Impact of SARS-CoV-2 Subvariants on Postoperative Outcomes in Geriatric Hip Fracture Patients – A Multinational Multicentre Study

Impact of SARS-CoV-2 Subvariants on Postoperative Outcomes in Geriatric Hip Fracture Patients – A Multinational Multicentre Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of SARS-CoV-2 Subvariants on Postoperative Outcomes in Geriatric Hip Fracture Patients – A Multinational Multicentre Study Gregor Toporowski, Christian Mueller-Mai, Katherine Rascher, Jonas Wiedemann This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7067692/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Dec, 2025 Read the published version in BMC Geriatrics → Version 1 posted 11 You are reading this latest preprint version Abstract Background Hip fractures (HF) are among the most prevalent diagnoses in geriatric traumatology, with persistently high incidence even during the COVID-19 pandemic. Concomitant SARS-CoV-2 infection adds clinical complexity and has been associated with increased mortality and prolonged hospitalisation. This study aimed to assess the impact of SARS-CoV-2 subvariants B.1.1.7 (Alpha), B.1.617.2 (Delta), and B.1.1.529 (Omicron) on postoperative outcomes in patients undergoing surgical treatment for HF. Methods A retrospective multicentre study was conducted using data from the German Registry for Geriatric Trauma (ATR-DGU®) between March 2021 and April 2022 across 119 hospitals. 12707 patients undergoing HF surgery were included and stratified by predominant subvariant periods: Alpha (n = 3714), Delta (n = 5434), and Omicron (n = 3559). Each cohort was further stratified by SARS-CoV-2 status at admission. Results During the Alpha period, in-hospital mortality and length of stay were similar between COVID-19-comorbid (8.3%, 13 days) and SARS-CoV-2-negative patients (5.4%, 15 days). In the Delta and Omicron periods, mortality was significantly higher among COVID-19-comorbid patients (14.3% and 13.9%) compared to SARS-CoV-2-negative patients (5.8%, p = 0.017; 5.7%, p < 0.001), with longer hospitalisations (17 vs. 15 days, p < 0.05). COVID-19-comorbid patients were more frequently institutionalised and exhibited lower levels of pre-fracture mobility compared to SARS-CoV-2-negative patients. Conclusion In contrast to the Alpha period, COVID-19 comorbidity during the Delta and Omicron periods was associated with elevated perioperative mortality and longer hospitalisation, highlighting the clinical relevance of SARS-CoV-2 subvariant characteristics in the management of HF in elderly patients. Trial registration Not applicable. This retrospective study used anonymized data from the German Registry for Geriatric Trauma (ATR-DGU®) and was approved by the ethics committee of the University Münster (reference number: 2022-268-f-S). This study was conducted in accordance with the Declaration of Helsinki. Hip Fracture Proximal Femur Fracture Orthogeriatric Management COVID-19 SARS-CoV-2 Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Hip fractures (HF) are among the most common diseases in geriatric traumatology and represent a challenge for healthcare management ( 1 ). Due to the shift towards an older and multimorbid population, increasing incidences of HF have been reported in European countries ( 2 ). More than 150000 patients in Germany experience an HF annually; approximately 85% are 70 years or older ( 3 ). The high prevalence of comorbidities in these patients adds complexity to their clinical management and increases the demands on inpatient care ( 4 ). The COVID-19 (Coronavirus Disease 2019) pandemic has disproportionately affected the health of geriatric patients. Accordingly, comorbidity with COVID-19 combined with HF is more likely to result in a severe outcome ( 5 , 6 ). Although the incidence of HF temporarily declined during the COVID-19 pandemic, it remained one of geriatric patients' most frequent admission diagnoses ( 7 ). Patients frequently presented to the emergency department with an already high COVID-19 disease burden, which severely deteriorated the surgical management conditions due to the significantly limited surgical capability ( 7 ). In some cases, stabilising the COVID-19 condition was prioritised before HF could be surgically addressed. However, despite recent studies showing no effect of delayed surgical treatment on postoperative outcomes during the COVID-19 pandemic ( 8 ), COVID-19-comorbid patients with HF are associated with significantly higher mortality and hospitalisation time ( 5 , 9 ). COVID-19, particularly its current SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) subvariant "Omicron," remains a significant public health concern. Despite reduced intrinsic virulence compared to earlier strains, the heightened transmissibility of recent subvariants continues to drive substantial overall mortality, particularly among geriatric patients who are at an elevated risk of severe outcomes, hospitalisation, and death ( 10 , 11 ). The coexistence of COVID-19 and HF presents a complex interplay of medical and logistical challenges, exacerbating clinical outcomes and placing considerable strain on healthcare systems, particularly in the management of frail, multimorbid patients. Different subvariants emerged in Germany and across the globe throughout the COVID-19 pandemic, which varied in the pathogenesis of COVID-19 ( 6 ). One of the first subvariants of concern was B.1.1.7 (Alpha), which was predominant in Germany starting from December 2020 up to summer 2021 ( 12 ). The even more contagious subvariant B.1.617.2 (Delta) was detected and the prevailing subvariant until December 2021 ( 13 ). As of January, the B.1.1.529 (Omicron) subvariant was predominant in Germany. The aim of this study was to evaluate whether distinct SARS-CoV-2 subvariants were associated with variation in postoperative outcomes in geriatric patients undergoing hip fracture surgery. Key clinical endpoints included in-hospital and 120-day mortality, complication rates, and hospital length of stay. While overall clinical attention to COVID-19 has declined, Omicron subvariants continue to circulate, and the susceptibility of elderly patients with multiple comorbidities remains unchanged. The findings may inform ongoing perioperative risk assessment and orthogeriatric care strategies under conditions of continued viral presence. 2. Patients and Methods 2.1. Study design The study period was set from March 2021 to April 2022. According to official data from the Robert Koch Institute, this period was subdivided into the following periods: Period 1 (March – June 2021), characterised by the dominance of the B.1.1.7 (Alpha) subvariant in Germany, period 2 (July – December 2021), when the B.1.617.2 (Delta) subvariant was predominant, and period 3 (January – April 2022), when the B.1.1.529 (Omicron) subvariant was predominant ( 12 , 13 ). The Registry for Geriatric Trauma (AltersTraumaRegister DGU®, ATR-DGU) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) was founded in 2016 to improve geriatric trauma care. The geriatric trauma centres certified by the DGU must conduct standardised assessments of the patients treated. During the observation period from March 2021 to April 2022, 119 centres from Germany, Switzerland and Austria were certified. Since July 2020, SARS-CoV-2 status has been recorded by the ATR-DGU. Data analysed in this study were acquired prospectively from the ATR-DGU using standardised and certified data recording tools ( 14 ). According to the criteria of the DGU, certificated geriatric trauma centres are obliged to submit pseudonymised data of their patients aged 70 years and older with HF, pathological femur fractures and peri-implant femur fractures with an indication of surgery to the ATR-DGU. The data is collected in five consecutive time phases: Admission, pre-OP, first post-OP week, discharge/transfer, and optionally follow-up on day 120 post-OP. The follow-up examination includes questions about walking ability, further surgery, and the health-related quality of life questionnaire EQ-5D on days 7 and 120 post-OP. The data were retrospectively evaluated following approval by the ATR-DGU, granted via a peer-review procedure in accordance with publication guidelines laid down by the Working Committee on Geriatric Trauma Registry of the DGU and the University of Muenster Ethics Committee (registration number: 2022-268-f-S). This study is registered under the ATR-DGU-ID 2022-004. Clinical trial number: not applicable. Our findings are reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines ( 15 ). 2.2 Participants 4190 patients received surgical treatment for HF in period 1. 324 patients were excluded due to pathological, peri-implant or periprosthetic fractures. 152 patients were excluded as no SARS-CoV-2 status was reported. Thus, 3714 patients were included in our study in period 1. In period 2, 6375 patients received surgical treatment for HF. 414 patients were excluded due to pathological, peri-implant or periprosthetic fractures. 527 patients were excluded as no SARS-CoV-2 status was reported. Thus, 5434 patients were included in our study in period 2. In period 3, 4329 patients received surgical treatment for HF. 595 patients were excluded due to pathological, peri-implant or periprosthetic fractures. 175 patients were excluded as no SARS-CoV-2 status was reported. Thus, 3559 patients were included in our study in period 3 (Fig. 1). Figure 1: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) flow diagram for patients with hip fractures (HF) treated between March 2021 and April 2022 documented in the Registry for Geriatric Trauma (AltersTraumaRegister, ATR) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU). 2.3 Outcome measures Patients in periods 1, 2, and 3 were stratified into COVID-19-comorbid and SARS-CoV-2-negative. The primary outcome was defined as mortality and duration of hospital stay. In addition, the ability to walk before fracture and on admission, the period from admission to surgical treatment, the ISAR (Identification of Seniors at Risk) score ( 16 ), the ASA (American Society of Anaesthesiologists) score, the living situation before fracture, treatment with anticoagulation, additional injuries, the walking ability on the seventh day after surgery, the living situation at discharge and reoperations were compared between the groups. 2.5 Statistical analysis The statistical evaluations were performed with the statistical software R version 4.0.2. For descriptive analyses, the median and the interquartile range (IQR) were calculated for non-parametric continuous data. Median values were compared using the Wilcoxon signed-rank test and dichotomous variables with the Chi² test. Absolute and relative frequencies represented all categorical data. The results of the EQ-5D-3L questionnaire (EuroQol five-dimension three-level questionnaire ( 11 )) were transformed into a single value for QoL using the time trade-off algorithm validated for Germany ( 17 ). Linear and logistic regression models were used to examine the impact of SARS-COV-2 subvariants on outcomes after controlling for ASA score, sex, age, and type of proximal femur fracture. Results are reported as regression coefficients (β) for linear regression and odds ratios (OR) for logistic regression, along with their 95% confidence interval. Differences were considered statistically significant when p < 0.05. 3. Results Of the total 3714 cases from 112 geriatric trauma centres in period 1, 24 patients were SARS-COV-2-positive, representing a rate of 0.65%. In period 2, out of 5434 cases from 116 geriatric trauma centres, 56 patients were SARS-COV-2-positive at admission, corresponding to a rate of 1.03%. In period 3, out of 3559 cases from 119 geriatric trauma centres, 166 patients were SARS-COV-2-positive at admission, resulting in a rate of 4.66% (Fig. 2). 3.1 Period 1 – Alpha subvariant In period 1, preoperative housing situation was significantly inferior in patients with HF and COVID-19 comorbidity, with a lower proportion of patients residing at home (58%) and a higher proportion of patients living in nursing homes (38%) or hospitals (4%) compared to SARS-COV-2-negative patients (78%/21%/1%, p=0.038). In contrast, no difference in preoperative walking ability was observed compared with SARS-COV-2-negative patients with HF (p=0.866). Concurrently, the in-hospital mortality rate was not significantly different for COVID-19 comorbidity (8.3%) compared to SARS-COV-2-negative patients (5.4%, p=0.851). The median hospitalisation time for SARS-COV-2-negative patients was 15 days (IQR 12) and showed no difference from COVID-19-comorbid patients (13 days, IQR 10, p=0.876). There were also no significant differences between sexes, age, ISAR score, ASA score, current anticoagulation, or additional injuries. At the 120-day follow-up, only 9 of the 22 SARS-COV-2-positive patients treated could be contacted. Although statistical differences were identified when comparing the SARS-COV-2-negative cohort, the small sample size limits the reliability of these findings, and no conclusive differences could be observed in terms of mortality, residential location, walking ability, or hospital readmission (Tab. 3). 3.2 Period 2 – Delta subvariant In period 2, preoperative housing situations did not differ between patients with HF and COVID-19 comorbidity and SARS-CoV-2-negative patients (p=0.358), as did walking ability (p=0.670). The median preoperative ISAR score was 3.0 (IQR 2.0) in COVID-19-comorbid patients, significantly higher than in SARS-COV-2-negative patients (3.0, IQR 1.0, p=0.004). The mortality rate was significantly higher with COVID-19 comorbidity (14.3%) compared to SARS-COV-2-negative patients (5.8%, p=0.017). A significant increase in median hospitalisation time was found in COVID-19-comorbid patients (17 days, IQR 16) compared to SARS-COV-2-negative patients (14 days, IQR 11, p=0.012). At 120 days after surgery, COVID-19-comorbid patients in period 2 showed a significant improvement in housing situation (17%) compared to SARS-COV-2-negative patients (3%, p=0.004) as well as an increased mortality rate of 35.0% compared to SARS-COV-2-negative patients (11.9%, p=0.004). There were no significant differences between sexes, age, ASA score, current anticoagulation, or additional injuries. 3.3 Period 3 – Omicron subvariant The preoperative housing situation in period 3 was inferior in patients with HF and COVID-19 comorbidity, with fewer patients residing at home (62%) and more patients residing in nursing homes (37%) compared with SARS-COV-2-negative patients (80%/19%, p<0.001). Moreover, the walking ability was significantly reduced in the COVID-19-comorbid cohort, resulting in a lower rate of independent walking (30%) and a higher rate of limited to indoor patients (26%) compared with SARS-COV-2-negative cohort (37%/16%, p<0.001). The median preoperative ASA score (3.0, IQR 2.0) and ISAR score (3.0, IQR 0) were significantly higher in COVID-19-comorbid patients compared to SARS-COV-2-negativ patients (p<0.001, p=0.002). The mortality rate was significantly increased with COVID-19 comorbidity (13.9%) compared to SARS-COV-2-negative patients (5.4%, p<0.001). Moreover, the median hospitalisation time was longer in COVID-19-comorbid patients (17 days, IQR 15) compared to SARS-COV-2-negative patients (15 days, IQR 12, p=0.03). No change in housing situation (p=0.774) or difference in mortality (p=0.774) 120 days after surgery was observed in COVID-19-comorbid patients in period 3 compared to SARS-COV-2-negative patients. There were no significant differences between sexes, age, current anticoagulation, or additional injuries. The preoperative physical condition and mobility status and the outcome parameters are detailed in Tables 1, 2, 3 and 4. 3.4 Multivariable analysis During periods 2 and 3, COVID-19 comorbidity was associated with significantly increased odds of in-hospital mortality (OR 2.9, 95% CI 1.2–5.9, p=0.009; OR 2.7, 95% CI 1.6–4.3, p<0.001, respectively). In period 2, the odds ratio for mortality at follow-up after 120 days was 3.1 (95% CI 1.1–8.6, p=0.033) (Fig. 3, Tab. 2). Additionally, the duration of hospitalisation increased by 5.4 days (95% CI 3.0–7.8, p<0.001) in period 2 and 2.4 days (95% CI 0.9–3.9, p=0.002) in period 3. The EQ-5D index after 7 days was significantly reduced in period 3 by 0.13 points (p<0.001) (Fig. 4, Tab. 2). 4. Discussion The COVID-19 pandemic has posed unprecedented challenges to global healthcare systems, particularly in managing vulnerable populations such as geriatric patients with HF. The World Health Organization has consistently monitored and reported the evolving patterns of SARS-COV-2 infection rates and associated mortality worldwide ( 18 ). Multiple studies have demonstrated that COVID-19-comorbid patients with concurrent HF present higher mortality rates and more extended hospital stays compared to SARS-COV-2-negative patients ( 9 , 19 , 20 ). The already vulnerable patient group suffering from geriatric HF is, therefore, at an even greater risk due to COVID-19, underscoring the necessity of a thorough understanding of comorbidity with COVID-19. As the pandemic progressed through various SARS-CoV-2 subvariants, each with distinct transmissibility and severity profiles ( 12 , 13 ), it became crucial to examine whether these subvariants exacerbated the already complex clinical and logistical challenges associated with treating HF in this high-risk population. This multinational, multicentre study provides a detailed analysis of the outcomes of patients with HF with and without COVID-19 comorbidity, stratified by the predominant subvariants: Alpha (B.1.1.7), Delta (B.1.617.2), and Omicron (B.1.1.529). To our knowledge, this represents one of the most comprehensive datasets, focusing on the impact of SARS-CoV-2 subvariants on postoperative outcomes. The initial studies identifying an increased rate of mortality and hospitalisation in patients with HF concurrent with SARS-COV-2 infection focused on the early phase of the pandemic, specifically from 2020 to 2021 ( 8 , 19 ). During this period, the wild-type strain of the virus was predominant, particularly in Germany ( 18 ). Subsequent studies, prompted by the high COVID-19-associated mortality observed during the initial phase, investigated the relationship between COVID-19 comorbidity and surgical treatments ( 21 ). The Alpha (B.1.1.7) subvariant, predominant from 2021, demonstrated both increased transmissibility and higher virulence compared to the wild-type strain ( 18 , 22 ), which resulted in a higher proportion of severe cases among all infections, particularly in individuals without prior immunity ( 23 ). The initiation of Germany's vaccination campaign in December 2020, accompanied by a progressive increase in vaccination coverage, significantly reduced the incidence of severe and fatal disease courses in older adults ( 18 , 24 ). The Delta subvariant, which became the dominant strain in July 2021, presented greater transmissibility and higher virulence than the Alpha subvariant ( 18 ). In contrast, emerging in 2022, the Omicron subvariant displayed increased transmissibility within vaccinated populations but was generally associated with less severe clinical outcomes ( 18 ). Evidence from a study conducted in Hong Kong suggests that the intrinsic virulence of Omicron is comparable to that of the original SARS-CoV-2 type from early 2020 ( 25 ). 4.1 Functional Status and Living Situation before Surgery In our study, the preoperative housing conditions during period 1 (Alpha) and preoperative housing situation and walking situation during period 3 (Omicron) were significantly lower in HF patients with concurrent SARS-COV-2 infection compared to SARS-COV-2-negative HF patients at hospital admission. Pass et al. also observed poorer walking ability and decreased living situations in COVID-19-comorbid patients with HF, analysing the onset of the COVID-19 pandemic, during which the wild-type virus was predominant ( 19 ). This disparity may be attributed to the elevated risk of SARS-COV-2 transmission in nursing homes and assisted living facilities ( 26 ). Moreover, individuals residing in nursing homes are generally characterised by higher levels of frailty and reduced mobility ( 27 ), which may contribute to immunological vulnerability and increased susceptibility to respiratory diseases such as SARS-COV-2 infection ( 28 ). A deterioration in mobilisation due to COVID-19 has also been observed in patients from assisted living settings without surgical treatment ( 26 ). As this patient group is particularly vulnerable, a SARS-COV-2 infection combined with surgical treatment represents an extraordinary burden on their health. During periods 2 (Delta) and 3 (Omicron), higher in-hospital mortality rates and hospitalisation times were observed among SARS-COV-2-positive patients with HF compared to SARS-COV-2-negative patients. This trend was not evident during period 1, although a numerical increase in in-hospital mortality was detected from 5.4–8.3%. In period 1, which represented the shortest observation period, the Alpha subvariant had a lower incidence rate than the Delta and Omicron subvariants in periods 2 and 3, primarily due to limited vaccine availability and, thus, frequent lockdowns as well as possible under-testing ( 18 , 29 ). As a result, only 24 HF patients were reported as SARS-COV-2-positive during this period, necessitating careful interpretation of the findings due to the small sample size and statistical limitations. 4.2 In-Hospital and 120-Day Outcomes across Variant Periods Early studies examining the impact of COVID-19 comorbidity on HF already confirmed an increase in in-hospital mortality and hospitalisation time ( 9 , 19 ). However, these studies focused on the wild-type virus, which exhibited lower mortality rates and disease severity compared to the Alpha and Delta subvariants. Regardless of the subvariant — particularly with the currently predominant subvariant Omicron — COVID-19 comorbidity tends to be associated with an increase in in-hospital mortality rates and hospitalisation time. A SARS-COV-2 screening remains indicated for patients with HF to assess potential risks. 120 days after surgical treatment, COVID-19-comorbid patients in period 2 showed a significant deterioration in housing conditions, which was not observed in periods 1 or 3. Mortality was also significantly higher 120 days after surgical treatment in COVID-19-comorbid patients in period 2. The higher incidence and morbidity of the Delta subvariant compared to the Alpha subvariant could contribute to a more complicated postoperative course in HF patients. At the same time, the clinical course of COVID-19 in individuals infected with the Omicron subvariant is considered milder than in those infected with the Delta subvariant ( 22 ). These associations may support our findings, but it is essential to emphasise the small number of COVID-19-comorbid patients in the cohorts, which limits statistical interpretation. Interestingly, although the Omicron subvariant has been associated with a generally milder disease course ( 11 ), our study found that COVID-19-comorbid HF patients continued to experience prolonged hospitalisation times and higher mortality rates. Notably, 90% of the German population aged over 60 years had received at least one dose of the COVID-19 vaccine by period 3 ( 30 ), thereby providing enhanced protection against severe COVID-19 outcomes. This paradox may reflect the cumulative strain on healthcare resources and the unique vulnerabilities of the geriatric population, characterised by multiple comorbidities and frailty. 4.3 Pathophysiological Mechanisms and Clinical Implications The present findings raise important questions regarding possible pathophysiological mechanisms contributing to the increased perioperative risk in COVID-19-comorbid patients, particularly during the Delta and Omicron periods. Inflammation-induced endothelial dysfunction, hypercoagulability, and myocardial involvement have been reported more frequently in Delta infections compared to earlier variants ( 21 , 22 ). These mechanisms may have contributed to the increased in-hospital and 120-day mortality observed in our cohort during period 2. Although the Omicron subvariant is generally associated with a reduced risk of severe outcomes in the general population ( 25 ), our results indicate that multimorbid elderly patients remain highly vulnerable. This is consistent with recent cohort studies reporting elevated mortality and complication rates in institutionalised older adults during Omicron waves despite high vaccination coverage ( 11 , 30 ). It is possible that frailty and baseline functional impairment outweigh the protective effects of reduced intrinsic virulence in this subgroup. From a clinical perspective, our data support the consideration of variant-specific risk when managing elderly fracture patients. During periods dominated by highly transmissible or more pathogenic variants, intensified perioperative monitoring and early rehabilitation may be warranted. Rapid identification of COVID-19 status on admission remains crucial to avoid delays in surgical care and to reduce nosocomial spread, particularly in geriatric wards. 4.4 Health System Response and Future Research Needs In terms of healthcare planning, the findings underscore the need for flexible, resilient orthogeriatric care structures that can respond to evolving pandemic conditions. Concepts such as modular team deployment, dynamic intensive care unit capacity management, and prioritisation of high-risk surgical patients based on real-time virological data may help optimise resource use in future waves ( 29 ). Finally, further studies are needed to evaluate long-term outcomes beyond mortality in this population. Given the potential interaction between systemic inflammation and postoperative functional decline, future research should include cognitive trajectories, dependency risk, and quality of life following COVID-19-associated hip fracture surgery ( 28 ). The sustained excess mortality observed during Delta and Omicron periods, despite evolving treatment standards and vaccination efforts, suggests a gap between general pandemic policy and the specific needs of orthogeriatric patients. Public health responses should not rely solely on variant virulence in the general population but must incorporate risk profiles of high-vulnerability subgroups ( 11 , 30 ). Real-time integration of variant-specific data into perioperative protocols, staffing logistics, and discharge planning may reduce preventable deaths in future waves. Our data underline the necessity of differentiated health system strategies tailored to elderly trauma populations, independent of overall case severity trends ( 25 , 28 ). 4.5 Study Limitations As a retrospective analysis, this study is subject to inherent biases, including selection and confounding factors. While data collection through the ATR-DGU is standardised and quality-controlled, the lack of detailed clinical data — such as vital signs, the severity of COVID-19 symptoms, vaccination, and specific causes of mortality — limits our ability to draw more granular conclusions. Additionally, the relatively small number of SARS-COV-2-positive patients, especially in the Alpha subgroup, may reduce the statistical power of the analyses, further limiting the ability to draw definitive conclusions. Furthermore, the focus on specialised geriatric trauma centres may restrict the generalizability of our findings to other healthcare settings. 5. Conclusion This multinational, multicentre study demonstrates that SARS-CoV-2 subvariants exert distinct effects on perioperative outcomes in geriatric patients with hip fractures. While COVID-19 comorbidity during the Delta and Omicron waves was associated with significantly increased in-hospital mortality and prolonged hospitalisation, such effects were not observed during the Alpha period. This subvariant-specific risk profile highlights the importance of ongoing virological surveillance and its integration into orthogeriatric decision-making. Our findings support the implementation of adaptable, evidence-informed perioperative strategies and underscore the need for dynamic resource allocation, including the development of preoperative triage pathways tailored to variant virulence, to protect this highly vulnerable patient population during current and future pandemic waves. Abbreviations AUC Academy for Trauma Surgery HF Hip fracture ATR-DGU German Registry for Geriatric Trauma COVID-19 Coronavirus Disease 2019 SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus 2 DGU German Trauma Society / Deutsche Gesellschaft für Unfallchirurgie STROBE Strengthening the Reporting of Observational Studies in Epidemiology ISAR Identification of Seniors at Risk ASA American Society of Anaesthesiologists IQR interquartile range EQ-5D-3L EuroQol five-dimension three-level questionnaire OR odds ratio Declarations Ethics approval and consent to participate The study was approved by the ethics committee of the University of Muenster (registration number: 2022-268-f-S). Each author certifies that their institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical research principles, and that informed consent for participation in the study was obtained. This study was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from AUC but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of AUC. Funding statement The authors received no financial or material support for the research, authorship, and/or publication of this article. Authors' contributions The data were interpreted, and the manuscript was drafted by GT and JW. Data acquisition, research design, data interpretation, critical manuscript revision, and substantial modifications were conducted collaboratively by CM, GT, KR and JW. JW, CM, and GT performed. GT, JW and CM were responsible for creating tables and figures. KR conducted the statistical analysis. All authors reviewed and approved the final version of the manuscript before submission. 7. Ethics, Consent to Participate, Consent for Publication. No animal studies are presented in this manuscript. The study involving human participants was reviewed and approved by the ethical committee of the University of Muenster (registration number: 2022-268-f-S). Clinical trial number: not applicable. 8. Competing interests The authors declare that they have no competing interests. 9. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 10. Data sharing Deidentified participant data underlying the findings of this study are not publicly available but may be accessed upon reasonable request. Data access requires prior approval from the Academic Board of the German Registry for Geriatric Trauma (AltersTraumaRegister DGU®). Requests should be directed to the registry office ( [email protected] ) and are subject to institutional policies and data use agreements. The study protocol and analysis plan are available from the corresponding author upon request. 11. Acknowledgements The authors are grateful to all the included patients in the study. References Veronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458-60. Beerekamp MSH, de Muinck Keizer RJO, Schep NWL, Ubbink DT, Panneman MJM, Goslings JC. Epidemiology of extremity fractures in the Netherlands. Injury. 2017;48(7):1355-62. Rupp M, Walter N, Pfeifer C, Lang S, Kerschbaum M, Krutsch W, et al. The Incidence of Fractures Among the Adult Population of Germany–an Analysis From 2009 through 2019. Deutsches Arzteblatt international. 2021;118(40):665-9. Pfeufer D, Kammerlander C, Stadler C, Roth T, Blauth M, Neuerburg C, et al. 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COVID-19 and Proximal Femur Fracture in Older Adults-A Lethal Combination? An Analysis of the Registry for Geriatric Trauma (ATR-DGU). Journal of the American Medical Directors Association. 2022;23(4):576-80. Knauf T, Eschbach D, Bücking B, Knobe M, Rascher K, Schoeneberg C, et al. Auswirkungen der COVID-19-Pandemie auf den Verlauf von alterstraumatologischen Patienten mit proximaler Femurfraktur. Die Unfallchirurgie. 2024;127(3):228-34. Nepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JFF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet. 2020;396(10243):27-38. Lin L, Liu Y, Tang X, He D. The Disease Severity and Clinical Outcomes of the SARS-CoV-2 Variants of Concern. Frontiers in public health. 2021;9:775224. Davies NG, Jarvis CI, Edmunds WJ, Jewell NP, Diaz-Ordaz K, Keogh RH. Increased mortality in community-tested cases of SARS-CoV-2 lineage B.1.1.7. Nature. 2021;593(7858):270-4. Perumal N, Steffen A, Ullrich A, Siedler A. Impact of COVID-19 immunisation on COVID-19 incidence, hospitalisations, and deaths by age group in Germany from December 2020 to October 2021. Vaccine. 2022;40(21):2910-4. Wong JY, Cheung JK, Lin Y, Bond HS, Lau EHY, Ip DKM, et al. Intrinsic and Effective Severity of Coronavirus Disease 2019 Cases Infected With the Ancestral Strain and Omicron BA.2 Variant in Hong Kong. The Journal of infectious diseases. 2023;228(9):1231-9. Sugg MM, Spaulding TJ, Lane SJ, Runkle JD, Harden SR, Hege A, et al. Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach. The Science of the total environment. 2021;752:141946. Kojima G. Prevalence of Frailty in Nursing Homes: A Systematic Review and Meta-Analysis. Journal of the American Medical Directors Association. 2015;16(11):940-5. Li H, Manwani B, Leng SX. Frailty, inflammation, and immunity. Aging and disease. 2011;2(6):466-73. Fritz M, Gries T, Redlin M. The effectiveness of vaccination, testing, and lockdown strategies against COVID-19. International Journal of Health Economics and Management. 2023;23(4):585-607. Robert-Koch-Institut. Monitoring des COVID-19-Impfgeschehens in Deutschland. 2022;Monatsbericht vom 01.12.2022. Tables Table 1: Outcome parameters of geriatric patients with (COVID-pos) and those without COVID-19 comorbidity (COVID-neg) and hip fracture (HF) across periods of Alpha, Delta, and Omicron variant predominance Group comparisons were performed using Wilcoxon rank-sum and Chi-squared tests as appropriate. Parameter Period 1 (Alpha) Period 2 (Delta) Period 3 (Omicron) COVID-neg COVID-pos p Value COVID-neg COVID-pos p Value COVID-neg COVID-pos p Value In-house mortality (n, %) 198/3489 (5%) 2/142 (8%) 0·851 313/5056 (6%) 8/48 (14%) 0·017 181/3197 (5%) 23/142 (14%) <0·001 Time of hospitalisation (n, days/IQR) 3475, 15 (IQR 12) 22, 13 (IQR 10) 0·876 5036, 14 (IQR 11) 47, 17 (IQR 16) 0·012 3172, 15 (IQR 12) 140, 17 (IQR 15) 0·030 Time to surgery (n, hours/IQR) 3664, 16 (IQR 16) 24, 16 (IQR 17) 0·756 5351, 16 (IQR 16) 56, 14 (IQR 16) 0·996 3325, 16 (IQR 16) 164, 17 (IQR 15) 0·104 EQ5d score 7 days after surgery (n, median/IQR) 2457, 0·701 (IQR 0·410) 19, 0·701 (IQR 0·457) 0·684 3535, 0·701 (IQR 0·410) 31, 0·378 (IQR 0·410) 0·361 2400, 0·701 (IQR 0·410) 100, 0·313 (IQR 0·638) <0·001 Table 2: Multivariable analysis using logistic regression (odds ratio [OR] with 95% confidence interval [CI]) for key outcomes and linear regression (β-coefficient with 95% CI) for key predictors after surgical treatment of HF in COVID-19-comorbid patients. All models were adjusted for sex, age, ASA score and fracture type. Parameter Period 1 (Alpha) Period 2 (Delta) Period 3 (Omicron) n OR (95% CI) p Value n OR (95% CI) p Value n OR (95% CI) p Value In-house mortality 3594 1·54 (0·24-5·49) 0·567 5239 2·85 (1·21-5·94) 0·009 3397 2·69 (1·62-4·31) <0·001 Acute reoperation 3587 1·30 (0·07-6·32) 0·800 5138 2·67 (0·91-6·22) 0·040 138 0·69 1 Follow-up mortality 1205 1·25 (0·15-10·42) 0·838 1611 3·07 (1·10-8·62) 0·033 908 0·96 (0·35-2·62) 0·938 n β (95% CI) p Value n β (95% CI) p Value n β (95% CI) p Value Time to surgery 3648 1·02 (-8·22-10·26) 0·829 5352 -2·35 (-8·33-3·63) 0·442 3356 1·92 (-2·28-6·13) 0·370 Hospitalisation time 3462 0·75 (-2·74-4·24) 0·673 5029 5·36 (2·95-7·76) <0·001 3177 2·43 (0·93-3·94) 0·002 EQ5d after 7 days 2427 0·01 (-0·13-0·14) 0·935 3501 -0·03 (-0·13-0·07) 0·536 2382 -0·13 (-0·18-0·07) <0·001 Table 3: Preoperative functional status, comorbidities, and social background in SARS-CoV-2-positive and -negative geriatric HF patients across periods of Alpha, Delta, and Omicron variant predominance. Data are shown as n (%) or median (IQR). Comparisons were conducted using Chi-squared and Wilcoxon rank-sum tests as appropriate. Parameter Period 1 (Alpha) Period 2 (Delta) Period 3 (Omicron) COVID-neg COVID-pos p Value COVID-neg COVID-pos p Value COVID-neg COVID-pos p Value Housing situation Home 2830 (78%) 14 (58%) 0·038 4190 (79%) 40 (71%) 0·358 2695 (80%) 101 (62%) <0·001 Nursing Home 760 (21%) 9 (38%) 1408 (20%) 15 (27%) 625 (19%) 61 (37%) Hospital or other 46 (1%) 1 (4%) 73 (1%) 1 (2%) 26 (1%) 2 (1%) Ambulatory status Independent 1228 (36%) 7 (33%) <0·001 1835 (37%) 15 (30%) <0·001 1169 (37%) 43 (30%) <0·001 With cane 345 (10%) 3 (14%) 470 (10%) 7 (14%) 294 (9%) 11 (8%) With crutches or walker 1177 (35%) 7 (33%) 1699 (35%) 18 (36%) 1059 (34%) 48 (33%) Limited to indoor 516 (15%) 4 (19%) 733 (15%) 9 (18%) 499 (16%) 37 (26%) Non-ambulatory 109 (3%) - 168 (3%) 1 (2%) 98 (3%) 4 (3%) ASA score 3·0 (IQR 0) 3·0 (IQR 0) 0·366 3·0 (IQR 0) 3·0 (IQR 0) 0·193 3·0 (IQR 0) 3·0 (IQR 0) 0·004 ISAR score 3·0 (IQR 2·0) 3·0 (IQR 2·0) 0·327 3·0 (IQR 2·0) 3·0 (IQR 1·0) 0·004 3·0 (IQR 2·0) 3·0 (IQR 2·0) <0·001 Table 4: Follow-up outcomes at 120 days after HF surgery in SARS-CoV-2-positive and -negative geriatric patients, stratified by variant period (Alpha, Delta, Omicron). Reported outcomes include mortality, readmission, revision surgery, walking ability, and housing status. Data are shown as n (%) or median (IQR). Group comparisons were conducted using Chi-squared and Wilcoxon rank-sum tests as appropriate. Parameter Period 1 (Alpha) Period 2 (Delta) Period 3 (Omicron) COVID-neg COVID-pos p Value COVID-neg COVID-pos p Value COVID-neg COVID-pos p Value Readmission No 1152 (96%) 9 (100%) <0·001 1455 (95%) 20 (91%) 0·615 758 (97%) 32 (100%) <0·001 Yes 44 (4%) 0 (0%) 69 (5%) 2 (9%) 25 (3%) 0 (0%) Walking ability No change 354 (36%) 1 (14%) 0·472 425 (35%) 4 (29%) 0·660 290 (39%) 17 (57%) 0·154 Improved 89 (9%) 1 (14%) 98 (8%) 2 (14%) 72 (10%) 2 (6%) reduced 530 (55%) 5 (72%) 705 (57%) 8 (57%) 381 (51%) 11 (37%) Housing situation No change 139 (18%) 0 (0%) <0·001 152 (15%) 2 (17%) 0·004 86 (13%) 3 (14%) 0·774 Improved 11 (1%) 0 (0%) 22 (2%) 2 (17%) 16 (2%) 1 (5%) reduced 638 (81%) 5 (100%) 851 (83%) 8 (66%) 561 (85%) 17 (81%) Mortality Yes 977 (87%) 7 (88%) 1 1274 (88%) 13 (65%) 0·004 778 (88%) 31 (78%) 0·774 No 146 (13%) 1 (12%) 172 (12%) 7 (35%) 108 (12%) 9 (22%) Revision surgery Yes 1124 (97%) 20 (95%) 0·619 1426 (97%) 20 (95%) 1 751 (97%) 32 (100%) <0·001 No 38 (3%) 1 (5%) 52 (3%) 1 (5%) 26 (3%) 0 (0%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Dec, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 07 Oct, 2025 Reviews received at journal 06 Oct, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviews received at journal 13 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers invited by journal 08 Aug, 2025 Editor assigned by journal 05 Aug, 2025 Editor invited by journal 18 Jul, 2025 Submission checks completed at journal 15 Jul, 2025 First submitted to journal 15 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7067692","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499443206,"identity":"96dbbc5c-8c05-4777-8b8c-41a416d76a89","order_by":0,"name":"Gregor Toporowski","email":"data:image/png;base64,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","orcid":"","institution":"University Hospital Münster","correspondingAuthor":true,"prefix":"","firstName":"Gregor","middleName":"","lastName":"Toporowski","suffix":""},{"id":499443207,"identity":"033810ca-0877-47dd-97ef-13b8f2fc86d3","order_by":1,"name":"Christian Mueller-Mai","email":"","orcid":"","institution":"Katholisches Klinikum Lünen/Werne , St.-Marien-Hospital Lünen","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Mueller-Mai","suffix":""},{"id":499443209,"identity":"9b875c0a-5982-4b75-8a0f-e20826aa7ee2","order_by":2,"name":"Katherine Rascher","email":"","orcid":"","institution":"AUC - Academy for Trauma Surgery (AUC)","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Rascher","suffix":""},{"id":499443211,"identity":"d69e889c-c225-4159-97c1-07f3dc660f30","order_by":3,"name":"Jonas Wiedemann","email":"","orcid":"","institution":"Katholisches Klinikum Lünen/Werne , St.-Marien-Hospital Lünen","correspondingAuthor":false,"prefix":"","firstName":"Jonas","middleName":"","lastName":"Wiedemann","suffix":""}],"badges":[],"createdAt":"2025-07-07 17:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7067692/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7067692/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-025-06840-6","type":"published","date":"2025-12-20T15:57:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89231089,"identity":"61c9c903-0ccb-4d06-bef8-381bad68fd91","added_by":"auto","created_at":"2025-08-17 14:17:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":792710,"visible":true,"origin":"","legend":"\u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology (STROBE) flow diagram for patients with hip fractures (HF) treated between March 2021 and April 2022 documented in the Registry for Geriatric Trauma (AltersTraumaRegister, ATR) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU).\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7067692/v1/716f2d853afa681ab27be356.jpg"},{"id":89230043,"identity":"e38ac080-2e72-45ca-8e1d-70ba23ff041b","added_by":"auto","created_at":"2025-08-17 14:09:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68992,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of geriatric hip fracture patients who tested positive for SARS-CoV-2 at admission, stratified by the dominant subvariant period: Alpha, Delta, and Omicron. Values represent the percentage of total hip fracture cases registered in the respective time periods.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7067692/v1/e0aca23e61b0f8a4de5c23ef.jpg"},{"id":89230060,"identity":"a0f8c97f-9447-4254-a2e1-35b76e152a49","added_by":"auto","created_at":"2025-08-17 14:09:44","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":111374,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariable logistic regression models estimating adjusted odds ratios with 95% confidence intervals for in-hospital mortality, acute reoperation, and 120-day mortality during follow-up across period 1 (blue), period 2 (red), and period 3 (green). All models were adjusted for sex, age, ASA score and fracture type.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7067692/v1/6d0e773dd224eee570bf5e9d.jpg"},{"id":89230050,"identity":"8911edc1-7269-4425-8f0b-7ab6c8543264","added_by":"auto","created_at":"2025-08-17 14:09:44","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":117604,"visible":true,"origin":"","legend":"\u003cp\u003eResults from multivariable linear regression models estimating the association between dominant SARS-CoV-2 subvariants and three postoperative outcomes: time to surgery, hospital length of stay, and EQ-5D score on postoperative day 7. Shapes indicate the dominant variant periods: Period 1 (blue), period 2 (red), period 3 (green). Models were adjusted for age, sex, ASA score, and fracture type. Error bars represent 95% confidence intervals.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7067692/v1/6a2bc44e263901f92b66e214.jpg"},{"id":98814953,"identity":"9755b9de-54a2-4d7a-8f90-b3ac229b828b","added_by":"auto","created_at":"2025-12-22 16:13:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2219685,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7067692/v1/5d368a61-906f-4274-824b-1f69dff5ad71.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of SARS-CoV-2 Subvariants on Postoperative Outcomes in Geriatric Hip Fracture Patients – A Multinational Multicentre Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHip fractures (HF) are among the most common diseases in geriatric traumatology and represent a challenge for healthcare management (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Due to the shift towards an older and multimorbid population, increasing incidences of HF have been reported in European countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). More than 150000 patients in Germany experience an HF annually; approximately 85% are 70 years or older (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The high prevalence of comorbidities in these patients adds complexity to their clinical management and increases the demands on inpatient care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe COVID-19 (Coronavirus Disease 2019) pandemic has disproportionately affected the health of geriatric patients. Accordingly, comorbidity with COVID-19 combined with HF is more likely to result in a severe outcome (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Although the incidence of HF temporarily declined during the COVID-19 pandemic, it remained one of geriatric patients' most frequent admission diagnoses (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Patients frequently presented to the emergency department with an already high COVID-19 disease burden, which severely deteriorated the surgical management conditions due to the significantly limited surgical capability (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In some cases, stabilising the COVID-19 condition was prioritised before HF could be surgically addressed. However, despite recent studies showing no effect of delayed surgical treatment on postoperative outcomes during the COVID-19 pandemic (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), COVID-19-comorbid patients with HF are associated with significantly higher mortality and hospitalisation time (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCOVID-19, particularly its current SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) subvariant \"Omicron,\" remains a significant public health concern. Despite reduced intrinsic virulence compared to earlier strains, the heightened transmissibility of recent subvariants continues to drive substantial overall mortality, particularly among geriatric patients who are at an elevated risk of severe outcomes, hospitalisation, and death (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The coexistence of COVID-19 and HF presents a complex interplay of medical and logistical challenges, exacerbating clinical outcomes and placing considerable strain on healthcare systems, particularly in the management of frail, multimorbid patients.\u003c/p\u003e\u003cp\u003eDifferent subvariants emerged in Germany and across the globe throughout the COVID-19 pandemic, which varied in the pathogenesis of COVID-19 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). One of the first subvariants of concern was B.1.1.7 (Alpha), which was predominant in Germany starting from December 2020 up to summer 2021 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The even more contagious subvariant B.1.617.2 (Delta) was detected and the prevailing subvariant until December 2021 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). As of January, the B.1.1.529 (Omicron) subvariant was predominant in Germany.\u003c/p\u003e\u003cp\u003eThe aim of this study was to evaluate whether distinct SARS-CoV-2 subvariants were associated with variation in postoperative outcomes in geriatric patients undergoing hip fracture surgery. Key clinical endpoints included in-hospital and 120-day mortality, complication rates, and hospital length of stay. While overall clinical attention to COVID-19 has declined, Omicron subvariants continue to circulate, and the susceptibility of elderly patients with multiple comorbidities remains unchanged. The findings may inform ongoing perioperative risk assessment and orthogeriatric care strategies under conditions of continued viral presence.\u003c/p\u003e"},{"header":"2. Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study design\u003c/h2\u003e\u003cp\u003eThe study period was set from March 2021 to April 2022. According to official data from the Robert Koch Institute, this period was subdivided into the following periods: Period 1 (March \u0026ndash; June 2021), characterised by the dominance of the B.1.1.7 (Alpha) subvariant in Germany, period 2 (July \u0026ndash; December 2021), when the B.1.617.2 (Delta) subvariant was predominant, and period 3 (January \u0026ndash; April 2022), when the B.1.1.529 (Omicron) subvariant was predominant (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Registry for Geriatric Trauma (AltersTraumaRegister DGU\u0026reg;, ATR-DGU) of the German Trauma Society (Deutsche Gesellschaft f\u0026uuml;r Unfallchirurgie, DGU) was founded in 2016 to improve geriatric trauma care. The geriatric trauma centres certified by the DGU must conduct standardised assessments of the patients treated. During the observation period from March 2021 to April 2022, 119 centres from Germany, Switzerland and Austria were certified. Since July 2020, SARS-CoV-2 status has been recorded by the ATR-DGU.\u003c/p\u003e\u003cp\u003eData analysed in this study were acquired prospectively from the ATR-DGU using standardised and certified data recording tools (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). According to the criteria of the DGU, certificated geriatric trauma centres are obliged to submit pseudonymised data of their patients aged 70 years and older with HF, pathological femur fractures and peri-implant femur fractures with an indication of surgery to the ATR-DGU. The data is collected in five consecutive time phases: Admission, pre-OP, first post-OP week, discharge/transfer, and optionally follow-up on day 120 post-OP. The follow-up examination includes questions about walking ability, further surgery, and the health-related quality of life questionnaire EQ-5D on days 7 and 120 post-OP.\u003c/p\u003e\u003cp\u003e The data were retrospectively evaluated following approval by the ATR-DGU, granted via a peer-review procedure in accordance with publication guidelines laid down by the Working Committee on Geriatric Trauma Registry of the DGU and the University of Muenster Ethics Committee (registration number: 2022-268-f-S). This study is registered under the ATR-DGU-ID 2022-004. Clinical trial number: not applicable.\u003c/p\u003e\u003cp\u003eOur findings are reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Participants\u003c/h2\u003e\u003cp\u003e4190 patients received surgical treatment for HF in period 1. 324 patients were excluded due to pathological, peri-implant or periprosthetic fractures. 152 patients were excluded as no SARS-CoV-2 status was reported. Thus, 3714 patients were included in our study in period 1. In period 2, 6375 patients received surgical treatment for HF. 414 patients were excluded due to pathological, peri-implant or periprosthetic fractures. 527 patients were excluded as no SARS-CoV-2 status was reported. Thus, 5434 patients were included in our study in period 2. In period 3, 4329 patients received surgical treatment for HF. 595 patients were excluded due to pathological, peri-implant or periprosthetic fractures. 175 patients were excluded as no SARS-CoV-2 status was reported. Thus, 3559 patients were included in our study in period 3 (Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eFigure 1: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) flow diagram for patients with hip fractures (HF) treated between March 2021 and April 2022 documented in the Registry for Geriatric Trauma (AltersTraumaRegister, ATR) of the German Trauma Society (Deutsche Gesellschaft f\u0026uuml;r Unfallchirurgie, DGU).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Outcome measures\u003c/h2\u003e\u003cp\u003ePatients in periods 1, 2, and 3 were stratified into COVID-19-comorbid and SARS-CoV-2-negative. The primary outcome was defined as mortality and duration of hospital stay. In addition, the ability to walk before fracture and on admission, the period from admission to surgical treatment, the ISAR (Identification of Seniors at Risk) score (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), the ASA (American Society of Anaesthesiologists) score, the living situation before fracture, treatment with anticoagulation, additional injuries, the walking ability on the seventh day after surgery, the living situation at discharge and reoperations were compared between the groups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e\u003cp\u003eThe statistical evaluations were performed with the statistical software R version 4.0.2. For descriptive analyses, the median and the interquartile range (IQR) were calculated for non-parametric continuous data. Median values were compared using the Wilcoxon signed-rank test and dichotomous variables with the Chi\u0026sup2; test. Absolute and relative frequencies represented all categorical data. The results of the EQ-5D-3L questionnaire (EuroQol five-dimension three-level questionnaire (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)) were transformed into a single value for QoL using the time trade-off algorithm validated for Germany (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Linear and logistic regression models were used to examine the impact of SARS-COV-2 subvariants on outcomes after controlling for ASA score, sex, age, and type of proximal femur fracture. Results are reported as regression coefficients (β) for linear regression and odds ratios (OR) for logistic regression, along with their 95% confidence interval. Differences were considered statistically significant when p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eOf the total 3714 cases from 112 geriatric trauma centres in period 1, 24 patients were SARS-COV-2-positive, representing a rate of 0.65%. In period 2, out of 5434 cases from 116 geriatric trauma centres, 56 patients were SARS-COV-2-positive at admission, corresponding to a rate of 1.03%. In period 3, out of 3559 cases from 119 geriatric trauma centres, 166 patients were SARS-COV-2-positive at admission, resulting in a rate of 4.66% (Fig. 2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.1 Period 1 \u0026ndash; Alpha subvariant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn period 1, preoperative housing situation was significantly inferior in patients with HF and COVID-19 comorbidity, with a lower proportion of patients residing at home (58%) and a higher proportion of patients living in nursing homes (38%) or hospitals (4%) compared to SARS-COV-2-negative patients (78%/21%/1%, p=0.038). In contrast, no difference in preoperative walking ability was observed compared with SARS-COV-2-negative patients with HF (p=0.866). Concurrently, the in-hospital mortality rate was not significantly different for COVID-19 comorbidity (8.3%) compared to SARS-COV-2-negative patients (5.4%, p=0.851). The median hospitalisation time for SARS-COV-2-negative patients was 15 days (IQR 12) and showed no difference from COVID-19-comorbid patients (13 days, IQR 10, p=0.876). There were also no significant differences between sexes, age, ISAR score, ASA score, current anticoagulation, or additional injuries. At the 120-day follow-up, only 9 of the 22 SARS-COV-2-positive patients treated could be contacted. Although statistical differences were identified when comparing the SARS-COV-2-negative cohort, the small sample size limits the reliability of these findings, and no conclusive differences could be observed in terms of mortality, residential location, walking ability, or hospital readmission (Tab. 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.2 Period 2 \u0026ndash; Delta subvariant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn period 2, preoperative housing situations did not differ between patients with HF and COVID-19 comorbidity and SARS-CoV-2-negative patients (p=0.358), as did walking ability (p=0.670). The median preoperative ISAR score was 3.0 (IQR 2.0) in COVID-19-comorbid patients, significantly higher than in SARS-COV-2-negative patients (3.0, IQR 1.0, p=0.004). The mortality rate was significantly higher with COVID-19 comorbidity (14.3%) compared to SARS-COV-2-negative patients (5.8%, p=0.017). A significant increase in median hospitalisation time was found in COVID-19-comorbid patients (17 days, IQR 16) compared to SARS-COV-2-negative patients (14 days, IQR 11, p=0.012). At 120 days after surgery, COVID-19-comorbid patients in period 2 showed a significant improvement in housing situation (17%) compared to SARS-COV-2-negative patients (3%, p=0.004) as well as an increased mortality rate of 35.0% compared to SARS-COV-2-negative patients (11.9%, p=0.004). There were no significant differences between sexes, age, ASA score, current anticoagulation, or additional injuries.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.3 Period 3 \u0026ndash; Omicron subvariant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe preoperative housing situation in period 3 was inferior in patients with HF and COVID-19 comorbidity, with fewer patients residing at home (62%) and more patients residing in nursing homes (37%) compared with SARS-COV-2-negative patients (80%/19%, p\u0026lt;0.001). Moreover, the walking ability was significantly reduced in the COVID-19-comorbid cohort, resulting in a lower rate of independent walking (30%) and a higher rate of limited to indoor patients (26%) compared with SARS-COV-2-negative cohort (37%/16%, p\u0026lt;0.001). The median preoperative ASA score (3.0, IQR 2.0) and ISAR score (3.0, IQR 0) \u0026nbsp;were significantly higher in COVID-19-comorbid patients compared to SARS-COV-2-negativ patients (p\u0026lt;0.001, p=0.002). The mortality rate was significantly increased with COVID-19 comorbidity (13.9%) compared to SARS-COV-2-negative patients (5.4%, p\u0026lt;0.001). Moreover, the median hospitalisation time was longer in COVID-19-comorbid patients (17 days, IQR 15) compared to SARS-COV-2-negative patients (15 days, IQR 12, p=0.03). No change in housing situation (p=0.774) or difference in mortality (p=0.774) 120 days after surgery was observed in COVID-19-comorbid patients in period 3 compared to SARS-COV-2-negative patients. There were no significant differences between sexes, age, current anticoagulation, or additional injuries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe preoperative physical condition and mobility status and the outcome parameters are detailed in Tables 1, 2, 3 and 4.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3.4 Multivariable analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring periods 2 and 3, COVID-19 comorbidity was associated with significantly increased odds of in-hospital mortality (OR 2.9, 95% CI 1.2\u0026ndash;5.9, p=0.009; OR 2.7, 95% CI 1.6\u0026ndash;4.3, p\u0026lt;0.001, respectively). In period 2, the odds ratio for mortality at follow-up after 120 days was 3.1 (95% CI 1.1\u0026ndash;8.6, p=0.033) (Fig. 3, Tab. 2). Additionally, the duration of hospitalisation increased by 5.4 days (95% CI 3.0\u0026ndash;7.8, p\u0026lt;0.001) in period 2 and 2.4 days (95% CI 0.9\u0026ndash;3.9, p=0.002) in period 3. The EQ-5D index after 7 days was significantly reduced in period 3 by 0.13 points (p\u0026lt;0.001) (Fig. 4, Tab. 2).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe COVID-19 pandemic has posed unprecedented challenges to global healthcare systems, particularly in managing vulnerable populations such as geriatric patients with HF. The World Health Organization has consistently monitored and reported the evolving patterns of SARS-COV-2 infection rates and associated mortality worldwide (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Multiple studies have demonstrated that COVID-19-comorbid patients with concurrent HF present higher mortality rates and more extended hospital stays compared to SARS-COV-2-negative patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The already vulnerable patient group suffering from geriatric HF is, therefore, at an even greater risk due to COVID-19, underscoring the necessity of a thorough understanding of comorbidity with COVID-19. As the pandemic progressed through various SARS-CoV-2 subvariants, each with distinct transmissibility and severity profiles (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), it became crucial to examine whether these subvariants exacerbated the already complex clinical and logistical challenges associated with treating HF in this high-risk population.\u003c/p\u003e\u003cp\u003eThis multinational, multicentre study provides a detailed analysis of the outcomes of patients with HF with and without COVID-19 comorbidity, stratified by the predominant subvariants: Alpha (B.1.1.7), Delta (B.1.617.2), and Omicron (B.1.1.529). To our knowledge, this represents one of the most comprehensive datasets, focusing on the impact of SARS-CoV-2 subvariants on postoperative outcomes.\u003c/p\u003e\u003cp\u003eThe initial studies identifying an increased rate of mortality and hospitalisation in patients with HF concurrent with SARS-COV-2 infection focused on the early phase of the pandemic, specifically from 2020 to 2021 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). During this period, the wild-type strain of the virus was predominant, particularly in Germany (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Subsequent studies, prompted by the high COVID-19-associated mortality observed during the initial phase, investigated the relationship between COVID-19 comorbidity and surgical treatments (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The Alpha (B.1.1.7) subvariant, predominant from 2021, demonstrated both increased transmissibility and higher virulence compared to the wild-type strain (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), which resulted in a higher proportion of severe cases among all infections, particularly in individuals without prior immunity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The initiation of Germany's vaccination campaign in December 2020, accompanied by a progressive increase in vaccination coverage, significantly reduced the incidence of severe and fatal disease courses in older adults (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The Delta subvariant, which became the dominant strain in July 2021, presented greater transmissibility and higher virulence than the Alpha subvariant (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In contrast, emerging in 2022, the Omicron subvariant displayed increased transmissibility within vaccinated populations but was generally associated with less severe clinical outcomes (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Evidence from a study conducted in Hong Kong suggests that the intrinsic virulence of Omicron is comparable to that of the original SARS-CoV-2 type from early 2020 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Functional Status and Living Situation before Surgery\u003c/h2\u003e\u003cp\u003eIn our study, the preoperative housing conditions during period 1 (Alpha) and preoperative housing situation and walking situation during period 3 (Omicron) were significantly lower in HF patients with concurrent SARS-COV-2 infection compared to SARS-COV-2-negative HF patients at hospital admission. Pass et al. also observed poorer walking ability and decreased living situations in COVID-19-comorbid patients with HF, analysing the onset of the COVID-19 pandemic, during which the wild-type virus was predominant (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This disparity may be attributed to the elevated risk of SARS-COV-2 transmission in nursing homes and assisted living facilities (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Moreover, individuals residing in nursing homes are generally characterised by higher levels of frailty and reduced mobility (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), which may contribute to immunological vulnerability and increased susceptibility to respiratory diseases such as SARS-COV-2 infection (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). A deterioration in mobilisation due to COVID-19 has also been observed in patients from assisted living settings without surgical treatment (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). As this patient group is particularly vulnerable, a SARS-COV-2 infection combined with surgical treatment represents an extraordinary burden on their health.\u003c/p\u003e\u003cp\u003eDuring periods 2 (Delta) and 3 (Omicron), higher in-hospital mortality rates and hospitalisation times were observed among SARS-COV-2-positive patients with HF compared to SARS-COV-2-negative patients. This trend was not evident during period 1, although a numerical increase in in-hospital mortality was detected from 5.4\u0026ndash;8.3%. In period 1, which represented the shortest observation period, the Alpha subvariant had a lower incidence rate than the Delta and Omicron subvariants in periods 2 and 3, primarily due to limited vaccine availability and, thus, frequent lockdowns as well as possible under-testing (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). As a result, only 24 HF patients were reported as SARS-COV-2-positive during this period, necessitating careful interpretation of the findings due to the small sample size and statistical limitations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e4.2 In-Hospital and 120-Day Outcomes across Variant Periods\u003c/h2\u003e\u003cp\u003eEarly studies examining the impact of COVID-19 comorbidity on HF already confirmed an increase in in-hospital mortality and hospitalisation time (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, these studies focused on the wild-type virus, which exhibited lower mortality rates and disease severity compared to the Alpha and Delta subvariants. Regardless of the subvariant \u0026mdash; particularly with the currently predominant subvariant Omicron \u0026mdash; COVID-19 comorbidity tends to be associated with an increase in in-hospital mortality rates and hospitalisation time. A SARS-COV-2 screening remains indicated for patients with HF to assess potential risks.\u003c/p\u003e\u003cp\u003e120 days after surgical treatment, COVID-19-comorbid patients in period 2 showed a significant deterioration in housing conditions, which was not observed in periods 1 or 3. Mortality was also significantly higher 120 days after surgical treatment in COVID-19-comorbid patients in period 2. The higher incidence and morbidity of the Delta subvariant compared to the Alpha subvariant could contribute to a more complicated postoperative course in HF patients. At the same time, the clinical course of COVID-19 in individuals infected with the Omicron subvariant is considered milder than in those infected with the Delta subvariant (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These associations may support our findings, but it is essential to emphasise the small number of COVID-19-comorbid patients in the cohorts, which limits statistical interpretation.\u003c/p\u003e\u003cp\u003eInterestingly, although the Omicron subvariant has been associated with a generally milder disease course (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), our study found that COVID-19-comorbid HF patients continued to experience prolonged hospitalisation times and higher mortality rates. Notably, 90% of the German population aged over 60 years had received at least one dose of the COVID-19 vaccine by period 3 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), thereby providing enhanced protection against severe COVID-19 outcomes. This paradox may reflect the cumulative strain on healthcare resources and the unique vulnerabilities of the geriatric population, characterised by multiple comorbidities and frailty.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Pathophysiological Mechanisms and Clinical Implications\u003c/h2\u003e\u003cp\u003eThe present findings raise important questions regarding possible pathophysiological mechanisms contributing to the increased perioperative risk in COVID-19-comorbid patients, particularly during the Delta and Omicron periods. Inflammation-induced endothelial dysfunction, hypercoagulability, and myocardial involvement have been reported more frequently in Delta infections compared to earlier variants (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). These mechanisms may have contributed to the increased in-hospital and 120-day mortality observed in our cohort during period 2.\u003c/p\u003e\u003cp\u003eAlthough the Omicron subvariant is generally associated with a reduced risk of severe outcomes in the general population (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), our results indicate that multimorbid elderly patients remain highly vulnerable. This is consistent with recent cohort studies reporting elevated mortality and complication rates in institutionalised older adults during Omicron waves despite high vaccination coverage (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). It is possible that frailty and baseline functional impairment outweigh the protective effects of reduced intrinsic virulence in this subgroup.\u003c/p\u003e\u003cp\u003eFrom a clinical perspective, our data support the consideration of variant-specific risk when managing elderly fracture patients. During periods dominated by highly transmissible or more pathogenic variants, intensified perioperative monitoring and early rehabilitation may be warranted. Rapid identification of COVID-19 status on admission remains crucial to avoid delays in surgical care and to reduce nosocomial spread, particularly in geriatric wards.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Health System Response and Future Research Needs\u003c/h2\u003e\u003cp\u003eIn terms of healthcare planning, the findings underscore the need for flexible, resilient orthogeriatric care structures that can respond to evolving pandemic conditions. Concepts such as modular team deployment, dynamic intensive care unit capacity management, and prioritisation of high-risk surgical patients based on real-time virological data may help optimise resource use in future waves (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFinally, further studies are needed to evaluate long-term outcomes beyond mortality in this population. Given the potential interaction between systemic inflammation and postoperative functional decline, future research should include cognitive trajectories, dependency risk, and quality of life following COVID-19-associated hip fracture surgery (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe sustained excess mortality observed during Delta and Omicron periods, despite evolving treatment standards and vaccination efforts, suggests a gap between general pandemic policy and the specific needs of orthogeriatric patients. Public health responses should not rely solely on variant virulence in the general population but must incorporate risk profiles of high-vulnerability subgroups (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Real-time integration of variant-specific data into perioperative protocols, staffing logistics, and discharge planning may reduce preventable deaths in future waves. Our data underline the necessity of differentiated health system strategies tailored to elderly trauma populations, independent of overall case severity trends (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Study Limitations\u003c/h2\u003e\u003cp\u003eAs a retrospective analysis, this study is subject to inherent biases, including selection and confounding factors. While data collection through the ATR-DGU is standardised and quality-controlled, the lack of detailed clinical data \u0026mdash; such as vital signs, the severity of COVID-19 symptoms, vaccination, and specific causes of mortality \u0026mdash; limits our ability to draw more granular conclusions. Additionally, the relatively small number of SARS-COV-2-positive patients, especially in the Alpha subgroup, may reduce the statistical power of the analyses, further limiting the ability to draw definitive conclusions. Furthermore, the focus on specialised geriatric trauma centres may restrict the generalizability of our findings to other healthcare settings.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis multinational, multicentre study demonstrates that SARS-CoV-2 subvariants exert distinct effects on perioperative outcomes in geriatric patients with hip fractures. While COVID-19 comorbidity during the Delta and Omicron waves was associated with significantly increased in-hospital mortality and prolonged hospitalisation, such effects were not observed during the Alpha period. This subvariant-specific risk profile highlights the importance of ongoing virological surveillance and its integration into orthogeriatric decision-making. Our findings support the implementation of adaptable, evidence-informed perioperative strategies and underscore the need for dynamic resource allocation, including the development of preoperative triage pathways tailored to variant virulence, to protect this highly vulnerable patient population during current and future pandemic waves.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAUC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Academy for Trauma Surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hip fracture\u003c/p\u003e\n\u003cp\u003eATR-DGU\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;German Registry for Geriatric Trauma\u003c/p\u003e\n\u003cp\u003eCOVID-19 \u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;Coronavirus Disease 2019\u003c/p\u003e\n\u003cp\u003eSARS-CoV-2 \u0026nbsp;Severe Acute Respiratory Syndrome Coronavirus 2\u003c/p\u003e\n\u003cp\u003eDGU\u0026nbsp; \u0026nbsp; German Trauma Society\u003cstrong\u003e\u0026nbsp;/\u0026nbsp;\u003c/strong\u003eDeutsche Gesellschaft f\u0026uuml;r Unfallchirurgie\u003c/p\u003e\n\u003cp\u003eSTROBE\u0026nbsp; \u0026nbsp;Strengthening the Reporting of Observational Studies in Epidemiology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eISAR\u0026nbsp; \u0026nbsp;Identification of Seniors at Risk\u003c/p\u003e\n\u003cp\u003eASA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American Society of Anaesthesiologists\u003c/p\u003e\n\u003cp\u003eIQR\u0026nbsp; \u0026nbsp; interquartile range\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEQ-5D-3L\u0026nbsp; \u0026nbsp;EuroQol five-dimension three-level questionnaire\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; odds ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the University of Muenster (registration number: 2022-268-f-S). Each author certifies that their institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical research principles, and that informed consent for participation in the study was obtained. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from AUC but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of AUC.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eFunding statement\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial or material support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAuthors\u0026apos; contributions\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data were interpreted, and the manuscript was drafted by GT and JW. Data acquisition, research design, data interpretation, critical manuscript revision, and substantial modifications were conducted collaboratively by CM, GT, KR and JW. JW, CM, and GT performed. GT, JW and CM were responsible for creating tables and figures. KR conducted the statistical analysis. All authors reviewed and approved the final version of the manuscript before submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Ethics, Consent to Participate, Consent for Publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo animal studies are presented in this manuscript. The study involving human participants was reviewed and approved by the ethical committee of the University of Muenster (registration number: 2022-268-f-S). Clinical trial number: not applicable.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003e8. Competing interests\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e9. Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10. Data sharing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeidentified participant data underlying the findings of this study are not publicly available but may be accessed upon reasonable request. Data access requires prior approval from the Academic Board of the German Registry for Geriatric Trauma (AltersTraumaRegister DGU\u0026reg;). Requests should be directed to the registry office ([email protected]) and are subject to institutional policies and data use agreements. The study protocol and analysis plan are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e11. Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to all the included patients in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVeronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458-60.\u003c/li\u003e\n\u003cli\u003eBeerekamp MSH, de Muinck Keizer RJO, Schep NWL, Ubbink DT, Panneman MJM, Goslings JC. Epidemiology of extremity fractures in the Netherlands. Injury. 2017;48(7):1355-62.\u003c/li\u003e\n\u003cli\u003eRupp M, Walter N, Pfeifer C, Lang S, Kerschbaum M, Krutsch W, et al. The Incidence of Fractures Among the Adult Population of Germany\u0026ndash;an Analysis From 2009 through 2019. Deutsches Arzteblatt international. 2021;118(40):665-9.\u003c/li\u003e\n\u003cli\u003ePfeufer D, Kammerlander C, Stadler C, Roth T, Blauth M, Neuerburg C, et al. Multidisciplinary inpatient rehabilitation improves the long-term functional status of geriatric hip-fracture patients. European Journal of Medical Research. 2020;25(1):31.\u003c/li\u003e\n\u003cli\u003eZhong H, Poeran J, Liu J, Wilson LA, Memtsoudis SG. Hip fracture characteristics and outcomes during COVID-19: a large retrospective national database review. British Journal of Anaesthesia. 2021;127(1):15-22.\u003c/li\u003e\n\u003cli\u003eZsichla L, M\u0026uuml;ller V. Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors. Viruses. 2023;15(1).\u003c/li\u003e\n\u003cli\u003eAnusitviwat C, Vanitcharoenkul E, Chotiyarnwong P, Unnanuntana A. Surgical treatment for fragility hip fractures during the COVID-19 pandemic resulted in lower short-term postoperative functional outcome and a higher complication rate compared to the pre-pandemic period. Osteoporosis International. 2022;33(10):2217-26.\u003c/li\u003e\n\u003cli\u003eDing L, Wei J, Wang B. The Impact of COVID-19 on the Prevalence, Mortality, and Associated Risk Factors for Mortality in Patients with Hip Fractures: A Meta-Analysis. Journal of the American Medical Directors Association. 2023;24(6):846-54.\u003c/li\u003e\n\u003cli\u003eFadulelmola A, Gregory R, Gordon G, Smith F, Jennings A. The impact of COVID-19 infection on hip fractures 30-day mortality. Trauma (London, England). 2021;23(4):295-300.\u003c/li\u003e\n\u003cli\u003eDickow J, Gunawardene MA, Willems S, Feldhege J, Wohlmuth P, Bachmann M, et al. Higher in-hospital mortality in SARS-CoV-2 omicron variant infection compared to influenza infection-Insights from the CORONA Germany study. PloS one. 2023;18(9):e0292017.\u003c/li\u003e\n\u003cli\u003eHedberg P, Parczewski M, Serwin K, Marchetti G, Bai F, Ole Jensen B-E, et al. In-hospital mortality during the wild-type, alpha, delta, and omicron SARS-CoV-2 waves: a multinational cohort study in the EuCARE project. The Lancet Regional Health \u0026ndash; Europe. 2024;38.\u003c/li\u003e\n\u003cli\u003eRobert-Koch-Institute. Daily Situation Report of the Robert Koch Institute. 2020.\u003c/li\u003e\n\u003cli\u003eRobert-Koch-Institute. Bericht zu Virusvarianten von SARS-CoV-2 in Deutschland. 2021.\u003c/li\u003e\n\u003cli\u003eKrause U, Jung K. 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Epid Bull. 2024;22:3-14.\u003c/li\u003e\n\u003cli\u003ePass B, Vajna E, Knauf T, Rascher K, Aigner R, Eschbach D, et al. COVID-19 and Proximal Femur Fracture in Older Adults-A Lethal Combination? An Analysis of the Registry for Geriatric Trauma (ATR-DGU). Journal of the American Medical Directors Association. 2022;23(4):576-80.\u003c/li\u003e\n\u003cli\u003eKnauf T, Eschbach D, B\u0026uuml;cking B, Knobe M, Rascher K, Schoeneberg C, et al. Auswirkungen der COVID-19-Pandemie auf den Verlauf von alterstraumatologischen Patienten mit proximaler Femurfraktur. Die Unfallchirurgie. 2024;127(3):228-34.\u003c/li\u003e\n\u003cli\u003eNepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JFF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet. 2020;396(10243):27-38.\u003c/li\u003e\n\u003cli\u003eLin L, Liu Y, Tang X, He D. The Disease Severity and Clinical Outcomes of the SARS-CoV-2 Variants of Concern. Frontiers in public health. 2021;9:775224.\u003c/li\u003e\n\u003cli\u003eDavies NG, Jarvis CI, Edmunds WJ, Jewell NP, Diaz-Ordaz K, Keogh RH. Increased mortality in community-tested cases of SARS-CoV-2 lineage B.1.1.7. Nature. 2021;593(7858):270-4.\u003c/li\u003e\n\u003cli\u003ePerumal N, Steffen A, Ullrich A, Siedler A. Impact of COVID-19 immunisation on COVID-19 incidence, hospitalisations, and deaths by age group in Germany from December 2020 to October 2021. Vaccine. 2022;40(21):2910-4.\u003c/li\u003e\n\u003cli\u003eWong JY, Cheung JK, Lin Y, Bond HS, Lau EHY, Ip DKM, et al. Intrinsic and Effective Severity of Coronavirus Disease 2019 Cases Infected With the Ancestral Strain and Omicron BA.2 Variant in Hong Kong. The Journal of infectious diseases. 2023;228(9):1231-9.\u003c/li\u003e\n\u003cli\u003eSugg MM, Spaulding TJ, Lane SJ, Runkle JD, Harden SR, Hege A, et al. Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach. The Science of the total environment. 2021;752:141946.\u003c/li\u003e\n\u003cli\u003eKojima G. Prevalence of Frailty in Nursing Homes: A Systematic Review and Meta-Analysis. Journal of the American Medical Directors Association. 2015;16(11):940-5.\u003c/li\u003e\n\u003cli\u003eLi H, Manwani B, Leng SX. Frailty, inflammation, and immunity. Aging and disease. 2011;2(6):466-73.\u003c/li\u003e\n\u003cli\u003eFritz M, Gries T, Redlin M. The effectiveness of vaccination, testing, and lockdown strategies against COVID-19. International Journal of Health Economics and Management. 2023;23(4):585-607.\u003c/li\u003e\n\u003cli\u003eRobert-Koch-Institut. Monitoring des COVID-19-Impfgeschehens in Deutschland. 2022;Monatsbericht vom 01.12.2022.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Outcome parameters of geriatric patients with (COVID-pos) and those without COVID-19 comorbidity (COVID-neg) and hip fracture (HF) across periods of Alpha, Delta, and Omicron variant predominance Group comparisons were performed using Wilcoxon rank-sum and Chi-squared tests as appropriate.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"989\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 1 (Alpha)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 2 (Delta)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 3 (Omicron)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn-house mortality (n, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e198/3489 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2/142 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e313/5056 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8/48 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e181/3197 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23/142 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime of hospitalisation (n, days/IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3475, 15 (IQR 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22, 13 (IQR 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;876\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5036, 14 (IQR 11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47, 17 (IQR 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3172, 15 (IQR 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e140, 17 (IQR 15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to surgery (n, hours/IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3664, 16 (IQR 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24, 16 (IQR 17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5351, 16 (IQR 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56, 14 (IQR 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3325, 16 (IQR 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e164, 17 (IQR 15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEQ5d score 7 days after surgery (n, median/IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2457, 0\u0026middot;701 (IQR 0\u0026middot;410)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19, 0\u0026middot;701 (IQR 0\u0026middot;457)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3535, 0\u0026middot;701 (IQR 0\u0026middot;410)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31, 0\u0026middot;378 (IQR 0\u0026middot;410)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;361\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2400, 0\u0026middot;701 (IQR 0\u0026middot;410)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100, 0\u0026middot;313 (IQR 0\u0026middot;638)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Multivariable analysis using logistic regression (odds ratio [OR] with 95% confidence interval [CI]) for key outcomes and linear regression (\u0026beta;-coefficient with 95% CI) for key predictors after surgical treatment of HF in COVID-19-comorbid patients. All models were adjusted for sex, age, ASA score and fracture type.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"758\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 1 (Alpha)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 2 (Delta)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 3 (Omicron)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;OR (95% CI)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOR (95% CI)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOR (95% CI)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIn-house mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3594\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026middot;54 (0\u0026middot;24-5\u0026middot;49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026middot;85 (1\u0026middot;21-5\u0026middot;94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3397\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026middot;69 (1\u0026middot;62-4\u0026middot;31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcute reoperation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3587\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026middot;30 (0\u0026middot;07-6\u0026middot;32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026middot;67 (0\u0026middot;91-6\u0026middot;22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026middot;25 (0\u0026middot;15-10\u0026middot;42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;838\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1611\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;07 (1\u0026middot;10-8\u0026middot;62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e908\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;96 (0\u0026middot;35-2\u0026middot;62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;938\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta; (95% CI)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta; (95% CI)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta; (95% CI)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3648\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026middot;02 (-8\u0026middot;22-10\u0026middot;26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-2\u0026middot;35 (-8\u0026middot;33-3\u0026middot;63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026middot;92 (-2\u0026middot;28-6\u0026middot;13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospitalisation time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;75 (-2\u0026middot;74-4\u0026middot;24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;673\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u0026middot;36 (2\u0026middot;95-7\u0026middot;76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u0026middot;43 (0\u0026middot;93-3\u0026middot;94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEQ5d after 7 days\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;01 (-0\u0026middot;13-0\u0026middot;14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;935\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0\u0026middot;03 (-0\u0026middot;13-0\u0026middot;07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0\u0026middot;13 (-0\u0026middot;18-0\u0026middot;07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3: Preoperative functional status, comorbidities, and social background in SARS-CoV-2-positive and -negative geriatric HF patients across periods of Alpha, Delta, and Omicron variant predominance. Data are shown as n (%) or median (IQR). Comparisons were conducted using Chi-squared and Wilcoxon rank-sum tests as appropriate.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"981\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 1 (Alpha)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 2 (Delta)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 3 (Omicron)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousing situation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHome\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2830 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4190 (79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2695 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e101 (62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNursing Home\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e760 (21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1408 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e625 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eHospital or other\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmbulatory status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIndependent\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1228 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1835 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1169 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWith cane\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e345 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e470 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e294 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eWith crutches or walker\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1177 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1699 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1059 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLimited to indoor\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e516 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e733 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e499 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37 (26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eNon-ambulatory\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e109 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e168 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eISAR score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 2\u0026middot;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 2\u0026middot;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 2\u0026middot;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 1\u0026middot;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u0026middot;004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 2\u0026middot;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u0026middot;0 (IQR 2\u0026middot;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4: Follow-up outcomes at 120 days after HF surgery in SARS-CoV-2-positive and -negative geriatric patients, stratified by variant period (Alpha, Delta, Omicron). Reported outcomes include mortality, readmission, revision surgery, walking ability, and housing status. Data are shown as n (%) or median (IQR). Group comparisons were conducted using Chi-squared and Wilcoxon rank-sum tests as appropriate.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"84%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 1 (Alpha)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 2 (Delta)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriod 3 (Omicron)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-neg\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cem\u003eCOVID-pos\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003cem\u003e\u0026nbsp;Value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReadmission\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1152 (96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e9 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1455 (95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e20 (91%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u0026middot;615\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e758 (97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e32 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e44 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e69 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e2 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e25 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWalking ability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo change\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e354 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u0026middot;472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e425 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e4 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u0026middot;660\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e290 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e17 (57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u0026middot;154\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eImproved\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e89 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e98 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e2 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e72 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e2 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003ereduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e530 (55%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e5 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e705 (57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e8 (57%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e381 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e11 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousing situation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo change\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e139 (18%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e152 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e2 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u0026middot;004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e86 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e3 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u0026middot;774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eImproved\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e11 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e22 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e2 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e16 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003ereduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e638 (81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e5 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e851 (83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e8 (66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e561 (85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e17 (81%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e977 (87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e7 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1274 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e13 (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u0026middot;004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e778 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e31 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u0026middot;774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e146 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e172 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e108 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e9 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRevision surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1124 (97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e20 (95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u0026middot;619\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1426 (97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e20 (95%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e751 (97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e32 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026lt;0\u0026middot;001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e38 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e52 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e26 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hip Fracture, Proximal Femur Fracture, Orthogeriatric Management, COVID-19, SARS-CoV-2","lastPublishedDoi":"10.21203/rs.3.rs-7067692/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7067692/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHip fractures (HF) are among the most prevalent diagnoses in geriatric traumatology, with persistently high incidence even during the COVID-19 pandemic. Concomitant SARS-CoV-2 infection adds clinical complexity and has been associated with increased mortality and prolonged hospitalisation. This study aimed to assess the impact of SARS-CoV-2 subvariants B.1.1.7 (Alpha), B.1.617.2 (Delta), and B.1.1.529 (Omicron) on postoperative outcomes in patients undergoing surgical treatment for HF.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective multicentre study was conducted using data from the German Registry for Geriatric Trauma (ATR-DGU®) between March 2021 and April 2022 across 119 hospitals. 12707 patients undergoing HF surgery were included and stratified by predominant subvariant periods: Alpha (n = 3714), Delta (n = 5434), and Omicron (n = 3559). Each cohort was further stratified by SARS-CoV-2 status at admission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the Alpha period, in-hospital mortality and length of stay were similar between COVID-19-comorbid (8.3%, 13 days) and SARS-CoV-2-negative patients (5.4%, 15 days). In the Delta and Omicron periods, mortality was significantly higher among COVID-19-comorbid patients (14.3% and 13.9%) compared to SARS-CoV-2-negative patients (5.8%, p = 0.017; 5.7%, p \u0026lt; 0.001), with longer hospitalisations (17 vs. 15 days, p \u0026lt; 0.05). COVID-19-comorbid patients were more frequently institutionalised and exhibited lower levels of pre-fracture mobility compared to SARS-CoV-2-negative patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast to the Alpha period, COVID-19 comorbidity during the Delta and Omicron periods was associated with elevated perioperative mortality and longer hospitalisation, highlighting the clinical relevance of SARS-CoV-2 subvariant characteristics in the management of HF in elderly patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This retrospective study used anonymized data from the German Registry for Geriatric Trauma (ATR-DGU®) and was approved by the ethics committee of the University Münster (reference number: 2022-268-f-S). This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e","manuscriptTitle":"Impact of SARS-CoV-2 Subvariants on Postoperative Outcomes in Geriatric Hip Fracture Patients – A Multinational Multicentre Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-17 14:09:39","doi":"10.21203/rs.3.rs-7067692/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-07T09:06:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T14:20:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99100345085291996404791601508336784080","date":"2025-09-16T08:11:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89471314537023914603742452126574912230","date":"2025-09-16T03:30:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-14T00:16:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1824099774607522897280132413275527079","date":"2025-09-13T23:42:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-08T12:03:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-05T07:44:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-18T12:03:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-15T14:59:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-07-15T14:06:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50f6a8c8-3375-464b-a1e8-adf0dd7cba90","owner":[],"postedDate":"August 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:08:50+00:00","versionOfRecord":{"articleIdentity":"rs-7067692","link":"https://doi.org/10.1186/s12877-025-06840-6","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-12-20 15:57:58","publishedOnDateReadable":"December 20th, 2025"},"versionCreatedAt":"2025-08-17 14:09:39","video":"","vorDoi":"10.1186/s12877-025-06840-6","vorDoiUrl":"https://doi.org/10.1186/s12877-025-06840-6","workflowStages":[]},"version":"v1","identity":"rs-7067692","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7067692","identity":"rs-7067692","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}