30-day mortality following trauma and orthopaedic surgery during the peak of the COVID-19 pandemic

Abstract

Aims Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region. Methods This multicentre study reviewed data on all patients undergoing trauma and orthopaedic surgery in a region from 18 March 2020 to 27 April 2020. Information was collated from regional databases. Patients were COVID-19-positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019. Results Overall, 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. Seven out of nine deceased patients underwent surgery for a fractured neck of femur. In all, 27 patients contracted COVID-19 in the peri-operative period; of these, four patients died within 30 days (14.8%). In addition, 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70 years (81.5%). Patients with American Society of Anesthesiologists (ASA) grade > 3 and/or age > 75 years were at significantly higher risk of death if they contracted COVID-19 within the study period. Conclusion Overall 30-day postoperative mortality in trauma and orthopaedic surgery patients remains low at 1.9%. There was no 30-day mortality in patients ASA 1 or 2. Patients with significant comorbidities, increasing age, and ASA 3 or above remain at the highest risk. For patients with COVID-19 infection, postoperative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective postoperative strategies should also be employed to try and reduce postoperative exposure to the virus. Cite this article: Bone Joint Open 2020;1-7:392–397.

Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods: A systematic review and meta-analysis

“…A total of 45 studies were retrieved after the search of electronic databases using the keywords; of which, eight studies were eligible for review after screening[ 9 , 19 , 20 , 27 - 29 , 38 , 39 ] (Figure 1 ). There were three prospective studies and five retrospective comparative studies.…”

“…The preoperative morbidity status of the patients in both pandemic and pre-pandemic periods were compared using the American Society of Anesthesiologists (ASA) classification. Pooled analysis of five studies ( n = 1159) revealed significantly increased number of severely morbid (ASA grade > 3) hip fracture patients who were treated during the pandemic period (OR, 1.43; 95%CI, 1.08, 1.89; P = 0.01)[ 9 , 27 , 29 , 38 , 39 ]. Egol et al [ 20 ] (2020) did not observe a significant difference in preoperative morbidity using the Charlson Co-morbidity index between 2020 hip fracture cohort and 2019 hip fracture cohort.…”

“…Only three studies ( n = 874) had provided details about the type anesthesia (regional vs general anesthesia) used during surgery[ 9 , 20 , 29 ]. There was significantly less use of general anesthesia during the pandemic period (37.17% vs 44.86%; OR, 0.57; 95%CI, 0.42, 0.77; P = 0.0003) (Figure 2 ).…”

“…Pooled analysis of 30-d mortality from the eight studies ( n = 1586) revealed a significantly increased death among hip fracture patients during the pandemic time (9.63% vs 6.33%; OR, 0.62; 95%CI, 0.33, 1.17; P = 0.14) (Table 3 , Figure 3 )[ 9 , 19 , 20 , 27 - 29 , 38 , 39 ]. There was no difference in 30-d mortality rate between COVID-19 negative patients who were treated during the pandemic time and all hip fractured patients treated during the pre-pandemic period (6.44% vs 5.74%; OR, 1.03; 95%CI, 0.61, 1.75; P = 0.91)[ 9 , 19 , 20 , 29 , 38 ]. However, a significant difference in mortality rate was observed between COVID-19 + and COVID-19 − patients with an OR of 6.99 (29.33% vs 5.73%; 95%CI, 3.45, 14.16; P < 0.00001) (Table 3 , Figure 3 )[ 9 , 19 , 20 , 29 , 38 ].…”

“…The most worrisome problem is that majority of these patients are elderly individuals with numerous comorbidities[ 6 - 10 ]. Management of such fractures in these vulnerable immunocompromised patients during COVID-19 pandemic time is a big challenge[ 11 - 29 ]. With the best possible care, the incidence of 30-d mortality in hip fracture has been reported between 9%-13% in the literature[ 14 , 15 ].…”