Aims

Orthopaedic surgery uses many varied instruments with high-speed, high-impact, thermal energy and sometimes heavy instruments, all of which potentially result in aerosolization of contaminated blood, tissue, and bone, raising concerns for clinicians’ health. This study quantifies the aerosol exposure by measuring the number and size distribution of the particles reaching the lead surgeon during key orthopaedic operations.

The covid-19 pandemic had a great impact in the daily clinical and surgical practice. Concerning patients with a femoral neck fracture, there is the need of a negative Sars-CoV-2 test or an established isolation period for the positive cases, pre-operatively. The goal of this study was to evaluate the impact of the pandemic in the management of patients with femoral neck fractures, who were submitted to surgical treatment with hemiarthroplasty, in our hospital. A retrospective, observational study was performed, analysing the patients with femoral neck fractures submitted to hip hemiarthroplasty, during the years 2019 (before the pandemic) and 2020 (first year of the pandemic). We analysed the first 5 patients operated in each month of the mentioned years. We analysed 56 and 60 patients submitted to surgery in the years 2019 and 2020, respectively. The inpatient days were, in average, 14.1 and 13.1. Patients were operated, in average, 3.0 and 3.8 days after admission (corrected to 2.5 and 3.6 days if the time of discontinuation of anticoagulants or antiplatelets needed before surgery is deducted). There were peri-operative complications in 53.6% and 46.7% of the patients, in 2019 and 2020 respectively. The most common complication in both groups was a low postoperative haemoglobin level needing red blood cell transfusion. One-year postoperative mortality rate was 17.9% and 13.3%, respectively. Despite the changes triggered by the new pandemic, there was an overall maintenance of the quality of the management of these patients, with only a slight increase in the interval between admission and surgery. Some of the remaining variables even showed an improvement when comparing the two groups of patients. Nevertheless, it is important to mention that there were patients infected with Covid-19 who died before being submitted to surgery, therefore not being present in these statistics

Aims

The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD).

In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimise exposure on the wards. In order to maintain throughput of elective cases, our hospital was forced to convert as many cases as possible to same day procedures rather than overnight admission. In this retrospective analysis we review the cases performed as same day arthroplasty surgeries compared to the same period 12 months previous. We conducted a retrospective analysis of patients undergoing total hip and knee arthroplasties in a three month period between October and December in 2019 and again in 2020, in the middle of the SARS-CoV-2 pandemic. Patient demographics, number of out-patient primary arthroplasty cases, length of stay for admissions, 30-day readmission and complications were collated. In total, 428 patient charts were reviewed for the months of October-December of 2019 (n=195) and 2020 (n=233). Of those, total hip arthroplasties comprised 60% and 58.8% for 2019 and 2020, respectively. Demographic data was comparable with no statistical difference for age, gender contralateral joint replacement or BMI. ASA grade I was more highly prevalent in the 2020 cohort (5.1x increase, n=13 vs n=1). Degenerative disc disease and fibromyalgia were less significantly prevalent in the 2020 cohort. There was a significant increase in same day discharges for non-DAA THAs (2x increase) and TKA (10x increase), with a reciprocal decrease in next day discharges. There were significantly fewer reported superficial wound infections in 2020 (5.6% vs 1.7%) and no significant differences in readmissions or emergency department visits (3.1% vs 3.0%). The SARS-CoV-2 pandemic meant that hospitals and patients were hopeful to minimise the exposure to the wards and to not put strain on the already taxed in-patient beds. With few positives during the Coronavirus crisis, the pandemic was the catalyst to speed up the outpatient arthroplasty program that has resulted in our institution being more efficient and with no increase in readmissions or early complications

SARS-CoV-2 emerged in Wuhan, China in December 2019 causing pneumonia and resulting in a pandemic, commonly known as COVID-19. This pandemic led to significant changes to our daily lives due to restrictions, such as social distancing, quarantining, stay at home orders and closure of restaurants and shops among other things. The psychological effects of this uncertainty as well as of these changes to our lives have been shown to be significant. This study is a prospective study investigating the mental effects of the pandemic on hand and wrist patients seen in our clinic during this pandemic. A prospective database on wrist pain was used to identify patients seen in our hand clinic from January 1, 2018 to December 10, 2021. All participants had been diagnosed with either radial sided wrist pain or ulnar side wrist pain. The Center for Epidemiological Studies Depression (CES-D) Scale was used to assess the mental health of our participants before and during this pandemic. An independent samples t-test was used to compare the scores of the 2 groups. A total of 437 CES-D questionnaires were collected during this period. 118 of them belonging to the pandemic group and 319 to the pre-pandemic group. A difference (p < 0 .05) in the CES-D score was observed between the pre-pandemic and during pandemic groups. The mean score for the pre-pandemic group was found to be 9.23 (8.94) and 12.81 (11.45) for the pandemic group. However, despite the increase in score, it didn't exceed the cut off score of 16 or greater used to assess depression. Our results indicate that there was a slight increase in score for depression in hand and wrist patients, but not above the cut off level of 16 to be of a significant risk for depression. Other global studies have shown an increase in depression in the general public. Our mild results might be attributed to the fact that British Columbia did not implement severe restrictions compared to other countries or regions, i.e no stay at home orders. Additionally, our study population was skewed and included more middle age and older patients compared to younger ones and age might be a factor in keeping the score down

Aims. Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. Methods. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. Results. Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days. Conclusion. COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival. Cite this article: Bone Joint J 2022;104-B(10):1156–1167

Aims

A number of anti-retroviral therapies (ART) have been implicated in potentially contributing to HIV-associated bone disease. The aim of this study was to evaluate the effect of combination ART on the fracture healing process.

Research into COVID-19 has been rapid in response to the dynamic global situation, which has resulted in heterogeneity of methodology and the communication of information. Adherence to reporting standards would improve the quality of evidence presented in future studies, and may ensure that findings could be interpreted in the context of the wider literature. The COVID-19 pandemic remains a dynamic situation, requiring continued assessment of the disease incidence and monitoring for the emergence of viral variants and their transmissibility, virulence, and susceptibility to vaccine-induced immunity. More work is needed to assess the long-term impact of COVID-19 infection on patients who sustain a hip fracture. The International Multicentre Project Auditing COVID-19 in Trauma & Orthopaedics (IMPACT) formed the largest multicentre collaborative audit conducted in orthopaedics in order to provide an emergency response to a global pandemic, but this was in the context of many vital established audit services being disrupted at an early stage, and it is crucial that these resources are protected during future health crises. Rapid data-sharing between regions should be developed, with wider adoption of the revised 2022 Fragility Fracture Network Minimum Common Data Set for Hip Fracture Audit, and a pragmatic approach to information governance processes in order to facilitate cooperation and meta-audit. This editorial aims to: 1) identify issues related to COVID-19 that require further research; 2) suggest reporting standards for studies of COVID-19 and other communicable diseases; 3) consider the requirement of new risk scores for hip fracture patients; and 4) present the lessons learned from IMPACT in order to inform future collaborative studies.

Cite this article: Bone Joint Res 2022;11(6):342–345.

Hip fracture principally affects the frailest in society, many of whom are care dependent, and are disproportionately at risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1st February 2019 and 31st October 2020, in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that amongst those with COVID-19 infection at presentation (n=1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.05 (95%CI 1.86–2.26), while for infections arising between 8–30 days after presentation (n=1,644) the figure was even higher at 2.52 (2.32–2.73). Malnutrition [1.44 (1.19–1.75)] and non-operative treatment [2.89 (2.16–3.86)] were the only modifiable risk factors for death in COVID-19 positive patients. Patients with previous COVID-19 initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1st January and 30th June 2020, 1,273 (99.7%CI 1,077–1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (20%–26%), with most deaths occurring within 30 days. COVID-19 infection more than doubled early hip fracture mortality; the first 30-days after injury were most critical, suggesting that targeted interventions in this period may have most benefit in improving survival

Aims. There is little published on the outcomes after restarting elective orthopaedic procedures following cessation of surgery due to the COVID-19 pandemic. During the pandemic, the reported perioperative mortality in patients who acquired SARS-CoV-2 infection while undergoing elective orthopaedic surgery was 18% to 20%. The aim of this study is to report the surgical outcomes, complications, and risk of developing COVID-19 in 2,316 consecutive patients who underwent elective orthopaedic surgery in the latter part of 2020 and comparing it to the same, pre-pandemic, period in 2019. Methods. A retrospective service evaluation of patients who underwent elective surgical procedures between 16 June 2020 and 12 December 2020 was undertaken. The number and type of cases, demographic details, American society of Anesthesiologists (ASA) grade, BMI, 30-day readmission rates, mortality, and complications at one- and six-week intervals were obtained and compared with patients who underwent surgery during the same six-month period in 2019. Results. A total of 2,316 patients underwent surgery in 2020 compared to 2,552 in the same period in 2019. There were no statistical differences in sex distribution, BMI, or ASA grade. The 30-day readmission rate and six-week validated complication rates were significantly lower for the 2020 patients compared to those in 2019 (p < 0.05). No deaths were reported at 30 days in the 2020 group as opposed to three in the 2019 group (p < 0.05). In 2020 one patient developed COVID-19 symptoms five days following foot and ankle surgery. This was possibly due to a family contact immediately following discharge from hospital, and the patient subsequently made a full recovery. Conclusion. Elective surgery was safely resumed following the cessation of operating during the COVID-19 pandemic in 2020. Strict adherence to protocols resulted in 2,316 elective surgical procedures being performed with lower complications, readmissions, and mortality compared to 2019. Furthermore, only one patient developed COVID-19 with no evidence that this was a direct result of undergoing surgery. Level of evidence: III. Cite this article: Bone Jt Open 2022;3(1):42–53

Abstract. Introduction. Minimising postoperative complications and mortality in COVID-19 patients who were undergoing trauma and orthopaedic surgeries is an international priority. Aim was to develop a predictive nomogram for 30-day morbidity/mortality of COVID-19 infection in patients who underwent orthopaedic and trauma surgery during the coronavirus pandemic in the UK in 2020 compared to a similar period in 2019. Secondary objective was to compare between patients with positive PCR test and those with negative test. Methods. Retrospective multi-center study including 50 hospitals. Patients with suspicion of SARS-CoV-2 infection who had underwent orthopaedic or trauma surgery for any indication during the 2020 pandemic were enrolled in the study (2525 patients). We analysed cases performed on orthopaedic and trauma operative lists in 2019 for comparison (4417). Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. Results. Of the 2525 patients admitted for suspicion of COVID-19, 658 patients had negative preoperative test, 151 with positive test and 1716 with unknown preoperative COVID-19 status. Preoperative COVID-19 status, sex, ASA grade, urgency and indication of surgery, use of torniquet, grade of operating surgeon and some comorbidities were independent risk factors associated with 30-day complications/mortality. The 2020 nomogram model exhibited moderate prediction ability. In contrast, the prediction ability of total points of 2019 nomogram model was excellent. Conclusions. Nomograms can be used by orthopaedic and trauma surgeons as a practical and effective tool in postoperative complications and mortality risk estimation

Aims

During the COVID-19 pandemic, drilling has been classified as an aerosol-generating procedure. However, there is limited evidence on the effects of bone drilling on splatter generation. Our aim was to quantify the effect of drilling on splatter generation within the orthopaedic operative setting.

A previously fit and well 58 year old male suffered from a bilateral psoas haematoma (PH) following 52 days of veno-venous extracorporeal membranous oxygenation (VV-ECMO) for severe Coronavirus disease (COVID-19), refractory to all non-invasive and medical therapies. He developed multiple complications, including inability to walk or weight-bear, due to lumbar plexopathy triggered by bilateral PH compression, compounded by COVID-19-related mononeuritis multiplex. The patient was referred to our institution with a known diagnosis of bilateral PH and after spinal multidisciplinary team (MDT) input, was deemed not for surgical or interventional radiology treatments. The patient received extensive neurorehabilitation, coordinated by multiple MDTs. Although PH has been correlated to COVID-19, to the best of our knowledge this is the first reported case of such a complex presentation resulting in a dramatic bilateral PH. Health records from 3 large UK teaching hospitals were collected regarding treatment and follow up appointments, following patient's written informed consent. Patient's comorbidities, duration in hospital units, MDT inputs, health assessments, mobilisation progress and neurologic assessments, were all recorded. Data was collected retrospectively then prospectively due to lengthy in-patient stay. The literature review was conducted via PubMed and open access sources, selecting all the relevant studies and the ECMO guidelines. Patient received treatment from 3 different units in 3 hospitals over 212 days including 103 days in neurorehabilitation. Involvement of physiotherapy, dietitians, speech and language teams, neurologist, neurophysiotherapists, occupational therapists was required. The patient progressed from a bed-bound coma and inability to walk, to standing with lower limb backslab at discharge. Additionally, he was referred for elective exploratory surgery of the psoas region for scar debridement and potential nerve graft repair of the lumbosacral plexus. The surgery outcome is cautiously optimistic, with some improvement in nerve conduction studies, however is currently unknown regarding recovery progress and return to premorbid functional baseline. The novelty of this presentation yields significant learning points regarding early recognition of PH, requirements for vast MDT input and specialist use of VV-ECMO in severe COVID-19 patients. It also highlights the broad pathophysiology of SARS-CoV-2 causing neuropathy and coagulopathy; understanding this will optimise robust anticoagulation guidelines, required in VV-ECMO

Aims

The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection.

Aims

The COVID-19 pandemic led to a swift adoption of telehealth in orthopaedic surgery. This study aimed to analyze the satisfaction of patients and surgeons with the rapid expansion of telehealth at this time within the division of adult reconstructive surgery at a major urban academic tertiary hospital.

Aims

It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site.

Aims. The COVID-19 pandemic posed significant challenges to healthcare systems across the globe in 2020. There were concerns surrounding early reports of increased mortality among patients undergoing emergency or non-urgent surgery. We report the morbidity and mortality in patients who underwent arthroplasty procedures during the UK first stage of the pandemic. Methods. Institutional review board approval was obtained for a review of prospectively collected data on consecutive patients who underwent arthroplasty procedures between March and May 2020 at a specialist orthopaedic centre in the UK. Data included diagnoses, comorbidities, BMI, American Society of Anesthesiologists grade, length of stay, and complications. The primary outcome was 30-day mortality and secondary outcomes were prevalence of SARS-CoV-2 infection, medical and surgical complications, and readmission within 30 days of discharge. The data collated were compared with series from the preceding three months. Results. There were 167 elective procedures performed in the first three weeks of the study period, prior to the first national lockdown, and 57 emergency procedures thereafter. Three patients (1.3%) were readmitted within 30 days of discharge. There was one death (0.45%) due to SARS-CoV-2 infection after an emergency procedure. None of the patients developed complications of SARS-CoV-2 infection after elective arthroplasty. There was no observed spike in complications during in-hospital stay or in the early postoperative period. There was no statistically significant difference in survival between pre-COVID-19 and peri-COVID-19 groups (p = 0.624). We observed a higher number of emergency procedures performed during the pandemic within our institute. Conclusion. An international cohort has reported 30-day mortality as 28.8% following orthopaedic procedures during the pandemic. There are currently no reports on clinical outcomes of patients treated with lower limb reconstructive surgery during the same period. While an effective vaccine is developed and widely accepted, it is very likely that SARS-CoV2 infection remains endemic. We believe that this report will help guide future restoration planning here in the UK and abroad. Cite this article: Bone Jt Open 2021;2(5):323–329

Aims

The primary aim was to determine the influence of COVID-19 on 30-day mortality following hip fracture. Secondary aims were to determine predictors of COVID-19 status on presentation and later in the admission; the rate of hospital acquired COVID-19; and the predictive value of negative swabs on admission.

The aims were: (1) assess the influence of COVID-19 on mortality in hip fracture; (2) identify predictors of COVID-19 status, and (3) investigate whether social lockdown influenced the epidemiology of hip fracture.

A multicentre retrospective study was conducted of all patients presenting to six hospitals with hip fracture over a 46-day period (23 days pre-/post-lockdown). Demographics, 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.

Of 317 patients with hip fracture 27 (8.5%) had a positive COVID-19 test; only 7 (26%) had symptoms on admission. COVID-19-positive patients had 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 adjusting for: (1) age, sex, residence (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). Platelet count predicted subsequent COVID-19 status; a value <217 ×109/L was 68% specific and sensitive (95% CI 58 to 77, p=0.002). A similar number of patients presented with hip fracture pre-lockdown (n=160) and post-lockdown (n=157); there was no significant difference in demographics, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management.

COVID-19 was independently associated with an increased 30-day mortality in hip fracture. Most patients with COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have urgent implications for the delivery of hip fracture services.