Elderly Hip Fracture during Covid-19 Pandemic: What we are Learning

Coral Sánchez Pérez, Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Spain, Email: spcoral@gmail.com

Received: 08-Feb-2021 Published: 01-Mar-2021

Introduction

In December 2019 when first cases of Coronavirus 19 Disease (COVID-19) appeared, we couldn’t imagine the spreading capacity neither infectious aggressive- ness of this virus. Europe health services have been blocked to control this pandemic state. Orthopaedic departments reduced their activities just for treating the emergent and urgent pathologies such as frac- tures, infections and tumors. Because of the specific biological conditions of the elderly that suffer a hip fracture, they usually present high rates of complica- tions and mortality after surgery [1]. The objective of this review is to know the impact of this viral infec- tion in patients with hip fracture, as COVID-19 seems to affect the global immune and inflammatory system.

Materials and Methods

This is an observational, retrospective, descriptive study. We have registered clinical and demographi- cal data from 43 patients that were admitted to the Emergency Department of Hospital General Univer- sitario Gregorio Marañón (HUGUGM), Madrid, Spain. All patients admitted with the diagnosis of hip frac- ture underwent laboratory test, Polymerase chain reaction (PCR) test and chest x-ray. According to the results patients were isolated as appropriate.

We consider COVID+ patients when nasal PCR was positive.

Hip fractures were classified according to AO classi- fication. To assess patient’s functional independence, we used Barthel index: 80–100 points indicate inde- pendency, 60–79 minimally dependency, 40–59 par- tially dependency, 20–39 severe dependency and less than 20 points indicates total dependency [2]. We also register Charlson comorbidity index [3], designed to predict 10 year survival of patients with multiple comorbidities; the American Society of Anesthesiol- ogists (ASA) score [4] and surgical delay (time from admission to operating room).

Data was collected from March 14th until April 22nd 2020 from patient’s medical history. We used Micro- soft Excel® 2014 V 14.0.0, for data register and codi- fication. Information was transferred to the statistics program SPSS® V.21 to be analysed by our statistics service.

Results

We registered 43 patients with hip fracture, 10 men and 33 women. Mean age was 85,81 ± 8,2 years old.

Hip fracture pattern distribution was 26 intertro- chanteric fractures (AO 31A), 14 subcapital fractures (AO 31B) and 3 subtrochanteric fractures (AO 32).

Barthel Index mean was 63,08 (5-100) points. Charl- son comorbidity index mean was 5 (2-9) points. ASA preoperative score showed 1 patient ASA 1, 32 ASA 3,
7 ASA 4, and 1 ASA 5. There were 9 patients infected with COVID-19 (nasal COVID19 PCR+), 5 diagnosed before surgeries and 4 after surgery.

Oxygen saturation (SatO2) mean upon admission was 95,25 (87-98)%, preoperative hemoglobin (Hb) mean was 11(8-14)g/dL, preoperative leukocytes median was 10150 (4200-86000)cells/μl. D-Dimer was only measured in 7 patients with a median value of 12807 (191-22653) ng/ml.

They were all managed operatively with a median time from admission until surgery of 57 hours and 22 minutes. 7 patients died, 2 of them were COVID-, and they died on days 6 and 8 after surgery. The five COVID+ patients died on days 4, 11, 12, 18 and 27 af- ter surgery.

There were more women than men infected, but in relative terms, among men 80% were COVID19- and 20% COVID19+, and among women 78,8% were COVID19- and 21,2% COVID19+, with no statistical difference.

Dyspnea was found the most frequent COVID19+ symptom. Beyond the COVID19+ patients 66,7% had dyspnea compared to the 2,9% in COVID19-, (p<0,005).

Pathological chest radiographs were found in 44,4% of COVID19+ and just in 3% of COVID- (p<0,002).

We compared the characteristics of COVID19+ and COVID19- patients. We found a COVID19+ Barthel index median of 35 (10-50) points and a COVID- Bar- thel index median of 70 (5-100) points, statistically significant (p<0,009). No statistical significance was found for time until surgery, Charlson index, ASA classification, preoperative SatO2, Hb, leukocytes or D-Dimer variables.

Mortality rate was 62,5% in COVID19+ patients and 9,5% in COVID19- (p<0,003). We found that patients that died had a Barthel index median of 35 (10-50) points and those alive had a Barthel index median of 65 (5-100) points (p<0,057). Preoperative Hb mean in death patients was 9,78 ± 1,3 g/dL and in patients that didn’t die 11,43 ± 1,7 g/dL (p<0,024). No statisti- cal significance was found when analyzing time until surgery, sex, age, Charlson index, ASA classification, preoperative SatO2, preoperative leukocytes nor D-Dimer.

Discussion

COVID- 19 disease is caused by SARS-CoV-2, a novel member of the Coronavirus family. These RNA viruses infect epithelial cells of the respiratory tract causing mainly mild respiratory symptoms such as the com- mon cold. Other strains are responsible for severe pa- thologies such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) or the ongoing COVID- 19 pandemic.

SARS- Cov-2 transmission occurs either by droplet, aerosol, contact and possibly fecal-oral route. Incuba- tion period ranges from 1 to 14 days, being asymp- tomatic carriers one of the main explanations for the SARS- CoV-2 high contagiousness and rapid spread. It symptoms range from fever, cough, myalgia to dys- pnea, pneumonia and multiple organ failure.

Previous studies show that older people are especial- ly vulnerable. Adults over 60 years [5] and more pre- cisely those with preexisting medical conditions are more likely to have severe illness. Having more than three comorbidities has been significantly associated with increased mortality in COVID-19- positive pa- tients [6-7].

A report by the WHO-China Joint Mission estimated that the risk of death in those without comorbidities was 1.4%; the incidence was higher in those with car- diovascular disease (13.2%), diabetes (9.2%), hyper- tension(8.4%), respiratory disease (8.0%), or cancer (7.6%) [8].

On the other hand, hip fracture in the elderly has a huge impact on the already compromised baseline functional status of these patients [9]. Surgical treat- ment is performed in most cases, unless the patient’s health condition cannot tolerate the operation. In a study previously published on nonagenarians patient with hip fracture in our hospital, we found an in hos- pital mortality rate of 9.6% and a 30-day mortality rate of 13.2%, being the most relevant treatable risk facor for 30 day mortality in nonagenarians the de- velopment of a respiratory infection [10].

Literature show equal numbers of cases of COVID-19 infection between men and women, but the severity and mortality seem to be higher in men. A study car- ried out in Wuhan on 168 patients showed a mortali- ty rate of 12,8% in men, compared to 7,3% in women [11].

It is probably due to sex-based immunological dif- ferences and behavioral patterns. However, previous studies carried out in the elderly described similar findings to ours; no statistical differences were ob- served in mortality rates regarding to gender [12].

In our cohort, 20% of COVID+ patients were male and 21,2% women, no statistical differences were found regarding sex and mortality (3 women versus 1 man).

In relation to symptoms in general population, previ- ous authors describe fever on admission in 43,8% of COVID+ patients and up to 88,7% during hospitaliza- tion, and cough in 61% of patients. In severe patients, around 14% of cases experience dyspnea, hypoxemia and acute respiratory distress syndrome [13]. When we analyze elderly patients clinical characteristics might be quite different. None of our COVID+ patients presented fever or cough on admission. However 66,7% of them experienced dyspnea throughout ad- mission. A multicenter study carried out in Scotland also highlights the scarcity of symptoms in COVID+ elderly patients; only 7 out of 317 had suggestive symptoms on admission [14]. Arentz et al described shortness of breath as the most common symptom in 76% of 21 critically ill patients with COVID+ showed [15].

We found that 44,4% of COVID+ patients presented pneumonia on chest radiograph. Among the whole Spanish population, pneumonia prevalence is known to be 53,9%, higher than the rate found in our cohort of people over 60 years old [16].

COVID 19+ patients had a lower Barthel score (medi- an 35, very dependent), when compared with COVID 19- patients (median 70, minimally dependent). COVID+ patients had higher mortality rates, so when comparing Barthel score and mortality we found higher mortality rate in those patients with lower Barthel scores, the difference being statistically sig- nificant. We have not carried out an stratified analysis according to Barthel score, so there might be a bias.

Although previous articles have shown ASA score as a good predictor of mortality in hip fracture patients [17], we found no statistical difference. The reason might be that in our cohort more than 70% of patients were classified as ASA 3, with a very little sample of patients classified as ASA 4 or 5.

As previous authors state, when analyzing periopera- tive data mortality, we found higher mortality rate between COVID+ (62,5%) and COVID- mortality (9,5%) after a minimum follow-up of 19 days. Previous me- ta-analysis point out coagulopathy in COVID-19 as one of the main reasons for the increase in mortality rates [18].

Muñoz vives et. al found a 30,4% mortality rate in COVID+ patients with a hip fracture at a mean follow up of 14 days [19]. The higher mortality rate observed in our cohort is probably due to a longer period of fol- low up, 42% of our deaths occurred on days 19, 25 and 30 postoperatively.

According to the literature performing surgery with- in 48 hours from hip fracture in elderly patients, has demonstrated a 20% lower mortality rate and fewer perioperative complications during first postopera- tive year [20]. In our cohort mean time until surgery was 57 hours. The delay was due to coagulation is- sues, clinical instability or unavailability of operating rooms.

Although clinical guidelines recommend performing surgery in the first 48 hours after hip fracture, and considering high mortality rates observed in COVID+ patients with hip fractures, we believe delaying sur- gery until clinical stability, especially in those pa- tients with adequate pain control, might be an option [21,22].

A small sample could be considered among the lim- itations of this review.

Also, an important bias might be under diagnosis due to low sensitivity in PCR tests.

Conclusion

The ongoing COVID-19 pandemic has completely changed our daily work in Orthopaedic Surgery and Traumatology Departments. It seems clear that the virus causes worse outcomes and higher mortality rates in the elderly and in patients with previous co- morbidities; if we add a hip fracture, mortality rates are even worse. In this study perioperative mortality reaches 62,5% with a minimum follow-up of 19 days among COVID+ patients.

SARS-COV-2 infection preoperative screening it’s mandatory to be able to predict patient’s outcome.

More studies are needed to clarify death rates among the high risk COVID19+ population such as ASA 4 or ASA 5, or lower Barthel punctuation results.

References

1. Medicine I. Annals of internal medicine hip fracture : A Complex Illness among Complex Patients.
2. Mahoney FIBD. Functional eevaluation: The Barthel Index. Md State Med J. 1965;14:61-5.
3. Charlson ME, Pompei P, Ales KL, MacKen- zie CR. A new method of classifying prog- nostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis 1987;40:373-83.
4. Mayhew D, Mendonca V, Murthy BVS. A re- view of ASA physical status: Historical per- spectives and modern developments. Anaes- thesia 2019;74:373-379.
5. Zhonghua Liu. The epidemiological charac- teristics of an outbreak of 2019 novel corona- virus diseases (COVID- 19) in China. Epidemi- ol Work Gr NCIP Epidemic Response, Chinese Cent Dis Control Prev 2020;41:145-51.
6. Kayani B, Onochie E, Patil V, Begum F, Cuthbert R, Ferguson D, et al. The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures. Bone Joint J 2020;102-B(9):1136-45.
7. Deng Y, Liu W, Liu K, Fang YY, Shang J, Zhou L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 in Wuhan, China: A retrospective study. Chin Med J 2020;133:1261-1267.
8. World Health Organization (WHO). Report of the WHO- China Joint Mission on Coronavirus Disease 2019 (COVID- 19). 2020.
9. Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. J American Medi Asso 2017;318:1994-2003.
10. Mayordomo-Cava J, Abásolo L, Monte- ro-Fernandez N, Ortiz-Alonso J, Vidán-Astiz M, Serra-Rexach JA. Hip fracture in nonage- narians: Characteristics and factors related to 30-day mortality in 1177 Patients. J Arthro- plasty 2020;35:1186-93.
11. Meng Y, Wu P, Lu W, Liu K, Ma K, Huang L, et al. Sex-specific clinical characteristics and prognosis of coronavirus disease-19 infection in Wuhan, China: A retrospective study of 168 severe patients. PLOS Pathog 2020;16:e1008520.
12. Leung C. Risk factors for predicting mor- tality in elferly patients with Covid-19: A review of clinical data in China. Mech Ageing Dev 2020;188:111255.
13. Vannabouathong C, Devji T, Ekhtiari S, Chang Y, Phillips SA, Zhu M, et al. Novel Corona- virus COVID-19: Current evidence and evolv- ing strategies. J Bone Jt Surg 2020;102:734- 744.
14. Hall AJ, Clement ND, Farrow L, MacLull- ich AMJ, Dall GF, Scott CEH, et al. IMPACT-Scot report on COVID-19 and hip fractures. Bone Joint J. 2020;102:1219-1228.
15. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and outcomes of 21 Critically Ill Patients with COVID-19 in Washington State. J American Medi Asso 2020; 323:1612-1614.
16. (ISCIII) EC-19. RCC. Situación de COVID- 19 en España a 14 de mayo de 2020. Informe no31. 2020.
17. Hamlet WP, Lieberman JR, Freedman EL, Dorey FJ, Fletcher A, Johnson EE. Influence of health status and the timing of surgery on mortality in hip fracture patients. Am J Or- thop (Belle Mead NJ) 1997;26:621-627.
18. Lim MA, Pranata R. Coronavirus disease 2019 (COVID-19) markedly increased mor- tality in patients with hip fracture - A system- atic review and meta-analysis. J Clin Orthop trauma. 2021;12: 187-193.
19. Muñoz Vives JM, Jornet-Gibert M, Cámara-Cabrera J, Esteban PL, Brunet L, Del- gado-Flores L, et al. Mortality rates of patients with proximal femoral fracture in a world- wide pandemic. J Bone Jt Surg. 2020;5.
20. Klestil T, Röder C, Stotter C, Winkler B, Nehrer S, Lutz M, et al. Impact of timing of surgery in elderly hip fracture patients: A systematic review and meta-analysis. Sci Rep. 2018;8:1-15.
21. Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of sur- gical delay in patients with hip fracture. Ann Intern Med. 2011;155:226-233.
22. Shahid Z, Kalayanamitra R, McClafferty B, Kepko D, Ramgobin D, Patel R, et al. COVID-19 and Older Adults: What We Know. J Am Geriatr Soc. 2020;68: 926-929.