INTRODUCTION
Severe acute respiratory distress syndrome-coronavirus-2 (SARS-CoV-2), also known as 2019 new coronavirus or Coronavirus disease-2019 (COVID-19), first appeared in China on December 31, 2019, and since then, it has spread rapidly and become a pandemic all over the world (1). The effects of this pandemic were widespread, but it had a significant impact on the healthcare system. Due to its effect on healthcare system, the capacity of surgical cases has significantly decreased in orthopedic surgery (1). Although observations show a decrease in the number of emergency department visits and decrease in the number of hip fractures, infact it is mainly resulted from stay-at-home orders, the need for hip fracture care in elderly patients still remains a source of concern (1-3).
Throughout the pandemic, orthopedic trauma services maintained their previous capacity. Patients with hip fractures in the elderly population, in particular, have continued to visit hospitals in numbers comparable to before the pandemic, even in areas most affected by the COVID-19 pandemic (3-6). The majority of patients with hip fractures have multiple comorbidities, and they usually developed this fracture after minor falls as a result of poor bone quality and neurologic disorders (3). Even though several studies show that the incidence of hip fractures during the pandemic period shares similar several characteristics with the pre-pandemic period, the effect of the pandemic on fracture type distribution and hip fracture rates is unclear (2,7-12).
The fracture type in geriatric hip fractures may affect the surgical procedure applied, length of postoperative hospitalization, and mortality rate (13-16). Therefore, in terms of managing this patient group in the pandemic period, exact information about fracture distribution can enhance health services. The differences in fracture types and the number of hip fractures studies could be due to two factors: Firstly, restrictions during the pandemic period may change the distribution of fracture types and the number of fractures by causing changes in these patients’ activities. Secondly, since most of the studies conducted were small sample studies examining the fracture profile covering short time intervals during the pandemic period, it may have caused differences in fracture types and rates. For this reason, the aim of the study was to clarify this situation by comparing the number of geriatric hip fractures and fracture distribution in one-year period of the COVID pandemic and the 5-year period preceding the pandemic.
METHODS
Study Design and Ethical Consideration
This study was a monocentric, observational, descriptive, and retrospective study. All patients in this study were those who applied to the emergency department of our tertiary hospital or were transferred from outer centers. Approval was received by the University of Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital Ethics Committee (number: 191, date: 03.05.2021). Patients with hip fractures were examined between the dates of March 11, 2016, and March 11, 2021. Dates were divided into two groups: The pandemic period, which is the one-year period between March 11, 2020, when the first COVID case was confirmed in Turkey, and March 11, 2021, and the pre-pandemic period, which is the 5-year period before pandemic between March 10, 2016, and March 10, 2020.
Patient Population
All patients over the age of 65 years who applied with hip fractures were involved in the study. The fracture types involved in this study are trochanteric fractures, intracapsular femoral neck fractures, and subtrochanteric fractures (proximal one-third of the femur). Patients with isolated trochanter major fractures, fractures in the middle or distal one-third of the femur, periprostatic femur fractures, and multiple trauma-related fractures were excluded from the study.
Patient Management
The patients were those who had hip fractures that were confirmed radiologically by X-ray in the emergency department or who had been diagnosed with hip fractures in another hospital and were transferred to our hospital’s emergency department. Patients were welcomed by the emergency personnel in the beginning and were examined in terms of COVID-19 symptoms. Among the suspicious cases, there were patients with fever or feverless cough or with an illness like influenza. In the first examination, physiological parameters, hematological and biochemical parameters, and thorax computed tomography were all scanned, and polymerase chain reaction (PCR) tests were performed on nasal and throat swabs routinely before the hospitalization. Patients who tested positive or had viral pneumonia findings on computed tomography were referred to an infectious diseases specialist and admitted to the COVID ward. Patients who tested negative were admitted to orthopedics and traumatology ward. In accordance with our hospital’s infection control protocols, patients in the orthopedics ward who developed COVID-19 symptoms were isolated and transferred to the COVID ward with the approval of the infectious disease specialist. COVID-19 patients with hip fractures were operated on in a special COVID-19 operating room and received post-operative care in a COVID ward. Patients without COVID were operated on in a “clean” and “non-COVID” operating room and received post-operative care in a “non-COVID” orthopedics ward. Hip fracture operations were accepted as aerosol-forming procedures, and thus fully surgical personal protective equipment was dressed by operating room staff to fully protect both patients and surgeons in both areas.
All operations were performed in the lateral decubitus position. The posterolateral surgical approach was used in patients performed arthroplasty. Osteosynthesis was performed using the proximal femoral nail of Tasarımmed in intertrochanteric and subtrochanteric fractures. The prosthesis from the TST company was used in the hemiarthroplasty procedures.
Data Collection
Codes for International Classification of Diseases-10 (ICD 10), fracture of head and neck of femur, pertrochanteric hip fractures, and subtrochanteric hip fractures (S72.0, S72.1, and S72.2 respectively) were scanned in the hospital system. After considering the excluded cases, cases involved in the study were classified as pre-pandemic (n=973) and pandemic (n=142) based on the date they applied to emergency department. Patients in the pandemic group were also examined in two subgroups as COVID (+) and COVID (-).
Age, sex, fracture type (intracapsular/extracapsular), length of hospital stays, three-month mortality rates, surgical treatment applied, need for intensive care rates, length of intensive care unit stay, complication rates, and COVID-19 test data were collected.
Categorising stages were completed with three groups; youngest-elderly ones (ranging from ages 65 to 74), middle-elderly group (ranging from ages 75 to 84) and last but not least, the oldest-elderly group (aged 85 years or older) (17).
The first year of the pandemic outbreak was analysed in four quarters (1st quarter: 11.03.2020-10.06.2021, 2nd quarter 11.06.2020-10.09.2021, 3rd quarter 11.09.2020-10.12.2020 and 4th quarter 11.12.2020-10.03.2021).
During the hospitalization period, the time from the first radiological confirmation of the fracture to discharge was calculated (or in case the death, to date of death). A positive COVID-19 situation was defined as the presence of clinical symptoms and a single positive result for the detection of the SARS-CoV-2 S gene (VIASURE SARS-CoV-2 gene real-time PCR detection kit, CerTest Biotect) from nose or throat swab samples or findings compatible with COVID-19 in thorax computed tomography. The COVID-19 situation was considered negative in the absence of clinical symptoms and a negative PCR test.
Statistical Analysis
For quantitative variables, including measures of central tendency, a general descriptive analysis was performed overall and by specific periods. Continuous variables were reported using means and standard deviations if they followed a normal distribution; otherwise, the median and range were used. Absolute frequency and rates were used to summarize categorical variables. Analysis of variance was used to compare continuous variables, and Pearson’s chi-squared test was used to compare categorical variables. If a p value was <0.05, it was accepted as statistically significant. IBM SPSS version 25.0 (IBM Corp., Armonk, New York, USA) statistical package was used for all analyses.
RESULTS
Duration of hospitalization period and age-related data are summarized in Table 1. There was no statistically significant difference in both groups according to gender, type of fracture, postoperative intensive care unit care requirement, and complication rates (Table 2). Fracture quantities and fracture patterns were dispersed non-significantly in all four sub-groups (Table 3). There was no statistically significant difference in the age distribution and fracture type distribution between the groups between pre-COVID and COVID periods. The fracture pattern and age distribution of the patients in the pre-pandemic and post-pandemic periods are presented in Table 4. During the pandemic period, femoral neck fractures have become dominant in the younger age group.
DISCUSSION
There was no significant difference in hip fracture patterns and fracture numbers between the pre-pandemic and pandemic periods. Moreover, other crucial data included the femoral neck fractures being the most common fracture pattern among the youngest aged hip fractures. A new strain of COVID was identified as an etiological factor for deadly pneumonia in Wuhan-China, followed by global spread. World Health Organization declared this infection as pandemic on March 11, 2020. At the same time, this is the same date that the first case in Turkey was reported. Due to the lack of preventive inoculation and therapeutic medications, public health precautions such as isolation, social distance, and quarantine were the only options for preventing the disease from spreading (18). Profound changes in social behavior and mobility during the early stages of the COVID-19 pandemic are directly associated with a significant decrease in orthopedics trauma referrals, but fragility fractures remain unaffected and service to these patients should be maintained (10). Furthermore, since these patients are typically elderly, fragile, living in nursing homes, and have multiple comorbidities, they are at a higher risk of developing a serious COVID-19 disease (19). Several cohort studies reported that there are no significant differences in time to operation, type of treatment, complications, or 30-day mortality rates among hip fracture patients admitted during the COVID-19 pandemic compared to those who admitted in the pre-pandemic period (3,5,7,20,21). Our results also support this situation.
Epidemiology is a significant way to predict the resource requirements of health services (10). Considering the burden of the COVID-19 pandemic on the health system, as well as the decisions taken and changes made in the health system, epidemiological evaluations become even more important during this period (18,22). For this reason, numerous studies on geriatric hip fractures in the COVID-19 pandemic have been conducted (1-3,7-9,18-20). Despite the fact that the majority of these studies showed that geriatric hip fractures did not decrease compared to the pre-pandemic period, the results of fracture type distribution differed (2,7-11). According to Malik-Tabassum et al. (7), Arafa et al. (11), and Scott et al. (10), the fracture type distribution was similar to the pre-pandemic period, while in the study of Egol et al. (9), the predominance of femoral neck fractures increased during the pandemic. Slullitel et al. (8) also performed fracture typing using the AO classification and found a statistical difference in fracture type between the pre-COVID and COVID periods. However, neither study discussed the possible reasons for this (8,9). We believe that the source of the difference between these studies is the comparison of patients in the time groups that cover specific months.
Although the general finding in the literature is that the rates of geriatric hip fractures did not change in the pandemic period, there are also opposite results (2,4,7,11,23). While Arafa et al. (11) claimed an increase in hip fracture rates, Nazemi et al. (23) found a significant decrease in hip fracture admission rates during the pandemic period. Both the theories that pandemic restrictions may lead to a decrease in these fractures due to decreased activity and the theory that elderly people being indoors alone at home may lead to an increase in these fractures are acceptable. However, during the ongoing pandemic process, more precise information about the number of fractures can be obtained over a wider period of time (18). Therefore, we believe that our study provides valuable information on the fact that geriatric hip fracture rates do not change during the pandemic period.
Although geriatric fractures usually occur in low energy traumas, high energy traumas are also a frequent cause that can not be underestimated (24-26). High-velocity traumas 68.7% resulted with extra-capsular fractures (26). Furthermore, the activity levels in the youngest age seniors group are significantly higher relative to middle and oldest aged seniors (17). The difference in the fracture patterns of younger seniors could have occurred due to pandemic-related governmental restrictions. At the same time, the fracture type of hip fractures in seniors 65 years old and older remained unaltered. This situation may be the 25.4% ratio of younger seniors composition among all the old hip fractures during a pandemic. On the contrary, this shift did not result in change in fracture profiles. Under these circumstances, we believe that the information gathered does not affect the management of hip fractures during the pandemic outbreak.
Three-month mortality rates in geriatric hip fractures represent more than 50% of the deaths associated with this disease (27-29). In many studies, mortality rates during the COVID period were evaluated at 1 month (3,5,7,21,22). In addition to including a 1-year pandemic period, our study can provide broader information with 3-month mortality rates. However, there was no difference in 3-month mortality between pre-COVID and COVID periods.
Study Limitations
The study has some limitations. The first of these is that when comparing mortality rates in the study, additional diseases, ASA scoring, and other factors that may affect mortality rates are not included in the analysis. Because the abnormal distribution of these factors between pre-COVID and COVID groups may cause bias by masking the increased mortality rates that may be caused by the COVID period. The other limitations are that the study is retrospective and monocentric, and the effect of the pandemic on the postoperative functional outcomes and quality of life of these patients is not known. However, considering that its main purpose is to investigate the effect of the pandemic on fracture rates and fracture type distribution, we believe that this study provides valuable information.
CONCLUSION
Despite the restrictions imposed during the COVID-19 pandemic, there were no changes in geriatric hip fracture rates. At the same time, fracture type distribution was similar to the pre-pandemic period. When the 3-month mortality rates were compared, they were similar between the pre-pandemic and pandemic periods.
Ethics
Ethics Committee Approval: Approval was received by the University of Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital Ethics Committee (number: 191, date: 03.05.2021).
Informed Consent: Written informed consents were obtained from all study participants.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: A.Y., M.Y., N.E., A.Ç.T., H.G., Concept: M.Y., H.G., Design: A.Y., M.A., H.G., Data Collection or Processing: A.Y., M.Y., N.E., S.G., M.A., Analysis or Interpretation: M.Y., S.G., A.Ç.T., M.A., Literature Search: A.Y., N.E., S.G., A.Ç.T., Writing: A.Y., N.E., S.G., A.Ç.T.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.