key: cord-320892-dcfi5u04 authors: Kaidi, Austin C.; Held, Michael B.; Boddapati, Venkat; Trofa, David P.; Neuwirth, Alexander L. title: Timing and Tips for Total Hip Arthroplasty in a Critically Ill COVID-19 Patient with a Femoral Neck Fracture: A Case Report date: 2020-07-14 journal: Arthroplast Today DOI: 10.1016/j.artd.2020.07.006 sha: doc_id: 320892 cord_uid: dcfi5u04 Expedited time to surgery following hip fracture is associated with decreased morbidity and mortality in appropriately optimized patients. However, the optimal timing of surgery in patients with novel coronavirus disease 2019 (COVID-19) infection remains unknown. This case report describes a patient with COVID-19 pneumonia complicated by multi-organ system failure requiring intubation who sustained a femoral neck fracture that required total hip arthroplasty (THA). This patient had a significant, deliberate delay in time to surgical intervention due to his critical state. When deciding the optimal timing for THA in COVID-19 patients we recommend utilizing inflammatory markers, such as procalcitonin and IL-6, as indicators of disease resolution and caution operative intervention when patients are nearing the 7-10(th) day of COVID-19 symptoms. Furthermore, implant cementation and spinal anesthesia in critically ill COVID-positive patients should be approached cautiously in the setting of pulmonary disease and multi-organ system failure. Close follow-up with medical doctors is recommended to minimize long-term sequelae and delay to baseline mobility. Expedited time to surgery following hip fracture is associated with decreased morbidity and 5 mortality in appropriately optimized patients. However, the optimal timing of surgery in patients 6 with novel coronavirus disease 2019 (COVID-19) infection remains unknown. This case report 7 describes a patient with COVID-19 pneumonia complicated by multi-organ system failure 8 requiring intubation who sustained a femoral neck fracture that required total hip arthroplasty 9 (THA). This patient had a significant, deliberate delay in time to surgical intervention due to his 10 critical state. When deciding the optimal timing for THA in COVID-19 patients we recommend 11 utilizing inflammatory markers, such as procalcitonin and IL-6, as indicators of disease 12 resolution and caution operative intervention when patients are nearing the 7-10 th day of 13 COVID-19 symptoms. Furthermore, implant cementation and spinal anesthesia in critically ill 14 COVID-positive patients should be approached cautiously in the setting of pulmonary disease 15 and multi-organ system failure. Close follow-up with medical doctors is recommended to 16 minimize long-term sequelae and delay to baseline mobility. 17 The novel coronavirus disease 2019 (COVID-19) pandemic has called into question many of the 22 heuristics orthopaedic surgeons use when designing treatment plans for operative injuries. 23 Expedited surgical intervention is recommended for hip fractures as there is associated increased 24 morbidity and mortality with delayed intervention. THA. Furthermore, this case describes early follow-up and sheds light on unique considerations 33 such as trending inflammatory markers to guide timing of surgery, the decisions to perform a 34 pressfit THA over cemented and to utilize general anesthesia over spinal anesthesia, and the 35 potential for prolonged postoperative monitoring. 36 The patient's health care proxy was informed that this case would be submitted for publication 38 and provided consent. A 67-year-old male with hypertension, hyperlipidemia, prior myocardial infarction requiring 41 percutaneous coronary intervention, and heart failure with reduced ejection fraction (20%) 42 presented to our emergency department (ED) after sustaining a ground level fall with right hip 43 pain and inability to ambulate. At baseline, the patient was fully ambulatory and independent. 2 44 days prior to presentation, the patient reported a new, non-productive cough with chills, myalgia, 45 fatigue and decreased appetite. positive. In conjunction with the medical team's evaluation, the patient was deemed "higher-risk" To optimize this patient for surgery, on hospital day (HD) 1 the medical team began aggressive, 63 experimental treatment of his COVID-19 pneumonia with hydroxychloroquine, azithromycin, 64 and ceftriaxone to prophylactically treat against a superimposed bacterial pneumonia. On HD2, 65 operative intervention of his hip fracture was considered, as he appeared clinically stable. Our 66 pulmonary/critical care and COVID-19 infectious disease (ID) services were concerned that the 67 patient was just reaching the 7-10 th day of COVID-19 infection, when many acutely 68 decompensate, and cautioned against surgical intervention 9 On HD4, the patient's oxygen requirement increased to 15L NRB. He subsequently developed 74 hypoxemic respiratory failure, and on HD5 was transferred to the intensive care unit (ICU). On 75 HD6, his respiratory status continued to worsen, and he was rapidly intubated. His ICU stay was 76 complicated by septic shock requiring significant vasopressor support, ARDS, seizures, and 77 acute renal failure requiring hemodialysis. 78 79 By HD10, the patient was clinically improving. He was weaned off vasopressors, required 80 minimal ventilator support and had down-trending inflammatory markers when compared to 81 peak ICU values ( Figure 3 ). The ICU team felt he was nearing medical optimization and 82 reconsulted orthopaedics for surgical intervention. To optimize the patient's care, a 83 multidisciplinary discussion was had with pulmonary/critical care, anesthesia, and orthopaedic 84 surgery. The anesthesia and pulmonary/critical care teams recommended surgery before extubation to prevent unnecessarily repeated anesthesia and intubation. Anesthesia also 86 recommended against spinal anesthesia given the risk of transient hypotension and subsequent 87 end-organ ischemia. Pressfit right THA was scheduled on HD13. 88 Unfortunately, the patient self-extubated on the morning of surgery due to inadequate sedation. 90 He was immediately sedated, re-intubated, and was later brought to the operating room (OR). 91 The patient was given general anesthesia, positioned supine on a regular radiolucent table and a 92 direct anterior approach was utilized. A standard pressfit THA was performed to avoid possible pressor-support, and on POD2 was transferred to a general medical floor. While on the general 100 medical floor, the patient had persistent altered mental status, thought to be secondary to ICU 101 delirium. Electroencephalogram and magnetic resonance imaging (MRI) were done to evaluate 102 for an acute process; both were negative. Physical therapy (PT) was initiated on POD3, however 103 the patient's fluctuating mental status made him unable to participate consistently. It was not 104 until POD17 when PT was able to successfully ambulate the patient. Timing Matters in Hip Fracture Surgery: Patients 227 Operated within 48 Hours Have Better Outcomes. 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