key: cord-0684319-rohf9iw1
authors: Orfanos, Georgios; Al Kaisi, Kahlan; Jaiswal, Anuj; Lim, Justin; Youssef, Bishoy
title: The Effect of Covid-19 Pandemic on the Care of Fragility Hip Fracture Patients in the United Kingdom. A Case Control Study in a Major Trauma Centre
date: 2021-02-12
journal: Surgeon
DOI: 10.1016/j.surge.2021.01.008
sha: 49c82a8cf7c1e32da6af19aa0e5e79a4b6778478
doc_id: 684319
cord_uid: rohf9iw1

Introduction Coronavirus disease 2019 is a pandemic that forced a transformation in the services provided by the National Health Service in the United Kingdom. Fragility hip fractures account for over 65,000 cases per year in the elderly population. The study aims to assess the impact of the pandemic on fragility hip fractures. Methods A retrospective data gather was performed to identify fragility hip fractures from the 23rd of March 2020 to the 13th of May 2020, and from the 23rd of March 2019 to the 13th of May 19. Two groups were formed and compared over their 30 day follow up. Results The control group comprised of 97 patients, with a mean age of 82.1 years old (62-102 years) and M:F ratio of 38:59. The case group comprised of 102 patients, with a mean age of 82.3 years old (60-100 years) and a M:F ratio of 16:86. Significant differences between groups were identified for gender (p<0.001), time to theatre (p=0.002), length of stay (p<0.001) and COVID-19 status (p=0.001). In the Case group, association with mortality was found for male gender (p=0.041), right side (p=0.031) and COVID-19 positive test results (p=0.011). Conclusion Early surgical intervention is advocated wherever possible, and sufficient optimisation, prior to surgery whenever a COVID-19 positive patient is identified. A safe rehabilitation environment is paramount for recovery in this group of patients. Further studies are required to understand the effect of this pandemic on the fragility hip fractures. Level of Evidence Level III: Retrospective case-control study.

differences between groups were identified for gender (p<0.001), time to theatre 26 (p=0.002), length of stay (p<0.001) and COVID-19 status (p=0.001). In the Case 27 group, association with mortality was found for male gender (p=0.041), right side 28 (p=0.031) and COVID-19 positive test results (p=0.011). 29

Early surgical intervention is advocated wherever possible, and sufficient 31 optimisation, prior to surgery whenever a COVID-19 positive patient is identified. A 32 safe rehabilitation environment is paramount for recovery in this group of patients. 33 cases per year reported in the United Kingdom. In an average trauma unit, hip 50 fracture care accounts for a large proportion of the daily trauma work load (6). Hip 51 fracture management follows an agreed care pathway, as per guidelines and 52 outcomes are recorded in the National Hip Fracture Database (NHFD) (6,7). A multi-53 disciplinary approach is utilised in treating this group of patients, which expedites 54 surgical management and it is associated with a reduction in morbidity and mortality 55 (8,9). The NHS England specialty guidelines for the COVID-19 crisis, state that the 56 care of patients with hip fractures remains urgent and is a surgical priority "Obligatory 57

In patient" (4). 58

In response to the COVID-19 pandemic, our hospital diverted resources and 59 staff to reconfigure clinical areas, in order to facilitate the management of excess 60 load induced by the pandemic. The theatre capacity was reduced to 4 theatres per 61 day, shared between all surgical specialties including general surgery, urology, 62 orthopaedics, spine surgery, neurosurgery, cardiothoracic surgery and plastic 63 surgery. The health board took the decision to treat all operative cases as potentially 64 COVID-19 positive. This lead to all theatre personnel wearing full personal protective 65 equipment, as to avoid transmission from aerosol generating procedures (AGP) (10). The inclusion criteria were individuals presenting with a proximal femoral 84 fracture in our emergency department, diagnosed radiologically from a low energy 85 J o u r n a l P r e -p r o o f mechanism of injury (fall from standing height, <1m). Participants were excluded if 86 they were under the age of 60 years old, had a pre-existing metastatic deposit 87 causing the hip fracture, or were diaphyseal or distal femoral fractures. 88

Basic demographic data was gathered, including, age, gender, laterality and 89 residence. The abbreviated mental test score (AMTS) and the clinical frailty scale 90

were measured to identify mental and functional pre-operative status (11, 14) . Data 91 gathered included preoperative mobility (independent, stick, frame, non-mobile), 92

American Society of Anaesthesiologists (ASA) grade (15) home. The patients preoperative mobility was 42 (43.3%) being independent, 23 117 (23.7%) using a stick, 32 (32.0%) using a frame and 1 (1.0%) being non-mobile. The 118 most common ASA grade was grade 3 (50.5%) and the most common clinical frailty 119 scale score was 4 (25.8%). The mean AMTS was 7 (0-10) and the median AMTS 120 was 9. The fracture classification identified 29 (29.9%) A1/A2 type fractures, 12 121 (12.4%) A3 type fractures, 5 (5.2%) intracapsular undisplaced fractures, 45 (46.4%) 122 intracapsular displaced fractures and 8 (6.2%) subtrochanteric type fractures (Fig.  123 1). The type of operation was 25 (25.8%) cemented hemiarthroplasties, 9 (9.3%) 124 uncemented hemiarthroplasties, 40 (41.2%) DHSs, 7 (7.2%) IM nails, 9 (9.3%) THAs 125 and 7 (7.2%) were treated conservatively (Fig. 2) . The mean time to theatre was 126 41.7 hours (12-192 hours) and the mean length of stay was 18.1 days (3-52 days). 127

There were 43 (44.3%) patients identified with a postoperative morbidity, which 128 (79.4%) resided in their own home and 21 (20.6%) resided in a care or nursing 136 home. The patients preoperative mobility was 51 (50.0%) being independent, 26 137 (25.5%) using a stick, 24 (23.5%) using a frame and 1 (1.0%) being non-mobile. The 138 most common ASA grade was grade 3 (60.8%) and the most common clinical frailty 139 scale score was 5 (22.5%). The mean AMTS was 7 (0-10) and the median AMTS (8.8%) IM nails, 6 (5.9%) THAs and 7 (6.9%) were treated conservatively (Fig. 2) . 146

The mean time to theatre was 25.5 hours (2-255 hours) and the mean length of stay The COVID-19 pandemic has created an unprecedented situation, which has 172 generated a serious public health concern (1,2,16). In our study between the two 173 groups, we found many similarities between different variables. Differences were 174 identified for gender (p<0.001), time to theatre (p=0.002), length of stay (p<0.001) 175

and COVID-19 status (p=0.001). 176

Regarding gender, Table 1 demonstrates that the Case group had 177 substantially more females (84.3%), which serves to explain the significant difference identified in males, rather than females (17). Our Case group had a high female 185 proportion (84.3%), which could explain the low number (10.8%) of COVID-19 186 positive patients. Furthermore, mortality was associated with right side (p=0.031) 187 accounting for 6 out of 8 dead patients in our Case group. Again, due to the low 188 numbers noted, this is believed to be a coincidence. 189

The mean time from admission to theatre was 25.5 hours (2-255 hours) and musculoskeletal conditions (myalgia, arthralgia) and COVID-19, but urged for further 225 studies as the association is poorly understood (23). The mean age of our Case 226 group was 82.3 years old (60-100 years). The pandemic will adversely affect this 227 demonstrates that COVID-19 has a higher 30 day mortality from conventional 235 fragility hip fractures (11). Furthermore in the United Kingdom, to date, London has 236 seen the largest mortality rate associated with COVID-19, whereas the West 237

Midlands has the 3 rd highest amount of deaths (24). Careful selection to theatre for 238 COVID-19 fragility hip fractures is advocated. Furthermore, the effect of COVID-19 239 and fragility hip fractures should be investigated in areas of higher COVID-19 240 prevalence, as to confirm or re-enforce our observations. 241

The limitations of our study include the fact that it is a retrospective study. The 

A global clinical measure of fitness and frailty in elderly 315 people

Grading of patients for surgical procedures

Services During the 2019 Novel Coronavirus Epidemic: An Experience in

JAMA Otolaryngol Head Neck Surg

COVID-19 Patients' Clinical Characteristics, Discharge Rate, and Fatality 323 Rate of Meta-Analysis

Is operative delay associated with increased 325 mortality of hip fracture patients? Systematic review, meta-analysis, and 326 meta-regression

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