Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study.

OBJECTIVE: To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications. DESIGN: Retrospective chart review. SETTING: Eleven Level I trauma centers. PATIENTS: From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included. INTERVENTION: Reamed IMN. MAIN OUTCOME MEASURES: Incidence of postoperative thromboembolic and respiratory complications. RESULTS: Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days. CONCLUSION: In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries. LEVELS OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy.

BACKGROUND: From February 20 to April 2020, the coronavirus SARS (severe acute respiratory syndrome)-CoV-2 spread in northern Italy, drastically challenging the care capacities of the national health care system. Unprepared for this emergency, hospitals have quickly reformulated paths of assistance in an effort to guarantee treatment for infected patients. Orthopaedic departments have been focused on elderly traumatology, especially the treatment of femoral neck fractures in patients with coronavirus disease-2019 (COVID-19). The purpose of the present study was to evaluate the orthopaedic management strategy for femoral fragility fractures in COVID-19-positive patients with the hypothesis that operative treatment may contribute to the overall stability of the patient. METHODS: Sixteen patients affected by proximal femoral fracture and a recent history of fever, shortness of breath, and desaturation were admitted to the emergency room. Thoracic computed tomography (CT) and oropharyngeal swabs confirmed that they were positive for COVID-19, requiring hospitalization and prophylaxis with low-molecular-weight heparin. RESULTS: Three patients died before surgery because of severe respiratory insufficiency and multiple-organ-failure syndrome. Ten patients underwent surgery on the day after admission, whereas 3 patients had suspended their use of direct thrombin inhibitors and needed surgery to be delayed until the third day after admission. In all patients except 1, we noted an improvement in terms of O2 saturation and assisted respiration. In 9 patients, hemodynamic and respiratory stability was observed at an average of 7 days postoperatively. Four patients who underwent surgical treatment died of respiratory failure on the first day after surgery (1 patient), the third day after surgery (2 patients), or the seventh day after surgery (1 patient). CONCLUSIONS: We noted a stabilization of respiratory parameters in 12 COVID-19-positive patients who underwent surgery treatment of proximal femoral fractures. We believe that in elderly patients with COVID-19 who have proximal femoral fractures, surgery may contribute to the overall stability of the patient, seated mobilization, improvement in physiological ventilation, and general patient comfort in bed. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effect of COVID-19 positivity on inflammatory parameters and thirty day mortality rates in patients over sixty five years of age with surgically treated intertrochanteric fractures.

PURPOSE: To evaluate the effect of COVID-19 positivity on inflammatory parameters and 30-day mortality rates in patients over 65 years of age who were operated on for intertrochanteric femur fractures (IFF). METHODS: Eighty-seven patients (31 males, 56 females) who had a dynamic hip screw (DHS) or proximal femur nail (PFN) for the IFF between March 2020 and November 2020 were included in the study. The patients were divided into two groups as COVID-19 confirmed and probable positive (Group 1) and COVID-19 negative (Group 2). Time to surgery, operation duration, length of hospital stay, 30-day mortality, rates of the intensive care unit (ICU) referral, and inflammatory parameters such as haemoglobin, CRP, sedimentation, PCT, D-Dimer, and ferritin were evaluated. RESULTS: No significant difference was observed in terms of demographic data such as age, gender, comorbidity, and fracture type between the groups. Thirty-day mortality, ICU referral rate, blood transfusion rate, and hospitalization period were higher in Group 1 (p = 0.016, p = 0.012, p = 0.031, and p = 0.011, respectively). The inflammatory parameters were higher in Group 1 compared to Group 2 in the preoperative and postoperative periods (p < 0.05). CONCLUSION: COVID-19 positivity increases inflammatory parameters (as expected) and increases the 30-day mortality and ICU requirement in patients with surgically treated IFF.

A preliminary experience with a new intramedullary nail for trochanteric fractures.

BACKGROUND AND AIM OF THE WORK: The worldwide incidence of fractures of the proximal end of the femur is increasing as the average age of the population rises. The current surgical gold treatment standard is intramedullary nail fixation. The Authors present their experience with the D-Nail system for intertrochanteric femur fractures. METHODS: From January 1st to February 21st 2020 (breakout of COVID-19 pandemic) 34 patients were treated with the D-Nail system: 11 with basicervical fractures, 16 with intertrochanteric stable fractures and 7 with intertrochanteric unstable fractures. In 11 cases, a single cephalic screw was used; in 23 cases, two of them were used. Distal locking was executed in 7 patients. Follow-up time ranged from 2 to 3 months. RESULTS: None of the reported intra- or post-operative complication was linked to the fixation device or the surgical technique. Patients were monitored with clinical and radiological checkups using modified Harris Hip Score to accurately evaluate the fluctuations in the rehabilitation period. CONCLUSION: The main advantages of this synthesis device are the proximal hole's peculiar shape, which allows the possibility to position one or two cephalic screws on the same nail, and the silicon coating, which provides numerous biological advantages. Distal locking was executed in selected cases only, based on fracture type. Optimum treatment involves rapid execution of surgery, minimal trauma during surgery, maximum mechanical stability, and rapid weight-bearing. Although our case number is small and follow-up time brief, our results are encouraging.