Risk Factors of 120-Day Mortality Among Hip Fractures With Concomitant COVID-19 Infection.

Background Hip fractures cause substantial morbidity and mortality worldwide, and the coronavirus disease 2019 (COVID-19) pandemic has only worsened the global burden. Increased 120-day mortality is well established in the literature among hip fractures with COVID-19. However, the risk factors associated with mortality have been poorly understood. We aimed to determine the risk factors associated with increased 120-day mortality among hip fractures with COVID-19. Methods Seventy patients with hip fractures with confirmed COVID-19 infection between March 2020 and December 2021 were included. Thirty-three patients who died within 120 days of admission were allotted to the non-survivor group and the rest 37 patients were allotted to the survivor group. Various parameters such as demographic variables, Nottingham Hip Fracture Score (NHFS), Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA), Abbreviated Mental Score Test (AMTS), National Early Warning Score (NEWS), fracture type, operation type, and delay in surgery were compared between the groups to determine the risk factors for increased mortality. Multivariate regression analysis was performed to know the independent association with increased mortality. Results A total of 33 patients died within 120 days giving the 120-day mortality rate of 47.1%. Baseline parameters such as ASA, AMTS on admission, NEWS on admission, and type of residence did not significantly affect mortality. The mean NHFS was significantly high in non-survivors (5.38 ± 1.52) compared to survivors (4.40 ± 1.75) (p < 0.001). Similarly, mean CCI was also significantly high in non-survivors (5.58 ± 1.74) compared to survivors (4.76 ± 2.29) (p < 0.001). A total of 70% (seven out of 10) of patients with delayed surgery of more than 36 hours from the admission died within 120 days of admission (p < 0.001). Mortality was significantly higher in patients who underwent internal fixation of fractures like a dynamic hip screw (DHS) or intramedullary (IM) nailing than in those who underwent hemiarthroplasty or total hip arthroplasty (THA). Post-operative parameters such as early mobilization and the multidisciplinary approach to review these patients made no difference to the mortality. Multivariate regression analysis of the parameters that made a significant difference in the mortality showed that delay in surgery and type of surgery (internal fixation) independently increased the mortality among these patients (p < 0.001). However, NHFS and CCI were not independently affecting the mortality among hip fractures with concomitant COVID-19. Conclusion The 120-day mortality rate among patients with hip fractures with concomitant COVID-19 was 47.1%. Delay in surgery of more than 36 hours and patients who underwent internal fixation were independent risk factors associated with increased mortality among these patients.

Improving Secondary Bone Protection Prescription in Patients Admitted With a Femoral Neck Fracture.

Background The socioeconomic burden caused by fragility fractures is well recognised in today's ageing society, with hip fractures making a notable contribution. There is a significant national drive for secondary-prevention bone-protection prescription given the high morbidity and mortality rates of femoral neck fractures. A Specific, Measurable, Achievable, Relevant, Time-bound (SMART) aim was constructed to reach the gold standard in a level 2 trauma centre, utilising the Model for Improvement methodology. Methodology Baseline data were collected for 79 consecutive patients admitted with a neck of femur fracture. A total of 14% were managed with bone-protection plans. The root cause analysis identified three elements having a major impact on the prescription of secondary bone-protection medication: the lack of awareness, education, and a structured multidisciplinary team (MDT) approach. Appropriate plan-do-study-act cycles were implemented and change audited. Results Following cycles one and two, the mean percentage of patients managed with bone-protection plans increased from 14% to 44% and 76%, respectively. A statistical process control chart demonstrated positive change for each cycle, with p-values of <0.01 and <0.001, respectively. After our final cycle, 100% of patients suffering from a femoral neck fracture were being managed with appropriate bone-protection plans according to the Royal College of Physicians' national hip fracture database. We observed 100% sustainability two years later, despite the coronavirus disease 2019 pandemic service disruptions and redeployment of staff. Conclusions Departmental awareness and education played an important role in this quality improvement project. The ultimatum and sustainability intervention was 'responsibility charting' among the MDT: setting clear roles within the team to deliver better patient care.

Cessation of Pulsed Lavage During the SARS-CoV-2 Pandemic: The Effect on Hip Hemiarthroplasty Cement Mantles.

Background With the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, we were issued with guidance to minimize aerosol-generating procedures and discontinued the use of pulsed lavage for hip hemiarthroplasty. Instead, we used a bladder syringe to wash the femoral canal. The aim of this study was to assess whether this change in practice had a detrimental effect on the quality of the bone cement mantles in patients undergoing cemented hip hemiarthroplasty. Methodology We performed a retrospective review of all patients treated at a tertiary teaching hospital in the United Kingdom (Addenbrookes, Cambridge University Hospitals) presenting with a neck of femur fracture requiring a hemiarthroplasty between October 2019 and June 2020. We retrospectively assessed 100 post-operative radiographs for patients who had received hip hemiarthroplasty following neck of femur fragility fracture (50 before the service change and 50 after). The Barrack classification was used to assess the quality of the bone cement mantle. Results Pre-SARS-CoV-2, 30% of hemiarthroplasties were deemed as being "at risk" of aseptic loosening. During SARS-CoV-2, 64% of hips were deemed as being "at risk." This represents a statistically significant absolute increase of 34% (P < 0.05, the P value is 0.000645). Both clinicians agreed on the classification of hips "at risk" or "not at risk" (i.e., grades C/D and A/B, respectively) in 85% of the cases. Cohen's kappa coefficient was calculated as 0.68, indicating substantial agreement. Conclusions Following our experience of this forced service change, we would discourage abandoning the use of pulsed lavage in future pandemics. We have demonstrated an association between abandoning pulsed lavage and detrimental effects on the procedural quality for hip hemiarthroplasty. Patients treated over this time period will be closely monitored for operative complications. As this was the only equipment change made for this procedure, we have demonstrated its detrimental effect on the procedural quality. Should pulsed lavage be discontinued, patients may need to be counseled for higher risk of early failure and revision surgery and may require long-term radiographic follow-up. In SARS-CoV-2-positive patients, Surgeons should carefully consider the risks and benefits of using pulsed lavage in accordance with the personal protective equipment they have available and the consequential impact on the bone cement mantle quality.

The Impact of COVID-19 on Neck of Femur Fracture Care: A Major Trauma Centre Experience, United Kingdom.

BACKGROUND: The aim of this study was to investigate the impact of the COVID-19 pandemic on the management and outcome of patients with neck of femur fractures. METHODS: Data was collected for 96 patients with neck of femur fractures who presented to the emergency department between March 1, 2020 and May 15, 2020. This data set included information about their COVID-19 status. Parameters including inpatient complications, hospital quality measures, mortality rates, and training opportunities were compared between the COVID-19 positive and COVID-19 negative groups. Furthermore, our current cohort of patients were compared against a historical control group of 95 patients who presented with neck of femur fractures before the COVID-19 pandemic. RESULTS: Seven (7.3%) patients were confirmed COVID positive by RT-PCR testing. The COVID positive cohort, when compared to the COVID negative cohort, had higher rates of postoperative complications (71.4% vs 25.9%), increased length of stay (30.3 days vs 12 days) and quicker time to surgery (0.7 days vs 1.3 days).The 2020 cohort compared to the 2019 cohort, had an increased 30-day mortality rate (13.5% vs 4.2%), increased number of delayed cases (25% vs 11.8%) as well as reduced training opportunities for Orthopaedic trainees to perform the surgery (51.6% vs 22.8%). CONCLUSION: COVID-19 has had a profound impact on the care and outcome of neck of femur fracture patients during the pandemic with an increase in 30-day mortality rate. There were profound adverse effects on patient management pathways and outcomes while also affecting training opportunities.

Thirty-day mortality and reliability of Nottingham Hip Fracture Score in patients with COVID19 infection.

In March 2020 Coronavisus-19 pandemic led to significant changes in operations in healthcare in the United Kingdom with national lockdown measures imposed to help protect the vulnerable and prevent transmission. Those deemed vulnerable fall into the cohort of patients at risk of fragility fractures such as fracture neck of femur (NOF). British Orthopaedic Association released guidelines advising that NOF fractures should continue to be treated urgently. AIM: Our unit aimed to identify changes in NOF caseload during the national lockdown and identify if Nottingham Hip Fracture Scores (NHFS) were reliable at predicting 30-day mortality in COVID-19 positive patients. METHODS: A retrospective observational study identifying NOF admissions over a 6-week period in 2020 during lockdown period, where demographics, NHFS, and 30-day mortality rates were compared against the same period in 2019. RESULTS: There was a reduction in NOF admissions by 17.8% (55 vs 67). No significant difference in patient demographics between groups. 30-day mortality rates were not significantly increased in 2020 compared with 2019. COVID-19 positive patients had significantly increased 30-day mortality rates (54%, p = 0.001) compared to COVID-19 negative (9.1%, p = 0.395) and 2019 (6%). DISCUSSION: NHFS was not reliable as a predictor for 30-day mortality in COVID-19 positive patients. Our unit reports increased mortality rates in NOF patients with covid-19 infection. This adds to the building evidence that COVID-19 is an independent predictor for mortality in NOF patients irrespective of NHFS. This should be communicated to patients who are admitted to hospital with NOF and units should continue with efforts to prevent hospital acquired COVID-19 infection.

Impact of COVID-19 pandemic on hip fractures: the central London experience COVID-related urgent geriatric hip trauma (COUGH) study COVERT ( COVid Emergency-Related Trauma and orthopaedics) collaborative.

INTRODUCTION: COVID-19 has been recognized as the unprecedented global health crisis in modern times. The purpose of this study was to assess the impact of COVID-19 on treatment of neck of femur fractures (NOFF) against the current guidelines and meeting best practice key performance indicators (KPIs) according to the National Hip Fracture Database (NHFD) in two large central London hospitals. MATERIALS AND METHODS: A multi-center, longitudinal, retrospective, observational study of NOFF patients was performed for the first 'golden' month following the lockdown measures introduced in mid-March 2020. This was compared to the same time period in 2019. RESULTS: A total of 78 cases were observed. NOFFs accounted for 11% more of all acute referrals during the COVID era. There were fewer overall breaches in KPIs in time to theatre in 2020 and also for those awaiting an orthogeriatric review. Time to discharge from the trust during the pandemic was improved by 54% (p < 0.00001) but patients were 51% less likely to return to their usual residence (p = 0.007). The odds ratio was significantly higher for consultant surgeon-led operations and consultant orthogeriatric-led review in the post-COVID era. There was no significant difference in using aerosol-generating anaesthetic procedures or immortality rates between both years. CONCLUSION: The impact of COVID-19 pandemic has not adversely affected the KPIs for the treatment of NOFF patients with significant improvement in numerous care domains. These findings may represent the efforts to ensure that these vulnerable patients are treated promptly to minimize their risks from the coronavirus.

Hip fracture care during the 2020 COVID-19 first-wave: a review of the outcomes of hip fracture patients at a Scottish Major Trauma Centre.

BACKGROUND AND PURPOSE OF THE STUDY: This study reviewed whether the response to the Coronavirus (COVID-19) pandemic affected the care for hip fracture patients at a major trauma centre in Scotland during the first-wave lock-down period. METHODS: All patients referred to Orthopaedics with a hip fracture in a major trauma centre in Scotland were captured between 14 th March and 28 th May (11 weeks) in 2020 and 2019. Patients were identified using electronic patient records. The primary outcomes are time to theatre, length of admission and 30-day mortality. Secondary outcomes are COVID-19 prevalence, duration of surgery, proportion of patients to theatre within 36 hours and COVID-19 positive 30-day mortality from time of surgery. 225 patients were included: 108 from 2019 and 117 from 2020. THE MAIN FINDINGS: 30-day mortality was 3.7% (n=4) in 2019 and 8.5% (n=10) in 2020 (p=0.142). There was no statistical difference with time to theatre (p=0.150) nor duration of theatre (p=0.450). Duration of admission was reduced from 12 days to 6.5 days (p=<0.005). 4 patients tested positive for COVID-19 during admission, one 5 days after discharge, all underwent surgical management. 30-day mortality for COVID-19 positive patients during admission was 40%. COVID-19 prevalence of patients that were tested (n=89) was 5.62%. CONCLUSIONS: This study has shown the care of hip fracture patients has been maintained during the COVID-19 pandemic. There is no statistically significant change in mortality, time to theatre, and duration of surgery, however, the patient's admission duration was significantly less than the 2019 cohort.

Impact of COVID-19 on clinical outcomes for patients with fractured hip: a multicentre observational cohort study.

AIMS: There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic. METHODS: We completed a multicentre cohort study across ten hospitals in England. Data were collected from 1 March 2020 to 6 April 2020, during which period the World Health Organization (WHO) declared COVID-19 to be a pandemic. Patients ≥ 60 years of age admitted with hip fracture and a minimum follow-up of 30 days were included for analysis. Primary outcome of interest was mortality at 30 days post-surgery or postadmission in nonoperative patients. Secondary outcomes included length of hospital stay and discharge destination. RESULTS: In total, 404 patients were included for final analysis with a COVID-19 diagnosis being made in 114 (28.2%) patients. Overall, 30-day mortality stood at 14.4% (n = 58). The COVID-19 cohort experienced a mortality rate of 32.5% (37/114) compared to 7.2% (21/290) in the non-COVID cohort (p < 0.001). In adjusted analysis, 30-day mortality was greatest in patients who were confirmed to have COVID-19 (odds ratio (OR) 5.64, 95% confidence interval (CI) 2.95 to 10.80; p < 0.001) with an adjusted excess risk of 20%, male sex (OR 2.69, 95% CI 1.37 to 5.29; p = 0.004) and in patients with ≥ two comorbidities (OR 4.68, CI 1.5 to 14.61; p = 0.008). Length of stay was also extended in the COVID-19 cohort, on average spending 17.6 days as an inpatient versus 12.04 days in the non-COVID-19 group (p < 0.001). CONCLUSION: This study demonstrates that patients who sustain a neck of femur fracture in combination with COVID-19 diagnosis have a significantly higher risk of mortality than would be normally expected.Cite this article: Bone Joint Open 2020;1-11:697-705.

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.