## 4 Discussion  
In patients undergoing femur fracture surgery during the second wave of COVID-19, the incidence of pressure ulcers was 21%, a significant increase over the 10% seen in the pre-pandemic period. In the second wave of the pandemic, the relative risk of developing a pressure ulcer was 2.06 as compared to the pre-pandemic period and this was in line with the relative risk calculated for the first wave. The population of persons undergoing surgery during the second wave of COVID-19 did not differ significantly from the pre-pandemic period; the mean age of the patients admitted for femur fracture during the second wave was 84 years, and there was no statistically significant difference from the age of the same population during the pre-pandemic period (mean age = 82 years). Looking at clinical practice factors that could be changed and that are known to prevent pressure ulcers, some significant differences emerged between the pre-pandemic period and the second wave. Bladder catheter management improved during the second wave and thus the number of people discharged with a bladder catheter and the number of days on a bladder catheter was reduced, a protective factor for patients. At the same time, moving of the patient did not differ statistically between the two periods, while the use of air mattresses fell from 90% in the pre-pandemic phase to 71%. Where air mattresses were not available, an anti-decubitus foam mattress was provided. In correcting the RR calculation for factors linked to patient characteristics and variables linked to the healthcare approach, it was found that none of the factors taken into consideration significantly modified this indicator. The explanation for the different RR in the two periods could be sought in the different organisation of the work established so that elective surgery could be resumed within a pandemic context. First, during the pandemic period, to reduce the risk of spreading the infection, the presence of any caregivers/family members was suspended. [PERSON] et al. (2018) postulated that this deficiency could be one of the possible explanations for the increased incidence in pressure ulcers during hospitalisation in patients diagnosed with COVID-19. [PERSON] et al. (2019) identified reduced caregiver presence as an independent risk factor for pressure ulcers. Second, although the flow of admissions and available beds was reduced during the pandemic period, an increase in the bed occupancy rate and the average stay for hip fracture patients made up the difference, thus the resulting workload was comparable in the two periods. In addition, in the second wave of the pandemic, the average patient complexity was increased, resulting in a higher care burden, which may have contributed to the increase in RR. Third, during the pandemic there was a significant increase in the number of newly recruited staff (12%). This reduction \begin{table}
\begin{tabular}{c c c} \hline \hline  & **2019** & **2020** \\ \hline \multicolumn{3}{c}{Surgical activity} \\ \hline N. of hospitalised patients & 3645 & 2703 \\ \hline Percentage of patients with & 3.0 & 8.5 \\ femoral fracture & 230 & 181 \\ \hline Bed occupancy rate (\%) & 81 & 96 \\ \hline Total number of health & & \\ professionals & 245 & 245 \\ \hline Health professionals’ new & & \\ employees (\textless{}1 year) (\%) & 0 (0) & 30 (12.2) \\ \hline \multicolumn{3}{c}{Index of patient complexity} \\ \hline Diagnosis Related Group & & \\ (DRG) weight & 1.48 & 1.56 \\ \hline Case-mix index & 0.99 & 1.01 \\ \hline \hline \end{tabular}
\end{table} 
Table 3: Orthopaedic surgical activity organization. in healthcare staff experience may have contributed to the increased risk of pressure ulcers despite the main prevention measures in place. In terms of the recovery of deambulation, the number of patients who were unable to recover deambulation during their hospital stay remained limited even in the second wave.