Implant surface factors and bacterial adhesion: a review of the literature

Antibacterial coating of implants in orthopaedics and trauma: a classification proposal in an evolving panorama

Implanted biomaterials play a key role in current success of orthopedic and trauma surgery. However, implant-related infections remain among the leading reasons for failure with high economical and social associated costs. According to the current knowledge, probably the most critical pathogenic event in the development of implant-related infection is biofilm formation, which starts immediately after bacterial adhesion on an implant and effectively protects the microorganisms from the immune system and systemic antibiotics. A rationale, modern prevention of biomaterial-associated infections should then specifically focus on inhibition of both bacterial adhesion and biofilm formation. Nonetheless, currently available prophylactic measures, although partially effective in reducing surgical site infections, are not based on the pathogenesis of biofilm-related infections and unacceptable high rates of septic complications, especially in high-risk patients and procedures, are still reported.In the last decade, several studies have investigated the ability of implant surface modifications to minimize bacterial adhesion, inhibit biofilm formation, and provide effective bacterial killing to protect implanted biomaterials, even if there still is a great discrepancy between proposed and clinically implemented strategies and a lack of a common language to evaluate them.To move a step forward towards a more systematic approach in this promising but complicated field, here we provide a detailed overview and an original classification of the various technologies under study or already in the market. We may distinguish the following: 1. Passive surface finishing/modification (PSM): passive coatings that do not release bactericidal agents to the surrounding tissues, but are aimed at preventing or reducing bacterial adhesion through surface chemistry and/or structure modifications; 2. Active surface finishing/modification (ASM): active coatings that feature pharmacologically active pre-incorporated bactericidal agents; and 3. Local carriers or coatings (LCC): local antibacterial carriers or coatings, biodegradable or not, applied at the time of the surgical procedure, immediately prior or at the same time of the implant and around it. Classifying different technologies may be useful in order to better compare different solutions, to improve the design of validation tests and, hopefully, to improve and speed up the regulatory process in this rapidly evolving field.

Bacterial adhesion on amorphous and crystalline metal oxide coatings

Several studies have demonstrated the influence of surface properties (surface energy, composition and topography) of biocompatible materials on the adhesion of cells/bacteria on solid substrates; however, few have provided information about the effect of the atomic arrangement or crystallinity. Using magnetron sputtering deposition, we produced amorphous and crystalline TiO2 and ZrO2 coatings with controlled micro and nanoscale morphology. The effect of the structure on the physical-chemical surface properties was carefully analyzed. Then, we studied how these parameters affect the adhesion of Escherichia coli and Staphylococcus aureus. Our findings demonstrated that the nano-topography and the surface energy were significantly influenced by the coating structure. Bacterial adhesion at micro-rough (2.6 μm) surfaces was independent of the surface composition and structure, contrary to the observation in sub-micron (0.5 μm) rough surfaces, where the crystalline oxides (TiO2>ZrO2) surfaces exhibited higher numbers of attached bacteria. Particularly, crystalline TiO2, which presented a predominant acidic nature, was more attractive for the adhesion of the negatively charged bacteria. The information provided by this study, where surface modifications are introduced by means of the deposition of amorphous or crystalline oxide coatings, offers a route for the rational design of implant surfaces to control or inhibit bacterial adhesion.

Differentiation, apoptosis, and GM-CSF receptor expression of human gingival fibroblasts on a titanium surface treated by a dual acid-etched procedure

OBJECTIVES

Analysis of the effects of titanium surface properties on the biological behavior of human gingival fibroblasts (HGFs).

MATERIALS AND METHODS

HGFs were in vitro cultured on a titanium surface modified by a dual acid-etched procedure and on a control machined surface. Cell adhesion, proliferation, apoptosis, production of certain extracellular matrix (ECM) proteins, and expression of granulocyte macrophage-colony stimulating factor receptor (GM-CSFR) were investigated using in each experiment a total of 18 samples for each titanium surface.

RESULTS

Cell attachment at 3 h of culture was statistically significantly higher on the etched surface. HGF growth increased on both surfaces during the entire experimental period and at day 14 of culture cell proliferation was statistically significantly higher on the treated surface than on the control. No statistically significant differences in percentage of apoptosis events were observed between the surfaces. ECM protein production increased progressively over time on both surfaces. A statistically significant deposition was observed at day 7 and 14 for collagen I and only at day 14 for fibronectin and tenascin, when compared to the baseline. GM-CSFR registered a positive expression on both surfaces, statistically significant at day 14 on the etched surface in comparison with the machined one.

CONCLUSIONS

Data showed that titanium surface microtopography modulates in vitro cell response and phenotypical expression of HGFs. The etched surface promoted a higher cell proliferation and differentiation improving the biological behavior of HGFs.

CLINICAL RELEVANCE

Results suggest a possible beneficial effect of surface etching modification on peri-implant biological integration and soft tissue healing which is critical for the formation of a biological seal around the neck of dental implants.

Antibacterial and osteogenic stem cell differentiation properties of photoinduced TiO2 nanoparticle-decorated TiO2 nanotubes

This article has been retracted: please see Future Science Group's Policy on retractions ( www.futuremedicine.com/authorguide/editorialpolicies ).

The following article has been retracted from Nanomedicine at the request of the authors and the editors:

Liu W, Su P, Chen S, Wang N, Wang J, Liu Y, Ma Y, Li H, Zhang Z, Webster TJ. Antibacterial and osteogenic stem cell differentiation properties of photoinduced TiO2 nanoparticle-decorated TiO2 nanotubes. Nanomedicine (Lond.) 10(5), 713–723 (2015).

The authors previously highlighted an issue relating to Figure 6 (Fluorescence images showing the viability of the Streptococcus mutans on samples) in this paper and a corrigendum was published to remove it. It was determined that the conclusions of the study were still valid without this figure.

However, it has since been identified that parts of the figure in question contained manipulated images. The authors have reconsidered the completeness of the paper and have decided to retract it.

The authors and editors of Nanomedicine regret any negative consequences this publication might have caused in the scientific and medical communities.

Novel anti-infective implant substrates: controlled release of antibiofilm compounds from mesoporous silica-containing macroporous titanium

Bone implants with open porosity enable fast osseointegration, but also present an increased risk of biofilm-associated infections. We design a novel implant material consisting of a mesoporous SiO2 diffusion barrier (pore diameter: 6.4 nm) with controlled drug release functionality integrated in a macroporous Ti load-bearing structure (fully interconnected open porosity: 30%; pore window size: 0.5-2.0 μm). Using an in vitro tool consisting of Ti/SiO2 disks in an insert set-up, through which molecules can diffuse from feed side to release side, a continuous release without initial burst effect of the antibiofilm compound toremifene is sustained for at least 9 days, while release concentrations (up to 17 μM daily) increase with feed concentrations (up to 4mM). Toremifene diffusivity through the SiO2 phase into H2O is estimated around 10(-13)m(2)/s, suggesting configurational diffusion through mesopores. Candida albicans biofilm growth on the toremifene-release side is significantly inhibited, establishing a proof-of-concept for the drug delivery functionality of mesoporous SiO2 incorporated into a high-strength macroporous Ti carrier. Next-generation implants made of this composite material and equipped with an internal reservoir (feed side) can yield long-term controlled release of antibiofilm compounds, effectively treating infections on the implant surface (release side) over a prolonged time.

Significance of biofilm for the prosthetic surgeon

Biofilm formation on implanted medical devices is becoming more recognized as both a common finding and a potential problem. Although seen frequently in nature, these sequestered bacterial communities are proving to be an assiduous enemy as medical device technologies advance. The penile prosthesis has gone through many improvements, now with a more reliable mechanical function and a reduced infection rate. However, there remains a notable increase in infectious risk in revisions compared to novel cases, with many implants found to harbor a subclinical bacterial presence isolated in biofilms. This article focuses on recent updates in implant technology and surgical technique to combat infection, and reviews current research on biofilm prevention and treatment.

Antibacterial surface treatment for orthopaedic implants

It is expected that the projected increased usage of implantable devices in medicine will result in a natural rise in the number of infections related to these cases. Some patients are unable to autonomously prevent formation of biofilm on implant surfaces. Suppression of the local peri-implant immune response is an important contributory factor. Substantial avascular scar tissue encountered during revision joint replacement surgery places these cases at an especially high risk of periprosthetic joint infection. A critical pathogenic event in the process of biofilm formation is bacterial adhesion. Prevention of biomaterial-associated infections should be concurrently focused on at least two targets: inhibition of biofilm formation and minimizing local immune response suppression. Current knowledge of antimicrobial surface treatments suitable for prevention of prosthetic joint infection is reviewed. Several surface treatment modalities have been proposed. Minimizing bacterial adhesion, biofilm formation inhibition, and bactericidal approaches are discussed. The ultimate anti-infective surface should be “smart” and responsive to even the lowest bacterial load. While research in this field is promising, there appears to be a great discrepancy between proposed and clinically implemented strategies, and there is urgent need for translational science focusing on this topic.

Initial Bacterial Adhesion on Different Yttria-Stabilized Tetragonal Zirconia Implant Surfaces in Vitro

Bacterial adhesion to implant biomaterials constitutes a virulence factor leading to biofilm formation, infection and treatment failure. The aim of this study was to examine the initial bacterial adhesion on different implant materials in vitro. Four implant biomaterials were incubated with Enterococcus faecalis, Staphylococcus aureus and Candida albicans for 2 h: 3 mol % yttria-stabilized tetragonal zirconia polycrystal surface (B1a), B1a with zirconium oxide (ZrO₂) coating (B2a), B1a with zirconia-based composite coating (B1b) and B1a with zirconia-based composite and ZrO₂ coatings (B2b). Bovine enamel slabs (BES) served as control. The adherent microorganisms were quantified and visualized using scanning electron microscopy (SEM); DAPI and live/dead staining. The lowest bacterial count of E. faecalis was detected on BES and the highest on B1a. The fewest vital C. albicans strains (42.22%) were detected on B2a surfaces, while most E. faecalis and S. aureus strains (approximately 80%) were vital overall. Compared to BES; coated and uncoated zirconia substrata exhibited no anti-adhesive properties. Further improvement of the material surface characteristics is essential.