The impact of COVID-19 on the management and outcomes of patients with proximal femoral fractures: a multi-centre study of 580 patients.

BACKGROUND: On the 11th March 2020, the World Health Organization declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this, and the pandemic has tested their adaptability. This study aimed to assess the impact of COVID-19 on the demographics, presentation, clinical management and outcomes of patients with proximal femoral (hip) fractures comparing them to a similar cohort of patients admitted a year earlier. METHODS: This retrospective multi-centre cohort study compared all patients admitted with hip fractures between 1st March and 30th May 2019 (group PC: pre-COVID-19) with hip fracture patients admitted over the same time period during the pandemic in 2020 (group C: COVID-19). The data was obtained from the hospitals' local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality. RESULTS: A total of 580 patients were included (304 group PC, 276 group C). Patient demographics including Charlson Comorbidity Index and Nottingham Hip Fracture Scores were broadly similar across the two cohorts. There was a significant reduction in the percentage of total hip replacements (11 to 5%, p = 0.006) in group C. There was an increase in conservative management (1 to 5%, p = 0.002) in group C. Time to theatre was significantly delayed in group C (43.7 h) vs group PC (34.6 h) (p ≤ 0.001). The overall length of hospital stay was significantly longer in group PC (16.6 days) vs group C (15 days) (p = 0.025). The 30-day mortality rate in group C was 9.8% compared to 8.2% in group PC (p = 0.746), but for COVID-19 (+) patients, it was significantly higher at 38.2% vs 5.8% in COVID-19 (-) patients (p < 0.001). CONCLUSION: This is one of the largest multi-centre comparative cohort study in the literature to date examining the impact of the COVID-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, COVID-19-positive patients were almost seven times more likely to die, reflecting the seriousness of the COVID-19 infection and its sequelae in such elderly, vulnerable patients.

Peri-operative Outcomes and Predictors of Mortality in COVID-19 Positive Patients with Hip Fractures: A Multicentre Study in the UK.

Aim: This UK based multi-centre study reports clinical characteristics, early outcomes and predictors of mortality in 34 consecutive COVID-19-positive hip fractures so that the lessons learnt could be utilised in other parts of World who are at a different phase of the pandemic. Methods: This study analysed patient admitted with hip fractures with COVID positive swabs, between March and May'2020 in three large hospitals covering a population of nearly two million. Data was collected on demographic profile, peri-operative variables, post-operative complications and mortality. The specific aim was to identify any variables, which could predict high 30-day mortality. Results: Overall, 12% of hip fractures were COVID positive with the mortality rate of 41.2%. The higher age (p = 0.036) and male gender (p = 0.025) was significantly associated with mortality and most of the deaths were between American Society of Anaesthesiologists (ASA) grade 3 and 4 patients. The patients having intramedullary (IM) nailing were more likely to die (p = 0.02). There was no difference in laboratory parameters but there was significant difference in findings on chest radiographs (p < 0.001), post-operative oxygen requirements (p = 0.006) and early respiratory complications (p = 0.006). Conclusion: This study suggests that the mortality following surgery for a hip fracture in COVID-positive patients is strikingly high and is associated with higher age and male gender. Higher mortality has been observed for extracapsular fracture operated with intramedullary nailing. In the immediate post-operative period, rapid deterioration of chest imaging, higher oxygen requirement and early pulmonary complications can serve as warning signs and predicting factors for higher mortality.

Unusual operative treatment and outcome of femoral shaft fracture in a non-ambulatory cerebral palsy patient.

Cerebral palsy patients are prone to spontaneous fractures due to poor bone quality. The treatment options of femoral fractures include conservative and operative management which is tailored according to the patient's needs, co-morbidities and the presence of skilled surgeon. We present a 20 year old non-ambulatory CP patient who had a fractured femoral shaft which was treated by surgical excision of the fracture which is a surgical modality that according to our knowledge hasn't been addressed before in literature.

A wear debris cyst following S.T.A.R. Total Ankle Replacement--surgical management.

We present a case of a 65-year-old gentleman who underwent a Total Ankle Replacement in January 2002. Four years later he required a revision procedure after developing edge loading and a polymer wear cyst within the fibula, which communicated directly with the ankle joint.

Noninsertional Achilles tendinopathy.

The treatment of noninsertional Achilles tendinopathy remains, to a large extent, empirical. Neither different operative techniques nor nonoperative regimes have been subjected to controlled trials. Rather, the condition is still treated on the basis of anecdotal evidence combined with personal experience. However, increased knowledge of the basic science of tendinopathy and tendon healing has directed therapeutic regimens and will continue to do so. Manipulation of proteolytic enzymes and control of neovascularization are probably the two areas that show most promise.

Internal fixation of a patella fracture using an absorbable suture.

This case report describes the use of an absorbable suture for the fixation of a patella fracture in a child. In this case the fracture was held satisfactorily by the suture until union. This technique means that there is no need for a second operation to remove the fixation material.

Total extrusion of a cranial peritoneal shunt per rectum.

This case report demonstrates an unusual complication of a cranial peritoneal shunt. The shunt perforated the bowel and was extruded per rectum. This caused significant anxiety for the individual but did not cause any serious morbidity.