Published online Jun 18, 2021. doi: 10.5312/wjo.v12.i6.386
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
The incidence of hip fractures has remained stable throughout the coronavirus disease 2019 (COVID-19) pandemic, and urgent surgical intervention continues to be prioritized. However, there remains a persistent lack of clinical guidance addressing the subject of informed consent for COVID-19 positive patients undergoing hip fracture surgery. This is of paramount medicolegal importance in a high-risk patient cohort.
The COVID-19 pandemic has created novel challenges and uncertainties in providing informed consent for surgery throughout the medical community. Hip fractures are the most common reason for inpatient orthopaedic trauma admission, with an estimated 1.6 million cases globally per year. Therefore, an evidence-based framework for facilitating an informed consent process for hip fracture surgery would provide clinicians with valuable support and clarity worldwide.
This study had two primary objectives. Firstly, we aimed to quantify the additional perioperative risks for COVID-19 positive patients undergoing hip fracture surgery. Secondly, we sought to provide clinicians with an evidence-based framework for facilitating informed consent in COVID-19 positive patients undergoing hip fracture surgery.
Two hundred and fifty nine consecutive patients undergoing hip fracture surgical intervention in four hospitals in the United Kingdom were recruited. 51 patients were confirmed positive for COVID-19. Predefined study outcomes were recorded over a 30-d period using a standardized collection proforma. COVID-19 positive and COVID-19 negative patients were compared statistically before and after adjustment for confounding factors. Logistic regression was performed to analyze binary outcomes. Survival analysis was performed using Cox regression to compare length of inpatient stay.
After adjusting for potentially confounding variables, in COVID-19 positive patients the odds of intensive care admission were 4.64 times higher (95%CI: 1.59-13.50, P = 0.005) and the odds of 30-d mortality were 3 times higher (95%CI: 1.22-7.40, P = 0.02). 75% of COVID-19 positive patients suffered post-operative complications. 35.3% experienced postoperative lower respiratory tract infections, 14.3% developed acute respiratory distress syndrome (ARDS) and symptomatic thromboembolic events were evident in 9.8%.
We conclude that the informed consent process for COVID-19 positive patients undergoing hip fracture surgery should discuss the additional risk of postoperative complications (particularly 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.
This study contributes to the body of literature reporting short-term surgical outcomes in COVID-19 positive patients. Future research in this field should analyze long-term surgical outcomes in COVID-19 positive patients. In the interim, it is integral that clinicians are transparent with patients that long-term risks of surgery in COVID-19 positive patients remain unknown.