Mortality and pulmonary complications in patients undergoing upper extremity surgery at the peak of the SARS-CoV-2 pandemic in the UK: a national cohort study

COVID-19 and Mortality in the Global Surgical Population: A Systematic Review and Meta-Analysis

INTRODUCTION

To date, no systematic review or meta-analysis has comprehensively estimated the risk of mortality by surgery type on an international scale. We aim to delineate the risk of mortality in patients with COVID-19 who undergo surgery.

METHODS

PubMed (MEDLINE), Scopus, OVID, the World Health Organization Global Literature on Coronavirus Disease, and Corona-Central databases were searched from December 2019 through January 2022. Studies providing data on mortality in patients undergoing surgery were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for abstracting data were followed and performed independently by two reviewers. The main outcome was mortality in patients with COVID-19.

RESULTS

Of a total of 4023 studies identified, 46 studies with 80,015 patients met our inclusion criteria. The mean age was 67 y; 57% were male. Surgery types included general (14.9%), orthopedic (23.4%), vascular (6.4%), thoracic (10.6%), and urologic (8.5%). Patients undergoing surgery with COVID-19 elicited a nine-fold increased risk of mortality (relative risk [RR] 8.99, 95% confidence interval [CI] 4.96-16.32) over those without COVID-19. In low-income and middle-income countries (RR: 16.04, 95% CI: 4.59-56.12), the mortality risk was twice as high compared to high-income countries (RR: 7.50, 95% CI: 4.30-13.09).

CONCLUSIONS

Mortality risk in surgical patients with COVID-19 compared to those without is increased almost 10-fold. The risk was highest in low-income and middle-income countries compared to high-income countries, suggesting a disproportionate effect of the pandemic on resource-constrained regions.

The rise in trauma & orthopaedic trainee-led research and audit collaborative projects in the United Kingdom since the start of the COVID-19 pandemic

Background and Objective

A significant increase has been observed globally in multi-centre trainee-led trauma & orthopaedic (T&O) research collaborative projects with more emphasis have been on tackling important research questions since the start of the COCID-19 pandemic. The objective of our analysis was to determine the number of trainee-led research collaborative projects in T&O in the United Kingdom that were started during the COVID-19 pandemic.

Methods

A retrospective analysis was conducted to determine how many trainee-led national collaborative projects in T&O were conducted since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021) and the number of projects identified were compared to the previous year (2019). Any regional collaborative projects, projects that were started before the onset of COVID and projects of other surgical specialities were not included in the study.

Results

There were no projects identified in 2019 while in the Covid pandemic lockdown we identified 10 trainee-led collaborative trauma & orthopaedic projects with six of them being published with level of evidence from three to four.

Conclusion

Covid was unprecedented and has placed considerable trials across healthcare. Our study highlights an increase in multi-centre trainee-led collaborative projects within the UK and it underlines the feasibility of such projects especially with the advent of social media and Redcap® which facilitate recruitment of new studies and data.

COVID-19 Vaccination: Does It Alter Postoperative Mortality and Morbidity in Hip Fractures?

Introduction The primary aim of our study was to evaluate the impact of coronavirus disease 2019 (COVID-19) vaccination on mortality in patients with hip fractures by comparing it to those who are unvaccinated. Our secondary objective was to compare the impact on postoperative morbidity parameters like length of hospital stay and complications. Methods A total of 619 hip fractures were divided into the 'Vaccinated group' consisting of 300 patients who had COVID-19 vaccination and the 'Unvaccinated group' consisting of 319 patients who were not vaccinated. Patient demographic variables, Nottingham hip fracture score, American Society of Anesthesiologists (ASA) grade, type of anaesthesia used, and Charlson Comorbidity Index were collected. Our primary outcome measures were 30- and 90-day mortality. Secondary outcome measures included postoperative complications like thromboembolic complications, cardiac, and respiratory complications, etc. Mortality among the COVID-positive patients was also compared between the groups. Results Thirty-day postoperative mortality was higher in the unvaccinated group at 13.2% than in the vaccinated group at 5.3%. A similar increase in 90-day mortality was also observed in the unvaccinated group at 24.8% when compared to 14.7% in the vaccinated group(p<0.001). Despite having a higher baseline prevalence of cardiac comorbidities, the Vaccinated group had fewer post-operative cardiac, thromboembolic, and neurological complications (p>0.05). Moreover, electrolyte imbalance and AKI were also seen in fewer patients in the vaccinated group compared to the control group (p<0.05). Furthermore, it was found that among the vaccinated patients who did have perioperative COVID-19 infection, the 30-day mortality was significantly lower (10%) compared to the control group (31.2%) (p<0.001). Similarly, 90-day mortality was significantly lower (25%) compared to the control group (43.75%) (p<0.001). Conclusion Vaccination against COVID-19 independently reduced mortality and morbidity among patients with hip fractures when compared to those who are not vaccinated. Furthermore, it decreased the risk of acquiring COVID-19, and subsequent postoperative complications. Among those who are infected with COVID-19 despite vaccination, the mortality was significantly lesser.

The UK foot and ankle COVID-19 national (FAlCoN) audit - Regional variations in COVID-19 infection and national foot and ankle surgical activity

AIMS

This paper details the impact of COVID-19 on foot and ankle activity in the UK. It describes regional variations and COVID-19 infection rate in patients undergoing foot and ankle surgery before, during and after the first national lock-down.

PATIENTS & METHODS

This was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13th January and 31st July 2020. Data was examined pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Regional, demographic and COVID-19 related data were captured.

RESULTS

6644 patients were included. In total 0.53% of operated patients contracted COVID-19 (n = 35). The rate of COVID-19 infection was highest during lockdown (2.11%, n = 16) and lowest after lockdown (0.16%, n = 3). Overall mean activity during lockdown was 24.44% of pre-lockdown activity with decreases in trauma, diabetic and elective foot and ankle surgery; the change in elective surgery was most marked with only 1.73% activity during lock down and 10.72% activity post lockdown as compared to pre-lockdown. There was marked regional variation in numbers of cases performed, but the proportion of decrease in cases during and after lockdown was comparable between all regions. There was also a significant difference between rates of COVID-19 and timing of peak, cumulative COVID-19 infections between regions with the highest rate noted in South East England (3.21%). The overall national peak infection rate was 1.37%, occurring during the final week of lockdown. General anaesthetic remained the most common method of anaesthesia for foot and ankle surgery, although a significant increase in regional anaesthesia was witnessed in the lock-down and post-lockdown periods.

CONCLUSIONS

National surgical activity reduced significantly for all cases across the country during lockdown with only a slow subsequent increase in elective activity. The COVID-19 infection rate and peaks differed significantly across the country.

Impact of COVID-19 on acute trauma and orthopaedic referrals and surgery in the UK during the first wave of the pandemic: a multicentre observational study from the COVid Emergency-Related Trauma and orthopaedics (COVERT) Collaborative

OBJECTIVE

This is the first British multicentre study observing the impact of the COVID-19 pandemic on orthopaedic trauma with respect to referrals, operative caseload and mortality during its peak.

DESIGN

A longitudinal, multicentre, retrospective, observational, cohort study was conducted during the peak 6 weeks of the first wave from 17 March 2020 compared with the same period in 2019.

SETTING

Hospitals from six major urban cities were recruited around the UK, including London.

PARTICIPANTS

A total of 4840 clinical encounters were initially recorded. 4668 clinical encounters were analysed post-exclusion.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes included the number of acute trauma referrals and those undergoing operative intervention, mortality rates and the proportion of patients contracting COVID-19. Secondary outcomes consisted of the mechanism of injury, type of operative intervention and proportion of aerosolising-generating anaesthesia used.

RESULTS

During the COVID-19 period, there was a 34% reduction in acute orthopaedic trauma referrals compared with 2019 (1792 down to 1183 referrals), and a 29.5% reduction in surgical interventions (993 down to 700 operations). The mortality rate was more than doubled for both risk and odds ratios during the COVID-19 period for all referrals (1.3% vs 3.8%, p=0.0005) and for those undergoing operative intervention (2.2% vs 4.9%, p=0.004). Moreover, mortality due to COVID-19-related complications (vs non-COVID-19 causes) had greater odds by a factor of at least 20 times. For the operative cohort during COVID-19, there was an increase in odds of aerosolising-generating anaesthesia (including those with superimposed regional blocks) by three-quarters, as well as doubled odds of a consultant acting as the primary surgeon.

CONCLUSION

Although there was a reduction of acute trauma referrals and those undergoing operative intervention, the mortality rate still more than doubled in odds during the peak of the pandemic compared with the same time interval 1 year ago.

Impact of the National Lockdown Due to the COVID-19 Pandemic On Upper Limb Trauma Workload in Central London: A Multi-Centre Longitudinal Observational Study During Implementation and Ease of National Lockdown

BACKGROUND

This study assessed the impact of the COVID-19 pandemic on acute upper limb referrals and operative case-mix at the beginning and ease of British lockdown.

METHODS

A longitudinal multicentre observational cohort study was conducted for both upper limb trauma referrals and operative case-mix over a 12-week period (6 weeks from the beginning and 6 weeks from the ease of the national lockdown). Statistical analysis included median (± median absolute deviation), risk and odds ratios, and Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05.

RESULTS

There was a 158% (n = 456 vs. 177) increase in upper limb referrals and 133% (n = 91 vs. 39) increase in the operative trauma caseload at the ease of lockdown compared with its commencement. An increase in sporting injuries was demonstrated (p=0.02), specifically cycling (p=0.004, OR=2.58). A significant increase in COVID-19 testing was demonstrated during the ease of lockdown (p=0.0001) with more patients having their management changed during the beginning of the pandemic (9.6% vs. 0.7%, p=0.0001). Of these patients, 47% went on to have delayed surgery within 6 months. No patients who underwent surgery tested positive for COVID-19 infection within 14 days post-operatively and no mortalities were recorded at 30 days.

CONCLUSION

The ease of lockdown has seen upper limb referrals and operations more than double compared to early lockdown. With no patients testing positive for COVID-19 within 14 days of the procedure, this demonstrates that having upper limb surgery during the current pandemic is safe.

The management of suspected scaphoid fractures in the UK: a national cross-sectional study

AIMS

Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance.

METHODS

This national cross-sectional study was carried out at 87 NHS centres in the UK involving 122 EDs and 184 minor injuries units (MIUs). The primary outcome was availability of MRI imaging direct from the ED. We also report the specifics of patient management pathways for suspected scaphoid fractures in EDs, MIUs, and orthopaedic services. Overall, 62 of 87 centres (71%) had a guideline for the management of suspected scaphoid fractures.

RESULTS

A total of 11 of 87 centres (13%) had MRI directly available from the ED. Overall, 14 centres (17%) used cross-sectional imaging direct from the ED: MRI in 11 (13%), CT in three (3%), and a mixture of MRI/CT in one (1%). Four centres (6%) used cross-sectional imaging direct from the MIU: MRI in three (4%) and CT in two (2%). Of 87 centres' orthopaedic specialist services, 74 (85%) obtained repeat radiographs, while the most common form of definitive imaging used was MRI in 55 (63%), CT in 16 (19%), mixture of MRI/CT in three (3%), and radiographs in 11 (13%).

CONCLUSION

Only a small minority of centres currently offer MRI directly from the ED for patients with a suspected scaphoid fracture. Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance. Cite this article: Bone Jt Open 2021;2(11):997-1003.

Risk of surgical site infection in hand trauma, and the impact of the SARS-CoV-2 pandemic: A cohort study

BACKGROUND

Despite the ubiquity of hand trauma, there remains insufficient published data to reliably inform these patients of surgical site infection (SSI) risk. We describe the risk of SSI in a single-centre cohort of patients with hand trauma, with an analysis of the impact of the coronavirus disease-2019 (COVID-19) pandemic.

METHODS

Retrospective data collection of consecutive patients who underwent surgery for hand and wrist trauma in a single plastic surgery centre over two, three-month periods. Demographic, injury and operative details, alongside prophylactic antibiotic use, were recorded. Burn injuries and wounds infected at presentation were excluded. Presence of SSI at 30 days (90 days if a surgical implant was used) was assessed.

RESULTS

Overall, 556 patients - 'Pre-COVID-19' (n = 310) and 'During COVID-19' (n = 246) - were included. Risk of SSI was 3.6% in the aggregated cohort. Female patients were more likely to develop an SSI, even when adjusted for their greater prevalence of bite aetiologies (adj OR 2.5; 95% CI, 1.00-6.37 and p < 0.05). The absolute risk of SSI in the 'Pre-COVID-19' group was 2.3% and 5.3% in the 'During COVID-19' group. The relative risk of developing an SSI in the 'During COVID-19' group was 2.34 (95% CI, 0.95-5.78 and p = 0.06). Baseline characteristics were equivalent between the two groups.

CONCLUSION

The risk of SSI in hand trauma is the same as the nationally estimated risk for all surgeries; 3-5%. Changes in presentation and practice associated with the first wave of the COVID-19 pandemic did not appear to alter the risk of SSI in patients undergoing surgery for hand trauma.

Mortality after surgery with SARS-CoV-2 infection in England: a population-wide epidemiological study

BACKGROUND

The COVID-19 pandemic has heavily impacted elective and emergency surgery around the world. We aimed to confirm the incidence of perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and associated mortality after surgery.

METHODS

Analysis of routine electronic health record data from NHS hospitals in England. We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between January 1, 2020 and February 28, 2021. The exposure was SARS-CoV-2 infection defined by International Classification of Diseases (ICD)-10 codes. The primary outcome measure was 90 day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, Index of Multiple Deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

We identified 2 666 978 patients undergoing surgery of whom 28 777 (1.1%) had SARS-CoV-2 infection. In total, 26 364 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 6153/28 777 [21.4%] vs no SARS-CoV-2: 20 211/2 638 201 [0.8%]; OR=5.7 [95% CI, 5.5-5.9]; P<0.001). Amongst patients undergoing elective surgery, 2412/1 857 586 (0.1%) had SARS-CoV-2, of whom 172/2412 (7.1%) died, compared with 1414/1 857 586 (0.1%) patients without SARS-CoV-2 (OR=25.8 [95% CI, 21.7-30.9]; P<0.001). Amongst patients undergoing emergency surgery, 22 918/582 292 (3.9%) patients had SARS-CoV-2, of whom 5752/22 918 (25.1%) died, compared with 18 060/559 374 (3.4%) patients without SARS-CoV-2 (OR=5.5 [95% CI, 5.3-5.7]; P<0.001).

CONCLUSIONS

The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed.

The UK Foot and Ankle COVID-19 National (FAlCoN) audit

Aims

The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.

Methods

This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates.

Results

A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19.

Conclusion

COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions.

Cite this article: Bone Joint Open 2021;2(4):216–226.