providers. While hospitals and medical facilities are still facing COVID-19 case surges, it is important to understand how this pandemic has impacted preparation, care, and opportunities for prevention education and ongoing care.

Traumatic Proximal Femoral Fractures during COVID-19 Pandemic in the US: An ACS NSQIP® Analysis

In order to determine the impact of COVID-19 on the treatment and outcomes in patients with proximal femoral fracture’s (PFF), we analyzed a national US sample. This is a retrospective review of American College of Surgery’s (ACS) National Surgical Quality Improvement Program (NSQIP) for patients with proximal femoral fractures. A total of 26,830 and 26,300 patients sustaining PFF and undergoing surgical treatment were sampled during 2019 and 2020, respectively. On multivariable logistic regression, patients were less likely to have ‘presence of non-healing wound’ (p < 0.001), functional status ‘independent’ (p = 0.012), undergo surgical procedures of ‘hemiarthroplasty’(p = 0.002) and ‘ORIF IT, Peritroch, Subtroch with plates and screws’ (p < 0.001) and to be ‘alive at 30-days post-op’ (p = 0.001) in 2020 as compared to 2019. Patients were more likely to have a case status ‘emergent’, ‘loss of ≥10% body weight’, discharge destination of ‘home’ (p < 0.001 for each) or ‘leaving against medical advice’ (p = 0.026), postoperative ‘acute renal failure (ARF)’ (p = 0.011), ‘myocardial infarction (MI)’ (p = 0.006), ‘pulmonary embolism (PE)’ (p = 0.047), and ‘deep venous thrombosis (DVT)’ (p = 0.049) in 2020 as compared to 2019. Patients sustaining PFF and undergoing surgical treatment during pandemic year 2020 differed significantly in preoperative characteristics and 30-day postoperative complications when compared to patients from the previous year.

The Effects of COVID-19 on Geriatric Hip Fracture Management and 1-Year Mortality in Beijing

Objectives

Concerns about the coronavirus disease 2019 (COVID‐19) pandemic resulted in unprecedented challenges to the management of geriatric hip fractures. We aimed to evaluate the effects of the COVID‐19 surge on the time to surgery and 1 year mortality in geriatric patients with hip fracture at a large, urban Level 1 trauma center in Beijing, and to guide the management of geriatric hip fracture patients throughout the COVID‐19 pandemic.

Methods

This single‐center retrospective study included consecutive patients aged ≥65 years and injured 3 weeks prior to admission. Demographic and surgical data were collected between January 20 and May 31, 2020, and from the same period in 2019. Mortality data and functional status were collected at follow‐up of 1‐year after surgery. The primary outcomes were time to surgery and 1 year mortality.

Results

There were no significant differences in sex, fracture type, and surgical pattern between the 2020 (n = 261) and 2019 time‐matched (n = 307) cohorts. The time from admission to surgery was significantly delayed in the 2020 cohort compared with that in the 2019 cohort (48.9 h vs 20.5 h, p < 0.001). Fewer patients underwent surgery within 48 h in the 2020 cohort (65.5% vs 87.6%, p < 0.001). Surgical delay was also associated with an increased risk of inpatient complications (30.2% vs 20.8%, p = 0.010), however there was no significant difference in the 1‐year mortality rate, nor between pre‐injury and 1 year follow‐up mobility as assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre‐injury mobility levels.

Conclusions

The COVID‐19 pandemic has significantly increased the surgery waiting time for geriatric patients with hip fractures, which resulted in increased inpatient complications without a higher mortality rate within 1 year. This reinforces the importance of maintaining timely and protocolized care for geriatric hip fractures throughout any subsequent waves of the pandemic.

Trends in osteoporotic fracture and related in-hospital complications during the COVID-19 pandemic in Alberta, Canada

Fragility fractures (i.e., low-energy fractures) account for most fractures among older Canadians and are associated with significant increases in morbidity and mortality. Study results suggest that low-energy fracture rates (associated with surgical intervention and outcomes) declined slightly, but largely remained stable in the first few months of the COVID-19 pandemic.

PURPOSE/INTRODUCTION

This study describes rates of low-energy fractures, time-to-surgery, complications, and deaths post-surgery in patients with fractures during the coronavirus disease (COVID-19) pandemic in Alberta, Canada, compared to the three years prior.

METHODS

A repeated cross-sectional study was conducted using provincial-level administrative health data. Outcomes were assessed in 3-month periods in the 3 years preceding the COVID-19 pandemic and in the first two 3-month periods after restrictions were implemented. Patterns of fracture- and hospital-related outcomes over the control years (2017-2019) and COVID-19 restrictions periods (2020) were calculated.

RESULTS

Relative to the average from the control periods, there was a slight decrease in the absolute number of low-energy fractures (n = 4733 versus n = 4308) during the first COVID-19 period, followed by a slight rise in the second COVID-19 period (n = 4520 versus n = 4831). While the absolute number of patients with low-energy fractures receiving surgery within the same episode of care decreased slightly during the COVID-19 periods, the proportion receiving surgery and the proportion receiving surgery within 24 h of admission remained stable. Across all periods, hip fractures accounted for the majority of patients with low-energy fractures receiving surgery (range: 58.9-64.2%). Patients with complications following surgery and in-hospital deaths following fracture repair decreased slightly during the COVID-19 periods.

CONCLUSIONS

These results suggest that low-energy fracture rates, associated surgeries, and surgical outcomes declined slightly, but largely remained stable in the first few months of the pandemic. Further investigation is warranted to explore patterns during subsequent COVID-19 waves when the healthcare system experienced severe strain.

Impact of the SARS-CoV-2 pandemic on trauma care: a nationwide observational study

PURPOSE

The SARS-CoV-2 pandemic severely disrupted society and the health care system. In addition to epidemiological changes, little is known about the pandemic's effects on the trauma care chain. Therefore, in addition to epidemiology and aetiology, this study aims to describe the impact of the SARS-CoV-2 pandemic on prehospital times, resource use and outcome.

METHODS

A multicentre observational cohort study based on the Dutch Nationwide Trauma Registry was performed. Characteristics, resource usage, and outcomes of trauma patients treated at all trauma-receiving hospitals during the first (W1, March 12 through May 11) and second waves (W2, May 12 through September 23), as well as the interbellum period in between (INT, September 23 through December 31), were compared with those treated from the same periods in 2018 and 2019.

RESULTS

The trauma caseload was reduced by 20% during the W1 period and 11% during the W2 period. The median length of stay was significantly shortened for hip fracture and major trauma patients (ISS ≥ 16). A 33% and 66% increase in the prevalence of minor self-harm-related injuries was recorded during the W1 and W2 periods, respectively, and a 36% increase in violence-related injuries was recorded during the INT. Mortality was significantly higher in the W1 (2.9% vs. 2.2%) and W2 (3.2% vs. 2.7%) periods.

CONCLUSION

The imposed restrictions in response to the SARS-CoV-2 pandemic led to diminished numbers of acute trauma admissions in the Netherlands. The long-lasting pressing demand for resources, including ICU services, has negatively affected trauma care. Further caution is warranted regarding the increased incidence of injuries related to violence and self-harm.

[Artículo traducido] Mortalidad a 30 días en pacientes con fractura de fémur proximal durante la pandemia COVID-19 en Vizcaya (País Vasco)

OBJECTIVES

Compare 30-day mortality rate following a proximal femur fracture (PFF) and SARS-CoV-2 infection versus a PFF and no SARS-CoV-2 infection.

DESIGN

Retrospective comparative study.

SETTING

Three university hospitals in Biscay province (Basque Country, Spain).

PATIENTS

77 patients over 65 years-old with PFF (AO 31-A and 31-B).

INTERVENTION

Study conducted between 9 March and 15 April 2020. The COVID-19 group included only patients with SARS-CoV-2 infection, confirmed by a positive RT-PCR test.

MAIN OUTCOME MEASUREMENTS

30-Day mortality rate and risk factors for mortality.

RESULTS

Of a total 77 patients, 10 were diagnosed with SARS-CoV-2 infection. Mean age was 85 years. Patients with SARS-CoV-2 infection had higher BMI (29.53 kg/m²) compared to patients without infection (24.09 kg/m²) (p = 0.001). No significant differences were found between both groups in terms of the Charlson Comorbidity Index, ASA score, use of oral anticoagulants or presence of cognitive impairment. Seven of the 10 patients in the COVID-19 group developed (viral) pneumonia, as compared to one single case (1/67) of (bacterial) pneumonia in the control group (p < 0.001). Thirty-days mortality was higher (p = 0.03) in COVID-19 patients (40%) than in those in the control group (11.9%). In the multivariate analysis, age ≥ 91 years-old, ASA class IV and BMI > 25 kg/m² were significant predictors of 30-day mortality. All deaths in the COVID-19 group occurred while the patients were hospitalized.

CONCLUSIONS

SARS-CoV-2 infection in patients with a PFF was seen to result in higher rates of early mortality, with COVID-19-related pneumonia being the leading direct cause of mortality.

LEVEL OF EVIDENCE

Level III study.

COVID-19 Elderly Patients Treated for Proximal Femoral Fractures during the Second Wave of Pandemic in Italy and Iran: A Comparison between Two Countries

Background and objevtive: The worldwide spread of SARS-CoV-2 has affected the various regions of the world differently. Italy and Iran have experienced a different adaptation to coexistence with the pandemic. Above all, fractures of the femur represent a large part of the necessary care for elderly patients. The aim of this study was to compare the treatment in Italy and Iran of COVID-19-positive patients suffering from proximal femur fractures in terms of characteristics, comorbidities, outcomes and complications. Materials and Methods: Medical records of COVID-19-positive patients with proximal femoral fractures treated at IRCCS Istituto Ortopedico Galeazzi in Milan (Italy) and at Salamat Farda and Parsa hospitals in the province of Tehran (Iran), in the time frame from 1 October 2020 to 16 January 2021, were analyzed and compared. Results: Records from 37 Italian patients and 33 Iranian patients were analyzed. The Italian group (mean age: 83.89 ± 1.60 years) was statistically older than the Iranian group (mean age: 75.18 ± 1.62 years) (p value = 0.0003). The mean number of transfusions for each patient in Italy was higher than the Iranian mean number (p value = 0.0062). The length of hospital stay in Italy was longer than in Iran (p value < 0.0001). Furthermore, laboratory values were different in the post-operative value of WBC and admission and post-operative values of CRP. Conclusions: The present study shows that differences were found between COVID-19-positive patients with proximal femoral fractures in these two countries. Further studies are required to validate these results and to better explain the reasons behind these differences.

Single vs Dual-site service reconfiguration during Covid-19 pandemic - A tertiary care centre experience in hip fractures and a Scoping review

Aims and objectives

The Covid-19 pandemic has had an unprecedented effect on surgical practice and healthcare delivery globally. We compared the impact of the care pathways which segregate Covid-19 Positive and Negative patients into two geographically separate sites, on hip fracture patients in our high-volume trauma center in 3 distinct eras - the pre-pandemic period, against the first Covid-19 wave with dual-site service design, as well as the subsequent surge with single-site service delivery. In addition, we sought to invoke similar experiences of centres worldwide through a scoping literature review on the current evidence on "Dual site" reconfigurations in response to Covid-19 pandemic.

Methods

We prospectively reviewed our hip fracture patients throughout the two peaks of the pandemic, with different service designs for each, and compared the outcomes with a historic service provision. Further, a comprehensive literature search was conducted using several databases for articles discussing Dual-site service redesign.

Results

In our in-house study, there was no statistically significant difference in mortality of hip fracture patients between the 3 periods, as well as their discharge destinations. With dual-site reconfiguration, patients took longer to reach theatre. However, there was much more nosocomial transmission with single-site service, and patients stayed in the hospital longer. 24 articles pertaining to the topic were selected for the scoping review. Most studies favour dual-site service reorganization, and reported beneficial outcomes from the detached care pathways.

Conclusion

It is safe to continue urgent as well as non-emergency surgery during the Covid-19 pandemic in a separate, geographically isolated site.

The Covid 19 Pandemic Effect on the Epidemiology of Thoracolumbar Fractures Presenting to the Emergency Department in Patients Above 65 years Old

Introduction

Studies investigating the Covid-19 Pandemic’s orthopedic aspects are accumulating, including reports on a 10-33% decrease in hip fracture incidence alongside shorter times to surgery. Osteoporotic vertebral compression fractures (VCF) have not yet been discussed. This study evaluated the effect of the Covid-19 pandemic’s first wave on VCF in the elderly.

Method

A retrospective cohort of elderly patients diagnosed with VCF between 2018-19 (Pre-Covid-19 pandemic) to 2020.

Results

The cohort included 172 patients above 65 years with VCF during 2018-2020. Patients’ age and gender were similar between the two study groups. We found a higher proportion of high-energy VCF during 2020 (10.5% vs 6.7%). Incidence of recurrent fractures was 7.5 times higher during 2020 (5.3% vs .7%, P =.06), and significantly higher rates of Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis in 2020 (7.9% vs 1.5%, P=.04). VCF ED admission rates were similar, with 60% treated conservatively. Admitted patients underwent more surgeries in 2020 (66.7% vs 60%, P =.71) and a tendency towards Precoutaneus Balloon Kyphoplasty (BKP) + fixation compared with BKP alone (15.8% in 2020 vs 7.5% in 2018-19, P =.29). RR for BKP + fixation vs BKP alone was 1.95, suggesting higher odds for a more complex surgery during the Covid-19 pandemic. The complication rate was significantly higher during 2020 (18.4% vs 3.7%, P <.001). Admission length was slightly longer during 2020 (12.2 days vs 9.9 days, P = .27), and time to surgery was marginally longer, 6.25 vs 5.3 days (P = .55). Many patients chose home over institutional rehabilitation during the Covid-19 pandemic (72.2% vs 58.8%).

Conclusion

The Covid-19 pandemic did not alter VCF incidence, but patients’ characteristics changed, affecting admissions, institutional rehabilitation, and a tendency towards complex surgery rather than BKP alone. It is still unclear if Covid-19 will remain an issue in the upcoming years, but its impact and lessons are still worthwhile.

Orthopedic Surgery in Ambulatory Surgery Centers During the COVID-19 Pandemic: Low Incidence of Infection Among Patients, Surgeons, and Staff

Background and objective

The coronavirus disease 2019 (COVID-19) pandemic has presented tremendous challenges to the healthcare systems worldwide. Consequently, ambulatory surgery centers (ASCs) have been forced to find new and innovative ways to function safely and maintain operations. We conducted a study at a large United States (US) private orthopedic surgery practice, where a universal screening policy and testing protocol for COVID-19 was implemented for patients and ASC personnel including surgeons, in order to examine the incidence of COVID-19 in patients scheduled for orthopedic surgery in ASC settings as well as the incidence among the surgeons and ASC personnel.

Methods

The universal screening protocol was implemented in the ASCs of the facility during the early stage of the pandemic for an eight-month period from April 28, 2020, to December 31, 2020. All ASC personnel including surgeons had their symptoms tracked daily and were rapid-tested every two weeks. All patients were screened and tested before they entered the ASC.

Results

A total of 70 out of 12,115 patients and 41 out of 642 ASC personnel tested positive for COVID-19, resulting in infection rates of 0.6% and 6.4%, respectively. Individual symptoms, age, the American Society of Anesthesiologists (ASA) scores, and comorbidities were documented, and no single factor was found to be common among positive (+) tests.

Conclusions

The implementation of universal screening and symptom-reporting procedures was associated with a very low rate of infections among ASC patients, staff, and surgeons, and it offers a reproducible framework for other facilities to continue to provide orthopedic outpatient operations in ASC settings during the ongoing iterations of the COVID-19 pandemic.

Epidemiology and postoperative complications of hip fracture during COVID-19 pandemic

Objectives

This study aims to analyze the changes in epidemiology and the postoperative outcomes in patients with hip fractures during the COVID-19 pandemic compared to non-pandemic period.

Methods

According to the date of declaration of “mandatory social distance”, we separated patients into 2 groups over a 1-year period: Period A and period B. We assessed the overall time to surgery, delay in surgery (> 24 hours, > 36 hours, and > 48 hours), reason of delay, length of hospital stay, type of surgery, and postoperative complications.

Results

The number of operated hip fractures and other trauma decreased in period B compared with period A by 17%, and 23%, respectively. The number of patients with delay in surgery by > 24 hours and > 36 hours was significantly higher in period B compared to that in period A (P = 0.035, P = 0.012, respectively). However, no significant difference in the number of delay in surgery > 48 hours and mean overall time to surgery between the 2 groups was observed (P = 0.856, P = 0.399, respectively). There was no difference in the duration of hospital stay, type of surgery, and postoperative complications between periods A and B.

Conclusions

During the COVID-19 pandemic, the decrease in hip fractures was relatively fewer compared to the decrease in orthopedic trauma. Although hip fracture surgeries were delayed for over 24 hours and 36 hours, there was no increase in delay for over 48 hours and postoperative complications.

Lockdown imposition due to COVID-19 and its effect on orthopedic emergency department in level 1 trauma center in South Asia

BACKGROUND

The coronavirus pandemic brought the entire world to a standstill. One of the most stringent lockdowns in the world was implemented in India. With the entire healthcare system being stretched, emergency orthopaedic services also take a hit. We studied the trends in patient presentation, testing, management, and restructuring of doctors at a tertiary care orthopaedic centre and compared them with the data from the same time period the previous year (2019).

METHOD

Data was collected separately for all the 5 different phases of lockdown and unlock, as well as for the same duration of months in 2019, and was analysed for epidemiological trends.

RESULTS

A rapid fall in the total number of cases was seen during the lockdown, followed by a skewed rise during the unlock. Forearm, wrist, and hip fractures were the most common fractures. Once nucleic acid testing of all patients intended to be admitted was started, a steep rise in coronavirus positivity was seen. There was a reduction in the total number of cases compared to 2019, but it was not as significant as would have been expected due to the complete standstill of activity during the lockdown.

CONCLUSION

During a pandemic, with the healthcare system under a crisis of workforce and infrastructure, there needs to be a separate task force for catering to orthopaedic emergencies since all fractures cannot be managed conservatively and the numbers of trauma-related patients did not show a stark fall as compared to normal months of last year.

LEVEL OF EVIDENCE

Level 3 Retrospective Case Series.

Excess mortality after hip fracture during COVID-19 pandemic: More about disruption, less about virulence—Lesson from a trauma center

To date, literature has depicted an increase in mortality among patients with hip fractures, directly related to acute coronavirus disease 2019 (COVID-19) infection and not due to underlying comorbidities. Usual orthogeriatric pathway in our Department was disrupted during the pandemic. This study aimed to evaluate early mortality within 30 days, in 2019 and 2020 in our Level 1 trauma-center. We compared two groups of patients aged >60 years, with osteoporotic upper hip fractures, in February/March/April 2020 and February/March/April 2019, in our level 1 trauma center. A total of 102 and 79 patients met the eligibility criteria in 2019 and 2020, respectively. Mortality was evaluated, merging our database with the French open database for death from the INSEE, which is prospectively updated each month. Causes of death were recorded. Charlson Comorbidity Index was evaluated for comorbidities, Instrumental Activity of Daily Living (IADL), and Activity of Daily Living (ADL) scores were assessed for autonomy. There were no differences in age, sex, fracture type, Charlson Comorbidity Index, IADL, and ADL. 19 patients developed COVID-19 infection. The 30-day survival was 97% (95% CI, 94%–100%) in 2019 and 86% (95% CI, 79%–94%) in 2020 (HR = 5, 95%CI, 1.4–18.2, p = 0.013). In multivariable Cox’PH model, the period (2019/2020) was significantly associated to the 30-day mortality (HR = 6.4, 95%CI, 1.7–23, p = 0.005) and 6-month mortality (HR = 3.4, 95%CI, 1.2–9.2, p = 0.01). COVID infection did not modify significantly the 30-day and 6-month mortality. This series brought new important information, early mortality significantly increased because of underlying disease decompensation. Minimal comprehensive care should be maintained in all circumstances in order to avoid excess of mortality among elderly population with hip fractures.

IMPACT OF COVID-19 ON MORTALITY AND HOSPITALIZATION IN OLDER ADULTS WITH HIP FRACTURE

ABSTRACT Objective: To evaluate the impact of the COVID-19 pandemic on hospital admission and mortality indicators in older adults with fractures of the proximal femur. Methods: Observational and retrospective study that took place from June 2016 to 2020. Patients of both genders who underwent surgical treatment for fractures of the proximal end of the femur, aged over 60 years, were included. Results: The population consisted of 379 patients, treated before (group 1; N = 278; 73.35%) and during the pandemic (group 2; N = 101; 26.65%). Higher mortality was observed in group 2 (N = 24; 23.8%) versus group 1 (N = 10; 3.6%), p < 0.001. The highest proportion of deaths in group 2 was maintained in patients aged 70-79 years (p = 0.011), 80-89 years (p ≤ 0.001) and > 90 years (p ≤ 0.001). In addition, the preoperative time and hospital stay were longer in group 2 compared to group 1 (p ≤ 0.001). Conclusion: The present study demonstrated that the pandemic period increased the mortality rate and the preoperative and hospitalization time in older patients with femur fractures. Thus, the pandemic has affected the care of fractures of the proximal femur in older adults, which reinforces the need to adopt measures to reduce complications and mortality. Level of Evidence II, Retrospective Study.

Impact of COVID-19 first wave on the in-hospital length of stay of operated proximal femur fracture patients in an industrial hospital in Eastern India

Objective:

The objective of this article is to study the impact of coronavirus disease 2019 (COVID-19) pandemic first wave on the in-hospital length of stay of operated proximal femur fractures.

Materials and Methods:

A retrospective analysis of data collected through the electronic record system of the hospital, after applying inclusion and exclusion criteria, was done. The data were collected from the pre-pandemic, early part first wave and later part first wave of COVID-19 pandemic to calculate the average preoperative stay (POS) and total length of stay (LOS) of operated proximal femur fracture patients. Also, a sub-analysis of POS and LOS was done as per age (male/female), sex (<60/≥60 years) and fracture subtype (intertrochanteric, neck of femur and subtrochanteric fracture) of the patients to study if any of these had a significant direct impact on the POS and LOS.

Results:

The LOS and POS were found to be significantly increased during early part of first wave of COVID-19 pandemic in comparison to the pre-pandemic era (13.6 ± 7.7 days vs. 11.1 ± 5.7 days). The later part of the first wave of the pandemic however saw the LOS and POS to return to near pre-pandemic values, although still remaining higher.

Conclusion:

The study highlights that unpreparedness during the early part of the unprecedented pandemic event leads to a significant increase in LOS of operated patients with its associated implications; however, prompt action by the government, hospital administration and hospital staff the LOS could be reduced to near pre-pandemic values in the later part of the first wave of the pandemic. Analysis of the causes that lead to a significant increase in LOS can help for better future management of similar events in future.

Geriatric Proximal Femur Fractures During the Covid-19 Pandemic - Fewer Cases, But More Comorbidities

Background:

The COVID-19 pandemic is challenging healthcare systems worldwide. This study examines geriatric patients with proximal femur fractures during the COVID-19 pandemic, shifts in secondary disease profile, the impact of the pandemic on hospitalization and further treatment.

Methods:

In a retrospective monocentric study, geriatric proximal femur fractures treated in the first six months of 2020 were analyzed and compared with the same period of 2019. Pre-traumatic status (living in a care home, under supervision of a legal guardian), type of trauma, accident mechanism, geriatric risk factors, associated comorbidities, time between hospitalization and surgery, inpatient time and post-operative further treatment of 2 groups of patients, aged 65-80 years (Group 1) and 80+ years (Group 2) were investigated.

Results:

The total number of patients decreased (70 in 2019 vs. 58 in 2020), mostly in Group 1 (25 vs. 16) while the numbers in Group 2 remained almost constant (45 vs. 42). The percentage of patients with pre-existing neurological conditions rose in 2020. This corresponded to an increase in patients under legal supervision (29.3%) and receiving pre-traumatic care in a nursing home (14.7%). Fractures were mostly caused by minor trauma in a home environment. In 2020, total number of inpatient days for Group 2 was lower compared to Group 1 (p = 0.008). Further care differed between the years: fewer Group 1 patients were discharged to geriatric therapy (69.6% vs. 25.0%), whereas in Group 2 the number of patients discharged to a nursing home increased.

Conclusions:

Falling by elderly patients is correlated to geriatric comorbidities, consequently there was no change in the case numbers in this age group. Strategic measures to avoid COVID-19 infection in hospital setting could include reducing the length of hospital stays by transferring elderly patients to a nursing home as soon as possible and discharging independent, mobile patients to return home.

Impact of COVID-19 on Key Performance Indicators of the National Hip Fracture Database and the Management of Hip Fracture Patients

Background: A hospital's performance regarding the management of hip fractures is based on six key performance indicators (KPIs) which are recorded onto the National Hip Fracture Database (NHFD). The aim of this study was to assess the overall impact of coronavirus disease 2019 (COVID-19) on the management and outcomes of hip fracture patients against a similar period in 2019 by utilizing the KPIs.

Method: Retrospective data collection of hip fracture patients during a six-week (pre-COVID) period in 2019 and a six-week (COVID-19) period in a single orthopedic unit. The following parameters were compared; patient age, time to theater, surgeon operating time, total time in the operating room, time from ward to recovery, time from hospital presentation to theater, and total time from presentation to hospital discharge.

Results: Some 38 patients in the pre-COVID-19 period vs. 27 patients with hip fractures in the COVID-19 period were included in the study. Time from diagnosis to theater and surgeon operating time were similar in both groups. The mean length of stay was 9.3 days vs. a mean of 31.34 days (p = 0.0004) in the COVID-19 and pre-COVID-19 groups respectively. A 30-day mortality was 22.2% (n = 6) in the COVID-19 group vs. 5.3% (n = 2) in the pre-COVID-19 group.

Conclusion: Our study demonstrates that the combination of surgical stress and COVID-19 leads to higher mortality rates. Our hospital’s structural reorganization during the pandemic has shown progress in achieving important KPIs and improved short-term outcomes for hip fracture and trauma patients.

Neck of Femur Fractures in the First Eight Months of the COVID-19 Pandemic: A UK Systematic Review and Meta-Analysis

Neck of femur (NOF) fracture patients have significant 30-day mortality. The incidence of NOF fractures remained high during the coronavirus disease 2019 (COVID-19) pandemic in the United Kingdom. Consequently, numerous cases were complicated with concurrent severe acute respiratory syndrome coronavirus 2 infection. We performed a systematic review and meta-analysis of all studies from the United Kingdom related to NOF fractures and 30-day mortality outcomes during the pandemic.   A systematic review and meta-analysis was performed and reported as per the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently searched on Medline for studies that were published between the 1st of March 2020 and the 1st of November 2020 in the United Kingdom. The following outcomes were compared: 30-day mortality, time to surgery, and anaesthetic risk.   A total of five articles were included in this review. In total, 286 patients with NOF fractures and COVID-19 infection were identified, with 30-day mortality ranging from 30.5% to 50% (odds ratio = 6.02; 95% confidence interval = 4.10-8.85; χ2 = 4.82; I2 = 58%). Increased time to surgery due to COVID-19-related delays was also noted for the majority of patients in some studies. Mortality scores (Charlson Comorbidity Index, Nottingham Hip Fracture Score) failed to accurately predict the mortality risk. Concurrent infection of COVID-19 in patients with NOF fractures increases the 30-day mortality sixfold compared to the COVID-19-negative group. Efforts should be made to optimise time to surgery as well as consideration of postoperative care in higher dependency units. Future updates in mortality predicting scores should include COVID-19 infection as a significant factor.

Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

OBJECTIVES

Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.

SETTING

Prospective, international, multicentre, observational cohort study.

PARTICIPANTS

Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).

PRIMARY OUTCOME

30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.

RESULTS

This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).

CONCLUSIONS

Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.

TRIAL REGISTRATION NUMBER

NCT04323644.

Thirty-Day Mortality for Proximal Femoral Fractures Treated at a U.K. Elective Center with a Site-Streaming Policy During the COVID-19 Pandemic

COVID-19 led to the reconfiguration of U.K. orthopaedic trauma services because surgical capacity was threatened in acute centers. We report the 30-day mortality of proximal femoral fractures in older adults treated at an elective orthopaedic center.

SARS-CoV-2 outbreak impact on a trauma unit

BACKGROUND

From February 2020 onwards, our country has been hit by the coronavirus severe acute respiratory syndrome-2 (SARS-CoV-2) infection. At a glance, hospitals became overrun and had to reformulate all the assistance guidelines, focusing on the coronavirus disease 2019. One year after the start of the pandemic, we present the results of a morbimortality study.

AIM

To analyze how our department was affected by the outbreak in terms of morbimortality, and to analyze demographic data, admission to hospital-related data, and subgroups analyses for patients with hip fractures and polytrauma.

METHODS

We designed a study comparing data from patients who were admitted to our unit due to a lower limb fracture or a high energy trauma during the pandemic (from March to April 2020) to those admitted during the same period in 2019 before the pandemic. during the pandemic situation. Both cohorts completed a minimum of 6 mo of follow-up.

RESULTS

The number of patients admitted to hospital in 2020 was nearly half of those in 2019. Hip fractures in the elderly represented 52 out of 73 of the admitted patients. Twenty patients had a positive test result for SARS-CoV-2 infection. Patients with SARS-CoV-2 infection were admitted to the hospital for a longer time than the non-infected (P < 0.001), and had a higher mortality rate during hospitalization and follow-up (P = 0.02). Patients with a hip fracture associated with a severe respiratory syndrome were mostly selected for conservative treatment (P = 0.03).

CONCLUSION

Mortality and readmission rates were higher in the 2020 cohort and during follow-up, in comparison with the cohort in 2019.

Epidemiology and Clinical Outcomes of Foot and Ankle Trauma During the First Wave of the COVID-19 Pandemic in the New York Metropolitan Area

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel respiratory virus that has rapidly changed the practice of medicine. The authors sought to evaluate the clinical presentation and clinical outcomes of patients presenting with foot and ankle (F&A) trauma to the emergency department during the first wave of the pandemic. The authors retrospectively studied all patients who presented to an emergency department within their multicenter institution during the first wave of the pandemic in their region from March 1 to June 30, 2020, with F&A trauma. They compared this cohort with a matched control group of patients who presented the prior year. Demographics, perioperative factors, coronavirus disease 2019 (COVID-19) polymerase chain reaction testing/positivity rates, 30-day readmissions, and 30-day mortalities were collected and analyzed. During the pandemic, the authors saw a 62.0% decrease in the total number of patients presenting with F&A trauma. Patients who presented during the pandemic were significantly older and a greater proportion were male. There was a greater proportion of ankle fractures, fewer ankle sprains, and more open fractures presenting during the pandemic. A greater proportion of patients presenting to the emergency department were admitted (18.2% vs 12.5%). The 30-day readmission (n=13 [5.8%] vs n=38 [9.3%]) and mortality (n=4 [1.8%] vs n=3 [0.7%]) rates for admitted patients were similar (P=.114 and P=.232, respectively). The authors found that 9.6% of patients who presented had a positive COVID-19 polymerase chain reaction test result and that these patients had 20% mortality and readmission rates. [Orthopedics. 2021;44(5):313-319.].

Diagnosis and Management of Osteoporosis During COVID-19: Systematic Review and Practical Guidance

It is acknowledged that the COVID-19 pandemic has caused profound disruption to the delivery of healthcare services globally. This has affected the management of many long-term conditions including osteoporosis as resources are diverted to cover urgent care. Osteoporosis is a public health concern worldwide and treatment is required for the prevention of further bone loss, deterioration of skeletal micro-architecture, and fragility fractures. This review provides information on how the COVID-19 pandemic has impacted the diagnosis and management of osteoporosis. We also provide clinical recommendations on the adaptation of care pathways based on experience from five referral centres to ensure that patients with osteoporosis are still treated and to reduce the risk of fractures both for the individual patient and on a societal basis. We address the use of the FRAX tool for risk stratification and initiation of osteoporosis treatment and discuss the potential adaptations to treatment pathways in view of limitations on the availability of DXA. We focus on the issues surrounding initiation and maintenance of treatment for patients on parenteral therapies such as zoledronate, denosumab, teriparatide, and romosozumab during the pandemic. The design of these innovative care pathways for the management of patients with osteoporosis may also provide a platform for future improvement to osteoporosis services when routine clinical care resumes.

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.

Characteristics and clinical outcomes of hip fracture patients during the first lockdown of COVID-19, lessons learnt: A retrospective cohort analysis

BACKGROUND

The management of hip fracture patients has been challenging across the UK in the wake of emergency coronavirus disease 2019 guidelines.

AIMS

This retrospective, observational cohort study analyses the impact of the first lockdown during the early part of the coronavirus disease 2019 pandemic on the management of hip fracture patients at a district general hospital in the UK.

METHODS

Comparative analysis to assess hip fracture patients treated at this Trust between 1 April to 31 May 2019 and 1 April to 31 May 2020 was undertaken. The primary outcome measures appraised were 30 and 60-day mortality and the secondary outcome measure included time to surgery.

RESULTS

There was a higher 30 and 60-day mortality rate in the first lockdown period at 8.1% and 13.5%, respectively, compared to 1.96% and 5.88% in 2019. A significantly lower proportion of hip fracture patients at 59.46% were operated within the 36h target time frame during the first lockdown.

CONCLUSION

In our Trust, hip fractures were treated as obligatory injuries. However, the mortality was higher in the 2020 cohort with a significant reduction in patients achieving the recommended '36 hours' time to surgery target and accruement of Best Practice Tariff. Enhanced infection control strategies have prepared us for the future.

Impact of COVID-19 on Orthopaedic Care and Practice: A Rapid Review

INTRODUCTION

The COVID-19 pandemic has led to a large body of literature regarding the impact of COVID-19 on orthopaedic care and practice. This rapid review aims to synthesize this published literature to give the orthopaedic fraternity an overview about the best practices that need to be followed during this period.

METHODOLOGY

A rapid review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for rapid reviews on the impact of COVID-19 on orthopaedic care and practice. A Pubmed search was done to identify all literature related to the impact of COVID-19 on orthopaedic care and practice, published between December 2019 and October 2020 using a predefined search strategy. The final review included 375 peer-reviewed articles addressing the objectives.

RESULTS

The majority of articles were expert opinions ( 37.1%) and narrative reviews (13.1%). There were 17.3% retrospective studies and 2.1% prospective studies with only one randomized control trial and ten systematic reviews.  83.8% of articles had levels of evidence IV and V, 79.5% of the articles were published in core-orthopaedic journals. Maximum publications were from the United States of America (31.7%), followed by India (11.5%). European countries together contributed to  32.0% of all publications.

CONCLUSION

COVID-19 has had a significant impact on all aspects of orthopaedic care and practice. The pandemic has affected outpatient clinics, emergency and elective surgery, rehabilitation, resident training, personnel management, use of personal protective equipment, telemedicine and all sub-specialities of orthopaedics. Orthopaedic practice will require the incorporation of new technologies, restructuring of health systems and reorganizing of training programs for optimal patient care. There would also be a need for frequent review of emerging literature to provide evidence-based guidelines to the orthopaedic fraternity which will not only help in mitigation of transmission of disease but also ensure continuity of optimum patient care.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00354-0.

[Thirty-day mortality in patients with a proximal femur fracture during the COVID-19 pandemic in Biscay (Basque Country).]

Objectives

Compare 30-day mortality rate following a proximal femur fracture (PFF) and SARS-CoV-2 infection versus a PFF and no SARS-CoV-2 infection.

Design

Retrospective comparative study.

Setting

Three university hospitals in Biscay province (Basque Country, Spain). Patients: 77 patients over 65 years-old with PFF (AO 31-A and 31-B).

Intervention

Study conducted between 9 March and 15 April 2020. The COVID-19 group included only patients with SARS-CoV-2 infection, confirmed by a positive RT-PCR test.

Main outcome measurements

30-day mortality rate and risk factors for mortality.

Results

Of a total 77 patients, 10 were diagnosed with SARS CoV-2 infection. Mean age was 85 years. Patients with SARS-Cov-2 infection had higher BMI (29.53 kg/m²) compared to patients without infection (24.09 kg/m²) (p = 0.001). No significant differences were found between both groups in terms of the Charlson Comorbidity Index, ASA score, use of oral anticoagulants or presence of cognitive impairment. Seven of the 10 patients in the COVID-19 group developed (viral) pneumonia, as compared to one single case (1/67) of (bacterial) pneumonia in the control group (p < 0.001). Thirty-days mortality was higher (p = 0.03) in COVID-19 patients (40%) than in those in the control group (11.9%). In the multivariate analysis, age ≥91 years-old, ASA class IV and BMI >25 kg/m² were significant predictors of 30-day mortality. All deaths in the COVID-19 group occurred while the patients were hospitalized.

Conclusions

SARS CoV-2 infection in patients with a PFF was seen to result in higher rates of early mortality, with COVID-19-related pneumonia being the leading direct cause of mortality.

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.

A Bibliometric Analysis of Fragility Fractures: Top 50

Background and Objectives: The population is aging and fragility fractures are a research topic of steadily growing importance. Therefore, a systematic bibliometric review was performed to identify the 50 most cited articles in the field of fragility fractures analyzing their qualities and characteristics. Materials and Methods: From the Core Collection database in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to fragility fractures were identified in February 2021 using a multistep approach. Year of publication, total number of citations, average number of citations per year since year of publication, affiliation of first and senior author, geographic origin of study population, keywords, and level of evidence were of interest. Results: Articles were published in 26 different journals between 1997 and 2020. The number of total citations per article ranged from 12 to 129 citations. In the majority of publications, orthopedic surgeons and traumatologists (66%) accounted for the first authorship, articles mostly originated from Europe (58%) and the keyword mostly used was “hip fracture”. In total, 38% of the articles were therapeutic studies level III followed by prognostic studies level I. Only two therapeutic studies with level I could be identified. Conclusions: This bibliometric review shows the growing interest in fragility fractures and raises awareness that more high quality and interdisciplinary studies are needed.

Rehabilitation guidance for hip fracture patients during the COVID-19 pandemic using chat software: A new model

BACKGROUND

Hip fractures are serious fractures for the elderly. The rehabilitation of patients with hip fractures has been greatly affected by the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE

We have piloted a new model for tracking patients and providing rehabilitation guidance that uses WeChat. The purpose of this study is to explore the role of chat software in rehabilitation guidance for hip fracture patients during COVID-19.

METHODS

Patients treated for hip fractures from February 1 to April 30, 2020 were randomly divided into a control group and an observation group. The control group was given conventional discharge guidance, while the observation group also followed up the patients using WeChat to guide the exercise. Satisfaction, the Harris Hip Score, complications and the mortality of the two groups after discharge were compared.

RESULTS

The incidence of complications and mortality in the observation group were significantly lower than in the control group: p= 0.022 and p= 0.048, respectively. The Harris Hip Score and satisfaction were significantly better than the control group's: p= 0.000 and p= 0.007, respectively.

CONCLUSION

During the COVID-19 pandemic, it is very helpful to use WeChat software or other social software with similar functions (such as WhatsApp and Facebook) to guide the rehabilitation of hip fractures.

Incidence of COVID-19 After Nonelective Hip and Knee Surgery During the Peak of the Pandemic: The New Jersey Experience

In an attempt to preserve essential equipment and health care system capacity and slow the spread of coronavirus disease 2019 (COVID-19) infection, Governor Murphy suspended all elective surgeries performed in New Jersey from March 27, 2020, through May 25, 2020. The objective of this study was to determine the incidence of postoperative COVID-19 infection following nonelective hip and knee surgery during the peak of the COVID-19 pandemic in New Jersey during this time. A retrospective cohort of 149 patients who underwent nonelective hip and knee surgery from March 27, 2020, through May 25, 2020, at 2 institutions was identified. The cohort was divided into hip fracture and non-fracture patients to compare the postoperative experience of these patient populations. The primary outcome was the incidence of postoperative COVID-19 infection diagnosed via severe acute respiratory syndrome coronavirus 2 nasopharyngeal real-time reverse transcription polymerase chain reaction. Secondary outcomes included length of stay, discharge disposition, postoperative complications, and mortality rate. A total of 149 patients underwent nonelective hip and knee surgeries, including 76 hip fracture cases and 73 nonelective hip and knee arthroplasty cases. A postoperative diagnosis of COVID-19 was made for 5 (6.6%) of 76 hip fracture patients, and 2 of the 5 died secondary to COVID-19. There were no infections in the arthroplasty cohort. This study describes a low incidence of COVID-19 infection after nonelective hip and knee surgery during the surge of the COVID-19 pandemic in New Jersey. Patients who underwent hip fracture surgery had an increased incidence of postoperative COVID-19 infection. [Orthopedics. 2021;44(3):180-186.].

Covid-19 orthopedic trauma patients characteristics and management during the first pandemic period: report from a single institution in Italy

Purpose

COVID-19 disease is a declared pandemic, affecting all aspects of healthcare, including orthopedics. The aim of this study is to describe the COVID-19 orthopedic trauma patients characteristics and management in a dedicated Orthopedic and Traumatology Hospital in Italy during the first pandemic period.

Material and methods

A cohort of 25 consecutive patients with suspected or confirmed COVID-19 infection were retrospectively analyzed. Health system rearrangement, patients’ clinical presentation, diagnostic tools role, laboratory finding, treatment and outcomes were evaluated.

Results

Health system rearrangement was fast. There was no clear prevalence of comorbidity or surgery type between confirmed and suspected COVID-19 cases. Nine positive swabs tests and 14 cases with only suspected CT scan findings were recorded. Several laboratory changes have been reported since the onset of symptoms: anemia, leukocytosis, lymphopenia, coagulation abnormalities, alkaline phosphatase, liver enzymes and C-reactive protein alterations. Nineteen patients were treated by oxygen supplement, three patients were administered antivirals, eight antibiotic therapy, and nine hydroxychloroquine. The number of discharges reported in this study was greater than 52% and the number of deaths reached 20%.

Conclusion

To our experience, the development of patient management algorithms allows the differentiation of the clinical pathways of negative and suspected/positive patients, reducing exposure, and virus spreading. The execution of swabs on all patients allows an early diagnosis and a more adequate management. Considering the different therapy patterns used, there were no significant differences, but anti-thromboembolic prophylaxis administered to all the orthopedic patients may have contributed to complications and mortality rates reduction.

30-Day Mortality Rate in Hip Fractures Among the Elderly with Coexistent COVID-19 Infection: A Systematic Review

PURPOSE

Hip fractures in the elderly require a multi-disciplinary approach and are associated with increased morbidity and mortality. The current COVID-19 pandemic has affected substantially this high-risk population group. This present review was done to ascertain whether or not the pandemic has affected the 30-day mortality and outcomes of hip fracture in the elderly.

RESEARCH QUESTION

Does the coexistence of COVID-19 infection and hip fractures in the elderly increase the mortality rates?

METHODOLOGY

A systematic review and meta-analysis were conducted using three databases (PubMed, EMBASE and SCOPUS) to compare the mortality rates between COVID-19 positive/suspect and COVID-19 negative patients. The secondary outcomes included comparison of in-hospital mortality, complication rate and length of hospital stay. Risk of bias assessment was done using the MINORS tool.

RESULTS

The present review included 20 studies. Primary outcome: A significantly higher 30 day mortality rate was seen in COVID-19 positive/suspect patients with an Odds ratio of 6.09 (95% CI 4.75-8.59, p < 0.00001). Secondary outcome: We observed significantly higher rates of inpatient mortality [OR 18.22, (95% CI 7.10-46.75], complication rate (OR 9.28, 95% CI 4.46-19.30), and length of hospital stay (MD: 4.96, 95% CI 2.86-7.05) in COVID-19 positive/suspect patients as compared to COVID-19 negative patients.

CONCLUSION

COVID-19 has deteriorated the outcomes in elderly patients with hip fractures and associated with higher rates of mortality in the short term. A multidisciplinary approach is needed to contain this "pandemic within a pandemic" and improve the overall outcome to survival.

COVID-19 among patients with orthopedic surgery: our experience from the Middle East

Background

We report our experiences with COVID-19 in one of the largest referral orthopedic centers in the Middle East and aimed to describe the epidemiology and clinical characteristics of these patients.

Methods

During February 20 and April 20, 2020, patients who underwent orthopedic surgery and healthcare staff who were in contact with these patients were screened for COVID-19. To identify patients who were in the incubation period of COVID-19 during their hospital stay, all patients were tested again for COVID-19 4 weeks after discharge.

Results

Overall, 1244 patients underwent orthopedic surgery (1123 emergency and 121 elective) during the study period. Overall, 17 patients were diagnosed with COVID-19 during hospital admission and seven after discharge. Among the total 24 patients with COVID-19, 15 were (62.5%) males with a mean (SD) age of 47.0±1.6 years old. Emergency surgeries were performed in 20 (83.3%) patients, and elective surgery was done in the remaining 4 patients which included one case of posterior spinal fusion, spondylolisthesis, acromioclavicular joint dislocation, and one case of leg necrosis. A considerable number of infections occurred in patients with intertrochanteric fractures (n=7, 29.2%), followed by pelvic fractures (n=2, 8.3%), humerus fractures (n=2, 8.3%), and tibial plateau fractures (n=2, 8.3%). Fever (n=11, 45.8%) and cough (n=10, 37.5%) were the most common symptoms among patients. Laboratory examinations showed leukopenia in 2 patients (8.3%) and lymphopenia in 4 (16.7%) patients. One patient with a history of cancer died 2 weeks after discharge due to myocardial infarction.

Among hospital staff, 26 individuals contracted COVID-19 during the study period, which included 13 (50%) males. Physicians were the most commonly infected group (n = 11), followed by operation room technicians (n = 5), nurses (n = 4), and paramedics (n = 4).

Conclusions

Patients who undergo surgical treatment for orthopedic problems, particularly lower limb fractures with limited ambulation, are at a higher risk of acquiring COVID-19 infections, although they may not be at higher risks for death compared to the general population. Orthopedic surgeons in particular and other hospital staff who are in close contact with these patients must be adequately trained and given appropriate personal protective equipment during the COVID-19 outbreak.

Clinical Activities, Contaminations of Surgeons and Cooperation with Health Authorities in 14 Orthopedic Departments in North Italy during the Most Acute Phase of Covid-19 Pandemic

Background: From 10 March up until 3 May 2020 in Northern Italy, the SARS-CoV-2 spread was not contained; disaster triage was adopted. The aim of the present study is to assess the impact of the COVID-19-pandemic on the Orthopedic and Trauma departments, focusing on: hospital reorganization (flexibility, workload, prevalence of COVID-19/SARS-CoV-2, standards of care); effects on staff; subjective orthopedic perception of the pandemic. Material and Methods: Data regarding 1390 patients and 323 surgeons were retrieved from a retrospective multicentric database, involving 14 major hospitals. The subjective directors' viewpoints regarding the economic consequences, communication with the government, hospital administration and other departments were collected. Results: Surgical procedures dropped by 73%, compared to 2019, elective surgery was interrupted. Forty percent of patients were screened for SARS-CoV-2: 7% with positive results. Seven percent of the patients received medical therapy for COVID-19, and only 48% of these treated patients had positive swab tests. Eleven percent of surgeons developed COVID-19 and 6% were contaminated. Fourteen percent of the staff were redirected daily to COVID units. Communication with the Government was perceived as adequate, whilst communication with medical Authorities was considered barely sufficient. Conclusions: Activity reduction was mandatory; the screening of carriers did not seem to be reliable and urgent activities were performed with a shortage of workers and a slower workflow. A trauma network and dedicated in-hospital paths for COVID-19-patients were created. This experience provided evidence for coordinated responses in order to avoid the propagation of errors.

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.

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.

COVID-19 pandemic did not affect emergency theatre patient demographic and length of stay in the first phase of UK countrywide lockdown in a district general hospital

INTRODUCTION

We aim to identify any changes in outcome for patients undergoing nonelective surgery at the start of the UK pandemic in our district general hospital. This was a single-centre retrospective cohort review of a UK district general hospital serving a population of over 250,000 people.

METHODS

Participants were all patients undergoing a surgical procedure in the acute theatre list between 23 March to 11 May in both 2019 and 2020. Primary outcome was 90-day postoperative mortality. Secondary outcomes include time to surgical intervention and length of inpatient stay.

RESULTS

A total of 132 patients (2020) versus 141 (2019) patients were included. Although overall 90-day postoperative mortality was higher in 2020 (9.8%) compared with 2019 (5.7%), this difference was not statistically significant (p=0.196). In 2020, eight patients tested positive for COVID-19 either as an inpatient or within 2 weeks of discharge, of whom five patients died. Time to surgical intervention was significantly faster for NCEPOD (National Confidential Enquiry into Patient Outcome and Death) code 3 patients in 2020 than in 2019 (p=0.027). There were no significant differences in mean length of inpatient stay.

CONCLUSIONS

We found that patients were appropriately prioritised using NCEPOD classification, with no statistically significant differences in 90-day postoperative mortality and length of inpatient stay compared with the 2019 period. A study on a larger scale would further elucidate the profile and outcomes of patients requiring acute surgery to generate statistical significance.

Early mortality outcomes of patients with fragility hip fracture and concurrent SARS-CoV-2 infection : a systematic review and meta-analysis

AIMS

Hip fracture is a common condition of the older, frailer person. This population is also at risk from SARS-CoV-2 infection. It is important to understand the impact of coexistent hip fracture and SARS-CoV-2 for informed decision-making at patient and service levels.

METHODS

We undertook a systematic review and meta-analysis of observational studies of older (> 60 years) people with fragility hip fractures and outcomes with and without SARS-CoV-2 infection during the first wave of the COVID-19 pandemic. The primary outcome was early (30-day or in-hospital) mortality. Secondary outcomes included length of hospital stay and key clinical characteristics known to be associated with outcomes after hip fracture.

RESULTS

A total of 14 cohort and five case series studies were included (692 SARS-CoV-2 positive, 2,585 SARS-CoV-2 negative). SARS-CoV-2 infection was associated with an overall risk ratio (RR) for early mortality of 4.42 (95% confidence interval (CI) 3.42 to 5.82). Early mortality was 34% (95% CI 30% to 38%) and 9% (95% CI 8% to 10%) in the infected and noninfected groups respectively. Length of stay was increased in SARS-CoV-2 infected patients (mean difference (MD) 5.2 days (3.2 to 7.2)). Age (MD 1.6 years (0.3 to 2.9)); female sex (RR 0.83 (95% CI 0.65 to 1.05)); admission from home (RR 0.51 (95% CI 0.26 to 1.00)); presence of dementia (RR 1.13 (95% CI 0.94 to 1.43)); and intracapsular fracture (RR 0.89 (95% CI 0.71 to 1.11)) were not associated with SARS-CoV-2 infection. There were statistically, but not clinically, significantly greater Nottingham Hip Fracture Scores in infected compared with non-infected patients (MD 0.7 (0.4 to 0.9)).

CONCLUSION

SARS-CoV-2 infection is associated with worse outcomes after hip fracture. This is not explained by differences in patient characteristics. These data can be used to support informed decision-making and may help track the impact of widespread adoption of system-level and therapeutic changes in management of the COVID-19 pandemic. Cite this article: Bone Jt Open 2021;2(5):314-322.