There were 328 patients referred to the orthopaedic team in 2019 vs 178 in 2020. The injury profiles seen in both 2019 and 2020 are described in Figure 1. Mean sample age was 51.2 years (SD 29.9) for 2019 and 58.2 years (SD 30.1) for 2020. This difference in age was statistically significant (p = 0.006, t = 2.76). We found that 162/328 referrals (49.4%) were male in 2019 and 88/178 referrals (49.4%) were male in 2020. There was no significant difference in gender between cohorts (p=0.992, χ2 <0.001).
There was no significant difference in the proportion of referred cases managed operatively (145/328 [2019] vs 87/178 [2020]; χ2 = 1.258, p = 0.262, Figure 2). There was also no significant difference in the proportion of cases managed with general anaesthesia (χ2 = 0.305, p = 0.581). A summary of demographic data is displayed in Table 3.
When we looked at whether the COVID-19 pandemic was associated with longer waiting times from presentation to operation, we found a mean waiting time of 4.91 days (SD 4.55) in 2020 and 2.94 days (SD 7.92) in 2019. This difference (1.97 days) was statistically significant (t = 2.401, p = 0.009, Figure 3).
Next, we wanted to test the hypothesis that the COVID-19 pandemic was associated with a difference in the overall complication rate of either operative or non-operative management between 2019 and 2020. There were significantly lower complication rates in patients managed operatively in 2020 (χ2 = 5.168, p <0.001; 36/145 [24.8%; 2019] vs 11/88 [12.5%; 2020]). This was also the case for non-operatively managed patients (χ2 = 3.826, p = 0.050; 32/183 [17.4%; 2019] vs 8/89 [8.99%; 2020]).
The next interesting question was whether the COVID-19 pandemic affected the severity of complications suffered following operative or non-operative management. To achieve this, we ran two ordinal logistic regression models with an independent variable of year (2019 or 2020) and an ordinal dependent variable of either the Clavien Dindo-Sink Classification Grade (I to V), or a classification grade determined in-house for non-operative management (1 to 5). For post-operative complications, we found a significant overall model fit (χ2 = 4.269, p = 0.039). Being operated on during the COVID-19 pandemic significantly increased the odds of having a higher grade of complication on the modified Clavien Dindo-Sink scoring system (Odds ratio [95% CI] 2.100 [1.020 to 4.327], p = 0.044; Figure 4). Since we observed a significant difference in age between 2019 and 2020, we added age as a covariate in this ordinal regression model. Age did not significantly affect the complication severity (OR 0.996 [95% CI 0.986 to 1.007], p = 0.499).
When investigating for differences in the severity of complications for patients managed non-operatively, the ordinal logistic regression showed a non-significant overall model fit (χ2 = 0.856, p = 0.355). Being managed non-operatively during the COVID-19 pandemic did not significantly change the odds of having a more severe complication (Odds ratio [95% CI] 0.510 [0.126 to 2.068], p= 0.346).
In 2020, 86/178 (48.3%) of total referrals had a COVID-19 swab test (Table 4). There was no significant difference in complication severity between COVID-19 positive and negative patients who were managed operatively (Mann-Whitney U = 9.5, p = 0.360) or non-operatively (Mann-Whitney U = 1, p = 0.400). Out of all six COVID-19 positive patients, one died after developing pneumonitis following a non-operatively managed acetabular fracture on a background of hypertension, ischaemic heart disease, chronic kidney disease and transient ischaemic attack. In 2019, there were a total of seven recorded deaths (five non-operative, two operative). This was also the case for 2020 (three non-operative and four operative).