Introduction: Klebsiella pneumoniae is one of the most frequent infection organism following orthopedic surgeries and specifically total hip arthroplasty. Recently, attitude toward herbal medicine is being popular both in people and health care systems. Ruta graveolens is a traditional herbal remedy Iranian medicine and some other countries with a wide spectrum of therapeutic utilities. Our purpose was to determine the effects of this medicinal plant on Klebsiella pneumoniae growth. Materials and methods: Standard Klebsiella pneumoniae was used. We assessed the hexane extracts of both leaf and stark of Ruta graveolens on growth of bacterial disc diffusion and serial dilution methods. We compared the results with some standard frequent chemical antibiotics. Results: Our results showed that all doses of leave extract including 200, 250, 300, 350 and 400 micrograms of stark extract had inhibited the growth. In disc diffusion test 500 μg of hexanic extract prevent the growth of bacteria rather than antibiotic discs. We determined minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) by doing their methods. Conclusion: Hexanic extract of Ruta can affect the growth of Klebsiella pneumoniae both for bactericidal and inhibitory effects. It can be a good candidate for more research in vivo to introduce new agent for treating this type of infection.

Introduction : Expandable cages for vertebral interbody fusion allow for in-situ expansion, optimizing fit while mitigating end plate damage. Studies comparing outcomes after using expandable or static cages have been conflicting. The aim of our study is to compare the clinical and radiological outcomes with usage of expandable and static interbody fusion cages in spondylodiscits patients operated by posterior approach corpectomies and to report any device related complications in a two year follow up period. Materials and Methods : This is a retrospective cohort study in 80 patients who underwent interbody fusion after corpectomy for spondylodiscitis with expandable (44) and static (36) cages between 2016 - 2019. Oswestry Disability Index(ODI), Visual Analog Score(VAS), intra-operative blood loss, surgery duration, hospital stay, post-operative complications and radiographic measurements using x-rays were compared with average follow up for 30 months. Results : VAS and ODI scores improved significantly during follow up in both groups (p<0.05). Statistically insignificant difference noted between groups with respect to intra-operative blood loss and hospital stay duration (p>0.05). However, operative time was significantly reduced in expandable cage group (p<0.05). Pre-operative inter-vertebral height increased significantly in both the groups (p<0.05). The cage subsidence was much lower in expandable cages (p<0.05). The post-operative complications were significantly higher in static cages group. Conclusion : Thus expandable cages provide a convenient surgery with decreased operative time, good radiological outcome, lower subsidence rate and lesser complications. However, more studies with larger cohort and longer follow up are the need of the hour.

There is paucity of data on drug resistance pattern in spinal TB. This prospective observational study was conducted to document incidence of drug resistance among primary and presumptive resistant cases. Methods:59 consecutive cases diagnosed clinico-radiologically(imaging) were grouped into-GroupA(n=51,primary cases) and GroupB(n=8,presumptive resistant cases) based on pre-defined criteria(INDEX-TB guidelines,2017). Tissue samples obtained percutaneously(37.29%,22/59) and surgery(62.71%,37/59) were subjected to genotypic DST(CBNAAT, LPA 1stand 2nd line) and phenotypic DST(BACTEC™ MGIT 960 culture and sensitivity using fixed critical concentration of drugs). Results:Etiological diagnosis was ascertained in all. 13/51(25.49%) in GroupA while 3/8(37.5%) in GroupB and 16/59(27.12%) overall demonstrated drug resistance. 12/16(75%) had no prior history of ATT intake. 4 had INH(Isoniazid) mono-resistance, 12 with polydrug resistance demonstrated:5MDR, 3pre-XDR, while RIF+FQ(fluoroquinolones), FQ+Lz(linezolid), only SLID(second line injectable drugs) and only FQ resistance observed in 1 case each. Isolated RIF(Rifampicin) resistance and XDR pattern was not observed. Overall frequency of RIF resistance was 16.4%(9/55) and INH was 25%(12/48) with low level INH resistance in 2 and high in 10. Among second line drugs, prevalence of FQ resistance was more than SLID resistance and within FQ, levofloxacin resistance was more frequent than moxifloxacin. MGIT had positive growth in 16/59 samples, out of which 1 sample was positive for nontuberculous mycobacteria(M.chelonae) but on genotypic testing demonstrated MTB resistant to RIF and FQ. Conclusion:First report on drug resistance pattern in culture positive/negative cases. 25.49% primary drug resistance is serious observation necessitating changed strategies for our goals of TB elimination. INH resistance is more than RIF with isolated RIF resistance unreported.

In patient with uninfected implant in the same bone as the infected implant, the surgeon might impact on the chance of developing subsequent PJI. We performed this study to determine if 1) there is a higher chance of developing a metachronous PJI if there is another implant in the same bone and 2) if there is a safe distance to be kept from the uninfected implant when performing septic revision surgery.We identified 161 patients with both knee and hip same side prosthesis at the time of PJI treatment.We analysed the standard radiographs to evaluate parameters that may increase the same side metachronous infection risk:distance between the tips of both knee femoral and hip implants, native medullar canal distance (between the end of cement of both knee femoral and hip stems) and cement restrictor failure.98 patients were included;20 had same side metachronous infection and the others were used as controls.The same side metachronous infection group had significant shorter native medullar canal distance (p=0.0001), distance between implants (p=0.001) and significant higher cement restrictor failure rate (p=0.0001).The same side metachronous infection group showed the same bacteria between first and second PJI in 70% of the cases.According to these data we reported a safe distance of 7 cm for native medullar canal (p=0.0001) and of 9.05 cm between the implants (p=0.001).In patients who had both knee and hip same side prosthesis at the time of PJI treatment,we recommend to preserve a minimum safe distance between the implants to prevent the developing of subsequent infection.

Aims
Despite numerous studies on periprosthetic joint infections (PJI), there are no robust data on the risk factors and timing of metachronous infections. This study was performed to answer the following questions: 1) Is there any difference of manifestation time of metachronous PJis between different localizations of multiple artificial joints? 2) Can we identify any specific risk factor for metachronous PJIs for different localizations of multiple artificial joints?
Methods
Between January 2010 and December 2018, 661 patients with more than one prosthetic joint at the time of PJI surgical treatment were recruited. Seventy-one developed metachronous PJI and were divided in group 1: metachronous infections in the same extremity (e.g. right hip and right knee); group 2: metachronous infections of the other extremity (e.g. right knee and left hip); group 3: metachronous infections of the lower extremity and upper extremity (e.g. right knee and left shoulder).
Results
We identified 32 PJI cases in group 1, 38 in group 2 and 1 in group 3. Diabetes mellitus was found higher in the metachronous infections (p<0.05).Rate of same side infection was significantly higher compared to contralateral and upper and lower infection (p<0.05). Time interval of metachrononous infection development was faster in same-side infections. Same bacteria sample rate between primary PJI and metachronous PJI in same side infections (21/32) was significantly higher than in the contralateral PJI group (13/38, p<0.05).
Conclusions
The current study underlined that the risk of metachronous infections are relatively high, particularly in the cases of prostheses on the same side.

Introduction. It is known that long bone cortex density in patients with chronic osteomyelitis changes along the entire length; however, the character of structural disorders of the cortex beyond the inflammation site has not been studied in details.
Purpose of the work: To study peculiarities of cortex structure of the femur and the tibia beyond the inflammation site in order to reveal micro-cavities and micro-abscesses.
Material and methods. The study is retrospective, monocentric. The level of evidence base is IV. In order to reveal peculiarities of cortex structure and micro-cavities we studied peculiarities of roentgen-morphology of the femur and the tibia in 92 patients with chronic osteomyelitis of long bones of lower limbs by the method of multiple view radiography and multi-slice CT (MSCT).
Results. The cause of osteomyelitis in 5 cases was the consequence of hematogenic osteomyelitis, and in 87 – trauma or surgery. In 12 patients as a result of long-lasting disease there was a non-union or bone defect. Anatomic changes of the femur and the tibia were individual in all patients As for roentgen-morphological manifestations, they were included general symptoms (osteoporosis, osteosclerosis, disorder of architectonics), however severity, extension and character of changes of structure were very different as well as changes of bone density with a big deviation.
Conclusion. The received data indicate that roentgen-morphological changes of the cortex beyond the site of destruction are observed in 15.6% of patients by formation of micro-cavities and micro-abscesses, playing an important role in possibility of recurrence of osteomyelitis.

Background
Surgical debridement of chronic osteomyelitis (COM) remains the gold standard. The distinction between infected and dead bone is rarely explained. Resection to bleeding bone is commonly applied. Although Xray remains the gold standard,its localization ability was not compared to PET/CT.
Methods
This prospective study included clinical photos and X-rays of ten patients with COM shown to ten consultant surgeons. They were asked to draw the infection area and the planned surgical debridement zone. Median years of surgeons’ experience were three years (1.5-6 years). Median annual infected cases were 28 cases (5-100 cases). The most common preferred tool for diagnosis was X-ray and CT together (50%), MRI(20%) ,all(20%), and CT alone(10%) .

Results
Based on x-rays, the inter-observer agreement Regarding height of the drawn segment, was poor between surgeons (ICC = 0.460, 95% CI = 0.266 – 0.685). The ten surgeons showed a low moderate agreement regarding perimeter, (ICC = 0.511, 95% CI = 0.307-0.732) and circularity (ICC = 0.577 & 95% CI = 0.392 – 0.770). Compared to the drawn infection area based on the PET-CT coronal and sagittal cuts, height and perimeter were significantly higher in X-ray than PET CT (P < 0.001). Years of experience or number of annual cases didn't correlate with a better assessment based on X-rays.
Conclusion
This report suggests that PET-CT would provide an accurate graphical method to localize the infection and plan for proper resection. It provides a tool to define the resection margins and avoid over/under debridement.

Introduction: Dissemination of knowledge regarding non-infectious conditions mimicking spinal tuberculosis can save the patient from being administered antitubercular treatment unnecessarily and avoid long and potentially hazardous delays in clinching the final diagnosis that can guide definitive treatment. The purpose of this study is to report a single-centre case series of non-infectious conditions mimicking spinal tuberculosis from a developing country.
Methods: Hospital records and imaging of patients who were diagnosed to have spinal tuberculosis without any histopathological or microbiological evidence of the disease, and with a lack of response to empirical antitubercular treatment were analysed. Patients who were found to have non-infectious conditions mimicking spinal tuberculosis on further review and investigations were included.
Results: A total of 23 patients were found to have non-infectious conditions mimicking spinal tuberculosis over a period of 6 years (2015-2020). These conditions included: vertebral body haemangioma, ankylosing spondylitis with or without Andersson lesion, rheumatoid pannus, osteoid osteoma, cystic hygroma, multiple myeloma, vertebral metastasis, malignant small round-cell tumour, pancreatic pseudocyst, esophageal duplication cyst, Modic changes in degenerative disc disease, Paget’s disease and psoas hematoma.
Conclusion: Many non-infectious conditions of the spine may be mistaken for spinal tuberculosis – particularly, in a country where tuberculosis is endemic. A tissue diagnosis of spinal tuberculosis should be assiduously sought prior to institution of antitubercular treatment. Features like central lesions and lack of soft tissue involvement in suspected spinal tuberculosis should prompt a second look at the diagnosis.

The accuracy of preoperative synovial fluid culture for microbe detection in shoulder periprosthetic joint infection(PJI) is poorly well-described. Our aim was to investigate the concordance between preoperative fluid cultures and intraoperative tissue cultures for the early identification of shoulder PJI. Fifty patients with shoulder PJI between January 2016 and December 2019 were retrospectively reviewed for clinical and demographic data. The concordance between the preoperative and intraoperative cultures formed the basis for dividing patients into two groups. Concordance between preoperative aspiration and intraoperative tissue culture was identified in 28 patients out of 50 (56%). Preoperative cultures positive for Gram-positive species were more likely to be concordant than discordant(p=0.015). Preoperative cultures positive for Cutibacterium acnes were more likely to be concordant with intraoperative cultures(p=0.022). There were more patients with polymicrobial infection in the discordant group compared to the concordant group(p<0.001). Staphylococcus aureus and coagulase-negative Staphylococci were associated with high specificity and negative predictive value(NPV). Preoperative cultures positive for Cutibacterium acnes demonstrated sensitivity, specificity, positive predictive value(PPV) and NPV lower than 0.8. Gram-negative pathogens demonstrated the highest sensitivity(1) and specificity(1), while polymicrobial infections exhibited the lowest sensitivity and PPV. Preoperative synovial fluid aspiration for shoulder PJI poorly predicts intraoperative culture results, with discordance of 44%. Preoperative monomicrobial cultures have better concordance, particularly for Gram-negative organisms and methicillin-sensitive Staphylococcus aureus. The high discordance between preoperative and intraoperative culture may prompt surgeons to decide on medical and surgical treatment based on patient history and other factors, and not solely on preoperative synovial fluid culture results.