Effect of COVID-19 on a rural orthopaedic hip fracture service

Aims Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures. Methods We reviewed our prospectively maintained trust database and National Hip Fracture Database records for the months of March and April between the years 2016 and 2020. Our assessment included fracture pattern (intrascapular vs extracapsular hip fracture), treatment intervention, length of stay and mortality. Results We treated 288 patients during March and April between 2016 and 2020, with a breakdown of 55, 58, 53, 68, and 54 from 2016 to 2020 respectively. Fracture pattern distribution in the pre-COVID-19 years of 2016 to 2019 was 58% intracapsular and 42% extracapsular. In 2020 (COVID-19 period) the fracture patterns were 65% intracapsular and 35% extracapsular. Our mean length of stay was 13.1 days (SD 8.2) between 2016 to 2019, and 5.0 days (6.3) days in 2020 (p < 0.001). Between 2016 and 2019 we had three deaths in hip fracture patients, and one death in 2020. Hemiarthroplasty and dynamic hip screw fixation have been the mainstay of operative intervention across the five years and this has continued in the COVID-19 period. We have experienced a rise in conservatively managed patients; ten in 2020 compared to 14 over the previous four years. Conclusion There has not been a reduction in the number of hip fractures during COVID-19 period compared to the same time period over previous years. In our experience, there has been an increase in conservative treatment and decreased length of stay during the COVID -19 period. Cite this article: Bone Joint Open 2020;1-8:500–507.

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The impact of COVID-19 infection on hip fracture 30-day mortality

Trauma ◽

10.1177/1460408620949725 ◽

2021 ◽

pp. 146040862094972

Author(s):

Ahmed Fadulelmola ◽

Rob Gregory ◽

Gavin Gordon ◽

Fiona Smith ◽

Andrew Jennings

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Hospital Admissions ◽

The Elderly ◽

Primary Outcome Measure ◽

Time To Death ◽

Significant Difference ◽

The Mean ◽

The Impact ◽

Mean Time

Introduction: A novel virus, SARS-CoV-2, has caused a fatal global pandemic which particularly affects the elderly and those with comorbidities. Hip fractures affect elderly populations, necessitate hospital admissions and place this group at particular risk from COVID-19 infection. This study investigates the effect of COVID-19 infection on 30-day hip fracture mortality. Method: Data related to 75 adult hip fractures admitted to two units during March and April 2020 were reviewed. The mean age was 83.5 years (range 65–98 years), and most (53, 70.7%) were women. The primary outcome measure was 30-day mortality associated with COVID-19 infection. Results: The COVID-19 infection rate was 26.7% (20 patients), with a significant difference in the 30-day mortality rate in the COVID-19-positive group (10/20, 50%) compared to the COVID-19-negative group (4/55, 7.3%), with mean time to death of 19.8 days (95% confidence interval: 17.0–22.5). The mean time from admission to surgery was 43.1 h and 38.3 h, in COVID-19-positive and COVID-19-negative groups, respectively. All COVID-19-positive patients had shown symptoms of fever and cough, and all 10 cases who died were hypoxic. Seven (35%) cases had radiological lung findings consistent of viral pneumonitis which resulted in mortality (70% of mortality). 30% ( n = 6) contracted the COVID-19 infection in the community, and 70% ( n = 14) developed symptoms after hospital admission. Conclusion: Hip fractures associated with COVID-19 infection have a high 30-day mortality. COVID-19 testing and chest X-ray for patients presenting with hip fractures help in early planning of high-risk surgeries and allow counselling of the patients and family using realistic prognosis.

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Design and biomechanical study of slide-poking external fixator for hip fracture

Journal of International Medical Research ◽

10.1177/0300060520950934 ◽

2020 ◽

Vol 48 (12) ◽

pp. 030006052095093

Author(s):

Hua-Biao Chen ◽

Hong-Bo Wu ◽

Min Chen ◽

Yu-Liang Huang

Keyword(s):

Hip Fracture ◽

Femoral Head ◽

Hip Fractures ◽

External Fixator ◽

Dynamic Hip Screw ◽

Control Groups ◽

Vertical Loading ◽

Hip Screw ◽

The Mean ◽

And Control

Background Femoral head collapse and coxa vara lead to internal fixator failure in elderly patients with hip fracture. External fixator application is an optimal choice; however, the existing methods have many disadvantages. Methods Type 31-A1.3 hip fracture models were developed in nine pairs of 1-year-old fresh bovine corpse femur specimens. Each left femur specimen was fixed by a dynamic hip screw (control group), and each right femur specimen was fixed by the slide-poking external fixator (experimental group). Vertical loading and torsion tests were then performed in both groups. Results In the vertical loading experiment, a 1000-N load was implemented. The mean vertical downward displacement of the femoral head in the experimental and control groups was 1.49322 ± 0.116280 and 2.13656 ± 0.166374 mm, respectively. In the torsion experiment, when the torsion was increased to 10.0 Nm, the mean torsion angle in the experimental and control groups was 7.9733° ± 1.65704° and 15.4889° ± 0.73228°, respectively. The slide-poking external fixator was significantly more resistant to compression and rotation than the dynamic hip screw. Conclusion The slide-poking external fixator for hip fractures that was designed and developed in this study can provide sufficient stability to resist compression and rotation in hip fractures.

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Meta-analysis and metaregression of risk factors associated with mortality in hip fracture patients during the COVID-19 pandemic

Scientific Reports ◽

10.1038/s41598-021-89617-2 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Firas J. Raheman ◽

Djamila M. Rojoa ◽

Jvalant Nayan Parekh ◽

Reshid Berber ◽

Robert Ashford

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Case Fatality Rate ◽

Excess Mortality ◽

Meta Analysis ◽

Case Fatality ◽

Pooled Analysis ◽

Fatality Rate ◽

Increased Risk ◽

The Impact

AbstractIncidence of hip fractures has remained unchanged during the pandemic with overlapping vulnerabilities observed in patients with hip fractures and those infected with COVID-19. We aimed to investigate the independent impact of COVID-19 infection on the mortality of these patients. Healthcare databases were systematically searched over 2-weeks from 1st–14th November 2020 to identify eligible studies assessing the impact of COVID-19 on hip fracture patients. Meta-analysis of proportion was performed to obtain pooled values of prevalence, incidence and case fatality rate of hip fracture patients with COVID-19 infection. 30-day mortality, excess mortality and all-cause mortality were analysed using a mixed-effects model. 22 studies reporting 4015 patients were identified out of which 2651 (66%) were assessed during the pandemic. An excess mortality of 10% was seen for hip fractures treated during the pandemic (OR 2.00, p = 0.007), in comparison to the pre-pandemic controls (5%). Estimated mortality of COVID-19 positive hip fracture patients was four-fold (RR 4.59, p < 0.0001) and 30-day mortality was 38.0% (HR 4.73, p < 0.0001). The case fatality rate for COVID-19 positive patients was 34.74%. Between-study heterogeneity for the pooled analysis was minimal (I2 = 0.00) whereas, random effects metaregression identified subgroup heterogeneity for male gender (p < 0.001), diabetes (p = 0.002), dementia (p = 0.001) and extracapsular fractures (p = 0.01) increased risk of mortality in COVID-19 positive patients.

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The independent patient factors that affect length of stay following hip fractures

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2018.0068 ◽

2018 ◽

Vol 100 (7) ◽

pp. 556-562 ◽

Cited By ~ 4

Author(s):

T Richards ◽

A Glendenning ◽

D Benson ◽

S Alexander ◽

S Thati

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Hospital Stay ◽

Hip Fractures ◽

Length Of Hospital Stay ◽

Hospital Length ◽

Acute Hospital ◽

Hospital Length Of Stay ◽

Patient Factors ◽

Mobility Status

Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.

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Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151458517722104 ◽

2017 ◽

Vol 8 (3) ◽

pp. 161-165 ◽

Cited By ~ 6

Author(s):

Alastair G. Dick ◽

Dominic Davenport ◽

Mohit Bansal ◽

Therese S. Burch ◽

Max R. Edwards

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Hip Fractures ◽

District General Hospital ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Retrospective Case ◽

Time To Surgery ◽

Surgery Mortality ◽

Hospital Acquired

Introduction: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. Methods: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. Results: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. Conclusion: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.

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Body Anthropometry and Bone Strength Conjointly Determine the Risk of Hip Fracture in a Sideways Fall

Annals of Biomedical Engineering ◽

10.1007/s10439-020-02682-y ◽

2020 ◽

Author(s):

Marco Palanca ◽

Egon Perilli ◽

Saulo Martelli

Keyword(s):

Hip Fracture ◽

Bone Strength ◽

Impact Energy ◽

Fracture Pattern ◽

Bone Morphology ◽

Fracture Dynamics ◽

Soft Tissue Thickness ◽

Definition Of ◽

The Impact ◽

Sideways Fall

AbstractWe hypothesize that variations of body anthropometry, conjointly with the bone strength, determine the risk of hip fracture. To test the hypothesis, we compared, in a simulated sideways fall, the hip impact energy to the energy needed to fracture the femur. Ten femurs from elderly donors were tested using a novel drop-tower protocol for replicating the hip fracture dynamics during a fall on the side. The impact energy was varied for each femur according to the donor’s body weight, height and soft-tissue thickness, by adjusting the drop height and mass. The fracture pattern, force, energy, strain in the superior femoral neck, bone morphology and microarchitecture were evaluated. Fracture patterns were consistent with clinically relevant hip fractures, and the superior neck strains and timings were comparable with the literature. The hip impact energy (11 – 95 J) and the fracture energy (11 – 39 J) ranges overlapped and showed comparable variance (CV = 69 and 61%, respectively). The aBMD-based definition of osteoporosis correctly classified 7 (70%) fracture/non-fracture cases. The incorrectly classified cases presented large impact energy variations, morphology variations and large subcortical voids as seen in microcomputed tomography. In conclusion, the risk of osteoporotic hip fracture in a sideways fall depends on both body anthropometry and bone strength.

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Az ellenoldali csípőtáji törésig eltelt időt befolyásoló prognosztikai tényezők vizsgálata

Orvosi Hetilap ◽

10.1556/650.2018.31179 ◽

2018 ◽

Vol 159 (38) ◽

pp. 1543-1547

Author(s):

Krisztina Juhász ◽

Imre Boncz ◽

Péter Kanizsai ◽

Andor Sebestyén

Keyword(s):

Risk Factors ◽

Prognostic Factors ◽

Hip Fracture ◽

Femoral Neck ◽

Femoral Neck Fracture ◽

Hip Fractures ◽

Age Groups ◽

Significant Difference ◽

Neck Fracture ◽

The Impact

Abstract: Introduction: Although several national studies reported on the risk factors for contralateral hip fracture, there are no data about the prognostic factors of the time until contralateral hip fractures. Aim: The aim of the study was to analyse the impact of different prognostic factors on the time until the development of contralateral fracture and to determine the incidence of contralateral hip fractures after femoral neck fractures. Method: Patients aged 60 years and over with contralateral hip fracture between 01 Jan 2000 and 31 Dec 2008 were identified among those who suffered their femoral neck fracture in Hungary in 2000. Risk factors as age, sex, comorbidities, type of fracture and surgery, place of living and hospitals providing treatment for primary fracture were analysed by one way ANOVA focusing on the time until the development of contralateral hip fracture. Results: 312 patients met the inclusion criteria. The incidence of contralateral hip fracture after femoral neck fracture ranged between 1.5% and 2.1%, the cumulative incidence was 8.24%. The mean time until the development of contralateral hip fracture was 1159.8 days. The incidence of contralateral hip fracture showed no significant deviation. Significantly shorter time (p = 0.010) was detected until the contralateral hip fracture in older patients with femoral neck fracture. Conclusions: The yearly incidence of contralateral hip fracture showed no significant difference by patients with femoral neck fracture over 60 years. The shorter time until the contralateral hip fracture by the older age groups highlights the need of elaboration of prevention strategies. Orv Hetil. 2018; 159(38): 1543–1547.

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Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459318806443 ◽

2018 ◽

Vol 9 ◽

pp. 215145931880644 ◽

Cited By ~ 6

Author(s):

Ján Dixon ◽

Fiona Ashton ◽

Paul Baker ◽

Karl Charlton ◽

Charlotte Bates ◽

...

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Pain Control ◽

Patient Comfort ◽

Central Feature ◽

Significant Finding ◽

Early Management ◽

Intravenous Paracetamol ◽

Number Of Patients ◽

The Impact

Introduction: As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented. Materials and Methods: Systematic review of preoperative IVP administration in patients presenting with a hip fracture. Results: Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia. Discussion: The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.

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The Benefits of Streamlined Hip Fracture Management in a Regional Hospital

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151458516689284 ◽

2017 ◽

Vol 8 (2) ◽

pp. 99-103 ◽

Cited By ~ 3

Author(s):

T. C. Mow ◽

Jen Lukeis ◽

A. G. Sutherland

Keyword(s):

Surgical Treatment ◽

Hip Fracture ◽

Hip Fractures ◽

Performance Indicator ◽

Cost Benefit ◽

Standard Of Care ◽

Regional Hospital ◽

Time To Surgery ◽

Fracture Management ◽

The Impact

Introduction: Hip fracture is an increasingly common injury in the growing elderly population. The morbidity and mortality associated with this injury can be reduced by minimizing delays to surgical treatment. We describe the impact of a regional hospital service redesign project that utilized the principles of smart simplicity, a management strategy that lays emphasis on collaboration to achieve desired goals. Methods: Prior to the redesign, patients with hip fractures were taking an average of 72 hours for surgical treatment. A hip fracture working group was created to examine closely the process of hip fracture care, and a single key performance indicator (KPI) of “surgery within 48 hours” was adopted. This allowed identification of processes that could be clarified and streamlined, with the agreement of relevant stakeholders, in the creation of a new hip fracture pathway. Results: In the first 3 months of the pathway’s implementation, 16 of 18 patients had surgery within 48 hours of presentation. In a 6-month follow-up audit after 2 years of implementation, 36 of 39 patients were treated within 48 hours. This was significantly different to the time to surgery seen in the 12 months prior to the redesign ( P < .001, Student t test). The mean time to surgery was reduced from 72 hours to 36 hours, a saving in an annual acute bed stay cost of A$152 000. Discussion: Decreased time to the operating room, the cost savings inherent to this, can be achieved with the introduction of the best standard of care. A redesign that mandates collaboration in achieving a single KPI has allowed a significant culture shift in the treatment of hip fractures in our institution in the months following its institution. Conclusion: Collaborative, multidisciplinary collaboration has facilitated a higher standard of care and demonstrated significant cost benefit.

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Impact of Comorbidities on Length of Stay and Mortality in Hospitalized Patients with Cancer and Febrile Neutropenia

Blood ◽

10.1182/blood.v124.21.2601.2601 ◽

2014 ◽

Vol 124 (21) ◽

pp. 2601-2601 ◽

Cited By ~ 3

Author(s):

Eva Culakova ◽

Marek S. Poniewierski ◽

Jeffrey Crawford ◽

David C. Dale ◽

Gary H. Lyman

Keyword(s):

Length Of Stay ◽

Hospital Mortality ◽

Research Funding ◽

Infectious Complications ◽

Hospitalized Patients ◽

Cancer Type ◽

Patients With Cancer ◽

Time Period ◽

Increased Risk ◽

The Impact

Background: Hematologic toxicities are common side effects of cancer chemotherapy. Despite advances in supportive care, febrile neutropenia (FN) continues to represent a serious adverse event often requiring hospitalization and is associated with an increased risk of mortality. The purpose of this analysis was to investigate the impact of comorbidities and infectious complications on in-patient length of stay (LOS) and mortality in hospitalized patients with cancer and neutropenia over the past decade. Methods: Hospitalization data from the University Health Consortium database inclusive of the years 2004-2012 from 239 US medical centers were analyzed. Cancer type, presence of neutropenia, comorbidities, and infection type were based on ICD-9-CM codes recorded during hospitalization. This analysis includes adult patients with malignant disease and neutropenia. Patients undergoing bone marrow or stem cell transplantation were excluded. For patients with multiple hospitalizations, the first admission during the time period studied was utilized. Primary study outcomes included hospital length of stay (LOS≥10 days) and in-hospital mortality. Multivariate logistic regression analysis was utilized to study the impact of major comorbidities on the primary outcomes. Major comorbidities under consideration included heart, liver, lung, renal, cerebrovascular, peripheral-vascular disease, diabetes and venous thromboembolism. Results: Among 135,309 patients with cancer hospitalized with neutropenic events, one-third were age 65 years or older and 51% were male. Approximately one-quarter (24.5%) of patients experienced more than one admission with FN. The mean (median) length of stay increased progressively from 11.1 (6) days in 2004 to 12.8 (7) days in 2012. Patients with leukemia, lymphoma and central nervous system (CNS) malignancies experienced the longest mean LOS (21.4, 10.5, 10.2 days, respectively). Overall, 50,846 (37.6%) had a LOS≥10 days and 10,261 (7.6%) patients died during the hospitalization with no difference seen over the time period of observation. (P=.30). Greater rates of mortality were observed in patients with lung (11.2%) or CNS (9.3%) malignancies, and leukemia (9.3%). Infectious complications were documented in 59.5% of patients and their presence was associated with greater LOS≥10 days (48.2% vs. 22.0%) and higher mortality (11.2% vs. 2.3%). Greater LOS≥10 days (51.6% vs. 37.1%) and increased mortality (9.8% vs. 7.5%) were also observed among obese patients with cancer. Likewise, patients with multiple comorbid conditions had more prolonged hospitalizations and a greater risk of in-hospital mortality. (Table) Abstract 2601. Table Solid tumors Lymphoma LeukemiaNo. of comorbiditiesNo. of patients% died% with LOS≥10 daysNo. of patients% died% with LOS≥10 daysNo. of patients% died% with LOS≥10 days017,8580.911.28,1890.617.010,3950.853.5118,1723.417.97,7512.626.611,3803.463.2214,2508.927.25,3868.141.08,6039.769.937,49918.038.42,86118.455.25,04022.877.742,70525.151.41,06033.670.52,00438.183.1≥ 560235.262.327839.980.657749.087.0All patients*61,0867.022.625,5256.632.237,9999.265.4 LOS – length of stay; * 10,699 patients with other type or multiple tumors not included in the table The trend toward longer LOS and greater mortality with increased number of comorbidities persisted in multivariate analyses after adjusting for cancer type, age, gender, ethnicity and type of infection (odds ratio (OR) per +1 comorbidity increase: [mortality: OR =1.89; 95% CI: 1.85-1.92; P<.0001], [LOS: OR=1.56; 95% CI: 1.54-1.58; P<.0001]). Conclusions: Major medical comorbidities are common among hospitalized patients with cancer and neutropenia. Importantly, such comorbidities are associated with prolonged hospitalization and increased risk of in-hospital mortality with significantly worse outcomes in patients with lymphoma or leukemia. Greater awareness of risk factors associated with poor prognosis in cancer patients hospitalized with neutropenic complications as well as validated risk tools to better identify low risk as well high risk patients may guide more personalized cancer care, potentially improving clinical outcomes and lowering the cost of care. Disclosures Crawford: Amgen: Consultancy. Dale:Amgen: Consultancy, Honoraria, Research Funding. Lyman:Amgen: Research Funding.

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