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.     

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.     

COVID-19 Pandemic Effects on the Epidemiology and Mortality of Pediatric Firearm Injuries; A Single Center Study

BackgroundThe COVID-19 pandemic has been associated with increased firearm injuries amongst adults, though the pandemic's effect on children is less clearly understood.MethodsThis cross-sectional study was performed at a Level 1 Pediatric Trauma Center and included youths 0–19 years. The trauma registry was retrospectively queried for firearm injuries occurring pre-COVID-19 pandemic (March 2015-February 2020). Baseline data was compared to prospectively collected data occurring during the COVID-19 pandemic (March 2020-March 2022). Fischer's exact, Pearson's Chi-square and/or correlation analysis was used to compare pre and post-COVID-19 firearm injury rates and intent, victim demographics and disposition. Temporal relationships between firearm injury rates and local COVID-19 death rates were also described.Results413 pre-COVID-19 firearm injuries were compared to 259 pandemic firearm injuries. Victims were mostly Black males with a mean age of 13.4 years. Compared to the 5 years pre-pandemic, monthly firearm injury rates increased 51.5% (6.8 vs 10.3 shootings/month), including a significant increase (p = 0.04) in firearm assaults/homicides and a relative decrease in unintentional shootings. Deaths increased 29%, and there were significantly fewer ED discharges and more admissions to OR and/or PICU (p = 0.005). There was a significant increase in Black victims (p = 0.01) and those having Medicaid or self-pay (p<0.001). Firearm injury spikes were noted during or within the 3 months following surges in local COVID-19 death rates.ConclusionsThe COVID-19 pandemic was associated with an increase in the frequency and mortality of pediatric firearm injuries, particularly assaults amongst Black children following surges in COVID death rates. Increased violence-intervention services are needed, particularly amongst marginalized communities.Level of evidenceThis is a prognostic study, evaluating the effects of the COVID-19 pandemic on pediatric firearm injuries, including victim demographics, injury intent and mortality. This study is retrospective and observational, making it Oxford Level III evidence.     

Epidemiology of pediatric trauma during the coronavirus disease-2019 pandemic

Background/purposeWe aimed to describe the epidemiology of trauma activations and variations in injury patterns, injury severity, and hospital length-of-stay for injured children in Los Angeles (LA) County during the coronavirus-disease-19 (COVID-19) pandemic.MethodsWe conducted a retrospective cross-sectional study of children aged < 18-years evaluated in 15 trauma centers from 2019 to 2020 and entered in the LA County trauma registry. We defined 01/01/2019–03/18/2020 as pre-pandemic and 03/19/2020–12/31/2020 as the pandemic period. Our primary outcome was pediatric trauma activations. We analyzed demographic and clinical data, including types and severity of injuries sustained. We conducted unadjusted bivariate analyzes of injury patterns between periods. Segmented linear regression models were used to test rates (per 100,000 LA County children) of trauma activations pre-pandemic versus the pandemic period.ResultsWe studied 4399 children with trauma activations, 2695 of which occurred pre-pandemic and 1701 in the pandemic period. Motor vehicle collisions, gunshot wounds, and burns increased during the pandemic (all p-values< 0.05), while sports injuries decreased (p < 0.001). Median injury severity scores (p = 0.323) and Glasgow Coma Scales (p = 0.558) did not differ between periods, however mortality (p = 0.023) decreased during the pandemic. Segmented linear regression estimates demonstrated that rates of trauma activations pre-pandemic were similar to the pandemic period (p = 0.384).ConclusionPediatric trauma activations in LA County did not significantly differ during the COVID-19 pandemic, but types and severity of injuries varied between pre-pandemic and pandemic periods. With lockdown restrictions being lifted and novel SARS-CoV-2 variants circulating, our investigation describes this recent epidemiologic phenomenon to aid future preparation for healthcare systems.Level of evidenceLevel IIIType of studyRetrospective cross-sectional study     

Effect of the COVID-19 pandemic on presentation and severity of traumatic injury due to physical child abuse across US children's hospitals

BackgroundPhysical child abuse affects 9 in every 1,000 children in the United States and associated traumatic injuries are often identified by the healthcare system. The COVID-19 pandemic has intensified risk factors for physical child abuse and increased avoidance of the healthcare system. This study examined the effect of the COVID-19 pandemic on presentation and severity of physical child abuse.MethodsA retrospective, cross-sectional study utilizing the Pediatric Health Information System was performed. An interrupted time series analysis estimated the effect of the COVID-19 pandemic on the number of children <15 years old presenting with physical child abuse to children's hospitals from March 1^st to June 30^th of 2020 by comparing to those presenting during the same period for years 2016–2019. Hierarchical regression models estimated the effect of the pandemic on likelihood of operative intervention, ICU admission, traumatic brain injury, and mortality.ResultsOver the study period, 20,346 physical child abuse encounters were reported by 47 children's hospitals. An interrupted times series model predicted a significant decline in cases due to the effect of the COVID-19 pandemic, representing a deficit of 2,645 cases (p = 0.001). Children presenting during the pandemic had increased odds of requiring ICU admission (p = 0.03) and having a traumatic brain injury in those under 5 years of age (p=<0.001).ConclusionsThe number of children with physical child abuse presenting to children's hospitals significantly declined during the COVID-19 pandemic, but those that did were more likely to be severe. The pandemic may be a risk factor for worse outcomes associated with physical child abuse.     

Comparing epidemiologic features,outcomes, and diagnostic and therapeutic procedures of traumatic patients before and during COVID-19 pandemic: Data from the National Trauma Registry of Iran

PurposeTo prepare for future possible communicable disease epidemics/pandemics, health care providers should know how the COVID-19 pandemic influenced injured patients. This study aimed to compare epidemiologic features, outcomes, and diagnostic and therapeutic procedures of trauma patients admitted to a university-affiliated hospital before and during the pandemic.MethodsThis retrospective study was performed on data from the National Trauma Registry of Iran. All injured patients admitted to the hospital from July 25, 2016 to March 10, 2021 were included in the study. The patients were excluded if they had hospital length of stay less than 24 h. The injury outcomes, trauma mechanisms, and therapeutic and diagnostic procedures of the 2 periods: before (from July 25, 2016 to February 18, 2020) and during (from February 19, 2020 to March 10, 2021) COVID-19 pandemic were compared. All analyses were performed using STATA version 14.0 software (Stata Corporation, College Station, TX).ResultsTotally, 5014 patients were included in the registry. Of them, 773 (15.4%) were registered after the beginning of the COVID-19 pandemic on February 19, 2020, while 4241 were registered before that. Gender, education level, and cause of injury were significantly different among the patients before and after the beginning of the pandemic (p < 0.001). In the ≤ 15 years and ≥ 65 years age groups, injuries decreased significantly during the COVID-19 pandemic (p < 0.001). The frequency of intensive care unit (ICU) admission decreased from 694 (16.4%) to 88 (11.4%) (p < 0.001). The mean length of stay at the hospital (days) and at the ICU (days) declined as follow: 8.3 (SD = 17.2) vs. 5.5 (SD = 6.1), p < 0.001 and 7.5 (SD = 11.5) vs. 4.5 (SD = 6.3), p < 0.022. The frequency of diagnostic and therapeutic procedures before and during the pandemic was as follows, respectively: ultrasonography 905 (21.3%) vs. 417 (53.9%) (p < 0.001), echocardiography 313 (7.4%) vs. 107 (13.8%) (p < 0.001), angiography 1597 (37.7%) vs. 534 (69.1%) (p < 0.001), MRI 166 (3.9%) vs. 51 (6.6%) (p < 0.001), surgery 3407 (80.3%) vs. 654 (84.6%) (p < 0.001), and internal/external fixation 1215 (28.6%) vs. 336 (43.5%) (p < 0.001).ConclusionThe pandemic affected the epidemiology of traumatic patients in terms of gender, age, educational level, and trauma mechanism. It changed the outcomes of injured patients: ICU admission, length of stay at the hospital and ICU decreased. The patients received more diagnostic and therapeutic procedures during the pandemic. To be more precise, more research is needed on the details.     

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.     

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial

BackgroundWe conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic.MethodsNinety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention.ResultsThirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4).ConclusionA psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic.Level of Evidence1.     

The impact of the COVID-19 pandemic on pediatric firearm injuries in Colorado

BackgroundIn 2019 firearm injuries surpassed automobile-related injuries as the leading cause of pediatric death in Colorado. In the spring of 2020, the COVID-19 pandemic led to community-level social, economic, and health impacts as well as changes to injury epidemiology. Thus, we sought to determine the impact of the COVID-19 pandemic on pediatric firearm injuries in Colorado.MethodsWe conducted a retrospective review of pediatric firearm injured patients (≤ 18-years-old) evaluated at three trauma centers in Colorado from 2018–2021. Patients were stratified into two groups based on the time of their firearm injury: pre- COVID injuries and post- COVID injuries. Group differences were examined using t-tests for continuous variables and Chi Squared or Fisher's exact tests for categorical variables.ResultsOverall, 343 firearm injuries occurred during the study period. There was a significant increase in firearm injuries as a proportion of overall pediatric ED trauma evaluations following the onset of the COVID-19 pandemic (pre COVID: 5.18/100 trauma evaluations; post COVID: 8.61/100 trauma evaluations, p<0.0001). Assaults were the most common injury intent seen both pre and post COVID (70.3% vs. 56.7%, respectively); however, unintentional injuries increased significantly from 10.3% to 22.5% (p = 0.004) following the onset of the pandemic. Additionally, the COVID-19 pandemic was associated with a 177% increase in unintentional injuries in adolescents.ConclusionPediatric firearm injuries, particularly unintentional injuries, increased significantly in Colorado following the onset of the COVID-19 pandemic. The substantial increase in unintentional injuries among adolescents highlights the necessity of multi-disciplinary approaches to limit or regulate their access to firearms.Level of EvidenceLevel III.Study TypeRetrospective.     

Breast cancer survivorship care during the COVID-19 pandemic within an urban New York Hospital System

PurposeTo examine clinicodemographic determinants associated with breast cancer survivorship follow-up during COVID-19.MethodsWe performed a retrospective, population-based cohort study including early stage (Stage I-II) breast cancer patients who underwent resection between 2006 and 2018 in a New York City hospital system. The primary outcome was oncologic follow-up prior to and during the COVID-19 pandemic. Secondary analyses compared differences in follow-up by COVID-19 case rates stratified by ZIP code.ResultsA total of 2942 patients with early-stage breast cancer were available for analysis. 1588 (54%) of patients had attended follow-up in the year prior to the COVID-19 period but failed to continue to follow-up during the pandemic, either in-person or via telemedicine. 1242 (42%) patients attended a follow-up appointment during the COVID-19 pandemic.Compared with patients who did not present for follow-up during COVID-19, patients who continued their oncologic follow-up during the pandemic were younger (p = 0.049) more likely to have received adjuvant radiation therapy (p = 0.025), and have lower household income (p = 0.031) on multivariate modeling. When patients who live in Bronx, New York, were stratified by ZIP code, there was a modest negative association (r = −0.56) between COVID-19 cases and proportion of patients who continued to follow-up during the COVID-19 period.ConclusionWe observed a dramatic disruption in routine breast cancer follow-up during the COVID-19 pandemic. Providers and health systems should emphasize reintegrating patients who missed appointments during COVID-19 back into regular surveillance programs to avoid significant morbidity and mortality from missed breast cancer recurrences.     

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.     

The COVID-19 pandemic and associated rise in pediatric firearm injuries: A multi-institutional study

BackgroundFirearm sales in the United States (U.S.) markedly increased during the COVID-19 pandemic. Our objective was to determine if firearm injuries in children were associated with stay-at-home orders (SHO) during the COVID-19 pandemic. We hypothesized there would be an increase in pediatric firearm injuries during SHO.MethodsThis was a multi institutional, retrospective study of institutional trauma registries. Patients <18 years with traumatic injuries meeting National Trauma Data Bank (NTDB) criteria were included. A “COVID” cohort, defined as time from initiation of state SHO through September 30, 2020 was compared to “Historical” controls from an averaged period of corresponding dates in 2016–2019. An interrupted time series analysis (ITSA) was utilized to evaluate the association of the U.S. declaration of a national state of emergency with pediatric firearm injuries.ResultsNine Level I pediatric trauma centers were included, contributing 48,111 pediatric trauma patients, of which 1,090 patients (2.3%) suffered firearm injuries. There was a significant increase in the proportion of firearm injuries in the COVID cohort (COVID 3.04% vs. Historical 1.83%; p < 0.001). There was an increased cumulative burden of firearm injuries in 2020 compared to a historical average. ITSA showed an 87% increase in the observed rate of firearm injuries above expected after the declaration of a nationwide emergency (p < 0.001).ConclusionThe proportion of firearm injuries affecting children increased during the COVID-19 pandemic. The pandemic was associated with an increase in pediatric firearm injuries above expected rates based on historical patterns.     

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.     

Consequences of fall-induced hip fractures on cognitive function,physical activity,and mortality: Korean longitudinal study of aging 2006–2016

BackgroundFew studies have investigated the consequences of fall-induced hip fractures among healthy, community-dwelling middle-aged adults.ObjectivesTo investigate the effects of fall-induced hip fractures on cognitive function, activities of daily living, and mortality from the time the fractures increase.DesignA secondary data analysis based on data from the Korean Longitudinal Study of Aging (2006–2016).MethodsParticipants were 8,571 people over 45 years in South Korea who had never experienced a fall-induced hip fracture by 2006. Participants were divided into a hip-fracture group (those who experienced one or more hip fractures between 2008 and 2016; N = 306), and a non-hip-fracture group (those who did not experience a hip fracture during this period; N = 8,265). A linear mixed model, Kaplan–Meier analysis, and Cox regression were used to analyze the effects of hip fractures on mortality, the Mini Mental State Examination, Activities of Daily Living, and Instrumental Activities of Daily Living scores during 2008–2016.ResultsIn the hip-fracture group, compared to the non-fracture group, the change in Mini Mental State Examination score was significantly greater (p = 001); however, although there was a significant difference at each time point (p < .001), the cumulative difference over time was not significant (p = .560). The hip-fracture group showed a faster time to initial decline in Mini Mental State Examination scores (hazard ratio = 1.16, CI = 1.022–1.318). The hip-fracture group showed significantly larger changes in Activities of Daily Living and Instrumental Activities of Daily Living scores (p < .001), shorter time until decline began (p < .001), and larger decline as time passed (p < .001). Furthermore, the time before assistance was required from others for activities of daily living and instrumental activities of daily living was also shorter (hazard ratio = 2.18, CI= 1.728–2.759; odds ratio = 1.44, CI = 1.198–1.732). Hip fractures also increased mortality (hazard ratio = 1.42, CI = 1.013–2.002).ConclusionsOur study found that hip fractures accelerate the decline of cognitive function, physical activity, and increased mortality. Our findings can be used to develop fall-prevention programs.     

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.     

A comparison of internal fixation and hemiarthroplasty in the management of un- or minimally displaced hip fractures in patients over 60 years old

BackgroundThe incidence of hip fractures in the elderly is increasing. Minimally displaced and undisplaced hip fractures can be treated with either internal fixation or hemiarthroplasty.ObjectivesTo identify the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method.MethodA retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study.Results1273 patients were included of which 26.2% (n = 334) had cannulated hip fixation (CHF), 19.4% (n = 247) had a dynamic hip screw (DHS) and 54.7% (n = 692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n = 23) vs. 33.3% (n = 3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively.ConclusionsFixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. Hemiarthroplasty is a suitable alternative with lowest revision rates. When considering an internal fixation method, DHS is more robust than a screw construct.     

Changes in Orthopaedic diagnoses during the COVID-19 pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has been accompanied by significant reductions in patient volumes for non-COVID-19-related conditions ranging from acute coronary syndrome to ischemic strokes to acute trauma. However, the impact of the COVID-19 pandemic on patient volumes for a broad range of orthopedic conditions remains unknown. The purpose of this study was to investigate the association of the COVID-19 pandemic with changes in patient volumes of 35 emergent (e.g. dislocations, open fractures), urgent (e.g. fractures), and nonurgent orthopedic conditions (e.g. osteoarthritis, sprains).MethodsA retrospective interrupted time-series analysis of patient volumes was conducted for 35 orthopedic conditions based on ICD-10 diagnosis codes. Patient hospitalizations and new problem visits were aggregated across two institutions in New York state, including one urban tertiary care orthopedic hospital, one urban academic medical center, and all state outpatient facilities affiliated with the orthopedic institution. Patient volumes in the COVID-19 peak period (03/2020–05/2020) and COVID-19 recovery period (06/2020–10/2020) were compared against pre-COVID-19 vol (01/2018–02/2020).ResultsOverall, 169,047 cases were included in the analysis across 35 conditions with 3775 emergent cases, 6376 urgent cases, and 158,896 nonurgent cases. During the COVID-19 peak period, patient caseloads for 1 out of 7 emergent conditions (p = 0.02) and 26 out of 28 urgent and nonurgent conditions (p < 0.05) were significantly reduced compared to the pre-COVID-19 period. During the COVID-19 recovery period, patient volumes in 3 out of 13 emergent and urgent conditions (p < 0.03) and 11 out of 22 nonurgent conditions (p < 0.04) were decreased compared to pre-COVID-19 vol.ConclusionsThis study found that the pandemic was associated with considerable changes in patient patterns for non-COVID-19 orthopedic conditions. The long-term effects of patient volume reductions on both patient outcomes and orthopedic health systems remain to be seen.Level of evidenceCohort study; level of evidence IV.     

The hidden impact of rapid spread of the COVID-19 pandemic in professional,financial, and psychosocial health of Latin American orthopedic trauma surgeons

ObjectiveTo assess the quality of life of Latin American orthopedic trauma surgeons during the beginning of COVID-19 pandemic in Latin America.MethodsA total of 400 orthopedic trauma surgeons from 14 Latin American countries were invited to complete an electronic survey aiming to understand the general situation of COVID-19 in each country and how COVID-19 had impacted life's participant financially and psychosocially. The relationship between the occurrence of the disease and the existence of legal regulations on the medical activity in the respondent's country, protocols for tracking the disease among patients hospitalized in an emergency basis due to skeletal trauma, and personal protective equipment to deal with patients diagnosed with COVID-19 who need orthopedic trauma surgery was investigated, as well as the financial and psychosocial impact caused by the disease. Data was statistically analyzed with significance p < 0.05.Results220 respondents completed the survey. 21 respondents were diagnosed with COVID-19. Local regulation was decisive in terms of increasing the risk for COVID-19 disease (p = 0.001). 91.8% of the respondents reported being concerned about their financial health and 57.7% described a state of feeling emotionally overextended. 75.0% believe that pandemic can change their professional activity.ConclusionThe rapid spread of the COVID-19 pandemic in Latin America has negatively impacted the professional, financial, and psychosocial health of orthopedic trauma surgeons. It seems reasonable to state that the combination of psychosocial distress and deprivation together with financial uncertainty and decreased revenue can be straightly related to development of burnout symptoms among doctors.