Major trauma care at a regional trauma centre during the COVID-19 lockdown in England.

INTRODUCTION: The COVID-19 pandemic has changed the presentation of many medical and surgical conditions, including major trauma. We aimed to assess how lockdown changed the presentation, severity and management of major trauma patients at our level 1 trauma centre in England. METHODS: Data were collected retrospectively from the Trauma Audit and Research Network's database between 23 March and 28 April 2020 and compared with the same period in 2019. Collected data included patient demographics, and the mechanism, severity and management of injuries. RESULTS: We experienced a 56.4% reduction in major trauma admissions during the lockdown period when compared with 2019. In 2020, more patients arrived in haemodynamic shock (25.3% vs 12.2%, p=0.02); however, Glasgow Coma Scale and Injury Severity Score were unchanged. A higher proportion of incidents occurred at home (37.2% vs 53.5%, p=0.018), with no difference in trauma secondary to substance abuse or assault. During lockdown, patients had a significantly shorter hospital (17 vs 10 days, p=0.029) and critical care stay (2 vs 1 day, p=0.033). A higher proportion of major trauma patients were assessed by specialty trainees in the emergency department in 2020 (12.8% vs 53.1%, p=0.0001) with a lower proportion assessed by a consultant (69.8% vs 46.7%, p=0.001). CONCLUSIONS: The COVID-19 pandemic and lockdown drastically changed human behaviour, as reflected in the change in presentation of major trauma. Changes in the management of these patients reflect adaptive measures to manage the pressures generated by the worldwide pandemic.

Low body mass index is associated with increased mortality in patients with pelvic and acetabular fractures.

AIMS: Fractures of the pelvis and acetabulum are often the consequence of high energy trauma in young individuals or fragility fractures in osteoporotic bone. They can be life-threatening or life changing injuries. No published data exists comparing body mass index (BMI) and mortality for this patient group. The aim of this study was to identify if low BMI (<18.5) was a predictor of morbidity and mortality for patients with these injuries. PATIENTS AND METHODS: Of the 1033 patients with pelvic or acetabular fractures referred to a single level 1 major trauma centre (MTC) over a 4.5-year period (August 2015 - January 2020); we retrospectively analysed data for all admitted patients. Data was collected on demographics, injury pattern, operative intervention and complications. Comparison was made between patients that were underweight (BMI<18.5) and patients that were not. Both in-hospital and post discharge complications were recorded including pulmonary embolus (PE), deep venous thrombosis (DVT), ileus, infection, loss of reduction and mortality at 6 months. RESULTS: 569 patients admitted to the MTC with a pelvic or acetabular fracture were included in our analysis. Underweight patients had a statistically significant increase in mortality both in-hospital (p = 0.019) and at 6 months post injury (p = 0.039) when compared to other BMI groups. No statistical significance was found between these BMI groups comparing morbidity: DVT (p = 0.712), PE (p = 0.736) nor ileus (p = 0.149). Covariate analysis showed that a low BMI was associated with triple the in-hospital mortality after correction for age and energy of injury (adjusted OR 3.028, 95% CI 1.059-8.659). CONCLUSION: This is the first published study that demonstrates a statistically significant increase in mortality in patients with pelvic or acetabular fractures who are underweight. Surgeons should carefully consider appropriate peri-operative optimisation for these patients. Further investigation into the effects of low BMI and response to trauma is required.

The global burden of trauma during the COVID-19 pandemic: A scoping review.

Purpose; The COVID-19 pandemic has necessitated profound adaptations in the delivery of healthcare to manage a rise in critically unwell patients. In an attempt to slow the spread of the virus nationwide lockdown restrictions were introduced. This review aims to scope the literature on the impact of the pandemic and subsequent lockdown on the presentation and management of trauma globally. Methods; A scoping review was conducted in accordance with PRISMA-ScR guidelines. A systematic search was carried out on the Medline, EMBASE and Cochrane databases to identify papers investigating presentation and management of trauma during the COVID-19 pandemic. All studies based on patients admitted with orthopaedic trauma during the COVID-19 pandemic were included. Exclusion criteria were opinion-based reports, reviews, studies that did not provide quantitative data and papers not in English. Results; 665 studies were screened, with 57 meeting the eligibility criteria. Studies reported on the footfall of trauma in the UK, Europe, Asia, USA, Australia and New Zealand. A total of 29,591 patients during the pandemic were considered. Mean age was 43.7 years (range <1-103); 54.8% were male. Reported reductions in trauma footfall ranged from 20.3% to 84.6%, with a higher proportion of trauma occurring secondary to interpersonal violence, deliberate self-harm and falls from a height. A decrease was seen in road traffic collisions, sports injuries and trauma occurring outdoors. There was no significant change in the proportion of patients managed operatively, and the number of trauma patients reported to be COVID-19 positive was low. Conclusion; Whilst the worldwide COVID-19 pandemic has caused a reduction in the number of trauma patients; the services managing trauma have continued to function despite infrastructural, personnel and pathway changes in health systems. The substantial effect of the COVID-19 pandemic on elective orthopaedics is well described, however the contents of this review evidence minimal change in the delivery of effective trauma care despite resource constraints during this global COVID-19 pandemic.

The impact of frailty in major trauma in older patients.

As our population ages and increasing numbers of older patients experience major trauma it is important to understand factors that influence outcomes in this patient cohort. The aim of this study is to assess the impact of frailty in older patients who experience major trauma (Injury Severity Score (ISS) greater than 15). A retrospective cohort review using the national trauma registry data (Trauma Audit and Research Network) and an institutional database was carried out on all patients aged 60 years or older with an ISS> 15 who were treated at the regional Major Trauma Centre from 2014 to 2017 following major trauma. Frailty was assessed using the modified frailty index (mFI). Outcomes assessed included mortality, complications, hospital stay, functional outcome and discharge destination. 819 patients were included in the study. The most common mechanism of injury was fall from a height less than 2m (57.4%). 412 (51.3%) patients had a low frailty score, 280 (35%) had an intermediate frailty score and 110 (14%) had high frailty score. Increased frailty was associated with increased mortality at discharge (18.7%, 14.6% and 26.4% for low, intermediate and high frailty groups) and at one year (26.2%, 35.2% and 51%, respectively). Other predictors of mortality included male sex, age >90 years and the occurrence of a serious complication. Increasing frailty was also associated with an increased risk of serious complications including unplanned intubation, infection and progressive renal failure, and discharge to a destination other than home. This is the first study that has delineated the impact of frailty in older patients who experience major trauma and provides important information for patients, their families and healthcare providers. Future studies should focus on identifying care pathways that counteract the impact of frailty in this setting.

Mechanisms, patterns and outcomes of paediatric polytrauma in a UK major trauma centre.

Introduction Paediatric trauma is a significant burden to healthcare worldwide and accounts for a large proportion of deaths in the UK. Methods This retrospective study examined the epidemiological data from a major trauma centre in the UK between January 2012 and December 2014, reviewing all cases of moderate to severe trauma in children. Patients were included if aged ≤16 years and if they had an abbreviated injury scale score of ≥2 in one or more body region. Results A total of 213 patients were included in the study, with a mean age of 7.8 years (standard deviation [SD]: 5.2 years). The most common cause of injury was vehicle related incidents (46%). The median length of hospital stay was 5 days (interquartile range [IQR]: 4-10 days). Approximately half (52%) of the patients had to stay in the intensive care unit, for a median of 1 day (IQR: 0-2 days). The mortality rate was 6.6%. The mean injury severity score was 19 (SD: 10). Pearson's correlation coefficient showed a positive correlation for injury severity score with length of stay in hospital (p<0.001). Conclusions There is significant variation in mechanism of injury, severity and pattern of paediatric trauma across age groups. A multidisciplinary team approach is imperative, and patients should be managed in specialist centres to optimise their care and eventual functional recovery. Head injury remained the most common, with significant mortality in all age groups. Rib fractures and pelvic fractures should be considered a marker for the severity of injury, and should alert doctors to look for other associated injuries.

Definitive use of external fixation for pelvic ring injuries (open book/APC2) in pregnancy.

Pelvic fractures in pregnancy are rare, resulting in a paucity of evidence-based management. We describe a case of open book pelvic injury in a 32-year-old woman in her third trimester of pregnancy. She was successfully managed with a supra-acetabular external fixator, which allowed the safe delivery of a healthy baby boy at 34 weeks, via caesarean section. The external fixator was removed postpartum, when the pelvis was deemed stable, and mother and baby both continue to do well. This is the only case in the literature that demonstrates the successful use of external fixation for pelvic injuries in pregnancy.

Can the pre-operative Western Ontario and McMaster score predict patient satisfaction following total hip arthroplasty?

In this study we evaluated whether pre-operative Western Ontario and McMaster Universities (WOMAC) osteoarthritis scores can predict satisfaction following total hip arthroplasty (THA). Prospective data for a cohort of patients undergoing THA from two large academic centres were collected, and pre-operative and one-year post-operative WOMAC scores and a 25-point satisfaction questionnaire were obtained for 446 patients. Satisfaction scores were dichotomised into either improvement or deterioration. Scatter plots and Spearman's rank correlation coefficient were used to describe the association between pre-operative WOMAC and one-year post-operative WOMAC scores and patient satisfaction. Satisfaction was compared using receiver operating characteristic (ROC) analysis against pre-operative, post-operative and δ WOMAC scores. We found no relationship between pre-operative WOMAC scores and one-year post-operative WOMAC or satisfaction scores, with Spearman's rank correlation coefficients of 0.16 and -0.05, respectively. The ROC analysis showed areas under the curve (AUC) of 0.54 (pre-operative WOMAC), 0.67 (post-operative WOMAC) and 0.43 (δ WOMAC), respectively, for an improvement in satisfaction. We conclude that the pre-operative WOMAC score does not predict the post-operative WOMAC score or patient satisfaction after THA, and that WOMAC scores can therefore not be used to prioritise patient care.

Reducing mortality for high risk surgical patients in the UK.

Over 40 million surgical procedures are performed per annum in the USA and Europe, including several million patients who are considered to be high risk (Bennett-Guerrero et al 2003). Overall, the risk of death or major complications after surgery in the general surgical patient population is low, with a post-operative mortality rate of less than1% during the same hospital admission (Niskanen et al 2001).

Using patient-reported outcome measures to assess health-care quality.

The transparency of surgical outcomes data and the drive for quality has been highlighted since the public inquiry, led by Professor Ian Kennedy, into children's heart surgery at the Bristol Royal Infirmary. This was formalized in Lord Darzi's 2008 report High Quality Care for All, that proposed the NHS should: 'systematically measure and publish information about the quality of care'. Subsequently the NHS White paper, Equity and Excellence: Liberating the NHS (Department of Health, 2010), set out the ambitions and aims of the NHS and in particular that it should provide: '...a service that offers care that is safe and of the highest quality.'

Birmingham hip resurfacing: the prevalence of failure.

Despite the increasing interest and subsequent published literature on hip resurfacing arthroplasty, little is known about the prevalence of its complications and in particular the less common modes of failure. The aim of this study was to identify the prevalence of failure of hip resurfacing arthroplasty and to analyse the reasons for it. From a multi-surgeon series (141 surgeons) of 5000 Birmingham hip resurfacings we have analysed the modes, prevalence, gender differences and times to failure of any hip requiring revision. To date 182 hips have been revised (3.6%). The most common cause for revision was a fracture of the neck of the femur (54 hips, prevalence 1.1%), followed by loosening of the acetabular component (32 hips, 0.6%), collapse of the femoral head/avascular necrosis (30 hips, 0.6%), loosening of the femoral component (19 hips, 0.4%), infection (17 hips, 0.3%), pain with aseptic lymphocytic vascular and associated lesions (ALVAL)/metallosis (15 hips, 0.3%), loosening of both components (five hips, 0.1%), dislocation (five hips, 0.1%) and malposition of the acetabular component (three hips, 0.1%). In two cases the cause of failure was unknown. Comparing men with women, we found the prevalence of revision to be significantly higher in women (women = 5.7%; men = 2.6%, p < 0.001). When analysing the individual modes of failure women had significantly more revisions for loosening of the acetabular component, dislocation, infection and pain/ALVAL/metallosis (p < 0.001, p = 0.004, p = 0.008, p = 0.01 respectively). The mean time to failure was 2.9 years (0.003 to 11.0) for all causes, with revision for fracture of the neck of the femur occurring earlier than other causes (mean 1.5 years, 0.02 to 11.0). There was a significantly shorter time to failure in men (mean 2.1 years, 0.4 to 8.7) compared with women (mean 3.6 years, 0.003 to 11.0) (p < 0.001).

The St. Leger total knee replacement: a 10-year clinical and radiological assessment.

The St. Leger total knee replacement (Zynergy Orthopaedics Ltd, Rotherham, UK) was developed as a cheaper alternative to similar implants of its time. Between October 1993 and June 1999, 144 St. Leger total knee replacements were implanted into 114 patients. Seventy-three patients (99 knees) were recalled for assessment (mean follow-up of 10.2 years). Eighteen patients had had their prostheses revised, 11 had died and 12 were lost to follow-up. Functional Score showed 90% poor results and the Objective Knee Score showed 31% poor results. Radiological assessment identified 12 arthroplasties that had failed and 58 that required close follow. Kaplan-Meier cumulative survivorship was 87% at 10 years. The St. Leger knee replacement did not perform as well as others of the same generation and was not worth the initial financial savings.