Paper of the Week: IMPACT-Restart: the influence of COVID-19 on postoperative mortality and risk factors associated with SARS-CoV- 2 infection after orthopaedic and trauma surgery

N. D. Clement, A. J. Hall, N. S. Makaram, P. G. Robinson, R. F. L. Patton, M. Moran, G. J. Macpherson, A. D. Duckworth, P. J. Jenkins

Bone Joint J 2020 Dec;102-B (12):1774-1781
PMID: 33249904 DOI: 10.1302/0301-620X.102B12.BJJ-2020-1395.R2

Summary by Ali Omari, MD

The SARS-2-CoV pandemic has had a profound impact on healthcare and society in general. In an effort to limit the spread of the virus, all elective orthopaedic procedures were suspended.¹ Patient safety could not be ensured due to the unquantified risk of postoperative mortality for patients with a confirmed COVID-19 diagnosis or for a patient who contracts COVID-19 perioperatively. This study reports the findings of the International Multicentre Project Auditing COVID 19 in Trauma & Orthopaedics (IMPACT)-Restart project from nine centers with the aim of assessing the independent association of a diagnosis of COVID-19 on 50- to 100-day postoperative mortality for patients undergoing orthopaedic and trauma surgery. A secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period.

Between March 1^st and April 19^th, 2020 1,659 elective and emergent procedures were performed in 1,569 patients across nine centers. Dates were chosen to reflect the initial positive case of SARS-CoV-2 in Scotland (March 1^st) and allow for a minimum follow-up of 50 days. Elective care was defined as planned non-trauma-related surgery. Data collected included: mortality status, date of death, COVID-19 status (pre- and postoperatively), and date of SARS-CoV-2 test.

In total, 68 patients were diagnosed with SARS-CoV-2 out of the 154 patients tested. At a median of 37 days after admission, 32.4% (22/68) of these patients died. Patients who were SARS-CoV-2 positive had a significantly lower rate of survival when compared to those without a proven infection (67.6% vs 95.8%; p < 0.001). Furthermore, when adjusting for confounding variables – older age (p < 0.001), female sex (p = 0.004), hip fracture (p = 0.003), and increasing ASA grade (p < 0.001) – a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, p = 0.014). Patients aged > 77 years (OR 3.16; p = 0.001), with increasing ASA grade (OR 2.74; p < 0.001), sustaining a hip (OR 4.56; p = 0.008) or periprosthetic fracture (OR 14.70; p < 0.001) were more likely to develop COVID-19 postoperatively.

This study helps to quantify the postoperative mortality risk during the COVID-19 pandemic. Patients with a confirmed COVID-19 diagnosis were at double their background mortality risk. These results are similar to other studies, including the COVIDSurg² study where a mortality rate of 24% was seen. This study also identified factors that were associated with developing COVID-19 during the postoperative period. Elderly patients with worsening physical status (ASA grade) and those undergoing hip or periprosthetic fracture surgery were found to be at the greatest risk of contracting COVID-19 postoperatively. As a result, these patients should be counseled appropriately regarding the risks of postoperative mortality during the SARS-CoV-2 pandemic.

References:

1. Jenkins PJ. The early effect of COVID-19 on trauma and elective orthopaedic surgery. The Transient Journal of Trauma, Orthopaedics and the Coronavirus. 2020. https://www. boa. ac. uk/ policy- engagement/ journal- of- trauma- orthopaedics/ journalof- trauma- orthopaedics- and- coronavirus/ the- early- effect- of- covid- 19- on- traumaand- elect. html (date last accessed 5 January 2021).
2. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27–38.