Hip Fracture Management during the COVID-19 Pandemic in South Korea

BackgroundThe purpose of this study was to introduce a screening system for coronavirus disease 2019 (COVID-19), to evaluate the overall orthopedic management in hip fracture patients during the COVID-19 pandemic in South Korea, and to compare the surgical results in hip fracture patients during the COVID-19 pandemic with those of the previous year.MethodsHip fracture patients who visited emergency rooms were screened at the screening clinics before admission. The medical management was carried out with the medical staff wearing surgical masks, meticulous hand hygiene observed, and a minimum distance of 2 m between patients maintained. The demographics, operative parameters, and surgical results of patients treated during the pandemic were compared with those from the previous year.ResultsFrom January 2020 to July 21, 2020, 119 patients with hip fractures (33 men and 86 women) were admitted to our institution for surgical treatment. Five patients showed symptoms of pneumonia, but no patient was positive for COVID-19. The mortality rate during the study period was 4.2%, and none of the patients died due to COVID-19. The interval between admission and surgery and the length of hospital stay were significantly shorter (p = 0.008, p = 0.002) and the proportion of spinal anesthesia was greater in hip fracture patients during the COVID-19 pandemic compared to those from the previous year (p = 0.011).ConclusionsThe COVID-19 screening system for hip fracture patients has proven to be effective in preventing intrahospital spread of the disease. Hip fracture surgery performed during the COVID-19 pandemic has shown comparable results without any COVID-19 infection and COVID-19-related mortality.     

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

BACKGROUNDTimely intervention in hip fracture is essential to decrease the risks of perioperative morbidity and mortality. However, limitations of the resources, risk of disease transmission and redirection of medical attention to a more severe infective health problem during coronavirus disease 2019 (COVID-19) pandemic period have affected the quality of care even in a surgical emergency.AIMTo compare the 30-d mortality rate and complications of hip fracture patients treated during COVID-19 pandemic and pre-pandemic times.METHODSThe search of electronic databases on 1^st August 2020 revealed 45 studies related to mortality of hip fracture during the COVID-19 pandemic and pre-pandemic times. After careful screening, eight studies were eligible for quantitative and qualitative analysis of data.RESULTSThe pooled data of eight studies (n = 1586) revealed no significant difference in 30-d mortality rate between the hip fracture patients treated during the pandemic and pre-pandemic periods [9.63% vs 6.33%; odds ratio (OR), 0.62; 95%CI, 0.33, 1.17; P = 0.14]. Even the 30-d mortality rate was not different between COVID-19 non-infected patients who were treated during the pandemic time, and all hip fracture patients treated during the pre-pandemic period (OR, 1.03; 95%CI, 0.61, 1.75; P = 0.91). A significant difference in mortality rate was observed between COVID-19 positive and COVID-19 negative patients (OR, 6.99; 95%CI, 3.45, 14.16; P < 0.00001). There was no difference in the duration of hospital stay (OR, -1.52, 95%CI, -3.85, 0.81; P = 0.20), overall complications (OR, 1.62; P = 0.15) and incidence of pulmonary complications (OR, 1.46; P = 0.38) in these two-time frames. Nevertheless, the preoperative morbidity was more severe, and there was less use of general anesthesia during the pandemic time.CONCLUSIONThere was no difference in 30-d mortality rate between hip fracture patients treated during the pandemic and pre-pandemic periods. However, the mortality risk was higher in COVID-19 positive patients compared to COVID-19 negative patients. There was no difference in time to surgery, complications and hospitalization time between these two time periods.     

A scoping review on the changes in vascular surgical practice during the early phases of the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a profound effect on the delivery of vascular surgery to patients around the world. In order to conserve resources and reduce the risk of COVID-19 infection, many institutions have postponed or cancelled surgical procedures. In this scoping review, we aim to review current literature and recapitulate the significant changes in elective and emergency vascular surgery during the COVID-19 pandemic. We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. We included all articles that had reported the effects of the COVID-19 pandemic on elective or emergency vascular surgery. A total of 28 articles were included in this scoping review. We identified eight distinct themes that were relevant to our study topic. We report global, regional, and local data on vascular surgical cases. We also discuss the adoption of vascular surgery triage systems, emergence of global collaborative vascular surgery research groups, increased use of endovascular techniques and locoregional anesthesia, delayed presentation of vascular surgery conditions, and poorer outcomes of patients with chronic limb threatening ischemia. This scoping review provides a snapshot of the impact of the COVID-19 pandemic on elective and emergency vascular surgery.     

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

BackgroundConcerns 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.MethodsA 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.Results35 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].ConclusionThe 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.     

Impact of Covid-19 on kidney transplant and waiting list patients: Lessons from the first wave of the pandemic

BackgroundThe first wave of the Covid-19 pandemic resulted in a drastic reduction in kidney transplantation and a profound change in transplant care in France. It is critical for kidney transplant centers to understand the behaviors, concerns and wishes of transplant recipients and waiting list candidates.MethodsFrench kidney patients were contacted to answer an online electronic survey at the end of the lockdown.ResultsAt the end of the first wave of the pandemic in France (11 May 2020), 2112 kidney transplant recipients and 487 candidates answered the survey. More candidates than recipients left their home during the lockdown, mainly for health care (80.1% vs. 69.4%; P < 0.001). More candidates than recipients reported being exposed to Covid-19 patients (2.7% vs. 1.2%; P = 0.006). Many recipients and even more candidates felt inadequately informed by their transplant center during the pandemic (19.6% vs. 54%; P < 0.001). Among candidates, 71.1% preferred to undergo transplant as soon as possible, 19.5% preferred to wait until Covid-19 had left their community, and 9.4% were not sure what to do.ConclusionsDuring the Covid-19 pandemic in France, the majority of candidates wished to receive a transplant as soon as possible without waiting until Covid-19 had left their community. Communication between kidney transplant centers and patients must be improved to better understand and serve patients’ needs.     

Risk of Covid-19 infection after resection of high grade transitional cell carcinoma with renal impairment

Introduction and importanceCovid-19 pandemic has had huge impact on health care system and put the health care system under strain, so efforts made to minimize the elective surgeries however some surgeries especially those for high risk malignant tumors cannot be postponed.The aim of this case report is to highlight the importance of screening cancer patients and those with co-morbidities such as renal impairment for Covid-19 and encouraging them to get vaccinated before undergoing elective surgeries.Case presentationWe report a case of an 80 year old male patient with renal impairment who developed Covid-19 infection after transurethral resection of high grade transitional cell carcinoma of urinary bladder.Clinical discussionAlthough intra-hospital contagion of Covid-19 is not rare, increased risk of acquiring Covid-19 among cancer patient particularly if they have co-morbidities like renal impairment should be kept in mind and strict protective measures for Covid-19 for those patients should be done before, during and after the procedure.ConclusionWe theorized that patients with high grade transitional cell carcinoma of urinary bladder should be screened for Covid-19 and get vaccinated before the procedure.     

Digital health technologies for osteopaths and allied healthcare service providers: A scoping review

BackgroundDigital health technologies are poised to revolutionise the healthcare industry by improving accessibility to services and patient outcomes. The novel coronavirus disease-19 (COVID-19) pandemic has presented unprecedented challenges for the delivery of allied healthcare and has catalysed rapid adoption of telehealth. As such, allied healthcare consumers and providers stand to benefit from the capabilities of the digital health movement, ultimately justifying a scoping review of current and emerging technologies.ObjectiveTo provide decision makers with up-to-date information on the allied health applications of new and emerging digital health technologies; their evidence of efficacy, scope of use, and limitations.MethodsA scoping review of the literature was conducted, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. To synthesise original research, MEDLINE, CINAHL, and EMBASE databases were searched from 2010 to June 2020 and reference lists were examined for randomised control trials analysing the efficacy of these technologies in allied health applications.ResultsA total of 14 articles were included with a focus on common musculoskeletal conditions managed by allied health service providers. Studies were selected for data extraction after abstract and full-text screening by three independent reviewers. The results of this review indicate that telehealth technology effectively monitors and progresses patient care, while mobile health applications provide remote support and enable data collection.ConclusionEmerging trends suggest that digital technologies serve as promising adjuncts to allied healthcare. Further research is warranted regarding the safety and efficacy of digital health technologies in this context.     

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

IntroductionThe Coronavirus Disease 2019 (COVID-19) pandemic resulted in major disruption to hip fracture services. This frail patient group requires specialist care, and disruption to services is likely to result in increases in morbidity, mortality and long-term healthcare costs.AimsTo assess disruption to hip fracture services during the COVID-19 pandemic.MethodsA questionnaire was designed for completion by a senior clinician or service manager in each participating unit between April–September 2020. The survey was incorporated into existing national-level audits in Germany (n = 71), Scotland (n = 16), and Ireland (n = 16). Responses from a further 82 units in 11 nations were obtained via an online survey.ResultsThere were 185 units from 14 countries that returned the survey. 102/160 (63.7%) units reported a worsening of overall service quality, which was attributed predominantly to staff redistribution, reallocation of inpatient areas, and reduced access to surgical facilities. There was a high rate of redeployment of staff to other services: two thirds lost specialist orthopaedic nurses, a third lost orthogeriatrics services, and a quarter lost physiotherapists. Reallocation of inpatient areas resulted in patients being managed by non-specialised teams in generic wards, which increased transit of patients and staff between clinical areas. There was reduced operating department access, with 74/160 (46.2%) centres reporting a >50% reduction. Reduced theatre efficiency was reported by 135/160 (84.4%) and was attributed to staff and resource redistribution, longer anaesthetic and transfer times, and delays for preoperative COVID-19 testing and using personal protective equipment (PPE).ConclusionHip fracture services were disrupted during the COVID-19 pandemic and this may have a sustained impact on health and social care. Protection of hip fracture services is essential to ensure satisfactory outcomes for this vulnerable patient group.     

Mondor's disease of the breast: A cutaneous thromboembolic manifestation of Covid-19?

BackgroundMondor's disease is a rare disorder characterised by thrombosis of superficial veins within the subcutaneous tissue of the breast and other organs. While factors such as trauma, infection, physical exertion, breast cancer and breast surgery have been implicated, in the majority no cause is identified.PatientsTwenty patients presented with a clinical diagnosis of Mondor's disease to the Edinburgh Breast Services in 2020. We present the etiopathogenic data as well as clinical and imaging diagnostic findings.ResultsDuring 2020, the annual incidence of Mondor's disease, in the UK's largest breast unit, increased five-fold compared to data from the previous year. This variation in the frequency of cases corresponded to trends in the frequency of Covid-19 infection during the pandemic. None of the patients had diagnosed COVID and few had any known etiopathogenic causes for their Mondor's.ConclusionSeveral recent studies have provided evidence for links between Covid-19 and thromboembolic events. Isolated reports have proposed a link between Covid-19 and Mondor's disease of the penis. Here we present data on a large series of Mondor's disease of the breast supporting a link between breast Mondor's and Covid-19.     

Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era

BACKGROUNDHip fractures are the most common reason for inpatient orthopaedic trauma admission. Urgent surgical intervention for hip fractures has remained a clinical priority throughout the coronavirus disease 2019 (COVID-19) pandemic. Despite this, there is a paucity of clinical guidance addressing the informed consent process for hip fracture surgery in COVID-19 positive patients. This is of paramount medicolegal importance in a high-risk patient population.AIMTo quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery and provide clinicians with an evidence-based framework to establish an informed consent process.METHODSTwo hundred and fifty nine consecutive patients undergoing surgical intervention for hip fractures in four hospitals in the United Kingdom were recruited. 51 patients were confirmed positive for COVID-19. Predefined outcomes were analyzed over a 30-d postoperative period. COVID-19 positive and COVID-19 negative patients were compared after adjustment for confounding factors.RESULTSCOVID-19 positive patients had more intensive care admissions (27% vs 5%, P < 0.001), longer inpatient stays (median 23 d vs 9 d, P < 0.001) and a higher 30-d mortality (29% vs 10%, P = 0.001) than COVID-19 negative patients. Postoperative complications were evident in 74.5% of COVID-19 positive patients. 35.3% of COVID-19 positive patients suffered postoperative lower respiratory tract infections with 13.7% developing acute respiratory distress syndrome (ARDS) and 9.8% experiencing symptomatic thromboembolic events.CONCLUSIONThe COVID-19 pandemic has created uncertainty in the medical community worldwide and poses unique challenges in providing informed consent for surgery. COVID-19 positive patients undergoing hip fracture surgery should be consented for the additional risk of postoperative complications (including lower respiratory tract infection, ARDS, deep vein thrombosis and pulmonary embolism), increased requirement for intensive care admission, longer inpatient stay and higher risk of mortality. Further, clinicians must be transparent about the potential for unknown risks as research into the long-term surgical outcomes of COVID-19 positive patients continues to evolve.     

Are there benefits to maintaining Covid-19 pandemic pathways for the long-term? A surgical assessment unit based study

BackgroundThe Covid-19 pandemic has led to the introduction of conservative non-operative approaches to surgical management favouring community driven care. The aim of this study was to determine the effect of these pathways on patients attending a surgical assessment unit (SAU).MethodThis was a retrospective observational cohort study. We included all consecutive attendances to the SAU in April 2020 (Covid-19 period) and April 2019 (pre-Covid-19). The Covid-19 period saw a shift in clinical practice towards a more conservative approach to the management of acute surgical presentations. The primary outcome measure was 30-day readmission. The secondary outcome measures were length of hospital stay, inpatient investigations undertaken and 30-day mortality.ResultsA total of 451 patients were included. This represented 277 and 174 attendances in pre-Covid-19, and Covid-19 groups respectively. The rates of unplanned 30-day readmission rates in the Covid-19 and pre-Covid-19 periods were 16.7% and 12.6% respectively (P = 0.232). There were significantly fewer planned follow-ups in the Covid-19 (36.2%) compared to the pre-Covid-19 group (49.1%; P < 0.01; OR 1.7, 95% CI 1.15–2.51). There were no significant differences in length of hospital stay (P = 0.802), and 30-day mortality rate (P = 0.716; OR 1.9, 95% CI 0.38–9.54) between the two periods.ConclusionThere were no differences in 30-day readmission rates, length of hospital stay, and 30-day mortality with the changes to pathways. Our findings suggest the resource efficient conservative Covid-19 pathways could potentially continue long-term. However, further multi-centre studies with larger sample sizes and longer follow-up duration will be required to validate our findings.     

Hip fracture care during the 2020 COVID-19 first-wave: a review of the outcomes of hip fracture patients at a Scottish Major Trauma Centre

Background and Purpose of the StudyThis study reviewed whether the response to the Coronavirus (COVID-19) pandemic affected the care for hip fracture patients at a major trauma centre in Scotland during the first-wave lock-down period.MethodsAll patients referred to Orthopaedics with a hip fracture in a major trauma centre in Scotland were captured between 14 th March and 28 th May (11 weeks) in 2020 and 2019. Patients were identified using electronic patient records. The primary outcomes are time to theatre, length of admission and 30-day mortality. Secondary outcomes are COVID-19 prevalence, duration of surgery, proportion of patients to theatre within 36 hours and COVID-19 positive 30-day mortality from time of surgery. 225 patients were included: 108 from 2019 and 117 from 2020.The main findings30-day mortality was 3.7% (n=4) in 2019 and 8.5% (n=10) in 2020 (p=0.142). There was no statistical difference with time to theatre (p=0.150) nor duration of theatre (p=0.450). Duration of admission was reduced from 12 days to 6.5 days (p=<0.005). 4 patients tested positive for COVID-19 during admission, one 5 days after discharge, all underwent surgical management. 30-day mortality for COVID-19 positive patients during admission was 40%. COVID-19 prevalence of patients that were tested (n=89) was 5.62%.ConclusionsThis study has shown the care of hip fracture patients has been maintained during the COVID-19 pandemic. There is no statistically significant change in mortality, time to theatre, and duration of surgery, however, the patient’s admission duration was significantly less than the 2019 cohort.     

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

PurposeHip 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 QuestionDoes the coexistence of COVID-19 infection and hip fractures in the elderly increase the mortality rates?MethodologyA 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.ResultsThe 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.ConclusionCOVID-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.     

Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study

PurposeThe COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3–4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture.MethodsA multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for “fragility hip fractures” were included in the study. Patients’ 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27.ResultsA total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865–3.978).ConclusionHip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of “long-COVID” and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.     

Caring in a crisis: Understanding the stressors and uplifts for National Health Service frontline staff through the lens of clinical psychologists

The unprecedented public health crisis of the Covid-19 pandemic resulted in a significant challenge to the delivery of healthcare that has rarely been experienced before. The stress already faced by healthcare staff working in the National Health Service (NHS) has been further exacerbated during Covid-19, putting them at risk of adverse mental health outcomes. Through the lens of clinical psychologists who had provided support to frontline healthcare staff during the Covid-19 pandemic, this study aimed to better understand the stressors and uplifts healthcare staff experienced during Covid-19, the impact of these on the wellbeing of staff and patient care, and to examine the support needed to deal with the impact of a crisis. A qualitative study design using a combination of diaries followed by semi-structured interviews was utilised. Data was analysed using thematic analysis. The following five themes represented the stressors and uplifts experienced by NHS frontline healthcare staff during Covid-19, the impact on staff wellbeing and patient care: facing change; risks of working in the NHS environment; transcending the negatives; challenging professional values and haunted by patient deaths. The findings also highlight the importance of providing psychological support and suggest the need to continue to provide this support service to help NHS staff manage through subsequent waves of the pandemic. These findings can contribute towards both the management of the current Covid-19 pandemic and other similar crises in the future.     

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

PurposeHip 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.MethodsA 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.ResultsAfter 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.ConclusionsThere 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.     

MRI diagnosis of occult hip fractures

Background Most fractures of the proximal femur are easily diagnosed by conventional radiography. When the images are judged to be negative or equivocal and a clinical suspicion of fracture persists, another approach is to use magnetic resonance imaging (MRI) to help reach a diagnosis.

Methods In a prospective study running from November 1998 to December 2001, we registered all patients being examined by MRI who had had a negative or equivocal radiograph and where there was continued clinical suspicion of hip fracture.

Results 100 consecutive patients (67 women) were included, with an average age of 80 (37–100) years. The MRI examinations corresponded to 4% of the 2,350 patients admitted with hip trauma during the study period. 46 patients had a femoral neck or intertrochanteric fracture on MRI. 27 patients had other fractures. 18 had other findings on MRI, and 10 were interpreted as being negative, although one of these was a false negative. In a separate interobserver analysis, two experienced radiologists agreed on the diagnoses in 19/23 cases (kappa value 0.78). They agreed with a less experienced radiologist in 17/23 and 19/23 cases, respectively (kappa values 0.66 and 0.76).

Interpretation MRI is a useful tool for demonstration of occult hip fractures. In the absence of a hip fracture, another explanation for the patient’s pain and disability will often be given.     

Target Price Adjustment for Hip Fractures Is Not Sufficient in the Bundled Payments for Care Improvement Initiative

BackgroundUnder the Bundled Payments for Care Improvement (BPCI) initiative, the Centers for Medicare and Medicaid Services (CMS) adjusts the target price for total hip arthroplasty (THA) based upon the historical proportion of fracture cases. Concerns exist that hospitals that care for hip fracture patients may be penalized in BPCI. The purpose of this study is to compare the episode-of-care (EOC) costs of hip fracture patients to elective THA patients.MethodsWe reviewed a consecutive series of 4096 THA patients from 2015 to 2018. Patients were grouped into elective THA (n = 3686), fracture THA (n = 176), and hemiarthroplasty (n = 274). Using CMS claims data, we compared EOC costs, postacute care costs, and performance against the target price between the groups. To control for confounding variables, we performed a multivariate analysis to identify the effect of hip fracture diagnosis on costs.ResultsElective THA patients had lower EOC ($18,200 vs $42,605 vs $38,371; P < .001) and postacute care costs ($4477 vs $28,093 vs $23,217; P < .001) than both hemiarthroplasty and THA for fracture. Patients undergoing arthroplasty for fracture lost an average of $23,122 (vs $1648 profit for elective THA; P < .001) with 91% of cases exceeding the target price (vs 20% for elective THA; P < .001). In multivariate analysis, patients undergoing arthroplasty for fracture had higher EOC costs by $19,492 (P < .001).ConclusionPatients undergoing arthroplasty for fracture cost over twice as much as elective THA patients. CMS should change their methodology or exclude fracture patients from BPCI, particularly during the COVID-19 pandemic.     

Worsening Arthroplasty Utilization With Widening Racial Variance During the COVID-19 Pandemic

BackgroundElective arthroplasty surgery in the United States came to a near-complete halt in the spring of 2019 as a response to the COVID-19 pandemic. Racial disparity has been a long-term concern in healthcare with increased focus during the pandemic. The purpose of this study is to evaluate the effects of COVID-19 and race on arthroplasty utilization trends during the pandemic.MethodsWe used 2019 and 2020 Center for Medicare and Medicaid Service fee-for-service claims data to compare arthroplasty volumes prior to and during the COVID-19 pandemic. We compared overall arthroplasty utilization rates between 2019 and 2020 and then sought to determine the effect of race and COVID-19, both independently and combined.ResultsThere was a decrease in primary total knee arthroplasty (?28%), primary total hip arthroplasty (?14%), primary total hip arthroplasty for fracture (?2%), and revision arthroplasty (?14%) utilization between 2019 and 2020. The highest decrease in overall arthroplasty utilization was in the Hispanic population (34% decrease vs 19% decrease in the White population). We found that a non-White patient was 39.9% (P < .001) less likely to receive a total joint arthroplasty prior to COVID-19. The COVID-19 pandemic further exacerbated the pre-existing racial differences in arthroplasty utilization by decreasing the probability of receiving a total joint arthroplasty for non-White patient by another 12.9% (P < .001).ConclusionWe found an overall decreased utilization rate of arthroplasty during the COVID-19 pandemic with further decrease noted in all non-White populations. This raises significant concern for worsening racial disparity in arthroplasty caused by the ongoing pandemic.