Do standards of care and early outcomes of periprosthetic fractures change during the COVID-19 pandemic? A multicentre study.

BACKGROUND: Periprosthetic fractures (PPFs) are a growing matter for orthopaedic surgeons, and patients with PPFs may represent a frail target in the case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The purpose of this study is to investigate whether hospital reorganisations during the most severe phase of the SARS-CoV-2 pandemic affected standards of care and early outcomes of patients treated for PPFs in Northern Italy. MATERIALS AND METHODS: Data were retrieved from a multicentre retrospective orthopaedics and traumatology database, including 14 hospitals. The following parameters were studied: demographics, results of nasopharyngeal swabs, prevalence of coronavirus disease 2019 (COVID-19), comorbidities, general health status (EQ-5D-5L Score), frailty (Clinical Frailty Scale, CFS), pain (visual analogue scale, VAS), anaesthesiologic risk (American Society of Anaesthesiology Score, ASA Score), classification (unified classification system, UCS), type of operation and anaesthesia, in-hospital and early complications (Clavien-Dindo Classification, CDC), and length of stay (LOS). Data were analysed by means of descriptive statistics. Out of 1390 patients treated for any reason, 38 PPFs were included. RESULTS: Median age was 81 years (range 70-96 years). Twenty-three patients (60.5%) were swabbed on admission, and two of them (5.3%) tested positive; in three patients (7.9%), the diagnosis of COVID-19 was established on a clinical and radiological basis. Two more patients tested positive post-operatively, and one of them died due to COVID-19. Thirty-three patients (86.8%) presented a proximal femoral PPF. Median ASA Score was 3 (range, 1-4), median VAS score on admission was 3 (range, 0-6), median CFS was 4 (range, 1-8), median EQ-5D-5L Score was 3 in each one of the categories (range, 1-5). Twenty-three patients (60.5%) developed post-operative complications, and median CDC grade was 3 (range, 1-5). The median LOS was 12.8 days (range 2-36 days), and 21 patients (55.3%) were discharged home. CONCLUSIONS: The incidence of PPFs did not seem to change during the lockdown. Patients were mainly elderly with comorbidities, and complications were frequently recorded post-operatively. Despite the difficult period for the healthcare system, hospitals were able to provide effective conventional surgical treatments for PPFs, which were not negatively influenced by the reorganisation. Continued efforts are required to optimise the treatment of these frail patients in the period of the pandemic, minimising the risk of contamination, and to limit the incidence of PPFs in the future. LEVEL OF EVIDENCE: IV.

Clinical Activities, Contaminations of Surgeons and Cooperation with Health Authorities in 14 Orthopedic Departments in North Italy during the Most Acute Phase of Covid-19 Pandemic.

Background: From 10 March up until 3 May 2020 in Northern Italy, the SARS-CoV-2 spread was not contained; disaster triage was adopted. The aim of the present study is to assess the impact of the COVID-19-pandemic on the Orthopedic and Trauma departments, focusing on: hospital reorganization (flexibility, workload, prevalence of COVID-19/SARS-CoV-2, standards of care); effects on staff; subjective orthopedic perception of the pandemic. Material and Methods: Data regarding 1390 patients and 323 surgeons were retrieved from a retrospective multicentric database, involving 14 major hospitals. The subjective directors' viewpoints regarding the economic consequences, communication with the government, hospital administration and other departments were collected. Results: Surgical procedures dropped by 73%, compared to 2019, elective surgery was interrupted. Forty percent of patients were screened for SARS-CoV-2: 7% with positive results. Seven percent of the patients received medical therapy for COVID-19, and only 48% of these treated patients had positive swab tests. Eleven percent of surgeons developed COVID-19 and 6% were contaminated. Fourteen percent of the staff were redirected daily to COVID units. Communication with the Government was perceived as adequate, whilst communication with medical Authorities was considered barely sufficient. Conclusions: Activity reduction was mandatory; the screening of carriers did not seem to be reliable and urgent activities were performed with a shortage of workers and a slower workflow. A trauma network and dedicated in-hospital paths for COVID-19-patients were created. This experience provided evidence for coordinated responses in order to avoid the propagation of errors.

Early mortality in hip fracture patients admitted during first wave of the COVID-19 pandemic in Northern Italy: a multicentre study.

BACKGROUND: Treatment of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic has posed unique challenges for the management of COVID-19-infected patients and the maintenance of standards of care. The primary endpoint of this study is to compare the mortality rate at 1 month after surgery in symptomatic COVID-positive patients with that of asymptomatic patients. A secondary endpoint of the study is to evaluate, in the two groups of patients, mortality at 1 month on the basis of type of fracture and type of surgical treatment. MATERIALS AND METHODS: For this retrospective multicentre study, we reviewed the medical records of patients hospitalised for proximal femur fracture at 14 hospitals in Northern Italy. Two groups were formed: COVID-19-positive patients (C+ group) presented symptoms, had a positive swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and received treatment for COVID-19; COVID-19-negative patients (C- group) were asymptomatic and tested negative for SARS-CoV-2. The two groups were compared for differences in time to surgery, survival rate and complications rate. The follow-up period was 1 month. RESULTS: Of the 1390 patients admitted for acute care for any reason, 477 had a proximal femur fracture; 53 were C+ but only 12/53 were diagnosed as such at admission. The mean age was > 80 years, and the mean American Society of Anesthesiologists (ASA) score was 3 in both groups. There was no substantial difference in time to surgery (on average, 2.3 days for the C+ group and 2.8 for the C- group). As expected, a higher mortality rate was recorded for the C+ group but not associated with the type of hip fracture or treatment. No correlation was found between early treatment (< 48 h to surgery) and better outcome in the C+ group. CONCLUSIONS: Hip fracture in COVID-19-positive patients accounted for 11% of the total. On average, the time to surgery was > 48 h, which reflects the difficulty of maintaining normal workflow during a medical emergency such as the present pandemic and notwithstanding the suspension of non-urgent procedures. Hip fracture was associated with a higher 30-day mortality rate in COVID-19-positive patients than in COVID-19-negative patients. This fact should be considered when communicating with patients and/or their family. Our data suggest no substantial difference in hip fracture management between patients with or without COVID-19 infection. In this sample, the COVID-19-positive patients were generally asymptomatic at admission; therefore, routine screening is recommended. LEVEL OF EVIDENCE: Therapeutic study, level 4.

The orthopaedic and traumatology scenario during Covid-19 outbreak in Italy: chronicles of a silent war.

BACKGROUND: From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals' organisation throughout Italy dramatically changed. METHODS: The CIO (Club Italiano dell'Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019). RESULTS: Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe. CONCLUSIONS: Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.

Management of Traumatology Patients During the Coronavirus (COVID-19) Pandemic: Experience in a Hub Trauma Hospital in Northern Italy.

BACKGROUND: As a result of the uncontrolled spread of the COVID-19 virus infection, a health reorganization according to the "hub and spoke" model was necessary. The purpose of the article was to document the adopted corporate protocol and describe the management of the traumatized patient in a Hub center. METHODS: Our hospital has been identified as one of the three regional Hubs for polytrauma and major traumas, requiring suitable pathways to receive confirmed or suspected COVID-19-positive patients, from the emergency room entrance to the operating room, and finally to the inpatient ward or ICU. From February 23th to April 30th 2020 we analyzed the total number of trauma patients hospitalized and the number of femoral neck fractures surgically treated within 48 h; the data were then compared with the corresponding period of the previous year. RESULTS: There has been a reduction in the overall number of traumas as a result of government restraint measures. Total occupancy time in the operating theater has increased, but not drastically considering dressing procedures and anesthesia (carried out inside the operating room). The number of patients with femoral neck fractures surgically treated within 48 h (none of the COVID-19-positive patients) decreased from 83.33 to 58.70%, but only slightly lower than the Italian pre-COVID average of 64.70%. CONCLUSIONS: The correct management of the hospital and the meticulous organization of the traumatized patient have made it possible to contain the potential negative effects on the medical care quality during this unexpected and severe health emergency.