Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

Shall We Not Pressurize It? Effects of Bone Cement Pressurization on Mortality and Revision After Hip Hemiarthroplasty for Neck of Femur Fracture Patients: A Comparative Cohort Study

OBJECTIVES

This study aimed to compare 30-day postoperative mortality, and revision for aseptic femoral component loosening and all-causes after hip hemiarthroplasty, performed with or without pressurization of the bone cement, in patients with neck of femur fracture.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients ≥60 years with OTA/AO 31B who underwent a cemented hip hemiarthroplasty from December 10, 2007 (database inception) to November 15, 2023 (search date) were reviewed.

OUTCOME MEASURES AND COMPARISONS

Comparisons were made between patients who underwent hip hemiarthroplasty with versus without pressurization of the bone cement for outcomes 30-day postoperative mortality, revision for aseptic femoral component loosening, and revision for all-causes.

RESULTS

There were 406 procedures among 402 patients, and 722 procedures among 713 patients that were performed with and without pressurization of the bone cement, respectively. Mean ages were 83.1 and 84.3 years ( P = 0.018), with 72.2% and 68.6% ( P = 0.205) women in the pressurized and non-pressurized cement patient groups, respectively. There were no differences in 30-day postoperative mortality (7.2% vs. 8.2%; HR 0.89, 95% CI 0.46-1.73, P = 0.727). There were no differences in all-cause revision (HR 1.04, 95% CI 0.27-4.04, P = 0.953). No revisions were performed for aseptic loosening. Survival at 10 years postoperatively was 15.3% (95% CI 11.46-19.64) and 12.6% (95% CI 7.67-18.82) among patients who underwent hemiarthroplasty with and without bone cement pressurization, respectively.

CONCLUSIONS

There were no differences in 30-day postoperative mortality among patients who underwent hemiarthroplasty with, compared to, without bone cement pressurization. Bone cement pressurization did not confer any advantages for revision outcomes that may be attributed, in part, to patients' high mortality rate and low survival beyond 10 years postoperatively.

LEVEL OF EVIDENCE

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

Effects of COVID-19 Status on Hip Fracture Surgical Outcomes: An ACS NSQIP Study

BACKGROUND

Studies have indicated that patients infected with the SARS-CoV-2 virus fare worse clinically after a traumatic injury, especially those who are older and have other comorbidities.

OBJECTIVE

This study aims to understand the effects of Corona Virus Disease 19 (COVID-19) diagnosis on patients undergoing surgery for hip fractures.

METHODS

This is a retrospective review of the 2021 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Targeted Hip Fracture database for patients who underwent surgery. Two cohorts were formed based on patients' preoperative COVID-19 status, as tested within 14 days prior to the operation. Several clinical factors were compared.

RESULTS

The COVID-positive cohort consisted of 184 patients, all of whom had a laboratory-confirmed or clinically suspected SARS-CoV-2 infection, while the COVID-negative cohort consisted of 12,211 patients with no infection. A lower proportion of COVID-positive patients had an emergent operation compared to the COVID-negative cohort (58.70% vs. 73.09%, p < .001). Preoperatively, the COVID-positive cohort showed higher rates of coagulopathy/bleeding disorders (22.83% vs. 14.12%), congestive heart failure (16.30% vs. 9.84%), diabetes mellitus (28.26% vs. 19.24%), and dementia (42.39% vs. 28.07%), with p ≤ .005 for all. Postoperatively, a higher proportion of COVID-positive patients died (9.78% vs. 5.40%) or had pneumonia (8.70% vs. 3.65%), hospital readmission within 30 days (10.87% vs. 6.76%), and pressure sores (8.15% vs. 4.55%), with p ≤ .033 for all.

CONCLUSION

The diagnosis of COVID-19 in hip fracture patients was associated with higher rates of postoperative complications, including mortality, when compared to COVID-negative patients, indicating the severity of the viral infection.

Lessons Learned in Elective Surgeries After 6 Pandemic Waves of SARS-CoV-2. A Single European Center Experience

BACKGROUND

The reported high surgical morbidity and mortality in patients with SARS-CoV-2 prompted preoperative screening and modification of surgical protocols. Although vaccination and treatment of COVID-19 have resulted in lower hospitalization rates and infection severity, publications on postoperative results have not been updated. The aim of the study was to analyze the outcomes of patients undergoing surgery in two periods with high incidence of SARS-CoV-2 infection, before and after vaccination.

MATERIALS AND METHODS

This is a prospective cohort study of patients undergoing surgery in two periods: March-June 2020 (Group2020) and December 2021-February 2022 (Group2022) (after massive vaccination).

RESULTS

In total, 618 patients who underwent surgery were included in the analysis (Group2020: 343 vs. Group2022: 275). Significantly more oncological procedures were performed in Group2020, and there were no differences in postoperative complications. Nosocomial SARS-CoV-2 infection occurred in 4 patients in Group2020 and 1 patient in Group2022. In Group 2022, 70 patients (25.4%) had COVID-19 prior to surgery, and 68 (97.1%) were vaccinated. Comparative analysis between patients with past COVID-19 and those without showed no difference in postoperative morbidity and mortality. According to the time elapsed between SARS-CoV-2 infection and surgery (≤ 7 or > 7 weeks), comparative analysis showed no significant differences.

CONCLUSION

The establishment of preoperative screening protocols for SARS-CoV-2 infection results in a low incidence of nosocomial infection and optimal postoperative outcomes. Preoperative SARS-CoV-2 infection in vaccinated patients was not associated with increased postoperative complications, even in shorter periods after infection. In surgical patients, individualized preoperative evaluation after SARS-CoV-2 infection may be more important than strict time limitation.

The impact of Covid-19 in proximal femur fractures. An observational study of the mortality rate

BACKGROUND AND AIM

Fractures of the proximal femur in the elderly are probably the leading cause of death in the orthopedic patients. Furthermore, after the spread of the pandemic, the mortality rate in the elderly has certainly increased. The aim of our study is to evaluate whether the mortality following proximal femur fractures is affected by the concomitant pandemic.

METHODS

We admitted to our study patients over 65 years old, who presented to our Emergency Room with a diagnosis of proximal femur fracture in the first quarter of the years 2019, the period before the development of the pandemic, of 2020 during the pandemic and of 2021 with the new wave of Covid-19. 2022 was not taken into consideration because the mortality data are not yet available and to have at least one year follow-up after surgery. All patients were divided by fracture's type and treatment; the time elapsed from trauma to surgery and from trauma to discharge was also evaluated. For each deceased patient, we considered the time elapsed from the operation to death and whether there was an episode of positivity to Covid-19 following the trauma and after discharge (all patients had a negative swab at the time of admission).

CONCLUSIONS

Fractures of the proximal femur in the elderly patient are undoubtedly an important cause leading to the death. The spreading of the Covid-19 pandemic has allowed our department to reduce the gap between trauma and intervention time and from trauma to discharge which is undoubtedly a positive prognostic factor. However, the concurrence of a positivity from the virus does not seem to influence the mortality times following the fracture.

The Impact of COVID-19 on the Prevalence, Mortality, and Associated Risk Factors for Mortality in Patients with Hip Fractures: A Meta-Analysis

OBJECTIVE

This study aimed to assess (1) the prevalence of COVID-19 in patients with hip fracture; (2) the mortality rate of patients with hip fracture associated with COVID-19; (3) risk factors associated with mortality in patients with hip fracture; and (4) the effects of COVID-19 on surgical outcomes of patients with hip fracture.

DESIGN

Meta-analysis.

SETTING AND PARTICIPANTS

Patients with hip fractures during COVID-19.

METHODS

PubMed, Web of Science, and Embase were systematically reviewed. The outcomes included the prevalence of COVID-19, case fatality rate, 30-day mortality, cause of death, risk factors associated with the mortality of patients with hip fracture, time to surgery, surgical time, and length of hospitalization. Risk ratio or weight mean difference with 95% confidence intervals were used to pool the estimates.

RESULTS

A total of 60 studies were included in this meta-analysis. The pooled estimate showed that the prevalence of COVID-19 was 21% in patents with hip fractures. Patients with hip fracture with COVID-19 had an increased 30-day mortality risk compared with those without the infection. The main causes of death were respiratory failure, COVID-19-associated pneumonia, multiorgan failure, and non-COVID-19 pneumonia. The hospitalization was longer in patients with COVID-19 when compared with those without the infection, but was shorter in patients during the pandemic period. The surgery time and time to surgery were not significantly different between patients during or before the pandemic period and in those with or without COVID-19.

CONCLUSIONS AND IMPLICATIONS

The 30-day mortality rate was significantly higher in patients with hip fracture with COVID-19 infection than those without. Patients with COVID-19 had a higher all-cause mortality rate than those without. This information can be used by the medical community to guide the management of patients with hip fracture with COVID-19.

SARS-CoV-2 susceptibility and COVID-19 illness course and outcome in people with pre-existing neurodegenerative disorders: systematic review with frequentist and Bayesian meta-analyses

BACKGROUND

People with neurodegenerative disease and mild cognitive impairment (MCI) may have an elevated risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and may be disproportionally affected by coronavirus disease 2019 (COVID-19) once infected.

AIMS

To review all eligible studies and quantify the strength of associations between various pre-existing neurodegenerative disorders and both SARS-CoV-2 susceptibility and COVID-19 illness course and outcome.

METHOD

Pre-registered systematic review with frequentist and Bayesian meta-analyses. Systematic searches were executed in PubMed, Web of Science and preprint servers. The final search date was 9 January 2023. Odds ratios (ORs) were used as measures of effect.

RESULTS

In total, 136 primary studies (total sample size n = 97 643 494), reporting on 268 effect-size estimates, met the inclusion criteria. The odds for a positive SARS-CoV-2 test result were increased for people with pre-existing dementia (OR = 1.83, 95% CI 1.16-2.87), Alzheimer's disease (OR = 2.86, 95% CI 1.44-5.66) and Parkinson's disease (OR = 1.65, 95% CI 1.34-2.04). People with pre-existing dementia were more likely to experience a relatively severe COVID-19 course, once infected (OR = 1.43, 95% CI 1.00-2.03). People with pre-existing dementia or Alzheimer's disease were at increased risk for COVID-19-related hospital admission (pooled OR range: 1.60-3.72). Intensive care unit admission rates were relatively low for people with dementia (OR = 0.54, 95% CI 0.40-0.74). All neurodegenerative disorders, including MCI, were at higher risk for COVID-19-related mortality (pooled OR range: 1.56-2.27).

CONCLUSIONS

Our findings confirm that, in general, people with neurodegenerative disease and MCI are at a disproportionally high risk of contracting COVID-19 and have a poor outcome once infected.

The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery

PURPOSE

For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data.

METHODS

A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance.

RESULTS

Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations.

CONCLUSION

The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.

COVID-19 Elderly Patients Treated for Proximal Femoral Fractures during the Second Wave of Pandemic in Italy and Iran: A Comparison between Two Countries

Background and objevtive: The worldwide spread of SARS-CoV-2 has affected the various regions of the world differently. Italy and Iran have experienced a different adaptation to coexistence with the pandemic. Above all, fractures of the femur represent a large part of the necessary care for elderly patients. The aim of this study was to compare the treatment in Italy and Iran of COVID-19-positive patients suffering from proximal femur fractures in terms of characteristics, comorbidities, outcomes and complications. Materials and Methods: Medical records of COVID-19-positive patients with proximal femoral fractures treated at IRCCS Istituto Ortopedico Galeazzi in Milan (Italy) and at Salamat Farda and Parsa hospitals in the province of Tehran (Iran), in the time frame from 1 October 2020 to 16 January 2021, were analyzed and compared. Results: Records from 37 Italian patients and 33 Iranian patients were analyzed. The Italian group (mean age: 83.89 ± 1.60 years) was statistically older than the Iranian group (mean age: 75.18 ± 1.62 years) (p value = 0.0003). The mean number of transfusions for each patient in Italy was higher than the Iranian mean number (p value = 0.0062). The length of hospital stay in Italy was longer than in Iran (p value < 0.0001). Furthermore, laboratory values were different in the post-operative value of WBC and admission and post-operative values of CRP. Conclusions: The present study shows that differences were found between COVID-19-positive patients with proximal femoral fractures in these two countries. Further studies are required to validate these results and to better explain the reasons behind these differences.