Original Article

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Hip Pelvis 2023; 35(4): 253-258

Published online December 31, 2023

https://doi.org/10.5371/hp.2023.35.4.253

© The Korean Hip Society

The Effects of COVID-19 Pandemic on the Recovery of Hip Fracture Patients

Young Yool Chung, MD , Sung Nyun Baek, MD , Tae Gyu Park, MD , Min Young Kim, MD

Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea

Correspondence to : Young Yool Chung, MD
(https://orcid.org/0000-0002-4959-1230)
Department of Orthopedic Surgery, Kwangju Christian Hospital, 37 Yangrim-ro, Nam-gu, Gwangju 61661, Korea
TEL: +82-62-650-5064
E-mail: wonderchung@naver.com

Received: June 12, 2023; Revised: September 12, 2023; Accepted: September 13, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose: To figure out how complete control of family visits to prevent infection of coronavirus disease 2019 (COVID-19) affected the activity recovery of hip fracture patients admitted to nursing hospitals.
Materials and Methods: Eighty-one patients with hip surgery in the two years prior to COVID-19 pandemic were classified as Group A, and 103 patients in the next two years were designated as Group B. The subjects’ walking ability was evaluated by using the modified Koval index (MKI). In order to analyze the impact of the family visit control to the subjects, each group was classified into two different groups: (1) inpatients group who admitted to nursing hospitals and (2) home-treated patients. Additionally, statistical elements were processed in consideration of other factors that may affect the results of the experiment.
Results: The MKI evaluated at 6 months postoperative was 3.31±1.79 in Group A and 2.77±1.91 in Group B, and it was meaningfully low after the pandemic (P=0.04). There was significantly low among both of Group A 2.74±1.76 and Group B 1.93±1.81 after the pandemic (P=0.03) among those treated at the nursing hospital. The rate of deterioration of the MKI was 35 (43.2%) in Group A and 57 (55.3%) in Group B, which increased by 12.1% after the pandemic.
Conclusion: The pandemic had a negative effect on the recovery of postoperative activities of elderly hip fracture patients who admitted to nursing hospitals when family access was completely restricted to prevent infection.

Keywords Femoral neck fractures, COVID-19 pandemic, Koval index, Rehabilitation

In modern society, increased occurrence of hip fractures has been reported, in line with the increasing elderly population1,2). The number of surgical treatments for hip fractures continues to increase, and recovery treatment, including early postoperative walking, can significantly affect recovery of physical function and early return to daily life3,4). However, performance of early exercise on their own after surgery can be difficult for elderly patients, and assistance from medical personnel and supporters is required for recovery. This type of support can reduce the occurrence of postoperative complications and can improve the potential for early discharge from the hospital and return to daily life5,6).

The number of elderly patients with hip fracture admitted to nursing hospitals for postoperative management has recently shown a continuous increase in South Korea. In regard to patients admitted to nursing hospitals, active participation of family members as assistants in recovery exercise treatment was believed to have a positive effect on improving symptoms by providing psychological stability and motivation, thus it was considered a normal routine before the pandemic. However, as a result of the continued coronavirus disease 2019 (COVID-19) pandemic over the two-year period, the severe restriction of unauthorized personnel in hospitals and isolation treatment systems has had a significant impact on the system of treatment for elderly patients with hip fracture. The plan for conduct of the study originated from the need to study the effect of the pandemic on postoperative recovery exercise for elderly patients admitted to nursing hospitals when family visits are prohibited, and to establish a treatment policy for patients who might be isolated from their families because of such a pandemic in the future. Thus, according to our hypothesis, restricting assistance from guardians such as family members who were responsible for a certain portion of walking recovery due to the COVID-19 pandemic would have negatively impacted the recovery of elderly patients with hip fracture.

A retrospective study of elderly patients (age ≥65 years) who underwent surgery for treatment of a hip fracture from January 2018 to December 2021 at Kwangju Christian Hospital was conducted; patients who had difficulty undergoing accurate evaluation due to severe cognitive impairment and those who could not be tracked for longer than six months after the surgeries were excluded. Patients who underwent surgical treatments from January 2018 to December 2019 were classified as Group A, and those who underwent surgical treatments from January 2020 to December 2021 after the outbreak of the COVID-19 pandemic were designated as Group B. As a routine, two weeks from the day of surgery, which was usually when stitches were removed, was scheduled as the date of discharge, and transfer from the nursing hospital was based on the guardian’s decision according to the patient’s condition. The modified Koval index was used to evaluate patients’ walking ability7). Interviews with both patients and their guardians were conducted for evaluation of the patients’ walking ability before the fracture. Recovery exercise treatments after surgery were started with use of walkers, and exercise time and the number of times exercise was performed were not limited. The final follow-ups for evaluation of gait ability were performed six months after surgery. Analysis and comparison of walking ability prior to the fracture, age and gender before the fracture, and whether or not the patient was hospitalized in a nursing hospital before and after the pandemic were performed in order to determine which factors affected the degree of recovery of walking ability. Independent t-test and multiple regression test from the PASW Statistics (ver. 18.0; IBM) program were used for statistical analysis. A P<0.05 was considered statistically significant. This retrospective study was conducted with the approval of Kwangju Christian Hospital’s Institutional Bioethics Committee (No. KCH-M-2022-11-014), and obtaining written consent from the patient was exempted by the Institutional Bioethics Committee. The conflict of interest is written accurately.

The study included 184 patients, 81 patients in Group A and 103 patients in Group B. Using means and standard deviation, the mean age of 81 patients in Group A was 76.59±10.60 years, with 64 females and 17 males. In Group A, 46 patients (56.8%) were re-admitted to nursing hospitals for recovery exercise treatments after discharge from the hospital, and the remaining patients were managed for recovery exercise with assistance from their families at home. The mean age of 103 patients in Group B was 77.70±10.12 years, with 80 females and 23 males. No study on the rates of transfer of hip fracture patients to a nursing hospital has been conducted; however, in our study, 46 patients (56.8%) with hip fracture from pre-pandemic (Group A) and 54 patients (52.4%) from post-pandemic (Group B) were transferred to nursing hospitals instead of home care for exercise recovery treatments after the surgeries. Regarding the rates of femoral neck and trochanteric fractures, there were 41 cases (50.6%) and 40 cases (49.4%) in Group A, and 61 cases (59.2%) and 42 cases (40.8%) in Group B. The ratio of arthroplasty and osteosynthesis was 58 cases (71.6%) and 23 cases (28.4%) in Group A and 90 cases (87.4%) and 13 cases (12.6%) in Group B, respectively. The modified Koval index before fracture was 4.23±1.13 in Group A and 4.04±1.28 in Group B, and no statistical difference was observed between the two groups (P=0.28). The modified Koval index for the follow-ups six months after surgery was 3.31±1.79 in Group A and 2.77±1.91 in Group B, indicating a statistical reduction in the recovery of walking ability in Group B (P=0.04). The modified Koval index before fracture for patients admitted to nursing hospitals was 3.87±1.22 in Group A and 3.67±1.39 in Group B, and no statistically significant differences were observed between the two groups (P=0.44). However, at six months after surgery, the modified Koval index was 2.74±1.76 in Group A and 1.93±1.81 in Group B, indicating a statistical decrease in the recovery of walking ability in patients who were admitted to nursing hospitals after the pandemic (P=0.03). The modified Koval index before fracture for patients who underwent exercise recovery treatments at home was 4.71±0.79 before surgery in Group A and 4.45±1.00 in Group B (P=0.20). At six months’ postoperative follow-up, the modified Koval index was 4.06±1.57 in Group A and 3.69±1.57 in Group B, showing no statistical difference (P=0.30) according to independent sample t-tests (Fig. 1).

The deterioration rate of the modified Koval index was 35 (43.2%) in Group A and 57 (55.3%) in Group B, an increase of 12.1% after the pandemic. The rate observed for patients admitted to nursing hospitals was 25 (54.3%) in Group A and 37 (68.5%) in Group B, an increase of 14.2% after the pandemic. By contrast, the rate observed for patients who received treatment at home was 10 (28.6%) in Group A and 20 (40.8%) in Group B, an increase of 12.2% after the pandemic (Table 1). The results of multiple regression analysis of the factors affecting the modified Koval index showed that the main factors were the COVID-19 pandemic (β=–0.12, P=0.04), age (β=–0.28, P<0.001), and nursing hospital admission (β=–0.36, P<0.001), and the influence index was in the order of nursing hospital admission, age, and COVID-19 pandemic (Table 2).

A higher rate of infection with COVID-19 was observed among elderly people compared to younger persons during the same period8). Higher mortality rates and serious complications resulting from infection have been reported, particularly among older patients with hip fracture, for which a large number of complications and a high mortality rate have been reported9,10,11,12). Although older patients must undergo surgery for treatment of fracture injuries as soon as possible, according to some reports, hospitalization and surgery were sometimes delayed in the early stage of the pandemic, increasing the hospitalization period and aggravating mortality13,14). However, it was also reported that acceptable results were achieved with prompt surgical treatment of patients with hip fracture without increasing complications even during the pandemic period15). As many studies have reported on increased complications and mortality rates after hip fracture during the pandemic, the necessity of thorough preparation for elderly patients with hip fracture was mentioned in the case of another such pandemic occurring in the future16).

When elderly patients receive active support provided by medical personnel and assistants for treatment aimed at recovery after surgery, early recovery and a normal return to daily life before fractures can be expected17). Therefore, various programs have been implemented for recovery of exercise ability in elderly patients with hip fracture. Use of a multidisciplinary team approach, which requires assistance from various specialties, is important for achievement of rapid recovery of exercise ability, and to reduce complications that may occur after surgery in elderly patients18). In particular, family-centered care, which involves family participation in the recovery stage after surgery, is regarded as a much better approach to recovery for older patients with hip fracture19,20,21). In the pre-pandemic period, families were able to visit their elderly family members at medical institutions without restriction, and they were responsible for not only pre-operative treatments but also exercise recovery treatments for the elderly patients. The family’s participation in the treatment of elderly patients was considered a positive experience for both physical and mental recovery after the surgeries. With the COVID-19 pandemic, almost every aspect of our society has changed. In many sectors of society, an unfamiliar environment known as non-face-to-face has replaced the face-to-face environment. PCR (polymerase chain reaction) testing was essential for all patients hospitalized in adjacent rooms located along the corridor22). Visits from patients’ guardians were also completely prohibited in an effort to minimize contact between inpatients and outsiders. These environmental changes would have impacted elderly hospitalized patients and their family members in many ways. In a study on postoperative exercise recovery in elderly patients with hip fracture during the pandemic, Anusitviwat et al.23) reported that recovery of motor ability decreased and complications increased over a period of three months after surgery compared to the pre-pandemic.

In our study, evaluation of walking ability using the modified Koval index six months after surgery showed a statistical decrease in walking ability since emergence of the pandemic. According to the results of a survey of the exacerbation rate of the modified Koval index, an increase also occurred after the pandemic. It is believed that these results were caused by direct and active prohibition of visits from guardians due to infection control policies after the pandemic. This tendency was more pronounced in patients admitted to nursing hospitals. No meaningful difference was observed between the pandemic and pre-pandemic groups among patients who were discharged to “home” where they can be with family members. However, a statistically significant decrease in walking ability was observed in patients admitted to nursing care hospitals after the pandemic. These results have been attributed to the lack of active support in management of exercise recovery treatments due to the complete control of parental visits to nursing hospitals and restrictions on contact with caregivers and medical personnel under the stringent infection control policies utilized during the pandemic. By contrast, in the case of home treatment where the influence of COVID-19 was relatively minor, the patient received active family support in performance of walking recovery exercise.

This study has some limitations. First, a retrospective research method was used in the design of this study. Due to the unexpected pandemic, designing a prospective study was difficult. Second, the study period of two years before and after the pandemic was short, and these patients were designated as the population subjects, so that the number was not sufficient. However, despite these limitations, the findings of this study can be regarded as meaningful in that they may be helpful in determining directions for the future as well as further research on treatment for recovery activities including postoperative gait exercise in elderly patients with hip fracture in situations such as the COVID-19 pandemic.

The COVID-19 pandemic had a negative effect on the recovery of walking ability of elderly patients who underwent surgery for treatment of hip fracture, which was particularly evident in nursing hospitals where family visits were completely prohibited. Therefore, establishment of a specific and accurate system for management of exercise recovery treatment for elderly patients with hip fracture in the event of a new pandemic such as COVID-19 in the future and for conduct of a prospective study will be necessary.

CONFLICT OF INTEREST: No other potential conflict of interest relevant to this article was reported.
Fig. 1.

Comparative graph of changes in modified Koval index in nursing hospitals and home care between pre-pandemic and pandemic.

Group A: patients who underwent surgical treatments from January 2018 to December 2019, Group B: patients who underwent surgical treatments from January 2020 to December 2021 after the outbreak of the COVID-19 pandemic.

*P<0.05.


Comparison of Modified Koval Index of All Patients Pre & Post Pandemic, Nursing Hospital and Home Care, and Comparison of Exacerbation Rate during Pre & Post Pandemic
All patientNursing hospitalHome care care
Pre-Group A (n=81)Pan-Group B (n=103)Pre-Group A(n=46)Pan-Group B (n=54)Pre-Group A (n=35)Pan-Group B (n=49)
Before fracture4.23±1.134.04±1.283.87±1.223.67±1.394.71±0.794.45±1.00
P-value0.280.440.20
After fracture3.31±1.792.77±1.912.74±1.761.93±1.814.06±1.573.69±1.57
P-value0.04*0.03*0.30
Exacerbation35 (43.2%)57 (55.3%)25 (54.3%)37 (68.5%)10 (28.6%)20 (40.8%)

Values are presented as mean±standard deviation.

Group A: patients who underwent surgical treatments from January 2018 to December 2019, Group B: patients who underwent surgical treatments from January 2020 to December 2021 after the outbreak of the COVID-19 pandemic. Pre-: pre-pandemic, Pan-: pandemic.

*P<0.05; by independent t-test.


Factors Affecting the Modified Koval Index
BSEβP-value
Pandemic (post)–0.460.24–0.120.04*
Age–0.050.01–0.280.00*
Sex (female)0.440.300.100.15
Nursing hospital care–1.340.25–0.360.00*

Reference: pandemic (pre), sex (male), home care.

R2=0.27, Durbin-Watson=1.78, F (P)=16.15(0.00).

SE: standard error.

*P<0.05; by multiple regression analysis.


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Article

Original Article

Hip Pelvis 2023; 35(4): 253-258

Published online December 31, 2023 https://doi.org/10.5371/hp.2023.35.4.253

Copyright © The Korean Hip Society.

The Effects of COVID-19 Pandemic on the Recovery of Hip Fracture Patients

Young Yool Chung, MD , Sung Nyun Baek, MD , Tae Gyu Park, MD , Min Young Kim, MD

Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea

Correspondence to:Young Yool Chung, MD
(https://orcid.org/0000-0002-4959-1230)
Department of Orthopedic Surgery, Kwangju Christian Hospital, 37 Yangrim-ro, Nam-gu, Gwangju 61661, Korea
TEL: +82-62-650-5064
E-mail: wonderchung@naver.com

Received: June 12, 2023; Revised: September 12, 2023; Accepted: September 13, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose: To figure out how complete control of family visits to prevent infection of coronavirus disease 2019 (COVID-19) affected the activity recovery of hip fracture patients admitted to nursing hospitals.
Materials and Methods: Eighty-one patients with hip surgery in the two years prior to COVID-19 pandemic were classified as Group A, and 103 patients in the next two years were designated as Group B. The subjects’ walking ability was evaluated by using the modified Koval index (MKI). In order to analyze the impact of the family visit control to the subjects, each group was classified into two different groups: (1) inpatients group who admitted to nursing hospitals and (2) home-treated patients. Additionally, statistical elements were processed in consideration of other factors that may affect the results of the experiment.
Results: The MKI evaluated at 6 months postoperative was 3.31±1.79 in Group A and 2.77±1.91 in Group B, and it was meaningfully low after the pandemic (P=0.04). There was significantly low among both of Group A 2.74±1.76 and Group B 1.93±1.81 after the pandemic (P=0.03) among those treated at the nursing hospital. The rate of deterioration of the MKI was 35 (43.2%) in Group A and 57 (55.3%) in Group B, which increased by 12.1% after the pandemic.
Conclusion: The pandemic had a negative effect on the recovery of postoperative activities of elderly hip fracture patients who admitted to nursing hospitals when family access was completely restricted to prevent infection.

Keywords: Femoral neck fractures, COVID-19 pandemic, Koval index, Rehabilitation

INTRODUCTION

In modern society, increased occurrence of hip fractures has been reported, in line with the increasing elderly population1,2). The number of surgical treatments for hip fractures continues to increase, and recovery treatment, including early postoperative walking, can significantly affect recovery of physical function and early return to daily life3,4). However, performance of early exercise on their own after surgery can be difficult for elderly patients, and assistance from medical personnel and supporters is required for recovery. This type of support can reduce the occurrence of postoperative complications and can improve the potential for early discharge from the hospital and return to daily life5,6).

The number of elderly patients with hip fracture admitted to nursing hospitals for postoperative management has recently shown a continuous increase in South Korea. In regard to patients admitted to nursing hospitals, active participation of family members as assistants in recovery exercise treatment was believed to have a positive effect on improving symptoms by providing psychological stability and motivation, thus it was considered a normal routine before the pandemic. However, as a result of the continued coronavirus disease 2019 (COVID-19) pandemic over the two-year period, the severe restriction of unauthorized personnel in hospitals and isolation treatment systems has had a significant impact on the system of treatment for elderly patients with hip fracture. The plan for conduct of the study originated from the need to study the effect of the pandemic on postoperative recovery exercise for elderly patients admitted to nursing hospitals when family visits are prohibited, and to establish a treatment policy for patients who might be isolated from their families because of such a pandemic in the future. Thus, according to our hypothesis, restricting assistance from guardians such as family members who were responsible for a certain portion of walking recovery due to the COVID-19 pandemic would have negatively impacted the recovery of elderly patients with hip fracture.

MATERIALS AND METHODS

A retrospective study of elderly patients (age ≥65 years) who underwent surgery for treatment of a hip fracture from January 2018 to December 2021 at Kwangju Christian Hospital was conducted; patients who had difficulty undergoing accurate evaluation due to severe cognitive impairment and those who could not be tracked for longer than six months after the surgeries were excluded. Patients who underwent surgical treatments from January 2018 to December 2019 were classified as Group A, and those who underwent surgical treatments from January 2020 to December 2021 after the outbreak of the COVID-19 pandemic were designated as Group B. As a routine, two weeks from the day of surgery, which was usually when stitches were removed, was scheduled as the date of discharge, and transfer from the nursing hospital was based on the guardian’s decision according to the patient’s condition. The modified Koval index was used to evaluate patients’ walking ability7). Interviews with both patients and their guardians were conducted for evaluation of the patients’ walking ability before the fracture. Recovery exercise treatments after surgery were started with use of walkers, and exercise time and the number of times exercise was performed were not limited. The final follow-ups for evaluation of gait ability were performed six months after surgery. Analysis and comparison of walking ability prior to the fracture, age and gender before the fracture, and whether or not the patient was hospitalized in a nursing hospital before and after the pandemic were performed in order to determine which factors affected the degree of recovery of walking ability. Independent t-test and multiple regression test from the PASW Statistics (ver. 18.0; IBM) program were used for statistical analysis. A P<0.05 was considered statistically significant. This retrospective study was conducted with the approval of Kwangju Christian Hospital’s Institutional Bioethics Committee (No. KCH-M-2022-11-014), and obtaining written consent from the patient was exempted by the Institutional Bioethics Committee. The conflict of interest is written accurately.

RESULTS

The study included 184 patients, 81 patients in Group A and 103 patients in Group B. Using means and standard deviation, the mean age of 81 patients in Group A was 76.59±10.60 years, with 64 females and 17 males. In Group A, 46 patients (56.8%) were re-admitted to nursing hospitals for recovery exercise treatments after discharge from the hospital, and the remaining patients were managed for recovery exercise with assistance from their families at home. The mean age of 103 patients in Group B was 77.70±10.12 years, with 80 females and 23 males. No study on the rates of transfer of hip fracture patients to a nursing hospital has been conducted; however, in our study, 46 patients (56.8%) with hip fracture from pre-pandemic (Group A) and 54 patients (52.4%) from post-pandemic (Group B) were transferred to nursing hospitals instead of home care for exercise recovery treatments after the surgeries. Regarding the rates of femoral neck and trochanteric fractures, there were 41 cases (50.6%) and 40 cases (49.4%) in Group A, and 61 cases (59.2%) and 42 cases (40.8%) in Group B. The ratio of arthroplasty and osteosynthesis was 58 cases (71.6%) and 23 cases (28.4%) in Group A and 90 cases (87.4%) and 13 cases (12.6%) in Group B, respectively. The modified Koval index before fracture was 4.23±1.13 in Group A and 4.04±1.28 in Group B, and no statistical difference was observed between the two groups (P=0.28). The modified Koval index for the follow-ups six months after surgery was 3.31±1.79 in Group A and 2.77±1.91 in Group B, indicating a statistical reduction in the recovery of walking ability in Group B (P=0.04). The modified Koval index before fracture for patients admitted to nursing hospitals was 3.87±1.22 in Group A and 3.67±1.39 in Group B, and no statistically significant differences were observed between the two groups (P=0.44). However, at six months after surgery, the modified Koval index was 2.74±1.76 in Group A and 1.93±1.81 in Group B, indicating a statistical decrease in the recovery of walking ability in patients who were admitted to nursing hospitals after the pandemic (P=0.03). The modified Koval index before fracture for patients who underwent exercise recovery treatments at home was 4.71±0.79 before surgery in Group A and 4.45±1.00 in Group B (P=0.20). At six months’ postoperative follow-up, the modified Koval index was 4.06±1.57 in Group A and 3.69±1.57 in Group B, showing no statistical difference (P=0.30) according to independent sample t-tests (Fig. 1).

The deterioration rate of the modified Koval index was 35 (43.2%) in Group A and 57 (55.3%) in Group B, an increase of 12.1% after the pandemic. The rate observed for patients admitted to nursing hospitals was 25 (54.3%) in Group A and 37 (68.5%) in Group B, an increase of 14.2% after the pandemic. By contrast, the rate observed for patients who received treatment at home was 10 (28.6%) in Group A and 20 (40.8%) in Group B, an increase of 12.2% after the pandemic (Table 1). The results of multiple regression analysis of the factors affecting the modified Koval index showed that the main factors were the COVID-19 pandemic (β=–0.12, P=0.04), age (β=–0.28, P<0.001), and nursing hospital admission (β=–0.36, P<0.001), and the influence index was in the order of nursing hospital admission, age, and COVID-19 pandemic (Table 2).

DISCUSSION

A higher rate of infection with COVID-19 was observed among elderly people compared to younger persons during the same period8). Higher mortality rates and serious complications resulting from infection have been reported, particularly among older patients with hip fracture, for which a large number of complications and a high mortality rate have been reported9,10,11,12). Although older patients must undergo surgery for treatment of fracture injuries as soon as possible, according to some reports, hospitalization and surgery were sometimes delayed in the early stage of the pandemic, increasing the hospitalization period and aggravating mortality13,14). However, it was also reported that acceptable results were achieved with prompt surgical treatment of patients with hip fracture without increasing complications even during the pandemic period15). As many studies have reported on increased complications and mortality rates after hip fracture during the pandemic, the necessity of thorough preparation for elderly patients with hip fracture was mentioned in the case of another such pandemic occurring in the future16).

When elderly patients receive active support provided by medical personnel and assistants for treatment aimed at recovery after surgery, early recovery and a normal return to daily life before fractures can be expected17). Therefore, various programs have been implemented for recovery of exercise ability in elderly patients with hip fracture. Use of a multidisciplinary team approach, which requires assistance from various specialties, is important for achievement of rapid recovery of exercise ability, and to reduce complications that may occur after surgery in elderly patients18). In particular, family-centered care, which involves family participation in the recovery stage after surgery, is regarded as a much better approach to recovery for older patients with hip fracture19,20,21). In the pre-pandemic period, families were able to visit their elderly family members at medical institutions without restriction, and they were responsible for not only pre-operative treatments but also exercise recovery treatments for the elderly patients. The family’s participation in the treatment of elderly patients was considered a positive experience for both physical and mental recovery after the surgeries. With the COVID-19 pandemic, almost every aspect of our society has changed. In many sectors of society, an unfamiliar environment known as non-face-to-face has replaced the face-to-face environment. PCR (polymerase chain reaction) testing was essential for all patients hospitalized in adjacent rooms located along the corridor22). Visits from patients’ guardians were also completely prohibited in an effort to minimize contact between inpatients and outsiders. These environmental changes would have impacted elderly hospitalized patients and their family members in many ways. In a study on postoperative exercise recovery in elderly patients with hip fracture during the pandemic, Anusitviwat et al.23) reported that recovery of motor ability decreased and complications increased over a period of three months after surgery compared to the pre-pandemic.

In our study, evaluation of walking ability using the modified Koval index six months after surgery showed a statistical decrease in walking ability since emergence of the pandemic. According to the results of a survey of the exacerbation rate of the modified Koval index, an increase also occurred after the pandemic. It is believed that these results were caused by direct and active prohibition of visits from guardians due to infection control policies after the pandemic. This tendency was more pronounced in patients admitted to nursing hospitals. No meaningful difference was observed between the pandemic and pre-pandemic groups among patients who were discharged to “home” where they can be with family members. However, a statistically significant decrease in walking ability was observed in patients admitted to nursing care hospitals after the pandemic. These results have been attributed to the lack of active support in management of exercise recovery treatments due to the complete control of parental visits to nursing hospitals and restrictions on contact with caregivers and medical personnel under the stringent infection control policies utilized during the pandemic. By contrast, in the case of home treatment where the influence of COVID-19 was relatively minor, the patient received active family support in performance of walking recovery exercise.

This study has some limitations. First, a retrospective research method was used in the design of this study. Due to the unexpected pandemic, designing a prospective study was difficult. Second, the study period of two years before and after the pandemic was short, and these patients were designated as the population subjects, so that the number was not sufficient. However, despite these limitations, the findings of this study can be regarded as meaningful in that they may be helpful in determining directions for the future as well as further research on treatment for recovery activities including postoperative gait exercise in elderly patients with hip fracture in situations such as the COVID-19 pandemic.

CONCLUSION

The COVID-19 pandemic had a negative effect on the recovery of walking ability of elderly patients who underwent surgery for treatment of hip fracture, which was particularly evident in nursing hospitals where family visits were completely prohibited. Therefore, establishment of a specific and accurate system for management of exercise recovery treatment for elderly patients with hip fracture in the event of a new pandemic such as COVID-19 in the future and for conduct of a prospective study will be necessary.

CONFLICTS OF INTEREST

CONFLICT OF INTEREST: No other potential conflict of interest relevant to this article was reported.

Fig 1.

Figure 1.

Comparative graph of changes in modified Koval index in nursing hospitals and home care between pre-pandemic and pandemic.

Group A: patients who underwent surgical treatments from January 2018 to December 2019, Group B: patients who underwent surgical treatments from January 2020 to December 2021 after the outbreak of the COVID-19 pandemic.

*P<0.05.

Hip & Pelvis 2023; 35: 253-258https://doi.org/10.5371/hp.2023.35.4.253
Comparison of Modified Koval Index of All Patients Pre & Post Pandemic, Nursing Hospital and Home Care, and Comparison of Exacerbation Rate during Pre & Post Pandemic
All patientNursing hospitalHome care care
Pre-Group A (n=81)Pan-Group B (n=103)Pre-Group A(n=46)Pan-Group B (n=54)Pre-Group A (n=35)Pan-Group B (n=49)
Before fracture4.23±1.134.04±1.283.87±1.223.67±1.394.71±0.794.45±1.00
P-value0.280.440.20
After fracture3.31±1.792.77±1.912.74±1.761.93±1.814.06±1.573.69±1.57
P-value0.04*0.03*0.30
Exacerbation35 (43.2%)57 (55.3%)25 (54.3%)37 (68.5%)10 (28.6%)20 (40.8%)

Values are presented as mean±standard deviation..

Group A: patients who underwent surgical treatments from January 2018 to December 2019, Group B: patients who underwent surgical treatments from January 2020 to December 2021 after the outbreak of the COVID-19 pandemic. Pre-: pre-pandemic, Pan-: pandemic..

*P<0.05; by independent t-test..


Factors Affecting the Modified Koval Index
BSEβP-value
Pandemic (post)–0.460.24–0.120.04*
Age–0.050.01–0.280.00*
Sex (female)0.440.300.100.15
Nursing hospital care–1.340.25–0.360.00*

Reference: pandemic (pre), sex (male), home care..

R2=0.27, Durbin-Watson=1.78, F (P)=16.15(0.00)..

SE: standard error..

*P<0.05; by multiple regression analysis..


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Vol.36 No.1 Mar 01, 2024, pp. 1~75

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