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Trauma

IMPACT-Scot report on COVID-19 and hip fractures

a multicentre study assessing mortality, predictors of early SARS-CoV-2 infection, and the effects of social lockdown on epidemiology



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Abstract

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 × 109/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.


Correspondence should be sent to Andrew J. Hall. E-mail:
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Jonathan Antrobus (Department of Anaesthetics, NHS Borders & Scottish Hip Fracture Audit); Stuart Baird (Public Health Scotland); James A Ballantyne (Department of Orthopaedics & Trauma, Victoria Hospital Kirkcaldy, NHS Fife); Jean Bell (Department of Orthopaedics & Trauma, Dumfries & Galloway Royal Infirmary, NHS Dumfries & Galloway); Caitlin Brennan (Department of Orthopaedics & Trauma, Royal Infirmary of Edinburgh, NHS Lothian); Lucy Campbell (Department of Orthopaedics & Trauma, University Hospital Ayr, NHS Ayrshire & Arran); Carol Carnegie (Department of Orthopaedics & Trauma, NHS Grampian); Alastair W Murray (Department of Orthopaedics & Trauma, NHS Lanarkshire & Scottish Committee for Orthopaedics & Trauma); James T Patton (Department of Orthopaedics & Trauma, Royal Infirmary of Edinburgh, NHS Lothian); Matilda Powell-Bowns (Department of Orthopaedics & Trauma, Royal Infirmary of Edinburgh, NHS Lothian); Dylan Jun Hao Tan (Department of Orthopaedics & Trauma, University Hospital Ayr, NHS Ayrshire & Arran); Thisara Weerasuriya (Department of Orthopaedics & Trauma, University Hospital Ayr, NHS Ayrshire & Arran); Janet Wood (Department of Orthopaedics & Trauma, Victoria Hospital Kirkcaldy, NHS Fife).


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