Mortality Rates of Patients with Proximal Femoral Fracture in a Worldwide Pandemic: Preliminary Results of the Spanish HIP-COVID Observational Study

The Impact of the COVID-19 Pandemic on One-Year Mortality in Geriatric Hip Fracture: A Retrospective Cohort Study

Introduction

The COVID-19 pandemic has profoundly impacted global healthcare systems, necessitating substantial shifts in patient care strategies. The pandemic's onset led to drastic operational changes in hospitals, including reduced bed capacity and staffing levels, which could have further influenced the mortality outcomes for geriatric patients. The study aimed to assess the impact of the COVID-19 pandemic on 1-year mortality rates of surgically treated geriatric hip fractures.

Methods

This retrospective, single-center cohort study included 346 participants aged 65 and above who underwent surgical treatment for hip fractures. We compared mortality rates between the pre-COVID and COVID eras. Data included demographics, treatment, complications, and COVID-19 status. The independent samples t test and Chi-square tests (or Fisher's exact test) were used for comparisons for era cohorts. Survival probabilities were assessed using Kaplan-Meier, while multivariate analysis identified mortality predictors.

Results

175 patients were included in the pre-COVID era, and 171 patients were included in the COVID era. During the COVID era, the 30-day mortality rate was 11.7% (compared to 13.7% in the pre-COVID era, p = 0.573), and the 1-year mortality rate was 43.9% (compared to 49.1% in the pre-COVID era, p = 0.325). The overall 1-year mortality rate was 46.5%. Patients who underwent surgery within 48 hours had a higher 1-year survival rate (60.5%) compared to those with delayed surgery (51.2%), p = 0.031. Additionally, patients not admitted to the ICU had a higher 1-year survival rate (74.7%) than those who were admitted (44.9%), p < 0.001. 70.1% of the total deaths occurred within the first 90 days.

Conclusion

Elderly patients with hip fractures experienced high mortality rates before and during the pandemic. This study demonstrates that the 1-year mortality rates of geriatric hip fractures were not significantly affected by the pandemic. The findings emphasize the importance of pandemic preparedness and prompt surgeries and attentive ICU care in reducing mortality rates.

Postoperative Outcomes After Emergency Surgery in COVID-19 Patients: An Ambispective Matched Cohort Study

Purpose There is limited data from the Indian subcontinent regarding the surgical outcomes of coronavirus disease (COVID-19) patients. In this observational study, we aimed to evaluate the postoperative outcomes after emergency surgery in COVID-19 patients compared to concurrent age and gender-matched controls. We also sought to analyze the possible predictors of postoperative mortality in COVID-19 patients. Methods This matched cohort study was conducted in a tertiary care teaching hospital in central India, between 1st July 2021 and 30th June 2022. COVID-19-positive patients undergoing emergency surgery under anesthesia were recruited as cases. Age and gender-matched COVID-19-negative patients undergoing a similar nature of surgery in the same period served as concurrent controls. The cases and controls were compared for the 30-day mortality and perioperative complications. Results The COVID-19-positive surgical cohort had a 12.3 times greater 30-day postoperative overall mortality risk as compared to a matched cohort of patients with a negative COVID-19 test. A positive COVID-19 status was associated with more postoperative complications of acute respiratory distress syndrome (ARDS), sepsis, shock, and persistent hyperglycemia. On analysis of predictors of mortality, the presence of preoperative dyspnea, ARDS, American Society of Anesthesiologists Physical Status (ASA-PS) Class IIIE/IVE, increase in sequential organ failure assessment (SOFA) score, Quick SOFA>1, higher creatinine, bilirubin, and lower albumin were observed to be associated with increased mortality. Conclusions Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients undergoing emergency surgery is significantly associated with higher postoperative complications and increased 30-day postoperative mortality.

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 Epidemiological Transition of Surgically Treated Proximal Hip Fractures in Austria over the Course of the Pandemic-Back to Normal or a New Normal?

BACKGROUND

The COVID-19 pandemic has had a significant impact on the treatment protocols of orthopedic and trauma departments, but its specific effect on the mortality of hip fracture patients due to possible delays in surgery remains uncertain. This study aimed to investigate whether the COVID-19 pandemic worsened the mortality of patients with hip fractures.

MATERIALS AND METHODS

This study included 246 prospectively enrolled patients who suffered from hip fractures during the Austrian State of Emergency period between 1 March and 30 June 2020 and 2021 and were admitted to a tertiary care trauma center. This cohort was compared with a retrospective control group of 494 patients admitted for hip fractures during the same timeframe in 2017, 2018, and 2019. These groups were compared to a prospective recruited "post-COVID-19 collective consisting of the years 2022 and 2023 including 313 patients.

RESULTS

This study found a 22% reduction in admissions during the COVID-19 period compared to the pre-COVID period (p = 0.018), as well as significant changes in gender (p = 0.013) and place of accident (p = 0.049). No other changes in demographic variables were observed. The 30-day mortality rate was 14.67% in the pre-COVID period, compared to 15.18% during the COVID-19 period (p = 0.381). No differences were observed in surgical complication rates or in the relationship between comorbidity burden and survival.

CONCLUSION

This study did not show a higher perioperative mortality rate due to COVID-19. However, under current circumstances, with potentially reduced surgical and hospital bed capacities, it is expected that this condition might require a high degree of resources in times when resources are potentially scarce, such as during an ongoing pandemic.

LEVEL OF EVIDENCE

Level 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.

Improving fragility hip fracture care through data: a multicentre experience from a country with an emerging economy during the COVID-19 pandemic

INTRODUCTION

In low-to-middle-income countries (LMIC), the orthogeriatric model of care is still in its early stages of development. This study describes the initial results of the first online fragility hip fracture database to be setup in the Philippines using a modified minimum common dataset to generate outcomes data based on current hospital practices.

METHODS

A multicentre prospective cohort study among 12 Philippine hospitals was conducted from June 2020 to February 2021. Thirty-day mortality, morbidity and mobility were measured. Significant factors associated with mortality were determined.

RESULTS

158 elderly patients with fragility hip fractures were included in the study. Nine patients (5.7%) were confirmed or suspected to have COVID-19 infection. Median time of injury to admission was at least 3 days (IQR: 1.0-13.7). Overall, 80% of patients underwent surgical intervention with a median time from admission to surgery of at least 5 days (IQR: 2.5-13.6). Thirty-day mortality and morbidity rates for acute fragility fractures were 3.7%. Factors significantly associated with early mortality were poor prefracture mobility, COVID-19 infection, radiograph of the abnormal chest and conservative treatment. Non-surgical patients had no functional mobility or were wheelchair users and had a significantly higher morbidity rate than surgically treated patients (13.6% vs 1.8%; p=0.031).

CONCLUSION

Despite treatment delays unique to an LMIC, short-term outcomes remain favourable for non-COVID-19 fragility hip fracture patients treated with surgery. Prompt admission and multidisciplinary care for elderly hip fracture patients while maintaining protective measures for COVID-19 infection control are recommended. The quality of data collected illustrates how this online database can provide a framework for a sustainable audit or registry as well as provide a platform for the introduction of orthogeriatric concepts at a multiregional scale.

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.

[Impact of the COVID-19 pandemic and the strict population confinement on hip fracture incidence in Spain: A systematic review]

BACKGROUND AND OBJECTIVE

During the COVID-19 pandemic, a strict population confinement was decreed in Spain. In a situation of health crisis and health system saturation, knowledge of pathologies whose treatment cannot be delayed is of great importance for the correct management of resources and processes. The objective was to determine the influence of the COVID-19 pandemic and the strict population confinement on hip fracture incidence in Spain.

MATERIAL AND METHOD

Systematic review following the PRISMA guidelines. Search in Pubmed and Chocrane Library on 11/11/2022: hip fracture and COVID-19 and Spain.

RESULTS

Six studies met the inclusion criteria, 50% showed a decrease in the hip fractures incidence during strict population confinement (all in Comunidad de Madrid hospitals), and in the other 50% there were no differences (all in other region hospitals). It was constant that hip fractures, either did not decrease, or decreased much less than the rest of fractures during the period of strict population confinement, increasing their relative number with respect to the total admissions in orthopedic surgery and traumatology.

CONCLUSIONS

The behavior of the hip fractures number during the strict population confinement decreed by the COVID-19 pandemic has not been symmetrical in all regions. To design and implement contingency plans in the event of a pandemic situation, these data must be taken into account in order to properly plan material and human resources.

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.

Postoperative mortality in the COVID-positive hip fracture patient, a systematic review and meta-analysis

PURPOSE

The extent to which concomitant COVID-19 infection increases short-term mortality following hip fracture is not fully understood. A systemic review and meta-analysis of COVID-19 positive hip fracture patients (CPHFPs) undergoing surgery was conducted to explore the association of COVID-19 with short-term mortality.

METHODS

Review of the literature identified reports of short-term 30-day postoperative mortality in CPHFPs. For studies including a contemporary control group of COVID-19 negative patients, odds ratios of the association between COVID-19 infection and short-term mortality were calculated. Short-term mortality and the association between COVID-19 infection and short-term mortality were meta-analyzed and stratified by hospital screening type using random effects models.

RESULTS

Seventeen reports were identified. The short-term mortality in CPHFPs was 34% (95% C.I., 30-39%). Short-term mortality differed slightly across studies that screened all patients, 30% (95% C.I., 22-39%), compared to studies that conditionally screened patients, 36% (95% C.I., 31-42%), (P = 0.22). The association between COVID-19 infection and short-term mortality produced an odds ratio of 7.16 (95% C.I., 4.99-10.27), and this was lower for studies that screened all patients, 4.08 (95% C.I., 2.31-7.22), compared to studies that conditionally screened patients, 8.32 (95% C.I., 5.68-12.18), (P = 0.04).

CONCLUSION

CPHFPs have a short-term mortality rate of 34%. The odds ratio of short-term mortality was significantly higher in studies that screened patients conditionally than in studies that screened all hip fracture patients. This suggests mortality prognostication should consider how COVID-19 infection was identified as asymptomatic patients may fare slightly better.

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.

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.

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.

Frailty, Comorbidity, and Associations With In-Hospital Mortality in Older COVID-19 Patients: Exploratory Study of Administrative Data

BACKGROUND

Older adults have worse outcomes following hospitalization with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes.

OBJECTIVE

We aimed to identify the key comorbidities and domains of frailty that were associated with in-hospital mortality in older patients with COVID-19 using models developed for machine learning algorithms.

METHODS

This was a retrospective study that used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for hospitalized patients in England aged 65 years or older. The data set was split into separate training (70%), test (15%), and validation (15%) data sets during model development. Global frailty was assessed using the Hospital Frailty Risk Score (HFRS) and specific domains of frailty were identified using the Global Frailty Scale (GFS). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Additional features employed in the random forest algorithms included age, sex, deprivation, ethnicity, discharge month and year, geographical region, hospital trust, disease severity, and International Statistical Classification of Disease, 10th Edition codes recorded during the admission. Features were selected, preprocessed, and input into a series of random forest classification algorithms developed to identify factors strongly associated with in-hospital mortality. Two models were developed; the first model included the demographic, hospital-related, and disease-related items described above, as well as individual GFS domains and CCI items. The second model was similar to the first but replaced the GFS domains and CCI items with the HFRS as a global measure of frailty. Model performance was assessed using the area under the receiver operating characteristic (AUROC) curve and measures of model accuracy.

RESULTS

In total, 215,831 patients were included. The model using the individual GFS domains and CCI items had an AUROC curve for in-hospital mortality of 90% and a predictive accuracy of 83%. The model using the HFRS had similar performance (AUROC curve 90%, predictive accuracy 82%). The most important frailty items in the GFS were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items in the CCI were cancer, heart failure, and renal disease.

CONCLUSIONS

The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with COVID-19.

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.

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.

Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget

Hip fractures are a leading cause of hospitalisation in elderly patients, representing an increasing socioeconomic problem arising from demographic changes, considering the increased number of elderly people in our countries. Adequate peri-operative treatment is essential to decrease mortality rates and avoid complications. Modern management should involve a coordinated multidisciplinary approach, early surgery, pain treatment, balanced fluid therapy, and prevention of delirium, to improve patients' functional and clinical outcomes. The operative treatment for intertrochanteric and subtrochanteric fractures is intramedullary nail or sliding/dynamic hip screw (DHS) on the basis of the morphology of the fracture. In the case of neck fractures, total hip replacement (THR) or hemiarthroplasty are recommended. However, several topics remain debated, such as the optimum thromboprophylaxis to reduce venous thromboembolism or the use of bone cement. Postoperatively, patients can benefit from early mobilisation and geriatric multidisciplinary care. However, during the COVID-19 pandemic, a prolonged time to operation with a subsequent increased complication rate have burdened frail and elderly patients with hip fractures. Future studies are needed with the aim to investigate better strategies to improve nutrition, postoperative mobility, to clarify the role of home-based rehabilitation, and to identify the ideal analgesic treatment and adequate tools in case of patients with cognitive impairment.

Holistic Symmetry Assessment Using Pedobarography after Treatment of Pertrochanteric Fractures in Elderly Patients

Pertrochanteric fractures (PFs) are life threatening due to the prolonged immobilization of the elderly patient that affects, indirectly, the function of most organs. PFs may have an impact on the symmetry of the human body and contribute to poor global alignment. The aim of the study is to evaluate the functional, pedobarographic and radiological outcomes in a group of subjects with PFs treated with either a dynamic hip screw (DHS) or an intramedullary gamma nail fixation. A study group of 40 patients, admitted to hospital for pertrochanteric fractures between 2015 and 2019, at a mean age of 74.87 (range 65–99), were enrolled. A control group included 20 subjects free from significant disorders of the musculoskeletal system and any other disorders that might induce a compensatory abnormal gait pattern. Functional results were assessed by the Harris Hip Score, and the plantar pressure distribution and arch index were measured with a pedobarographic examination. Radiographic parameters were assessed based on the preoperative and postoperative standing AP pelvic radiographs and axial projection of the hip. The obtained results were evaluated at 9-month follow-up. The obtained results showed no significant difference between both study groups within the scope of the variables under study. To sum up, surgical treatment, either with DHS or intramedullary gamma nail fixation, and rehabilitation treatment support the symmetry of the musculoskeletal system. However, the full return of symmetry was not achieved at 9-month follow-up compared to the control group.

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.

Trends in osteoporotic fracture and related in-hospital complications during the COVID-19 pandemic in Alberta, Canada

Fragility fractures (i.e., low-energy fractures) account for most fractures among older Canadians and are associated with significant increases in morbidity and mortality. Study results suggest that low-energy fracture rates (associated with surgical intervention and outcomes) declined slightly, but largely remained stable in the first few months of the COVID-19 pandemic.

PURPOSE/INTRODUCTION

This study describes rates of low-energy fractures, time-to-surgery, complications, and deaths post-surgery in patients with fractures during the coronavirus disease (COVID-19) pandemic in Alberta, Canada, compared to the three years prior.

METHODS

A repeated cross-sectional study was conducted using provincial-level administrative health data. Outcomes were assessed in 3-month periods in the 3 years preceding the COVID-19 pandemic and in the first two 3-month periods after restrictions were implemented. Patterns of fracture- and hospital-related outcomes over the control years (2017-2019) and COVID-19 restrictions periods (2020) were calculated.

RESULTS

Relative to the average from the control periods, there was a slight decrease in the absolute number of low-energy fractures (n = 4733 versus n = 4308) during the first COVID-19 period, followed by a slight rise in the second COVID-19 period (n = 4520 versus n = 4831). While the absolute number of patients with low-energy fractures receiving surgery within the same episode of care decreased slightly during the COVID-19 periods, the proportion receiving surgery and the proportion receiving surgery within 24 h of admission remained stable. Across all periods, hip fractures accounted for the majority of patients with low-energy fractures receiving surgery (range: 58.9-64.2%). Patients with complications following surgery and in-hospital deaths following fracture repair decreased slightly during the COVID-19 periods.

CONCLUSIONS

These results suggest that low-energy fracture rates, associated surgeries, and surgical outcomes declined slightly, but largely remained stable in the first few months of the pandemic. Further investigation is warranted to explore patterns during subsequent COVID-19 waves when the healthcare system experienced severe strain.

Impact of the SARS-CoV-2 pandemic on trauma care: a nationwide observational study

PURPOSE

The SARS-CoV-2 pandemic severely disrupted society and the health care system. In addition to epidemiological changes, little is known about the pandemic's effects on the trauma care chain. Therefore, in addition to epidemiology and aetiology, this study aims to describe the impact of the SARS-CoV-2 pandemic on prehospital times, resource use and outcome.

METHODS

A multicentre observational cohort study based on the Dutch Nationwide Trauma Registry was performed. Characteristics, resource usage, and outcomes of trauma patients treated at all trauma-receiving hospitals during the first (W1, March 12 through May 11) and second waves (W2, May 12 through September 23), as well as the interbellum period in between (INT, September 23 through December 31), were compared with those treated from the same periods in 2018 and 2019.

RESULTS

The trauma caseload was reduced by 20% during the W1 period and 11% during the W2 period. The median length of stay was significantly shortened for hip fracture and major trauma patients (ISS ≥ 16). A 33% and 66% increase in the prevalence of minor self-harm-related injuries was recorded during the W1 and W2 periods, respectively, and a 36% increase in violence-related injuries was recorded during the INT. Mortality was significantly higher in the W1 (2.9% vs. 2.2%) and W2 (3.2% vs. 2.7%) periods.

CONCLUSION

The imposed restrictions in response to the SARS-CoV-2 pandemic led to diminished numbers of acute trauma admissions in the Netherlands. The long-lasting pressing demand for resources, including ICU services, has negatively affected trauma care. Further caution is warranted regarding the increased incidence of injuries related to violence and self-harm.

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.

[Artículo traducido] Mortalidad a 30 días en pacientes con fractura de fémur proximal durante la pandemia COVID-19 en Vizcaya (País Vasco)

OBJECTIVES

Compare 30-day mortality rate following a proximal femur fracture (PFF) and SARS-CoV-2 infection versus a PFF and no SARS-CoV-2 infection.

DESIGN

Retrospective comparative study.

SETTING

Three university hospitals in Biscay province (Basque Country, Spain).

PATIENTS

77 patients over 65 years-old with PFF (AO 31-A and 31-B).

INTERVENTION

Study conducted between 9 March and 15 April 2020. The COVID-19 group included only patients with SARS-CoV-2 infection, confirmed by a positive RT-PCR test.

MAIN OUTCOME MEASUREMENTS

30-Day mortality rate and risk factors for mortality.

RESULTS

Of a total 77 patients, 10 were diagnosed with SARS-CoV-2 infection. Mean age was 85 years. Patients with SARS-CoV-2 infection had higher BMI (29.53 kg/m²) compared to patients without infection (24.09 kg/m²) (p = 0.001). No significant differences were found between both groups in terms of the Charlson Comorbidity Index, ASA score, use of oral anticoagulants or presence of cognitive impairment. Seven of the 10 patients in the COVID-19 group developed (viral) pneumonia, as compared to one single case (1/67) of (bacterial) pneumonia in the control group (p < 0.001). Thirty-days mortality was higher (p = 0.03) in COVID-19 patients (40%) than in those in the control group (11.9%). In the multivariate analysis, age ≥ 91 years-old, ASA class IV and BMI > 25 kg/m² were significant predictors of 30-day mortality. All deaths in the COVID-19 group occurred while the patients were hospitalized.

CONCLUSIONS

SARS-CoV-2 infection in patients with a PFF was seen to result in higher rates of early mortality, with COVID-19-related pneumonia being the leading direct cause of mortality.

LEVEL OF EVIDENCE

Level III study.

Preoperative Severe Acute Respiratory Syndrome Coronavirus 2 Polymerase Chain Reaction Test at Between 48 and 72 Hours Preoperatively is Safe for Patients Undergoing Primary and Revision Hip and Knee Arthroplasty: A Multicentre International Study

BACKGROUND

Patients undergoing lower limb arthroplasty who are severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive at the time of surgery have a high risk of mortality. The National Institute for Health and Clinical Care Excellence and the British Orthopaedic Association advise self-isolation for 14 days preoperatively in patients at a high risk of adverse outcomes due to COVID-19. The aim of the study is to assess whether preoperative polymerase chain reaction (PCR) for SARS-CoV-2 could be performed at between 48 and 72 hours preoperatively with specific advice about minimizing the risk of SARS-CoV-2 restricted to between PCR and admission.

METHODS

A multicentre, international, observational cohort study of 1,000 lower limb arthroplasty cases was performed. The dual primary outcomes were 30-day conversion to SARS-CoV-2 positive and 30-day SARS-CoV-2 mortality. Secondary outcomes included 30-day SARS-CoV-2 morbidity.

RESULTS

Of the 1,000 cases, 935 (94%) had a PCR between 48 and 72 hours preoperatively. All cases were admitted to and had surgery through a COVID-free pathway. Primary knee arthroplasty was performed in 41% of cases, primary hip arthroplasty in 40%, revision knee arthroplasty in 11%, and revision hip arthroplasty in 9%. Six percent of operations were emergency operations. No cases of SARS-CoV-2 were identified within the first 30 days.

CONCLUSION

Preoperative SARS-CoV-2 PCR test between 48 and 72 hours preoperatively with advice about minimizing the risk of SARS-CoV-2 restricted to between PCR and admission in conjunction with a COVID-free pathway is safe for patients undergoing primary and revision hip and knee arthroplasty. Preoperative SARS-CoV-2 PCR test alone may be safe but further adequately powered studies are required. This information is important for shared decision making with patients during the current pandemic.

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

Aims and objectives

The Covid-19 pandemic has had an unprecedented effect on surgical practice and healthcare delivery globally. We compared the impact of the care pathways which segregate Covid-19 Positive and Negative patients into two geographically separate sites, on hip fracture patients in our high-volume trauma center in 3 distinct eras - the pre-pandemic period, against the first Covid-19 wave with dual-site service design, as well as the subsequent surge with single-site service delivery. In addition, we sought to invoke similar experiences of centres worldwide through a scoping literature review on the current evidence on "Dual site" reconfigurations in response to Covid-19 pandemic.

Methods

We prospectively reviewed our hip fracture patients throughout the two peaks of the pandemic, with different service designs for each, and compared the outcomes with a historic service provision. Further, a comprehensive literature search was conducted using several databases for articles discussing Dual-site service redesign.

Results

In our in-house study, there was no statistically significant difference in mortality of hip fracture patients between the 3 periods, as well as their discharge destinations. With dual-site reconfiguration, patients took longer to reach theatre. However, there was much more nosocomial transmission with single-site service, and patients stayed in the hospital longer. 24 articles pertaining to the topic were selected for the scoping review. Most studies favour dual-site service reorganization, and reported beneficial outcomes from the detached care pathways.

Conclusion

It is safe to continue urgent as well as non-emergency surgery during the Covid-19 pandemic in a separate, geographically isolated site.

Impact of strict population confinement on fracture incidence during the COVID-19 pandemic. Experience from a public Health Care Department in Spain

BACKGROUND

the COVID-19 pandemic has led to drastic "stay-at-home" measures for the population. The aim of this study was to know the influence of the population strict confinement on the presentation of the different types of fracture as well as on the needs of hospital admission by the Orthopedic Surgery and Traumatology Service.

METHODS

a retrospective observational analytical descriptive study was carried out on the population attended in the Emergency Services of two general hospitals in a public Health Care Department in Spain. Data were studied from the two-months confinement period in 2020 and compared with the same period in 2018 and 2019.

RESULTS

A total of 56,332 emergency cases were included. There was a decrease in the total number of patients attended along the confinement period compared to the same period in the two previous years. Fracture cases decreased by 58,8% in the confinement period (330 in 2020; 715 in 2018 and 884 in 2019). Also there was a 37,6% reduction in fractures needing admission or surgery. The percentage distribution of the types of fractures that required admission resulted in a decrease in upper and lower limb fractures, whereas the number of vertebral and hip fractures remained unchanged.

CONCLUSIONS

both the reduction of fractures attended in the emergency department and the maintenance of the number of hip fractures must be taken into account when establishing contingency plans in the event of a pandemic situation in order to properly plan human resources and materials.

Mortality and Epidemiological Changes in Proximal Hip Fractures in the Course of a Pandemic

Background: Coronavirus disease 2019 (COVID-19) has had an immense impact on the treatment protocols of orthopedic and trauma departments, yet its specific effect on mortality in patients with hip fractures due to possible surgical delays is still unclear. The purpose of this paper was to investigate whether the COVID-19 pandemic worsened the mortality rate of hip fracture patients. Patients and methods: This study comprised 175 prospectively included patients who (1) suffered from hip fractures, (2) presented during the Austrian state of emergency period from 15 March 2020 to 30 May 2021, and (3) were admitted to a level I trauma center. This cohort was compared with a retrospective control group of 339 patients admitted for hip fractures during the same timeframe in 2017, 2018, and 2019. Results: An admission reduction of 22% in the COVID period compared with the pre-COVID period was evident (p = 0.018). The 30-day mortality rate was 14.67% (pre-COVID) compared with 15.18% (p = 0.381). No differences in surgical complication rates or relationships between comorbidity burden and survival were observed. There were no significant changes in demographic variables, except for admission rate, gender (p = 0.013), and place of accident (p = 0.049). Conclusion: Surgeons should be reassured to take COVID-19 precautions, as this study did not show higher perioperative mortality due to COVID-19 measures. Under the current circumstances, with possibly reduced surgical and hospital bed capacities, it is expected that hip fractures may continue to require a high degree of resources.

Epidemiology and postoperative complications of hip fracture during COVID-19 pandemic

Objectives

This study aims to analyze the changes in epidemiology and the postoperative outcomes in patients with hip fractures during the COVID-19 pandemic compared to non-pandemic period.

Methods

According to the date of declaration of “mandatory social distance”, we separated patients into 2 groups over a 1-year period: Period A and period B. We assessed the overall time to surgery, delay in surgery (> 24 hours, > 36 hours, and > 48 hours), reason of delay, length of hospital stay, type of surgery, and postoperative complications.

Results

The number of operated hip fractures and other trauma decreased in period B compared with period A by 17%, and 23%, respectively. The number of patients with delay in surgery by > 24 hours and > 36 hours was significantly higher in period B compared to that in period A (P = 0.035, P = 0.012, respectively). However, no significant difference in the number of delay in surgery > 48 hours and mean overall time to surgery between the 2 groups was observed (P = 0.856, P = 0.399, respectively). There was no difference in the duration of hospital stay, type of surgery, and postoperative complications between periods A and B.

Conclusions

During the COVID-19 pandemic, the decrease in hip fractures was relatively fewer compared to the decrease in orthopedic trauma. Although hip fracture surgeries were delayed for over 24 hours and 36 hours, there was no increase in delay for over 48 hours and postoperative complications.

Incidence of hip fractures during the COVID-19 pandemic in the Brazilian public health care system

This study compared the incidence of hip fractures before and during the COVID-19 pandemic in Brazil, aged ≥ 60 years excluding all fractures related to any trauma. There was a significant reduction in the number of hip fractures and the length of hospital stay during the period of social isolation.

PURPOSE

To compare the incidence of hip fractures before and during the COVID-19 pandemic in Brazil and in the main regions of the country in patients covered by the Brazilian public health care system (SUS). As far as we are aware, no studies have evaluated the impact of COVID-19 pandemic on hip fractures in Brazil.

METHODS

Descriptive, cross-sectional study in individuals aged ≥ 60 years who presented with a hip fracture before and during the COVID-19 pandemic and received treatment covered by the SUS. The data were collected from the DATASUS electronic database. We calculated the incidence, mortality, lethality, duration of hospitalization, and average reimbursement associated with the treatment of the fractures.

RESULTS

There was a significant reduction in the incidence of hip fractures among individuals aged ≥ 60 years in Brazil during the period of social isolation due to COVID-19. The observed incidence was 15.58/10,000 inhabitants between March and December 2020 and 16.07/10,000 inhabitants in the same period of 2019 (p < 0.005; main decline observed in the age groups > 70 years). The average length of hospital stay reduced from 8.35 days in 2019 to 7.33 days in 2020, following a similar pattern of reduction across all regions. The Southeast was the only region with a significant reduction in mortality during the pandemic (relative risk 0.90, 95% confidence interval 0.84-0.97, p < 0.005).

CONCLUSION

During the COVID-19 pandemic in Brazil, the incidence rate of hip fractures and the associated duration of hospital stay decreased among patients aged ≥ 60 years.

The Effect of COVID-19 on Pediatric Traumatic Orthopaedic Injuries: A Database Study

INTRODUCTION

Stay-at-home orders and other social distancing restrictions had a profound effect on the lives of children during the pandemic. This study characterizes pediatric orthopaedic injuries and in-hospital outcomes during the COVID-19 pandemic and compares them with pre-COVID patterns.

METHODS

A retrospective review of pediatric patients presenting to hospitals with Pennsylvania Trauma Systems Foundation designations was performed. All patients younger than 18 years who presented with orthopaedic injuries were included. Patient demographics, injuries, hospital stays, and mortality were compared between the COVID and pre-COVID cohorts.

RESULTS

Overall, 1112 patients were included. During the pandemic, more injuries occurred at home (44.7% versus 54.9%, P = 0.01) and fewer at sporting areas, parks, and pools (7.8% versus 1.6%, P < 0.01) as well as at schools (3.4% versus 0.5%, P = 0.03). Injuries caused by child abuse were more prevalent during the pandemic (5.6% versus 11.0%, P < 0.01). Finally, the COVID cohort had a longer mean hospital length of stay (3.1 versus 2.4 days, P = 0.01), higher mean number of ICU days (1.0 versus 0.7 days, P = 0.02), and higher mortality rate (3.8% versus 1.3%, P = 0.02).

DISCUSSION

Pediatric patients sustained injuries in differing patterns during the pandemic, but these led to worse hospital outcomes, including higher mortality rates.

Short-Term Hip Fracture Outcomes during the COVID-19 Pandemic

Introduction  Despite many significant changes as a result of the coronavirus disease 2019 (COVID-19) pandemic, and reductions in overall trauma workload, patients with fragility hip fractures continued to present to hospital. As we plan for ongoing service provision during future waves of the pandemic, valuable lessons can be learned from patients that have been treated surgically during the “first wave.”

Methods  All patients admitted to our center (a busy District General Hospital in London, United Kingdom) with a hip fracture during a 13-week period representing the initial rise (“United Kingdom first wave”) in COVID-19 cases, from February 17 ^th to May 17 ^th , 2020 (study group) were compared with hip fracture patients from the equivalent 13-week period in February to May 2019 (control group). The primary outcome was 30-day mortality, and additional information was collected in terms of length of stay (LOS), SARS-CoV-2 antigen testing, and cause of death.

Results  During the COVID-19 study period, 69 patients were admitted with a hip fracture, compared with 70 patients in the control group ( p  = 0.949). There was no significant difference in 30-day mortality between the two groups (5.8 vs. 7.1%, p  = 0.747). Mean LOS was shorter in the COVID-19 period compared with the control group (11.6 vs. 19.6 days, p <0.001, effect size 0.572).

Forty-six patients (66.7%) had a SARS-CoV-2 antigen swab test, as testing was not available in the early period, and 10 patients (14.5%) tested positive. None of the patients, who presented before the antigen testing was available, had clinical suspicion of COVID-19 retrospectively. Two “COVID-19 positive” patients (20%) died within 30 days of admission.

Conclusion  We report reassuring short-term results demonstrating no statistically significant difference in the 30-day mortality rate of hip fracture patients admitted during the United Kingdom's first wave of the COVID-19 pandemic compared to the equivalent period in the previous year. Hip fracture incidence remained stable, and LOS was reduced, likely due to recent departmental changes as well as a drive to discharge patients quickly during the pandemic. We agree with existing reports that elderly hip fracture patients with COVID-19 have a higher risk of perioperative mortality, however, our results suggest that overall mortality for the whole hip fracture population was similar to the previous year, in which deaths were more commonly attributed to respiratory infections associated with other pathogens. Further work may be needed to evaluate the outcomes during subsequent waves of the pandemic as mutations in the virus and conditions may affect outcomes.

Impact of Sars-Cov-2 pandemic on hip fractures: Clinical and radiographic outcomes

Introduction: Hip fractures affecting older people are at a higher risk of complications during the SARS-CoV-2 pandemic. The aim of this study is to provide data about proximal femoral fractures management and early outcomes during COVID-19 pandemic compared to the same period in 2019. Material and Methods: Retrospective and comparative study performed in two different periods were analyzed: from March 15, 2020, to April 30, 2020 (the first six weeks of Spain´s current confinement) and the same period in 2019. Data regarding demographics (age and sex, housing), type of fracture, surgical performance, early outcomes (at 30 days), and at 1-year follow-up were collected. A total of 146 patients were evaluated, 89 in 2019 and 57 in 2020. Results: Despite the drop ∼35.6% in hip fractures during SARS-CoV-2 period, distribution (age (P = 0.985), sex (P = 0.43), housing (P = 0.61), type of fracture (P = 0.41)) and Charlson comorbidity index (P = 0.12) were similar to a 2019 period. Surgical performance did not worsen in spite of the tough situation and the use of personal protective equipment, improving in some radiological variables (tip-to-apex and calcar reduction). In terms of postoperative outcomes, although there is a tendency to a short-term mortality increase (from 3.4% to 5.2%, P = 0.22), there were no differences at 1-year follow-up (20.2% in 2019 and 20.4% in 2020, P=0.587). In the same line, although in both groups the patients lost functionality at 1 year, there were no significant differences (P = 0.42). Conclusion: Even in challenging times, protocols and adequate organization ensure proper outcomes, reaching satisfying clinical and surgical outcomes during the COVID-19 pandemic, despite an increasing trend in short term mortality not seen at 1-year follow-up.

Hip fracture mortality in patients co-infected with coronavirus disease 2019: a comparison of the first two waves of the United Kingdom pandemic during the pre-vaccine era

Aims

In the UK, deaths associated with COVID-19 have occurred in two waves. Evidence has shown an increase in 30-day mortality for hip fracture patients co-infected with COVID-19. However, there are no studies analysing mortality trends between the first two waves of the UK pandemic. Additionally, hospital versus community acquired COVID-19 infection between the two waves has not been analysed. Furthermore, predictive factors of 30-day mortality have not been fully evaluated.

Methods

Data from two audits conducted by the CHIP collaborative group were used: a published regional audit in England of nine hospitals providing the COVID-19 negative cases and an unpublished UK national audit of 43 hospitals, which provided the COVID-19 positive cases. Data collection for the COVID-19 positive cases was from 23 March to 31 December 2020. September 1, 2020 was used to define the transition between the two waves.

Results

There were 517 COVID-19 positive hip fracture patients and 1445 COVID-19 negative hip fracture patients. Overall, 30-day mortality rates were 5.7% in the COVID-19 negative group and 22.4% in the COVID-19 positive patients (p < 0.001). A difference in survival function between the first and second waves was found (p = 0.038). To allow for significant demographic differences, a matched analysis of 185 patients found a 26.5% 30-day mortality in the first wave compared to 21.1% in the second wave (p = 0.222). Within the COVID-19 positive groups, the virus was hospital acquired in 66.7% of cases in the first wave and 72.8% of cases in the second wave (p = 0.130). Independent predictors of mortality were found to include COVID-19 positive status, AMTS ≤ 6, male gender and age.

Conclusion

There was a reduction in 30-day mortality for hip fracture patients co-infected with COVID-19 between the two UK pandemic waves but this was not statistically significant. There was no reduction in hospital acquired COVID-19 infection between the two waves.

Association Between COVID-19 and Mortality in Hip Fracture Surgery in the National COVID Cohort Collaborative (N3C): A Retrospective Cohort Study

Background:

This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database.

Methods:

This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality.

Results:

In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period.

Dicussion:

We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.

Hip fracture predicts subsequent hip fracture: a retrospective observational study to support a call to early hip fracture prevention efforts in post-fracture patients

In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs.

PURPOSE

This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients.

METHODS

A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017.

RESULTS

Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture.

CONCLUSION

A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.

Risk of Mortality for Proximal Femoral Fracture in Patients With and Without COVID-19. A Retrospective Cohort Study

Background

SARS-CoV-2 (COVID-19) has resulted in a widespread loss of lives, morbidity, and major disruptions to the healthcare system. Hip fractures are an emergent condition which require early intervention to reduce increased risk of mortality and morbidity. Infection of SARS-CoV-2 may contribute to increased mortality due to the role of infection and immune response. This study investigated the impact of COVID-19 infection (defined by clinical symptoms) on mortality following proximal femoral fracture (PFF) repair procedures.

Methods

This study was a retrospective cohort study. Data from the Premier Healthcare Database® was extracted for patients presenting for PFF during 2019 for control, and February 2020-September 2020 to represent a COVID time-period.

Results

A total of N = 73 953 subjects were enrolled for the 2019 period, and a total of N = 34 842 subjects were enrolled for the COVID period. For the 2019 period, subjects who had a PFF procedure and who had flu/COVID-like illness had 2.47 (CI:2.11, 2.88) times the odds of mortality compared to those who did not have flu/COVID-like illness. Subjects who had a PFF procedure and who had flu/COVID-like illness during the COVID period had 2.85 times (CI:2.36, 3.42) the odds of mortality compared to those who did not have flu/COVID-like illness. For the COVID period, within subjects who did not have a PFF procedure, those with flu/COVID-like illness had increased odds of mortality compared to those who did not have flu/COVID-like illness (OR:2.26, CI:1.57, 3.21).

Conclusions

Hip fractures present high risk for mortality and morbidity, where timely intervention is critical to improved outcomes. Presence of infection such as flu/COVID-like illness may influence mortality in patients undergoing hip fracture repair procedures. Consideration of infection status as a comorbidity is important to proper management and achieving optimal outcomes.

IMPACT OF COVID-19 ON MORTALITY AND HOSPITALIZATION IN OLDER ADULTS WITH HIP FRACTURE

ABSTRACT Objective: To evaluate the impact of the COVID-19 pandemic on hospital admission and mortality indicators in older adults with fractures of the proximal femur. Methods: Observational and retrospective study that took place from June 2016 to 2020. Patients of both genders who underwent surgical treatment for fractures of the proximal end of the femur, aged over 60 years, were included. Results: The population consisted of 379 patients, treated before (group 1; N = 278; 73.35%) and during the pandemic (group 2; N = 101; 26.65%). Higher mortality was observed in group 2 (N = 24; 23.8%) versus group 1 (N = 10; 3.6%), p < 0.001. The highest proportion of deaths in group 2 was maintained in patients aged 70-79 years (p = 0.011), 80-89 years (p ≤ 0.001) and > 90 years (p ≤ 0.001). In addition, the preoperative time and hospital stay were longer in group 2 compared to group 1 (p ≤ 0.001). Conclusion: The present study demonstrated that the pandemic period increased the mortality rate and the preoperative and hospitalization time in older patients with femur fractures. Thus, the pandemic has affected the care of fractures of the proximal femur in older adults, which reinforces the need to adopt measures to reduce complications and mortality. Level of Evidence II, Retrospective Study.

Impact of the COVID-19 pandemic on a trauma center of a university hospital in Japan

BACKGROUND

The Coronavirus disease 2019 pandemic caused the Japanese government to declare a State of Emergency on April 7, 2020. The aim of this study is to provide an overview of the effects of the pandemic on surgical cases at a university hospital trauma center.

METHODS

An observational study was performed at a trauma center in a tertiary hospital in Tokyo, Japan. The number of surgeries was compared between two periods: a historical control period (Tuesday April 9 to Monday May 27, 2019) and the period of the Japan State of Emergency due to COVID-19 (Tuesday April 7-Monday May 25, 2020). Information on patient age, gender, and surgical diagnosis, site, and procedure was collected for cases operated on in each period. The number of trauma surgeries was compared between the two periods. Data from the two periods were compared statistically.

RESULTS

The total number of surgical cases was 151 in the control period and 83 in the COVID-19 period (including no cases with COVID-19), a decrease of 45.0%. There were significantly more surgeries for patients with hip fractures in the COVID-19 period (9 vs. 19, P < 0.001 by Fisher exact test).

CONCLUSIONS

During the State of Emergency in Japan, the number of operations for trauma patients at the trauma center decreased, but surgeries for hip fracture increased.

Impact of COVID-19 first wave on the in-hospital length of stay of operated proximal femur fracture patients in an industrial hospital in Eastern India

Objective:

The objective of this article is to study the impact of coronavirus disease 2019 (COVID-19) pandemic first wave on the in-hospital length of stay of operated proximal femur fractures.

Materials and Methods:

A retrospective analysis of data collected through the electronic record system of the hospital, after applying inclusion and exclusion criteria, was done. The data were collected from the pre-pandemic, early part first wave and later part first wave of COVID-19 pandemic to calculate the average preoperative stay (POS) and total length of stay (LOS) of operated proximal femur fracture patients. Also, a sub-analysis of POS and LOS was done as per age (male/female), sex (<60/≥60 years) and fracture subtype (intertrochanteric, neck of femur and subtrochanteric fracture) of the patients to study if any of these had a significant direct impact on the POS and LOS.

Results:

The LOS and POS were found to be significantly increased during early part of first wave of COVID-19 pandemic in comparison to the pre-pandemic era (13.6 ± 7.7 days vs. 11.1 ± 5.7 days). The later part of the first wave of the pandemic however saw the LOS and POS to return to near pre-pandemic values, although still remaining higher.

Conclusion:

The study highlights that unpreparedness during the early part of the unprecedented pandemic event leads to a significant increase in LOS of operated patients with its associated implications; however, prompt action by the government, hospital administration and hospital staff the LOS could be reduced to near pre-pandemic values in the later part of the first wave of the pandemic. Analysis of the causes that lead to a significant increase in LOS can help for better future management of similar events in future.

Hip fracture care during the COVID-19 pandemic: retrospective cohort and literature review

Objectives:

The goal of this study was to investigate whether the COVID-19 pandemic has affected hip fracture care at a Level I Trauma hospital. The secondary goal was to summarize the published hip fracture reports during the pandemic.

Design:

A retrospective cohort study.

Setting:

Level I Trauma Center.

Patients/Participants:

Eighty-six operatively treated hip fracture patients age ≥65 years, occurring from January 17 to July 2, 2020.

Intervention (if any):

N/A.

Main Outcome Measurements:

We defined 3 phases of healthcare system response: pre-COVID-19 (period A), acute phase (period B), and subacute phase (period C). The primary outcome was 30-day mortality. Clinical outcomes including time to surgery (TTS) and length of stay (LOS) were extracted from the electronic medical record.

Results:

Twenty-seven patients from Period A, 27 patients from Period B, and 32 patients from Period C were included. The 30-day mortality was not statistically different. The mean TTS was 20.0 +/− 14.3 hours and was the longest in Period C (22.1 +/− 9.8 hours), but the difference was not statistically significant. The mean LOS was 113.0 +/− 66.2 hours and was longest in Period B (120.9 +/− 100.6 hours). However, the difference was not statistically significant.

Conclusions:

The 30-day mortality, TTS, and LOS were not statistically different across multiple phases of pandemic at a level 1 trauma center. Our results suggest that we successfully adapted new protocol changes and continued to provide evidence-based care for hip fracture patients. Our results were comparable with that of other authors around the world.

Neck of Femur Fractures in the First Eight Months of the COVID-19 Pandemic: A UK Systematic Review and Meta-Analysis

Neck of femur (NOF) fracture patients have significant 30-day mortality. The incidence of NOF fractures remained high during the coronavirus disease 2019 (COVID-19) pandemic in the United Kingdom. Consequently, numerous cases were complicated with concurrent severe acute respiratory syndrome coronavirus 2 infection. We performed a systematic review and meta-analysis of all studies from the United Kingdom related to NOF fractures and 30-day mortality outcomes during the pandemic.   A systematic review and meta-analysis was performed and reported as per the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently searched on Medline for studies that were published between the 1st of March 2020 and the 1st of November 2020 in the United Kingdom. The following outcomes were compared: 30-day mortality, time to surgery, and anaesthetic risk.   A total of five articles were included in this review. In total, 286 patients with NOF fractures and COVID-19 infection were identified, with 30-day mortality ranging from 30.5% to 50% (odds ratio = 6.02; 95% confidence interval = 4.10-8.85; χ2 = 4.82; I2 = 58%). Increased time to surgery due to COVID-19-related delays was also noted for the majority of patients in some studies. Mortality scores (Charlson Comorbidity Index, Nottingham Hip Fracture Score) failed to accurately predict the mortality risk. Concurrent infection of COVID-19 in patients with NOF fractures increases the 30-day mortality sixfold compared to the COVID-19-negative group. Efforts should be made to optimise time to surgery as well as consideration of postoperative care in higher dependency units. Future updates in mortality predicting scores should include COVID-19 infection as a significant factor.

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

OBJECTIVES

Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.

SETTING

Prospective, international, multicentre, observational cohort study.

PARTICIPANTS

Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).

PRIMARY OUTCOME

30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.

RESULTS

This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).

CONCLUSIONS

Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.

TRIAL REGISTRATION NUMBER

NCT04323644.

Mortality and Incidence Rate of SARS-CoV-2 (COVID-19) Infection in Patients Admitted and Operated for Hip Fracture during SARS-CoV-2 pandemic in a London Hospital

Objective  We are doing a study on patients admitted with hip fractures to determine the impact of COVID-19 on a vulnerable patients group in the United Kingdom. This will help us in making informed decisions about restarting elective surgical services and expanding trauma surgical services. The objectives of the study are: 1) to find the incidence of COVID-19 in patients admitted with hip fractures; 2) To find the 30-day mortality in patients operated with hip fractures; 3) To find the 30-day mortality of patients with hip fracture and COVID 19; and 4) to compare this data with the mortality in hip fractures in previous years.

Methods  This is a single-center, observational, retrospective, cohort study involving 65 patients who were admitted in our trust with hip fractures. Besides epidemiological data, patient records were followed-up for 14 days to look for COVID positive polymerase chain reaction (PCR) swabs, and the patient records were followed-up for 30 days to look for mortality.

Results  A total of 64% of the patients had no significant comorbidity. The incidence of hospital-acquired COVID-19 infections in our trust was 9%. Overall, the 30-day mortality was of 15%. Mortality was much higher in COVID positive patients (40%) and in patients with “very high risk” (63%) operated during this period.

Conclusion  It should be safe to start elective surgery in patients with low, moderate and high risk without an appreciable rise in mortality. We will need more data to understand the impact of COVID-19 on very high risk patients.