Israel Medical Association Journal

Modern armed conflicts increasingly expose civilian infrastructure, including hospitals, to direct military threats such as missile attacks. Hospitals provide care for some of the most vulnerable patients, including bedridden individuals and those requiring continuous monitoring that cannot be easily relocated. Protecting these patients during active hostilities presents a major operational challenge. Hospitals must maintain clinical care, prepare for potential infrastructure damage, and remain ready to receive mass casualty victims. Previous disasters and conflict-related evacuations have demonstrated the complexity and risks of relocating hospitalized patients under emergency conditions [1,2].

Background: The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems globally, affecting chronic disease management like osteoporosis and the prevention of fragility hip fractures. We hypothesized that it led to suboptimal prevention of secondary femoral neck fractures, reduced treatment frequency, and delayed treatment initiation.

Objectives: To evaluate the treatment initiation rate for secondary prevention of femoral neck fractures, comparing pre-COVID-19, COVID-19, and post-COVID periods, considering patient demographics.

Methods: This retrospective diagnostic cohort study used automated electronic medical records database from Clalit Health Services. Data regarding patients with hip fractures from January 2017 through September 2021 were extracted from the database. Treatment for osteoporosis included one of the following treatments: alendronate, risedronate, zoledronate, abaloparatide, denosumab, romosozumab, and teriparatide. The primary outcome variable in the study is the time taken to initiate appropriate therapy for the secondary prevention of femoral neck fractures.

Results: Treatment frequency decreased over time, with rates declining from 40.4% in 2019 to 33.5% in 2021 (P-value < 0.05). However, the percentage of prompt care management (within 3 months) increased between 2020 and 2021 (47.3%–62.5%) and between 2019 and 2021 (48.7%–62.5%), P < 0.05.

Conclusions: The COVID-19 pandemic reduced the rate of appropriate treatment initiation following hip fractures. However, adherence to timely treatment within 3 months of the fracture has improved. The findings highlight the effectiveness of the health system response in managing crises and ensuring the timely delivery of critical treatment.

The long-standing Iran–Israel conflict escalated sharply in April 2024, with Iran’s attack on Israeli territory (13–14 April) and Israel’s retaliation in Isfahan (19 April) [1]. As predicted, a full-scale war erupted between 13–24 June 2025 involving direct strikes on sovereign land and vital infrastructure.