Title : Impact of COVID-19: Current guidance on management of neck of femur fractures. What have we learned?
Introduction: The COVID-19 pandemic has had a profound effect on healthcare systems worldwide, and in all departments. With reference to trauma and orthopaedics, COVID-19 has effected change in many facets of our work. We have been forced to revisit and reshape management pathways in the face of significant risk and resource limitation. Given the reduced operative capacity, trialled conservative management has become more prevalent. By extension, this debate has included the management of fragility fractures, of which there has remained a significant burden. Patients presenting with neck of femur fractures (NOFF) represent a frail and vulnerable cohort, and some have argued for a non-operative management plan in select cases. Aims: This review aims to present current clinical guidance on the management of NOFF patients during the COVID-19 pandemic. A literature review notes research from various countries on outcomes for NOFF patients with concurrent COVID-19 infection. An extensive PubMed search was carried out for [COVID19] and variants and [neck of femur] to cover the largest number of studies available which yielded 12 relevant studies. This work provides insight into future considerations in the management of NOFF fractures in challenging circumstances given the proven mortality benefit. Results: Current guidance has been evolving during the pandemic from the British Orthopaedic Association (BOA), however most studies acknowledge a cessation of elective operating, and only where necessary in the emergency setting. Few studies have been performed assessing the outcomes of NOFF in COVID-19 patients; however, overall results suggest a statistically significant increased mortality rate in COVID-19 patients with NOFF. The body of research advocates for operative management of NOFF patients despite the increased surgical risk. During the pandemic, there have been multiple attempts to produce evidence-based guidance on the management of various traumatic injuries. Given the unprecedented nature of the times in which we find ourselves, there is a limited data set, and our practice has had to reshape and adapt. The prevalence of patients presenting with NOFF has remained constant despite the pandemic and resultant lockdown measures across Europe. Of those NOFF patients who test positive for COVID-19, either at the point of admission or in the days following the procedure, outcomes are worse with a higher mortality rate. However, the body of evidence does not advocate for a non-operative management approach. Moreover, in some centres, operative interventions have adjusted to consider hip hemiarthroplasty in COVID-19 patients who may previously have been suitable for a total hip replacement. Interestingly there is some evidence to suggest operative intervention has led to improved respiratory function in patients with COVID-19. This is likely due to the fact that it can facilitate upright posture and better lung expansion, improved mobility, better pain control. Conclusion: Non operative management remains an option in individual cases, however generally speaking this should only be considered in cases where patients are critically unwell. This should be discussed as part of a multidisciplinary decision and should include anaesthetic input.