Inflammatory and Coagulative Considerations for the Management of Orthopaedic Trauma Patients With COVID-19: A Review of the Current Evidence and Our Surgical Experience

Abstract

Mounting evidence suggests that the pathogenesis of coronavirus disease 2019 (COVID-19) involves a hyperinflammatory response predisposing patients to thromboembolic disease and acute respiratory distress. In the setting of severe blunt trauma, damaged tissues induce a local and systemic inflammatory response through similar pathways to COVID-19. As such, patients with COVID-19 sustaining orthopaedic trauma injuries may have an amplified response to the traumatic insult because of their baseline hyperinflammatory and hypercoagulable states. These patients may have compromised physiological reserve to withstand the insult of surgical intervention before reaching clinical instability. In this article, we review the current evidence regarding pathogenesis of COVID-19 and its implications on the management of orthopaedic trauma patients by discussing a case and the most recent literature.

Early mortality after hip fracture surgery in COVID-19 patients: A systematic review and meta-analysis

“… 40 The hyperinflammatory and hypercoagulable state induced by COVID-19 infection may therefore amplify the initial inflammatory response to low-energy trauma such as a hip fracture (i.e., “first hit”), and thereby predispose this high risk patient population to a catastrophic “second hit”. 41 …”

Potential Immune Indicators for Predicting the Prognosis of COVID-19 and Trauma: Similarities and Disparities

“…Hence, determining the cut-off point for T cells, especially CD4+ and CD8+ T cells after the development of COVID-19 symptoms, can be a valuable prognostic indicator and may predict disease progression (158). However, in individuals with severe COVID-19, the frequencies of CD8+ T cells that express activation markers such as HLA-DR and exhaustion markers including PD-1, Tim-3, and NKG2A are higher than in mild cases (16,225,255). Thus, activated CD8+ T cells in patients with critical and severe COVID-19 have reduced degranulation and secretion of granzyme B (GrZB) and perforin as compared to healthy donors (225,243).…”

“…In the setting of trauma, although traumatic insult is considered as the first driver of inflammatory responses, other hyperinflammatory states, such as COVID-19, has also the capacity to augment the inflammation (16,17). Recent evidence reported elevated inflammatory response in COVID-19 patients sustaining orthopaedic trauma injuries due to their baseline hyperinflammatory states (16). Moreover, it has been documented that the clinical characteristics of COVID-19 patients with fractures were more serious than those of patients without fractures (18).…”

Postoperative mortality in the COVID-positive hip fracture patient, a systematic review and meta-analysis

“…Patients who sustain hip fractures are often elderly with a high comorbidity burden, increasing risk of poor COVID-19 outcomes [5][6][7][8][9][10][11][12]. Overlapping inflammatory responses between orthopedic injury and SARS-CoV-2 infection may also contribute to poor outcomes [13][14][15]. Several studies have shown COVID-positive status in hip fracture patients to be associated with increased 30-day mortality [2,12].…”