Quality Improvement Project: Improving Osteoporosis Treatment for Patients with a Neck of Femur Fracture

Background/Aims The Fracture Liaison Service (FLS) identifies patients >50 who have sustained a fragility fracture (FF). These patients need prompt assessment and decision on appropriate treatment for osteoporosis in order to reduce their risk of sustaining further FFs. Without treatment, 1/5 patients can go on to have a further FFs which carry significant risk to mortality and morbidity. Zoledronate is a bone agent that halves the risk of another FF. Patients with a neck of femur fracture (#NOF) present as one of the most at-risk groups for a further FF. These patients are generally elderly and frail and attendance to outpatient hospital appointments are difficult. Therefore, transforming the FLS from an out-patient-based service, to one that is streamlined to systematically identify and opportunistically treat patients whilst they are still in hospital means delivering timely, effective and efficient patient-centred care. Methods We used various Plan-Do-Study-Act cycles to aim to deliver Zoledronate to>=90% of appropriately assessed in-patients >60 who have had a #NOF within a year of commencing QIP. Results PDSA cycle 1-Involvement of ortho-geriatrician: P-Improve working relationship with ortho-geriatrician with an interest in bone health over a 6-month period;D-Regular meetings with wider MDT;S-Priority of bone health assessments made greater through ward round documentation;A-Expand knowledge throughout the wider ortho-geriatrician team. PDSA cycle 2-Timing of Zoledronate delivery: P-Literature review regarding delivery of Zoledronate timing;D-Discuss as MDT;SNo evidence to suggest delay in fracture healing if given on day 7;AAdopted process and communicated. PDSA cycle 3-FLS team on the wards as a result of PDSA cycle 2 not improving treatment outcomes: P-FLS nurses to join ortho-geriatrician ward round twice-weekly for 3- month trial period;D-Bank holidays and spike in Covid cases presented a challenge. Solution: Improvement of MDT relationships;S-At the end of the trial period an increase in patients who received treatment was shown and proved our prediction;A-Adaptation to documentation in FLS to streamline and reduce duplication. Conclusion The ability to deliver Zoledronate to>=90% of appropriate patients with a #NOF as an inpatient was reached after 8 months of initiating QIP. Furthermore, maintaining this was consistently achieved throughout the following year and beyond. A few of the main reasons for this included earlier drug delivery, having a dedicated ortho-geriatrician as part of the FLS, and the FLS team attending the wards. A prompt bone health assessment of patients has enabled appropriate treatment to be delivered efficiently. The delivery of Zoledronate as an in-patient has meant that a significantly greater proportion of patients receive treatment, and sooner, in comparison to awaiting an outpatient assessment (that they may not attend). Therefore, this QIP has demonstrated time- and cost-effective management of patients with #NOF requiring Zoledronate.

Management for A Depressive Patient with Femoral Neck Fracture by Electroconvulsive Therapy during COVID-19 Pandemic: A Case Report and Literature Review.

Electroconvulsive therapy (ECT) is an effective treatment for refractory major depressive disorder with suicidal ideation. The most common adverse medical events are transient retrograde amnesia, falls and pneumonia. Hip fractures, associated with high-energy trauma by convulsions, were occasionally reported in western countries, in the period before the COVID-19 pandemic. Strict COVID-19 regulations influenced the course and further investigation of the treatment of post-ECT complications. A 33-year-old man, previously diagnosed with major depressive disorder, had a history of nine successful sessions of ECT treatment for depression five years ago. He was hospitalized again for 12 sessions of ECT for recurrent depression. Unfortunately, an ECT-induced right hip-neck fracture was noted after the ninth session of ECT, in March 2021. After receiving close reduction and internal fixation of the right femoral neck fracture, with three screws, his original daily function was restored. His treatment was regularly followed up at the outpatient clinic for 20 months; he achieved partial remission with three combined antidepressants. This case of ECT-induced right hip-neck fracture informed psychiatric staff to be aware of this rare adverse complication and ensure its appropriate management, especially during the COVID-19 pandemic.

Effects of SARS-CoV­2 infections on inpatient mortality of geriatric patients after proximal femoral fracture surgery.

BACKGROUND: The medical challenges caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV­2) pose a tremendous burden on the healthcare system. This study aimed to analyze the effects of a SARS-CoV­2 infections or disease progression on inpatient mortality of geriatric patients after proximal femoral fracture surgery. METHODS: A retrospective analysis was conducted in all patients with a proximal femoral fracture surgically treated in an urban regional trauma center from 01/01/2020 to 01/31/2021. According to PCR test results detecting SARS-CoV­2, the patients were divided into two groups (SARS-CoV­2 positive vs. SARS-CoV­2 negative). Patient data, disease progression data, and treatment-related information were evaluated for all patients. Statistical data analysis was performed using unpaired Student's t test or non-parametric Mann-Whitney U test. RESULTS: A total of 311 patients (women: 70.4%, age: 82.0 ± 11.0 years) were included in this study. Of these 3.9% (12/311) had a positive test result for SARS-CoV­2. Significantly more deceased patients were found in the group tested positive for SARS-CoV­2 (SARS-CoV­2 positive: 41.7%, SARS-CoV­2 negative: 5.4%, p < 0.001). In addition, the number of proximal femoral fracture associated deaths correlated with the number of positive test results performed in the Clinic. The length of stay of SARS-CoV­2 COVID-19 survivors tended to be greater than in those who were tested negative (SARS-CoV­2 COVID-19 positive: 15.6 ± 13.1 days, SARS-CoV­2 COVID-19 negative: 11.5 ± 6.5 days, p = 0.683). Furthermore, a significant difference in age was found in SARS-CoV­2 survivors and SARS-CoV­2 decedents (deceased: 95.5 ± 7.5 years, alive: 83.5 ± 7.3 years, p = 0.020). CONCLUSION: The study was conducted before the introduction of SARS-CoV­2 vaccination. The results therefore refer to immune naive (unvaccinated) patients. In our study, more than 40% of all patients with proximal femoral fractures who tested positive for SARS-CoV­2 died during hospitalization. An additional, critical factor in this respect was the age of the infected patients. Nonetheless, a positive correlation was demonstrated between the mortality rate and the number of positive SARS-CoV­2 detections. Regarding the greater length of stay of patients tested positive for SARS-CoV­2, the limited transfer options (further rehabilitation, skilled nursing facility) of the infected ones can be considered as causal. Particularly the vulnerable older patients are increasingly endangered by a combination of proximal femoral fracture and SARS-CoV­2.

The impact of confinement on orthopaedic and trauma surgical activity

Introduction: Le 16 mars 2020, devant l'état d'urgence sanitaire décrété en France, le gouvernement a imposé des mesures de confinement dont l'impact sur l'activité de chirurgie orthopédique et traumatologique reste à démontrer. L'hypothèse de cette étude était que le confinement a diminué l'activité chirurgicale orthopédique et traumatologique. L'objectif principal était d'évaluer l'activité chirurgicale d'orthopédie et de traumatologie en période de confinement et de la comparer à l'activité hors confinement. Matériels & méthodes: Il s'agissait d'une étude rétrospective, monocentrique, observationnelle et comparative d'une cohorte continue de patients inclus pendant la période de confinement du 16 mars au 11 mai 2020. Cette cohorte a été comparée à un groupe de patients inclus de manière rétrospective sur la même période hors confinement l'année précédente du 16 mars au 11 mai 2019. Le critère de jugement principal était le taux d'incidence de l'activité chirurgicale en 2020 versus 2019 sur une période identique. Le critère secondaire était l'analyse des traumatismes recensés. Résultats: Le nombre de patients opérés était significativement diminué en période de confinement: 194 patients inclus en 2020 soit une incidence de 57 pour 100 000 habitants contre 772 patients inclus en 2019 soit une incidence de 227 pour 100 000 habitants;p < 0,001. L'activité chirurgicale d'orthopédie programmée passait d'un taux d'incidence de 147 en 2019 à 5 en 2020 pour 100 000 habitants (p < 0,001). L'activité chirurgicale de traumatologie passait d'un taux d'incidence de 80 en 2019 à 50 en 2020 pour 100 000 habitants (p: NS). Nous retrouvions une augmentation significative des patients de plus de 65 ans pendant le confinement, 70% contre 61% en 2019;p = 0,04. Le taux de fractures du col du fémur était significativement augmenté pendant le confinement, 48,5% contre 39,3% en 2019;p = 0,03. La chirurgie dégénérative était significativement diminuée pendant le confinement (p < 0,001). Discussion: Cette étude montre que l'activité chirurgicale d'orthopédie et de traumatologie a été significativement diminué par le confinement, avec une différence d'incidence de 170 pour 100 000 habitants, confirmant ainsi l'hypothèse des auteurs. Cette diminution est due à la fois à l'arrêt de l'orthopédie programmée et à la diminution de 40% du nombre de patients traumatisés. En période de confinement, le pourcentage de patients âgés de plus de 65 ans victime d'une fracture a significativement augmenté. Conclusion: Le confinement a eu un impact significatif sur l'activité de chirurgie orthopédique et traumatologique. Niveau de preuve: III;comparative et rétrospective. © 2021 Elsevier Masson SAS

Avascular Necrosis of the Hip: A Post COVID-19 Sequela.

A 60-year-old African American male presented to the hospital with seven months of progressively worsening left anterior hip pain with no known trauma. Two months after the pain onset, he underwent an x-ray of the pelvis with the lateral left hip, revealing dystrophic soft tissue calcification adjacent to the superolateral left acetabulum. Pain at this time was attributed to presumed sciatica vs arthritis. The patient underwent multimodal treatment for his pain without relief. In the month prior to the presentation, the patient also developed right hip pain. He then underwent a bilateral hip x-ray, revealing left femoral neck lucency suspicious for a nondisplaced fracture. CT pelvis was ordered at this time for further evaluation and demonstrated bilateral subcapital hip fractures. He was subsequently discharged from the emergency department with pending laboratory work and plans for close outpatient orthopedic surgery follow-up. The following day, the patient was instructed to return to the hospital due to an elevated erythrocyte sedimentation rate of 39 mm/hr and C-reactive protein of 41.6 mg/L. Subsequent MRI pelvis revealed bilateral subcapital femoral neck fractures with avascular necrosis (AVN) requiring surgical intervention with bilateral hip arthroplasty. Our patient underwent an extensive workup with no evidence of traditional risk factors for osteonecrosis, osteopenia, or other bone diseases. A pertinent finding in the patient's history was an admission for severe SARS-CoV-2 (COVID-19) infection 10 months prior. 'Long COVID' is a complex illness that has been shown to affect intravascular blood flow, and likely contributed to the development of bilateral hip AVN in our patient. Given this novel presentation, it is crucial that AVN be considered early in evaluating anterior hip pain for patients with a history of COVID-19 infection in order to avoid severe consequences such as femoral neck fractures.

No Excess Mortality in Geriatric Patients With Femoral Neck Fractures Due to Shorter Intensive Care Caused by COVID-19.

Background Since March 2020, increasing numbers of hospitalized patients with coronavirus disease-2019 (COVID-19) infections have been registered. The first and the second waves necessitated the extensive restructuring of hospital infrastructure with prioritization of intensive care capacity. Elective surgeries in all surgical disciplines were postponed to preserve intensive care capacity for COVID-19 patients. However, emergency care for trauma patients had to be maintained. Especially, geriatric patients with hip fractures often require intensive care. This study sought to investigate the possible excess mortality of geriatric patients with femoral neck fractures due to shorter intensive care unit stays because of COVID-19. Material and methods All patients over the age of 70 between March 2019 and February 2020 who underwent surgical treatment for femoral neck fractures were included. This cohort (group 1) was compared with all patients over 70 who received surgical treatment for hip fractures during the period of the pandemic between March 2020 and February 2021 with attention to potential excess mortality due to low intensive care capacity (group 2). Demographic data, American Society of Anesthesiologists (ASA) score, surgical modality, ICU stay, complications, and mortality were analyzed and compared. Results A total of 356 patients with 178 in each cohort with a mean age of 82.7 in group 1 and 84.8 in group 2 (p<0.05) were included. No significant difference was seen in sex and ASA scores. During the pandemic, patients with hip fractures had a significantly shorter stay in ICU (0.4 ± 0.9 vs 1.2 ± 2.8 days; p<0.05), shorter time to surgery (29.9 ± 8.2 vs 16.8 ± 5.3 h; p<0.05) and operations were significantly more often performed out-of-hour (4 pm-12 am 47.8% vs 56.7%; 12 am-8 am 7.9% vs 13.5%, p<0.05). Interestingly, mortality was lower during the pandemic, but the difference did not reach significance (6.7% vs 12.4%, p=0.102). Conclusion During the pandemic, ICU capacity was reserved for COVID patients. Due to a change in the law of the Joint Federal Committee with effect from January 1, 2021, all patients with proximal femur fractures had to be operated on within the first 24 hours, which is why a significantly shorter time to surgery was observed during the pandemic period. As a consequence, a lower mortality rate was observed, although no significance could be reached.

Improving the Quality of Clinical Coding and Documentation to Record Accurate Outcomes in Non-Operatively Managed Hip Fractures

Background: Our 2019 Clinical Audit for non-operatively managed hip fractures at our Trust was 9.76% against the national standard of 5% at The National Hip Fracture Database (NHFD) annual report 2017. A re-audit was conducted to review reasons for higher incidence as recommended by NICE and improve outcomes. Method: Hip fracture patients admitted between 1st April 2019 and 31st August 2020 to Southport and Ormskirk NHS Trust were reviewed clinico-radiologically. Data was collected from NHFD, EVOLVE patient records, and PACS imaging systems. Following appropriate “Primary Diagnosis” of hip fracture, confirmation of operative or non-operative management was undertaken following a joint assessment by the Orthopaedic staff and the Clinical Coding department evaluating reasons behind the decision. Secondary outcome measures compared 30-day and one-year mortality with the previous cohort. Results: In the re-audit, 512 cases were reviewed, 50 patients excluded following correct Clinical Coding, 440 hips were operated and 22 (4.8%) managed non-operatively. However, 30-day mortality rose from 30.5% during the audit to 54.50% possibly due to the effect of COVID-19. Conclusions: The newly introduced “Neck of Femur Proforma” has remarkably improved the quality and organization of clinical documentation of diagnosis. Appropriate Clinical Coding allows correct information for the NHFD Trust figures.

Bone health monitoring and treatment at an adult cystic fibrosis centre

Objective: To assess if current practices in bone health monitoring and treatment at a specialist regional cystic fibrosis (CF) centre are in line with current European CF guidelines. Methods: An audit of bone health of all adolescents and adults atWolfson CF centre UK was conducted. Data was gathered between December 2020 and November 2021 from medical records which included timing of last DEXA scan and if it had been within last 5 years, DEXA scan T/Z scores, vitamin D status and bisphosphonate use. Results: 237 individuals were identified, 106 female with a median age of 30 (±15) years. DEXA scans had been conducted in the last 5 years for 70% of the clinic. Of thosewho had a DEXA scan (n = 199), 53% were conducted on time in line with guidelines and 27% were overdue by more than 3 years. Median Z scores were −0.7 (±1.9) at the spine, −0.4 (±1.63) at the neck of femur, −0.6 (±1.5), total femur, and −0.4 (±1.75) total body. CF-related low bone mineral diseasewas present in 0.4–11% of clinic depending on the site of the Z score. 80% of the clinic had had vitamin D levels checked within the last year, with 47% being classed as sufficient (≥75 nmol/L). However, only 3% were classed as deficient with levels below 25 nmol/L. Bisphosphonate treatmentwas indicated in 19% of individuals. However, this had happened in just half of this group. 46% used oral medication, 54% intravenous. Conclusion: The majority of individuals had DEXA scans on time and repeated within 5 years. However, roughly a quarter of individuals were overdue by ≥3 years. Vitamin D levels should be checked at least annually as a minimum and this occurred in the majority of the clinic. There was a very low proportion of vitamin D deficiency but improved monitoring is needed, especially in those with vitamin D insufficiency. Although these results suggest that more robust measures could be in place for bone health monitoring and treatment, the coronavirus pandemic would have had an effect.

Determiners of pressure ulcers formation – analyses from hospital information system

Introductions: Pressure ulcers (PUs) represents an undesirable complication during hospitalization. Aim: Retrospective data analysis to verify the prevalence of PUs since 2015 (since the mandatory registration of the PUs an adverse event) by principal diagnosis, type of surgery and length of hospital stay in the period 2015–2021. Sample and methods: Retrospective analysis of data from the hospital information system (HIS), at 0.05 level of significance (T-Test) with the variables: age, number of pressure ulcers, principal diagnosis, operation, length of hospitalization and prevalence of COVID-19 to length of hospitalization. Results: A total of 2,350 PU cases in 1,539 patients (1.52 PUs/patient) were registered in the HIS, and 930 (40%) patients were admitted to hospital with PUs. The most common locations of PUs were: heel (33%), sacrum 6% less, buttocks (17%). Between 2015 and 2021;17,247 patients were operated on, of whom 289 had a Pus. The most common principal diagnosis in the occurrence of PUS was femoral neck fracture (14.35%) and neurological (9.09%) or oncological disease (12.03%). The incidence of PUs was surprising in patients with ileal conditions (11.57%). COVID-19 was found in 163 patients in 2020 and 2021, six of whom had PUs and prolonged hospitalization. Conclusion: It is important to view the health status of people with chronic wounds and PUs in a comprehensive manner and to develop an individualized care plan to improve patients‘ lives and chances of recovery.

Femoral neck fracture surgery: Should it be delayed?

Femoral neck fracture is a national health care issue in western countries due to the increase number of aged patients in the whole population. Mortality increases when the operative delay is higher than 24 hours in patients without associated morbidity. Patients with co-morbidities have to be evaluated using specific scores. Preoperative check up have to be planned in order to improve patient’ condition without compromising the time for surgery. Relatives have to be questioned about preoperative patient’ autonomy and quality of life. A recent Sars-Cov-2 infection increases postoperative mortality. Operative delay depends on the severity of the disease. Anti-platelets and anticoagulants may also delay surgery. The choice of regional vs. general anaesthesia has no documented effect on mortality.

Fracture de l’extrémité supérieure du fémur : quand faut-il opérer ?

Résumé La prise en charge des fractures du col du fémur est un sujet de santé publique qui concerne une population âgée à prédominance féminine. La mortalité augmente lorsque le délai de prise en charge est supérieur à 24heures chez les patients sans co-morbidités. Les patients souffrant de co-morbidités peuvent être identifiés avec des scores spécifiques et doivent faire l’objet d’une évaluation préopératoire. Les bilans préopératoires doivent faire l’objet de pragmatisme mais des actions correctrices peuvent être nécessaires avant la chirurgie. L’entourage doit être associé à l’appréciation de l’autonomie préopératoire. L’infection concomitante par la COVID-19 augmente fortement la mortalité et le délai opératoire dépend de la sévérité de la maladie. La prise d’un traitement anticoagulant ou antiplaquettaire peut également retarder l’intervention. La technique d’anesthésie a finalement peu d’impact sur la mortalité et la récupération fonctionnelle. Summary Femoral neck fracture is a national health care issue in western countries due to the increase number of aged patients in the whole population. Mortality increases when the operative delay is higher than 24hours in patients without associated morbidity. Patients with co-morbidities have to be evaluated using specific scores. Preoperative check up have to be planned in order to improve patient’ condition without compromising the time for surgery. Relatives have to be questioned about preoperative patient’ autonomy and quality of life. A recent Sars-Cov-2 infection increases postoperative mortality. Operative delay depends on the severity of the disease. Anti-platelets and anticoagulants may also delay surgery. The choice of regional vs. general anaesthesia has no documented effect on mortality.

Managing a Vaccinated Versus a Non-Vaccinated COVID 19 Positine Diagnosed Elderly Patient Who Had Sustained Intracapsular Neck of Femur Hip Fracture Challenges and Complications

Introduction: hip fractures in elderly patients have been associated with high morbidity and mortality rate and are dependent on the presence of associated comorbidities. SARS-CoV-2 disease (Covid-19) is nowadays considered to be an independent risk factor increasing mortality rates. The aim of our report was to analyse the management of a vaccinated versus a non-vaccinated elderly patient that were both diagnosed positive to SARS-CoV-2 after having sustained an intracapsular neck of femur fracture. Methods: Two patients (Patient A 91 and Patient B 88 years old, both female) were referred to our hospital after sustaining an intracapsular neck of femur hip fracture as a result of low energy trauma. Both patients tested positive for Covid-19 during their preoperative screening tests. Patient A had not been vaccinated against Covid-19 in contrast to patient B who had completed the 2 dose regimen of the Pfizer-BioNTech COVID-19 vaccine. Patient A presented on arrival Leukopenia (WBC: 1.2 μc/l, Neutrophils 0.4 mcL) and Thrombocytopenia (PLT 70.000). The Procalcitonin, C-Reactive Protein and Ferritin levels long as Arterial blood Gases were measured in both patients on arrival. Patient A required administration of Granulocyte colony stimulating factor and platelet transfusion prior to surgery. Results: Both patients underwent uncemented hip hemiarthroplasty. Patient A was operated 5 days after hospital admission as optimization of the patient's Covid-19 related Leukopenia and Thrombocytopenia was required and Patient B was operated within 24 hours after hospital admission. Patient A required transfusion of 4 blood Units (bleeding related to Thrombocytopenia) compared to 2 blood units that were administered in Patient B. Patient A developed Covid 19 related Pneumonia and Lung disease on the 6th post-operative day (PO2 SO2) and required high flow nasal cannula therapy for 7 days followed by oxygen therapy for 8 days delaying her mobilization and hospital discharge. Patient A was discharged on the 29th post-operative day and Patient B was discharged on the 6th post-operative day. Conclusion: Covid 19 related complications in elderly hip fracture patients are challenging and require multidisciplinary approach and hospital resources. However, Vaccination against covid-19 seems to prevent Covid related complications and can improve the outcome. Large series studies and further research is required to support our thesis.

A novel, cost-effective and easily reproducible simulation method for teaching fascia iliaca blocks significantly improves peri-operative administration rates in neck of femur fracture patients

Despite high-level evidence supporting early fascia iliaca block (FIB) administration in patients sustaining neck of femur (NOF) fractures, administration remains suboptimal, restricted primarily by limited training opportunities. We present a novel, cost-effective and easily reproducible simulation session designed to teach the landmark technique during the Covid-19 pandemic. A simulation mannequin was used with four absorbent swabs, two banana skins and a clear dressing were applied to the inguinal region to recreate the 'two-pop' texture of the landmark technique. Ten participants attended, limited by social distancing. A 1 (poor) to 5 (excellent) feedback sheet was handed to all participants for the five domains of content, delivery, interaction, usefulness, and quality of the practical skills session, with opportunities for qualitative feedback. The FIB administration rates in all NOF fracture patients between August -October 2019, before the simulation session, were statistically compared to November-December 2020, following it. All participants gave a 5/5 (excellent) rating for all five domains, confirming good acceptability amongst practitioners. In the time period before the session, 9/29 NOF fracture patients received a FIB, improving to 18/31 patients following it (p=0.042;two-tailed Fisher's exact test), a statistically significant increase in administration. The average cost per participant for the single-use materials in the session was £1.56, whereas the multiple-use items costed £7.88 per participant. Adoption of this novel, cost-effective and widely reproducible simulation method is deemed highly useful and acceptable by a diverse range of healthcare professionals, resulting in a statistically significant increase in FIB administration in NOF fracture patients.

Adherence to best practice tariffs (BPT) for neck of femur (NOF) fracture admissions during the COVID-19 pandemic

Introduction: For patients with fragility hip fractures, care needs to be promptly organised to undertake a holistic assessment and preparation for surgery. The aim of the Best Practice Tariffs (BPT) is to promote hip fracture programmes that provide best practice in the care and secondary prevention of fragility fractures. Method: • Retrospective audit. • Time frame: 11/03/2020 - 22/04/2020. • Data retrieved from trauma management and radiology systems. Results: • Among 33 patients with mean age of 82, 61 % showed compliance to BPT criteria. • 39% did not meet the criteria: 33% had delayed surgery .36 hours, 3% had delayed orthogeriatric assessment, and 3% not fit for surgery. • 33 % delayed surgeries due to requirement for medical optimisation, and further investigation. • Among COVID patients: 41.6 % mortality rate, of which 40 % were perioperative. • There was a loss of BPT income (around £17k) during these unprecedented times. However, the provisions of NOF care did not fluctuate despite extreme pressures on our services. Conclusions: • Ensuring all members of the MDT have access to clinical management system. • Implementation of early supported discharge programmes allowed reduction in length of acute hospital stay (from 14.2 in Jan 2020 to 8 in March 2020). • Improving access to pacemaker check services.

Incidence of acute kidney injury in neck of femur fracture patients during the COVID-19 pandemic in princess royal hospital, Telford

Aim: Patients undergoing surgical repair of neck-of-femur (NOF) fractures are at higher risk of acute kidney injury (AKI). NICE and BOAST have published guidelines to help prevent the occurrence of AKI, including adequate fluid resuscitation pre- and post-operatively. An audit was conducted during the COVID-19 pandemic to explore whether the department was adhering to NICE guidelines. Method: AKI was defined, as per NICE Clinical Knowledge Summaries, as an increase in serum creatinine levels by 26 μmol/L or greater. Data was collected prospectively starting from December 2020 to February 2021 in the Princess Royal Hospital during the COVID-19 pandemic. All patients with NOFs were included and data on sex, age, comorbidities, and type of surgery were collected. Results: In total, 32 patients were included in the audit with an average age of 82 years;of these, eleven patients had dynamic hip screws and eighteen patients had hemiarthroplasties. Five patients had chronic kidney disease, six patients had previous myocardial infarctions and thirteen patients had hypertension. Two patients (6.3%) were found to have an AKI post-surgery with increased creatinine levels of 27 and 28 μmol/L. Both had hypertension and underwent hemiarthroplasties. Conclusions: Complications such as AKIs are reversible and preventable. Especially during the COVID-19 pandemic such complications can increase morbidity and mortality of patients suffering from NOF leading to longer hospital stays. The low rate of AKI following NOF repair in our Department of Trauma and Orthopaedic is attributable to adherence to NICE and BOAST fluid resuscitation guidelines.

To Evaluate the Outcome of Neck of Femur Fracture Treated by Bipolar Hemiarthroplasty in COVID-19-positive patients:- A Retrospective Study

Background: Orthopaedic trauma surgery focused mainly on femoral fragility fractures in the elderly, since the “lockdown” began on March 23, 2020 in our country. Proximal femur fractures carry a high mortality rate due the age and complications. Thus, orthopaedic surgeons face the daily dilemma of performing life-saving surgery on patients who, have severe respiratory compromise, have a higher risk of peri-operative death. The optimal surgical treatment of displaced femoral neck fractures is still debated. Hemiarthroplasty4 contributes to early ambulation and good functional recovery. Determining mortality and risk factors for adverse outcomes for patients with COVID-19 and a concurrent hip fracture is of great importance, as it can improve clinical pathways, perioperative management, and resource allocation. Methods: This was a retrospective study of 10 patients ≥60 years of age with a neck of femur fracture and COVID-19 who underwent hip hemiarthroplasty. Clinical characteristics and early postoperative outcomes were reported. Results: Seven out of the 10 COVID-positive hip fracture patients in our series were asymptomatic on admission with no clinical signs or symptoms of COVID-19 infection. One of the patient had cough and other 2 patients presented with hypoxia. 7 patients was given supplemental oxygen postoperatively which includes the patient presented with hypoxia. 7 patients required post op blood transfusion.None of the patients were put on mechanical ventilation. There was no case of surgical site infection.Average harris hip score was 80 with good outcome. The average length of inpatient stay was 15 days. Conclusions: Our study shows that neck of femur fracture patients who present with asymptomatic or mild COVID-19 who underwent hip hemiarthroplasty had a good functional outcome with few post op complications.

The effect of CIVID-19 on the management and outcome of neck of femur fractures in a district General Hospital-a comparative study

Aim: We wanted to see how the virus has impacted the management and outcome of our neck of femur fracture patients during Spring 2020. Method: We performed a retrospective study of all neck of femur fracture patients presenting to our hospital from 23rd March 2020 (start of official lockdown in UK) until the end of May 2020 and compared them to patients presenting in the same time period in 2019. We recorded patient demographics, COVID-19 swab results, time to surgery, length of stay, transfers between wards, and 30-day mortality rates. Results: We identified 75 patients in 2020 compared to 88 in 2019. Average length of stay was 11.4 days compared to 14.3 a year earlier. Mean time to surgery was 32.3 hours compared to 31.6 in 2019. The 30- day mortality increased significantly from 5.7% (5/88) in 2019 to 16% (12/75) in 2020 (p<0.05) From 73 patients tested for COVID-19, 3 had a positive swab. Of these, 2 died. During their admission, 14 patients were transferred to 3 or more wards;in this group, 30-day mortality was 42.9% (6/14). Conclusions: There has been a significant increase in 30-day mortality during COVID-19. Despite maintaining our time to surgery and reducing overall length of stay, we saw an increase in mortality, associated with multiple ward transfers rather than a high number of COVID-19 positive swab cases. Changes in pathways and wards configurations led to some patients requiring multiple transfers. This can cause difficulties in coordinated, multidisciplinary care for patients with NOF Fractures.

The impact of CIVID-19 on individuals with neck of femur fracture in the united kingdom: A systematic review and meta-analysis

Aim: All Neck of Femur fracture patients have a significant 30 - day mortality despite efforts to improve their outcomes. Incidence of NOF cases remained high during the pandemic in the UK and as a result numerus cases were complicated with SARS-CoV-2 infection. We performed a systematic review and meta-analysis of all UK published studies related to NOF fractures and 30-day mortality outcomes during the COVID 19 pandemic. Method: A systematic review and meta-analysis was performed and reported as per the PRISMA checklist. Two reviewers independently searched on Medline for UK studies that were published between 1stof March 2020 and 1stof November 2020. Outcomes compared were 30- day mortality, time to surgery and anaesthetic risk. Results: A total of 5 articles were included in our study. These studies were all case series with evidence level 3 or 4. A total of 286 patients complicated with COVID infection with a range of 30-day mortality 30.5%-50%. OR 6.02(95CI: 4.10-8.85), Chi24.82, I2 58%. Increased time to surgery due to Coronavirus related delays was also noted for the majority of studies. Mortality scores (Charlson Comorbidity Index, Nottingham Hip fracture score) failed to accurately predict the mortality risk. Conclusions: Concurrent infection of COVID -19 in patients with NOF fractures increases the 30-day mortality 6 times compared to the negative group. Efforts should be made to optimise time to surgery as well as postoperative care via higher dependency units. Updates in mortality predicting scores is deemed necessary to include the SARS-CoV-2 infection as a factor.

Informed consent for neck of femur fracture surgery during the CIVID-19 pandemic: An evidence-based approach

Background: Surgical intervention for neck of femur fractures continues to be prioritised during the Covid-19 pandemic. However, there remains a lack of clarity for clinicians during the consent process. This study quantifies additional perioperative risks for Covid-19 positive patients undergoing neck of femur fracture surgery and establishes an evidence-based framework for facilitating informed consent during the Covid-19 pandemic. Method: 259 patients undergoing neck of femur fracture surgery in four hospitals at the epicentre of the United Kingdom's first wave of Covid-19 were recruited. 51 patients were positive for Covid-19. Predefined outcomes were recorded in a 30-day postoperative period. Results: Odds of intensive care admission were 4.64 times higher (95% CI 1.59-13.50, p=0.005) and odds of 30-day mortality were 3 times higher (95% CI 1.22-7.40, p=0.02) in Covid-19 positive patients. 74.5% of Covid-19 positive patients suffered post-operative complications. 35.3% of Covid-19 positive patients developed lower respiratory tract infection with 13.7% progressing to acute respiratory distress syndrome. 9.8% of Covid-19 positive patients experienced symptomatic thromboembolic events with a 3.9% incidence of pulmonary emboli. Conclusions: The implications of Covid-19 on the informed consent process for neck of femur fracture surgery are profound. Covid-19 positive patients should be consented for increased risk of postoperative complications (including lower respiratory tract infection, acute respiratory distress syndrome and thromboembolic events), longer inpatient stay, increased frequency of intensive care admission and higher risk of mortality.