Should we operate on all patients with COVID-19 and proximal femoral fractures? An analysis of thirty, sixty, and ninety day mortality rates based on patients' clinical presentation and comorbidity: a multicentric study in Northern Italy.

PURPOSE: This study aims to evaluate 30-60-90-day mortality of operated proximal femur fractures (PFFs) suffering from COVID-19 and correlation with patients' clinical presentation and comorbidities. METHODS: Between February 1, 2020, and December 31, 2020, patients with COVID-19 infection and surgically treated PFF were included. Patients' demographic characteristics, oxygen (O2) therapy, comorbidities, and AO type fracture were collected. Chi-square test or Fisher test and hazard ratio were used to assessing the correlation between mortality rate, patient characteristics, and COVID-19 status. Kaplan-Meyer curve was used to analyze 30-60-90-day mortality. Level of significance was set as p < 0.05. RESULTS: Fifty-six patients (mean age of 82.7 ± 8.85 years) were included. Thirty-day mortality rate was 5%, which increased to 21% at 60 days and 90 days. Eleven patients died, eight due to AO type A-like and three due to AO type B-like fractures. No significant difference in mortality rate between patients with cardiopulmonary comorbidity or no cardiopulmonary comorbidity was found (p = 0.67); a significant difference in patients with chronic obstructive pulmonary disease (COPD) or history of pulmonary embolism (PE) and patients without COPD was found (p = 0.0021). A significant difference between asymptomatic/mild symptomatic COVID-19 status and symptomatic COVID-19 status was found (p = 0.0415); a significant difference was found for O2 therapy with < 4 L/min and O2 therapy ≥ 4 L/min (p = 0.0049). CONCLUSION: Thirty-day mortality rate of COVID-19 infection and PFFs does not differ from mortality rate of non-COVID-19 PFFs. However, patients with pre-existing comorbidities and symptomatic COVID-19 infection requiring a high volume of O2 therapy have a higher incidence of 60-90-day mortality when surgically treated.

Osteoporotic vertebral fractures: predictive factors for conservative treatment failure. A systematic review.

PURPOSE: To analyze clinical, radiographic and magnetic resonance findings that might predict risk of complications and conservative treatment failure of osteoporotic vertebral fractures. METHODS: The authors conducted a systematic review of observational studies, collecting data on osteoporotic vertebral fracture and complications like vertebral collapse, kyphosis, pseudoarthrosis, and neurologic deficit. MeSH items such as 'spinal fracture/radiology,' 'spinal fracture/complications,' 'spinal fracture/diagnosis' were used. PRISMA statement criteria were applied, and the risk of bias was classified as low, medium, high, following the Newcastle-Ottawa Quality Assessment Scale (NOS). RESULTS: Eleven cohort studies, either retrospective or prospective, met the eligibility criteria and were included in the review. Major risk factors that were statistically predictive of the following complications were as follows; (1) vertebral collapse: presence of intravertebral cleft, MR T1-WI 'total type fractures' and T2-WI 'hypointense-wide-type'. (2) Pseudoarthrosis (nonunion): middle-column damage, thoracolumbar vertebrae involvement, MR T2-WI confined high-intensity pattern and diffuse low intensity pattern. (3) Kyphotic deformity: thoracolumbar fracture and superior endplate fracture. (4) Neurologic impairment: a retropulsed bony fragment occupying more than 42% of the sagittal diameter of the spinal canal and a change of more than 15° in vertebral wedge angle on lateral dynamic radiography. CONCLUSIONS: Shape and level of the fracture were risk factors associated with the progression of collapse, pseudoarthrosis, kyphotic deformity and neurologic impairment. MRI findings were often related to the failure of conservative treatment. If prognosis can be predicted at the early fracture stage, more aggressive treatment options, rather than conservative ones, might be considered.

Optimizing indications and technique in osteotomies around the knee.

Osteotomies around the knee represent a valid surgical treatment in young active patients affected by unicompartmental osteoarthritis and/or knee ligament instability. This review article describes the main osteotomies performed around the knee and their optimization, with particular attention to indications and surgical technique in light of the most recent literature and author experience. Further developments have to be expected from technological advances, focusing particularly on surgical planning and the control of intraoperative deformity correction by pre-shaped cutting blocks.

Can We Predict the Progression of Vertebral Collapse in Conservative Treatment of Osteoporotic Vertebral Fractures? A 3-Year Retrospective Study of 180 Patients From the Emergency Department.

BACKGROUND: Osteoporotic vertebral fractures (OVFs) have a high incidence in the elderly population and are usually treated conservatively with good outcomes. Nevertheless, failure of the conservative treatment may lead to serious complications. The aim of the study is to identify clinical, radiographic, and magnetic resonance imaging findings potentially related to the failure of the conservative treatment of OVFs. METHODS: Data from 620 patients treated in the emergency department for vertebral fracture from 2014 to 2016 were analyzed; after patient identification and inclusion criteria, only fresh OVFs of patients older than 65 years have been included. Main outcome measurements were vertebral collapse, fracture shape types, and progression of vertebral collapse. A progression of vertebral collapse >100% was taken as an independent variable to underline the statistically significant difference among the risk factors. RESULTS: A total of 180 patients (138 women; 42 men) and 200 OVFs were analyzed (mean age = 77 years, range = 65-94 years). Potential risks factors for the progression of vertebral collapse >100% were found when fractures occurred in the thoraco-lumbar junction. The swelling type and the bow-shaped type showed higher risk of vertebral collapse, while the concave was the most stable type of fracture with good prognosis. Traumatic fractures had lower risks of fracture progression compared to nontraumatic fractures (eg, fractures after an effort). A linear black signal pattern on short inversion time inversion recovery findings of magnetic resonance imaging corresponded to a risk of progression of the vertebral collapse. CONCLUSIONS: Thoraco-lumbar fractures, swelling and bow-shaped fractures, and a linear black area at MR are negative prognostic factors for the failure of conservative treatment. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: The identification of negative prognostic factors may lead to different strategies of treatment to prevent vertebral collapse or failure of conservative treatment.