PMMA bone cement containing a quaternary amine comonomer with potential antibacterial properties

A review on the promising antibacterial agents in bone cement-From past to current insights

Antibacterial bone cements (ABCs), such as antibiotic-loaded bone cements (ALBCs), have been widely utilized in clinical treatments. Currently, bone cements loaded with vancomycin, gentamicin, tobramycin, or clindamycin are approved by the US Food and Drug Administration. However, traditional ALBCs exhibit drawbacks like burst release and bacterial resistance. Therefore, there is a demand for the development of antibacterial bone cements containing novel agents to address these defects. In this review, we provide an overview and prospect of the new antibacterial agents that can be used or have the potential to be applied in bone cement, including metallic antibacterial agents, pH-switchable antibacterial agents, cationic polymers, N-halamines, non-leaching acrylic monomers, antimicrobial peptides and enzymes. Additionally, we have conducted a preliminary assessment of the feasibility of bone cement containing N-halamine, which has demonstrated good antibacterial activities. The conclusion of this review is that the research and utilization of bone cement containing novel antibacterial agents contribute to addressing the limitations of ALBCs. Therefore, it is necessary to continue expanding the research and use of bone cement incorporating novel antibacterial agents. This review offers a novel perspectives for designing ABCs and treating bone infections.

Antimicrobial Polymer Surfaces Containing Quaternary Ammonium Centers (QACs): Synthesis and Mechanism of Action

Synthetic polymer surfaces provide an excellent opportunity for developing materials with inherent antimicrobial and/or biocidal activity, therefore representing an answer to the increasing demand for antimicrobial active medical devices. So far, biologists and material scientists have identified a few features of bacterial cells that can be strategically exploited to make polymers inherently antimicrobial. One of these is represented by the introduction of cationic charges that act by killing or deactivating bacteria by interaction with the negatively charged parts of their cell envelope (lipopolysaccharides, peptidoglycan, and membrane lipids). Among the possible cationic functionalities, the antimicrobial activity of polymers with quaternary ammonium centers (QACs) has been widely used for both soluble macromolecules and non-soluble materials. Unfortunately, most information is still unknown on the biological mechanism of action of QACs, a fundamental requirement for designing polymers with higher antimicrobial efficiency and possibly very low toxicity. This mini-review focuses on surfaces based on synthetic polymers with inherently antimicrobial activity due to QACs. It will discuss their synthesis, their antimicrobial activity, and studies carried out so far on their mechanism of action.

Preparation and efficacy of antibacterial methacrylate monomer-based polymethyl methacrylate bone cement containing N-halamine compounds

Introduction

Our objective in this study was to prepare a novel type of polymethyl methacrylate (PMMA) bone cement, analyze its material properties, and evaluate its safety and antibacterial efficacy.

Methods

A halamine compound methacrylate antibacterial PMMA bone cement containing an N-Cl bond structure was formulated, and its material characterization was determined with Fourier transform infrared spectroscopy (FT-IR) and 1H-NMR. The antibacterial properties of the material were studied using contact bacteriostasis and releasing-type bacteriostasis experiments. Finally, in vitro and in vivo biocompatibility experiments were performed to analyze the toxic effects of the material on mice and embryonic osteoblast precursor cells (MC3T3-E1).

Results

Incorporation of the antibacterial methacrylate monomer with the N-halamine compound in the new antibacterial PMMA bone cement significantly increased its contact and releasing-type bacteriostatic performance against Staphylococcus aureus. Notably, at 20% and 25% additions of N-halamine compound, the contact and releasing-type bacteriostasis rates of bone cement samples reached 100% (p < 0.001). Furthermore, the new antibacterial bone cement containing 5%, 10%, and 15% N-halamine compounds showed good biocompatibility in vitro and in vivo.

Conclusion

In this study, we found that the novel antibacterial PMMA bone cement with N-halamine compound methacrylate demonstrated good contact and releasing-type bacteriostatic properties against S. aureus. In particular, bone cement containing a 15% N-halamine monomer exhibited strong antibacterial properties and good in vitro and in vivo biocompatibility.

Preparation and characterizations of antibacterial poly(methyl methacrylate) bone cement via copolymerization with a quaternary ammonium monomer of dimethylaminotriclosan methacrylate

Poly (methyl methacrylate) (PMMA) bone cement relies on the loaded antibiotic to realize the antibacterial purpose. But the exothermic behavior during setting often makes temperature-sensitive antibiotics inactivated. It is necessary to develop new material candidates to replace antibiotics. In this study, a new quaternary ammonium methacrylate (QAM) monomer called dimethylaminetriclosan methacrylate (DMATCM) was designed by the quaternization between 2-(Dimethylamino)ethyl methacrylate and triclosan, then employed as the modifier to explore the feasibility of equipping bone cement with antibacterial activity, and to investigate the variations on the physical and biological performances brought by the substitution ratio of DMATCM to MMA. Results showed that DMATCM opened its C=C bonding to participate in the MMA polymerization, and the quaternary ammonium group helped it to perform broad-spectrum antibacterial property against both Gram-positive Staphylococcus aureus and Gram-negative Escherichia coli. With an increased substitution ratio of DMATCM to MMA, the glass transition temperatures, the maximum exothermic temperatures, and the contact angles of bone cements declined, but the residual monomer contents, the fluid uptakes, and the setting times under Vical indentation increased. Long-term soaking made almost no changes to the weight loss and the mechanical properties of DMATCM-modified cements with lower substitution ratios of 0∼20%, and the activation rather enhanced the strengths of uncured AMBC-4 and AMBC-5 samples. Owing to more DMATCM exposed on the cement surface, the inhibition ring diameter produced by modified cement was improved to a maximum of 28.09 mm, and MC3T3-E1 cells performed the cell viabilities all beyond 70% and healthy adhesion after 72 h co-culturing. Taking all measured properties and ISO standards into account, the antibacterial bone cement under the ratio of 10% performed better, besides its good bactericidal effect, the other properties satisfied the requirements for clinical application.

Dental delivery systems of antimicrobial drugs using chitosan, alginate, dextran, cellulose and other polysaccharides: A review

Dental caries, periodontal disease, and endodontic disease are major public health concerns worldwide due to their impact on individuals' quality of life. The present problem of dental disorders is the removal of the infection caused by numerous microbes, particularly, bacteria (both aerobes and anaerobes). The most effective method for treating and managing dental diseases appears to be the use of antibiotics or other antimicrobials, which are incorporated in some drug delivery systems. However, due to their insufficient bioavailability, poor availability for gastrointestinal absorption, and pharmacokinetics after administration via the oral route, many pharmaceutical medicines or natural bioactive substances have limited efficacy. During past few decades, a range of polysaccharide-based systems have been widely investigated for dental dug delivery. The polysaccharide-based carrier materials made of chitosan, alginate, dextran, cellulose and other polysaccharides have recently been spotlighted on the recent advancements in preventing, treating and managing dental diseases. The objective of the current review article is to present a brief comprehensive overview of the recent advancements in polysaccharide-based dental drug delivery systems for the delivery of different antimicrobial drugs.

Antibiotic-free antimicrobial poly (methyl methacrylate) bone cements: A state-of-the-art review

Prosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty, this being because it is associated with, among other things, high morbidity and low quality of life, is difficult to prevent, and is very challenging to treat/manage. The many shortcomings of antibiotic-loaded poly (methyl methacrylate) (PMMA) bone cement (ALBC) as an agent for preventing and treating/managing PJI are well-known. One is that microorganisms responsible for most PJI cases, such as methicillin-resistant S. aureus, have developed or are developing resistance to gentamicin sulfate, which is the antibiotic in the vast majority of approved ALBC brands. This has led to many research efforts to develop cements that do not contain gentamicin (or, for that matter, any antibiotic) but demonstrate excellent antimicrobial efficacy. There is a sizeable body of literature on these so-called "antibiotic-free antimicrobial" PMMA bone cements (AFAMBCs). The present work is a comprehensive and critical review of this body. In addition to summaries of key trends in results of characterization studies of AFAMBCs, the attractive features and shortcomings of the literature are highlighted. Shortcomings provide motivation for future work, with some ideas being formulation of a new generation of AFAMBCs by, example, adding a nanostructured material and/or an extract from a natural product to the powder and/or liquid of the basis cement, respectively.

Effect of Physiological Saline Solution Contamination on Selected Mechanical Properties of Seasoned Acrylic Bone Cements of Medium and High Viscosity

Bone cements play a key role in present-day surgery, including the implantation of hip and knee joint endoprostheses. The correct and durable bonding of the prosthesis to the bone is affected by both the static strength characteristics determined in accordance with ISO 5833:2002 and the resistance to long-term exposure to an aggressive environment of the human body and the impurities that may be introduced into the cement during implementation. The study attempts to demonstrate statistically significant degradation of cement as a result of the seasoning of cement samples in Ringer’s solution with simultaneous contamination of the material with saline solution, which is usually present in the surgical field (e.g., during the fixing of endoprostheses). The results of statistical analysis showed the nature of changes in compressive strength and microhardness due to seasoning time and degree of contamination.

The Role of Chitosan and Graphene Oxide in Bioactive and Antibacterial Properties of Acrylic Bone Cements

Acrylic bone cements (ABC) are widely used in orthopedics for joint fixation, antibiotic release, and bone defect filling, among others. However, most commercially available ABCs exhibit a lack of bioactivity and are susceptible to infection after implantation. These disadvantages generate long-term loosening of the prosthesis, high morbidity, and prolonged and expensive treatments. Due to the great importance of acrylic bone cements in orthopedics, the scientific community has advanced several efforts to develop bioactive ABCs with antibacterial activity through several strategies, including the use of biodegradable materials such as chitosan (CS) and nanostructures such as graphene oxide (GO), with promising results. This paper reviews several studies reporting advantages in bioactivity and antibacterial properties after incorporating CS and GO in bone cements. Detailed information on the possible mechanisms by which these fillers confer bioactive and antibacterial properties to cements, resulting in formulations with great potential for use in orthopedics, are also a focus in the manuscript. To the best of our knowledge, this is the first systematic review that presents the improvement in biological properties with CS and GO addition in cements that we believe will contribute to the biomedical field.

PMMA-Based Bone Cements and the Problem of Joint Arthroplasty Infections: Status and New Perspectives

Polymethyl methacrylate (PMMA)-based bone cement is a biomaterial that has been used over the last 50 years to stabilize hip and knee implants or as a bone filler. Although PMMA-based bone cement is widely used and allows a fast-primary fixation to the bone, it does not guarantee a mechanically and biologically stable interface with bone, and most of all it is prone to bacteria adhesion and infection development. In the 1970s, antibiotic-loaded bone cements were introduced to reduce the infection rate in arthroplasty; however, the efficiency of antibiotic-containing bone cement is still a debated issue. For these reasons, in recent years, the scientific community has investigated new approaches to impart antibacterial properties to PMMA bone cement. The aim of this review is to summarize the current status regarding antibiotic-loaded PMMA-based bone cements, fill the gap regarding the lack of data on antibacterial bone cement, and explore the progress of antibacterial bone cement formulations, focusing attention on the new perspectives. In particular, this review highlights the innovative study of composite bone cements containing inorganic antibacterial and bioactive phases, which are a fascinating alternative that can impart both osteointegration and antibacterial properties to PMMA-based bone cement.

3D-printed bioceramic scaffolds with antibacterial and osteogenic activity

Bacterial infection poses a significant risk with the wide application of bone graft materials. Designing bone grafts with good antibacterial performance and excellent bone-forming activity is of particular significance for bone tissue engineering. In our study, a 3D printing method was used to prepare β-tricalcium phosphate (β-TCP) bioceramic scaffolds. Silver (Ag) nanoparticles were uniformly dispersed on graphene oxide (GO) to form a homogeneous nanocomposite (named Ag@GO) with different Ag-to-graphene oxide mass ratios, with this being synthesized via the liquid chemical reduction approach. Ag@GO nanocomposites were successfully modified on the β-TCP scaffolds by a simple soaking method to achieve bifunctional biomaterials with antibacterial and osteogenic activity. The prepared scaffolds possessed a connected network with triangle pore morphology and the surfaces of the β-TCP scaffolds were uniformly modified by the Ag@GO nanocomposite layers. The Ag content in the scaffolds was controlled by changing the coating times and concentration of the Ag@GO nanocomposites. The antibacterial activity of the scaffolds was assessed with Gram-negative bacteria (Escherichia coli, E. coli). The results demonstrated that the scaffolds with Ag@GO nanocomposites presented excellent antibacterial activity. In addition, the scaffolds coated with Ag@GO nanocomposites conspicuously accelerated the osteogenic differentiation of rabbit bone marrow stromal cells by improving their alkaline phosphatase activity and bone-related gene expression (osteopontin, runt-related transcription factor 2, osteocalcin and bone sialoprotein). This study demonstrates that bifunctional scaffolds with a combination of antibacterial and osteogenic activity can be achieved for the reconstruction of large-bone defects while preventing or treating infections.

Quaternary ammonium-based biomedical materials: State-of-the-art, toxicological aspects and antimicrobial resistance

Microbial infections affect humans worldwide. Many quaternary ammonium compounds have been synthesized that are not only antibacterial, but also possess antifungal, antiviral and anti-matrix metalloproteinase capabilities. Incorporation of quaternary ammonium moieties into polymers represents one of the most promising strategies for preparation of antimicrobial biomaterials. Various polymerization techniques have been employed to prepare antimicrobial surfaces with quaternary ammonium functionalities; in particular, syntheses involving controlled radical polymerization techniques enable precise control over macromolecular structure, order and functionality. Although recent publications report exciting advances in the biomedical field, some of these technological developments have also been accompanied by potential toxicological and antimicrobial resistance challenges. Recent evidenced-based data on the biomedical applications of antimicrobial quaternary ammonium-containing biomaterials that are based on randomized human clinical trials, the golden standard in contemporary medicinal science, are included in the present review. This should help increase visibility, stimulate debates and spur conversations within a wider scientific community on the implications and plausibility for future developments of quaternary ammonium-based antimicrobial biomaterials.

Inhibition of Staphylococcus epidermidis biofilms using polymerizable vancomycin derivatives

BACKGROUND

Biofilm formation on indwelling medical devices is a ubiquitous problem causing considerable patient morbidity and mortality. In orthopaedic surgery, this problem is exacerbated by the large number and variety of material types that are implanted. Metallic hardware in conjunction with polymethylmethacrylate (PMMA) bone cement is commonly used.

QUESTIONS/PURPOSES

We asked whether polymerizable derivatives of vancomycin might be useful to (1) surface modify Ti-6Al-4V alloy and to surface/bulk modify PMMA bone cement to prevent Staphylococcus epidermidis biofilm formation and (2) whether the process altered the compressive modulus, yield strength, resilience, and/or fracture strength of cement copolymers.

METHODS

A Ti-6Al-4V alloy was silanized with methacryloxypropyltrimethoxysilane in preparation for subsequent polymer attachment. Surfaces were then coated with polymers formed from PEG(375)-acrylate or a vancomycin-PEG(3400)-PEG(375)-acrylate copolymer. PMMA was loaded with various species, including vancomycin and several polymerizable vancomycin derivatives. To assess antibiofilm properties of these materials, initial bacterial adherence to coated Ti-6Al-4V was determined by scanning electron microscopy (SEM). Biofilm dry mass was determined on PMMA coupons; the compressive mechanical properties were also determined.

RESULTS

SEM showed the vancomycin-PEG(3400)-acrylate-type surface reduced adherent bacteria numbers by approximately fourfold when compared with PEG(375)-acrylate alone. Vancomycin-loading reduced all mechanical properties tested; in contrast, loading a vancomycin-acrylamide derivative restored these deficits but demonstrated no antibiofilm properties. A polymerizable, PEGylated vancomycin derivative reduced biofilm attachment but resulted in inferior cement mechanical properties.

CLINICAL RELEVANCE

The approaches presented here may offer new strategies for developing biofilm-resistant orthopaedic materials. Specifically, polymerizable derivatives of traditional antibiotics may allow for direct polymerization into existing materials such as PMMA bone cement while minimizing mechanical property compromise. Questions remain regarding ideal monomer structure(s) that confer biologic and mechanical benefits.