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Aim: Prosthetic joint infection (PJI) is a common complication following orthopedic megaprosthetic implantations (EPR), estimated up to 50%. Silver coatings were introduced in order to reduce the incidence of PJI, by using the antibacterial activity of silver. Three different silver coatings are available: MUTARS ® (Implantcast), Agluna ® (Accentus Medical), PorAg ® (Waldemar Link). The aim of this review is to provide an overview on efficacy and safety of silver-coated EPR both in primary and revision surgery, comparing infection rate according to the type of implant., Methods: Through an electronic systematic search, we reviewed the articles concerning silver-coated EPRs. Infection rate, silver-related complications, local and blood concentrations of the silver were evaluated. Meta-analyses were performed to compare results from each study included., Results: Nineteen studies were included. The overall infection rate in patients with silver-coated implants was 17.6% (133/755). Overall infection rate in primary silver-coated EPR was been 9.2% (44/445), compared to 11.2% (57/507) of non-silver-coated implants. The overall infection rate after revisions was 13.7% (25/183) in patients with silver-coated EPR and 29.2% (47/161) when uncoated EPR were used, revealing a strength statistically significative utility of silver coatings in preventing infections in this group (p: 0.019). Generally, the use of MUTARS ® EPR had produced an almost constant decrease in the incidence of primary PJI but there are few data on the effectiveness in revisions. The results from the use of Agluna ® in both primary and revisions implants are inconstant. Conversely, PorAg ® had proven to be effective both in PJI prevention but, especially, when used in PJI revision settings. Local argyria was reported in 8 out of 357 patients (2.2%), while no systemic complications were described. Local and blood concentrations of silver were always reported very far to the threshold of toxicity, with the lowest concentration found using PorAg ® ., Conclusions: Silver-coated EPRs are safe and effective in reduction in PJI and re-infection rate, in particular when used in higher risk patients and after two-stage revisions to fight PJI.

Aims: We report a series of patients treated with intercalary bone graft (IBG) of the tibia diaphysis (TD) after resection of primary bone tumors. The purpose of this study was to evaluate the mid- and long-term survival of TD IBG reconstruction in children and adults, characterizing patterns of success and failure., Methods: A total of 35 patients were included in this retrospective study. Median age was 22 years (range, 8-57). This series included 19 patients (54.3%) treated with homologous bone graft alone and 16 patients (45.7%) treated combining intercalary allograft with fibular autograft. Complications were recorded according to Henderson classification., Results: Median follow-up was 36 months (range, 1-165). Local recurrence occurred in 2 patients (5.7%) after 12 and 60 months, respectively. Major complications included graft fracture (9 cases), non-union (5 cases) and infection (4 cases). Other complications were axial deformity (2 cases), superficial infection (2 cases), compartmental syndrome (1 case)., Conclusion: Intercalary bone grafts of TD have been recommended as a reliable solution with long-term success rates and good functional outcome in more than 80% of patients. However, approximately half of the patients may require further surgeries to treat major complications (deep infection, delayed or non-union and graft fracture). Additional vascularized fibula graft may ameliorate final result.

Introduction: We aim to evaluate the use of silver (PorAg ® ) coated compared to uncoated prosthesis in two-stage revision for prosthetic joint infection (PJI) of distal femur and proximal tibia megaprosthesis in oncological patients., Materials and Methods: In total, 68 patients were retrospectively evaluated. Median age was 30 years (range 14-83). In total, 29 patients were re-implanted with PorAg ® prosthesis and 39 with uncoated prosthesis (Megasystem C ® , Waldemar Link GmbH & Co. KG, Hamburg, Germany). All patients had PJI confirmed according to Musculoskeletal Infection Society (MSIS) criteria. In 10 cases, no microorganism was identified at the time of first-stage revision, but all had a sinus communicating with the prosthesis. Successful eradication of the infection was defined by the absence of clinical/serologic evidence of infection at 6 months after the second stage or at latest follow-up. Infection was again defined according to the MSIS criteria., Results: At 3-year follow-up, estimated reinfection rate in the silver group was slightly lower than in uncoated EPR (10.3% vs. 17.5%, p = 0.104). Among reinfected patients, only one out of three patients (33%) in the silver group required an amputation compared to 80% in the nonsilver group (p = 0.047)., Conclusions: Our results show the efficacy of PorAg ® coating in the two-stage revision of knee EPR. PorAg ® -coated EPR may have possible advantages over this traditional strategy, in particular when applied to patients with a higher risk of reinfection.

En bloc or extralesional resection means resection of the tumor in one piece together with a layer of healthy tissue: the margin is either marginal or wide. The prerequisite for an en bloc or extralesional spondylectomy is a tumor involvement of no more than one side of the posterior structures, so that a corridor can be created through which the spinal cord is released. This article presents a two-stage, combined anterior and posterolateral, three-level en bloc spondylectomy, and local flap wound coverage for a patient with a recurrent post-radiation sarcoma of the lumbar spine and infected wound after intralesional treatment. The patient had radiation therapy for an L4 Hodgkin's lymphoma 5 years before the development of the post-radiation sarcoma. Two-stage, three-level en bloc spondylectomy was done through a combined anterior and posterolateral approach. The resection margins were microscopically negative. Dural tear occurred intraoperatively because of tightly adherent dense scar tissue. Two years after spondylectomy, there was no evidence of tumor or infection recurrence; however, the patient died from her lymphoma. In surgically difficult spinal resections, we recommend the two-stage, combined anterior and posterolateral approach for en bloc spondylectomy. The staged procedure may provide for reduced perioperative complications and mortality, and meticulous dissection in the irradiated area, especially if infected. The combined approach provides for easier and safer dissection of the tumor and the spine from the anterior elements under direct visual control, and wide tumor resection.