The UK Foot and Ankle COVID-19 National (FAlCoN) audit
      				:
      			
   <br/>rate of COVID-19 infection and 30-day mortality in foot and ankle surgery in the UK
      during the COVID-19 pandemic

Author(s): Jitendra Mangwani , MBBS (Gold Medal), MS (Orth), MRCS (Ed), FRCS (Tr&Orth) ¹ ^, ² , Karan Malhotra , MBChB (Hons), MRCS, FRCS (Tr&Orth) ³ ^, ⁴ , Linzy Houchen-Wolloff , BSc (Hons), PhD, MCSP ⁵ ^, ⁶ , Lyndon Mason , MB BCh, MRCS(Eng), FRCS (Tr&Orth), FRCS (Glasg) ⁷ ^, ⁸ , UK FAICoN Audit Collaborative

Publication date (Electronic): 08 April 2021

Journal: Bone & Joint Open

Publisher: The British Editorial Society of Bone & Joint Surgery

Keywords: COVID-19, SARS-Cov-2, National audit, Mortality, Complications, Foot and ankle surgery

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Abstract

Aims

The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice.

Methods

This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates.

Results

A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19.

Conclusion

COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions.

Cite this article: Bone Joint Open 2021;2(4):216–226.

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Most cited references 17

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Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Dmitri Nepogodiev, James C. D. Glasbey, Elizabeth Li … (2020)

Summary Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

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GRADING OF PATIENTS FOR SURGICAL PROCEDURES

Meyer Saklad (1941)

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The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures: a multicentre cohort study

Babar Kayani, Elliot Onochie, Vijay H Patil … (2020)

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136–1145.

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Author and article information

Contributors

Jitendra Mangwani: Role: Consultant Trauma and Orthopaedics, Honorary Fellow

Karan Malhotra: Role: Trauma and Orthopaedic Consultant, Honorary Clinical Lecturer

Linzy Houchen-Wolloff:

ORCID: https://orcid.org/0000-0003-4940-8835

Role: Senior Research Associate, Therapy Research Lead

Lyndon Mason:

ORCID: https://orcid.org/0000-0002-0371-3183

Role: Musculoskeletal System Lead, Trauma and Orthopaedic Consultant

Journal

Journal ID (nlm-ta): Bone Jt Open

Journal ID (iso-abbrev): Bone Jt Open

Journal ID (publisher-id): BJO

Title: Bone & Joint Open

Publisher: The British Editorial Society of Bone & Joint Surgery (London )

ISSN (Electronic): 2633-1462

Publication date (Electronic): 08 April 2021

Publication date Collection: April 2021

Volume: 2

Issue: 4

Pages: 216-226

Affiliations

[1 ] org-divisionAcademic Team of Musculoskeletal Surgery (AToMS) , org-divisionUniversity Hospitals of Leicester , Leicester, UK

[2 ] org-divisionCollege of Life Sciences , org-divisionUniversity of Leicester , Leicester, UK

[3 ] org-divisionRoyal National Orthopaedic Hospital NHS Trust , London, UK

[4 ] org-divisionDepartment of Ortho & MSK Science , org-divisionUniversity College London , London

[5 ] org-divisionNIHR Leicester Biomedical Research Centre , Leicester, UK

[6 ] org-divisionPhysiotherapy Department , org-divisionUniversity Hospitals of Leicester NHS Trust , Leicester, United Kingdom

[7 ] org-divisionSchool of Medicine , org-divisionUniversity of Liverpool , Liverpool, UK

[8 ] org-divisionTrauma and Orthopaedic Department , org-divisionLiverpool University Hospitals NHS Foundation Trust , Liverpool

[9 ] org-divisionTrauma and Orthopaedics , org-divisionUniversity Hospitals of Leicester NHS Trust , Leicester, UK

Author notes

Correspondence should be sent to Prof Lyndon Mason. E-mail: lyndon.mason@ 123456liverpool.ac.uk

J. Mangwani and L. Mason are joint senior authors.

*UK FAlCoN Audit Collaborative: Ziad Harb, Ruth Richardson (Ashford & St Peter’s Hospitals NHS Trust), Richard Gadd, Alexander Kerr, William Clay (Barnsley Hospital), Arijit Mallick, Amit Bhargava, Madhu Tiruveedhula, Renos Marios Jeropoulos, Gabriel Campaner (Basildon and Thurrock University Hospitals NHS Trust), Andrew Walls, Mr Maurice O'Flaherty, Miss Julie Craig, Mr Daniel Dawson, Mr Philip McCaughey, Mr Jonathan Crean (Belfast Health & Social Care Trust), Brijesh Ayyasamy, Pradeep Prasad, Anoop Ansnd, Yasir Tarar, Xin Yin Choo (Blackpool Teaching Hospital NHS Trust), Shaik Yousufuddin, Mr Andrew Stone, Mr Mohammed Amer, Francesca Haarer, Dr Tom Barrow, Dr Vishwajeet Singh, Mr Sayani Junaid, Miss Natasha Houssain (Brighton and Sussex University Hospital), Vivek Dhukaram, Mr Khalil Elbayyouk (Coventry & Warwickshire University Hospitals), Zain ul Abiddin, Samir Salih, Mr Angus Fong, Mr Abhishek Arora (Doncaster & Bassetlaw teaching hospital NHS trust), Luc Louette, Giles Faria, Andrew Smith (East Kent Hospitals University Foundation Trust), Shivashanker Aithal, Dhanushka Palihawadana, Ramtin Pir-Siahbazy, Aamir Zubairy (East Lancashire Hospital NHS trust), Barry Rose, Ms Annie McCormack, Dr Maira Vega-Poblete, Mr Karim Wahed, Mr Khalid Malik (East Sussex Healthcare NHS Trust), Sohail Yousaf, Andrea Sott, Dimosthenis Evangelidis, Paul Hamilton, Sarah Abbott, Akarshan Naraen (Epsom & St Helier University Hospitals NHS Trust), Turab A. Syed, Biju Benjamin, Catarina Ferreira, Efstathios Drampalos (Forth Valley Royal Hospital Scotland), Kishore Kumar Dasari, Ahmed Galhoum (George Eliot NHS Trust), Daniel Marsland, Robin Elliot, Alex Chowdhury (Hampshire Hospitals NHS Foundation Trust), Tareq Tareef, Javed Salim, Viren Mishra (Hull University Teaching Hospitals NHS Trust), Suheil Amanat (Imperial College Healthcare NHS Trust), Robbie Ray, Raju Ahluwalia, Zaid Marhoon, Michael Hughes, Marjan Raad (Kings College London NHS Foundation Trust), Rohi Shah (Leicester University Hospitals NHS Trust), Shirley Lyle, Andrew Molloy (Liverpool University Hospitals NHS Foundation Trust), Verity Currall, Catherine Hatzantonis, Joseph Dixon (Luton & Dunstable University Hospital), Thomas Goff, Jason Eyre, Ehab Kheir, Kurt Haendlmayer, Erin Demoulin, Zulfikar Ali, Faye Loughenbury, Sufyan Mansoor, Alexander Butcher, Rory Bonner, Anamika Saha, Gareth Ewan Mcknight, Prashan Lokanathan, Rupert Lees, Peter Harrison (Mid Yorkshire NHS Trust), Andrew Kelly, Hamish Macdonald, George Slade (Musgrove Park, Taunton), Robert Clayton, Scott Middleton, Erlend Oag (NHS Fife), David T Loveday (Norfolk & Norwich University Hospitals), Henry Atkinson, James Dalrymple, Amit Zaveri, Priya Jani, Ramon Fernandes (North Middlesex University Hospital), Sarah Johnson-Lynn, Lynne Robertson-McPartlin, Elizabeth Alderton (North Tees and Hartlepool Hospitals NHS Foundation Trust), Dave Townshend, Anna Porter, Nicole McLaughlin, John Guiguis (Northumbria Healthcare Foundation Trust), Harish Kurup, Nijil Vasukutty, Ashim Wokhlu, Abidemi Ogunsola (Pilgrim Hospital, Boston), Togay Koc, Simon Hodkinson, Billy Jowett, Samer Shamoon, Qamar Mustafa, Adam Stoneham, Luke Duggleby (Portsmouth Hospitals NHS Trust/ Queen Alexandra), Kar Teoh, Shahahoor Ali, Raisa Islam (Princess Alexandra Hospital, Harlow, Essex), Mike Butler, Ciaran Brennan, Toby Jennison, Tariq Karim (Royal Cornwall Hospital and St Michael's Hospital), Stephen Milner, Ayra Mishra, Hemant Singh (Royal Derby Hospital), Anil Haldar (Royal National Orthopaedic Hospital), Basil Budair, James MacKenzie, Huan Dong, Hari Prem, Rosemary Wall (Royal Orthopaedic Hospital NHS Trust), Mr Edward Dawe, Ms Sarah Sexton, Mr Christopher O'Dowd-Booth, Dr Sadeeq Azeez, Dr Galini Mavromatidou (St Richards Hospital, Chichester), Claire Topliss (Swansea Bay University Health Board), Nilesh Makwana, Debashis Dass, Sameera Abas, Manikandar Srinivas Cheruvu, Adam Devany (The Robert Jones and Agnes Hunt Hospital), Edmund Ieong, Ben Rudge, Prathamesh Kane (West Hertfordshire NHS Trust), Eric Ho Ming Suen, Amr Eldessouky (Worcestershire Acute Hospitals NHS Trust), Ahmed Isam Saad, Ibrahim Ali, Benjamin Hickey (Wrexham Maelor Hospital), Anand Pillai, Amirul Islam, Zeeshan Akbar, Tom Naylor, Umair Khan (Wythenshawe Hospital Manchester), Charlie Jowett, Mohamed Mahmoud, Gunay Cryer, Stuart Place (York Hospitals NHS Trust).

Author information

Linzy Houchen-Wolloff https://orcid.org/0000-0003-4940-8835

Lyndon Mason https://orcid.org/0000-0002-0371-3183

Article

Publisher ID: BJO-2-216

DOI: 10.1302/2633-1462.24.BJO-2021-0008.R1

PMC ID: 8085618

PubMed ID: 33829856

SO-VID: 68604b6b-46f6-4969-b559-cb8d609f1492

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

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principal-institution University Hospitals of Leicester NHS Trust, Leicester, UK

article-type Foot & Ankle

coi-statement Data was collected by each participating NHS trust site and transferred securely to University Hospitals of Leicester NHS Trust (primary trust). The data collected locally on encrypted dated sheets was then uploaded to the Research Electronic Data Capture web application. All data was anonymised. Only anonymised data was transferred to the primary trust. All data complied with the requirements of the current legal framework in relation to data processing and with the Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation) as set out in the data processing agreement (uploaded separately). The study will be carried out in accordance with national and international guidelines, as well as the basic principles of the protection of the rights and dignity of Human Beings, as set out in the Helsinki Declaration (64th Assembly Fortaleza, Brazil, in October 2013), and according to current legislation.

Keywords: covid-19,sars-cov-2,national audit,mortality,complications,foot and ankle surgery

Data availability:

Keywords: covid-19, sars-cov-2, national audit, mortality, complications, foot and ankle surgery

The UK Foot and Ankle COVID-19 National (FAlCoN) audit : rate of COVID-19 infection and 30-day mortality in foot and ankle surgery in the UK during the COVID-19 pandemic

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Results

Conclusion

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UCL: Covid-19 Research

Most cited references 17

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

GRADING OF PATIENTS FOR SURGICAL PROCEDURES

The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures: a multicentre cohort study

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