Introduction Increased mortality has been demonstrated in older adults with COVID-19, but the effect of frailty has been unclear. Methods This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty, and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation, and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS), and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results Data from 5,711 patients from 55 hospitals in 12 countries were included (median age 74, IQR 54–83; 55.2% male). The risk of death increased independently with increasing age (>80 vs 18–49: HR 3.57, CI 2.54–5.02), frailty (CFS 8 vs 1–3: HR 3.03, CI 2.29–4.00) inflammation, renal disease, cardiovascular disease, and cancer, but not delirium. Age, frailty (CFS 7 vs 1–3: OR 7.00, CI 5.27–9.32), delirium, dementia, and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusions Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.

Level III. This study is a meta-analysis of studies containing level of evidence of III or greater.

Background Femoral version measurement techniques based on MRI studies have been developed as an alternative to the high levels of ionizing radiation associated with CT based methods. Previous studies have not evaluated the reliability, repeatability, and accuracy of MRI based femoral version measurements in an adolescent population. Methods Subjects that underwent MRI and CT studies for clinical suspicion of hip pain secondary to hip dysplasia or femoroacetabular impingement between 2011 and 2013 were identified. Rapid sequence femoral version images were obtained from MRI Hip dGEMRIC and/or post arthrogram studies. Femoral version images were also obtained from bilateral CT lower extremity, without contrast, studies. Measurements were made by one fellowship trained, pediatric hip preservation attending surgeon, two pediatric orthopaedic surgical fellows and one fellowship trained musculoskeletal radiologist on two separate occasions. Linear mixed models were used to estimate the reliability and repeatability associated with CT and MRI based measurements (Intraclass correlation coefficients, ICC) and to estimate the agreement (CT – MRI) between the two techniques. Results The mean age of 36 subjects was 15.4 yrs (±4.1 yrs). Inter-rater reliability was 0.91 [95% CI: 0.86–0.95] for the CT technique compared to 0.90 [95% CI: 0.86–0.94] for the rapid sequence MRI technique. Intra-rater reliability for the CT technique was 0.96 [95% CI: 0.91–0.98] compared to 0.95 [95% CI: 0.90 to 0.97] for the MRI technique. The agreement between the MRI and CT based techniques (Bias: 1.9°, Limits of Agreement: −11.3–14.9°) was similar to the agreement between consecutive MRI measurements (Bias: 0.4°, Limits of Agreement: −7.8–8.6°) as well as consecutive CT measurements (Bias: 0.5°, Limits of Agreement: −8.8–9.9°). Conclusions The inter- and intra-rater reliability and repeatability estimates (ICC values) associated with both techniques was excellent (>0.90). Acquirement of axial images at the pelvis and knee during MRI for investigation of adolescents with hip pain allows for reliable measurement of femoral version. Level of Evidence II – Diagnostic Study

BackgroundLong-term outcomes of patients undergoing extensive fusions for adolescent idiopathic scoliosis (AIS) have conflicting results. Moskowitz found uninstrumented scoliosis fusion patients had similar back pain as a normal age matched population. Recently, long-term outcomes of patients with Harrington rod instrumentation were reviewed and found similar functional outcome scores to non-scoliosis patients, with trending toward worse outcomes when fusions extended to L4. Our study examined long-term functional outcomes of patients treated with Cotrel-Dubousset (CD) instrumentation and determined whether distal level of instrumented fusion (L4 and L5) correlate with increased back pain or lower functional level.MethodsRetrospective review of AIS surgeries from 1986 to 1996 was undertaken. Patient demographics and surgical data were collected via case-note audit. Patients were contacted and asked to complete a series of functional outcome questionnaires including visual analog scales (VAS) for pain, Short-Form 36 (SF-36), Scoliosis Research Society 22 (SRS-22) and Oswestry Disability Index (ODI) for function. ANOVA technique categorically compared outcome scores to most distal levels of fusion. Linear regression compared patient reported outcomes to time elapsed since surgery. Statistical significance was p < 0.05.ResultsOne hundred twelve patients were identified, 50 patients were contacted, and 22 agreed to participation and completed a full assessment. Follow-up time since surgery ranged from 15 to 26 years and age ranged from 30 to 43 years. Six patients reported daily VAS back pain of ≥5; with a mean of 2.5. Back pain was not associated with level of distal fusion (p = 0.92). ODI was 15.36, with six patients' ODI >20. No relationship was shown between ODI and distal level of fusion (p = 0.72). SF-36 and SRS 22 values were also not related to distal level of instrumentation. Patient reported VAS back pain scores (r2 = 0.18, p = 0.05), ODI (r2 = 0.09, p = 0.17), and SF-36 and SRS-22 were not worse in patients with longer follow-up over time. Back pain and certain functional score subcategories of the SF-36 and SRS-22 trended toward improved results over time.ConclusionsMost patients who underwent multi-segment spinal fixation appeared to do well long-term, with minimal back pain. Lowest instrumented segment did not appear to be associated with increased back pain after 15 to 25 years follow-up.