Introduction: Megaprostheses (MP) are used in major bone loss’ situations. Large surface of MP allows biofilm growth, making periprosthetic joint infection (PJI) difficult to eradicate. Silver, combining antibacterial activity with low toxicity, has been used to coat these MP - silver coated megaprosthesis/SCM.
Methods: A search in Pubmed ® database was made with the combination of the following keywords: megaprosthes* OR endoprosthes* AND silver [MESH]. We obtained 54 results. We excluded the articles written in non-english language (8), in which the subjects weren’t humans (7), not published in a journal (1), an erratum (1) non-original articles (4), except 2 meta-analysis, case series articles (4) and an isolated clinical case. We also exclude 10 articles by the title reading and 3 articles by the abstract.
Results: We obtained 15 articles (2 meta-analysis, 1 case-control study, 12 retrospective cohort studies).The incidence of PJI in SCM groups ranged between 3% and 40%, with an overall infection rate of 17,6%. The original articles, showed a downward tendency regarding the incidence of PJI in SCM groups comparing with non silver-coated megaprosthesis groups. Parry et al. published the only study showing bigger PJI rate in SCM grou, in which selection bias was obvious, once the patients with higher infection risk were selected mainly to SCM group.
Discussion: The data available in literature favours the use of SCM to avoid PJI, specially in revision arthroplasty surgeries, although more studies (better designed) are needed. The price, and complications, such as local argyria, need to be accounted.

Introduction: Unicompartmental knee arthroplasty (UKA) has an infection rate of 0.1%-0.8%. This condition determines a unique clinical scenario: the contemporary infection of the prosthesis components, native cartilage-bone tissue and biomechanically fundamental soft tissues. The aim is to present the clinical and radiological outcomes along with complication rates of a series of septic UKA treated with two stage exchange. Methods: We retrospectively reviewed 16 patient treated with staged UKA revision for infection between June 2015 and September 2019 in a single Bone Infection Unit. Main demographic and surgical data were recorded. Clinical scores (KSS, OKS, postoperative ROM), radiological parameters (osseointegration, loosening and radiolucencies) and complications were reported. The mean follow up was 33.5 ± 6.9 months. Results: Mean age at surgery was 68.5 ± 9.1. All but one were medial UKA. Mean number of previous surgeries was 2.9 ± 1.9. The mean ROM, KSS and OKS of the entire population improved significantly (p<0.01). Radiological analysis does not showed any migration or implant loosening. Ten constrained condylar and 6 posterior stabilized prosthesis were finally implanted. One intraoperative pathogen isolation was recorded and managed with suppressive therapy with good final outcome. Conclusion: A real consensus about optimal management of UKA infection is still far. According to our results, staged revision represents a reliable ad effective option in chronically infected UKAs. This technique provide optimal clinical and radiological results with acceptable complication rates. To the best of our knowledge, this represent the widest case series on infected UKA managed with two stage exchange.

Introduction: Septic arthritis of the native joint is a challenging condition, since it may lead to wide bone defects and impairment of joint function. Furthermore, adult patients who develop septic arthritis often suffer from severe medical comorbidities. Two-stage procedures seem to be the best treatment option in case of septic arthritis with extensive joint degeneration.
Methods: A retrospective single center analysis of patients treated for septic arthritis of the hip and the knee joints through a two-stage surgery was conducted. Clinical and radiological records were collected from the prospectively collected Institutional Arthroplasty Registry. Preoperative Harris Hip Score and Knee Society Score of patients included were compared to the scores obtained at latest follow-up. Kaplan-Meier curves were generated in order to assess survival from septic failure or treatment failure for any reason.
Results: A total of 47 patients were included. The mean follow-up was 94.2 ± 18.4 months. Mean Harris Hip Score improved from 39.4 ± 9.9 to 84.5 ± 10.8 points (p<0.001). Mean Knee Society Score improved from 40.7 ± 8.4 points to 86.0 ± 7.8 (p<0.001). Mean Knee Society Score-function increased from 25.7 ± 14.2 points to 85.4 ± 23.4 (p<0.001). Infection eradication rate was 92.0% and 90.9% in patients operated to the hip and knee respectively (p=0.891). Overall survivorship of implants after second stage was 93.6%.
Conclusions: Two-stage replacement surgery provides good to excellent clinical outcomes in case of active septic arthritis of the hip and the knee, and high percentages of infection control and implants’ survival.
 

Introduction: With the advent of an unprecedented aging society, pyogenic spondylitis tends to increase with the increase in so-called compromised hosts with complications. We report the usefulness of percutaneous pedicle screw (PPS) and complete endoscopic spinal surgery (FESS) for treating spondylitis. Methods: The subjects were 15 patients who underwent surgical treatment for this conservative treatment-resistant pyogenic spondylitis from April 2017 to March 2021. We investigated the underlying disease, bacterium responsible for the infection, the number of days until surgery, and length of hospital stay. Results: The average age was 69 years old in 13 males and 3 females. Diabetes and other underlying diseases were observed in all 15 cases, and the bacterium responsible for an infection could be identified in 13 cases. The average number of days until surgery was 39 days. The average duration of hospital stay was 74 days. In all 15 cases, the infection subsided, and finally 10 of the 15 cases showed bone fusion at the affected site. Conclusion: the basic treatment is conservative treatment. In principle, the surgical treatment for it at our hospital is to stabilize the affected vertebral body by PPS. However, FESS is a very useful tool that can identify the causative organism necessary for the diagnosis and treatment,  irrigate with copious amounts of saline, scratch the lesion under direct vision, and drainage. It is considered that good results were obtained by treating by combining these 2 methods depending on the case.

Introduction: Wide, tumor-like resection for chronic osteomyelitis (COM), a standard practice previously, has been challenged recently with local debridement. This paper reviews the evolution of surgical debridement for long bone osteomyelitis, and presents the outcome of adequate debridement in a tertiary bone infection unit. Methods: Retrospective records review from 2014 to 2020 of patients with long bone osteomyelitis. All patient records were searched electronically and imaging reviewed. All patients were managed by Multidisciplinary Infection Team protocol. Results: 53 patients (55 segments) with median age of 45.5 years (16 - 74) and mean follow up period of 29 months (12 - 59) were identified. According to Cierny Mader Classification, 10 bones with type I, 10 with type II, 30 with type III, and 5 with type IV and the BACH Classification of Long Bone Osteomyelitis were 12 uncomplicated bone infections, 40 complex, and three with limited options. All patients were managed with single-stage management of COM. 47 bone infections (85%) grew microbial cultures. Eight infections recurred, with overall 87% resolution rate. 6 patients had complications. Conclusion: We report high COM resolution rate and high microbial yield in our study. Adequate debridement provides satisfactory results, in most cases of COM thereby eliminating the need for segmental resections.

Introduction and Objective:
Chronic osteomyelitis is a major surgical challenge in orthopaedic surgery. In children, this challenge is exacerbated by a smaller bone stock, risk of growth arrest, in addition to the lack of a single surgical solution to eradicate the infection. Bone defect after debridement is another orthopaedic challenge in children. Antibiotic loaded Calcium sulphate has been used with promising results, we report our experience in Sohag University, Egypt, in 21 children.
Materials and Methods:
Surgical debridement, guttering, and curettage with application of vancomycin loaded calcium sulphate STIMULAN were carried out in 21 cases, mean age was 14+/- 5 years, mean follow up was 15+/- 4 months. Infection was in the tibia in 9 cases, in the femur in 7 cases, in the humerus in 4 cases and in the metacarpal bone in one case.
Results: Discharge has stopped in 19 out of 21 cases, in two cases, additional surgical debridement was performed at 5th and 7th months due to exacerbation of infection, clearance of infection was achieved after the second debridement at 8th and 11th week respectively. Complete bone integration of the substitute was achieved in 17 cases, within a mean time of 10 +/-3 weeks. Full weight bearing was allowed after complete integration to the host bone in plain radiographs.
Conclusions:
Single stage surgical debridement with administration of vancomycin loaded calcium sulphate, along with administration of antibiotics provide an attractive surgical solution for treatment of chronic osteomyelitis in children.

Spondylodiscitis is a potentially life-threatening spinal infection that involves the intervertebral disc and the adjacent vertebral bodies. This prospective study aimed to evaluate the safety and efficacy of surgical management of pyogenic spondylodiscitis. Fifteen cases diagnosed with thoracolumbar pyogenic spondylodiscitis were enrolled in this study. Indications for surgical treatment were progressive neurological deficit, kyphosis, significant vertebral body destruction, instability, and failure of antibiotic therapy. Debridement, discectomy, decompression, and posterior instrumentation via a single-stage posterior approach were carried out. A Titanium Pyramesh cage was used in 10 cases for reconstruction. Patients were assessed clinically using the Visual Analogue Scale (VAS) for back pain, Oswestry Disability Index (ODI), and Frankel Grade classification for neurological evaluation. A radiological assessment of fusion was also performed. The mean follow-up was 20.4 months (12 to 30 months). There were 4 males and 11 females. The mean age was 55.8 years (range 40-66). The thoracic spine was affected in 7 cases, and the lumbar spine was affected in 8. The most isolated microorganism was Staphylococcus aureus. A significant improvement in the pain and disability scores was detected postoperatively and at the last follow-up. According to the Frankel classification, four patients with preoperative neurological impairment showed postoperative improvement of at least one grade. Fusion was achieved in all cases. None had signs of relapse or residual infection until the last follow-up. Our results suggest that surgical debridement is a safe and effective treatment option for pyogenic spondylodiscitis resistant to antibiotic therapy.

Aim:
Chronic osteomyelitis(COM) carries a significant disease burden worldwide with over 50000 admissions/yr. Surgical management of osteomyelitis typically involves a two-stage approach. We present the short-term outcomes from a single-stage treatment approach using antibiotic-impregnated CaSO4 (Stimulan®) pellets.

Methods:
Patients were identified from our prospective database, and all patients managed with single stage using CaSO4 pellets (Stimulan®). and with a minimum 12-month follow-up period were included in the study.

Results:
All patients were reviewed and managed by the dedicated bone infection team with standard unit protocol. 91 patients with mean age 51.1(SD18.6) years, of which 63(69.2%) were male were included in the study. The mean follow-up was 18(SD 5.6) months. The commonest site was the tibia (n=42, 46.2%). Infected metalwork was the commonest cause (n=59,55.8%), of which 35(59.3%) were plates. Eighteen patients required a concomitant soft-tissue procedure (19.8%), of which one required further surgery due to flap necrosis. Postoperative stimulan drainage was seen in 15 cases (16.5%). Postoperative infection was seen in 11 patients (12.8%). Seven patients (7.7%) required further surgery. At the time of the last follow-up, only 2 patients(2.1%) had persistent infection after treatment.

Adjusted serum Calcium concentration post-stimulan treatment increased by 0.07mmol/L. Although statistically significant(p=0.004) it did not translate to clinically significant hypercalcaemia.

Conclusions: Single-stage management of osteomyelitis using antibiotic-impregnated CaSO4 pellets is a clinically safe and effective way of managing COM.

Introduction: The myriad presentation of osteoarticular brucellosis make the patient seek the help of general practitioners, orthopedic and rheumatology specialists. Moreover, lack of disease-specific symptomatology is the main cause for the delay in the diagnosis of osteoarticular brucellosis. However, with our experience, we formulated an algorithm for the management of spinal brucellosis. Materials and methods: A single-centered prospective observational study was conducted with 25 confirmed cases of spinal brucellosis. Patients were analyzed and graded clinically, serologically, and radiologically and were managed with antibiotics 10-12 weeks, and if necessary stabilization and fusion were done based on the treatment algorithm devised. All patients were followed up to ensure clearance of disease at serial follow-up with relevant investigations. Results: The mean age of the study participants was 52.16±12.53 years. According to SSC grading, 4 patients belong to grade 1, 12 patients belong to grade 2 and 9 patients belong to grade 3 at presentation. Erythrocyte sedimentation rate (p=0.02), c-reactive protein (p<0.001), Brucella agglutination titers (p<0.001), and radiological outcomes improved statistically by 6-months. The treatment duration was individualized according to the response of the patient to the treatment with a mean duration of 11.42±2.66 weeks. The mean follow-up period was 14.42±8 months. Conclusion: High index of suspicion of patients from endemic regions, proper clinical assessment, serological evaluation, radiological assessment, appropriate decision making (medical/surgical) in treatment, and regular follow-up were the key to success in the comprehensive management of spinal brucellosis.

Introduction: Patients with lesions affecting C7 and C8 roots (in addition to C56) demonstrate loss of independent wrist dorsiflexion. Traditionally, this deficit has been addressed using tendon transfers after useful function at the shoulder and elbow has been restored by primary nerve surgery. Confidence with nerve transfer techniques has prompted attempts to replace this method by incorporating procedures for wrist dorsiflexion in the primary operation itself.
Aim: The objective of this study was to report the results of pronator quadratus motor branch transfers to the extensor carpi radialis brevis motor branch to reconstruct wrist extension in C5–C8 root lesions of the brachial plexus.
Methodology: Twenty-three patients, average age 30 years, with C5–8 root injuries underwent operations an average of 4.7 months after their accident. Extrinsic extension of the fingers and thumb was weak or absent in two cases while the remaining 18 patients could open their hand actively. The patients lacked independent wrist extension when they were examined with the fingers flexed as the compensatory action of the extrinsic finger extensors was removed. The average follow-up was 21 months postoperative with the minimal follow-up period was at least 12 months.
Results: Successful reinnervations of the extensor carpi radialis brevis (ECRB) were demonstrated in all patients. In 17 patients, wrist extension scored M4, and in 3 patients it scored M3.
Conclusion: The pronator quadratus (PQ) to ECRB nerve transfer in C5–C7 or C5–C8 brachial plexus injuries for independent wrist extension reconstruction gives consistently good results with minimal donor morbidity.

schwannomas are benign neoplasms derived from schwann cells. usually encapsulated, which rarely undergo malignant transformation. represents 5% of soft tissue tumors, most commonly found between the fourth to sixth decades of life.the tumor has a predilection for the head, neck and flexor surfaces of the upper and lower extremities, but schwannomas of the tibial nerve are extremely rare.we report a case of a 43-year-old male presented to our center with a 3-year history of diffuse pain in the left foot, diagnosis was delayed during all this period. he had seen multiple specialists without diagnosis. at examination we found a palpable and painful mass in popliteal fossa with a positive tinel’s sign.ultrasonography and mri of the knee were performed, and the diagnosis of schwannoma of the tibial nerve was made, based on clinical and radiological findings. excision of the tumor was easily performed by a posterior approach without neural lesioning. histopathological examination revealed the tumor to be a schwannoma. no neurologic deficit was noted postoperatively which confirms the good prognosis of this tumor.schwannomas can be excised en mass, as they arise within the nerve sheath and are surrounded by a true capsule comprised of epineurium, enabling a complete enucleation without damage to the parent nerve. schwannomas have a good prognosis and a low incidence of recurrence or malignant transformation, unlike neurofibromatosis. nonetheless, expertise in peripheral nerve surgery is necessary to reduce the risk of neurological deficit.

Background: This study aimed to illustrate the surgical methods and clinical efficacy of modified great toe wraparound flap with preservation of partial toenail repaired with artificial dermis for aesthetic reconstruction of the distal thumb and fingers. Method: Between 2013 and 2018, 13 patients (two cases of thumb defects and 11 cases of other finger defects) underwent reconstruction with our improved approach. Bilateral combined wraparound flap and unilateral wraparound flap were harvested to reconstruct thumb and fingers, respectively. The donor site of wraparound flap was repaired by artificial dermis. At the final follow-up visits, static two-point discrimination, disabilities of the arm, shoulder and hand, Michigan hand outcome questionnaire, Foot and Ankle Disability Index score, and width of residual toenail were used to evaluate surgical outcomes. Results: All cases survived well. The contour of the reconstructed digits was similar to the contralateral digit. Follow-up period was 32-57 months (mean 42.7 months). Mean two-point discrimination of reconstructed digits was 6.1 mm. The average DASH score for hand function (reconstructed hand) was 7.5. The average MHQ score for the aesthetic appearance of the donor site was 80.5. Mean Foot and Ankle Disability Index score was 94.2. The average width of residual toenail was 1.47 cm. Conclusions: Reconstruction of the digits with the modified great toe wraparound flap by preserving partial toenail repaired with artificial dermis, results in excellent contour and functional outcome for the surgical site. In addition, all toenails were preserved and donor site morbidity in the foot was minimal.