The coronavirus disease clavicle study: a predictor of future trauma trends.

Background: Clavicle fractures are a common presentation to the emergency department after falls and sporting injuries. During 2020, the coronavirus disease 2019 (COVID-19) pandemic brought with it a long period of social isolation, resulting in a change of behavior patterns and, in return, the presentation of fractures to our local hospitals. The effects of this global pandemic on the presentation and management of clavicles were noted with particular interest to the change in mechanism and its future implications. Methods: We performed a longitudinal observational study in 10 hospitals in the North West of England, reviewing all patients presenting with a clavicle fracture during 6 weeks in the first peak of COVID-19 pandemic and compared these with the same period in 2019. Collection points included the patient demographics, fracture characteristics, mechanism of injury, and management. Results: A total of 427 clavicle fractures were assessed with lower numbers of patients presenting with a clavicle fracture during the COVID-2020 period (n = 177) compared with 2019 (n = 250). Cycling-related clavicle fractures increased 3-fold during the pandemic compared with the 2019 control group. We also noted an overall increase in clavicle fractures resulting from higher energy trauma as opposed to low energy or fragility fracture. We also found a faster time to surgery in the COVID cohort by 2.7 days on average when compared with 2019. Conclusions: Government restrictions and the encouragement of social distancing led to behavioral changes with a vast increase in cyclists on the road. This created a significant rise in clavicle fractures related to this activity. This is likely to be further driven by the government pledge to double cyclists on the road by 2025 in the United Kingdom. We forecast that this increase in cyclists, a behavior change accelerated by the pandemic, is a reliable predictor for future trauma trends.

One Hundred Twenty-Day Mortality Rates for Hip Fracture Patients with COVID-19 Infection.

BACKGROUND: Increased 30-day mortality rates have been reported for patients with hip fractures and a concurrent diagnosis of coronavirus disease 19 (COVID-19) infection. Due to nosocomial spread of infection and the variable incubation period with the virus, follow-up past 30 days after injury is required to evaluate the true mortality amongst these patients. We aim to assess 120-day mortality rates in hip fracture patients with COVID-19 infection and compare this to hip fracture patients without COVID-19 infection presenting during the same time period. METHODS: This is a retrospective multicenter review of all patients aged ≥ 60 years admitted with a fractured neck of femur between March 5 and April 5, 2020, at nine U.K. trauma units. COVID-19 status, demographic data, comorbidities, and date of death (if applicable) were collected. RESULTS: Data were collected for 265 hip fracture patients. Forty-six patients (17.4%) tested positive for COVID-19 infection. There were no significant differences in age or Charlson comorbidity score between those with or without COVID-19. Those with COVID-19 infection were more likely to be male (p = 0.01). Patients with COVID-19 had a 30-day mortality of 35% versus 10% in patients without (p < 0.01). One hundred twenty-day mortality was also greater in those with COVID-19 infection at 63% compared to those without at 17% (p < 0.01). Previous history of myocardial infarction was the only independent factor that showed to increase mortality rate (p = 0.03). Subgroup analysis also revealed significantly increased mortality rates at 120 days in men (27% vs. 67%), women (14% vs. 59%), and those undergoing surgery (56% vs. 30%). CONCLUSIONS: We report a significantly increased mortality rate at 30 and 120 days after injury in an already high-risk cohort of surgical patients. With nearly half of patients being diagnosed with COVID-19 at 14 days or greater following admission, this study highlights the importance of taking appropriate measures to decrease the incidence of nosocomial infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in hip fracture patients.

COVID-19 infection is related to differences in the use of personal protective equipment by orthopaedic specialist trainees caring for hip fracture patients during the second surge of COVID-19 in the North West of England.

INTRODUCTION: Personal protective equipment (PPE) may protect health-care workers from COVID-19 infection and limit nosocomial spread to vulnerable hip fracture patients. METHODS: We performed a cross-sectional survey amongst orthopaedic trainees to explore PPE practice in 19 hospitals caring for hip fracture patients in the North West of England. RESULTS: During the second wave of the pandemic, 14/19 (74%) hospitals experienced an outbreak of COVID-19 amongst staff or patients on the orthopaedic wards. An FFP3 respirator mask was used by doctors in only 6/19 (32%) hospitals when seeing patients with COVID-19 and a cough and in 5/19 (26%) hospitals when seeing asymptomatic patients with COVID-19. A COVID-19 outbreak was reported in 11/13 (85%) orthopaedic units where staff wore fluid resistant surgical masks compared to 3/6 (50%) units using an FFP3 respirator mask (RR 1.69, 95% CI 0.74-3.89) when caring for symptomatic patients with COVID-19. Similarly, a COVID-19 outbreak was reported in more orthopaedic units caring for asymptomatic patients with COVID-19 where staff wore fluid resistant surgical masks (12/14 (86%)) as compared to an FFP3 respirator mask (2/5 (40%)) (RR 2.14, 95% CI 0.72-6.4). CONCLUSION: Urgent re-evaluation of PPE use is required to reduce nosocomial spread of COVID-19, amongst highly vulnerable patients with hip fracture.

30-day mortality for fractured neck of femur patients with concurrent COVID-19 infection.

INTRODUCTION: Risk factors for mortality associated with COVID-19 have been reported to include increased age, male sex and certain comorbidities. Fracture neck of femur (NOF) patients is high-risk surgical patients, often with multiple comorbidities and advanced age. We quantify the 30-day mortality rate in fractured NOF patients with a positive peri-operative COVID-19 antigen test and identify risk factors for increased mortality. METHODS: This is a retrospective multi-centre review of all patients admitted with a fractured NOF and a confirmed laboratory diagnosis of COVID-19 between 1 March and 26 April 2020. Demographic data, comorbidities, ASA grade and date of death (if applicable) were collected. RESULTS: There were 64 patients in the cohort with an overall 30-day mortality rate of 32.8% (n = 21). Thirty-five (55%) were female, and mean age was 83 (SD 9, range 46-100) years. There was significantly increased mortality for those with a history of myocardial infarction (p = 0.03). Sixty-four percent of patients underwent surgery within the 36-h target, which is comparable to previous data for the same time of year. Overall mortality increased to 50% (n = 32) at 45 days post-operatively. CONCLUSION: This is a large review of 30-day mortality in NOF patients with concurrent COVID-19 infection. We report a substantial increase from the pre-COVID-19 mean 30-day mortality rate (6.5% in 2019). We highlight the need for counselling patients when presenting with a NOF in relation to peri-operative COVID-19 infection and the associated increased risks.

Where did all the trauma go? A rapid review of the demands on orthopaedic services at a UK Major Trauma Centre during the COVID-19 pandemic.

AIMS: This retrospective study aims to quantify the early impact of the COVID-19 pandemic on trauma and orthopaedic surgery at a Major Trauma Centre (MTC) in the United Kingdom. We hypothesise that the social restrictions placed on the public by the government will reduce the amount of trauma presentations and operations performed. METHODS: A database of all trauma patients at the MTC was retrospectively reviewed from start of social restrictions on 16 March 2020, to 22nd April 2020 inclusive. Referrals to the orthopaedic team were identified and included; these were sub-classified into major trauma patients, fragility hip fractures and paediatric trauma. All patients undergoing surgical intervention were identified. The outcome measures were the total number of referrals and trauma operations performed in the time period. This was compared with the corresponding dates of the 2019. RESULTS: There was an overall decrease in the number of referrals to the orthopaedic team from 537 in 2019 to 265 in 2020 (50.7% reduction). The number of trauma operations carried out at the trust decreased from 227 in 2019 to 129 in 2020 (43.2% reduction). The number of paediatric referrals decreased from 56 in 2019 to 26 in 2020 (53.6% reduction), and the number of major trauma patients reduced from 147 in 2019 to 95 in 2020 (35.4%). Fragility hip fracture referrals remained similar, with 52 in 2019 compared to 49 in 2020. CONCLUSION: The COVID-19 pandemic has had a profound effect of the provision of trauma and orthopaedic surgery. We report a significant decrease in all orthopaedic referrals during the pandemic, leading to a greatly reduced number of trauma operations performed. This has allowed for reallocation of staff and resources. We must plan for the lifting of social restrictions, which may lead to an increase in patients presenting with trauma requiring operative intervention.

Performance anxiety amongst trauma and orthopaedic surgical trainees.

BACKGROUND: This study aims to assess performance anxiety amongst orthopaedic trainees. Operating is equivalent in its skill level, both dexterous and mental, to that of elite sport. This study uses a slightly altered version of the validated Sports Competition Anxiety Test (SCAT), making it relevant to operating, rather than to sport, to evaluate peri-operative stress and anxiety in orthopaedic surgeons. METHODS: The SCAT questionnaire was sent to trainees across 3 UK. deaneries via email. A score of <17 suggests low-levels of anxiety, 17-24 suggests medium-levels of anxiety and >24 suggest high-levels of anxiety. Data was anonymised except from training grade and sex. RESULTS: 109 of 273 (40%) responded to the survey, 71% of respondents were male (n = 77). The mean SCAT score amongst Core Surgical Trainees was 16.9 (n = 21, range 12-23), Specialist Trainees years 3-5 was 18.7 (n = 51, range 12-28), Specialist Trainees years 6-8 was 16.8 (n = 26, range 11-24) and consultants was 16 (n = 11, range 11-28). Across all groups, when sub-divided by sex, females had higher mean scores, this was statistically significant for Specialist Trainees years 3-5 (p = 0.029) and Specialist Trainees years 6-8 (p = 0.042) groups. DISCUSSION: Surgical performance anxiety exists amongst orthopaedic surgeons, with females scoring higher than males. Five respondents scored "high-levels of anxiety" including 2 consultants level surgeons, suggesting experience does not entirely eliminate anxiety. Stress and anxiety are known to lead to surgical mistakes and "burnout" amongst surgeons which is highly topical at present. It is important to highlight this significant issue and it could be taken forward as a national survey to evaluate further.

Platelet-Rich Plasma Injections as a Treatment for Refractory Patellar Tendinosis: A Meta-Analysis of Randomised Trials.

Purpose: Patellar tendinosis (PT) is a common condition amongst athletes. In this study, we perform a meta-analysis on randomised controlled trials (RCTs) to evaluate the use of platelet-rich plasma (PRP) for refractory PT. Methods: A literature search was undertaken in various databases from their year of inception to October 2015. The primary outcome measure was the Victorian Institute of Sports Assessment-Patella (VISA-P) score. Results: We identified 2 RCTs comparing PRP injections to alternative treatment options (extracorporeal shockwave therapy [ESWT] and dry needling of the tendon). Meta-analysis showed no significant difference in mean VISA-P scores between PRP injection and control at early assessment (2 or 3 months; estimated difference in means, 11.9; standard error [SE], 7.4; 95% confidence interval [CI], -2.7 to 26.4; p=0.109). However, PRP was statistically better than control with regards to VISA-P scores at longer follow-up (6 months or longer; estimated difference in means, 12.7; SE, 4.4; 95% CI, 4.1 to 21.3; p=0.004). Conclusions: There is a paucity of RCTs evaluating the role of PRP in PT. Our results suggest that, based on limited evidence, PRP is superior over other established non-surgical treatments (dry needling and ESWT) for refractory PT. Larger RCTs may allow better characterisation of the role of PRP in this condition.

Meckel's diverticulitis: a rare entity of Meckel's diverticulum.

Meckel's diverticulum is the most common congenital abnormality of the small intestine that results from incomplete closure of the vitelline (omphalo-mesenteric) duct. This true diverticulum, ~2 ft from the ileocecal valve commonly found on the anti-mesenteric border of the ileum, is benign and majority asymptomatic. Diagnosis challenges arise when it became inflamed or presented in following ways, for example, haemorrhage (caused by ectopic pepsin-and hydrochloric acid-secreting gastric mucosa), intestinal obstruction (secondary to intussusception or volvulus) or the presence of diverticulum in the hernia sac (Littre's hernia). We report a case of a 59-year-old male who was admitted under the surgical service at Blackpool Victoria Hospital with suspected appendicitis that turned out to be a Meckel's diverticulitis, a rare presentation of an acute abdomen. We discuss the issues involved in his investigation and management as well as perform a literature review comparing different surgical approaches.

An unusual cause of pain in the hip.

Colorectal Carcinoma is the second biggest killer after lung and bronchial carcinoma. Due to its insidious onset and late manifestation of symptoms a national screening programme was started in 2006 within the UK. We present a rare case of colorectal adenocarcinoma mimicking osteosarcoma and presenting as hip pain at initial consultation in the orthopaedic clinic. Further adding to the rarity of this case is that of an apparent bony metastasis in isolation. Our case demonstrates the vital role that histological sampling plays in the diagnosis and treatment of carcinomatous disease. It also demonstrates the need to maintain high index of clinical suspicion, no matter how benign the presenting complaint may seem.

Secondary infection of haematoma following closed acromioclavicular joint dislocation.

An unusual case of a patient presenting with a large infected haematoma following a traumatic grade II acromioclavicular joint dislocation is reported. Diagnosis of this rare complication, of an otherwise common self-limiting injury, was delayed until 19 days postinjury despite several presentations during this time with worsening swelling and pain. The patient was found to have significant tissue destruction by the time washout was performed and required multiple procedures to treat the infection. This case highlights the need for a high index of suspicion for complications, even following common self-limiting injuries, when patients represent with symptoms that do not fit the usual natural history of the condition, particularly if they have risk factors for bleeding and infection.