key: cord-0997269-j5f4cqko
authors: Cheung, Zoe B.; Forsh, David A.
title: Early outcomes after hip fracture surgery in COVID-19 patients in New York City
date: 2020-06-06
journal: J Orthop
DOI: 10.1016/j.jor.2020.06.003
sha: d8d99966df2aac9e6878c2f5913c7489af6adac6
doc_id: 997269
cord_uid: j5f4cqko

INTRODUCTION: The COVID-19 pandemic has spread globally and placed healthcare systems under substantial strain. Hip fracture patients represent a high-risk population for severe COVID-19 symptoms, as they are generally older with multiple medical comorbidities. There has been limited information available on the presenting characteristics and outcomes of COVID-positive patients with hip fractures who undergo surgical treatment. METHODS: This was a retrospective study of 10 patients ≥60 years of age with a hip fracture and COVID-19 who underwent surgical treatment in New York City during the COVID-19 outbreak from March 1, 2020 to May 22, 2020. Clinical characteristics and early postoperative outcomes were reported. RESULTS: Eight out of the 10 COVID-positive hip fracture patients in our series were asymptomatic on admission with no clinical signs or symptoms of COVID-19 infection. Only 2 patients presented with hypoxia. All 10 patients underwent surgery within 2 days of admission. Five out of the 10 patients – including the patients who presented with hypoxia – subsequently required supplemental oxygen postoperatively. Two patients had persistently elevated oxygen demands requiring prolonged administration of supplemental oxygen therapy beyond postoperative day 3. None of the patients were put on mechanical ventilation. One patient had a presumed venous thromboembolism postoperatively and subsequently died on postoperative day 19, likely due to respiratory failure. There were no other deaths in the early postoperative period. The average length of inpatient stay was 7.8 days. CONCLUSIONS: Our findings suggest that hip fracture patients who present with asymptomatic or mild COVID-19 infection may have temporarily increased oxygen demands postoperatively, but they can safely undergo early surgical intervention after appropriate medical optimization.

The first confirmed case of severe acute respiratory syndrome coronavirus 2 (SARS-27 CoV-2) or COVID-19 infection in the United States was reported on January 31, 2020 in 28 Washington state. Soon thereafter, the COVID-19 pandemic spread across the country and 29 placed the United States healthcare system under substantial strain. Following the first confirmed 30 case of COVID-19 in New York state on March 1, 2020, New York City quickly became the 31 epicenter of the COVID-19 outbreak in the United States. 32

As the COVID-19 outbreak continues, there have been anecdotal and epidemiological 33 evidence of patients avoiding hospitals and clinics despite requiring medical care, with 34 significant decreases in hospital admissions for non-COVID-19 diagnoses 1 

presentation for hip fractures are concerning given the morbidity and mortality associated with 36 prolonged immobilization and delayed care 2-4 . An additional concern is the potential independent 37 effects of COVID-19 infection on early outcomes in the subgroup of hip fracture patients who 38 are infected. The 1-year mortality rate in hip fracture patients has traditionally been estimated to 39 be approximately 30% 5 , while the 30-day mortality rate has been reported to be 5% to 7% 4,6 . 40

Early reports from Wuhan, China and Italy, however, have showed significantly higher early 41 mortality rates in patients with a hip fracture and COVID-19 infection 7-9 . 42

As of May 26, 2020, there have been no studies specifically examining outcomes in 43 patients with hip fractures and COVID-19 infection who undergo surgical intervention in the 44 United States. The purpose of this study was to report the clinical characteristics and early 45 outcomes in a series of COVID-19-positive hip fracture patients who underwent surgery during 46 the COVID-19 outbreak in New York City.

This research was approved by our internal Institutional Review Board. A retrospective 49 cohort study was performed of patients ≥60 years of age who had positive COVID-19 diagnostic 50 testing and underwent primary hip fracture surgery at our institution in New York City during 51 the COVID-19 outbreak from March 1, 2020 to May 22, 2020. All patients at our institution who 52 were hospitalized during the COVID-19 outbreak underwent COVID-19 diagnostic testing with 53 a real-time reverse transcription polymerase chain reaction (RT-PCR) assay for the qualitative 54 detection of nucleic acid from SARS-CoV-2 in nasopharyngeal swabs. COVID-positive hip 55 fracture patients who were treated non-operatively were excluded, as our specific aim in this 56 study was to examine outcomes after operative treatment of hip fractures. Other exclusion 57 criteria included bilateral hip fractures, periprosthetic hip fractures, and revision hip surgery. 58

Patient demographics were collected, including age, gender, and medical comorbidities. 59

Evidence of COVID-19 infection was recorded, including clinical signs and symptoms, as well 60 as laboratory testing and chest radiograph findings. The administration of any COVID-19-61 specific medical treatments were noted. The mechanism of injury, fracture type, and surgery 62 performed were reviewed for all patients. Fractures were classified according to the AO/OTA 63 classification. All patients were allowed to weight bear as tolerated postoperatively. being found unresponsive, likely due to respiratory failure. One patient (Case 10) remained 116 hospitalized at the time of reporting; he was medically cleared for discharge to a rehabilitation 117 facility, but awaiting insurance authorization. Four of the remaining 8 patients had a LOS ≥7 118 days, with the average LOS among these patients being 7.8 days. Seven patients were discharged 119 to rehabilitation facilities and 1 patient was discharged home with services. Lastly, there were 2 120 early readmissions. One patient (Case 2) was readmitted at our institution for symptomatic 121 COVID-19 infection. The other patient (Case 3) was readmitted at an outside hospital and we 122 were unable to access the outside records to assess the reason for readmission. 123

In this study, we presented the clinical characteristics and early outcomes from a cohort with the incidence of these complications estimated to be approximately 4% to 9% 11,12 . 153 At our institution, all patients who underwent surgical procedures during the COVID-19 154 outbreak were required to have COVID-19 diagnostic testing within 48 hours of the procedure. 155

The operating room protocols for COVID-positive patients at our institution are outlined in 156 gowns, and gloves. Anesthesiologists utilized neuraxial or regional anesthesia when appropriate, 161

and video laryngoscopes to assist with endotracheal intubations to reduce exposure. A designated "runner" outside the operating room was available to retrieve any required equipment or supplies 163 throughout the procedure, in order to limit incoming and outgoing traffic in the operating room. In our study, nearly half of the patients had an inpatient stay ≥7 days, and the average 206 LOS among discharged patients was 7.8 days. This is slightly longer than the average LOS after 207 hip fracture surgery reported in past studies, which has ranged between 5 to 6 days 14,15 . Three of 208 In conclusion, this study described the clinical characteristics and early outcomes after 228 hip fracture surgery in patients who presented with asymptomatic or mild COVID-19 infection in 229

New York City. Despite the absence of clinical signs and symptoms of COVID-19 infection in 230 nearly all of these patients on admission, half of these patients subsequently had increased 231 oxygen demand postoperatively requiring supplemental oxygen therapy. However, more than 232 half of these patients who had increased oxygen demand postoperatively were successfully 233 weaned off oxygen therapy within 3 days after surgery. Furthermore, the mortality rate in the 234 early postoperative period in our series was only 10%, which is in contrast to the higher 235 mortality rates reported from studies in China and Europe. Our findings suggest that hip fracture 236 patients who present with asymptomatic or mild COVID-19 infection may have temporarily 237 increased oxygen demands postoperatively, but they can safely undergo early surgical 238 intervention after appropriate medical optimization. 

Reduced rate of hospital admissions for ACS during Covid-19 outbreak in northern Italy

Delay from fracture to hospital admission: a new risk factor for hip fracture mortality

Delay in hip fracture surgery: 247 an analysis of patient-specific and hospital-specific risk factors

Association 250 between wait time and 30-day mortality in adults undergoing hip fracture surgery

Early mortality after hip fracture: is delay 253 before surgery important?

The impact of time to 255 surgery after hip fracture on mortality at 30-and 90-days: does a single benchmark apply to 256 all?

COVID-19 infection in fracture patients

Treatment of 260 proximal femoral fragility fractures in patients with COVID-19 during the SARS-CoV-2 261 outbreak in northern Italy

Mortality rates of patients with proximal femoral fracture in a worldwide 264 pandemic: preliminary results of the Spanish HIP-COVID observational study

COVID-19 267 diagnosis and management: a comprehensive review

Medical complications and 270 outcomes after hip fracture repair

Clinical characteristics and risk factors of 272 postoperative pneumonia after hip fracture surgery: a propective cohort study

Proximal 275 femur fractures in COVID-19 emergency: the experience of two orthopedics and 276 traumatology departments in the first eight weeks of the Italian epidemic

Mortality rate of 279 geriatric acetabular fractures is high compared to hip fractures. A matched cohort study

Traumatic hip fracture and primary elective 282 total hip patients are not the same: a comparison of comorbidity burden, hospital course, 283 postoperative complications and cost of care analysis

COVID-19 and Hip Fracture Surgery