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The spinal column represents the third most common site for metastases after the lungs and the liver, and the most common site for metastatic bone disease. With life-extending advances in the systemic treatment of cancer patients, the surgical procedures performed for spinal metastases will increase, and their related complications will increase unavoidably. Furthermore, considering the high complication rates reported in the spinal literature regarding spine surgery overall, it becomes clear that a better understanding of complications that the cancer patients with spinal metastases may experience is necessary. This article aims to summarize and critically examine the current evidence for complications after spine surgery for metastatic spinal disease, in both the perioperative and postoperative period. This paper would be useful for the treating physicians of these patients in their clinical practice.

Spinal infection poses a demanding diagnostic and treatment problem for which a multidisciplinary approach with spine surgeons, radiologists, and infectious disease specialists is required. Infections are usually caused by bacterial microorganisms, although fungal infections can also occur. The most common route for spinal infection is through hematogenous spread of the microorganism from a distant infected area. Most patients with spinal infections diagnosed in early stages can be successfully managed conservatively with antibiotics, bed rest, and spinal braces. In cases of gross or pending instability, progressive neurological deficits, failure of conservative treatment, spinal abscess formation, severe symptoms indicating sepsis, and failure of previous conservative treatment, surgical treatment is required. In either case, close monitoring of the patients with spinal infection with serial neurological examinations and imaging studies is necessary.

Several causes contribute to the high infection rate in tumor prostheses, including extensive tissue dissection and patients’ immunosuppression due to the neoplastic disease. Most of these infections develop within the first 2 years following surgery with 70% of them occurring during the first year, while they are often associated with a low pathogen burden. The pathogenesis of infections in tumor prostheses is linked to bacteria developing in biofilms. Approximately half of them are caused by Staphylococcus spp., followed by Streptococcus spp., Enterococcus spp., and Enterobacteriaceae spp., while multiple pathogens may be isolated in up to 25% of the cases, with coagulase-negative Staphylococci (CoNS) and Enterococccus spp. being the most frequent pair. Although early detection and timely management are essential for complete resolution of these challenging infections, prompt diagnosis is problematic due to the highly varying clinical symptoms and the lack of specific preoperative and intraoperative diagnostic tests. Surgical management with one- or two-stage revision surgery is the mainstay for successful eradication of these infections. The recent advances in laboratory diagnostics and the development of biofilm-resistant prostheses over the past years have been areas of great interest, as research is now focused on prevention strategies. The aim of this study is to review and consolidate the current knowledge regarding the epidemiology, risk factors, microbiology, and diagnosis of infections of tumor prostheses, and to review the current concepts for their treatment and outcomes.

There has been a major resurgence of tuberculosis (TB) and drug-resistant tuberculosis in the last few decades. Although it has been brought under control in most Western countries, it is still a major cause of death in endemic regions like India. Osteoarticular tuberculosis (OA TB) forms a small proportion of the total cases of tuberculosis. Perceptions and practices of orthopedic surgeons are entirely different in endemic and non-endemic regions around the world, due to the vast difference in exposure. Literature from endemic areas puts stress on clinico-radiological diagnosis and empirical anti-tubercular treatment (ATT). Such practices, although non-invasive, simple to implement, and economical, carry a significant risk of missing TB mimics and developing drug resistance. However, OA TB is still perceived as a “diagnostic enigma” in non-endemic regions, leading to a delay in diagnosis. Hence, a high index of suspicion, especially in a high-risk population, is needed to improve the diagnosis. Evolving drug resistance continues to thwart efforts to control the disease globally. This review article discusses the perceptions and practices in different parts of the world, with India as an example of the endemic world, and lays down priorities for overcoming the challenges of diagnosing osteoarticular TB.

Purpose The outcomes of mini open discectomy in lumbar disc herniation are usually satisfying. Our study aims at finding if its results are still good at long-term follow-up. Methods We reviewed 552 patients operated between 1993 and 2013 by mini open discectomy procedure. Our main evaluation criterion is a modified Stauffer and Coventry classification applied during follow-up visits at three months, one year, five years, and every five years. The secondary criterion was the Oswestry Disability Index. Results The outcomes are considered good to very good in 87.3% of the cases at one year follow-up. These results deteriorate after an average follow-up of 14.7 years but remain satisfactory with 63.7%. The global decrease is 23.6%. The Oswestry Score decreases by 35 points at the same follow-up. In addition, 6.52% of patients required fusion at first revision and 1.08% at second revision. We also noticed 51 (9.2%) post-operative recurrences at the same level. In 23 (4.16%) of them, we proceeded to a new discectomy in an average interval of 41.4 months. At an adjacent level, 29 patients (5.2%) presented a new symptomatic disc herniation; among them, eight cases (1.44%) needed discectomy. The re-operative rate (including recurrent disc herniation and fusion for degenerative indications) is 10.68% at the last follow-up. Conclusions Nearly 2/3 of our patient series keep satisfactory outcomes after about 15-year follow-up. The mini open discectomy remains a reliable surgical technique provided we respect the indications and surgical requirements. This procedure also avoids excessive instrumentation and its possible iatrogenic complications. Powerful randomized and controlled trials are needed to strengthen these deductions.

Purpose To present the pathophysiology, biology, clinical presentation, diagnosis, and current treatment options for lumbar disc herniation. Methods A thorough literature search was undertaken in PubMed and Google Scholar to summarize the current knowledge and future perspectives on lumbar disc herniation. Results Several changes in the biology of the intervertebral disc are thought to contribute to disc herniation; nevertheless, the exact inciting event leading to disc herniation is yet to be discovered. Non-operative treatments have stood the test of time as the first-line treatment for most patients with lumbar disc herniation; however, operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Conclusions The exact event leading to disc herniation remains unclear. Non-operative treatments should be the first-line treatment for most patients with lumbar disc herniation. Operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Regenerative medicine is promising.

Peri-prosthetic joint infection (PJI) definition plays an important role in diagnostic and therapeutic decisions. However, while several criteria have been proposed by eminent institutions to define a PJI in the last decade, their clinical validation has been rarely performed. Aim of the present multicenter, international, retrospective study was to validate the World Association against Infection in Orthopedics and Trauma (WAIOT) pre/intra-operative PJI definition with post-operative confirmatory tests. A total of 210 patients, undergoing hip (n = 86) or knee (n = 124) revision surgery for any reason in six orthopedic centers in Africa, Asia, Europe and South America, were retrospectively evaluated at a two years minimum follow-up after surgery. All the available pre-, intra- and post-operative findings were collected and analyzed according to the WAIOT criteria, which include a set of tests to confirm (Rule In) or to exclude (Rule Out) a PJI. On average, patients were investigated pre/intra-operatively with 3.1 ± 1.1 rule out and 2.7 ± 0.9 rule in tests; the presence of a fistula or exposed implant was reported in 37 patients (17.6%). According to pre/intraoperative findings, 36.2% of the patients were defined as affected by high-grade PJI (n = 76; average score: 2.3 ± 0.8), 21.9% by low-grade PJI (n = 46; average score: 0.8 ± 0.8), 10.5% by biofilm-related implant malfunction (n = 22; average score: –1.6 ± 0.8), 2.9% as contamination (n = 6; average score: –3.5 ± 1.0), and 28.6% as no infection (n = 60; average score: –3.0 ± 1.4). Pre/intra-operative PJI definitions matched post-operative confirmatory tests, in 97.1% of the patients. This is, to our knowledge, one of the largest study ever conducted to validate a PJI definition The retrospective analysis in different centers was greatly facilitated by the structure of the WAIOT definition, that allows to include different tests on the basis of their sensitivity/specificity, while the comparison between pre/intra-operative and post-operative findings offered the internal validation of the scoring system. Our results authenticate the WAIOT definition as a reliable, simple tool to identify patients affected by PJI prior to joint revision surgery.

Bone and joint infections are associated with a devastating global burden. The successful treatment of these infections requires a multidisciplinary approach between orthopedic surgeons and experts of different disciplines. This multidisciplinary approach has gained ground over the past decades in modern infection units as a more effective treatment strategy, yielding better outcomes regarding infection eradication rates, length of hospital stay, and overall cost of treatments. Additionally, preventing and managing musculoskeletal infections requires strong connections between medical associations, biological laboratories, and the pharmaceutical industry worldwide. In this context, SICOT and World Association against Infection in Orthopaedics and Trauma (WAIOT) relationships have been increasing. The present editorial article discusses the multidisciplinary approach for managing bone and joint infections worldwide, explores the controversies in practices in terms of training, area of expertise, and extent of clinical involvement, and emphasizes the role of societies in research, prevention and management of musculoskeletal infections. The purpose is to acknowledge what orthopedics can obtain from specialists dealing with bone and joint infections and to consolidate their practice to provide the best care for orthopedic patients.