Aim. The coronavirus disease 2019 (COVID-19) pandemic presents significant challenges to healthcare systems globally. Orthopaedic surgeons are at risk of contracting COVID-19 due to their close contact with patients in both outpatient and theatre environments. The aim of this review was to perform a literature review, including articles of other coronaviruses, to formulate guidelines for orthopaedic healthcare staff. Methods. A search of Medline, EMBASE, the Cochrane Library, World Health Organization (WHO), and Centers for Disease Control and Prevention (CDC) databases was performed encompassing a variety of terms including ‘coronavirus’, ‘covid-19’, ‘orthopaedic’, ‘personal protective environment’ and ‘PPE’. Online database searches identified 354 articles. Articles were included if they studied any of the other coronaviruses or if the basic science could potentially applied to COVID-19 (i.e. use of an inactivated virus with a similar diameter to COVID-19). Two reviewers independently identified and screened articles based on the titles and abstracts. 274 were subsequently excluded, with 80 full-text articles retrieved and assessed for eligibility. Of these, 66 were excluded as they compared personal protection equipment to no personal protection equipment or referred to prevention measures in the context of bacterial infections. Results. There is a paucity of high quality evidence surrounding COVID-19. This review collates evidence from previous coronavirus outbreaks to put forward recommendations for orthopaedic surgeons during the COVID-19 pandemic. The key findings have been summarized and interpreted for application to the orthopaedic operative setting. Conclusion. For COVID-19 positive patients, minimum suggested PPE includes N95 respirator, goggles, face shield, gown, double gloves, and surgical balaclava. Space suits not advised. Be trained in the correct technique of donning and doffing PPE. Use negative pressure theatres if available. Minimize aerosolization and its effects (smoke evacuation and no pulse lavage). Minimize further unnecessary patient-staff contact (dissolvable sutures, clear dressings, split casts)

Aims

Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with ‘COVID’ and ‘COVID-free’ hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic.

The coronavirus pandemic has reduced the capability of Canadian hospitals to offer elective orthopaedic surgery requiring admission, despite ongoing and increasing demands for elective total hip and total knee arthroplasty surgery (THA and TKA). We sought to determine if the coronavirus pandemic resulted in more outpatient THA and TKA in Nova Scotia, and if so, what effect increased outpatient surgery had on 90 day post-operative readmission or Emergency Department/Family Doctor (FD) visits. The study cohort was constructed from hospital Discharge Abstract Data (DAD), inpatient admissions, and National Ambulatory Care Reporting System (NACRS) data, day surgery observations, using Canadian Classification of Health Intervention codes to select all primary hip and knee procedures from 2005-2020 in Nova Scotia. Emergency Department and General Practitioner visits were identified from the Physician Billings data and re-admissions from the DAD and NACRS. Rates were calculated by dividing the number of cases with any visit within 90 days after discharge. Chi-squared statistics at 95% confidence level used to test for statistical significance. Knee and hip procedures were modelled separately. There was a reduction in THA and TKA surgery in Nova Scotia during the coronavirus pandemic in 2020. Outpatient arthroplasty surgery in Nova Scotia in the years prior to 2020 were relatively stable. However, in 2020 there was a significant increase in the proportion and absolute number of outpatient THA and TKA. The proportion of THA increased from 1% in 2019 to 14% in 2020, while the proportion of TKA increased from 1% in 2019 to 11% in 2020. The absolute number of outpatient THA increased from 16 cases in 2019, to 163 cases in 2020. Outpatient TKA cases increased from 21 in 2019, to 173 in 2020. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED following TKA but not THA which was not statistically significant. For outpatient THA and TKA, there was a decrease in 90 day readmissions, and a statistically significant decrease in FD presentations. Outpatient THA and TKA increased significantly in 2020, likely due to the restrictions imposed during the coronavirus pandemic on elective Orthopaedic surgery requiring admission to hospital. The increase in outpatient surgery resulted in an increase in 90 day presentations to ED for TKA, and a decrease in 90 day readmissions and FD presentations for THA and TKA. Reducing the inpatient surgical burden may result in a post-operative burden on ED, but does not appear to have caused an increase in hospital readmission rates

Background. There remains a paucity of clinical studies on the effects of coronavirus on perioperative outcomes, with no existing trials reporting on risk factors associated with increased risk of postoperative mortality in these patients. The objectives of this study were to assess perioperative complications and identify risk factors for increased mortality in patients with coronavirus undergoing surgery. Methods. This multicentre cohort study included 340 coronavirus negative patients versus 82 coronavirus positive patients undergoing surgical treatment for neck of femur fractures across nine NHS hospitals within Greater London, United Kingdom. Predefined study outcomes relating to patient demographics, fracture configuration, operative treatment, perioperative complications and mortality were recorded by observers using a standardised data collection proforma. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. Findings. Coronavirus positive patients had increased risk of postoperative complications (89.0% vs 35.0%, p<0.001), higher rates of admission to high dependency and intensive care units (61.0% vs 18.2%, p<0.001), and increased length of hospital stay (13.8 ± 4.6 days vs 6.7 ± 2.5 days, p<0.001) compared to coronavirus negative patients. Postoperative complications in coronavirus positive patients included respiratory infections (13.4%), thromboembolic disease (13.4%), acute kidney injury (12.2%), and multi-organ dysfunction (12.2%). Coronavirus positive patients had increased risk of postoperative mortality (30.5% vs 10.3%, p<0.001) compared to coronavirus negative patients, with positive smoking status (Hazard ratio: 15.4 (95% CI: 4.55–52.2, p<0.001) and greater than three comorbidities (Hazard ratio: 13.5 (95% CI: 2.82–66.0, p<0.001) associated with increased risk of mortality. Interpretation. Surgery in coronavirus positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications and increased mortality compared to coronavirus negative patients. Multivariate analysis revealed that smoking and multiple pre-existing comorbidities were associated with increased risk of postoperative mortality

Aims. The aims of this meta-analysis were to assess: 1) the prevalence of coronavirus disease 2019 (COVID-19) in hip fracture patients; 2) the associated mortality rate and risk associated with COVID-19; 3) the patient demographics associated with COVID-19; 4) time of diagnosis; and 5) length of follow-up after diagnosis of COVID-19. Methods. Searches of PubMed, Medline, and Google Scholar were performed in October 2020 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Search terms included “hip”, “fracture”, and “COVID-19”. The criteria for inclusion were published clinical articles reporting the mortality rate associated with COVID-19 in hip fracture patients. In total, 53 articles were identified and following full text screening 28 articles satisfied the inclusion criteria. Results. A total of 28 studies reported the mortality of COVID-19-positive patients, of which 21 studies reported the prevalence of COVID-19-positive patients and compared the mortality rate to COVID-19-negative patients. The prevalence of COVID-19 was 13% (95% confidence interval (CI) 11% to 16%) and was associated with a crude mortality rate of 35% (95% CI 32% to 39%), which was a significantly increased risk compared to those patients without COVID-19 (odds ratio (OR) 7.11, 95% CI 5.04 to 10.04; p < 0.001). COVID-19-positive patients were more likely to be male (OR 1.51, 95% CI 1.16 to 1.96; p = 0.002). The duration of follow-up was reported in 20 (71.4%) studies. A total of 17 studies reported whether a patient presented with COVID-19 (n = 108 patients, 35.1%) or developed COVID-19 following admission (n = 200, 64.9%), of which six studies reported a mean time to diagnosis of post-admission COVID-19 at 15 days (2 to 25). Conclusion. The prevalence of COVID-19 was 13%, of which approximately one-third of patients were diagnosed on admission, and was associated with male sex. COVID-19-positive patients had a crude mortality rate of 35%, being seven times greater than those without COVID-19. Due to the heterogenicity of the reported data minimum reporting standards of outcomes associated with COVID-19 are suggested. Cite this article: Bone Joint Res 2020;9(12):873–883

Introduction. Patients undergoing complex limb reconstruction are often under immense physical, psychological and financial stress. We already provide psychological support within our unit. We have identified that patients struggle to obtain proper advice on the financial support to which they are entitled. In September 2019, . rebuildcharity.org. commissioned a Citizens Advice Clinic. One advisor from the local Citizens Advice staffs the clinic. Currently we have no set criteria for referral and patients can be referred by any member of the limb reconstruction team. Although severely affected by the coronavirus pandemic and the disruption of all routine work we were able to run clinics from September 2019 to March 2020 and September 2020 to January 2021. We present our initial results. Materials and Methods. In total 19 patients (68% male) have been seen. There have been 58 clinic appointments which have been a combination of face to face and virtual. The majority (80%) of issues dealt with relate to benefits – including claiming tax credits, universal credits and Personal Independence Payments. Other issues include housing problems, employment and claiming for travel and transport. Results. Through the advice given our cohort of patients have been able to claim back £51,175 in total. The cost for the charity is £11,000 per annum based on one clinic per week. Patient satisfaction is high with 100% expressing satisfaction with the service and reporting decrease levels of stress. 100% of patients are better able to pay for essential bills and 50% to pay for their travel to hospital. Conclusions. Our study identified the difficulties our patients have negotiating the complexities of the benefit system and how Citizens Advice can help. This project is in its early days with an initial slow uptake and then severely affected by the coronavirus pandemic such that no clinics were held for 6 months. Despite this our early results are promising

There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well. A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions

Abstract. Introduction. A spotlight has been placed upon virtual assessment of patients during the coronavirus pandemic. This has been particularly prevalent in the assessment of acute knee injuries. In this study we aim to assess the accuracy of telephone triage, confirmed by Magnetic Resonance Imaging (MRI) in the diagnosis of acute knee injuries. Methods. Case records of patients triaged by telephone in the acute knee clinic at Leeds General Infirmary were analysed. Provisional diagnoses made following telephone triage were compared to radiological diagnoses made on subsequent MRI scans. Diagnostic accuracy was compared between those patients assessed virtually and those assessed in face-to-face clinics. Results. 1160 patients were referred to the acute knee injury clinic during the study period. 587 of these were triaged telephonically. MRI scans were requested for 107 (18%) virtually reviewed patients. Of these patients, 92 (79%) had an MRI scan requested after making a provisional diagnosis over the phone. Of the MRI requests made after virtual consultation, there was a 75% diagnostic accuracy of the pre-imaging diagnosis. Of the patients seen in face-to-face appointments, a diagnostic accuracy of 73% was observed. Conclusion. Virtual assessment can provide an efficient and cost-effective establishment of diagnosis of acute knee injuries whilst reducing hospital attendance. A combination of virtual and in-person clinics may allow quicker access to specialist opinion and therefore reduce patient waiting times

Aims. The primary aim of this study was to assess the independent association of the coronavirus disease 2019 (COVID-19) on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period. Methods. A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1 March 2020 to 19 April 2020) with a minimum of 50 days follow-up. Patient demographics, American Society of Anesthesiologists (ASA) grade, priority (urgent or elective), procedure type, COVID-19 status, and postoperative mortality were recorded. Results. During the study period, 1,659 procedures were performed in 1,569 patients. There were 68 (4.3%) patients who were diagnosed with COVID-19. There were 85 (5.4%) deaths postoperatively. Patients who had COVID-19 had a significantly lower survival rate when compared with those without a proven SARS-CoV-2 infection (67.6% vs 95.8%, p < 0.001). When adjusting for confounding variables (older age (p < 0.001), female sex (p = 0.004), hip fracture (p = 0.003), and increasing ASA grade (p < 0.001)) a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, 95% confidence interval (CI) 1.14 to 3.12; p = 0.014). A total of 62 patients developed COVID-19 postoperatively, of which two were in the elective and 60 were in the urgent group. Patients aged > 77 years (odds ratio (OR) 3.16; p = 0.001), with increasing ASA grade (OR 2.74; p < 0.001), sustaining a hip (OR 4.56; p = 0.008) or periprosthetic fracture (OR 14.70; p < 0.001) were more likely to develop COVID-19 postoperatively. Conclusion. Perioperative COVID-19 nearly doubled the background postoperative mortality risk following surgery. Patients at risk of developing COVID-19 postoperatively (patients > 77 years, increasing morbidity, sustaining a hip or periprosthetic fracture) may benefit from perioperative shielding. Cite this article: Bone Joint J 2020;102-B(12):1774–1781

Aims. The primary aim was to assess the rate of patient deferral of elective orthopaedic surgery and whether this changed with time during the coronavirus disease 2019 (COVID-19) pandemic. The secondary aim was to explore the reasons why patients wanted to defer surgery and what measures/circumstances would enable them to go forward with surgery. Methods. Patients were randomly selected from elective orthopaedic waiting lists at three centres in the UK in April, June, August, and September 2020 and were contacted by telephone. Patients were asked whether they wanted to proceed or defer surgery. Patients who wished to defer were asked seven questions relating to potential barriers to proceeding with surgery and were asked whether there were measures/circumstances that would allow them to go forward with surgery. Results. There was a significant decline in the rate of deferral for surgery from April (n = 38/50, 76%), June (n = 68/233, 29%), to August (n = 6/50, 12%) and September (n = 5/100, 5%) (p < 0.001). Patients wishing to defer were older (68 years (SD 10.1) vs 65 (SD 11.9)), more likely to be female (65% (44/68) vs 53% (88/165)) and waiting for a knee arthroplasty (65% (44/68) vs 41% (67/165); p < 0.001). By September 2020, all patients that deferred in June at one centre had proceeded or wanted to proceed with surgery due to a perceived lower risk of acquiring COVID-19 perioperatively (68%, n = 15) or because their symptoms had progressed (32%, n = 7). The most common reason (n = 14/17, 82%) for patients deferring surgery in September was the perceived risk of acquiring COVID-19 while as an inpatient. When asked what measures or circumstances would enable them to proceed with surgery, the most common (n = 7, 41%) response was reassurance of a COVID-19 free hospital. Conclusion. The rate of deferral fell to 5% by September, which was due to a lower perceived risk of contracting COVID-19 perioperatively or worsening of symptoms while waiting. The potential of a COVID-19-free hospital and communication of mortality risk may improve a patient’s willingness to go forward with surgery. Cite this article: Bone Joint Open 2020;1-10:663–668

With the coronavirus disease 2019 (COVID-19) pandemic, remote working has been ubiquitously implemented to reduce disease transmission via minimization of in-person interactions. Low back pain (LBP) is the first cause of disability worldwide and is frequently reported by workers with sedentary occupations. This cross-sectional study aimed to assess the role of remote working in a population of adults affected by LBP through an online questionnaire. We enrolled 136 teleworkers affected by LBP. A total of 101 responses were received and 93 suitable questionnaires were included in the final analysis. Demographic data, remote working features and tasks, and LBP burden were analysed. The psychological burden of remote working was evaluated with the World Health Organization Five Well-Being Index (WHO-5) and the Patient Health Questionnaire-2 (PHQ-2). LBP severity was evaluated using a visual analog scale (VAS). LBP-related disability was assessed using the Oswestry Disability Index (ODI). The effect of LBP on working capacity was examined with the Occupational Role Questionnaire (ORQ). Independent risk factors related to LBP worsening were identified using a multivariate logistic regression model. LBP severity was significantly higher compared to previous in-person working (p<0.0001) as well as average weekly work hours (p<0.001). Furthermore, the risk of LBP deterioration was associated with being divorced (OR: 4.28, 95% CI: 1.27-14.47; p=0.019) or living with others (OR: 0.24, 95% CI: 0.07-0.81; p=0.021), higher ill-being (OR: 0.91, 95% CI: 0.83-0.99; p=0.035) and depression scores (OR: 1.38, 95% CI: 1.00-1.91; p=0.048), as well as having reported unchanged (OR: 0.22, 95% CI: 0.08-0.65; p=0.006) or decreased job satisfaction (OR: 0.16, 95% CI: 0.05-0.54; p=0.003) and increased stress levels (OR: 3.00, 95% CI: 1.04-8.65; p=0.042). These findings highlight key factors to consider for improving remote workers’ physical and mental wellbeing and decrease their LBP burden

Aims. A systematic literature review focusing on how long before surgery concurrent viral or bacterial infections (respiratory and urinary infections) should be treated in hip fracture patients, and if there is evidence for delaying this surgery. Methods. A total of 11 databases were examined using the COre, Standard, Ideal (COSI) protocol. Bibliographic searches (no chronological or linguistic restriction) were conducted using, among other methods, the Patient, Intervention, Comparison, Outcome (PICO) template. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for flow diagram and checklist. Final reading of the complete texts was conducted in English, French, and Spanish. Classification of papers was completed within five levels of evidence (LE). Results. There were a total of 621 hits (526 COre; 95 Standard, Ideal) for screening identification, and 107 records were screened. Overall 67 full-text articles were assessed for eligibility, and 21 articles were included for the study question. A total of 46 full-text articles were excluded with reasons. No studies could be included in quantitative synthesis (meta-analyses), and there were many confounding variables including surgeons’ experience, prosthesis models used, and surgical technique. Conclusion. Patients with hip fracture and with a viral infection in the upper respiratory tract or without major clinical symptoms should be operated on as soon as possible (LE: I-III). There is no evidence that patients with coronavirus disease 2019 (COVID-19) should be treated differently. In relation to pneumonia, its prevention is a major issue. Antibiotics should be administered if surgery is delayed by > 72 hours or if bacterial infection is present in the lower respiratory tract (LE: III-V). In patients with hip fracture and urinary tract infection (UTI), delaying surgery may provoke further complications (LE: I). However, diabetic or immunocompromised patients may benefit from immediate antibiotic treatment. Cite this article: Bone Joint Res 2020;9(12):884–893

Aims. The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway. Methods. The probability of SARS-CoV-2 infection with a false negative test was calculated using a lower-end RT-PCR sensitivity of 71%, specificity of 95%, and the UK disease prevalence of 0.24% reported in May 2020. Subsequently, a case fatality rate of 20.5% was applied as a worst-case scenario. Results. The probability of SARS-CoV-2 infection with a false negative preoperative test was 0.07% (around 1 in 1,400). The risk of a patient with an undetected infection being admitted for surgery and subsequently dying from the coronavirus disease 2019 (COVID-19) is estimated at approximately 1 in 7,000. However, if an estimate of the current global infection fatality rate (1.04%) is applied, the risk of death would be around 1 in 140,000, at most. This calculation does not take into account the risk of nosocomial infection. Conversely, it does not factor in that patients will also be clinically assessed and asked to self-isolate prior to surgery. Conclusion. Our estimation suggests that the risk of patients being inadvertently admitted with an undetected SARS-CoV-2 infection for elective orthopaedic surgery is relatively low. Accordingly, the risk of death following elective orthopaedic surgery is low, even when applying the worst-case fatality rate. Cite this article: Bone Joint J 2020;102-B(9):1256–1260

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

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period. Cite this article: Bone Joint Open 2020;1-6:222–228

Aims. The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a 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. Methods. A 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, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. Results. Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; 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 × 10. 9. /l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. Conclusion. COVID-19 was independently associated with an increased 30-day mortality rate for patients with a 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 fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219–1228

Introduction and Objective. The coronavirus (Covid-19) pandemic, first identified in China in December 2019, halted daily living with mandatory lockdowns imposed in Israel in March 2020. This halt induced a sedentary lifestyle for most citizens as well as a decreased physical activity time. These are both common risk factors for the development of low back pain (LBP) which is considered a major global medical and economical challenge effecting almost 1 in 3 people and a leading cause of Emergency Department (ED) visits. It is hypothesized that prevalence of minor LBP episodes during the first total lockdown should have increased compared to previous times. However, due to “Covid-19 fear” we expect a decrease in ED visits. We also speculate that rate of visits due to serious spinal illness (causing either immediate hospitalization or spinal surgery within 30-days of presentation) did not change. Materials and Methods. Retrospective study based on patients visiting the ED in Tel Aviv Sourasky Medical Center During the first pandemic stage in 2020 compared to parallel periods in 2018 and 2019 due to LBP. Results. During the first lockdown period on March 11th-April 21st, only 171 patients attended the ED due to non-traumatic LBP compared to more than 330 patients in the corresponding time during the years 2018 and 2019. This represents a statistically significant drop of 52.5% (p-value < 0.01) and 48.7% (p-value < 0.01) in LBP ED visits during the first pandemic lockdown of 2020 compared to 2019 and 2018, respectively. Additionally, there was no significant drop in immediate hospitalization or spine surgeries within 30 days following the ED visit (p-value >0.10 for all analysis types). Conclusions. “Covid-19 fear” was probably the main reason for patients with an LBP episode to stay at home during the Covid-19 massive outbreak. Since no significant change was shown in the more severe cases, it seems that the minor LBP patients were able to contain the episode outside hospital walls. This presents an opportunity for clinicians and policy decisions makers to learn and find ways to improve our care of back pain in the community and to reduce unnecessary burden on EDs and the healthcare system

The coronavirus 2019 (COVID-19) global pandemic has had a significant impact on trauma and orthopaedic (T&O) departments worldwide. To manage the peak of the epidemic, orthopaedic staff were redeployed to frontline medical care; these roles included managing minor injury units, forming a “proning” team, and assisting in the intensive care unit (ICU). In addition, outpatient clinics were restructured to facilitate virtual consultations, elective procedures were cancelled, and inpatient hospital admissions minimized to reduce nosocomial COVID-19 infections. Urgent operations for fractures, infection and tumours went ahead but required strict planning to ensure patient safety. Orthopaedic training has also been significantly impacted during this period. This article discusses the impact of COVID-19 on T&O in the UK and highlights key lessons learned that may help to proactively prepare for the next global pandemic. Cite this article: Bone Joint Open 2020;1-7:420–423

Abstract. Objectives. Our objective was to determine the incidence of post-operative COVID-19 infection within the first two weeks following treatment at the COVID-free site. During the COVID-19 pandemic our hospital saw one of the highest rates of COVID-19 infection in the United Kingdom. As a result, our trauma services were relocated to a vacant private elective hospital to provide a ‘COVID-free’ setting for trauma patients. Patients admitted to the COVID-free site were screened for coronavirus infection and only treated at that site if asymptomatic. Those with symptoms were treated at the ‘COVID’ site. Method. We collected data at the COVID-free site during the first seven weeks of its’ establishment. Inclusion criteria were all patients presenting for operative management of limb trauma; however, fragility hip fractures were excluded. All patients were screened for symptoms of COVID-19 infection at their 2-week follow-up appointment. Results. 72 patients presented to our service during the study period. The mean age was 34.9 years (21 to 89). 62 patients had general anaesthesia (86%), 7 patients had regional anaesthesia (10%) and 3 patients had local anaesthesia (4%). One asymptotic patient who was swabbed for COVID-19 on admission returned a positive result. This patient had contracted the infection before surgery and was excluded from further analysis. 71 patients (100%) remained asymptomatic at follow-up and none had required medical attention for suspected COVID-19 infection. Conclusion. A ‘COVID-free’ trauma service was established in a private elective hospital during the pandemic. None of the patients undergoing urgent trauma surgery in this setting developed COVID-19 symptoms as a result of their hospital admission. Establishing a separate site with screening to avoid admission of patients with COVID-19 infection can allow safe emergency surgery. This data can support informed consent and reassure patients of their risks when we resume day case and elective surgery. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Elective surgery elicits a systemic immune response and may result in immunosuppression in certain patients. It is currently unknown whether patients are at an increased risk for viral infection and associated illness in the immediate postoperative period following total joint arthroplasty. This question has become more important given the ongoing coronavirus disease 2019 (COVID-19) pandemic. Methods. We analyzed 3 large administrative datasets (Medicare 5% and 100% standard analytic files, Humana claims database) to identify patients who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) from 2005 to 2013. The influenza vaccination status of each patient was defined using the presence or absence of a code for vaccination. The incidence of a flu diagnosis was recorded in both vaccinated and unvaccinated patients at 1 month, 3 months, and 6 months following the date of surgery and was compared to a cohort of vaccinated patients who did not undergo surgery. Results. The incidence of postoperative influenza diagnoses codes in TKA and THA patients were similar to that of vaccinated patients who did not undergo TJA at all time points. The results were largely consistent across all three datasets. Conclusion. Large administrative databases fail to show an increased incidence of influenza codes in patients who have recently undergone total joint arthroplasty. While the lack of signal is reassuring and provides evidence, these findings are limited by the nature of large administrative datasets and the accuracy of coding for influenza. Further studies will be necessary to fully understand an individual patient's postoperative risk for contracting a viral illness