A dual-site trauma system during COVID-19 pandemic - Our experience in a high-risk area with 60-day mortality report.

AIM: We set up a COVID-free trauma site due to the high rates of COVID-19 infections within our hospital. We aimed to determine the incidence of post-operative COVID-19 infection within the first two weeks post-treatment at the COVID-free site and the postoperative mortality rate. We analysed data for non-hip fracture and fragility hip fracture patients separately. METHOD: Data was collected for 138 patients presented during the study period, having 147 operations in total. 103 were non-hip fracture patients and 35 were hip fracture patients. RESULTS: All patients were followed up and none of the non-hip fracture cohort developed symptoms of COVID-19 infection. Postoperative 60-day mortality rate for this cohort was 0.97%. Of the 35 hip fracture patients, none were tested positive for COVID-19. However, two patients were treated as suspected COVID cases due to their symptoms. CONCLUSION: Establishing a separate site with screening for COVID-19 infection can allow safe emergency surgery.

Evaluating the efficacy of a two-site ('COVID-19' and 'COVID-19-free') trauma and orthopaedic service for the management of hip fractures during the COVID-19 pandemic in the UK.

AIMS: Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with 'COVID' and 'COVID-free' hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic. METHODS: A vacated private elective surgical centre was repurposed to facilitate a two-site, 'COVID' and 'COVID-free', hip fracture service. Patients were screened for COVID-19 infection and either kept at our 'COVID' site or transferred to our 'COVID-free' site. We collected data for 30 days on patient demographics, Clinical Frailty Scale (CFS), Nottingham Hip Fracture Scores (NHFS), time to surgery, COVID-19 status, mortality, and length of stay (LOS). RESULTS: In all, 47 hip fracture patients presented to our service: 12 were admitted to the 'COVID' site and 35 to the 'COVID-free' site. The 'COVID' site cohort were older (mean 86.8 vs 78.5 years, p = 0.0427) and with poorer CFS (p = 0.0147) and NHFS (p = 0.0023) scores. At the 'COVID-free' site, mean time to surgery was less (29.8 vs 52.8 hours, p = 0.0146), and mean LOS seemed shorter (8.7 vs 12.6 days, p = 0.0592). No patients tested positive for COVID-19 infection while at the 'COVID-free' site. We redirected 74% of our admissions from the base 'COVID' site and created 304 inpatient days' capacity for medical COVID patients. CONCLUSION: Acquisition of unused elective orthopaedic capacity from the private sector facilitated a two-site trauma service. Patients were treated expeditiously, while successfully achieving strict infection control. We achieved significant gains in medical bed capacity in response to the COVID-19 demand. The authors propose the repurposing of unused elective operating facilities for a two-site 'COVID' and 'COVID-free' model as a safe and effective way of managing hip fracture patients during the pandemic.Cite this article: Bone Joint Open 2020;1-6:190-197.

Trauma and orthopaedic team members' mental health during the COVID-19 pandemic: results of a UK survey.

AIMS: Healthcare systems have been rapidly restructured to meet COVID-19 demand. Clinicians are working to novel clinical guidelines, treating new patient cohorts and working in unfamiliar environments. Trauma and orthopaedics (T&O) has experienced cancellation of routine clinics and operating, with redistribution of the workload and human resources. To date, no studies have evaluated the mental health impact of these changes on the T&O workforce. We report the results of a novel survey on the impact of the pandemic on the mental health of our orthopaedic workforce and the contributory factors. METHODS: A 20-question survey-based cross-sectional study of orthopaedic team members was conducted during the COVID-19 pandemic. The primary objective was to identify the impact of the pandemic on mental health in the form of major depressive disorder (MDD) and general anxiety disorder (GAD). The survey incorporated the patient health questionnaire (PHQ-2), which is validated for screening of MDD, and the generalized anxiety disorder questionnaire (GAD-2), which is validated for screening of GAD. RESULTS: There were 62 respondents (18 females and 44 males). As compared to the general population, we noted a greater estimated prevalence of GAD (17.7% vs 5.9%, p = 0.0009297) and MDD (19.4% vs 3.3%, p = 0.0000007731). The prevalence of MDD symptoms was greatest among senior house officers (SHOs) (p = 0.02216). Female respondents scored higher for symptoms of MDD (p = 0.03583) and GAD (p = 0.0001086). Those identifying as 'Black, African, Caribbean or Black British' displayed a higher prevalence of GAD symptoms (p = 0.001575) and felt least supported at work (p = 0.001341). CONCLUSION: Our study, in the first of its kind, shows a significant prevalence of GAD and MDD in the workforce. We found that SHOs, females and those of Black, African, Caribbean, or Black British origin were disproportionately affected. Action should be taken to help prevent adverse mental health outcomes for our colleagues during the pandemic.Cite this article: Bone Joint Open 2020;1-6:316-325.

Thirty-Day Mortality Rate of Patients With Hip Fractures During the COVID-19 Pandemic: A Single Centre Prospective Study in the United Kingdom.

OBJECTIVES: During the COVID-19 pandemic, the care of hip fracture patients remains a clinical priority. Our study aims to investigate the 30-day mortality rate of hip fracture patients during the first 30 days of the pandemic in the United Kingdom. METHODS: A single-center, observational, prospective study of patients presenting with hip fractures. Data collection started from "day 0" of the COVID-19 pandemic in the United Kingdom and continued for 30 days. We collected data on time to surgery, Clinical Frailty Scale score, Nottingham Hip Fracture Score, COVID-19 infection status, 30-day mortality, and cause of death. For comparison, we collected retrospective data during the same 30-day period in 2018, 2019, and the previous 6 months (Control groups A, B, and C, respectively). RESULTS: Forty-three patients were included in the study. There was no difference in age or gender between the Study and Control groups. The 30-day mortality rate of the Study group was 16.3%, which was higher than Control groups A (P = 0.022), B (P = 0.003) and C (P = 0.001). The prevalence of COVID-19 infection in our Study group was 26%. Of the 7 mortalities recorded, 4 patients tested positive for COVID-19 infection. In our Study group, COVID-19 infection correlated significantly with 30-day mortality (P = 0.002, odds ratio 2.4). CONCLUSIONS: Our study demonstrated a significant increase in 30-day mortality among hip fracture patients during the first 30 days of the COVID-19 pandemic in the United Kingdom. A positive COVID-19 test result in patients with hip fractures is associated with a 2.4-fold increase in risk of 30-day mortality. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Utilisation of the falciform ligament pedicle flap as an alternative approach for the repair of a perforated gastric ulcer.

An 83-year-old woman presented to the emergency department with sudden onset of severe abdominal pain. She had a background of ulcerative colitis managed surgically at the age of 18 years with panproctocolectomy and permanent ileostomy. On admission, clinical assessment suggested a visceral perforation and an urgent CT scan demonstrated a perforated prepyloric ulcer. Emergency laparotomy was performed and confirmed a 3 cm perforated pre-pyloric ulcer. Repair of the defect was challenging due to the absence of omental fat to patch the perforation. A modification to the standard technique was therefore performed: the falciform ligament was mobilised and its free end used as a patch to repair the defect. The patient made a good postoperative recovery. This case report highlights an alternative operative technique for the treatment of perforated gastric/duodenal ulcers in patients who lack omentum, or when omentum cannot be used to cover perforated gastroduodenal ulcers.

An adhesion-related small bowel obstruction occurring within 36 h of a total abdominal hysterectomy and bilateral salpingo-oophorectomy.

We present a case of adhesion-related small bowel obstruction occurring within only 36 h of a total abdominal hysterectomy and bilateral salpingo-oophorectomy. There has been no previously reported case where there has been such a short interval between surgery and adhesion-related small bowel obstruction. This is important to note, as it ensures that adhesion-related small bowel obstruction is on the list of differential diagnoses for patients who present very soon after surgery with symptoms such as abdominal pain and vomiting. It is also important as it allows the pathogenesis of adhesion formation to be reviewed in light of this rapid onset of adhesion formation and its complications.

Diaphragmatic hernia: an unusual presentation.

A 53-year-old lady presented to A&E with a 3-day history of severe epigastric pain and vomiting. This was preceded by a 3-month history of generalised abdominal discomfort, early satiety and increasing shortness of breath. A CT scan showed a left-sided posterior diaphragmatic defect. Urgent repair of the hernia showed herniation of three-quarter of the stomach, half of the transverse colon, the 13 cm spleen and the pancreas in the chest. There were no postoperative complications. Traumatic diaphragmatic hernias are known to be a complication of major trauma. However, the patient in this case report presented acutely, after mild physical trauma related to using a rowing machine. This exercise, when not performed correctly can raise intra-abdominal pressure. It is plausible that this trauma, although mild, was sufficient in causing the lady's diaphragmatic hernia. This case would suggest that the trauma required to cause a diaphragmatic hernia need not be as severe as originally thought.