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

Risk Factors of 120-Day Mortality Among Hip Fractures With Concomitant COVID-19 Infection

Background Hip fractures cause substantial morbidity and mortality worldwide, and the coronavirus disease 2019 (COVID-19) pandemic has only worsened the global burden. Increased 120-day mortality is well established in the literature among hip fractures with COVID-19. However, the risk factors associated with mortality have been poorly understood. We aimed to determine the risk factors associated with increased 120-day mortality among hip fractures with COVID-19. Methods Seventy patients with hip fractures with confirmed COVID-19 infection between March 2020 and December 2021 were included. Thirty-three patients who died within 120 days of admission were allotted to the non-survivor group and the rest 37 patients were allotted to the survivor group. Various parameters such as demographic variables, Nottingham Hip Fracture Score (NHFS), Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA), Abbreviated Mental Score Test (AMTS), National Early Warning Score (NEWS), fracture type, operation type, and delay in surgery were compared between the groups to determine the risk factors for increased mortality. Multivariate regression analysis was performed to know the independent association with increased mortality. Results A total of 33 patients died within 120 days giving the 120-day mortality rate of 47.1%. Baseline parameters such as ASA, AMTS on admission, NEWS on admission, and type of residence did not significantly affect mortality. The mean NHFS was significantly high in non-survivors (5.38 ± 1.52) compared to survivors (4.40 ± 1.75) (p < 0.001). Similarly, mean CCI was also significantly high in non-survivors (5.58 ± 1.74) compared to survivors (4.76 ± 2.29) (p < 0.001). A total of 70% (seven out of 10) of patients with delayed surgery of more than 36 hours from the admission died within 120 days of admission (p < 0.001). Mortality was significantly higher in patients who underwent internal fixation of fractures like a dynamic hip screw (DHS) or intramedullary (IM) nailing than in those who underwent hemiarthroplasty or total hip arthroplasty (THA). Post-operative parameters such as early mobilization and the multidisciplinary approach to review these patients made no difference to the mortality. Multivariate regression analysis of the parameters that made a significant difference in the mortality showed that delay in surgery and type of surgery (internal fixation) independently increased the mortality among these patients (p < 0.001). However, NHFS and CCI were not independently affecting the mortality among hip fractures with concomitant COVID-19. Conclusion The 120-day mortality rate among patients with hip fractures with concomitant COVID-19 was 47.1%. Delay in surgery of more than 36 hours and patients who underwent internal fixation were independent risk factors associated with increased mortality among these patients.

Direct Anterior versus Lateral Approach for Femoral Neck Fracture: Role in COVID-19 Disease

Background: During the COVID-19 emergency, the incidence of fragility fractures in elderly patients remained unchanged. The management of these patients requires a multidisciplinary approach. The study aimed to assess the best surgical approach to treat COVID-19 patients with femoral neck fracture undergoing hemiarthroplasty (HA), comparing direct lateral (DL) versus direct anterior approach (DAA). Methods: A single-center, observational retrospective study including 50 patients affected by COVID-19 infection (30 males, 20 females) who underwent HA between April 2020 to April 2021 was performed. The patients were allocated into two groups according to the surgical approach used: lateral approach and anterior approach. For each patient, the data were recorded: age, sex, BMI, comorbidity, oxygen saturation (SpO2), fraction of the inspired oxygen (FiO2), type of ventilation invasive or non-invasive, HHb, P/F ratio (PaO2/FiO2), hemoglobin level the day of surgery and 1 day post operative, surgical time, Nottingham Hip Fractures Score (NHFS) and American Society of Anesthesiologists Score (ASA). The patients were observed from one hour before surgery until 48 h post-surgery of follow-up. The patients were stratified into five groups according to Alhazzani scores. A non-COVID-19 group of patients, as the control, was finally introduced. Results: A lateral position led to a better level of oxygenation (p < 0.01), compared to the supine anterior approach. We observed a better post-operative P/F ratio and a reduced need for invasive ventilation in patients lying in the lateral position. A statistically significant reduction in the surgical time emerged in patients treated with DAA (p < 0.01). Patients within the DAA group had a significantly lower blood loss compared to direct lateral approach. Conclusions: DL approach with lateral decubitus seems to preserved respiratory function in HA surgery. Thus, the lateral position may be associated with beneficial effects on gas exchange.