COVID-19 is associated with increased care needs and a decreased likelihood of returning home following a hip fracture: The IMPACT frailty study.

PURPOSE: The primary aim was to evaluate the impact of COVID-19 on frailty in patients surviving a hip fracture. Secondary aims were to assess impact of COVID-19 on (i) length of stay (LoS) and post-discharge care needs, (ii) readmissions, and (iii) likelihood of returning to own home. METHODS: This propensity score-matched case-control study was conducted in a single centre between 01/03/20-30/11/21. A 'COVID-positive' group of 68 patients was matched to 141 'COVID-negative' patients. 'Index' and 'current' Clinical Frailty Scale (CFS) scores were assigned for frailty at admission and at follow-up. Data were extracted from validated records and included: demographics, injury factors, COVID-19 status, delirium status, discharge destination, and readmissions. For subgroup analysis controlling for vaccination availability, the periods 1 March 2020-30 November 2020 and 1 February 2021-30 November 2021 were considered pre-/post-vaccine periods. RESULTS: Median age was 83.0 years, 155/209 (74.2%) were female and median follow-up was 479 days (interquartile range [IQR] 311). There was an equivalent median increase in CFS in both groups (+1.00 [IQR 1.00-2.00, p = 0.472]). However, adjusted analysis demonstrated COVID-19 was independently associated with a greater magnitude change (Beta coefficient [ß] 0.27, 95% confidence interval [95% CI] 0.00-0.54, p = 0.05). COVID-19 in the post-vaccine availability period was associated with a smaller increase versus pre-vaccine (ß -0.64, 95% CI -1.20 to -0.09, p = 0.023). COVID-19 was independently associated with increased acute LoS (ß 4.40, 95% CI 0.22-8.58, p = 0.039), total LoS (ß 32.87, 95% CI 21.42-44.33, p < 0.001), readmissions (ß 0.71, 95% CI 0.04-1.38, p = 0.039), and a four-fold increased likelihood of pre-fracture home-dwelling patients failing to return home (odds ratio 4.52, 95% CI 2.08-10.34, p < 0.001). CONCLUSIONS: Hip fracture patients that survived a COVID-19 infection had increased frailty, longer LoS, more readmissions, and higher care needs. The health and social care burden is likely to be higher than prior to the COVID-19 pandemic. These findings should inform prognostication, discharge-planning, and service design to meet the needs of these patients.

IMPACT of COVID-19 on hip fracture services: A global survey by the International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic resulted in major disruption to hip fracture services. This frail patient group requires specialist care, and disruption to services is likely to result in increases in morbidity, mortality and long-term healthcare costs. AIMS: To assess disruption to hip fracture services during the COVID-19 pandemic. METHODS: A questionnaire was designed for completion by a senior clinician or service manager in each participating unit between April-September 2020. The survey was incorporated into existing national-level audits in Germany (n = 71), Scotland (n = 16), and Ireland (n = 16). Responses from a further 82 units in 11 nations were obtained via an online survey. RESULTS: There were 185 units from 14 countries that returned the survey. 102/160 (63.7%) units reported a worsening of overall service quality, which was attributed predominantly to staff redistribution, reallocation of inpatient areas, and reduced access to surgical facilities. There was a high rate of redeployment of staff to other services: two thirds lost specialist orthopaedic nurses, a third lost orthogeriatrics services, and a quarter lost physiotherapists. Reallocation of inpatient areas resulted in patients being managed by non-specialised teams in generic wards, which increased transit of patients and staff between clinical areas. There was reduced operating department access, with 74/160 (46.2%) centres reporting a >50% reduction. Reduced theatre efficiency was reported by 135/160 (84.4%) and was attributed to staff and resource redistribution, longer anaesthetic and transfer times, and delays for preoperative COVID-19 testing and using personal protective equipment (PPE). CONCLUSION: Hip fracture services were disrupted during the COVID-19 pandemic and this may have a sustained impact on health and social care. Protection of hip fracture services is essential to ensure satisfactory outcomes for this vulnerable patient group.

Socioeconomically-deprived patients suffer hip fractures at a younger age and require more hospital admissions, but early mortality risk is unchanged: The IMPACT Deprivation Study.

INTRODUCTION: Socioeconomic deprivation is associated with multi-morbidity and frailty, but influence on hip fracture outcomes is poorly understood. The primary aim was to investigate the association between deprivation and mortality, and secondary aims were to assess the effects on: (i) age at presentation; (ii) inpatient outcomes, and (iii) post-discharge outcomes. METHOD: This cohort study included all patients aged >50 years admitted with a hip fracture to a high-volume centre between 01 March 2020 and 20 November 2021. Data were collected contemporaneously by specialist auditors and underwent validation using live health records after 180 days follow-up. Variables were demographics including Scottish Index of Multiple Deprivation, injury and management factors, and outcome measures including length of stay, discharge destination, readmission, and mortality status at 180 days. RESULTS: There were 1822 patients of which 1306/1822 (72%) were female. Deprivation was independently associated with younger age at hip fracture, demonstrating a linear correlation with each deprivation level. The overall mean age was 80.7 years (range 50-102), with the mean age in the most deprived group being 77.2 years (95% CI; 75.7-78.7) versus 82.8 years (95% CI; 82.0-83.5) in the least deprived. Multivariate logistic regression showed no association between deprivation and 30- or 180-day mortality risk. Kaplan-Meier survival analysis demonstrated no difference between the most deprived versus least deprived (log-rank, p = 0.854). Deprivation had no influence on length of stay, discharge destination, or COVID-19 status, but deprived patients had an increased risk of readmission (OR 1.63, 95% CI [1.18-2.24]; p = 0.003). CONCLUSION: Deprivation showed no linear correlation with early mortality risk (within 180 days of injury), but it was associated with an earlier age at presentation (the most deprived sustained a hip fracture 5.6 years earlier than the least deprived) which may impact overall life expectancy. More deprived patients were more likely to require further acute hospital admissions.

COVID-19 during the index hospital admission confers a 'double-hit' effect on hip fracture patients and is associated with a two-fold increase in 1-year mortality risk.

PURPOSE: The aims were to: (1) determine 1-year mortality rates for hip fracture patients during the first UK COVID-19 wave, and (2) assess mortality risk associated with COVID-19. METHODS: A nationwide multicentre cohort study was conducted of all patients presenting to 17 hospitals in March-April 2020. Follow-up data were collected one year after initial hip fracture ('index') admission, including: COVID-19 status, readmissions, mortality, and cause of death. RESULTS: Data were available for 788/833 (94.6%) patients. One-year mortality was 242/788 (30.7%), and the prevalence of COVID-19 within 365 days of admission was 142/788 (18.0%). One-year mortality was higher for patients with COVID-19 (46.5% vs. 27.2%; p < 0.001), and highest for those COVID-positive during index admission versus after discharge (54.7% vs. 39.7%; p = 0.025). Anytime COVID-19 was independently associated with 50% increased mortality risk within a year of injury (HR 1.50, p = 0.006); adjusted mortality risk doubled (HR 2.03, p < 0.001) for patients COVID-positive during index admission. No independent association was observed between mortality risk and COVID-19 diagnosed following discharge (HR 1.16, p = 0.462). Most deaths (56/66; 84.8%) in COVID-positive patients occurred within 30 days of COVID-19 diagnosis (median 11.0 days). Most cases diagnosed following discharge from the admission hospital occurred in downstream hospitals. CONCLUSION: Almost half the patients that had COVID-19 within 365 days of fracture had died within one year of injury versus 27.2% of COVID-negative patients. Only COVID-19 diagnosed during the index admission was associated independently with an increased likelihood of death, indicating that infection during this time may represent a 'double-hit' insult, and most COVID-related deaths occurred within 30 days of diagnosis.

The IMPACT of COVID-19 on trauma & orthopaedic surgery provides lessons for future communicable disease outbreaks : minimum reporting standards, risk scores, fragility trauma services, and global collaboration.

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies. Cite this article: Bone Joint Res 2022;11(6):342-345.

IMPACT-Global Hip Fracture Audit: Nosocomial infection, risk prediction and prognostication, minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic.

AIMS: This international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients. METHODS: A multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1st March-31st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded. RESULTS: A total of 7090 patients were included, with a mean age of 82.2 (range 50-104) years and 4959 (69.9%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) were positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p = 0.001), residential care (OR 2.15, p < 0.001), inpatient fall (OR 2.23, p = 0.003), cancer (OR 0.63, p = 0.009), ASA grades 4 (OR 1.59, p = 0.008) or 5 (OR 8.28, p < 0.001), and longer admission (OR 1.06 for each increasing day, p < 0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p < 0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p < 0.001). Increasing age (HR 1.03, p = 0.028), male sex (HR 2.35, p < 0.001), renal disease (HR 1.53, p = 0.017), and pulmonary disease (HR 1.45, p = 0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders. CONCLUSION: The prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher 30-day mortality risk.

IMPACT-Scot 2 report on COVID-19 in hip fracture patients.

AIMS: The primary aim was to determine the influence of COVID-19 on 30-day mortality following hip fracture. Secondary aims were to determine predictors of COVID-19 status on presentation and later in the admission; the rate of hospital acquired COVID-19; and the predictive value of negative swabs on admission. METHODS: A nationwide multicentre retrospective cohort study was conducted of all patients presenting with a hip fracture to 17 Scottish centres in March and April 2020. Demographics, presentation blood tests, COVID-19 status, Nottingham Hip Fracture Score, management, length of stay, and 30-day mortality were recorded. RESULTS: In all, 78/833 (9.4%) patients were diagnosed with COVID-19. The 30-day survival of patients with COVID-19 was significantly lower than for those without (65.4% vs 91%; p < 0.001). Diagnosis of COVID-19 within seven days of admission (likely community acquired) was independently associated with male sex (odds ratio (OR) 2.34, p = 0.040, confidence interval (CI) 1.04 to 5.25) and symptoms of COVID-19 (OR 15.56, CI 6.61 to 36.60, p < 0.001). Diagnosis of COVID-19 made between seven and 30 days of admission to hospital (likely hospital acquired) was independently associated with male sex (OR 1.73, CI 1.05 to 2.87, p = 0.032), Nottingham Hip Fracture Score ≥ 7 (OR 1.91, CI 1.09 to 3.34, p = 0.024), pulmonary disease (OR 1.68, CI 1.00 to 2.81, p = 0.049), American Society of Anesthesiologists (ASA) grade ≥ 3 (OR 2.37, CI 1.13 to 4.97, p = 0.022), and length of stay ≥ nine days (OR 1.98, CI 1.18 to 3.31, p = 0.009). A total of 38 (58.5%) COVID-19 cases were probably hospital acquired infections. The false-negative rate of a negative swab on admission was 0% in asymptomatic patients and 2.9% in symptomatic patients. CONCLUSION: COVID-19 was independently associated with a three times increased 30-day mortality rate. Nosocomial transmission may have accounted for approximately half of all cases during the first wave of the pandemic. Identification of risk factors for having COVID-19 on admission or acquiring COVID-19 in hospital may guide pathways for isolating or shielding patients respectively. Length of stay was the only modifiable risk factor, which emphasizes the importance of high-quality and timely care in this patient group. Cite this article: Bone Joint J 2021;103-B(5):888-897.

The rate of COVID-19 and associated mortality after elective hip and knee arthroplasty prior to cessation of elective services in UK.

AIMS: The primary aim was to assess the rate of postoperative COVID-19 following hip and knee arthroplasty performed in March 2020 in the UK. The secondary aims were to assess whether there were clinical factors associated with COVID-19 status, the mortality rate of patients with COVID-19, and the rate of potential COVID-19 in patients not presenting to healthcare services. METHODS: A multicentre retrospective study was conducted of patients undergoing hip or knee arthroplasty during the first wave of the COVID-19 pandemic (1 March 2020 to 31 March 2020) with a minimum of 60 days follow-up. Patient demographics, American Society of Anesthesiologists grade, procedure type, primary or revision, length of stay (LOS), COVID-19 test status, and postoperative mortality were recorded. A subgroup of patients (n = 211) who had not presented to healthcare services after discharge were contacted and questioned as to whether they had symptoms of COVID-19. RESULTS: Five (0.5%) of 1,073 patients who underwent hip or knee arthroplasty tested positive for SARS-CoV-2 postoperatively. When adjusting for confounding factors, increasing LOS (p = 0.022) was the only significant factor associated with developing COVID-19 following surgery and a stay greater than three days was a reliable predictor with an area under the curve of 81% (p = 0.018). There were three (0.3%) deaths in the study cohort and the overall mortality rate attributable to COVID-19 was 0.09% (n = 1/1,073), with one (20%) of the five patients with COVID-19 dying postoperatively. Of the 211 patients contacted, two had symptoms within two to 14 days postoperatively with a positive predictive value of 31% and it was therefore estimated that one patient may have had undiagnosed COVID-19. CONCLUSION: The rate of postoperative COVID-19 was 0.5% and may have been as high as 1% when accounting for those patients not presenting to healthcare services, which was similar to the estimated population prevalence during the study period. The overall mortality rate secondary to COVID-19 was low (0.09%), however the mortality rate for those patients developing COVID-19 was 20%. Cite this article: Bone Joint J 2021;103-B(4):681-688.

A multicentre national study of the effectiveness of virtual fracture clinic management of orthopaedic trauma during the COVID-19 pandemic (MAVCOV): a cross-sectional study protocol.

AIMS: Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines. METHODS: This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the 'second wave' (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation. ETHICS AND DISSEMINATION: The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit. Cite this article: Bone Jt Open 2021;2(3):211-215.

The prevalence, mortality, and associated risk factors for developing COVID-19 in hip fracture patients: a systematic review and meta-analysis.

AIMS: The aims of this meta-analysis were to assess: 1) the prevalence of coronavirus disease 2019 (COVID-19) in hip fracture patients; 2) the associated mortality rate and risk associated with COVID-19; 3) the patient demographics associated with COVID-19; 4) time of diagnosis; and 5) length of follow-up after diagnosis of COVID-19. METHODS: Searches of PubMed, Medline, and Google Scholar were performed in October 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Search terms included "hip", "fracture", and "COVID-19". The criteria for inclusion were published clinical articles reporting the mortality rate associated with COVID-19 in hip fracture patients. In total, 53 articles were identified and following full text screening 28 articles satisfied the inclusion criteria. RESULTS: A total of 28 studies reported the mortality of COVID-19-positive patients, of which 21 studies reported the prevalence of COVID-19-positive patients and compared the mortality rate to COVID-19-negative patients. The prevalence of COVID-19 was 13% (95% confidence interval (CI) 11% to 16%) and was associated with a crude mortality rate of 35% (95% CI 32% to 39%), which was a significantly increased risk compared to those patients without COVID-19 (odds ratio (OR) 7.11, 95% CI 5.04 to 10.04; p < 0.001). COVID-19-positive patients were more likely to be male (OR 1.51, 95% CI 1.16 to 1.96; p = 0.002). The duration of follow-up was reported in 20 (71.4%) studies. A total of 17 studies reported whether a patient presented with COVID-19 (n = 108 patients, 35.1%) or developed COVID-19 following admission (n = 200, 64.9%), of which six studies reported a mean time to diagnosis of post-admission COVID-19 at 15 days (2 to 25). CONCLUSION: The prevalence of COVID-19 was 13%, of which approximately one-third of patients were diagnosed on admission, and was associated with male sex. COVID-19-positive patients had a crude mortality rate of 35%, being seven times greater than those without COVID-19. Due to the heterogenicity of the reported data minimum reporting standards of outcomes associated with COVID-19 are suggested. Cite this article: Bone Joint Res 2020;9(12):873-883.

IMPACT-Restart: the influence of COVID-19 on postoperative mortality and risk factors associated with SARS-CoV-2 infection after orthopaedic and trauma surgery.

AIMS: The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period. METHODS: A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1 March 2020 to 19 April 2020) with a minimum of 50 days follow-up. Patient demographics, American Society of Anesthesiologists (ASA) grade, priority (urgent or elective), procedure type, COVID-19 status, and postoperative mortality were recorded. RESULTS: During the study period, 1,659 procedures were performed in 1,569 patients. There were 68 (4.3%) patients who were diagnosed with COVID-19. There were 85 (5.4%) deaths postoperatively. Patients who had COVID-19 had a significantly lower survival rate when compared with those without a proven SARS-CoV-2 infection (67.6% vs 95.8%, p < 0.001). When adjusting for confounding variables (older age (p < 0.001), female sex (p = 0.004), hip fracture (p = 0.003), and increasing ASA grade (p < 0.001)) a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, 95% confidence interval (CI) 1.14 to 3.12; p = 0.014). A total of 62 patients developed COVID-19 postoperatively, of which two were in the elective and 60 were in the urgent group. Patients aged > 77 years (odds ratio (OR) 3.16; p = 0.001), with increasing ASA grade (OR 2.74; p < 0.001), sustaining a hip (OR 4.56; p = 0.008) or periprosthetic fracture (OR 14.70; p < 0.001) were more likely to develop COVID-19 postoperatively. CONCLUSION: Perioperative COVID-19 nearly doubled the background postoperative mortality risk following surgery. Patients at risk of developing COVID-19 postoperatively (patients > 77 years, increasing morbidity, sustaining a hip or periprosthetic fracture) may benefit from perioperative shielding. Cite this article: Bone Joint J 2020;102-B(12):1774-1781.

Population mobility and adult orthopaedic trauma services during the COVID-19 pandemic: fragility fracture provision remains a priority.

AIMS: This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google. METHODS: A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google. RESULTS: Orthopaedic trauma referrals reduced by 42% (1,056 compared to 1,820) during the study period, and by 58% (405 compared to 967) following national lockdown. Outpatient referrals reduced by 44%, and inpatient referrals by 36%, and the number of surgeries performed by 36%. The regional incidence of traumatic injury fell from 5.07 (95% confidence interval (CI) 4.79 to 5.35) to 2.94 (95% CI 2.52 to 3.32) per 100,000 population per day. Significant reductions were seen in injuries related to sports and alcohol consumption. No admissions occurred relating to major trauma (Injury Severity Score > 16) or violence against the person. Changes in population mobility and trauma volume from baseline correlated significantly (Pearson's correlation 0.749, 95% CI 0.58 to 0.85, p < 0.001). However, admissions related to fragility fractures remained unchanged compared to the 2019 baseline. CONCLUSION: The profound changes in social behaviour and mobility during the early stages of the COVID-19 pandemic have directly correlated with a significant decrease in orthopaedic trauma referrals, but fragility fractures remained unaffected and provision for these patients should be maintained.Cite this article: Bone Joint Open 2020;1-6:182-189.

IMPACT-Scot report on COVID-19 and hip fractures.

AIMS: The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures. METHODS: A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. RESULTS: Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; p < 0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: 1) age, sex, type of residence (hazard ratio (HR) 2.93; p = 0.008); 2) Nottingham Hip Fracture Score (HR 3.52; p = 0.001); and 3) ASA (HR 3.45; p = 0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of < 217 × 109/l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. CONCLUSION: COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219-1228.