Cuthbert R, Ferguson D, Kayani B, Haque S, Ali A, Parkar A, Bates P, Vemulapalli K. Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era. World J Orthop 2021; 12(6): 386-394 [PMID: 34189076 DOI: 10.5312/wjo.v12.i6.386]
Corresponding Author of This Article
Rory Cuthbert, BSc, MBBS, Surgeon, Department of Trauma & Orthopaedic Surgery, Queen's Hospital-Romford, Rom Valley Way, London RM7 0AG, United Kingdom. rory.cuthbert@nhs.net
Research Domain of This Article
Orthopedics
Article-Type of This Article
Case Control Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Orthop. Jun 18, 2021; 12(6): 386-394 Published online Jun 18, 2021. doi: 10.5312/wjo.v12.i6.386
Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era
Rory Cuthbert, David Ferguson, Babar Kayani, Saeef Haque, Aoun Ali, Asif Parkar, Peter Bates, Krishna Vemulapalli
Rory Cuthbert, David Ferguson, Saeef Haque, Aoun Ali, Asif Parkar, Krishna Vemulapalli, Department of Trauma & Orthopaedic Surgery, Queen's Hospital-Romford, London RM7 0AG, United Kingdom
Babar Kayani, Peter Bates, Department of Trauma & Orthopaedic Surgery, Royal London Hospital, London E1 1FR, United Kingdom
Author contributions: Cuthbert R designed the research study, performed data acquisition, and wrote the manuscript; Ferguson D and Kayani B designed the research study and performed data acquisition; Haque S and Ali A performed data acquisition; Parkar A, Bates P and Vemulapalli K contributed towards conception of the study and final editing; all authors revised the article critically for important intellectual content, and provided final approval for the paper to be published.
Institutional review board statement: Local research approval was obtained from respective departmental leads, and the NHS Research Ethics Committee decision tool excluded need for ethical review.
Informed consent statement: Informed consent was not required for the above study as data was collected retrospectively and anonymized.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Rory Cuthbert, BSc, MBBS, Surgeon, Department of Trauma & Orthopaedic Surgery, Queen's Hospital-Romford, Rom Valley Way, London RM7 0AG, United Kingdom. rory.cuthbert@nhs.net
Received: February 22, 2021 Peer-review started: February 22, 2021 First decision: May 3, 2021 Revised: May 15, 2021 Accepted: May 25, 2021 Article in press: May 25, 2021 Published online: June 18, 2021
Abstract
BACKGROUND
Hip fractures are the most common reason for inpatient orthopaedic trauma admission. Urgent surgical intervention for hip fractures has remained a clinical priority throughout the coronavirus disease 2019 (COVID-19) pandemic. Despite this, there is a paucity of clinical guidance addressing the informed consent process for hip fracture surgery in COVID-19 positive patients. This is of paramount medicolegal importance in a high-risk patient population.
AIM
To quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery and provide clinicians with an evidence-based framework to establish an informed consent process.
METHODS
Two hundred and fifty nine consecutive patients undergoing surgical intervention for hip fractures in four hospitals in the United Kingdom were recruited. 51 patients were confirmed positive for COVID-19. Predefined outcomes were analyzed over a 30-d postoperative period. COVID-19 positive and COVID-19 negative patients were compared after adjustment for confounding factors.
RESULTS
COVID-19 positive patients had more intensive care admissions (27% vs 5%, P < 0.001), longer inpatient stays (median 23 d vs 9 d, P < 0.001) and a higher 30-d mortality (29% vs 10%, P = 0.001) than COVID-19 negative patients. Postoperative complications were evident in 74.5% of COVID-19 positive patients. 35.3% of COVID-19 positive patients suffered postoperative lower respiratory tract infections with 13.7% developing acute respiratory distress syndrome (ARDS) and 9.8% experiencing symptomatic thromboembolic events.
CONCLUSION
The COVID-19 pandemic has created uncertainty in the medical community worldwide and poses unique challenges in providing informed consent for surgery. COVID-19 positive patients undergoing hip fracture surgery should be consented for the additional risk of postoperative complications (including lower respiratory tract infection, ARDS, deep vein thrombosis and pulmonary embolism), increased requirement for intensive care admission, longer inpatient stay and higher risk of mortality. Further, clinicians must be transparent about the potential for unknown risks as research into the long-term surgical outcomes of COVID-19 positive patients continues to evolve.
Core Tip: Coronavirus disease 2019 positive patients undergoing hip fracture surgery should be consented for the increased risk of postoperative complications (including lower respiratory tract infection, acute respiratory distress syndrome, deep vein thrombosis and pulmonary embolism), increased requirement for intensive care admission, longer inpatient stay and a higher risk of mortality. It is medicolegally imperative that these risks are addressed as part of an informed consent process.
