key: cord-0809031-mciz6wi9 authors: Rizkallah, Maroun; Melhem, Elias; Sadeqi, Mansour; Meyblum, Jean; Jouffroy, Pomme; Riouallon, Guillaume title: Letter to the editor on the outcomes in fracture patients infected with COVID-19. date: 2020-06-25 journal: Injury DOI: 10.1016/j.injury.2020.06.046 sha: ab3de7cfa8062da6aeca464c15661d3cce1cbc02 doc_id: 809031 cord_uid: mciz6wi9 nan In January 2020, China's center of disease control identified a novel coronavirus(COVID-19) as responsible of a cluster of respiratory infections [1, 2] . This virus rapidly spread through the world, and the World Health Organization (WHO) declared the outbreak a Pandemic [3] [4] [5] . In France, the situation became worrisome and evolved quickly despite lockdown [6, 7] . Local health authorities urged hospitals to cancel scheduled surgeries and to deal only with emergent cases. In orthopedics, this meant dealing mainly with surgical trauma patients. Being conscious that patients with fracture are very susceptible to pneumonia, strict preventive and protective measures were offered to all patients [8, 9] . Some trauma patients presented with covid-19 infection and we wondered if these patients with emergent fractures (spine, hip, ankle..) should be operated. Available literature shows only one report from Wuhan reporting their experience with fracture patients infected with Covid-19, and one paper from Italy showing their experience on 13 Covid-19 operated trauma patients [10, 11] . Through this letter, we share with you our incrisis experience as an orthopedic surgery department from France, so we can draw conclusions, lessons, and be ready for a possible second epidemic surge. Through the pandemic, we dealt with twelve patients having a surgical fracture and a Table 1 shows the details of the patients. This high mortality rate is comparable to the reported mortality rate in trauma patients infected with Covid-19 from Wuhan(40%) [10] and Italy(31%) [11] . However both reports were descriptive and increased mortality couldn't be directly imputable to the concomitant infection. We matched each of these twelve patients to two patients from our hospitalized fracture patient database. We created therefore a control group with 24 patients Covid-negative patients matched for sex, age, diagnosis and ASA score. In this group, no intra-hospital death was recorded. The Differences in mortality were tested using Fisher's exact test. All analyses were performed using the R software v3.6.1(R Foundation for Statistical Computing). Through this letter, we share the first report that compares the mortality of Covid-19 patients with concomitant fracture or dislocation requiring surgery or hospitalization, to that of Covid-19 patients without a fracture, or patients operated on for a fracture without Covid-19 infection. Governments around the world have recommended to cancel all non-emergent surgeries [12, 13] . Orthopedic surgeons still had to operate on trauma, septic, and tumor patients. Some fractures, such as proximal femoral fracture, open fractures, and unstable spine fractures are considered emergencies and should be operated as soon as the patient is medically stable, as delaying surgery leads to a poor outcome. Despite the fact that all three patients with proximal femoral fractures were stable on the day of surgery, all three died postoperatively. More, the only patient with a proximal femoral fracture who was not deemed medically fit to undergo surgery eventually died. Therefore, we cannot recommend against surgery at this level but we believe that that a decision by a multidisciplinary team is necessary to evaluate the risk, taking into consideration the notable increase in mortality caused by the novel coronavirus. This should also be discussed with the patient, especially in cases when trauma surgery aims to improve a functional outcome. Two patients in this cohort were diagnosed with Covid-19 infection postoperatively when they started to show clinical symptoms, so the virus was probably in its incubation period when they were operated. We believe that as more tests become available, all trauma patients who require surgery should undergo screening for Covid-19, to avoid unnecessary risk to the patient if the surgery can be delayed by a couple of weeks with minimal impact on outcome. We know that this report has several limitations as during lockdown, most fractures are low energy fractures in the frail elderly, who are at higher risk of perioperative death, but we tried to control this bias by having a matched control group. The sample is small, but fractures in Covid- Outbreak of pneumonia of unknown etiology in Wuhan, China: The mystery and the miracle A pneumonia outbreak associated with a new coronavirus of probable bat origin A Comprehensive Literature Review on the Clinical Presentation, and Management of the Pandemic Coronavirus Disease 2019 (COVID-19) The impact of the COVID-19 pandemic on the provision of surgical care First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures Situation update for the EU/EEA and the UK, as of 14 ministere des solidarites et de la sante. Carte du nombre de cas en France 2020 Risk of long-term infection-related death in clinical osteoporotic vertebral fractures: A hospital-based analysis Principles and current concepts in the surgical treatment of fragility fractures in the elderly Characteristics and Early Prognosis of COVID-19 Infection in Fracture Patients COVID-19 in Europe: the Italian lesson Novel Coronavirus and Orthopaedic Surgery A Review of State Guidelines for Elective Orthopaedic Procedures During the COVID-19 No funding.Maroun Rizkallah, Elias Melhem, Jean Meyblum, Mansour Sadeqi, Pomme Jouffroy and Guillaume Riouallon declare that they have no conflicts of interest.