Impact of COVID-19 on acute trauma and orthopaedic referrals and surgery in the UK during the first wave of the pandemic: a multicentre observational study from the COVid Emergency-Related Trauma and orthopaedics (COVERT) Collaborative

Abstract

Objective: This is the first British multicentre study observing the impact of the COVID-19 pandemic on orthopaedic trauma with respect to referrals, operative caseload and mortality during its peak.

Design: A longitudinal, multicentre, retrospective, observational, cohort study was conducted during the peak 6 weeks of the first wave from 17 March 2020 compared with the same period in 2019.

Setting: Hospitals from six major urban cities were recruited around the UK, including London.

Participants: A total of 4840 clinical encounters were initially recorded. 4668 clinical encounters were analysed post-exclusion.

Primary and secondary outcome measures: Primary outcomes included the number of acute trauma referrals and those undergoing operative intervention, mortality rates and the proportion of patients contracting COVID-19. Secondary outcomes consisted of the mechanism of injury, type of operative intervention and proportion of aerosolising-generating anaesthesia used.

Results: During the COVID-19 period, there was a 34% reduction in acute orthopaedic trauma referrals compared with 2019 (1792 down to 1183 referrals), and a 29.5% reduction in surgical interventions (993 down to 700 operations). The mortality rate was more than doubled for both risk and odds ratios during the COVID-19 period for all referrals (1.3% vs 3.8%, p=0.0005) and for those undergoing operative intervention (2.2% vs 4.9%, p=0.004). Moreover, mortality due to COVID-19-related complications (vs non-COVID-19 causes) had greater odds by a factor of at least 20 times. For the operative cohort during COVID-19, there was an increase in odds of aerosolising-generating anaesthesia (including those with superimposed regional blocks) by three-quarters, as well as doubled odds of a consultant acting as the primary surgeon.

Conclusion: Although there was a reduction of acute trauma referrals and those undergoing operative intervention, the mortality rate still more than doubled in odds during the peak of the pandemic compared with the same time interval 1 year ago.

Keywords: COVID-19; epidemiology; orthopaedic & trauma surgery; trauma management.

Figure 1

Types and mechanisms of injuries for acute referrals. Comps, complications; NOF, neck of femur fracture; RTC, road traffic collision.

Figure 2

Types and mechanisms of injuries for operative cases. Comps, complications; DIY, do-it-yourself; NOF, neck of femur fracture; RTC, road traffic collision.

Figure 3

Operative and anaesthetic techniques compared between pre-COVID-19 and post-COVID-19. CRIF, closed reduction and internal fixation; DHS, dynamic hip screw; Ex-fix; external fixation; FB, foreign body; GA, general anaesthetic; IMN, intramedullary nailing; MUA, manipulation under anaesthesia; ORIF, opeen reduction and internal fixation; ST, soft tissue.

Figure 4

COVID-19 status for acute referrals and operative cases as a measure of proportions.

Figure 5

Types and mechanism of injury for mortalities in acute referral cohorts. LL, lower limb; NOF, neck of femur fracture; RTA, road traffic accidents; UL, upper limb.

Figure 6

Types and mechanism of injury for mortalities in operative casemix cohorts. LL, lower limb; NOF, neck of femur fracture; UL, upper limb.

Figure 7

Surgical and anaesthetic techniques used in mortalities as a means of proportions. AGP, aerosolising-generating procedures; DHS, dynamic hip screw; Ex-fix; external fixation; IMN, intramedullary nailing; MUA, manipulation under anaesthesia.

Figure 8

Six-week Kaplan-Meier survival probability analysis for mortalities between pre-COVID-19 and post-COVID-19 for acutely referred from the emergency department.

Figure 9

Six-week Kaplan-Meier survival probability analysis for mortalities between pre-COVID-19 and post-COVID-19 for those undergoing surgery.