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.     

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.     

The effect of COVID-19 pandemic on the care of fragility hip fracture patients in the United Kingdom. A case control study in a major trauma centre

IntroductionCoronavirus disease 2019 is a pandemic that forced a transformation in the services provided by the National Health Service in the United Kingdom. Fragility hip fractures account for over 65,000 cases per year in the elderly population. The study aims to assess the impact of the pandemic on fragility hip fractures.MethodsA retrospective data gather was performed to identify fragility hip fractures from the 23rd of March 2020 to the 13th of May 2020, and from the 23rd of March 2019 to the 13th of May 19. Two groups were formed and compared over their 30 day follow up.ResultsThe control group comprised of 97 patients, with a mean age of 82.1 years old (62–102 years) and M:F ratio of 38:59. The case group comprised of 102 patients, with a mean age of 82.3 years old (60–100 years) and a M:F ratio of 16:86. Significant differences between groups were identified for gender (p < 0.001), time to theatre (p = 0.002), length of stay (p < 0.001) and COVID-19 status (p = 0.001). In the Case group, association with mortality was found for male gender (p = 0.041), right side (p = 0.031) and COVID-19 positive test results (p = 0.011).ConclusionEarly surgical intervention is advocated wherever possible, and sufficient optimisation, prior to surgery whenever a COVID-19 positive patient is identified. A safe rehabilitation environment is paramount for recovery in this group of patients. Further studies are required to understand the effect of this pandemic on the fragility hip fractures.Level of evidenceLevel III: Retrospective case–control study.     

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.     

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.     

Impact of the COVID-19 Pandemic on Nephrology Fellow Training and Well-Being in the United States: A National Survey

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Impact of COVID-19 pandemic on the care of severe burns in Japan: Repeated survey of specialized burn care facilities

BackgroundThe spread of coronavirus disease 2019 (COVID-19), which began in 2020, has had a major impact on healthcare systems. The spread of COVID-19 has been reported to have affected the readiness to treat patients with burns worldwide. However, the existing reports have evaluated burn care status within a limited time period during the pandemic, and no report clarifies the change in the impact of infection status on burn care from the beginning of the pandemic to the present.MethodsJapanese Society for Burn Injuries–accredited burn care facilities were surveyed using questionnaires on April 9–23, 2020; June 23–July 6, 2020; July 9–21, 2021; and January 21–31, 2022. Differences between groups were evaluated using Friedman’s test or Bonferroni’s multiple comparison test, as appropriate.ResultsFrom the 103 facilities included in the study, we received 85, 55, 56, and 58 responses in the first, second, third, and fourth surveys, respectively. We could continuously observe 34 facilities. The rate of acceptance of patients with severe burns improved significantly over time (P < 0.05). However, in the second and third surveys, there was an increase in the number of respondents who did not accept patients with burns irrespective of COVID-19 status.ConclusionsThe number of facilities treating patients with burns who have COVID-19 is increasing; however, COVID-19 care may negatively impact routine burn care. It is necessary to continuously examine medical resource allocation through methods such as information sharing by academic societies.     

IMPACT-Global Hip Fracture Audit: Nosocomial infection,risk prediction and prognostication,minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

AimsThis international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients.MethodsA multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1st March-31st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded.ResultsA total of 7090 patients were included, with a mean age of 82.2 (range 50–104) years and 4959 (69.9%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) were positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p = 0.001), residential care (OR 2.15, p < 0.001), inpatient fall (OR 2.23, p = 0.003), cancer (OR 0.63, p = 0.009), ASA grades 4 (OR 1.59, p = 0.008) or 5 (OR 8.28, p < 0.001), and longer admission (OR 1.06 for each increasing day, p < 0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p < 0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p < 0.001). Increasing age (HR 1.03, p = 0.028), male sex (HR 2.35, p < 0.001), renal disease (HR 1.53, p = 0.017), and pulmonary disease (HR 1.45, p = 0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.ConclusionThe prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher 30-day mortality risk.     

Accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity score and the Nottingham risk score in hip fracture patients in Sweden — A prospective observational study

Background

Little is known about accuracy of common risk prediction scores in elderly patients suffering from hip fractures. The objective of this study was to investigate accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) score, Portsmouth‐POSSUM (P‐POSSUM) score and the Nottingham Hip Fracture Score (NHFS) for prediction of mortality and morbidity in this patient group.

Methods

This was a prospective single centre observational study on 997 patients suffering out‐of‐hospital cervical, trochanteric or subtrochanteric fracture of the neck of the femur. Calibration and discrimination was assessed by calculating the ratio of observed to expected events (O:E) and areas under receiver operating characteristics curves (ROC).

Results

The 30‐day mortality was 6.2% and complications, as defined by POSSUM, occurred in 41% of the patients. Overall O:E ratios for POSSUM, P‐POSSUM and NHFS scores for 30‐day mortality were 0.90, 0.98, and 0.79 respectively. The models underestimated mortality in the lower risk bands and overestimated mortality in the higher risk bands. In contrast, POSSUM predicted morbidity well with O:E ratios close to unity in most risk bands. The areas under the ROC curves for the scoring systems was 0.60‐0.67.

Conclusion

The POSSUM score and NHFS show moderate calibration and poor discrimination in this cohort. The results suggest that mortality and morbidity in hip fracture patients are largely dependent on factors that are not included in these scores.     

The Impact of COVID-19 on Plastic Surgery Training in the United Kingdom,Canada and Australia—A Cross-Sectional Study

Background Surgical trainees worldwide have been thrust into a period of uncertainty, with respect to the implications COVID-19 pandemic will have on their roles, training, and future career prospects. It is currently unclear how plastic surgery trainees are being affected by COVID-19. This study examined the experience of plastic surgery trainees in Canada, the UK, and Australia to determine trainee roles during the early COVID-19 emergency response and how training changed during this time. Methods A cross-sectional survey-based study was designed for plastic surgery trainees in the UK, Canada and Australia. In total, 110 trainees responded to the survey. Statistical tests were conducted to determine differences in responses, based on year of training and country of residence. Results In total, 9.7% (10/103) of respondents reported being deployed to cover another service. There was a significant difference between redeployment based on country ( p = 0.001). Within the UK group, 28.9% of respondents were redeployed. For trainees not deployed, 95.5% (85/89) reported that there has been a reduction in operative volume. Ninety-seven (94.1%) respondents reported that there were ongoing teaching activities offered by their program. The majority of trainees (66.4%) were concerned about their training. There was a significant difference between overall concern and country ( p < 0.05). Conclusion In these unprecedented times, training programs in plastic surgery should be aware of the major impact that COVID-19 has had on trainees and will have on their training. The majority of plastic surgery trainees have experienced a reduction in surgical exposure but have maintained some form of regular teaching.     

Isolated and anxious: A qualitative exploration of the impact of the COVID-19 pandemic on individuals living with spinal cord injury in the UK

ObjectivePeople living with spinal cord injury (SCI) are often immunocompromised, and at increased risk of respiratory infection. Given the restrictions in response to the COVID-19 pandemic, those with SCI may be at increased risk of health deterioration, though how this is experienced is poorly understood. This study explored the experiences of people living with SCI during the COVID-19 pandemic.DesignParticipants completed an online survey consisting of demographic questions, and open-ended qualitative questions pertaining to their experiences during the pandemic. Thematic analysis was utilized for the analytical approach.SettingCommunity-based sample in the UK.ParticipantsParticipants were recruited via social media outlets of UK-based SCI-specific support charities, and snowball sampling (N = 42, F = 34, M = 8).ResultsKey themes included: (1) lost access to health services and support, capturing concerns surrounding barriers to healthcare and rehabilitation, which intensified secondary consequences of SCI such as spasm and pain; (2) health anxiety, which was perpetuated by perceived heightened vulnerabilities to respiratory complications; (3) social isolation, with significantly reduced social contact, even with care providers, compounding health experiences.ConclusionPeople living with SCI during the COVID-19 pandemic experienced a variety of personal physical, psychological, and social challenges, each of which could disrupt daily functioning and quality of life. Increased utilization of telehealth is recommended to support continued engagement in rehabilitation, and foster connection and community amongst others with SCI and health professionals.