Www.research.ed.ac.uk
IMPACT-Scot Report on COVID-19 and Hip Fracture: A multicentre study assessing mortality, predictors of SARS-CoV-2 infection and the effects of social?lockdown on epidemiologyABSTRACTAimsThe primary aim was to assess the independent influence of COVID-19 on 30-day mortality for patients with hip fracture. The secondary aims were to determine whether (1) there were clinical predictors of COVID-19 status and (2) whether social lockdown influenced the incidence and epidemiology of hip fractures.MethodsA national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23-days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, ASA grade, anaesthetic, length of stay, COVID-19 status and 30-day mortality were recorded.ResultsOf 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only 7 (26%) had suggestive symptoms on admission. COVID-19 positive patients had a significantly lower 30-day survival compared to those without COVID-19 (67% versus 92%, p<0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: (1) age, sex, type of residence (hazard ratio (HR) 2.93, p=0.008); (2) Nottingham Hip Fracture Score (HR 3.52, p=0.001), and (3) ASA (HR 3.45, p=0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of <217 x109/L was 68% specific and sensitive (95% CI 58 to 77, p=0.002). A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n=160) and 23 days post-lockdown (n=157); there was no significant (all p>0.15) difference in patient demographics, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA or management. ConclusionCOVID-19 was independently associated with an increased 30-day mortality rate for patients with hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fracture, in particular the need for COVID-19 testing.INTRODUCTIONThe SARS-CoV-2 (COVID-19) pandemic has transformed orthopaedic services with cessation of elective operating and a reduction in orthopaedic trauma operating capacity.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkplbmtpbnM8L0F1dGhvcj48WWVhcj4yMDIwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 1, 2 This has been associated with a widespread reduction in population activity (work, travel, and recreation) and the enforcement of public health messages to stay home. The epidemiology of orthopaedic trauma demonstrates a reduction in major trauma and activity-related trauma, but the incidence of fragility fractures is unchanged.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk51bmV6PC9BdXRob3I+PFllYXI+MjAyMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 5, so hip fracture patients are as a population at high risk of poor outcomes from COVID-19. Care pathways may need to be modified to try and optimise outcome.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxpdTwvQXV0aG9yPjxZZWFyPjIwMjA8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 6There is a paucity of data relating to the effect of COVID-19 on the mortality of patients with a hip fracture. A report from Spain that included 136 patients with a hip fracture demonstrated the unadjusted mortality rate was 10% at a mean follow of 10-days, which increased to 30% at a mean of 14-days in 23 patients they identified as COVID-19 positive.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk11bm96IFZpdmVzPC9BdXRob3I+PFllYXI+MjAyMDwvWWVh
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ADDIN EN.CITE.DATA 7 However, these mortality rates are not adjusted for age, sex and place of residence, or other factors associated with early patient mortality after a hip fracture ADDIN REFMGR.CITE <Refman><Cite><Author>Wiles</Author><Year>2011</Year><RecNum>9</RecNum><IDText>Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>9</Ref_ID><Title_Primary>Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur</Title_Primary><Authors_Primary>Wiles,M.D.</Authors_Primary><Authors_Primary>Moran,C.G.</Authors_Primary><Authors_Primary>Sahota,O.</Authors_Primary><Authors_Primary>Moppett,I.K.</Authors_Primary><Date_Primary>2011/4</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Comorbidity</Keywords><Keywords>Epidemiologic Methods</Keywords><Keywords>Female</Keywords><Keywords>Femoral Neck Fractures</Keywords><Keywords>Fracture Fixation</Keywords><Keywords>Health Status Indicators</Keywords><Keywords>Hip Fractures</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>mortality</Keywords><Keywords>Prognosis</Keywords><Keywords>surgery</Keywords><Keywords>Time Factors</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>501</Start_Page><End_Page>504</End_Page><Periodical>Br.J.Anaesth.</Periodical><Volume>106</Volume><Issue>4</Issue><Misc_3>aeq405 [pii];10.1093/bja/aeq405 [doi]</Misc_3><Address>University Division of Anaesthesia and Intensive Care, University of Nottingham, Nottingham, UK. matt.wiles@nottingham.ac.uk</Address><Web_URL>PM:21278153</Web_URL><ZZ_JournalStdAbbrev><f name="System">Br.J.Anaesth.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>8. Therefore, the true independent effect of COVID-19 on the mortality rate of patients with a hip fracture is not clear.It is essential to avoid cross-infection of COVID-19 in patients presenting with a hip fracture and future patient pathways may need to be amended to account for this.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxpdTwvQXV0aG9yPjxZZWFyPjIwMjA8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 6 If there were factors associated with a late positive diagnosis of COVID-19 in patients presenting with a hip fracture, this would help risk stratify patients and aid care pathways to minimise the risk of cross-infection, which might in turn reduce the mortality risk in such a frail patient group. In addition, the effect of social lockdown on the epidemiology and standards of care of hip fracture patients is not reported, to the authors knowledge, and this may be important to enable the planning of services in future pandemics. This study reports the early findings of International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) from Scottish centres contributing data to the collaborative. The primary aim of this study was to assess the independent influence of a positive diagnosis of COVID-19 on 30-day mortality for patients with a hip fracture. The secondary aims were to assess (1) whether there were clinical predictors at the time of presentation associated with having or developing COVID-19 and (2) whether social lockdown influenced the epidemiology of hip fracture patients and the standard of care. PATIENTS AND METHODSIn March 2020 data collection for the Scottish Hip Fracture Audit (SHFA) ADDIN REFMGR.CITE <Refman><Cite><RecNum>383</RecNum><IDText>The Scottish Hip Fracture Audit (Last accessed 25/05/2020)</IDText><MDL Ref_Type="Generic"><Ref_Type>Generic</Ref_Type><Ref_ID>383</Ref_ID><Title_Primary>The Scottish Hip Fracture Audit <u> (Last accessed 25/05/2020)</u></Title_Primary><Keywords>classification</Keywords><Reprint>Not in File</Reprint><Web_URL_Link2><u> was suspended due to the disruption caused by the COVID-19 viral pandemic to the Local Audit Coordinator (LAC) infrastructure. A multicentre emergency clinical audit response was initiated and supported by the SHFA, Scottish Government and the Scottish Committee for Orthopaedics & Trauma (SCOT) in response to the need for urgent clinical audit into COVID-19 and hip fractures. The IMPACT network is active in all Scottish centres that provide acute hip fracture services. A multicentre observational study was conducted of data collected retrospectively from six Scottish hospitals, including two major trauma centres and four district general hospitals (DGH), providing acute orthopaedic trauma management of patients with hip fracture. These six centres were identified as being able to collect reliable data promptly as part of the existing audit activity of LAC or orthopaedic surgeons. Data were collected in accordance with UK Caldicott principles and local data governance guidance, and no patient-identifiable data were transferred out with the local units or accessed by the central IMPACT research team. Inclusion and exclusion criteriaAll patients with a hip fracture who were aged 50 years and over and admitted to any of the six participating hospitals over the study period (1st March to 14th April 2020) were included. This period was chosen in order to capture the period from the first recorded COVID-19 case in Scotland (1st of March), spanning the introduction of social distancing measures and the enforced UK ‘lockdown’ on 23rd March 2020 (first 23 days), and continuing to the time at which confirmed COVID-19 cases in Scotland reached their highest point in mid-April 2020 (23 days after lockdown). The same lockdown guidelines and restrictions were in place for Scotland as the rest of the UK for the study period. We employed the same inclusion criteria as the SHFA, which is to include all intracapsular and extracapsular fractures involving the proximal femur up until the distal limit of the subtrochanteric region (defined as being five centimetres distal to the lesser trochanter). As per the SHFA criteria, isolated fractures of the acetabulum, pubic ramus, greater trochanter and periprosthetic fractures were excluded.Baseline data collectionA priori questions were developed before the collection of data, which was achieved through retrospective examination of local admission lists that were cross-referenced with patient medical records, trauma operating lists and discharge letters. Data were collected using a bespoke digital IMPACT Hip Fracture Audit data collection tool comprising data-validated fields to ensure accuracy and consistency of coding, thus increasing intra- and inter-observer reliability. Additionally, data collectors were provided with an IMPACT Hip Fracture Audit user guide and had continuous access for queries to the audit designer (AH). Demographics, injury, and surgical data were collected and included: age; sex; pre-fracture residence; date of injury; location where the injury was sustained; date of admission; date of surgery; procedure type; surgical delay status (defined as being surgery out with 36 hours of diagnosis); nonoperative management and anaesthetic type. Data pertaining to clinical status and comorbidity were collected and included: American Society of Anaesthesiologists (ASA) classification ADDIN REFMGR.CITE <Refman><Cite><RecNum>383</RecNum><IDText>The Scottish Hip Fracture Audit (Last accessed 25/05/2020)</IDText><MDL Ref_Type="Generic"><Ref_Type>Generic</Ref_Type><Ref_ID>383</Ref_ID><Title_Primary>The Scottish Hip Fracture Audit <u> (Last accessed 25/05/2020)</u></Title_Primary><Keywords>classification</Keywords><Reprint>Not in File</Reprint><Web_URL_Link2><u>, presence or absence of each of six major comorbidity groups (cardiovascular disease, renal disease, pulmonary disease, dementia, acute neoplastic disease, and diabetes mellitus) and admission laboratory blood test results (haemoglobin, lymphocyte count, platelet count, serum sodium and serum albumin). 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ADDIN EN.CITE.DATA 10-14 Data were collected for COVID-19 status in the preoperative and postoperative periods separately. This included data pertaining to the presence or absence of symptoms or signs as being suggestive of COVID-19 (defined by the World Health ADDIN REFMGR.CITE <Refman><Cite><RecNum>384</RecNum><IDText>World Health Organization (Last accessed 25/05/2020)</IDText><MDL Ref_Type="Generic"><Ref_Type>Generic</Ref_Type><Ref_ID>384</Ref_ID><Title_Primary>World Health Organization <u>; (Last accessed 25/05/2020)</Title_Primary><Keywords>classification</Keywords><Reprint>Not in File</Reprint><Web_URL_Link2><u>, or features associated with COVID-19 in the frail population ADDIN REFMGR.CITE <Refman><Cite><RecNum>385</RecNum><IDText>British Geriatrics Society. COVID-19: Managing COVID-19 pandemic in care homes for older people. (Last accessed 25/05/2020)</IDText><MDL Ref_Type="Generic"><Ref_Type>Generic</Ref_Type><Ref_ID>385</Ref_ID><Title_Primary><u>British Geriatrics Society. COVID-19: Managing COVID-19 pandemic in care homes for older people. ; (Last accessed 25/05/2020)</Title_Primary><Keywords>classification</Keywords><Reprint>Not in File</Reprint><Web_URL_Link2><u>) from inpatient medical records, laboratory swab requests and discharge summaries. The results of SARS-CoV-2 RNA polymerase chain reaction (PCR) testing was collected from local microbiology laboratory databases and was used to determine COVID-19 status: positive or negative. Swabs were obtained via the standard oropharyngeal and nasopharyngeal swab technique as part of the patients’ routine clinical management. Outcome data collectionData relevant to early outcome measures were collected: date and destination of discharge from acute admission (defined as being the acute orthopaedic admission, or the total acute hospital admission if a patient was transferred from an acute orthopaedic unit to another acute unit of comparable care level); date of death, and death occurring during the acute admission. Patients were followed up for a minimum of 30 days.Statistical methodsStatistical analysis was performed using Statistical Product and Service Solutions version 17.0 (SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc.). Parametric and non-parametric tests were used as appropriate to assess continuous variables for significant differences between groups. For numerical variables, an unpaired t-test (normally distributed data) was used to compare values between groups. Dichotomous variables were assessed using a Chi square test or a Fishers exact test (if 5 or less in one cell) between group comparisons. Kaplan-Meier methodology was used to investigate 30-day survival after hip fracture and Log rank was used to compare survival between COVID-19 positive patients to those without a positive diagnosis. Cox regression analysis was used to assess the independent association of COVID-19 status and 30-day mortality. Logistic regression analyses were used to assess the independence of predictors associated with a COVID-19 positive patient with a hip fracture. Variables with (p<0.1) significance or a trend towards significance on univariable analyses were included in the multivariable model. Receiver operating characteristic (ROC) curve analysis was used to identify a threshold value in the scaler variables that were identified as predictors associated with a COVID-19 positive patient. The area under the ROC curve (AUC) ranges from 0.5, indicating a test with no accuracy in distinguishing whether a patient is COVID-19 positive, to 1.0 where the test is perfectly accurate identifying all COVID-19 positive patients. The threshold value was defined as the point at which the sensitivity and specificity were maximal in predicting a COVID-19 positive patient.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkZhcnJhcjwvQXV0aG9yPjxZZWFyPjIwMDE8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 17 A p-value of <0.05 was defined as statistically significant. RESULTSDuring the study period 317 patients presented to the six study centres with a hip fracture. There were 211 (67%) female and 106 (33%) male patients with a mean age of 80 (range 50 to 101) years old (Table I).Primary aim: the independent influence of COVID-19 on patient mortalityThere were 27 patients in total that were proven to be infected with COVID-19 in the study cohort, of which 6 were symptomatic and swab-positive at admission, and the remaining 21 were asymptomatic on admission but later became swab-positive during the admission. Of the 20 asymptomatic patients, 11 tested positive before 14 days and nine tested positive after 14 days from admission. There were 33 patient deaths in the first 30 days following hip fracture, of which 9 were directly related to COVID-19. Patients that were COVID-19 positive at any time point had a significantly lower rate of survival when compared to those without a proven COVID-19 infection (67% versus 92%, Log rank p<0.001, Figure 1). When patients who had COVID-19 on admission were compared to those that were diagnosed positive during admission, there was no difference in survival, and moreover survival for both groups remained significantly lower than for patients without COVID-19 (Figure 2). Univariate analysis demonstrated that factors significantly associated with 30-day mortality were older age (5.7 years, p=0.004), male sex (odds ratio (OR) 2.67, p=0.007), care/nursing home residence (OR 2.4, p=0.030), a higher Nottingham Hip Fracture Score (1.1, p<0.001), increasing ASA grade (p<0.001), non-operative management (OR 9.75, p<0.001) and a positive COVID-19 status (OR 5.54, p<0.001) (Table I). The influence of non-operative management was thought to be a secondary marker of risk of death and was not included in the regression models. The Nottingham Hip Fracture Score includes age, sex and place of residence and was therefore not independent of these factors, and the same was found with the ASA grade due to high multicollinearity. Three separate Cox regression models were used to assess the independent association of COVID-19 with mortality risk when adjusting for (1) age, sex, and place of residence, (2) Nottingham Hip Fracture Score and (3) the patients ASA grade. When adjusting for these confounding variables COVID-19 positive status was independently associated with a higher mortality risk (Table II).Secondary aims (1) Predictors at time of presentation associated with having or developing COVID-19 The 27 patients that tested positive for COVID-19 either at admission (n=6) or subsequently became positive during their admission (n=21) were assessed on univariate analysis and male sex (OR 2.32, p=0.034) and a lower platelet count (54.2, p=0.006) were found to be associated with a positive COVID-19 diagnosis (Table III). Sex and platelet count were independently associated with a positive COVID-19 diagnosis when adjusting for one another (Table IV). ROC curve analysis illustrated that platelet count at time of presentation was a reliable predictor of COVID-19 status with a AUC of 68% (95% CI 58 to 77, p=0.002) and a threshold value in the platelet count of 217 (Figure 3). This threshold value was then entered into the regression model with male sex, and a platelet count of <217 remained a significant independent predictor associated with an increased risk of the patient being COVID-19 positive at presentation or at any time in the study period (Table V).(2) Social lockdown and influence on the epidemiology of hip fractureA similar number of patients presented with a hip fracture in the 23 days prior to social lockdown (n=160) and in the 23 days following lockdown (n=157). There was no significant (all p>0.15) differences found in patient demographics (age and sex), place of injury, Nottingham Hip Fracture Score, time to surgery, ASA grade or management pre- or post-lockdown (Table VI). However, there were significantly fewer general anaesthetics preformed after lockdown (OR 0.20, p<0.001) and there was a shorter length of stay (11.3 days vs 7.8 days, p<0.001). In addition, there was also a trend (OR 2.74, p=0.102) towards a greater rate of non-operative management post-lockdown. Of the 14 patients managed non-operatively, two had tested positive for COVID-19, and a further three patients were clinically suspected of having COVID-19 without a positive laboratory diagnosis.DISCUSSIONThis multicentre study has demonstrated that a positive diagnosis of COVID-19 either at admission or during admission for a hip fracture is associated with an increased 30-day mortality, which is four times that of hip fractures patients without COVID-19. The mortality rate was independent of age, sex, residence, Nottingham Hip Fracture Score and ASA grade. The death rate was somewhat higher than that reported in a UK study of adult hospitalised patients (all categories) with COVID-19 (mortality 26%), though in that study the mean age was 73 years, and reporting time was variable (minimum two weeks).PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkRvY2hlcnR5PC9BdXRob3I+PFllYXI+MjAyMDwvWWVhcj48
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ADDIN EN.CITE.DATA 5 Male sex and lower platelet count at admission were independently associated with a COVID-19 positive diagnosis in patients with a hip fracture in our study, with a platelet count of <217 x109 g/L was 68% sensitive and specific. The incidence of hip fractures was not affected by social lockdown during the study period. However, there was an increased rate of spinal anaesthesia and a shorter length of acute hospital stay after social lockdown.The results of this study, which used data from a healthcare system in which hip fracture care is delivered consistently and in accordance with a set of nationally-agreed evidence-based care standardsPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkZhcnJvdzwvQXV0aG9yPjxZZWFyPjIwMTg8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 7, 19 However, the current study is the largest to date and the first to use survivorship methodology to quantify the risk and adjust for confounding variables. A positive diagnosis of COVID-19 was also demonstrated to be independent of the Nottingham Hip Fracture Score that may now require revision in the context of COVID-19 and the association with postoperative mortality. ADDIN REFMGR.CITE <Refman><Cite><Author>Wiles</Author><Year>2011</Year><RecNum>9</RecNum><IDText>Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>9</Ref_ID><Title_Primary>Nottingham Hip Fracture Score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur</Title_Primary><Authors_Primary>Wiles,M.D.</Authors_Primary><Authors_Primary>Moran,C.G.</Authors_Primary><Authors_Primary>Sahota,O.</Authors_Primary><Authors_Primary>Moppett,I.K.</Authors_Primary><Date_Primary>2011/4</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Comorbidity</Keywords><Keywords>Epidemiologic Methods</Keywords><Keywords>Female</Keywords><Keywords>Femoral Neck Fractures</Keywords><Keywords>Fracture Fixation</Keywords><Keywords>Health Status Indicators</Keywords><Keywords>Hip Fractures</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>mortality</Keywords><Keywords>Prognosis</Keywords><Keywords>surgery</Keywords><Keywords>Time Factors</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>501</Start_Page><End_Page>504</End_Page><Periodical>Br.J.Anaesth.</Periodical><Volume>106</Volume><Issue>4</Issue><Misc_3>aeq405 [pii];10.1093/bja/aeq405 [doi]</Misc_3><Address>University Division of Anaesthesia and Intensive Care, University of Nottingham, Nottingham, UK. matt.wiles@nottingham.ac.uk</Address><Web_URL>PM:21278153</Web_URL><ZZ_JournalStdAbbrev><f name="System">Br.J.Anaesth.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>8 Extrapolation of the survival curve for patients who experience the onset of active infection during admission for a period longer than the current 30-day follow-up may demonstrate patterns of early mortality consistent with that of patients who had active infection with a positive diagnosis at admission. Some authors have advocated the option of non-operative management for hip fracture patients with COVID-19. ADDIN REFMGR.CITE <Refman><Cite><Author>Cronin</Author><Year>20 A.D.</Year><RecNum>234</RecNum><IDText>COVID-19 causes a SHiFT in the sands for proximal femoral fracture management?</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>234</Ref_ID><Title_Primary>COVID-19 causes a SHiFT in the sands for proximal femoral fracture management?</Title_Primary><Authors_Primary>Cronin,M.</Authors_Primary><Authors_Primary>Mullins,M.</Authors_Primary><Authors_Primary>Pathmanaban,P.</Authors_Primary><Authors_Primary>Williams,P.</Authors_Primary><Authors_Primary>Dodd,M.</Authors_Primary><Date_Primary>20 AD/3/14</Date_Primary><Keywords>surgery</Keywords><Reprint>Not in File</Reprint><Periodical>The Transient Journal of Trauma, Orthopaedics and the Coronavirus</Periodical><Volume> name="System">The Transient Journal of Trauma, Orthopaedics and the Coronavirus</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>20 Any decision to operate should be made on a case-by-case basis, however we would suggest that the evidence from this study and from the existing literature does not support routine deviation from operative management. Although the 30-day mortality risk is increased in patients with COVID-19, only two of the 27 patients with a positive diagnosis were managed non-operatively in view of significant respiratory compromise, and both subsequently died at day two and day 11 of their admission respectively. Whilst the mortality for patients with COVID-19 was higher than those without, two-thirds of these patients were still alive one month following their admission. Indeed surgical management has been demonstrated to aid the respiratory function and recovery in hip fracture patients affected by COVID-19. ADDIN REFMGR.CITE <Refman><Cite><Author>Catellani</Author><Year>2020</Year><RecNum>126</RecNum><IDText>Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>126</Ref_ID><Title_Primary>Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy</Title_Primary><Authors_Primary>Catellani,F.</Authors_Primary><Authors_Primary>Coscione,A.</Authors_Primary><Authors_Primary>D'Ambrosi,R.</Authors_Primary><Authors_Primary>Usai,L.</Authors_Primary><Authors_Primary>Roscitano,C.</Authors_Primary><Authors_Primary>Fiorentino,G.</Authors_Primary><Date_Primary>2020/4/28</Date_Primary><Reprint>Not in File</Reprint><Periodical>J Bone Joint Surg.Am.</Periodical><User_Def_5>PMC7224593</User_Def_5><Misc_3>10.2106/JBJS.20.00617 [doi]</Misc_3><Address>Department of Orthopaedics and Traumatology, Humanitas Gavazzeni, Bergamo, Italy
Department of Orthopaedics and Traumatology, Humanitas Gavazzeni, Bergamo, Italy
IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
Department of Orthopaedics and Traumatology, Humanitas Gavazzeni, Bergamo, Italy
Department of Orthopaedics and Traumatology, Humanitas Gavazzeni, Bergamo, Italy
Department of Orthopaedics and Traumatology, Humanitas Gavazzeni, Bergamo, Italy</Address><Web_URL>PM:32345864</Web_URL><ZZ_JournalStdAbbrev><f name="System">J Bone Joint Surg.Am.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>19 The majority (74%) of patients in our study became symptomatic and tested positive for COVID-19 after acute hip fracture admission, of whom six patients tested positive 14 days from admission. COVID-19 is associated with an asymptomatic incubation period reported to be most frequently between 5-8 daysPFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxhdWVyPC9BdXRob3I+PFllYXI+MjAyMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 21 and patients (especially elderly and frail patients who are at greatest risk of hip fracture) may remain asymptomatic or demonstrate atypical or non-specific features such as delirium, during which period they can be considered asymptomatic carriers and at risk of infecting patients or staff.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlJvZ2VyczwvQXV0aG9yPjxZZWFyPjIwMjA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 6, 22-24 Importantly, patients who were reported as having the onset of symptoms and a positive COVID-19 test result beyond 14 days into admission for hip fracture may have contracted the infection whilst as an inpatient, which raises the serious concern of patient-to-patient and staff-to-patient spread in the hospital setting.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxpdTwvQXV0aG9yPjxZZWFyPjIwMjA8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 6, 21 These findings may support the development of strategies and pathways to mitigate against in-hospital spread of COVID-19, such as managing hip fracture patients in small protected ‘cohorts’ or in ‘ring-fenced’ areas, ensuring minimum patient movement, and introducing repeated testing throughout the duration of the hospital admission. Patient pathways have been suggested by previous authors to prevent cross-infection between patients.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkxpdTwvQXV0aG9yPjxZZWFyPjIwMjA8L1llYXI+PFJlY051
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ADDIN EN.CITE.DATA 6, 19A major limitation of the current study is the reliance on positive nasopharyngeal swabs for SARS-CoV-2 RNA to assign the diagnosis of COVID-19 to patients with hip acute hip fractures. The sensitivity of the reverse transcriptase polymerase chain reaction (PCR) is not 100%, with a systematic review suggesting it could be as low as 71% and one study reporting a false negative rate of 29%.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkFyZXZhbG9lLVJvZHJpZ3VlejwvQXV0aG9yPjxZZWFyPjIw
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ADDIN EN.CITE.DATA 25, 26 The sensitivity also varies according to the anatomical site (sputum 72%, nasal swab 63%, throat swab 32%) and the stage of the disease.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPldhbmc8L0F1dGhvcj48WWVhcj4yMDIwPC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA 27, 28 As there is no clear “gold standard” to assign the diagnosis of COVID-19 both clinical suspicion and current swab testing may be the best way to identify patients at risk of being infected with SARS-CoV-2. The pre-test probability of a patient having COVID-19 directly affects the chance of a patient having a false negative test for SARS-CoV-2. For example, a cohort of 100 patients with a test sensitivity of 71% and specificity of 95%PFJlZm1hbj48Q2l0ZT48QXV0aG9yPkFyZXZhbG9lLVJvZHJpZ3VlejwvQXV0aG9yPjxZZWFyPjIw
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ADDIN EN.CITE.DATA 12, 29At the time of data collection there was no specific SARS-CoV-2 antigen testing strategy with regards to indication or timing of testing, which was consistent within all participating hospitals. Consistency of approach to testing for active COVID-19 infection, such as routine for all patients on admission, or prior to discharge from the acute care setting, may provide a more reliable and predictable context within which to interpret results and guide inpatient cohorting and discharge planning decisions. The number of patients admitted with a hip fracture during the 23 days prior to lockdown and 23 day following lockdown were nearly identical and this is consistent with other authors that have found no change in the rate of these fractures during the COVID-19 pandemic.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlNjb3R0PC9BdXRob3I+PFllYXI+MjAyMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 3, 4, 30 These data strongly suggest that the pathways and clinical resources for the management of these frail patients should be preserved and prioritised in future lockdowns and pandemics. The number of spinal anaesthetics increased significantly after the lockdown period, which likely reflects the recognised increased risk of aerosol-transmitted infection associated with an airway intubation. ADDIN REFMGR.CITE <Refman><Cite><Author>Raghavan</Author><Year>2020</Year><RecNum>109</RecNum><IDText>Minimising aerosol generation during orthopaedic surgical procedures- Current practice to protect theatre staff during Covid-19 pandemic</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>109</Ref_ID><Title_Primary>Minimising aerosol generation during orthopaedic surgical procedures- Current practice to protect theatre staff during Covid-19 pandemic</Title_Primary><Authors_Primary>Raghavan,R.</Authors_Primary><Authors_Primary>Middleton,P.R.</Authors_Primary><Authors_Primary>Mehdi,A.</Authors_Primary><Date_Primary>2020/5</Date_Primary><Reprint>Not in File</Reprint><Start_Page>506</Start_Page><End_Page>507</End_Page><Periodical>J Clin.Orthop Trauma</Periodical><Volume>11</Volume><Issue>3</Issue><User_Def_5>PMC7194550</User_Def_5><Misc_3>10.1016/j.jcot.2020.04.024 [doi];S0976-5662(20)30138-7 [pii]</Misc_3><Address>Borders General Hospital, Melrose, TD69BS, United Kingdom
Borders General Hospital, Melrose, TD69BS, United Kingdom
Borders General Hospital, Melrose, TD69BS, United Kingdom</Address><Web_URL>PM:32362733</Web_URL><ZZ_JournalStdAbbrev><f name="System">J Clin.Orthop Trauma</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>31 The length of acute hospital stay was significantly shorter post-lockdown and may reflect an increased focus on early discharge from hospital to avoid potential exposure to infection, or it may be that there are more resources available as a result of refined decision making for many injuries and a significant reduction in the polytrauma workload.PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlNjb3R0PC9BdXRob3I+PFllYXI+MjAyMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 3, 4 The large sample size and multicentre nature of the data collection is a strength of the current study. The authors appreciate that there is variation with respect to COVID-19 infection and hip fracture incidence between regions, as well as with respect to testing strategies, social distancing policies and enforced lockdown measures. More evidence from a larger sample size (gathered from a larger number of centres and units, with a greater geographical spread providing greater generalisability with respect to public health measures, COVID-19 prevalence and infection control strategies) is required for a better understanding of hip fracture incidence, epidemiology, patterns of COVID-19 infection and the effects of variation in community infection rates and disease control strategies. More information is needed to identify factors that may be predictive of COVID-19 infection and early mortality in order to guide clinical decision-making, as well as to assess the impact and mitigate the disruption of the viral pandemic on hip fracture services. ConclusionsA positive diagnosis of COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Most patients that had a hip fracture and were COVID-19 positive were asymptomatic at presentation, which suggests standardised patient pathways may be needed to prevent cross-infection. Platelet count at admission was found to be an indicator of risk of COVID-19 status and could be used as part of risk assessment pathways. There was no change in the rate or epidemiology of hip fracture patients pre- and post-social lockdown and clinical resources for the management of these frail patients should be prioritised in future lockdowns and pandemics. ADDIN REFMGR.REFLIST References1. 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Patient demographics, Nottingham Hip Fracture Score, residence, place of injury, study centre, surgery within 36 hours, ASA grade, surgical management and COVID status according to 30-day mortality.DemographicDescriptive30-day MortalityDifference / Odds Ratio (95% CI)p-value*Dead(n=33)Alive (n=284)Age (years: mean, SD)85.8 (7.9)80.1 (10.8)Diff 5.7 (1.9 to 9.4)0.004**Sex(n, % of group)Female15 (45.5)196 (69.0)Reference0.007Male18 (54.5)88 (31.0)2.67 (1.29 to 5.55)Nottingham Hip Score (mean, SD)5.8 (1.4)4.7 (1.7)Diff 1.1 (0.5 to 1.7)<0.001**Residence(n, % of group)Home18 (54.5)212 (74.6)ReferenceCare/Nursing home11 (33.3)54 (19.0)OR 2.40 (1.07 to 5.38)0.030Hospital4 (12.1)18 (6.30OR 2.62 (0.80 to 8.56)0.111Place of injury(n, % of group)Home / Indoor23 (69.7)198 (69.7)ReferenceOutdoor5 (15.2)64 (22.5)OR 0.67 (0.25 to 1.84)0.495Hospital5 (15.2)21 (7.4)OR 2.05 (0.71 to 5.96)0.190Centre(mean, SD)A9 (27.3)91 (32.0)-0.872B4 (12.1)46 (16.2)C3 (9.1)19 (6.7)D9 (27.3)64 (22.5)E3 (9.1)34 (12.0)F5 (15.2)30 (10.6)Surgery <36 hoursYes17 (51.5)197 (69.4)Reference(n, % of group)No10 (30.3)80 (28.2)OR 1.44 (0.64 to 3.30)0.376ASA grade103 (1.1)-<0.001(n, % of group)23 (9.1)79 (27.8)316 (48.5)166 (58.5)48 (24.2)27 (9.5)51 (3.0)0Management(n, % of group)Fixation16 (48.5)156 (54.9)ReferenceArthroplasty10 (30.3)121 (42.6)OR 0.81 (0.35 to 1.84)0.610Non-operative7 (21.2)7 (2.5)OR 9.75 (3.03 to 31.3)<0.001COVID status(n, % of group)No24 (72.7)266 (93.7)ReferenceYes9 (27.3)18 (6.3)OR 5.54 (2.25 to 13.67)<0.001* chi square test unless otherwise stated **unpaired Students t-testTable II. Cox regression models of 30-day survival according to COVID status.Predictors in modelHazard Ratio95% CIp-valueLowerUpper1. Age, Sex, Place of residence and COVID statusCOVIDNoReferenceYes2.931.336.450.0082. Nottingham Hip Fracture Score and COVID statusCOVIDNoReferenceYes3.521.637.630.0013. ASA grade and COVID statusCOVIDNoReferenceYes3.451.507.970.004Table III. Patient demographics, Nottingham Hip Fracture Score, presentation blood results, residence, place of injury, study centre and management according to COVID status.DemographicDescriptiveCOVID19 PositiveDifference / Odds Ratio (95% CI)p-value*Yes (n=27)No (n=290)Age (years: mean, SD)83.6 (11.3)80.4 (10.6)Diff 3.2 (-1.0 to 7.4)0.137**Sex(n, % of group)Female13 (48.1)198 (86.3)ReferenceMale14 (51.9)92 (31.7)OR 2.32 (1.05 to 5.13)0.034Nottingham Hip Score (mean, SD)5.3 (1.7)4.7 (1.7)Diff 0.5 (-0.1 to 1.2)0.113**Bloods(mean, SD)Haemoglobin124.6 (17.1)123.6 (19.6)Diff 1.0 (-6.7 to 8.7)0.799White cell11.1 (3.2)11.6 (3.8)Diff 0.5 (-1.3 to 2.4)0.566Neutrophil9.2 (3.0)9.6 (3.7)Diff 0.4 (-1.4 to 2.1)0.688Lymphocyte1.0 (0.4)1.2 (0.6)Diff 0.1 (-0.1 to 0.4)0.236Platelets194.6 (67.7)248.8 (100.4)Diff 54.2 (15.3 to 93.0)0.006CRP (n=12 vs 53)52.9 (87.0)54.0 (74.6)Diff 1.2 (-48.0 to 50.3)0.962Albumin (n=18 vs 195)35.9 (4.6)37.5 (9.3)Diff 1.5 (-2.9 to 5.9)0.501Sodium138.5 (4.9)136.4 (13.2)Diff 2.1 (-3.0 to 7.1)0.420Residence(n, % of group)Home19 (70.4)211 (72.8)ReferenceCare/Nursing home6 (22.2)59 (20.3)OR 1.01 (0.93 to 1.10)0.806Hospital2 (7.4)20 (6.9)OR 1.11 (0.24 to 5.12)0.999Place of injury(n, % of group)Home19 (70.4)202 (69.7)ReferenceOutdoor6 (22.2)63 (21.7)OR 1.01 (0.39 to 2.65)0.999Hospital2 (7.4)24 (8.3)OR 0.89 (0.19 to 4.04)0.999Centre(n, % of group)A11 (40.7)89 (30.7)0.608B5 (18.5)45 (15.5)C2 (7.4)20 (6.9)D3 (11.1)70 (24.1)E2 (7.4)35 (12.1)F4 (14.8)31 (10.7)Management(n, % of group)Fixation16 (59.3)157 (54.1)ReferenceArthroplasty10 (37.0)121 (41.7)OR 0.98 (0.92 to 1.05)0.617Non-operative2 (7.4)12 (4.1)OR 1.64 (0.34 to 7.96)0.629* chi square test unless otherwise stated **unpaired Students t-test Table IV. Logistic regression analysis was used to adjust for confounding between the groups to assess the independent association with COVID19. Variables demonstrating a trend (p<0.1) or significant differences between the groups on univariable analyses were entered into the model. Nagelkerke R2 =0.1Predictors in modelOdds Ratio95% CIp-valueLowerUpperSexFemaleReferenceMale2.311.035.180.042Platelet Count0.990.980.990.005Table V. Sex and the threshold platelet value of 217 were entered into a logistic regression analysis to assess the independent association with COVID19. Nagelkerke R2 =0.1Predictors in modelOdds Ratio95% CIp-valueLowerUpperSexFemaleReferenceMale2.130.954.760.065Platelet Count≥217Reference<2172.311.035.200.043Table VI. Patient demographics, Nottingham Hip Fracture Score, residence, place of injury, study centre, ASA grade, anaesthetic, surgical management, length of stay and place of discharge according to whether their hip fracture was sustained pre or post social lockdown.DemographicDescriptiveSocial LockdownDifference / Odds Ratio (95% CI)p-value*No (n=160)Yes (n=157)Age (years: mean, SD)80.8 (10.5)80.6 (10.8)Diff 0.2 (-2.2 to 2.5)0.887*Sex(n, % of group)Male54 (33.8)52 (33.1)Reference0.906Female106 (66.3) 105 (66.9)OR 0.97 (0.61 to 1.55)Nottingham Hip Score (mean, SD)4.7 (1.7)4.9 (1.6)Diff 0.2 (-0.2 to 0.5)0.432*Residence(n, % of group)Home120 (75.0)110 (70.1)ReferenceCare/Nursing home27 (16.9)38 (24.2)OR 1.22 (0.96 to 1.56)0.130Hospital13 (8.1)9 (5.7)OR 0.86 (0.31 to 1.84)0.532Place of injury(n, % of group)Home / Indoor112 (70.0)109 (69.4)ReferenceOutdoor31 (19.4)38 (24.2)OR 1.26 (0.73 to 2.17)0.403Hospital17 (10.6) 9 (5.7)OR 0.54 (0.23 to 1.27)0.155Centre(n, % of group) RIE48 (30.0)52 (33.1)-0.766 VHK24 (15.0)26 (16.6) BGH11 (6.9)11 (7.0) ARI36 (22.5)37 (23.6) DGRI19 (11.9)18 (11.5) Ayr22 (13.8)13 (8.3)Surgery <36 hoursYes112 (70.0)102 (65.0)ReferenceNo45 (28.1)45 (28.7)OR 0.91 (0.56 to 1.49)0.710AnaestheticSpinal38 (23.8)62 (39.5)Reference(n, % of group)General39 (24.4)13 (8.3)OR 0.20 (0.10 to 0.43)<0.001Both1 (0.6)4 (2.5)OR 2.45 (0.26 to 22.8)0.649ASA grade13 (1.9)0-0.255(n, % of group)241 (25.6)41 (26.1)389 (55.6)93 (59.2)421 (13.1)14 (8.9)51 (0.6)0Management(n, % of group) Fixation90 (56.3)82 (52.2) Reference Arthroplasty66 (41.3)65 (41.4)OR 1.08 (0.69 to 1.70)0.740 Non-operative4 (2.5)10 (6.4)OR 2.74 (0.83 to 9.09)0.102Length of stay(mean, SD)11.3 (7.5)7.8 (4.6)Diff 3.5 (1.9 to 5.1)<0.001*DischargedHome58 (36.3)43 (27.4)Reference(n, % of group)Care/Nursing27 (16.9)30 (19.1)OR 1.50 (0.78 to 2.88)0.223Ongoing NHS58 (36.3)49 (31.2)OR 1.14 (0.66 to 1.98)0.639Rehabilitation5 (3.1)2 (1.3)OR 0.54 (0.10 to 2.91)0.697Other12 (7.5)33 (21.0)OR 3.71 (1.72 to 8.00)<0.001* chi square test unless otherwise stated **unpaired ................
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