The impact of COVID-19 on trauma and orthopaedic patients requiring surgery during the peak of the pandemic

Abstract

Aims COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department. Methods We retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19. Results A total of 214 patients had orthopaedic surgical procedures, with 166 included for analysis. Patients undergoing procedures under general or spinal anaesthesia had a higher risk of contracting perioperative COVID-19 compared to regional/local anaesthesia (p = 0.0058 and p = 0.0007, respectively). In all, 15 patients (9%) had a perioperative diagnosis of COVID-19, 14 of whom had fragility fractures; six died within 30 days of their procedure (40%, 30-day mortality). For proximal femoral fractures, our 30-day mortality was 18.2%, compared to 7% in 2019. Conclusion Based on our findings, patients undergoing procedures under regional or local anaesthesia have minimal risk of developing COVID-19 perioperatively. Those with multiple comorbidities and fragility fractures have a higher morbidity and mortality if they contract COVID-19 perioperatively; therefore, protective care pathways could go some way to mitigate the risk. Our 30-day mortality of proximal femoral fractures was 18.2% during the COVID-19 pandemic in comparison to the annual national average of 6.1% in 2018 and the University Hospital Coventry average of 7% for the same period in 2019, as reported in the National Hip Fracture Database. Patients undergoing procedures under general or spinal anaesthesia at the peak of the pandemic had a higher risk of contracting perioperative COVID-19 compared to regional block or local anaesthesia. We question whether young patients undergoing day-case procedures under regional block or local anaesthesia with minimal comorbidities require fourteen days self-isolation; instead, we advocate that compliance with personal protective equipment, a negative COVID-19 swab three days prior to surgery, and screening questionnaire may be sufficient. Cite this article: Bone Joint Open 2020;1-9:520–529.

Impact of COVID-19 on acute trauma and orthopaedic referrals and surgery in the UK during the first wave of the pandemic: a multicentre observational study from the COVid Emergency-Related Trauma and orthopaedics (COVERT) Collaborative

“…Those with NOF fractures remain at greatest risk of mortality and there have been further studies evaluating the risk of COVID-19 on this inherently high-risk cohort. [25][26][27][28] COVID-19 itself has been identified as an independent risk factor in increasing mortality in neck of femur fractures. 29 30 The increased mortality reflect the increased proportion of patients with NOF fractures that have a higher baseline mortality which has been echoed by the Scottish IMPACT-Restart study.…”

The rate of patient deferral and barriers to going forward with elective orthopaedic surgery during the COVID-19 pandemic

“…the false negative rate was low). 24 Mackay et al 25 has questioned whether younger and less vulnerable patients require a 14-day preoperative isolation period, which may increase the rate of patients proceeding with surgery as this was main barrier for three (18%) of the patients in the current study to going forward with their surgery. Also to be considered is the risk of acquiring COVID-19 during the patient’s hospital stay.…”

The UK foot and ankle COVID-19 national (FAlCoN) audit – Regional variations in COVID-19 infection and national foot and ankle surgical activity

“… 31 This reduction in risk was reported by Mackay et al who found a reduction in perioperative risk of developing COVID-19 in patients undergoing regional and local anaesthesia compared to general anaesthesia. 32 However, there was significant selection bias in their groups with higher risk patients and more complex surgical procedures requiring general and spinal anaesthetic. Other factors such as reducing risk to staff and a lack of resources (ventilators) may also have contributed.…”