Hip fracture care during Covid-19: a regional trauma centre’s experience

Abstract

Introduction The Covid-19 pandemic has caused worldwide upheaval from early 2020. Trauma and orthopaedic services are no different. A fundamentally important and significant portion of trauma services is the treatment of fragility fractures of the proximal femur, otherwise known as hip fractures. The hip fracture "Blue book Standards", the key performance indicators (KPIs) associated with appropriate hip fracture care are challenging during non-crisis times. We aim to review Blue Book compliance during the Covid-19 crisis and review outcomes of hip fractures, including Covid-19 infection rates. Methods We retrospectively reviewed IHFD data to collection demographic data, IHFD standards of care, 30-day mortality rates and complications between 23rd March and 20th May 2020 and 2019. Covid-19 rates in 2020 were also recorded. Results A total of 36 hip fractures were recorded in 2020, compared with 45 in 2019, resulting in a 20% reduction in presentations. Thirty-day mortality in hip fractures during the Covid-19 crisis was 8.3% compared with 2.2% in 2020. Covid-19 infection was statistically associated with 30-day mortality in the 2020 cohort. Statistically significant improvements in timedependent KPIs (time to ward and time to surgery) were noted in the 2020 cohort. Conclusions Despite improvements in hip fracture care KPIs, the Covid-19 crisis was associated with increased 30-day mortality in hip fracture patients. A positive Covid-19 swab was associated with higher mortality. These observations are of paramount importance to ensure adequate service planning and provision in the face of a potential "second wave" of Covid-19 infections leading into the winter months of 2020.

Outcomes of COVID-19 Negative Hip Fracture Patients During the Acute and Subacute Pandemic

“…Preliminary studies from various countries have noted increased mortality with hip fracture cases during this pandemic when compared to similar study cohorts in prior years. [19][20][21][22][23][24][25][26][27] The shortage of personal protective equipment (PPE), reduced OR availability, lack of familiarity with the evolving COVID-19 protocols, visitor restrictions, and reduced physical and occupational therapy potentially negatively impacted the treatment of hip fracture patients.…”

The Impact of COVID-19 on the Optimal Management of Osteoporosis

“…[ 17 ] However, HF is still a major burden, one study showed that HFs were the most common type of OF in the epidemic patient group, accounting for 68.4%, followed by thoracolumbar VF (17.0%) and similar observations have been made internationally. [ 10 , 17 ] Moreover the combination of osteoporotic HF and COVID-19 is associated with very poor outcomes. A positive COVID-19 test was associated with a significantly increased risk of 30-day mortality (from 8.5% in April 2019 to 18.2% in April 2020) and even upto 80% for those patients who test positive for COVID-19 as an inpatient.…”

“…[ 10 ] This does appear to be consistent with other jurisdictions, which have noted a 32% reduction in trauma presentations during the COVID-19 pandemic. [ 17 ] However, HF is still a major burden, one study showed that HFs were the most common type of OF in the epidemic patient group, accounting for 68.4%, followed by thoracolumbar VF (17.0%) and similar observations have been made internationally. [ 10 , 17 ] Moreover the combination of osteoporotic HF and COVID-19 is associated with very poor outcomes.…”

“…A positive COVID-19 test was associated with a significantly increased risk of 30-day mortality (from 8.5% in April 2019 to 18.2% in April 2020) and even upto 80% for those patients who test positive for COVID-19 as an inpatient. [ 17 , 18 ] In that sense, it is notable that redeployment of secondary prevention of osteoporotic HF significantly improve management of bone health compared to the post lockdown period and was comparable to the prelockdown data. [ 19 ]…”

Letter to the Editor: “Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?”

“…Patients with multiple comorbidities scheduled for elective TJA may be at higher risk of succumbing if infected with COVID-19 perioperatively and may also require inpatient recovery in rehabilitation units or nursing homes, further increasing the risk of transmission [16]. With a demonstrated higher complication rate in COVID-19positive patients undergoing hip fracture management, these studies highlight the importance of avoiding contraction during the perioperative period of the elective orthopedic surgery [19,20].…”