Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

Abstract

ObjectivesStudies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.SettingProspective, international, multicentre, observational cohort study.ParticipantsPatients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).Primary outcome30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.ResultsThis study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).ConclusionsPatients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.Trial registration numberNCT04323644

COVID-19 in the perioperative setting: A review of the literature and the clinical landscape

“… 13 , 14 , 15 , 16 , 17 , 18 , 19 This elevated risk of postoperative complications is also seen with postoperative acquisition of COVID-19 infection. 4 , 6 , 20 , 21 …”

“…An additional research question is whether the type of anesthesia has a role in mitigating post-COVID-19 surgical patients’ perioperative risk. For example, one study showed no impact on mortality risk between regional or general anesthesia for patients with proximal femur fractures, 20 and case reports regarding the role of regional anesthesia are emerging. 66 Another area for future investigation is optimizing care for post-COVID-19 patients in an ambulatory (non-hospital) setting.…”

Lessons Learned in Elective Surgeries After 6 Pandemic Waves of SARS‐CoV‐2. A Single European Center Experience

“…Subsequent studies have demonstrated an elevated postoperative risk that persists for at least four weeks after the index infection, including increased mortality, pulmonary complications and venous thromboembolic events [5,[22][23][24][25][26][27]. This elevated risk of postoperative complications is also observed with the postoperative acquisition of SARS-CoV-2 infection [28][29][30].…”

COVID‐19 during the index hospital admission confers a ‘double‐hit’ effect on hip fracture patients and is associated with a two‐fold increase in 1‐year mortality risk

“…Project Auditing COVID-19 in Trauma and Orthopaedics (IMPACT) Group found that, after adjusting for confounding factors, the risk of 30-day mortality for hip fracture patients with COVID-19 was three times greater than COVID-negative patients (COVIDSurg, 2021;Hall et al, 2020;Hall & Public Health Scotland, 2021). The multinational IMPACT-Global Hip Fracture Audit demonstrated that, in the context of COVID-19 infection, increased age, male sex, frailty, and pre-existing renal and pulmonary disease were associated with an increased 30-day mortality risk (Hall, Clement, IMPACT-Global, et al, 2022;Hall, Clement, MacLullich, Simpson, Johansen, et al, 2022;.…”