key: cord-0709299-2x9m37cw authors: Kumar Jain, Vijay; Lal, Hitesh; Kumar Patralekh, Mohit; Vaishya, Raju title: Fracture management during COVID-19 pandemic: A systematic review and meta-analysis date: 2020-06-30 journal: J Clin Orthop Trauma DOI: 10.1016/j.jcot.2020.06.035 sha: 878f4127f5d2a15bc05e339fc97cd9154af2bc65 doc_id: 709299 cord_uid: 2x9m37cw PURPOSE: The COVID-19 pandemic has affected orthopedic practices worldwide. Few studies focusing on epidemiology and management of fractures in COVID 19 patients have been published. We conducted a systematic review and meta-analysis to evaluate the fracture types, presentation, treatment, complications, and early outcomes of fractures occurring amidst COVID-19 pandemic. METHODS: A systematic review and meta-analysis of the all published papers was conducted with a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Library database using keywords ‘COVID-19’, ‘Coronavirus’, ‘trauma*'and ‘fracture’ from January–April 2020. RESULTS: The searches yielded a total of ten studies with 112 Patients who were positive for COVID 19 associated with fractures. Individual patient data meta-analysis was performed as feasible, for six studies, reporting data separately for 44 patients with COVID 19 and an associated fracture. Meta-analysis showed that a diagnosis of COVID 19 was made on the basis of positive Computed Tomography scan in 39 patients and 30 patients had a positive Reverse Transcription-Polymerase Chain Reaction test. Overall, there were 29 proximal femoral fractures, 8 spine fractures, 7 fractures of the other bones. The fractures were treated surgically in 30 cases (68.18%) and the remaining 14 cases (31.82%) were managed conservatively. There were 16 patients (36.36%) who died, mostly due to respiratory failure with a median age of 82 years. CONCLUSION: COVID-19 has led to a significant reduction in a load of fracture patients globally, though the incidence of fragility fractures continues to be unaffected. There is a significantly higher risk of mortality in elderly patients with fractures and hence they should only be operated in a facility with a robust intensive care. Conservative treatment should be adopted as far as possible in non-obligatory fractures and in lesser equipped centers. Surgery in patients with proximal femur fragility fractures when judiciously selected did result in improvement in respiratory status. Reorganizing medical services is vital to deliver effective fracture care and also mitigate disease transmission. COVID-19 has led to a significant reduction in a load of fracture patients globally, though the incidence of fragility fractures continues to be unaffected. There is a significantly higher risk of mortality in elderly patients with fractures and hence they should only be operated in a facility with a robust intensive care. Conservative treatment should be adopted as far as possible in nonobligatory fractures and in lesser equipped centers. Surgery in patients with proximal femur fragility fractures when judiciously selected did result in improvement in respiratory status. Reorganizing medical services is vital to deliver effective fracture care and also mitigate disease transmission. Keywords: Fracture; hip; COVID-19; Meta-analysis; Pneumonia; Systematic review; conservative; operative; mortality; pandemic The novel coronavirus disease -2019 (COVID- 19) , has significantly affected trauma services globally. Though the motor vehicle accidents (MVA) have drastically reduced due to extensive lockdown, still the patients with low energy and fragility fractures are seeking treatment in emergency. Till date, only a few case reports or series with a small number of patients with fractures have been published in the literature. Hence, the information from one study may not give clear guidance to fracture treatment during COVID 19 pandemic. In many countries the surgeons have not started doing surgeries for various fractures despite various available guidelines due to lack of resources, experience to treat such patients, limited access to negative pressure operation theatres, and COVID related anxiety. We have performed a systematic review and a meta-analysis of the available studies, by analyzing the fracture types, presentation, treatment, complication, and early outcomes among COVID-19 negative and positive patients. We aim to provide more insight into how the fracture treatment can be improvised, adapted, or innovated so as to provide a quality fracture care, similar to the pre-COVID era without harming the patients and health care workers. We have performed a systematic search of the following electronic databases: PubMed, Embase, Google Scholar, Scopus, Cochrane Library, and Web of Science using keywords 'COVID-19', 'Coronavirus', 'trauma*'and 'fracture' from 1st January to 30th April 2020, to identify relevant articles reporting fractures during COVID 19 pandemic. Relevant articles reporting data on fractures in the form of case series, case-control, and cohort studies were included. Articles related to non-orthopedic injuries were excluded. Reference lists of articles were also screened for more relevant papers and we also hand-searched popular premier orthopedic journals (JBJS, BJJ, CORR, INJURY, ABJS, Acta Orthopaedica, IJO) and general medical journals (JAMA, NEJM, Lancet) to avoid missing any paper. Studies were excluded if it did not report fractures. We also included relevant editorials, opinions, and reviews for qualitative summarization. The descriptive data regarding patient characteristics available from all studies were summarized in tabulated form. Study quality of individual studies was ascertained using the methodological quality assessment tool proposed by Murad The search yielded a total of 180 articles on PubMed, 122 on Scopus, and one on Cochrane library. Hand search revealed 6 more papers, and 5 relevant papers were revealed on Google Scholar search. After screening duplicates and excluding irrelevant articles based on the title, twenty relevant papers were considered and a total of ten studies with 112 Patients who were positive for COVID 19 and had suffered a fracture were finally included for analysis after fulltext assessment. (Figure 1 ( Figure 2B) We focused on these comorbidities because these have been reported as risk factors for mortality in COVID 19 patients in the earlier studies. [24] Obesity and Chronic Obstructive Pulmonary Disease (COPD) were also considered as a risk factor for mortality, but we could not analyze it as it was not reported, in the most included studies. Oxygen therapy with a Venturi mask was used in most of the cases, and ventilators were also used when necessary, although complete data has not been provided by all the authors. Details regarding antiviral therapy were available in all six manuscripts and as per the synthesized data (HCQS alone-2 cases, HCQS+Oseltamivir-5 cases, HCQSDr+Azithro-17 cases, Oseltamivir alone-11 cases, HCQS+ lopinavir +ritonavir-1 case and HCQS +Azithromycin + Oseltamivir-1 case) the usage pattern has been depicted in (Figure 3 ). PPE Usage: Data regarding usage of PPE was not reported by most authors, and among those who reported it or responded to personal queries, considerable variability was found in its usage ( Table 2) . There were 16 patients (36.36%) who died, mostly due to respiratory failure and one case had in their 13 fracture patients with COVID-19. But, Maniscalo et al. [19] reported a high mortality rate of (43.75%) in their 32 COVID cases with proximal femoral fractures, from Italy. The main cause of death was cardiac arrest (4 cases, 44.4%), multiple organ failure (3 cases, 33 .3%), septic shock (1 case, 11.1%) and renal failure (1 case, 11.1%) among the 9 deaths reported from Piacenza. Among the five COVID positive deaths reported from Parma, causes were cardio-respiratory arrest (4 cases, 66.7%) and septic shock (1 case, 16.7%). Among these patients, RT-PCR for COVID 19 was positive in 12 cases before death, it came positive after death in one case. In the rest, the diagnosis was based on positive CT chest findings. There were 3 patients with hypertension, 1 with cardiac disease and 4 with diabetes type 2. It is important to note that only one case had both heart disease and diabetes. Hip fractures were predominant in patients suffering mortality; 13 cases (29.54%) had proximal femoral fractures, whereas there was only one case of cervical spine injury and two dorsolumbar fractures. Ten patients were surgically managed and six were treated conservatively. Seven of these patients were receiving Hydroxychloroquine-Azithromycin combination, five were receiving Oseltamivir alone and one each was receiving Hydroxychloroquine with Oseltamivir combination, and Lopinavir-Ritonavir-Hydroxychloroquine combination. The difference in age groups of people who experienced mortality, and those who did not approach a statistical significance (P=0.0519). No other significant relationship could be found overall. Most papers related to fractures and COVID-19 came from Iran (4), followed by Italy (3) This study was designed to reflect on how the COVID-19 pandemic has affected fracture care globally, with a propensity to some fractures over other, the surgeon's treatment selection mode, preoperative investigations done, anesthesia administered (did not mention in the result anywhere), the surgeon and patient protective measures taken, the remodeling or modification of the operating theatres, union rate (did not mention in the result anywhere), hospital stay, antibiotic pattern, the complications localized to fracture (did not mention in the result anywhere) and general complications peculiar to COVID 19, morbidity and mortality. In this study, we aimed to assess also the prevalence of accompanying comorbidities in fracture patients tested positive for COVID-19. The main points investigated in this review have been summarized in Table 3 . We have noticed a massive breakdown in trauma orthopedic fracture surgeries in the world during the COVID-19 pandemic. The main approach of most orthopedic surgeons was to save the hospital resources, to decrease the risks of a nosocomial infection like COVID-19 and to protect their staff and colleagues. Due to imposed quarantines, travel bans and lockdown, forcing the people to stay at home, there is a substantial decrease in MVA which has caused a reduction in visits to the emergency trauma service. The mean age of the patients with a fracture, in this series, was found to be around 67 years. It is intuitive that younger age groups did not suffer fractures, perhaps due to restrictions on travel on the road, sporting activities, industrial activities etc., and the majority of these patients had a low velocity or a fragility fracture in an older person with osteoporosis. The male to female ratio was 24/20, which is not significant. Recent articles demonstrated that despite the decreased frequency of accidental trauma over the course of the COVID-19 the outbreak, the number of osteoporotic hip fractures remained stable. [8, 16, 17] Zhu et al. [16] reported hip fracture and low-energy injury (fall from standing height and fall from a low height) as most the prevalent injury mechanism, and the home being placed where these injuries commonly occurred. These findings highlighted the importance of primary prevention (home prevention) measures, and could be used for references for individuals, health care providers, or health administrators. [16] Hip fractures in the elderly are overwhelming injuries that frequently result in long-term disability and can lead to death. Recent studies have shown that elderly patients with fractures associated with medical comorbidities such as diabetes, hypertension, COPD, and obesity are more badly affected by COVID-19 infections, due to their reduced functional reserves and weakened immune systems. [4, 12] These patients should be operated as soon as they are medically optimized, as any operative delays beyond 48 hours after admission may increase the odds of 30-day all-cause mortality. [25, 17] This dictum is also applicable to the patients with COVID-19 infection, despite their higher mortality rate, as they might benefit from early An accelerated care pathway should be adopted for a shorter length of hospital stay and subsequently early discharge of patients from the hospital. We suggest that in countries and healthcare facilities where the resources for orthopedic surgery and critical care are not very well developed, the conservative management still has a role to play, in the present pandemic al. [15] opined that old hip fractures if have other underlying medical conditions that may lead to a lengthy hospital stay and increase the chances of transmitting the infection to the health care workers and other patients. Also, a higher death rate is seen in these elderly people, possibly due to a weaker immune system, which also permits faster progression of viral infection. Finally, the stress associated with the fracture and the surgery might itself trigger a series of oxidative stress responses and excessive inflammation leading to a more severe course of infection. Hence, it is advisable to carefully evaluate these elderly patients (with fragility fractures) for surgery, during an outbreak of COVID-19 in order to protect themselves and the health care workers attending to them. [15] The recent COVID Surg multicenter collaborative study included all patients undergoing surgery and having SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery at 235 hospitals in 24 countries and assessed 30-day postoperative mortality,7-day mortality and pulmonary complications. Out of 1128 patients 835 had emergency surgery and 280 had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 patients. 30-day mortality was 23·8% and 7-day mortality was 5·2%( higher risk for ASA grades 3-5 and lower risk for postoperative diagnosis). Pulmonary complications happened in 51·2% cases; and 30-day mortality among these cases was 38·0%, accounting for 81·7% of all deaths. In adjusted analyses, 30-day mortality was associated with male sex, age 70 years or older,major surgery,emergency surgery, malignant versus benign or obstetric diagnosis, and higher ASA American Society of Anesthesiologists (ASA) classification is certainly a useful tool for foreseeing the patients' outcome significant trend an increase in the ASA physical status is associated with higher perioperative mortality in ICU. [28]The only independent predictor for 30-day pulmonary complications in COVIDSurg Collaborative study was ASA grades 3-5. Also, ASA grades 3-5 versus grades 1-2 was associated with increased odds of 7-day mortality. [27] Nunez et al. [17] have also warned that contingency plans should not automatically assume that all the trauma cases will decrease during a pandemic. Osteoporotic hip fractures remain stable. The resumption of elective orthopaedic surgery should be withheld for the time being and only emergency and semi-urgent cases should be operated, as of now. [32, 33] The orthopedic and trauma surgery which is likely to produce more aerosol, more invasion, requiring general anesthesia and prolonged-time must be avoided [26] . The strength of this study lies in being able to find 20 relevant studies for analysis, related to fracture management amidst COVID 19 Pandemic. Furthermore, we could analyze 112 COVID positive cases, associated with the fractures. We could not find any published data on such a large number of cases, for this subset of patients. The current study also has some limitations. Firstly, the studies were heterogeneous in nature, from different geographical populations. Secondly, some studies were focused on proximal femoral fractures, some on spinal injuries, and others on all types of fractures. Therefore there is a lack of uniformity in the patient populations, which may be related to the risk of mortality and morbidity. Thirdly, the follow up of published studies is quite a short term and final outcomes of fracture treatments and union rates have not been reported so far. Conclusion: COVID-19 has led to a significant reduction in a load of fracture patients globally, though the incidence of fragility fractures continues to be unaffected. Conservative treatment should be adopted as far as possible in non-obligatory fractures and in lesser equipped centers. TJTO&C C Notingham hip fracture score(NFHS) and clinical frailty score(CFS) added together to make a SHIFT score may be used to select hip fracture cases for surgery in the COVID era, with patient to be considered for non-operative care if the score is more than 12, due to high risk og mortality in this group(53%).The mortality risk was 34% with score 9-12 and just 2% with score less than 9. ASJ Rabie H et al [13] Used in 2 cases, Mentioned details in one case (N95 face mask, antiviral hood and guan, and latex antiviral gloves) Shariraye MJ et al [13] N95 face mask, antiviral hood and guan, and latex antiviral gloves (personal communication) Chehrassan M et al [6] All PPE in 2 cases, only extra face shield in one case, only protective clothing in one case and none in one case Did countries segregate COVID patients needing fracture care from non-COVID at entry into a health care facility or did they have different COVID and non-COVID areas in a health center? What was the PPE used? Majority had, and it's better to have different COVID and non COVID health care facilities. If not possible; make a separated contaminated and sterile corridors in a health center (separate OPD, wards, OT, pharmacy) to decrease nosocomial infections. Separate isolation wards in emergency are a must till patient's COVID clearance. [5, 6, 7, 11, 12, 13] Did this review consider only emergency trauma surgeries? Fracture care in emergency was mostly available and was researched. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] What major changes have occurred in the epidemiology of fractures in the COVID 19 era? Overall fracture incidence has decreased but new types of injuries were also seen. [14, 17, 19] Contingency plans in these times need to be targeted for osteoporotic hip fractures. Were the patients triaged? Was there any screening protocol followed in case of emergency? Should all in patients be screened and sampled? How is OT-emergency zoned. Two types of triaging needs to be done one of emergency of trauma by ATLS,SHiFT scores etc. [7] and other is on basis of COVID status. There is consensus that All admitted patients should be screened clinically into covid positive, covid suspects (clinically & pandemic zones >100/100000 resident) and clinically covid negative at ER gate for direction to clean covid free pathways and nonclean /covid facility or zones for clearance by covid swab for RT-PCR and /or CT. BUT Operate emergency cases with universal precautions and less emergency cases after RT-PCR or CT chest scan (experienced radiologist) report. [1, 5, 6, 12, 15, 17] Were clinical symptoms of COVID different? What were the common modes of injury? No Fragility fractures were seen most often. [4, 6, 12, 15, 16] Response to: Management of Traumatic Spinal Fracture in the Coronavirus Disease 2019 Situation Doing Our Part to Conserve Resources: Determining Whether All Personal Protective Equipment Is Mandatory for Closed Reduction and Percutaneous Pinning of Supracondylar Humeral Fractures Carpal Fracture and COVID-19 Infection: Observation from Thailand Characteristics and Early Prognosis of COVID-19 Infection in Fracture Patients Emergency and Urgent Orthopaedic Surgeries in non covid patients during the COVID 19 pandemic: Perspective from India Covid-19 Special Issue):270-6. the SARS-CoV-2 Outbreak in Northern Italy Novel Coronavirus Infection In Orthopedic Patients; Report Of Seven Cases The Early Effect of COVID-19 on Trauma and Elective Orthopaedic Surgery Association of New Coronavirus Disease With Fragility Hip and Lower Limb Fractures in Elderly Patients Epidemiologic characteristics of traumatic fractures in elderly patients during the outbreak of coronavirus disease 2019 in China Impact of the COVID-19 Pandemic on an Emergency Traumatology Service: Experience at a Tertiary Trauma Centre in Spain The management of emergency spinal surgery during the COVID-19 pandemic in Italy Proximal femur fractures in COVID-19 emergency: the experience of two Orthopedics and Traumatology Departments in the first eight weeks of the Italian epidemic Fracture Surgery in known COVID-19 infected patients: what are the Challenges?Arch Bone Jt Surg Association between wait time and 30-day mortality inadults undergoing hip fracture surgery 2020) what we do when a COVID-19 patient needs an operation: operating room preparation and guidance Methodological quality and synthesis of case series and case reports. BMJ evidence-based medicine Risk factors for severity and mortality in adult COVID-19 inpatients in Wuhan Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines Developed by the International Consensus Group (ICM) Post COVID-19: Planning strategies to resume orthopaedic surgery -challenges and considerations Which blood parameters were altered commonly and which were peculiar to trauma in covid?Leukocytosis, neutrophilic with raised CRP is common. Lymphopenia and raised D dimer was more common in fractures. LDH &D dimer are prognostic factors [4, 6, 12, 13] What about sensitivity of HRCT/Chest CT and RT-PCR, should both be done, do they complement each other? Which is a better screening tool in an emergency setting? Do they prognosticate?CT Chest though has increased radiation risk is a fast screening tool with high sensitivity in emergency settings, and is also a prognosticating tool. RT-PCR is specific, needs to be done in all and has important role in patients with equivocal CT. False positive and false negative should be avoided-use both. [6, 12, 13, and 15] . A separate spine center/unit if developed the authors feel would reduce surgical time. [1, 6, 8] When should COVID testing be done in preoperative period?If a patient has been tested in last seven days repeat test is not required, It's better to do RT-PCR test 24-72 hours before surgery in new patient. [1, 18] Did hospitals have outpatient-fracture clinics? How to optimize fracture care visitsIt is better to have a fracture clinic with a dedicated x-ray room so that conservatively treated patients can be managed separately and swiftly. Mild cases can be sent home and followed up via telemedicine. Screening and social distancing to be practiced [9]Were more and more fractures treated conservatively? Was skeletal traction a mode of treatment used?Tendency of treating fractures conservatively was more. (Mildly displaced intra articular fracture distal radius) Patients who were sick /associated serious systemic problems should be managed conservatively. [4, 13] Which fracture is emergency and to be operated first? Any objective tool? What was the time from presentation to surgery?It is upto the health authorities do a risk assessment and determine whether the patient's surgery can be postponed until COVID results return negative or positive patients are no longer infectious and if the situation is an emergency. [5] The tier system, ACS and IOA recommendations and SHIFT tools do guide us in making this decision. [5] Unnecessary procedures for spine trauma patients should be avoided in order to reduce complications related to surgery and to preserve ICU beds. [6] surgery be done for emergent or urgent cases, that is fractures truly requiring operative fixation to avoid mortality or significant morbidity due to a delay of greater than 30 days". [9] All open fractures, hemodynamically unstable fractures, proximal femoral fragility fractures, spine fractures with increasing neurological deficit, cauda equina syndrome should be considered for urgent surgery.If fracture surgery can be delayed for 30 days without disability and life/limb risk it should be .[9]Is proximal femoral fracture an emergency for surgery. Yes, unless patient is unfit for surgery (PO2,temperature, SHiFT tool may act as guides).[8].In principle, active surgical treatment should be performed unless the patient's health condition is very poor, the patient cannot tolerate the operation, the risk of death during the operation is very high or postoperative nursing would be very difficult It improved O2 saturation and assisted respiratory support [4, 8, 12, 15, 17, 19, 21] Dictum: Operate within 24 hours reduce blood loss and early respiratory rehab to avoid ICU.[12]Is spine fracture an emergency? How to proceed after primary survey and immobilization?Spine fractures with increasing deficit, incomplete deficit, cauda equina syndrome in unstable fracture, or cervical fractures should be operated but All Non urgent spine surgery should be stopped or should be planned for non lockdown after critical assessment, as it carries more risk of pneumonia. [11, 18] TIMELINE:• Was there any special PAC advise or preoperative advice? Antiviral and chemotherapy-what and when to start -preop or postop?It is agreed upon that all antiviral, hydroxychloroquine and oxygen support should be started as soon as possible in fracture with COVID. Steroids can be used in spine, head injury with deficit though not recommended due to its impairing effect on immune system [3, 4, 6, 8, [11] [12] [13] [14] [15] [16] Were fractures due to fall more common for the reason of febrile patient's general or systemic weakness? Was there a need for health education by media? Were any new fracture patterns seen?Yes, may be due to febrile fatigue fractures can occur due to fall. Health education in preventing falls will reduce [16] number of osteoporotic hip fracture.. The panic, depression, or irritability during the epidemic /lockdown period is also a topic that needs to be counselled [15, 16] What was the influence on fracture care of associated systemic injuries?Thus, the decision was based on individual patient considerations, and was surgeon based, though more inclined towards conservative treatment for fractures. [4, 6, 13] Was the OT setup different or it required change /refurbishing for COVID with fracture Airflow, negative suction and zoning COVID and non COVID facility to be separate and OT to be zoned according to sterility and utility, Negative suction and air changes are essential for treating COVID with fracture. Isolation areas to be setup separately. Postop HDU to have less and only needy patients, daily assessment for speedy turnover. HEPA filter and AC of closed type as per norm. [4, 5, 11, 16] There should be 30 minutes wait after surgery for aerosol to settle before deep cleaning of OT is started. All agree on breathing time for OT though vary from 1-4 hours for sanitization and cleaning. Zoning of OT a must.(donning in area,a sterile passage and doffing area).Air exchangers to function before anyone who has no respirator protection enters the room and before environment cleaning.[11, 22] What was the details of PPE kit used in OT. How many persons should be there in OTIn Emergency/unknown /unconscious unstable patients complete PPE should be used by surgeon &anaesthetist ( positive pressure hood, water repellant gowns n95 respirators, face shields and antiviral latex disposable gloves). covid negative: anaesthesia given complete ppe and rest n95 ,latex gloves, hood and standard precautions(as may be in window period) ; Minimize the number of person in the OR. Maximum of 8 people to should be there for any procedure, including anesthesia, surgical team, nursing and technicians. [2, 4, 5, 8] What is the type of anaesthesia used/preferred: Regional anesthesia preferred unless as in indicated.blood loss was minimized by avoiding fluid overload and managing patients who had hemoglobin values of po2 deg.C, SHIFT tool>13 ,ASA grade >4,smokinig etc increased risk. [6, 11, 12, 19] What is the mortality rate of COVID with fracture /spine/hip In our review of 44 cases of COVID with fracture, there were total 16 deaths; mostly due to respiratory failure (one case had hematuria also). Pneumonia and respiratory failure, kidney dysfunction were common cause of death. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19]