Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions

BackgroundWarfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear.MethodsThis was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the “wait and watch” method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery.ResultsThere were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.ConclusionsPartial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.     

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis

Purpose: By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality, dislocation, infection, reoperation rate, and thromboembolic event. Methods: The PubMed, EMBASE databases, and Cochrane library were systematically searched from the inception dates to April 1, 2020 for relevant randomized controlled trials in English language using the keywords: “total hip arthroplasty”, “hemiarthroplasty” and “femoral neck fracture” to identify systematic reviews and meta-analyses. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration’ stools, and discussed any disagreements. The third reviewer was consulted for any doubts or uncertainty. We derived risk ratios and 95% confidence intervals. Mortality was defined as the primary outcome. Secondary outcomes were other complications, dislocation, infection, reoperation rate, and thromboembolic event. Results: This meta-analysis included 10 studies with 1419 patients, which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation, infection rate, and thromboembolic event. However, there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up. Conclusion: Based on our results, we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.     

Does Surgeon Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review

Background

Surgeon volume has been identified as an important factor impacting postoperative outcome in patients undergoing orthopedic surgeries. With an absence of a detailed systematic review, we sought to collate evidence on the impact of surgeon volume on postoperative outcomes in patients undergoing primary total hip arthroplasty.

Equivalence of DOACS and LMWH for thromboprophylaxis after hip fracture surgery: Systematic review and meta-analysis

BackgroundPatients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF.Materials and MethodsWe searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH.ResultsThe search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25–1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding.ConclusionsMeta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH.     

Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database

BackgroundRegional clinical pathways, a new type of clinical pathway, are practiced with the aim of standardizing and optimizing medical care by cooperation among multiple medical institutions in a region. However, current evaluation of the effectiveness of regional clinical pathways for hip fracture, a major health problem requiring hospitalization for orthopedic surgery, is insufficient. This study aimed to determine the association between regional clinical pathways and postoperative hospital length of stay (LOS) among hip fracture patients. In particular, we focused on the variation in postoperative LOS of hip fracture patients among hospitals and the contribution of regional clinical pathways to this variation.MethodsUsing data from the Diagnosis Procedure Combination (DPC) database in Japan from April 2011 to March 2013, patients who were diagnosed with “fracture of head and neck of femur” (ICD10 code S72.0) or “pertrochanteric fracture” (S72.1) and received “bipolar hip arthroplasty” or “open reduction and internal fixation” were extracted. A total of 110,133 patients were included. Associations between regional clinical pathways and postoperative LOS were analyzed using cross-sectional analysis with multilevel regression models.ResultsHospitals that implemented a regional clinical pathway showed a significant reduction (13 days) in the postoperative LOS of hip fracture patients. We found a 16% inter-hospital variation in postoperative LOS, which might be explained by hospital-level implementation of regional clinical pathways. Application of regional clinical pathways at the patient level resulted in a 4-day decrease in postoperative LOS.ConclusionsImplementation of regional clinical pathways for hip fracture patients at the hospital level was associated with reduced postoperative LOS, regardless of whether or not pathways were implemented at the patient level. This suggests that regional clinical pathways are effective for patient care management in hospitals.     

Dislocation After Debridement,Antibiotics, and Implant Retention for Periprosthetic Joint Infections of the Hip

BackgroundDebridement, antibiotics, and implant retention (DAIR) is a common treatment option for hip periprosthetic joint infection (PJI). However, noninfectious outcomes of DAIR such as instability are not well reported. The purpose of this study was to evaluate risk factors for hip dislocation post-DAIR for PJI of both primary and revision total hip arthroplasty (THA).MethodsA retrospective chart review identified all patients who underwent DAIR of a primary or revision THA over a 20-year period with a minimum 1-year follow-up. A total of 151 patients met inclusion criteria, 19.9% of whom had a post-DAIR dislocation. Demographic and intraoperative variables were obtained. Patients who had modular components exchanged during DAIR to those with increased offset, increased “jump distance”, or a more stable acetabular liner were defined as patients who had “components exchanged to increase stability.” Predictors of hip dislocation post-DAIR were inserted into a multivariate linear regression.ResultsPost-DAIR dislocation rates were 16.3% in primary THAs and 25.4% in revision THAs. In patients who had “components exchanged to increase stability” during hip DAIR, there was at least an 11-fold reduction (1/odds ratio (OR), 0.09) in dislocation risk compared to patients who had no components altered during modular component exchange during hip DAIR (OR, 0.09; 95% confidence interval, 0.02-0.44; P < .001), while a 13-fold increased dislocation risk was seen in patients with a history of neuromuscular disease (OR, 13.45; 95% confidence interval, 1.73-104.09; P = .01).ConclusionsDuring DAIR of hip PJI, surgeons should consider prophylactically exchanging components to increase stability even if components appear stable intraoperatively.     

Urinary tract infection (UTI) at time of geriatric hip fracture surgery increases the risk of experiencing adverse 30-day outcomes

IntroductionPre-operative urinary tract infection (UTI) may be associated with a high rate of complications following surgeries. Few studies have investigated the clinical impact of a pre-operative UTI on post-operative outcomes following surgeries for hip-fracture in geriatric patients.MethodsThe 2015–2016 ACS-NSQIP database was queried for patients undergoing hip fracture surgery using CPT-Codes for Total Hip Arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). Only patients ≥65 years of age undergoing surgery due to a traumatic hip fracture were included in the study.ResultsOut of 31,621 patients undergoing surgical treatment for a hip fracture, 410 (1.3%) had UTI at the time of the surgery. Following adjusted logistic regression analysis, UTI present at the time of surgery was associated with a longer length of stay>5 days (OR 5.46 [95% CI 2.27–13.1]; p = 0.008), any complication (OR 1.33 [95% CI 1.49–1.63]; p = 0.007), infectious complications (OR 1.71 [95% CI 1.19–2.47]; p = 0.004), non-infectious complications (OR 1.28 [95% CI 1.04–1.58]; p = 0.021), 30-day unplanned re-operations (OR 1.96 [95% CI 1.25–3.06]; p = 0.003) and 30-day readmissions (OR 2.04 [95% CI 1.57–2.66]; p < 0.001). With regards to infectious complications, presence of a UTI at time of surgery was a significant independent predictor of sepsis (OR 2.44 [95% CI 1.24–4.80]; p = 0.010) and septic shock (OR 4.05 [95% CI 2.03–8.08]; p < 0.001).ConclusionsPatients undergoing hip-fracture surgery with a concurrent UTI at the time of surgery have more adverse 30-day outcomes as compared to hip fracture patients who do not present with a UTI. Despite adjustment for a delay in the time to surgery, the impact of UTI on post-operative outcomes remained significant. While it is difficult to eradicate a UTI in a non-elective population, the findings stress the need for clinical optimization and potential need for early recognition/management of UTI in patients who sustain a hip fracture to minimize the risk of adverse outcomes.     

Prognostic Role of Serum Albumin,Total Lymphocyte Count,and Mini Nutritional Assessment on Outcomes After Geriatric Hip Fracture Surgery: A Meta-Analysis and Systematic Review

BackgroundHip fracture is a significant health risk for older adults and malnutrition indicates hip fracture risk.MethodsWe evaluated whether nutrition status could predict clinical outcomes and mortality after hip fracture surgery in older adults. MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched for studies published until July 1, 2018, in patients with serum albumin or total lymphocyte count (TLC) at admission, nutritional status by Mini Nutritional Assessment (MNA), and in-hospital follow-up. Data extracted were analyzed using random-effects or fixed-effects models.ResultsNineteen studies with 34,363 adults aged 74-85 years receiving hip fracture surgery were eligible for inclusion. Among these studies, 13 were screened for low albumin, 4 were evaluated for TLC, and 4 for nutritional status by MNA. Hypoalbuminemia was significantly associated with higher total mortality and higher risk of in-hospital death (both P < .001). Low TLC and MNA results “at risk of malnutrition” (hazard ratio, 1.67; 95% confidence interval = 1.28-2.18) and “malnourished” nutritional status (hazard ratio, 2.65; 95% CI = 1.81-3.88) also were significantly associated with higher total mortality (all P < .001).ConclusionLow serum albumin level is a sole indicator for increased risk of in-hospital death, postoperative complications, and total mortality after hip fracture surgery in older adults. Low TLC and malnutrition classified by MNA predict increased mortality. These indicators provide valuable prognostic information and routine use may be prudent.     

Trauma Risk Score Matching for Observational Studies in Orthopedic Trauma

ObjectivesTo determine if matching by trauma risk score is non-inferior to matching by chronic comorbidities and/or a combination of demographic and patient characteristics in observational studies of acute trauma in a hip fracture model.DesignRetrospective cohort studySettingLevel-1 Trauma CenterPatients1,590 hip fracture [AO/OTA 31A and 31B] patients age 55 and over treated between October 2014 and February 2020 at 4 hospitals within a single academic medical center.InterventionRepeatedly matching randomized subsets of patients by (1) Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA), (2) Charlson Comorbidity Index (CCI), or (3) a combination of sex, age, CCI and body mass index (BMI).Main Outcome Measurements“Matching failures” where rate of significant differences in variables of matched cohorts exceeds the 5% expected by chance.ResultsSTTGMA and combination matching resulted in no “matching failures”. Matching by CCI alone resulted in “matching failures” of BMI, ASA class, STTGMA, major complications, sepsis, pneumonia, acute respiratory failure, and 90-day readmission.ConclusionsSTTGMA matching in observational cohort studies is less likely to yield significant differences of demographics and outcomes than CCI matching. STTGMA matching is noninferior to matching a combination of demographic variables optimized for each treatment cohort. STTGMA matching is apt to reflect equipoise of health at admission and outcome likelihood in observational cohort studies of orthopedic trauma, while maintaining consistent weighting of demographic and injury characteristic variables that may expand the generalizability of these studies.Level of EvidenceLevel III     

The role of geographic disparities in outcomes after orthopaedic trauma surgery

IntroductionHealthcare disparities linked to patient rurality and socioeconomic status are known to exist, but few studies have examined the effect of urban versus rural status on outcomes after orthopedic trauma surgery. The aim of this study was to examine the correlation between patient rurality, socioeconomic status, and outcomes after orthopedic trauma.Materials and methodsThis is a retrospective cohort study of patients diagnosed with a hip or long bone fracture between January 2016 and December 2017. Data were collected from the Nationwide Inpatient Sample (NIS), a 20% weighted sample of 95% of the U.S. inpatient population. Patients were stratified into 3 groups: isolated hip fracture, isolated long bone fracture, and polytrauma. Bivariate analysis was completed using chi-squared tests for categorical variables and t-tests for continuous variables. Multivariable analysis was completed using population-weighted logistic regression models, based on a conceptual model derived selection of covariates.ResultsWe included 235,393 patients diagnosed with a hip or extremity fracture. These were weighted to represent 1,176,965 patients nationally. In the hip fracture group, rural patient status was associated with higher odds of mortality (OR 1.32, P < 0.001) but not complications (OR 0.95, P = 0.082). In the extremity fracture and polytrauma groups, rural patient status was not associated with significantly higher odds of mortality or complications. In the urban polytrauma group, zip code with below-median income was associated with increased odds of mortality (OR 1.23, P = 0.002) but not complications. In the rural polytrauma group, zip code with below-median income was not associated with significantly increased odds of mortality or complications. In the hip fracture and extremity fracture groups, below-median income was not associated with significantly higher odds of mortality.ConclusionWe found that rural patients with hip fracture have higher mortality compared to urban patients and that socioeconomic disparities in mortality after a polytrauma exist in urban settings. These results speak to the ongoing need to develop objective measures of disparity-sensitive healthcare and optimize trauma systems to better serve low-income patients and patients in rural areas.     

Pre-injury use of antiplatelet and anticoagulations therapy are associated with increased mortality in a cohort of 1038 hip fracture patients

BackgroundHip fractures are a large burden on the health care systems of developed nations. Patients usually have multiple co-morbidities and the pre-injury use of anticoagulants and anti-platelet medication is common.Materials and methodsThis study used a single hospital hip fracture database to facilitate a retrospective analysis of the impact of anti-coagulation and anti-platelet therapy on mortality and complications after surgical management of hip fractures. There were 92 patients on warfarin, 69 on DOAC, 260 antiplatelet patients and 617 control patients.ResultsMortality rates at 30 days were 4.8% for the control group, 12.6% for the antiplatelet group, warfarin 7.0%, 9.5% for Direct Oral Anticoagulant (DOAC) group, p = 0.004. Mortality rates at 1 year were 22.4% for the control group, 32.3% for the antiplatelet group, 29.3% for the warfarin group and 29.0% for DOAC group (p=0.007).Amongst complications, significant differences were found in transfusion (DOAC) and wound ooze (warfarin) rates, but the study did not detect significant clinical consequences arising from these differences.A matched analysis for age, sex, and ASA was undertaken to look in more detail at mortality data. Some mortality differences remained between groups with anti-platelet medication associated with increased mortality, but the differences no longer appeared to be significant.Our data suggests that this is a non-causal association, which could be incorporated into predictive mortality risk scores such as the Nottingham hip fracture score.ConclusionWe believe that pre-injury antiplatelet therapy is a strong indicator for high risk patients with higher expected mortality after hip fracture surgery. We saw no evidence to support delayed surgery in patients taking DOACs     

Greater length of hospital stay for concurrent hip and upper limb fractures compared to isolated hip fractures: a systematic review of 13 studies including 210,289 patients and meta-analysis

BackgroundThe impact of concurrent upper limb and fragility hip fractures has not been well defined. A greater understanding of this can guide decision making in the early peri-operative period and subsequent rehabilitation of such patients.AimsTo identify if patients with concurrent upper limb and fragility hip fractures have different outcomes and demographics than those with an isolated hip fracture.MethodsA search of MEDLINE and EMBASE was performed to identify cohort and case-control studies, comparing concurrent hip and upper limb fractures with isolated hip fractures. Meta-analysis was conducted using RevMan 5.4. Subgroup analyses were performed for concurrent distal radius and concurrent proximal humerus fractures.Results13 studies were included reporting on 196,916 patients with an isolated hip fracture and 13,373 with concurrent hip and upper limb fractures. Patients with concurrent upper limb fractures had a significantly longer length of hospital stay (mean difference: 3.97 days, 95% CI: 1.36, 6.57, P=0.003) as compared to those with isolated hip fractures. Patients with concurrent upper limb fractures were significantly more likely to be female (OR: 0.57, 95% CI: 0.46, 0.70, P<0.00001), reside at home pre-injury (OR: 0.6, 95% CI: 0.37, 0.96, P=0.03) and have no cognitive impairment (OR: 0.54, 95% CI: 0.35, 0.84, P=0.006). Patients with concurrent distal radius fractures had significantly lower 90-day mortality (OR: 0.70, 95% CI: 0.49, 0.99, P=0.04) and 1-year mortality (OR: 0.68, 95% CI: 0.51, 0.90, P=0.008).ConclusionsConcurrent fragility hip and upper limb fractures are associated with increased length of hospital stay. We recommend early, aggressive, individualised rehabilitation to help improve outcomes and early hospital discharge in this highly vulnerable patient group.     

Is Oxidized Zirconium Femoral Head Superior to Other Bearing Types in Total Hip Arthroplasty? A Systematic Review and Meta-Analysis

BackgroundOxidized zirconium (OxZi) is a relatively new type of material that combines the strength of a metal with the surface/wears properties of a ceramic. Our aim was to investigate whether OxZi femoral heads lead to lower polyethylene wear, higher survival rate, and better clinical outcomes than the other bearing types in patients treated with total hip arthroplasty (THA).MethodsTwo reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms: a. “oxidized” AND “zirconium” AND “total” AND “hip” AND “arthroplasty”; b. “oxinium” AND “total” AND “hip” AND “arthroplasty”. The primary outcome measures were the survival rate of the bearing surfaces as well as the polyethylene wear.ResultsThe vast majority (85.7%) of the studies, which reported the mean polyethylene wear rate, showed that there was not any significant difference between OxZi and cobalt-chrome (CoCr) femoral heads (rate ratio: 0.836; 95% confidence interval: 0.362-1.928; P = .674). All studies comparing the survival rate of OxZi and CoCr femoral heads illustrated almost excellent survivorship with both implants.ConclusionOxZi femoral heads did not lead to lower polyethylene wear rate or higher survival rate, when compared with CoCr femoral heads in patients treated with THA. On the basis of these results and taking into account the higher cost of these implants, we would not recommend the routine use of OxZi femoral heads in primary THAs.Level of EvidenceSystematic review and meta-analysis of therapeutic studies I-III.     

Increased hip fracture and mortality in chronic kidney disease individuals: The importance of competing risks

BackgroundMany studies have shown a correlation between chronic kidney disease (CKD) and fracture. However, increased mortality in CKD patients is a competing risk scenario not accounted for in previous studies. Our aim was to investigate the true impact of CKD on hip fracture after accounting for a competing risk with death.MethodsWe conducted a population-based cohort study to determine the impact of CKD on hip fractures in individuals aged ≥ 50 years old registered in the SIDIAP^Q database (representative of 1.9 million people in Catalonia, Spain). Cox regression was used to estimate hazard ratio (HR) for death and hip fracture according to CKD status. A competing risk (Fine and Gray) model was fitted to estimate sub-HR for hip fracture in CKD or CKD-free patients accounting for differential mortality.ResultsA total of 873,073 (32,934 (3.8%) CKD) patients were observed for 3 years. During follow-up, 4,823 (14.6%) CKD and 36,328 (4.3%) CKD-free participants died (HR, 1.83 [95% CI, 1.78–1.89]), whilst 522 (1.59%) and 6,292 (0.75%) sustained hip fractures, respectively. Adjusted Cox models showed a significantly increased risk of hip fractures for the CKD group (HR, 1.16 [1.06–1.27]), but this association was attenuated in competing risk models accounting for mortality (SHR, 1.14 [1.03–1.27]).ConclusionsBoth death and hip fracture rates are increased (by 83% and 16%, respectively) in CKD patients. However, the association between CKD and hip fractures is attenuated when an excess of mortality is taken into account. A competing risk with death must be considered in future analyses of association between CKD and any health outcomes.     

Approach to gynecomastia and pseudogynecomastia surgical techniques and its outcome: a systematic review

BackgroundTo date, various surgical techniques were developed for gynecomastia and pseudogynecomastia surgery, providing surgeons vast range of options. These variations of techniques, however, may have different efficacy and results depending on the severity of patients’ conditions.ObjectivesThis review aims to delineate comprehensively the variations of surgical approaches to gynecomastia and pseudogynecomastia in relation to surgical and patients’ outcomes.MethodsDatabase search (October 28, 2020) from PubMed, Scopus, Science Direct, and Cochrane Library was performed to identify relevant studies using the keywords (“gynecomastia” OR “pseudogynecomastia”) AND (“surgery” AND “mastectomy” OR “liposuction”) within January 2011–November 2020, published in English. Inclusion criteria were approached according to patients, intervention, comparator, outcomes, and study design (PICOS). Data from the included studies were extracted based on study and subjects’ characteristics, type of intervention, and outcome measures.ResultsOut of all relevant studies revealed, 53 studies met inclusion criteria with 5345 subjects included. Most subjects, from 44 studies, were classified as Simon's Grade II (68.49%) with idiopathic cause (94.51%). Most cases were approached using the minimally invasive techniques (37.50%) and were highly satisfied. Among intervention groups, complication rates vary from 12.12–22.30%, with the minimally invasive approach having the lowest rate. Hematoma and bruise were the most reported complications. However, the risk of bias was relatively high due to missing data.ConclusionsDifferent surgical approaches for gynecomastia treatment have been described and were consistent with good outcomes. To achieve a low rate of complications, the minimally invasive techniques can be considered, since most patients seem to be satisfied.     

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.     

Efficacy and safety of tranexamic acid in hip fracture surgery. How does dosage affect outcomes: A meta-analysis of randomized controlled trials

AimThe objective of this study was to assess the efficacy and safety of intravenous TXA administration in elderly patients undergoing hip fracture surgery focusing on the effect of various dosages.MethodsA systematic search of PubMed, Embase and Cochrane Library was conducted until February 2021. Our primary outcome was peri?operative total blood loss, while secondary outcomes included transfusion rate, mean count of transfused RBC units and thromboembolic events’ incidence. A subgroup analysis was performed with respect to TXA dosage.ResultsOut of 146 records identified, 10 randomized controlled studies met the selection criteria. Data synthesis revealed that TXA resulted in a significant reduction in total blood loss by 229.45 ml in favor of TXA; 95% CI: [189.5, 269.4] and transfusion rate by 40%, RR = 0.60; 95% CI: [0.47, 0.78]. No increase in thromboembolic events rate was observed (RR = 1.08, 95% CI: [0.68, 1.69]) Furthermore, sub-analysis with respect to TXA dosage showed no significant difference in total blood loss reduction between “single” and “multiple doses” studies (223 vs 233.5 ml, p = 0.85.), while a trend for lower complications rate was observed in patients receiving a single dose of ≤ 15 mg/kg.ConclusionsThis meta-analysis provides strong evidence that TXA is a safe and effective agent to reduce perioperative blood loss in hip fracture surgery. When compared with higher dosages, a single dose of 15 mg/kg is associated with a non-significant reduction in adverse events, while achieving comparable outcomes.     

Total hip arthroplasty for posttraumatic osteoarthritis following acetabularfracture: A systematic review of characteristics, outcomes, and complications

Purpose: Posttraumatic arthritis (PTA) may develop years after acetabular fracture, hindering joint function and causing significant chronic musculoskeletal pain. Given the delayed onset of PTA, few studies have assessed outcomes of delayed total hip arthroplasty (THA) in acetabular fracture patients. This study systematically reviewed the literature for outcomes of THA in patients with PTA and prior acetabular fracture. Methods: Pubmed, EMBASE, SCOPUS, and Cochrane library were searched for articles containing the keywords “acetabular”, “fracture”, “arthroplasty”, and “post traumatic arthritis” published between 1995 and August 2017. Studies with less than 10 patients, less than 2 years of follow-up, conference abstracts, and non-English language articles were excluded. Data on patient demographics, surgical characteristics, and outcomes of delayed THA, including implant survival, complications, need for revision, and functional scores, was collected from eligible studies. Results: With 1830 studies were screened and data from 10 studies with 448 patients were included in this review. The median patient age on date of THA was 51.5 years, ranging from 19 to 90 years. The median time from fracture to THA was 37 months, with a range of 27-74 months. Mean follow-up times ranged from 4 to 20 years. The mean Harris hip scores (HHS) improved from 41.5 pre-operatively, to 87.6 post-operatively. The most prevalent postoperative complications were heterotopic ossification (28%-63%), implant loosening (1%-24%), and infection (0%-16%). The minimum 5-year survival of implants ranged from 70% to 100%. Revision rates ranged from 2% to 32%. Conclusion: Despite the difficulties associated with performing THA in patients with PTA from previous acetabular fracture (including soft tissue scarring, existing hardware, and acetabular bone loss) and the relatively high complication rates, THA in patients with PTA following prior acetabular fracture leads to significant improvement in pain and function at 10-year follow-up. Further high quality randomized controlled studies are needed to confirm the outcomes after delayed THA in these patients.     

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

Aims and objectivesThe 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.MethodsWe 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.ResultsIn 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.ConclusionIt is safe to continue urgent as well as non-emergency surgery during the Covid-19 pandemic in a separate, geographically isolated site.