Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective

Orthopedic Surgery Volume Trends During the COVID-19 Pandemic and Postvaccination Era: Implications for Healthcare Planning

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic decreased surgical volumes, but prior studies have not investigated recovery through 2022, or analyzed specific procedures or cases of urgency within orthopedic surgery. The aims of this study were to (1) quantify the declines in orthopedic surgery volume during and after the pandemic peak, (2) characterize surgical volume recovery during the postvaccination period, and (3) characterize recovery in the 1-year postvaccine release period.

METHODS

We conducted a retrospective cohort study of 27,476 orthopedic surgeries from January 2019 to December 2022 at one urban academic quaternary referral center. We reported trends over the following periods: baseline pre-COVID-19 period (1/6/2019 to 1/4/2020), COVID-19 peak (3/15/2020 to 5/16/2020), post-COVID-19 peak (5/17/2020 to 1/2/2021), postvaccine release (1/3/2021 to 1/1/2022), and 1-year postvaccine release (1/2/2022 to 12/30/2022). Comparisons were performed with 2 sample t-tests.

RESULTS

Pre-COVID-19 surgical volume fell by 72% at the COVID-19 peak, especially impacting elective procedures (P < .001) and both hip and knee joint arthroplasty (P < .001) procedures. Nonurgent (P = .024) and urgent or emergency (P = .002) cases also significantly decreased. Postpeak recovery before the vaccine saw volumes rise to 92% of baseline, which further rose to 96% and 94% in 2021 and 2022, respectively. While elective procedures surpassed the baseline in 2022, nonurgent and urgent or emergency surgeries remained low.

CONCLUSIONS

The COVID-19 pandemic substantially reduced orthopedic surgical volumes, which have still not fully recovered through 2022, particularly nonelective procedures. The differential recovery within an orthopedic surgery program may result in increased morbidity and can serve to inform department-level operational recovery.

Radiologic and histopathologic effects of favipiravir and hydroxychloroquine on fracture healing in rats

Fracture healing is a process in which many factors interact. In addition to many treatments, physical and biological therapy methods that affect different steps of this process, there are many biological and chemical agents that cause fracture union delay. Although the number of studies on fracture healing is increasing day by day, the mechanism of fracture healing, which is not fully understood, still attracts the attention of all researchers. In this study, we aimed to investigate the effects of favipiravir and hydroxychloroquine used in the treatment of COVID-19. In this study, 48 male Wistar rats weighing 300 ± 50 g were used. Each group was divided into eight subgroups of six rats each to be sacrificed at the 2nd and 4th weeks and evaluated radiologically and histologically. Favipiravir (group 1), hydroxychloroquine (group 2), favipiravir + hydroxychloroquine (group 3), and random control (group 4) were used. A statistically significant difference was observed between the 15th day histological scoring averages of the groups (p < 0.05). Although there was no statistically significant difference between the 15th day radiological score distributions of the groups (p > 0.05), we obtained different results in terms of complete bone union distributions and radiological images of the fracture line. Although favipiravir has a negative effect on fracture union in the early period, favipiravir may have a positive effect on fracture union in the late period. We did not find any effect of hydroxychloroquine on fracture union.

Increased 90-Day Mortality and Morbidity Among Patients Recovering From Elective Primary Arthroplasty During the COVID-19 Pandemic in New York City

All elective procedures were stopped in March 2020 because of the coronavirus disease 2019 (COVID-19) pandemic. We report the 90-day mortality and complications of patients who underwent primary arthroplasty before the stopping of elective procedures at a single academic medical center. A retrospective cohort study was conducted including patients who underwent elective primary arthroplasty between December 2019 and mid-March 2020. Their 90-day postoperative mortality and medical complications were statistically compared with those of a historical cohort from the same operative period in 2019. The 2020 and 2019 cohorts included 372 and 410 patients, respectively. Except for the prevalence of diabetes, there was no significant difference between the two cohorts regarding baseline characteristics or preoperative health. The 2020 cohort had statistically significant higher rates of pneumonia (2.7% vs 0.7%; P=.03), readmission (9.1% vs 5.4%; P=.04), pulmonary embolism (1.6% vs 0.2%; P=.04), and 90-day mortality (1.1% vs 0%; P=.04). The 2020 cohort also had a trend for increased rates of deep venous thrombosis (1.1% vs 0.7%; P=.7) and cardiac complications (1.9% vs 0.5%; P=.07) and no change in emergency department visits (14.0% vs 11.7%; P=.3). There were 7 confirmed cases of COVID-19 in the 2020 cohort and 1 death. This study demonstrates that patients who underwent primary arthroplasty procedures at our institution close to the time of the first wave of the COVID-19 pandemic experienced a statistically significant increase in mortality, pneumonia, pulmonary embolism, and readmission compared with a historical cohort. As elective procedures have resumed during the ongoing pandemic, providers and patients should be aware of these increased risks. [Orthopedics. 2024;47(3):135-140.].

A Longitudinal Evaluation of Coronavirus Disease 2019 and Its Effects on Spinal Decompressions With or Without Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The objectives were to (1) compare the safety of spine surgery before and after the emergence of coronavirus disease 2019 (COVID-19) and (2) determine whether patients with a history of COVID-19 were at increased risk of adverse events.

SUMMARY AND BACKGROUND DATA

The COVID-19 pandemic had a tremendous impact on several health care services. In spine surgery, elective cases were canceled and patients received delayed care due to the uncertainty of disease transmission and surgical outcomes. As new coronavirus variants arise, health care systems require guidance on how to provide optimal patient care to all those in need of our services.

PATIENTS AND METHODS

A retrospective review of patients undergoing spine surgery between January 1, 2019 and June 30, 2021 was performed. Patients were split into pre-COVID or post-COVID cohorts based on local government guidelines. Inpatient complications, 90-day readmission, and 90-day mortality were compared between groups. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome.

RESULTS

A total of 2976 patients were included for analysis with 1701 patients designated as pre-COVID and 1275 as post-COVID. The pre-COVID cohort had fewer patients undergoing revision surgery (16.8% vs 21.9%, P < 0.001) and a lower home discharge rate (84.5% vs 88.2%, P = 0.008). Inpatient complication (9.9% vs 9.2%, P = 0.562), inpatient mortality (0.1% vs 0.2%, P = 0.193), 90-day readmission (3.4% vs 3.2%, P = 0.828), and 90-day mortality rates (0.8% vs 0.8%, P = 0.902) were similar between groups. Patients with positive COVID-19 tests before surgery had similar complication rates (7.7% vs 6.1%, P = 1.000) as those without a positive test documented.

CONCLUSIONS

After the emergence of COVID-19, patients undergoing spine surgery had a greater number of medical comorbidities, but similar rates of inpatient complications, readmission, and mortality. Prior COVID-19 infection was not associated with an increased risk of postsurgical complications or mortality.

LEVEL OF EVIDENCE

Level III.

[Effects of the COVID-19 pandemic on the course of geriatric trauma patients with proximal femoral fractures]

BACKGROUND/OBJECTIVE

In 2020 the COVID-19 pandemic posed a major challenge to the healthcare system. The hypothesis is that the COVID-19 pandemic in 2020 had an impact on the care of older adults with proximal femoral fractures due to resource scarcity, regardless of whether or not the patient was infected.

MATERIAL AND METHODS

This study analyzed the data of 87 hospitals which entered 15,289 patients in the Geriatric Trauma Register ("AltersTraumaRegister DGU®", ATR-DGU) in Germany in 2019 and 2020. In this study we analyzed the influence of the COVID-19 pandemic on the inpatient treatment of hip fractures as well as the mid-term follow-up during the first 120 days. For the main analysis, we compared patients documented during the COVID-19 pandemic in 2020 (April-December) with a control group in 2019 (April-December). Additionally, we performed a subgroup analysis of the periods with high COVID-19 incidence rates.

RESULTS

Between 2019 and 2020 a total of 11,669 patients (2020: n = 6002 patients vs. 2019: n = 5667 patients) were included in this study. Only minor differences were found between the patients treated during the pandemic; however, when the COVID-19 incidence in Germany was greater than 50/100,000 residents, significantly fewer patients (p < 0.001) were discharged to a geriatric rehabilitation ward (27.2% vs. 36.3%) and an increased mortality rate during inpatient treatment was determined (8.4% vs. 4.6%) (p < 0.001).

DISCUSSION

The healthcare system was able to respond to the pandemic and patients' clinical courses were not impaired as long as the incidences were low. Nevertheless, the healthcare system reached its limits in times of higher incidence, which was also directly reflected in the patient outcome, mortality and place of discharge.

Preoperative COVID-19 infection status negatively impacts postoperative outcomes of geriatric hip fracture surgery

OBJECTIVES

Compare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

Retrospective propensity score matched cohort.

METHODS

Patients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts.

RESULTS

After matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 - 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 - 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 - 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 - 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 - 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 - 3.06).

CONCLUSIONS

Active COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population.

LEVEL OF EVIDENCE

III.

A multi-institutional study of short-term mortality in COVID-positive patients undergoing hip fracture surgery: is survival better than expected?

PURPOSE

Early reports of 30-day mortality in COVID-positive patients with hip fracture were often over 30% and were higher than historical rates of 10% in pre-COVID studies. We conducted a multi-institutional retrospective cohort study to determine whether the incidence of 30-day mortality and complications in COVID-positive patients undergoing hip fracture surgery is as high as initially reported.

METHODS

A retrospective chart review was performed at 11 level I trauma centers from January 1, 2020 to May 1, 2022. Patients 50 years or older undergoing hip fracture surgery with a positive COVID test at the time of surgery were included. The primary outcome measurements were the incidence of 30-day mortality and complications. Post-operative outcomes were reported using proportions with 95% confidence interval (C.I.).

RESULTS

Forty patients with a median age of 71.5 years (interquartile range, 50-87 years) met the criteria. Within 30-days, four patients (10%; 95% C.I. 3-24%) died, four developed pneumonia, three developed thromboembolism, and three remained intubated post-operatively. Increased age was a statistically significant predictor of 30-day mortality (p = 0.01), with all deaths occurring in patients over 80 years.

CONCLUSION

In this multi-institutional analysis of COVID-positive patients undergoing hip fracture surgery, 30-day mortality was 10%. The 95% C.I. did not include 30%, suggesting that survival may be better than initially reported. While COVID-positive patients with hip fractures have high short-term mortality, the clinical situation may not be as dire as initially described, which may reflect initial publication bias, selection bias introduced by testing, or other issues.

LEVELS OF EVIDENCE

Therapeutic Level III.

The Effects of COVID-19 Pandemic on the Recovery of Hip Fracture Patients

Purpose

To figure out how complete control of family visits to prevent infection of coronavirus disease 2019 (COVID-19) affected the activity recovery of hip fracture patients admitted to nursing hospitals.

Materials and Methods

Eighty-one patients with hip surgery in the two years prior to COVID-19 pandemic were classified as Group A, and 103 patients in the next two years were designated as Group B. The subjects' walking ability was evaluated by using the modified Koval index (MKI). In order to analyze the impact of the family visit control to the subjects, each group was classified into two different groups: (1) inpatients group who admitted to nursing hospitals and (2) home-treated patients. Additionally, statistical elements were processed in consideration of other factors that may affect the results of the experiment.

Results

The MKI evaluated at 6 months postoperative was 3.31±1.79 in Group A and 2.77±1.91 in Group B, and it was meaningfully low after the pandemic (P=0.04). There was significantly low among both of Group A 2.74±1.76 and Group B 1.93±1.81 after the pandemic (P=0.03) among those treated at the nursing hospital. The rate of deterioration of the MKI was 35 (43.2%) in Group A and 57 (55.3%) in Group B, which increased by 12.1% after the pandemic.

Conclusion

The pandemic had a negative effect on the recovery of postoperative activities of elderly hip fracture patients who admitted to nursing hospitals when family access was completely restricted to prevent infection.

Outcomes of SARS-CoV-2 infection among patients with orthopaedic fracture surgery in the National COVID Cohort Collaborative (N3C)

BACKGROUND

The objective of this study was to investigate the outcomes of COVID-19-positive patients undergoing orthopaedic fracture surgery using data from a national database of U.S. adults with a COVID-19 test for SARS-CoV-2.

METHODS

This is a retrospective cohort study using data from a national database to compare orthopaedic fracture surgery outcomes between COVID-19-positive and COVID-19-negative patients in the United States. Participants aged 18-99 with orthopaedic fracture surgery between March and December 2020 were included. The main exposure was COVID-19 status. Outcomes included perioperative complications, 30-day all-cause mortality, and overall all-cause mortality. Multivariable adjusted models were fitted to determine the association of COVID-positivity with all-cause mortality.

RESULTS

The total population of 6.5 million patient records was queried, identifying 76,697 participants with a fracture. There were 7,628 participants in the National COVID Cohort who had a fracture and operative management. The Charlson Comorbidity Index was higher in the COVID-19-positive group (n = 476, 6.2 %) than the COVID-19-negative group (n = 7,152, 93.8 %) (2.2 vs 1.4, p<0.001). The COVID-19-positive group had higher mortality (13.2 % vs 5.2 %, p<0.001) than the COVID-19-negative group with higher odds of death in the fully adjusted model (Odds Ratio=1.59; 95 % Confidence Interval: 1.16-2.18).

CONCLUSION

COVID-19-positive participants with a fracture requiring surgery had higher mortality and perioperative complications than COVID-19-negative patients in this national cohort of U.S. adults tested for COVID-19. The risks associated with COVID-19 can guide potential treatment options and counseling of patients and their families. Future studies can be conducted as data accumulates.

LEVEL OF EVIDENCE

Level III.

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

Venous thromboembolism and major adverse cardiovascular events in patients with hip fractures suffering from SARS-CoV-2 infection: a systematic review

INTRODUCTION

Hip fractures represent 1 of the most common injuries in older adults. They are associated with increased perioperative morbidity and mortality. Additionally, current research suggests that SARS-COV-2 infection may worsen the prognosis of the hip fracture patients who undergo hip fixation. The aims of the present study were: (1) to determine the rate of specific adverse events including VTE (venous thromboembolism) and major adverse cardiovascular events (MACEs) in patients with hip fracture and concomitant SARS-CoV-2 infection undergoing surgery; and (2) to examine if the aforementioned population is at increased risk for VTE and MACEs, when compared to SARS-CoV-2 free patients with hip fracture.

METHODS

PubMed, EMBASE, Cochrane, Web of Science, Google scholar and medRxiv were searched from March 2020 to January 2021 for English language studies with patients suffering from hip fractures and SARS-COV-2 -CoV-2. 2 researchers were involved in the data extraction and the quality assessment of the studies respectively.

RESULTS

The literature search yielded a total of 1256 articles of which 14 were included in the systematic review and 7 in the meta-analysis respectively. The estimated pooled rate for VTE and MACE were 4.3% and 6.3% respectively. Patients with hip fracture and concomitant SARS-CoV-2 infection who undergo surgery are at increased risk for VTE, when compared to SARS-CoV-2 free patients (odds ratio 2.8 [95% CI, 1.1-7.1]). These patients are also at increased risk for MACE postoperatively as indicated by the odds ratio 2.4 (95% CI, 1.0-5.8). The quality of the studies was moderate.

CONCLUSIONS

Although there is a lack of high-quality data it seems that patients with hip fractures and concomitant SARS-CoV-2 infection are facing a 2.8 and 2.4 times increased risk for VTE and MACE.

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022

INTRODUCTION

Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture.

METHODS

Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination.

RESULTS

The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications.

DISCUSSION

In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

The Impact of the COVID-19 Pandemic on the Practice of Hip and Knee Arthroplasty

» The COVID-19 global pandemic resulted in unprecedented disruptions in care including massive surgical cancelations, a shift to outpatient surgery, and novel medical risks posed by COVID-19 infection on patients undergoing joint replacement surgery.» Refined patient optimization pathways have facilitated safe, efficient outpatient total joint arthroplasty in patient populations that may not otherwise have been considered eligible.» Rapid innovations emerged to deliver care while minimizing the risk of disease transmission which included the widespread adoption of telemedicine and virtual patient engagement platforms.» The widespread adoption of virtual technology was similarly expanded to resident education and continuing medical activities, which has improved our ability to propagate knowledge and increase access to educational initiatives.» Novel challenges borne of the pandemic include profound personnel shortages and supply chain disruptions that continue to plague efficiencies and quality of care in arthroplasty and require creative, sustainable solutions.

Incidence and risk factors for stroke after hip fracture: a meta-analysis

Hip fractures represent a high burden and are associated with mortality in up to 30% of the cases. Stroke complications can be devastating and increase mortality and disability in elderly patients. This study aimed to determine the overall incidence and risk factors for stroke in patients with hip fractures. A systematic search of the literature using PubMed, EMBASE, Scopus, and Cochrane Collaboration Library databases was carried out. Studies have reported the incidence of stroke in patients > 50 years of age with hip fractures. Data were extracted according to PRISMA guidelines (PROSPERO: CRD42023384742). Data were combined using Review Manager version 5.4. A random-effects model was adopted if a significant heterogeneity was observed. The primary outcome was the incidence of stroke in patients with hip fractures. The secondary outcomes of interest included the influence on the incidence of demographic factors, associated conditions, habits, and analytical parameters. Of the 635 initially retrieved studies, 18 were included, with 256,197 patients. The mean age of the patients ranged from 55 to 84 years old. The overall incidence of stroke in patients with hip fracture was 6.72% (95% CI 4.37-9.07%. The incidence of stroke by region was highest in the American continent (8.09%, 95% CI 3.60-12.58%; P > 0.001). Regarding associated conditions diabetes significantly increased the risk of stroke (OR 1.80, 95% CI 1.41-2.30). Respect to patient characteristics, BMI greater than 24.4 and female gender did not significantly increase the risk of stroke: (OR 1.07, 95% CI 0.74-1.56) and (OR 1.15, 95% CI 0.91-1.46). Lastly, lower albumin concentrations were a risk factor for stroke in patients with hip fracture (MD - 3.18, 95% CI - 4.06 to 2.31). In conclusion, the incidence of stroke after hip fracture was 6.72%. The incidence of stroke increases over time, and the closely associated risk factors are diabetes and low albumin level.

The Cost We Bear: Financial Implications for Hip Fracture Care Amidst the COVID-19 Pandemic

INTRODUCTION

The purpose of this study was to assess the impact of COVID-19 on the cost of hip fracture care in the geriatric/middle-aged cohort, hypothesizing the cost of care increased during the pandemic, especially in COVID+ patients.

METHODS

Between October 2014 and January 2022, 2,526 hip fracture patients older than 55 years were analyzed for demographics, injury details, COVID status on admission, hospital quality measures, and inpatient healthcare costs from the inpatient admission. Comparative analyses were conducted between: (1) All comers and high-risk patients in the prepandemic (October 2014 to January 2020) and pandemic (February 2020 to January 2022) cohorts and (2) COVID+ and COVID- patients during the pandemic. Subanalysis assessed the difference in cost breakdown for patients in the overall cohorts, the high-risk quartiles, and between the prevaccine and postvaccine pandemic cohorts.

RESULTS

Although the total costs of admission for all patients, and specifically high-risk patients, were not notably higher during the pandemic, further breakdown showed higher costs for the emergency department, laboratory/pathology, radiology, and allied health services during the pandemic, which was offset by lower procedural costs. High-risk COVID+ patients had higher total costs than high-risk COVID- patients ( P < 0.001), most notably in room-and-board ( P = 0.032) and allied health ( P = 0.023) costs. Once the pandemic started, subgroup analysis demonstrated no change in the total cost in the prevaccine and postvaccine cohort.

CONCLUSION

The overall inpatient cost of hip fracture care did not increase during the pandemic. Although individual subdivisions of cost signified increased resource utilization during the pandemic, this was offset by lower procedural costs. COVID+ patients, however, had notably higher total costs compared with COVID- patients driven primarily by increased room-and-board costs. The overall cost of care for high-risk patients did not decrease after the widespread administration of the COVID-19 vaccine.

LEVEL OF EVIDENCE

III.

Clinical outcomes of non-COVID-19 orthopaedic patients admitted during the COVID-19 pandemic: a multi-centre interrupted time series analysis across hospitals in six different countries

OBJECTIVES

To assess across seven hospitals from six different countries the extent to which the COVID-19 pandemic affected the volumes of orthopaedic hospital admissions and patient outcomes for non-COVID-19 patients admitted for orthopaedic care.

DESIGN

A multi-centre interrupted time series (ITS) analysis.

SETTING

Seven hospitals from six countries who collaborated within the Global Health Data@Work collaborative.

PARTICIPANTS

Non-COVID-19 patients admitted for orthopaedic care during the pre-pandemic (January/2018-February/2020) and COVID-19 pandemic (March/2020-June/2021) period. Admissions were categorised as: (1) acute admissions (lower limb fractures/neck of femur fractures/pathological fractures/joint dislocations/upper limb fractures); (2) subacute admissions (bone cancer); (3) elective admissions (osteoarthritis).

OUTCOME MEASURES

Monthly observed versus expected ratios (O/E) were calculated for in-hospital mortality, long (upper-decile) length-of-stay and hospital readmissions, with expected rates calculated based on case-mix. An ITS design was used to estimate the change in level and/or trend of the monthly O/E ratio by comparing the COVID-19 pandemic with the pre-pandemic period.

RESULTS

69 221 (pre-pandemic) and 22 940 (COVID-19 pandemic) non-COVID-19 orthopaedic patient admissions were included. Admission volumes were reduced during the COVID-19 pandemic for all admission categories (range: 33%-45%), with more complex patients treated as shown by higher percentages of patients admitted with ≥1 comorbidity (53.8% versus 49.8%, p<0.001). The COVID-19 pandemic was not associated with significant changes in patient outcomes for most diagnostic groups. Only for patients diagnosed with pathological fractures (pre-pandemic n=1671 and pandemic n=749), the COVID-19 pandemic was significantly associated with an immediate mortality reduction (level change of -77.7%, 95% CI -127.9% to -25.7%) and for lower limb fracture patients (pre-pandemic n=9898 and pandemic n=3307) with a significantly reduced trend in readmissions (trend change of -6.3% per month, 95% CI -11.0% to -1.6%).

CONCLUSIONS

Acute, subacute, as well as elective orthopaedic hospital admissions volumes were reduced in all global participating hospitals during the COVID-19 pandemic, while overall patient outcomes for most admitted non-COVID-19 patients remained the same despite the strain caused by the surge of COVID-19 patients.

The impact of COVID-19 on mortality in trauma patients undergoing orthopedic surgery: a systematic review and meta-analysis

OBJECTIVE

The global spread of the COVID-19 pandemic has affected all aspects of medicine, including orthopedic trauma surgery. This study aims to investigate whether COVID-19 patients who underwent orthopedic surgery trauma had a higher risk of postoperative mortality.

METHODS

ScienceDirect, the Cochrane COVID-19 Study Register, and MEDLINE were searched for original publications. This study adhered to the PPRISMA 2020 statement. The validity of the studies was evaluated using a checklist developed by the Joanna Briggs Institute. Study and participant characteristics, as well as the odds ratio, were extracted from selected publications. Data were analyzed using RevMan ver. 5.4.1.

RESULTS

After applying the inclusion and exclusion criteria, 16 articles among 717 total were deemed eligible for analysis. Lower-extremity injuries were the most common condition, and pelvic surgery was the most frequently performed intervention. There were 456 COVID-19 patients (6.12%) and 134 deaths among COVID-19 patients, revealing an increase in mortality (29.38% vs. 5.30%; odds ratio, 7.72; 95% confidence interval, 6.01-9.93; P<0.001).

CONCLUSION

Among COVID-19 patients who received orthopedic surgery due to trauma, the postoperative death rate increased by 7.72 times.

Elective Joint Arthroplasty Should be Delayed by One Month After COVID-19 Infection to Prevent Postoperative Complications

BACKGROUND

It remains unclear whether a history of recent COVID-19 infection affects the outcomes and risks of complications of total joint arthroplasty (TJA). The purpose of this study was to compare the outcomes of TJA in patients who have and have not had a recent COVID-19 infection.

METHODS

A large national database was queried for patients undergoing total hip and total knee arthroplasty. Patients who had a diagnosis of COVID-19 within 90-days preoperatively were matched to patients who did not have a history of COVID-19 based on age, sex, Charlson Comorbidity Index, and procedure. A total of 31,453 patients undergoing TJA were identified, of which 616 (2.0%) had a preoperative diagnosis of COVID-19. Of these, 281 COVID-19 positive patients were matched with 281 patients who did not have COVID-19. The 90-day complications were compared between patients who did and did not have a diagnosis of COVID-19 at 1, 2, and 3 months preoperatively. Multivariate analyses were used to further control for potential confounders.

RESULTS

Multivariate analysis of the matched cohorts showed that COVID-19 infection within 1 month prior to TJA was associated with an increased rate of postoperative deep vein thrombosis (odds ratio [OR]: 6.50, 95% confidence interval: 1.48-28.45, P = .010) and venous thromboembolic events (odds ratio: 8.32, confidence interval: 2.12-34.84, P = .002). COVID-19 infection within 2 and 3 months prior to TJA did not significantly affect outcomes.

CONCLUSION

COVID-19 infection within 1 month prior to TJA significantly increases the risk of postoperative thromboembolic events; however, complication rates returned to baseline after that time point. Surgeons should consider delaying elective total hip arthroplasty and total knee arthroplasty until 1 month after a COVID-19 infection.

Effects of the COVID-19 Pandemic on Humeral Shaft Fracture Management and Its Outcomes

Background and objective The coronavirus disease 2019 (COVID-19) pandemic necessitated a sudden and drastic shift in patient management throughout the healthcare system, to curb the spread of the disease and deal with resource limitations. Many surgical cases were canceled or delayed with only the most urgent and emergent cases taken up for treatment. It is unknown if and how these alterations affected patient outcomes. The purpose of this study was to compare time to fracture care and outcomes between patients treated for humeral shaft fractures prior to the COVID-19 pandemic and those treated during the pandemic. We hypothesized that the pandemic cohort would have a prolonged time to fracture care and worse outcomes than the pre-pandemic cohort. Materials and methods This was a retrospective cohort study performed within a single healthcare system. All humeral shaft fractures treated from March to June 2019 (pre-pandemic cohort) and March to June 2020 (pandemic cohort) were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and ICD-10-CM codes as well as Current Procedural Terminology (CPT) codes. Data on demographics, fracture characteristics, treatment, and outcomes were collected via chart and radiograph review. Outcomes analyzed included time to being made weight-bearing as tolerated (WBAT), radiographic union, and final follow-up; range of motion (ROM) at radiographic union and final follow-up; and rate of complications. Results The pre-pandemic cohort (n=19) was significantly younger with a mean age of 29 years than the pandemic cohort (n=17) with a mean age of 49 years (p=0.010). There were no other significant differences in demographics, fracture characteristics, or treatment type between the groups. Time to fracture care was not significantly different in the pre-pandemic cohort (five days) versus the pandemic cohort (four days). Time to being made WBAT, radiographic union, and final follow-up were not significantly different between the pre-pandemic (86, 113, and 98 days) and the pandemic cohorts (77, 106, and 89.5 days). ROM measurements in abduction at radiographic union were significantly different between the cohorts: in the pre-pandemic cohort, 100% of patients reached greater than 160 degrees; in the pandemic cohort, only 16.7% of patients reached greater than 160 degrees (p=0.048). There was a non-significant decrease in the proportion of patients who achieved the maximal category of ROM measurements in forward elevation and extension at radiographic union and abduction, forward elevation, and extension at final follow-up, as well as a non-significant increase in visual analog scale (VAS) pain scores at final follow-up between cohorts. There were no significant differences in the rate of complications. Conclusions Despite limited resources, reduced operating room availability, and increased utilization of virtual visits due to the COVID-19 pandemic, patients with humeral shaft fractures may not have faced delays in fracture care or worse outcomes compared to the pre-pandemic period. The pandemic cohort may have experienced significantly decreased ROM compared to the pre-pandemic cohort, which may reflect the decreased availability of physical therapy services and overall decreased activity levels due to the quarantine orders. However, we could not identify any other significant differences in the type of treatment, pain, complications, or time to union.

EVALUATION OF THE EPIDEMIOLOGY OF EXPOSED FRACTURES BEFORE AND DURING THE COVID-19 PANDEMIC

Objective

To assess the impact of the COVID-19 pandemic on the epidemiology and clinical outcomes of open fractures considering the periods before and during the pandemic.

Methods

An observational and retrospective study, which included patients aged over 18 years, admitted to the Orthopedics and Traumatology Ward of Hospital São Paulo, of the Federal University of São Paulo (UNIFESP). Data was collected in two moments: pre-pandemic (March 1, 2019, to February 29, 2020) and during the pandemic (March 1, 2020, to February 28, 2021).

Results

In total, 183 patients were evaluated with a mean age of 36 years ± 14 years. In the pre-pandemic period, 94 patients underwent surgery, 81 men (85.37%) and 13 women (14.2%), with a mean age of 36 ± 3 years. During the pandemic period, 89 patients were subjected to surgery, 77 men (86.6%) and 12 women (13.4%), with a mean age of 38 ± 3 years.

Conclusion

During the pandemic, open fractures were still more common in men. Regarding hospital indicators, the prevalence of infections in the surgical wound and the length of stay of patients with open fractures increased, however, with little significance. Fractures classified as Gustilo IIIA were the most common, while the most common according to the AO classification were 33, 34, 42, 43, 2R3, and 2R3 + 2U2. The frequency of run overs during the pandemic decreased. However, firearm projectile injuries and falls and occupational injuries increased. Level of Evidence III, Retrospective Comparative Study.

Hip Fracture Care during COVID-19: Evolution through the Pandemic

INTRODUCTION

The purpose of this epidemiologic study was to analyze the care provided by our institution to middle-aged and geriatric hip fracture patients throughout the pandemic to examine for any differences compared to pre-pandemic care and across the pandemic stages.

METHODS

Consecutive patients >55 years old treated for hip fractures at our institution between October 2014 and January 2022 were analyzed for demographics, coronavirus disease 2019 (COVID-19) and vaccination status at admission, injury characteristics, hospital quality measures, and outcomes. Patients were divided into three separate cohorts: Pre-COVID-19 (PRECOV), COVID-19 Pre-Vaccine (PREVAX), and COVID-19 Post-Vaccine (POSTVAX). A sub-analysis removed COVID-19-positive patients across the study period. Comparative analyses were conducted.

RESULTS

A total of 2,633 hip fracture patients were included. For the overall cohort, there was no difference in the rate of inpatient deaths between the PRECOV, PREVAX, and POSTVAX cohorts (p=0.278). PRECOV had a significantly lower 30-day mortality rate compared to PREVAX or POSTVAX (p=0.012). Differences in complication rates for surgical site infection, urinary tract infection, and anemia (p<0.01 for all) were seen between cohorts. PRECOV had the longest length of hospital stay (p<0.01). PREVAX patients required more ICU level of care (p<0.01). When removing COVID-19-positive patients, all three cohorts had similar inpatient (p=0.872) and 30-day mortality rates (p=0.130).

CONCLUSION

The care of patients treated for hip fractures did not change throughout the pandemic at our institution. The elevated mortality rate due to the effects of COVID-19 seen in the pre-vaccine cohort decreased over time as the understanding of COVID-19 improved and the vaccine was introduced. We recommend continuation of the same hip fracture care protocols as used pre-pandemic.

Role of academia in enhancing technology and innovation for a post COVID-19 recovery and growth

The COVID-19 pandemic represents one of the greatest challenges of this century with wide ranging impacts not only on health but practically every sector of the human society. The pandemic stretched our resources and coping capacities to almost breaking points even in wealthy economies and further exposed crucial weaknesses in infrastructure, human resources and emergency preparedness of most nations. This review article explored the role of technology and innovation in post COVID-19 growth and recovery. The academia has facilitated better understanding of the COVID-19 pandemic by increasing the body of knowledge on the disease. Better understanding of the disease informed technology and innovations which has made it possible to end the pandemic lockdown, and chart the course for recovery and growth. Relevant articles from a search of electronic databases were reviewed and the role of academia as well as some of the innovations that opened the pathway for recovery were highlighted. Recovery and growth after the COVID-19 pandemic will require synergistic efforts between the academia and the industry, more like taking the "Gown" to "Town". Research and development in academia, and industrial technology and innovation are veritable tools for a post COVID-19 recovery.

Impact of COVID-19 Pandemic on Fragility Fractures of the Hip: An Interrupted Time-Series Analysis of the Lockdown Periods in Western Greece and Review of the Literature

Since December 2019, the COVID-19 pandemic has had a significant impact on healthcare systems worldwide, prompting policymakers to implement measures of isolation and eventually adopt strict national lockdowns, which affected mobility, healthcare-seeking behavior, and services, in an unprecedented manner. This study aimed to analyze the effects of these lockdowns on hip-fracture epidemiology and care services, compared to nonpandemic periods in previous years. We retrospectively collected data from electronic patient records of two major hospitals in Western Greece and included patients who suffered a fragility hip fracture and were admitted during the two 5-week lockdown periods in 2020, compared to time-matched patients from 2017-2019. The results showed a drop in hip-fracture incidence, which varied among hospitals and lockdown periods, and conflicting impacts on time to surgery, time to discharge after surgery, and total hospitalization time. The study also found that differences between the two differently organized units were exaggerated during the COVID-19 lockdown periods, highlighting the impact of compliance with social-distancing measures and the reallocation of resources on the quality of healthcare services. Further research is needed to fully understand the specific variations and patterns of geriatric hip-fracture care during emergency health crises characterized by limited resources and behavioral changes.

Mid-term Surgery Outcomes in Patients With COVID-19: Results From a Nationwide Analysis

OBJECTIVE

Determine mid-term postoperative outcomes among coronavirus disease 2019 (COVID-19)-positive (+) patients compared with those who never tested positive before surgery.

BACKGROUND

COVID-19 is thought to be associated with prohibitively high rates of postoperative complications. However, prior studies have only evaluated 30-day outcomes, and most did not adjust for demographic, clinical, or procedural characteristics.

METHODS

We analyzed data from surgeries performed at all Veterans Affairs hospitals between March 2020 and 2021. Kaplan-Meier curves compared trends in mortality and Cox proportional hazards models estimated rates of mortality and pulmonary, thrombotic, and septic postoperative complications between patients with a positive preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test [COVID (+)] and propensity score-matched COVID-negative (-) patients.

RESULTS

Of 153,741 surgical patients, 4778 COVID (+) were matched to 14,101 COVID (-). COVID (+) status was associated with higher postoperative mortality ( P <0.0001) with a 6-month survival of 94.2% (95% confidence interval: 93.2-95.2) versus 96.0% (95% confidence interval: 95.7.0-96.4) in COVID (-). The highest mortality was in the first 30 postoperative days. Hazards for mortality and postoperative complications in COVID (+) decreased with increasing time between testing COVID (+) and date of surgery. COVID (+) patients undergoing elective surgery had similar rates of mortality, thrombotic and septic complications, but higher rates of pulmonary complications than COVID (-) patients.

CONCLUSIONS

This is the first report of mid-term outcomes among COVID-19 patients undergoing surgery. COVID-19 is associated with decreased overall and complication-free survival primarily in the early postoperative period, delaying surgery by 5 weeks or more reduces risk of complications. Case urgency has a multiplicative effect on short-term and long-term risk of postoperative mortality and complications.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the pandemic

Objectives

To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort.

Design

Retrospective cohort study.

Setting

Academic medical center.

Patients/Participants

Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020).

Intervention

Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility].

Main Outcome Measurements

Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L).

Results

In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes.

Conclusions

All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic.

Level of Evidence

III.

Current Strategies in Medical Management of the Geriatric Hip Fracture Patient

Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.

Comparing the 30-Day Mortality for Hip Fractures in Patients with and without COVID-19: An Updated Meta-Analysis

We conducted an updated meta-analysis to evaluate the 30-day mortality of hip fractures during the COVID-19 pandemic and assess mortality rates by country. We systematically searched Medline, EMBASE, and the Cochrane Library up to November 2022 for studies on the 30-day mortality of hip fractures during the pandemic. Two reviewers used the Newcastle-Ottawa tool to independently assess the methodological quality of the included studies. We conducted a meta-analysis and systematic review including 40 eligible studies with 17,753 patients with hip fractures, including 2280 patients with COVID-19 (12.8%). The overall 30-day mortality rate for hip fractures during the pandemic was 12.6% from published studies. The 30-day mortality of patients with hip fractures who had COVID-19 was significantly higher than those without COVID-19 (OR, 7.10; 95% CI, 5.51-9.15; I² = 57%). The hip fracture mortality rate increased during the pandemic and varied by country, with the highest rates found in Europe, particularly the United Kingdom (UK) and Spain. COVID-19 may have contributed to the increased 30-day mortality rate in hip fracture patients. The mortality rate of hip fracture in patients without COVID-19 did not change during the pandemic.

Low Prevalence but High Impact of COVID-19 Positive Status in Adult Trauma Patients: A Multi-institutional Analysis of 28 904 Patients

BACKGROUND

Few large investigations have addressed the prevalence of COVID-19 infection among trauma patients and impact on providers. The purpose of this study was to quantify the prevalence of COVID-19 infection among trauma patients by timing of diagnosis, assess nosocomial exposure risk, and evaluate the impact of COVID-19 positive status on morbidity and mortality.

METHODS

Registry data from adults admitted 4/1/2020-10/31/2020 from 46 level I/II trauma centers were grouped by: timing of first positive status (Day 1, Day 2-6, or Day ≥ 7); overall Positive/Negative status; or Unknown if test results were unavailable. Groups were compared on outcomes (Trauma Quality Improvement Program complications) and mortality using univariate analysis and adjusted logistic regression.

RESULTS

There were 28 904 patients (60.7% male, mean age: 56.4, mean injury severity score: 10.5). Of 13 274 (46%) patients with known COVID-19 status, 266 (2%) were Positive Day 1, 119 (1%) Days 2-6, 33 (.2%) Day ≥ 7, and 12 856 (97%) tested Negative. COVID-19 Positive patients had significantly worse outcomes compared to Negative; unadjusted comparisons showed longer hospital length of stay (10.98 vs 7.47;P < .05), higher rates of intensive care unit (57.7% vs 45.7%; P < .05) and ventilation use (22.5% vs 16.9%; P < .05). Adjusted comparisons showed higher rates of acute respiratory distress syndrome (1.7% vs .4%; P < .05) and death (8.1% vs 3.4%; P < .05).

CONCLUSIONS

This multicenter study conducted during the early pandemic period revealed few trauma patients tested COVID-19 positive, suggesting relatively low exposure risk to care providers. COVID-19 positive status was associated with significantly higher mortality and specific morbidity. Further analysis is needed with consideration for care guidelines specific to COVID-19 positive trauma patients as the pandemic continues.

COST ANALYSIS OF MOTORCYCLE ACCIDENT VICTIMS AT A UNIVERSITY HOSPITAL: PERSPECTIVES FROM 2017 AND 2020

Introduction

Motorcycle accidents constitute a public health problem that affects public and private health services due to the expenses of the victim's treatment and rehabilitation.

Objective

Evaluate the impact of motorcycle accident costs in a university hospital in 2020.

Method

Comparative analysis of the costs of motorcycle accident patients in 2020 and 2017.

Results

Among 151 patients included in the study, the average cost was U$3,083.54, and the average days of hospitalization were 5.3 days. The patient with the highest cost to the hospital spent U$22,504.05, and the patient with the lowest cost spent U$356.72. The longest stay among these patients was 41 days, and the shortest was one day. The average cost per patient per day for the entire sample was U$581.80.

Conclusion

The formulation and application of strategies that promote the reduction of motorcycle accidents in the city of Campinas are necessary. Level of evidence II, Retrospective study.

Decreasing incidence rates of osteoporotic hip fractures in Ecuador during the COVID-19 pandemic

We aimed at comparing the incidence of hip fractures in older adults from Ecuador before and during the COVID-19 pandemic. There was a significant reduction in the number of hip fractures, with no change in the length of hospital stay, mortality, and case-fatality rate, during the period of social isolation.

INTRODUCTION

The impact that the COVID-19 pandemic has had on fragility fractures is being recently evaluated in the literature. Despite this, data from Latin America in this regard is scarce.

PURPOSE

This study aims to compare the incidence rate of hip fractures before and during the COVID-19 pandemic in older adults who received care in the public and private health system of Ecuador.

METHODS

This was a descriptive and retrospective study that analyzed data of individuals aged 60 years and older who had hip fractures before and during the COVID-19 pandemic. The information was obtained from the National Hospital Discharge Yearbook. We calculated the incidence, average length of hospital stay, mortality, and case-fatality rate associated with hip fractures.

RESULTS

There was a significant reduction in the incidence of hip fractures in adults 60 or older during the period of social isolation due to COVID-19. Between March and December 2019, there was an incidence of 152 hip fractures per 100,000 inhabitants, whereas during the same period but in 2020 in the incidence was 110 per 100,000 inhabitants (p < 0.0001). The main decrease was observed in women aged 80 or more. The average length of hospital stay did not show significant changes. Mortality displayed a non-significant decrease (p = 0.14), although this decrease was significant among women (p = 0.02). Case-fatality rate showed a non-significant increase for the whole group (p = 0.68) and for men (p = 0.09).

CONCLUSION

Hip fracture rates decreased significantly in adults aged 60 and older in 2020 compared to 2019. This decrease of hip fracture incidence rates was mainly due to the reductions observed in older people and women. The average length of hospital stay, mortality, and case-fatality rate associated with hip fractures did not show significant changes during the pandemic.

Positive SARS-CoV-2 detection on intraoperative nasopharyngeal viral testing is not associated with worse outcomes for asymptomatic elective surgical patients

Background

It has been demonstrated that surgical patients with COVID-19 are at increased risk for postoperative complications. However, this association has not been tested in asymptomatic elective surgical patients.

Methods

A retrospective cohort study among elective gynecological and spine surgery patients at a single tertiary medical center from July 2020 through April 2022 (n = 1,130) was performed. The primary endpoint was prolonged (>75th percentile for the corresponding surgical service) length of stay. Secondary endpoints included postoperative respiratory complications, duration of supplemental oxygen therapy, and other major adverse events. The association between SARS-CoV-2 detection and the above outcomes was investigated with univariate and multivariable analyses.

Findings

Of 1,130 patients who met inclusion criteria, 30 (2.7%) experienced intraoperative detection of SARS-CoV-2. Those with intraoperative viral detection did not experience an increased incidence of prolonged length of stay [16.7% vs. 23.2%; RR, 0.72 (95% CI, 0.32-1.61); P = 0.531] nor did they have a longer mean length of stay (4.1 vs. 3.9 days; P = 0.441). Rates of respiratory complications [3.3% vs. 2.9%; RR, 1.15 (95% CI, 0.16-8.11); P = 0.594] and mean duration of supplemental oxygen therapy (9.7 vs. 9.3 h; P = 0.552) were similar as well. All other outcomes were similar in those with and without intraoperative detection of SARS-CoV-2 (all P > 0.05).

Interpretation

Asymptomatic patients with incidental detection of SARS-CoV-2 on intraoperative testing do not experience disproportionately worse outcomes in the elective spine and gynecologic surgical population.

Outcomes of hip fracture surgery during the COVID-19 pandemic

PURPOSE

To investigate if changes to hospital operational models during the COVID-19 pandemic negatively impacted overall time to surgery (TtS) as well as morbidity and mortality rates of hip fractures (HFx).

METHODS

416 patients treated for OTA 31 fractures at a single institution between January 2019 and November 2020 were reviewed. TtS as well as morbidity and mortality rates were obtained from pre-pandemic and pandemic groups.

RESULTS

263 patients were treated pre-pandemic and 153 were treated during the pandemic. There were no significant differences in median TtS, readmission rates (p = 0.134), reoperation rates (p = 0.052), 30-day (p = 0.095) and 90-day (p = 0.22) mortality rates.

CONCLUSION

Reallocation of hospital resources in response to the COVID-19 pandemic did not negatively impact surgical timing or complications. TtS for HFx remains a challenge and often requires multidisciplinary care, which is complicated by a pandemic. However, this study demonstrates HFx standard of care can be maintained despite COVID-19 obstacles to treatment efficiency and efficacy.

Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study

OBJECTIVE

To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications.

DESIGN

Retrospective chart review.

SETTING

Eleven Level I trauma centers.

PATIENTS

From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included.

INTERVENTION

Reamed IMN.

MAIN OUTCOME MEASURES

Incidence of postoperative thromboembolic and respiratory complications.

RESULTS

Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days.

CONCLUSION

In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries.

LEVELS OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Coronavirus in hip fractures (CHIP) 4 : has vaccination improved mortality outcomes in hip fracture patients?

AIMS

Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.

METHODS

A multicentre observational study was carried out at 19 NHS Trusts in England. The study period for the data collection was 1 February 2021 until 28 February 2022, with mortality tracing until 28 March 2022. Data collection included demographic details, data points to calculate the Nottingham Hip Fracture Score, COVID-19 status, 30-day mortality, and vaccination status.

RESULTS

A total of 337 patients tested positive for COVID-19. The overall 30-day mortality in these patients was 7.7%: 5.5% in vaccinated patients and 21.7% in unvaccinated patients. There was no significant difference between post-vaccine mortality compared with pre-pandemic 2019 controls (7.7% vs 5.0%; p = 0.068). Independent risk factors for mortality included unvaccinated status, Abbreviated Mental Test Score ≤ 6, male sex, age > 80 years, and time to theatre > 36 hours, in decreasing order of effect size.

CONCLUSION

The vaccination programme has reduced 30-day mortality rates in hip fracture patients with concomitant COVID-19 infection to a level similar to pre-pandemic. Mortality for unvaccinated patients remained high.Cite this article: Bone Joint J 2022;104-B(12):1362-1368.

Changes in trends of orthopedic services due to the COVID-19 pandemic: A review

As of June 10, 2022, the World Health Organization has recorded over 532 million documented coronavirus disease 2019 (COVID-19) [(Coronavirus) SARS-CoV-2] cases and almost 6.3 million deaths worldwide, which has caused strain on medical specialties globally. The aim of this review is to explore the impact that COVID-19 has had on orthopedic practices. Providers observed a rapid decline in the number of orthopedic patients’ admissions due to cancellation of elective procedures; however, emergent cases still required treatment. Various observational studies, case reports, and clinical trials were collected through a PubMed database search. Additional sources were found through Google. The search was refined to publications in English and between the years of 2019 and 2021. The keywords used were “COVID-19” and/or “Orthopedic Injuries”. Thirty-seven studies were retained. The pandemic brought on significant changes to the mechanism of injury, number of admissions, type of injuries, and patient outcomes. Mortality rates significantly increased particularly amongst patients with hip fractures and COVID-19. Road traffic injuries remained a common cause of injury and domestic injuries became more prevalent with lockdown. Social isolation negatively affected mental health resulting in several orthopedic injuries. Telehealth services and separation for COVID-positive and COVID-negative patients benefited both patients and providers. While hospitals and medical facilities are still facing COVID-19 case surges, it is important to understand how this pandemic has impacted preparation, care, and opportunities for prevention education and ongoing care.

Traumatic Proximal Femoral Fractures during COVID-19 Pandemic in the US: An ACS NSQIP® Analysis

In order to determine the impact of COVID-19 on the treatment and outcomes in patients with proximal femoral fracture’s (PFF), we analyzed a national US sample. This is a retrospective review of American College of Surgery’s (ACS) National Surgical Quality Improvement Program (NSQIP) for patients with proximal femoral fractures. A total of 26,830 and 26,300 patients sustaining PFF and undergoing surgical treatment were sampled during 2019 and 2020, respectively. On multivariable logistic regression, patients were less likely to have ‘presence of non-healing wound’ (p < 0.001), functional status ‘independent’ (p = 0.012), undergo surgical procedures of ‘hemiarthroplasty’(p = 0.002) and ‘ORIF IT, Peritroch, Subtroch with plates and screws’ (p < 0.001) and to be ‘alive at 30-days post-op’ (p = 0.001) in 2020 as compared to 2019. Patients were more likely to have a case status ‘emergent’, ‘loss of ≥10% body weight’, discharge destination of ‘home’ (p < 0.001 for each) or ‘leaving against medical advice’ (p = 0.026), postoperative ‘acute renal failure (ARF)’ (p = 0.011), ‘myocardial infarction (MI)’ (p = 0.006), ‘pulmonary embolism (PE)’ (p = 0.047), and ‘deep venous thrombosis (DVT)’ (p = 0.049) in 2020 as compared to 2019. Patients sustaining PFF and undergoing surgical treatment during pandemic year 2020 differed significantly in preoperative characteristics and 30-day postoperative complications when compared to patients from the previous year.

No Excess Mortality in Geriatric Patients With Femoral Neck Fractures Due to Shorter Intensive Care Caused by COVID-19

Background

Since March 2020, increasing numbers of hospitalized patients with coronavirus disease-2019 (COVID-19) infections have been registered. The first and the second waves necessitated the extensive restructuring of hospital infrastructure with prioritization of intensive care capacity. Elective surgeries in all surgical disciplines were postponed to preserve intensive care capacity for COVID-19 patients. However, emergency care for trauma patients had to be maintained. Especially, geriatric patients with hip fractures often require intensive care.

This study sought to investigate the possible excess mortality of geriatric patients with femoral neck fractures due to shorter intensive care unit stays because of COVID-19.

Material and methods

All patients over the age of 70 between March 2019 and February 2020 who underwent surgical treatment for femoral neck fractures were included. This cohort (group 1) was compared with all patients over 70 who received surgical treatment for hip fractures during the period of the pandemic between March 2020 and February 2021 with attention to potential excess mortality due to low intensive care capacity (group 2). Demographic data, American Society of Anesthesiologists (ASA) score, surgical modality, ICU stay, complications, and mortality were analyzed and compared.

Results

A total of 356 patients with 178 in each cohort with a mean age of 82.7 in group 1 and 84.8 in group 2 (p<0.05) were included. No significant difference was seen in sex and ASA scores. During the pandemic, patients with hip fractures had a significantly shorter stay in ICU (0.4 ± 0.9 vs 1.2 ± 2.8 days; p<0.05), shorter time to surgery (29.9 ± 8.2 vs 16.8 ± 5.3 h; p<0.05) and operations were significantly more often performed out-of-hour (4 pm-12 am 47.8% vs 56.7%; 12 am-8 am 7.9% vs 13.5%, p<0.05). Interestingly, mortality was lower during the pandemic, but the difference did not reach significance (6.7% vs 12.4%, p=0.102).

Conclusion

During the pandemic, ICU capacity was reserved for COVID patients. Due to a change in the law of the Joint Federal Committee with effect from January 1, 2021, all patients with proximal femur fractures had to be operated on within the first 24 hours, which is why a significantly shorter time to surgery was observed during the pandemic period. As a consequence, a lower mortality rate was observed, although no significance could be reached.

Impact of the COVID-19 Pandemic on Mortality Following Hip and Knee Joint Arthroplasty Surgeries: A Systematic Review and Meta-Analysis

We performed a meta-analysis comparing the mortality rates after hip and knee joint arthroplasty between the coronavirus 2019 (COVID-19) pandemic and pre-pandemic periods. The purpose of present study was to investigate the impact of the COVID-19 pandemic on mortality rates after hip and knee joint arthroplasty. We systematically searched the MEDLINE, Embase, and Cochrane Library databases for studies published up to 28 March 2022. We included studies which directly compared mortality rates after hip and knee joint arthroplasty between the COVID-19 pandemic and pre-pandemic periods. The methodological quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies (MINORS). We compared the overall mortality rate as the primary outcome. For the subgroup analysis, the mortality rates included were: within 30 days and unrelated to COVID-19; we excluded studies with only elective arthroplasties. Readmission rates following arthroplasties were also compared. We included five studies with 3044 patients, of which 838 patients underwent surgeries during the pandemic period and 2206 patients underwent surgeries in the pre-pandemic period. The mean MINORS score was 15.4/24 (range: 15–16). The overall mortality rate showed no significant differences between the pandemic and pre-pandemic periods (OR, 2.71; 95% CI, 0.78–9.35; p = 0.12; I² = 19%). No differences were observed in mortality following arthroplasties within 30 days and unrelated to COVID-19 nor in the readmission rates. Mortality, after excluding studies with only elective arthroplasty, presented significant differences between the COVID-19 pandemic and pre-pandemic periods (OR, 3.80; 95% CI, 1.18–12.28; p = 0.03, I² = 0%). The limitation of the present study was that elective arthroplasty and urgent arthroplasty were not completely differentiated. The overall mortality rate in the COVID-19 pandemic period following hip and knee arthroplasty did not show a significant increase. This finding could help to maintain the practice of elective arthroplasty during a pandemic situation in the future (PROSPERO–CRD42022335471).

The Effects of COVID-19 on Geriatric Hip Fracture Management and 1-Year Mortality in Beijing

Objectives

Concerns about the coronavirus disease 2019 (COVID‐19) pandemic resulted in unprecedented challenges to the management of geriatric hip fractures. We aimed to evaluate the effects of the COVID‐19 surge on the time to surgery and 1 year mortality in geriatric patients with hip fracture at a large, urban Level 1 trauma center in Beijing, and to guide the management of geriatric hip fracture patients throughout the COVID‐19 pandemic.

Methods

This single‐center retrospective study included consecutive patients aged ≥65 years and injured 3 weeks prior to admission. Demographic and surgical data were collected between January 20 and May 31, 2020, and from the same period in 2019. Mortality data and functional status were collected at follow‐up of 1‐year after surgery. The primary outcomes were time to surgery and 1 year mortality.

Results

There were no significant differences in sex, fracture type, and surgical pattern between the 2020 (n = 261) and 2019 time‐matched (n = 307) cohorts. The time from admission to surgery was significantly delayed in the 2020 cohort compared with that in the 2019 cohort (48.9 h vs 20.5 h, p < 0.001). Fewer patients underwent surgery within 48 h in the 2020 cohort (65.5% vs 87.6%, p < 0.001). Surgical delay was also associated with an increased risk of inpatient complications (30.2% vs 20.8%, p = 0.010), however there was no significant difference in the 1‐year mortality rate, nor between pre‐injury and 1 year follow‐up mobility as assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre‐injury mobility levels.

Conclusions

The COVID‐19 pandemic has significantly increased the surgery waiting time for geriatric patients with hip fractures, which resulted in increased inpatient complications without a higher mortality rate within 1 year. This reinforces the importance of maintaining timely and protocolized care for geriatric hip fractures throughout any subsequent waves of the pandemic.

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

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

Comparative Outcomes and Surgical Timing for Operative Fragility Hip Fracture Patients during the COVID-19 Pandemic: A Retrospective Cohort Study

The COVID-19 pandemic had wide-reaching effects on healthcare delivery, including care for hip fractures, a common injury among older adults. This study characterized factors related to surgical timing and outcomes, length-of-stay, and discharge disposition among patients treated for operative hip fractures during the first wave of the COVID-19 pandemic, compared to historical controls. A retrospective, observational cohort study was conducted from 16 March-20 May 2020 with a consecutive series of 64 operative fragility hip fracture patients at three tertiary academic medical centers. Historical controls were matched based on sex, surgical procedure, age, and comorbidities. Primary outcomes included 30-day mortality and time-to-surgery. Secondary outcomes included 30-day postoperative complications, length-of-stay, discharge disposition, and time to obtain a COVID-19 test result. There was no difference in 30-day mortality, complication rates, length-of-stay, anesthesia type, or time-to-surgery, despite a mean time to obtain a final preoperative COVID-19 test result of 17.6 h in the study group. Notably, 23.8% of patients were discharged to home during the COVID-19 pandemic, compared to 4.8% among controls (p = 0.003). On average, patients received surgical care within 48 h of arrival during the COVID-19 pandemic. More patients were discharged to home rather than a facility with no change in complications, suggesting an opportunity for increased discharge to home.

Prior Diagnosis of COVID Has No Increased Complications in Total Joint Arthroplasty

Introduction

Although a substantial portion of the United States population has been infected with and recovered from Coronavirus Disease-19 (COVID-19), many patients may have persistent symptoms and complications from disease-driven respiratory disease, arrhythmias, and venous thromboembolism (VTE). With institutions resuming elective total joint arthroplasties (TJA), it is unclear whether a prior resolved diagnosis of COVID has any implications on postoperative outcomes.

Methods

All elective TJA performed in 2021 at our institution were retrospectively reviewed and a history of prior COVID+ result recorded. Baseline demographics, days from prior COVID+ result to surgery date, preoperative methicillin-resistant Staphylococcus aureus (MRSA) nares colonization, and laboratory markers were obtained to determine baseline characteristics. Postoperative estimated blood loss (EBL), length of stay (LOS), rate of revision surgery, and discharge destination were compared between groups. Perioperative and postoperative rates of VTE, urinary tract infection (UTI), pneumonia, postoperative oxygen supplementation, cardiac arrhythmia, renal disease, sepsis, and periprosthetic joint infections within six months of surgery were recorded.

Results

Of the 155 elective TJA performed in 2021, 24 patients had a prior COVID+ diagnosis with a mean of 253 days from positive result to surgery date. There were no significant differences in baseline demographics, comorbidities, and preoperative lab markers between groups. Surgeries on patients with a prior COVID+ had a significantly higher EBL (260 vs 175cc), but postoperative outcomes of VTE, UTI, pneumonia, oxygen supplementation requirement, nares MRSA+, cardiac disease, and infection rates between groups were similar. Bivariate logistic regression revealed increased days from COVID+ diagnosis (>6 months) to surgery date were associated with a shorter LOS.

Conclusion

Although a prior COVID+ diagnosis had increased intraoperative blood loss, there were no significant differences in respiratory, infectious, cardiac, and thromboembolic complications up to six months after elective TJA. This study suggests that asymptomatic C+ patients receiving elective TJA do not require more aggressive prophylactic anticoagulation or antibiotic regimens to prevent VTE or perioperative infections. As institutions around the nation resume pre-COVID rates of arthroplasty surgeries, a prior diagnosis of COVID appears to have no effects on postoperative complications.

Mortality in COVID-19 patients after proximal femur fracture surgery: a systematic review and meta-analysis

BACKGROUND

COVID-19 infection first emerged in December 2019 in China and has since rapidly spread to become a worldwide pandemic. Orthopaedic surgery suffered a significant decline in the volume of surgical cases, while the orthopaedic trauma services maintained or increased the activity. Emergency operations for proximal femur fractures (PFF) in the elderly population assumed levels comparable to before the pandemic, with the 1-year mortality rate ranging from 14% to 36%.

AIMS

To determine whether patients with PFF affected by COVID-19 have a higher risk of postoperative mortality through a systematic review and meta-analysis.

METHODS

PubMed, Web of Science, Scopus and BMC were searched from January 2020 to January 2021 to identify original studies reporting the mortality in COVID-19 patients after PFF surgery. Study and participants' characteristics, mortality rate and odds ratio (OR) were extracted. Risk of bias assessment was carried, and visual inspection of the funnel plot was used to assess publication bias. A random-effects model for meta-analysis was adopted.

RESULTS

Among 656 articles that came from the search query and hand-search, 10 articles were eligible after applying inclusion and exclusion criteria. Overall, the sum of the study participants was 1882, with 351 COVID-19 positive patients (18.7%) and a total number of 117 deaths, with an overall mortality rate of 33.3%. The mortality rate of COVID-19 positive patients varied from 14.8% to 60% and was higher than of those without COVID-19, with OR ranging from 2.424 to 72.00. The inverse variance method showed an OR = 3.652. All studies showed a statistically significant p-value.

CONCLUSIONS

The postoperative mortality in hip fracture patients with concomitant COVID-19 was 3.65 times higher than the mortality in non-COVID patients. The currently available literature demonstrates that COVID-19 infection represents a substantial risk factor for postoperative mortality in the already susceptible hip fracture population.

Hospital length of stay for COVID-19 patients: A systematic review and meta-analysis

The length of stay in the hospital for COVID-19 can aid in understanding the disease's prognosis. Thus, the goal of this study was to collectively estimate the hospital length of stay (LoS) in COVID-19 hospitalized individuals. To locate related studies, international databases (including Google Scholar, Science Direct, PubMed, and Scopus) were searched. The I² index, the Cochran Q test, and T² were used to analyze study heterogeneity. The mean LoS in COVID- 19 hospitalized patients was estimated using a random-effects model. COVID-19's total pooled estimated hospital LoS was 15.35, 95%CI:13.47-17.23; p<0.001, I² = 80.0). South America had the highest pooled estimated hospital LoS of COVID-19 among the continents, at 20.85 (95%CI: 14.80-26.91; p<0.001, I² = 0.01), whereas Africa had the lowest at 8.56 8 (95%CI: 1.00-22.76). The >60 age group had the highest pooled estimated COVID-19 hospital LoS of 16.60 (95%CI: 12.94-20.25; p<0.001, I² = 82.6), while the 40 age group had the lowest hospital LoS of 10.15 (95% CI: 4.90-15.39, p<0.001, I² = 22.1). The metanalysis revealed that COVID-19's hospital LoS was more than 10 days. However, it appears that this duration varies depending on a number of factors, including the patient's age and the availability of resources.

Speculation on the pathophysiology of musculoskeletal injury with COVID-19 infection

Coronavirus disease 2019 (COVID-19) primarily affects the respiratory tract, but also many other organs and tissues, leading to different pathological pictures, such as those of the musculoskeletal tissues. The present study should be considered as a speculation on the relationship between COVID-19 infection and some frequent musculoskeletal pathologies, in particular sarcopenia, bone loss/osteoporosis (OP) and fracture risk and osteoarthritis (OA), to hypothesize how the virus acts on these pathologies and consequently on the tissue regeneration/healing potential. The study focuses in particular on the modalities of interaction of COVID-19 with Angiotensin-Converting Enzyme 2 (ACE2) and on the “cytokine storm.” Knowing the effects of COVID-19 on musculoskeletal tissues could be important also to understand if tissue regenerative/reparative capacity is compromised, especially in elderly and frail patients. We speculate that ACE2 and serine proteases together with an intense inflammation, immobilization and malnutrition could be the responsible for muscle weakness, altered bone remodeling, increase in bone fracture risk and inflammatory joint pathologies. Future preclinical and clinical studies may focus on the regenerative/reparative properties of the musculoskeletal tissues after COVID-19 infection, toward a personalized treatment usually based on scaffolds, cells, and growth factors.

Seasonality Affects Elderly Hip Fracture Mortality Risk During the COVID-19 Pandemic

Background

The incidence of geriatric hip fractures, respiratory infections (e.g., coronavirus disease 2019 (COVID-19), influenza), and mortality is higher during the fall and winter. The purpose of this study is to assess whether the addition of seasonality to a validated geriatric inpatient mortality risk tool will improve the predictive capacity and risk stratification for geriatric hip fracture patients. We hypothesize that seasonality will improve the predictive capacity.

Methodology

Between October 2014 and August 2021, 2,421 patients >55-year-old treated for hip fracture were analyzed for demographics, date of presentation, COVID-19 status (for patients after February 2020), and mortality. Patients were grouped by season based on their admission dates into the following four cohorts: fall (September-November), winter (December-February), spring (March-May), and summer (June-August). Patients presenting during the fall/winter and spring/summer were compared. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMAHIP_FX_SCORE) and the seasonality iteration (STTGMA_SEASON) were also compared. Sub-analysis was conducted on 687 patients between February 2020 and August 2021 amid the COVID-19 pandemic. The baseline score (STTGMAHIP_FX_SCORE) and the COVID-19 iteration (STTGMACOVID_ORIGINAL_2020) were modified to include seasonality (STTGMA_COVID/SEASON). Patients were stratified by risk score and compared. The predictive ability of the models was compared using DeLong’s test.

Results

For the overall cohort, patients who presented during the fall/winter had a higher rate of inpatient mortality (2.87% vs. 1.25%, p < 0.01). STTGMA_SEASON improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE but not significantly (0.773 vs. 0.672, p = 0.105) On sub-analysis, regression weighting showed a coefficient of 0.643, with fall and winter having a greater absolute effect size (fall = 2.572, winter = 1.929, spring = 1.286, summer = 0.643). STTGMA_COVID/SEASON improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.882 vs. 0.581, p < 0.01) and STTGMACOVID_ORIGINAL_2020 (0.882 vs. 0.805, p = 0.04). The highest risk quartile contained 89.5% of patients who expired during their index inpatient hospitalization (p < 0.01) and 68.2% of patients who died within 30 days of discharge (p < 0.01).

Conclusions

Seasonality may play a role in both the incidence and impact of COVID-19 and additional respiratory infections. Including seasonality improves the predictive capacity and risk stratification of the STTGMA tool during the COVID-19 pandemic. This allows for effective triage and closer surveillance of high-risk geriatric hip fracture patients by better accounting for the increased respiratory infection incidence and the associated mortality risk seen during fall and winter.