Increased perioperative mortality for femoral neck fractures in patients with coronavirus disease 2019 (COVID-19): experience from the United Kingdom during the first wave of the pandemic

Abstract

Background The coronavirus disease 19 (COVID-19) pandemic has presented modern healthcare with an unprecedented challenge. At the peak of the pandemic, trauma and orthopaedic services at our institutions undertook internal restructuring, diverting resources to frontline medical care. Consequently, we sought to assess the impact on the elderly and comorbid patients presenting with femoral neck fractures, with a particular focus on 30-day mortality, length of stay, multidisciplinary team involvement and departmental structuring. Method A retrospective analysis of patients presenting with femoral neck fractures at three separate West London NHS Trusts was undertaken between March 11, 2020, to April 30, 2020. Length of stay, 30-day mortality and adherence to parameters constituting the best care evidence-based practice tariffs were compared between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive and negative patients. A similar comparison was also conducted between our cohort and the equivalent period in 2018 using data from the National Hip Fracture Database. Results A total of 68 patients presenting with femoral neck fractures were identified, mean age 81 (range 38–98), 73% female. There were 10 confirmed/suspected cases of COVID-19 on admission and a further seven confirmed as inpatients. The 30-day mortality within our cohort was 11.76% compared to 6% nationally in 2018 (p = 0.045). Orthogeriatric reviews occurred within 72 h in 71% of cases compared to 88% in the equivalent 2018 period. Within the cohort, mean length of stay was 17.13 days (SD 5.6, range 8-27 days) for SARS-CoV-2 positive patients compared to 10 days (SD 8.7, range 1–53 days) for negative patients (p < 0.05). Thirty-two patients (47%) required increased packages of care on discharge or rehabilitation. Conclusions The increase in 30-day mortality for SARS-CoV-2 positive patients presenting with femoral neck fractures is multifactorial, resulting from a combination of the direct effects of COVID-19 pneumonia as well as changes to the delivery of orthopaedic services. The provision of multidisciplinary care was directly affected by staff redeployment, particularly reorganisation of orthogeriatric services and lack of continuity of ward based clinical care. Our experiences have re-directed efforts towards the management of theatre teams, patient services and staffing, should we be faced with either a resurgence of COVID-19 or a future pandemic.

Comparative Outcomes and Surgical Timing for Operative Fragility Hip Fracture Patients during the COVID-19 Pandemic: A Retrospective Cohort Study

“…Outbreaks of COVID-19 at select skilled nursing facilities in our catchment area may have affected public perception of the safety of these facilities and decrease patient/patient family desire to be discharged to them. This contrasts with the findings of Wright et al [ 43 ], where 47% of hip fracture patients required increased support or a higher level of care at discharge. A similar study in the United Kingdom found patients were less likely to return home after hip fracture surgery during the pandemic [ 44 ].…”

“…This aligns with the majority of studies conducted to date, which suggest that time-to-surgery for hip fracture patients has not changed during the COVID-19 pandemic [ 30 , 31 , 35 , 36 , 37 ]. Changes to timing of other aspects of the healthcare system have been posited to impact outcomes, such as changes in time to orthogeriatric or multidisciplinary care [ 37 , 43 ]. Arafa et al [ 38 ] found an increase in anesthesia preparation and induction time, although this was only significant in patients who were positive for COVID-19 compared to historical controls.…”

Editorial: The impact of COVID-19 on immune system-related complications in surgical patients

“…This includes the release of a "cytokine storm" and activation of the complement system which promotes a systemic environment of hyperinflammation and hypercoagulability (8)(9)(10)(11)(12)(13)(14)(15). These pathophysiological changes may contribute to the increased perioperative risk of thromboembolic complications and the high postoperative mortality observed in surgical patients with COVID-19 (16)(17)(18)(19)(20). The current special edition in Frontiers in Surgery was designed to improve the understanding of the immune-mediated pathophysiological events that lead to adverse outcomes in the vulnerable population of COVID-19 patients undergoing surgical procedures.…”

Coronavirus in hip fractures (CHIP) 4

“…During the first wave of the pandemic, from march to september 2020, early small studies investigating the effect of covid-19 on hip fracture mortality found a significant increase in mortality, ranging from 11.7% to 40%. [6][7][8][9][10][11][12][13] our previously published regional audit of 1,633 patients conducted in the North West of England, also conducted in the first wave, found that 30-day mortality had increased from 6.8% (2019 control) to 35.6% in covid-19 positive patients. 14 similarly, meta-analyses found mortality rates of 32.6% and 36%, respectively.…”