How did the pandemic affect hip fracture care in SG?

A recent study at Singapore General Hospital has noted no change in the volume of hip fractures during the COVID-19 pandemic, but patients admitted during this period appear to be more “deconditioned.”

“[T]hrough our institution’s experience in managing hip fracture patients during a year fraught with disruptions in workflow and productivity, we recommend preserving the resources and pathways dedicated to [older] patients, who appear to be more deconditioned during a pandemic, as the volume of osteoporotic hip fractures remains unchanged,” the researchers said.

The study included patients admitted under a hip fracture bundled care protocol. Participants were then divided into two groups: COVID group (n=307; patients admitted in 2020 during the pandemic) and PRE-COVID group (n=350; those admitted in 2019). No significant between-group difference was seen in age, gender, and type of hip fracture.

The research team retrospectively examined time to admission, time to surgery, length of stay, discharge disposition, as well as rates of 30-day revision surgery, 30-day readmission, and inpatient mortality.

The COVID group showed a higher proportion of patients with American Society of Anesthesiologists (ASA) classification III and IV compared with the PRE-COVID group (61.4 percent vs 50.2 percent; p=0.004). [Singapore Med J 2024;65:669-673]

The proportion of patients admitted to the ward within 4 h were similar between arms, but the mean time to surgery was longer in the COVID group (71.8 vs 60.4 h; p=0.046), which also saw fewer patients undergoing operations within 48 h (41.7 percent vs 60.3 percent; p<0.001).

In addition, the mean postoperative length of stay, discharge disposition, and rates of inpatient mortality, 30-day revision surgery, and 30-day readmission did not significantly differ between groups.

"[H]ip fracture patients face an increased time to admission and surgery during the COVID-19 pandemic, with a lower proportion meeting the criteria of definitive surgery within 48 h. Interestingly, these patients were also assessed to be at higher ASA status,” the researchers said. 

“Despite the effects of the COVID-19 pandemic on these key performance indicators, our hip fracture bundled care protocol successfully preserved short-term surgical outcomes during this global pandemic,” they added.

Improved outcomes

According to the American Academy of Orthopaedic Surgeons, there is some evidence that hip fracture surgery within 48 h of admission often leads to better outcomes. [Can Med Assoc J 2010;182:1609-1616; Am J Orthop 2018;doi:10.12788/ajo.2018.0071; https://aaos.org/globalassets/quality-and-practice-resources/hip-fractures-in-the-elderly/hip-fx-timing-measure-technical-report.pdf]

Previous studies have also reported delays in time to surgical intervention during the COVID-19 pandemic in the US, UK, and Argentina. [Int J Orthop Trauma Nurs 2021;41:100817; Br J Anaesth 2021;127:15-22; Int Orthop 2021;45:23-31; J Orthop Surg Res 2021;16:155]

Such delays were attributed to new contingency measures of polymerase chain reaction testing, using full PPE during aerosol-generating procedures, performing surgery in specific theatres dedicated to suspected or positive COVID-19 patients, and workforce constraints, among others. [Geriatr Orthop Surg Rehabil 2021;12:21514593211006692]

“It is important to ensure that measures are implemented to prevent disease outbreak within healthcare institutions, even if this may delay necessary surgical treatment for hip fractures,” the researchers said. “However, we have shown that an established hip fracture bundled care protocol can preserve short-term outcomes despite an initial delay in treatment.”