Increased Comorbidity Burden Among Hip Fracture Patients During the COVID-19 Pandemic in New York City.

BACKGROUND: The coronavirus disease 19 (COVID-19) pandemic had a devastating effect on New York City in the spring of 2020. Several global reports suggested worse early outcomes among COVID-positive patients with hip fractures. However, there is limited data comparing baseline comorbidities among patients treated during the pandemic relative to those treated in non-pandemic conditions. MATERIALS AND METHODS: A multicenter retrospective cohort study was performed at two Level 1 Trauma centers and one orthopedic specialty hospital to assess demographics, comorbidities, and outcomes among 67 hip fracture patients treated (OTA/AO 31, 32.1) during the peak of the COVID-19 pandemic in New York City (March 20, 2020 to April 24, 2020), including 9 who were diagnosed with COVID-19. These patients were compared to a cohort of 76 hip fracture patients treated 1 year prior (March 20, 2019 to April 24, 2019). Baseline demographics, comorbidities, treatment characteristics, and respiratory symptomatology were evaluated. The primary outcome was inpatient mortality. RESULTS: Relative to patients treated in 2019, patients with hip fractures during the pandemic had worse Charlson Comorbidity Indices (median 5.0 vs 6.0, P = .03) and American Society of Anesthesiologists (ASA) scores (mean 2.4 vs 2.7, P = .04). Patients during the COVID-19 pandemic were more likely to have decreased ambulatory status (P<.01) and a smoking history (P = .04). Patients in 2020 had longer inpatient stays (median 5 vs 7 days, P = .01), and were more likely to be discharged home (61% vs 9%, P<.01). Inpatient mortality was significantly increased during the COVID-19 pandemic (12% vs 0%, P = .002). CONCLUSIONS: Patients with hip fractures during the COVID-19 pandemic had worse comorbidity profiles and decreased functional status compared to patients treated the year prior. This information may be relevant in negotiations regarding reimbursement for cost of care of hip fracture patients with COVID-19, as these patients may require more expensive care.

Hip Fracture Outcomes During the COVID-19 Pandemic: Early Results From New York.

OBJECTIVE: To evaluate inpatient outcomes among patients with hip fracture treated during the COVID-19 pandemic in New York City. DESIGN: Multicenter retrospective cohort study. SETTING: One Level 1 trauma center and one orthopaedic specialty hospital in New York City. PATIENTS/PARTICIPANTS: Fifty-nine consecutive patients (average age 85 years, range: 65-100 years) treated for a hip fracture (OTA/AO 31, 32.1) over a 5-week period, March 20, 2020, to April 24, 2020, during the height of the COVID-19 crisis. MAIN OUTCOME MEASUREMENTS: COVID-19 infection status was used to stratify patients. The primary outcome was inpatient mortality. Secondary outcomes were admission to the intensive care unit, unexpected intubation, pneumonia, deep vein thrombosis, pulmonary embolus, myocardial infarction, cerebrovascular accident, urinary tract infection, and transfusion. Baseline demographics, comorbidities, treatment characteristics, and COVID-related symptomatology were also evaluated. RESULTS: Ten patients (15%) tested positive for COVID-19 (COVID+) (n = 9; 7 preoperatively and 2 postoperatively) or were presumed positive (n = 1), 40 (68%) patients tested negative, and 9 (15%) patients were not tested in the primary hospitalization. American Society of Anesthesiologists' scores were higher in the COVID+ group (d = -0.83; P = 0.04); however, the Charlson Comorbidity Index was similar between the study groups (d = -0.17; P = 0.63). Inpatient mortality was significantly increased in the COVID+ cohort (56% vs. 4%; odds ratio 30.0, 95% confidence interval 4.3-207; P = 0.001). Including the one presumed positive case in the COVID+ cohort increased this difference (60% vs. 2%; odds ratio 72.0, 95% confidence interval 7.9-754; P < 0.001). CONCLUSIONS: Hip fracture patients with concomitant COVID-19 infection had worse American Society of Anesthesiologists' scores but similar baseline comorbidities with significantly higher rates of inpatient mortality compared with those without concomitant COVID-19 infection. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Fascia Iliaca Block as the Primary Intraoperative Anesthesia for Hip Fracture Surgery: A Preliminary Study.

BACKGROUND: Early surgical intervention for hip fractures in the elderly has proven efficacious. However, surgical delays commonly occur in this patient population due to comorbid conditions that put these patients at a high risk for hypotension-related complications of general or neuraxial anesthesia or anticoagulants that delay the safe use of neuraxial anesthesia. QUESTIONS/PURPOSES: The questions/purposes of this study are (1) to investigate if a fascia iliaca block in conjunction with light to moderate sedation could provide adequate analgesia throughout open surgery for intertrochanteric hip fractures (AO/OTA 31-1) without requiring conversion to general anesthesia with airway support and (2) to assess its perioperative complication profile. METHODS: A retrospective chart review was conducted to identify patients with intertrochanteric hip fractures who underwent anesthesia with a fascia iliaca block over a 1.5-year period. RESULTS: In the six patients identified, there were no intraoperative conversions to general anesthesia requiring airway support. Additionally, there were no intraoperative complications, no mortalities within 30 days, 2 patients on anticoagulation who required a blood transfusion, and a single patient who developed a postoperative hospital-acquired pneumonia that resolved with an antibiotic course. CONCLUSIONS: In this series of patients, we demonstrate that a fascia iliaca block can reliably be utilized as the primary anesthetic for patients undergoing surgical fixation of intertrochanteric hip fractures, with an acceptable perioperative complication profile. Although concomitant sedation was provided with the block, this anesthesia strategy has the potential to reduce preoperative delays and minimize the overall burden of sedative and anesthetic medications in a geriatric population. These initial findings may serve as a basis for future, higher-quality prospective and comparative studies.

Leveraging the plate: reliably restoring volar tilt of distal radius fractures.

Restoration of volar tilt is critical when performing open reduction and internal fixation of distal radius fractures. A reproducible technique is required to consistently achieve this goal. A simple technique using the locking plate and an electrocautery scratch pad as reduction tools can reliably generate volar tilt. This technique can be performed with minimal aid from surgical assistants.

Intraoperative contralateral view for assessing accurate syndesmosis reduction.

Accurate reduction of ankle syndesmosis following injury is essential to minimize tibiofibular diastasis and optimize patient outcomes. Although several radiographic parameters have been described in the coronal plane to assist in reduction, tibiofibular diastasis following syndesmotic injury often occurs in the sagittal plane, with the fibula displacing posterior relative to the tibia. A technique using lateral fluoroscopic assessment of the uninjured contralateral ankle as a comparison and guide for accurate syndesmotic reduction is described.