A year of COVID-19: Effects of a global pandemic on a hip fracture bundled care protocol.

Introduction: Our aim was to analyse how the coronavirus disease 2019 (COVID-19) pandemic affects a hip fracture bundled care protocol. We hypothesised that key performance indicators, but not short-term outcomes, may be adversely affected. Methods: Patients admitted under a hip fracture bundled care protocol were divided into two arms: 'COVID' group included patients admitted in 2020 during the COVID-19 pandemic and 'PRE-COVID' group included patients admitted in 2019. We retrospectively analysed time to admission, time to surgery, length of stay, discharge disposition, as well as rates of 30-day revision surgery, 30-day readmission and inpatient mortality. Results: There were 307 patients in the PRE-COVID group and 350 patients in the COVID group. There was no significant difference in terms of gender, age and type of hip fracture. The COVID group had a higher proportion of American Society of Anesthesiologists classification III and IV patients (61.4% vs. 50.2% in the PRE-COVID group; P = 0.004). In the COVID group, similar proportion of patients were admitted to the ward within 4 h, but the mean time to surgery was longer (71.8 ± 73.0 h vs. 60.4 ± 72.8 h in the PRE-COVID group; P = 0.046) and few patients underwent operations within 48 h (41.7% vs. 60.3% in the PRE-COVID group; P < 0.001). Mean postoperative length of stay, discharge disposition, as well as rates of inpatient mortality, 30-day revision surgery and 30-day readmission were similar. Conclusion: The volume of hip fractures during the COVID-19 pandemic remained unchanged, although patients admitted during the COVID-19 pandemic appeared to be more deconditioned. Nevertheless, having robust protocols and staff familiar with hip fracture treatment can preserve short-term outcomes for this group of patients, even with strict isolation measures in place during a pandemic.

Lower socioeconomic status is associated with increased co-morbidity burden and independently associated with time to surgery, length of hospitalisation, and readmission rates of hip fracture patients.

This study examines the relationship between socioeconomic status, comorbidities, and clinical outcomes of hip fracture patients. Lower socioeconomic status is not only associated with poorer comorbidities but is also independently impacting surgical access and outcomes. This can be considered a "double setback" in the management of hip fractures. PURPOSE: The effect of socioeconomic status on hip fracture outcomes remains controversial. We examine the relationship between SES and patient comorbidity, care access, and clinical outcomes of surgically managed hip fracture patients. METHODS: Using healthcare payor status as a surrogate for SES, patients operated for fragility hip fractures between 2013 and 2016 were dichotomised based on payor status, namely private healthcare (PRIV) versus subsidised healthcare (SUB). PRIV patients were compared with SUB patients in terms of demographic data, ASA scores, co-morbidity burden (Charlson comorbidity index, CCI), time to surgery, length of acute hospitalisation, and 90-day readmission rates. RESULTS: A total of 145 patients in group PRIV and 1146 patients in group SUB were included. SUB patients had a higher mean Charlson Co-morbidity Index (CCI) (p = 0.01), a longer length of hospitalisation (p = 0.001), an increased delay in surgery (p = 0.005), and higher 90-day readmission rates (p = 0.013). Lower SES (p = 0.01), older age (p = 0.01), higher CCI (p < 0.01), and a higher American Society of Anaesthesiologists score (ASA) (p = 0.03) were predictive of time to surgery. Lower SES (p = 0.02) and higher CCI (p < 0.001) were predictive of the length of hospitalisation. Lower SES (p = 0.04) and higher CCI (p < 0.001) were predictive of 90-day readmission rates. CONCLUSIONS: Low SES is associated with higher CCI in surgically treated hip fracture patients. However, it is independently associated with slower access to surgery, a longer hospital stay, and higher readmission rates. Hence, lower SES, with its associated higher CCI and independent impact on surgical access and outcomes, can be considered a "double setback" in the management of fragility hip fractures.

Developing a Simpler Prognosticating Tool: Comparing the Combined Assessment of Risk Encountered in Surgery Score with Deyo-Charlson Comorbidity Index and The American Society of Anesthesiologists Physical Status Score in Predicting 2 years Mortality after Hip Fracture Surgery.

Background: The use of risk stratification tools in identifying high-risk hip fracture patients plays an important role during treatment. The aim of this study was to compare our locally derived Combined Assessment of Risk Encountered in Surgery (CARES) score with the the American Society of Anesthesiologists physical status (ASA-PS) score and the Deyo-Charlson Comorbidity Index (D-CCI) in predicting 2-year mortality after hip fracture surgery. Methods and Material: A retrospective study was conducted on surgically treated hip fracture patients in a large tertiary hospital from Jan 2013 through Dec 2015. Age, gender, time to surgery, ASA-PS score, D-CCI, and CARES score were obtained. Univariate and multivariable logistic regression analyses were used to assess statistical significance of scores and risk factors, and area under the receiver operating characteristic (ROC) curve (AUC) was used to compare ASA-PS, D-CCI, and CARES as predictors of mortality at 2 years. Results: 763 surgically treated hip fracture patients were included in this study. The 2-year mortality rate was 13.1% (n = 100), and the mean ± SD CARES score of surviving and demised patients was 21.2 ± 5.98 and 25.9 ± 5.59, respectively. Using AUC, CARES was shown to be a better predictor of 2-year mortality than ASA-PS, but we found no statistical difference between CARES and D-CCI. A CARES score of 23, attributable primarily to pre-surgical morbidities and poor health of the patient, was identified as the statistical threshold for "high" risk of 2-year mortality. Conclusion: The CARES score is a viable risk predictor for 2-year mortality following hip fracture surgery and is comparable to the D-CCI in predictive capability. Our results support the use of a simpler yet clinically relevant CARES in prognosticating mortality following hip fracture surgery, particularly when information on the pre-existing comorbidities of the patient is not immediately available.

The psychological impact on an orthopaedic outpatient setting in the early phase of the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: World Health Organization declared coronavirus disease-19 (COVID-19) a global pandemic on 11 March 2020, after the coronavirus claimed 4628 lives worldwide. Mental health challenges such as making impossible decisions and working under extreme pressures are expected to be faced by frontline healthcare workers who are directly involved in the care of COVID-19 patients. However, we question if significant stress levels might also be observed in a subspecialty musculoskeletal outpatient department, where staff are not first-line care providers of COVID-19 patients. We hypothesize that these healthcare workers also face significant psychological strain, and we aim to objectively determine the prevalence using a validated caregiver strain index. METHODS: A cross-sectional study was conducted in outpatient musculoskeletal clinics in a tertiary hospital in Singapore. We collected basic demographic data and used a 13-question tool adapted from the validated Caregiver Strain Index (CSI) to measure psychological strain in these healthcare workers. Participants were divided into 2 groups depending on the level of strain experienced. RESULTS: A total of 62 healthcare workers volunteered for this study. There were 32 participants (51.6%) who had 7 or more positive responses (group 1) and the remaining 30 participants (48.4%) were allocated to group 2. There were no significant differences between the two groups in terms of demographic data. "Work adjustments" (74.2%), "changes in personal plans" (72.6%), and finding it "confining" (72.6%) garnered the most positive responses in the questionnaire. On the other hand, "financial concerns" garnered the least positive responses (21.0%). CONCLUSION: The protracted duration of the COVID-19 outbreak and its resultant prolonged adjustments can have unintended consequences of wearing down healthcare resources otherwise allocated to chronic and elective conditions. Countries should ensure that measures are put in place to safeguard the mental well-being of our healthcare workers to avoid needing another reactive strategy in this battle against COVID-19.

An anatomical and biomechanical assessment of the interosseous membrane of the cadaveric forearm.

Ten cadaveric specimens underwent biomechanical assessment on a motorized jig with an in-built torque sensor. A differential variable reluctance transducer was placed on the central bundle of the interosseous membrane to detect changes in strain. Torque was measured with an intact interosseous membrane and a sectioned central bundle of the interosseous membrane. Changes in strain and torque were plotted against the degree of rotation of the cadaveric forearms. We found that the overall magnitude of strain to be greatest in pronation and smallest in supination. However, the relative displacement of the interosseous membrane between pronation and supination was minimal in absolute terms. There was no difference in torque between an intact and cut central bundle. We conclude that the interosseous membrane acts as a static longitudinal stabilizer of the forearm and less so as a rotational stabilizer.

Strain behavior of native and reconstructed medial patellofemoral ligaments during dynamic knee flexion - a cadaveric study.

BACKGROUND: Surgical reconstruction of the Medial Patello-Femoral Ligament (MPFL) has been recognized as an effective treatment for patients with instability despite conservative treatment. The purpose of this cadaveric study is to compare the strain patterns within the native and reconstructed single and double-bundle MPFL. This will help ascertain if the native biomechanics are restored with the reconstructions. METHODS: Twelve cadaveric knees were dissected and the native MPFL of each specimen was identified. The knees were subjected to dynamic flexion using a customized jig. Continuous strain measurements were taken for each knee from 0 to 120 degrees flexion and then back to full extension using differential variable reluctance transducers (DVRTs). The MPFL was then cut. Six single bundle and six double bundle MPFL reconstructions were performed using hamstring tendon grafts. The DVRTs were reattached to the grafts and strain measurements were retaken. Statistical analysis was performed using a paired t-test. RESULTS: Strain patterns of the native and reconstructed MPFL showed an increase in strain from 0 to 120 degrees of flexion except for the inferior bundle of the double bundle reconstruction. The strain patterns in the intact specimens were higher than the reconstructed MPFL through different degrees of knee flexion. In the double-bundle group, the superior graft had statistically significantly lower strains compared to the native MPFL with p-value <.05 at all flexion angles. The reconstructed inferior band showed loss of tension as the knee flexed. Higher strain with statistical significance (p-value <.05) was found in the single-bundle compared to the superior band of the double-bundle reconstruction at flexion angles less than 90 degrees. CONCLUSION: The strain variation at progressive angles of knee flexion is dissimilar between the native and reconstructed MPFL. The reconstructed MPFL exhibited non-physiological biomechanics with the inferior band losing tension. Although the single-bundle reconstruction shows a better strain profile compared to double-bundle reconstruction, the grafts are significantly stiffer than the native MPFL.

Preoperative Anemia, Functional Outcomes, and Quality of Life After Hip Fracture Surgery.

OBJECTIVES: To determine whether preoperative anemia, perioperative blood transfusion, and predischarge anemia affect function and health-related quality of life (HRQoL) after hip fracture surgery. DESIGN: Retrospective single-center cohort study PARTICIPANTS: Individuals undergoing traumatic hip fracture surgery from 2012 to 2016 (N=973). MEASUREMENTS: Demographic data, Charlson Comorbidity Index, preoperative hemoglobin level, perioperative blood transfusion, predischarge hemoglobin level, type of surgery (replacement or fixation). Anemia was divided into quintiles at 10.0, 11.0, 12.0, and 13.0 g/dL. Baseline, 6-week, and 6-month Harris Hip Scale (HHS), Parker Mobility Scale (PMS), and Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) scores were obtained. PMS; HHS and SF-36 role physical (RP), physical function (PF), and social functioning (SF) domains had more than 20% change from baseline to 6 weeks and from 6 weeks to 6 months. Univariate and multivariate analyses were conducted to examine the association between preoperative anemia, transfusion and predischarge anemia on 6-month scores. RESULTS: On univariate analysis, preoperative hemoglobin less than 10.0 g/dL was associated with lower baseline prefall PMS, PF, RP, and SF scores. Predischarge anemia did not affect 6-month scores. On multivariate analysis, preoperative anemia (hemoglobin <10.0 g/dL) was associated with lower 6-month HHS, PMS, PF, and RP scores, whereas transfusion was not significant. CONCLUSION: Preoperative anemia (hemoglobin <10.0 g/dL) is associated with poorer physical function and HRQoL after hip fracture surgery. Perioperative blood transfusion and predischarge anemia had no effect.

Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years.

BACKGROUND: A previously published study found positive outcomes for a novel technique for ultrasound-guided percutaneous ultrasonic tenotomy, showing good tolerability, safety, and early efficacy within an office setting. PURPOSE: In this follow-up study, all 20 members of the original cohort were contacted after 3 years to explore the sustainability of symptomatic relief, functional improvement, and sonographic soft tissue response for percutaneous ultrasonic tenotomy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All 20 subjects of the clinical trial that was performed from June to November 2011 were further assessed at 36 months after the procedure in terms of visual analog scale for pain, Disabilities of the Arm, Shoulder and Hand (DASH)-Compulsory/Work scores, need for adjunct procedures, and overall satisfaction. Importantly, all 20 were reassessed with ultrasound imaging at 36 months, and evidence of the common extensor tendon response was assessed in terms of tendon hypervascularity, tendon thickness, and the progress of the hypoechoic scar tissue. RESULTS: A 100% clinical follow-up was achieved, inclusive of ultrasonographic assessment. None of the subjects required further treatment procedures, and 100% expressed satisfaction. Previous improvements in visual analog scale (current median ± SD, 0 ± 0.9; range, 0-3) and DASH-Work scores (current median, 0 ± 0) were sustained with conformity to a linear pattern on polynomial measures. There was further reduction in DASH-Compulsory scores to a median of 0 ± 0.644 (range, 0-2) with a significant decrease on repeated measures (P = .008). Tendon hypervascularity was resolved in 94% of patients, and 100% had reduction in tendon thickness. Overall reduction in the hypoechoic scar tissue was observed in all subjects, with a 90% response achieved by 6 months. Between 6 and 36 months, further reduction in the scar was observed in around 60% of patients, with 20% of patients having complete resolution of the hypoechoic scar. CONCLUSION: Minimally invasive percutaneous ultrasonic tenotomy provided sustained pain relief and functional improvement for recalcitrant tennis elbow at 3-year follow-up. It is one of the few procedures to demonstrate positive sonographic evidence of tissue-healing response and is an attractive alternative to surgical intervention for definitive treatment of recalcitrant elbow tendinopathy.

Role of the anterior intermeniscal ligament in tibiofemoral contact mechanics during axial joint loading.

The anterior intermeniscal ligament (AIML) is an anatomically distinct structure that connects the anterior horns of the medial and lateral menisci. We hypothesized that both menisci work together as a unit in converting axial joint loading into circumferential hoop stresses, due to intermeniscal attachments. Therefore, loss of the AIML could lead to increased tibiofemoral contact stress and predispose to arthritic change. In this cadaveric study, we compared tibiofemoral contact pressures on axial loading, before and after sectioning of the AIML. Five fresh frozen human cadaveric knees were mounted on a linear x-y motion table and loaded in extension under axial compression of 1800N (about 2.5 times body weight for a 70kg individual), using a materials testing machine. Tibiofemoral contact pressures before and after sectioning of the AIML were measured using resistive pressure sensors. Contrary to our hypothesis, sectioning of the AIML produced no statistically significant increase in mean contact pressure, peak contact pressure or change in contact area, in either the medial or lateral compartment of the knees. This implies that the menisci work independently in converting axial loads into circumferential hoop stresses, and is probably due to their individual root attachments to the tibia. Based on this study, inadvertent sectioning of the AIML during knee surgery, e.g., arthroscopy, anterograde tibia nailing, anterior cruciate ligament reconstruction, meniscus transplantation and unicondylar knee replacement, is functionally insignificant.