Multi-disciplinary antimicrobial strategies for improving orthopaedic implants to prevent prosthetic joint infections in hip and knee

Survivorship and Outcomes of 2-Stage Revision for Infected Total Hip Arthroplasty at a Mean of 7-Year Follow-Up

BACKGROUND

Periprosthetic joint infection (PJI) continues to be one of the leading causes of failure following total hip arthroplasty (THA). The objectives of the study were to (1) determine the minimum 2-year infection-free survivorship of 2-stage revision THA, (2) determine the causative organisms for repeat 2-stage revision THA, and (3) characterize the results of failed 2-stage revisions and evaluate patient-reported outcome measures (PROMs).

METHODS

A retrospective chart review was completed for patients who underwent 2-stage revision THA for PJI. Prospective data were collected on each patient, including demographics, causative organisms, complications, and type of reoperation. The PROMs, including Harris Hip Score, 12-item Short-Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index scores were obtained prior to 2-stage revision THA surgery and annually as part of standard clinical and radiographic follow-up.

RESULTS

A total of 328 patients who underwent a 2-stage revision THA for a PJI were included in the study (mean age 67 years [range, 28 to 90], mean body mass index of 30.6 [range, 15 to 57]). The overall infection-free survivorship for 2-stage revision THA was 73.8% at a minimum of 2 years (range, 2 to 20). Overall, 194 (59.1%) patients who had successful infection eradication underwent a 2-revision THA only. The most common single organisms infected were Staphylococcus aureus (12.5%) and Staphylococcus epidermidis (11%). Higher reoperation rates were found in cases with methicillin-resistant Staphylococcus aureus and polymicrobial infections. All PROMs showed statistical improvement from preoperatively to the latest follow-up appointment.

CONCLUSIONS

Two-stage revision THA is associated with a good success rate in the treatment of PJIs at mid-term to long-term follow-up. Polymicrobial and methicillin-resistant Staphylococcus aureus infections are poor prognostic factors, making the eradication of infection more difficult. The management of PJIs continues to be one of the most important orthopaedic challenges to treat.

Biofilm and How It Relates to Prosthetic Joint Infection

Prosthetic joint infection following total joint arthroplasty is a devastating complication, resulting in increased morbidity and mortality for the patient. The formation of a biofilm on implanted hardware contributes to the difficulty in successful identification and eradication of the infection. Antibiotic therapy and surgical intervention are necessary for addressing this condition; we present a discussion on different treatment options, including those that are not yet routinely utilized in the clinical setting or are under investigation, to highlight the present and future of PJI management.

Biofilm Producing Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in Humans: Clinical Implications and Management

Since its initial description in the 1960s, methicillin-resistant Staphylococcus aureus (MRSA) has developed multiple mechanisms for antimicrobial resistance and evading the immune system, including biofilm production. MRSA is now a widespread pathogen, causing a spectrum of infections ranging from superficial skin issues to severe conditions like osteoarticular infections and endocarditis, leading to high morbidity and mortality. Biofilm production is a key aspect of MRSA's ability to invade, spread, and resist antimicrobial treatments. Environmental factors, such as suboptimal antibiotics, pH, temperature, and tissue oxygen levels, enhance biofilm formation. Biofilms are intricate bacterial structures with dense organisms embedded in polysaccharides, promoting their resilience. The process involves stages of attachment, expansion, maturation, and eventually disassembly or dispersion. MRSA's biofilm formation has a complex molecular foundation, involving genes like icaADBC, fnbA, fnbB, clfA, clfB, atl, agr, sarA, sarZ, sigB, sarX, psm, icaR, and srtA. Recognizing pivotal genes for biofilm formation has led to potential therapeutic strategies targeting elemental and enzymatic properties to combat MRSA biofilms. This review provides a practical approach for healthcare practitioners, addressing biofilm pathogenesis, disease spectrum, and management guidelines, including advances in treatment. Effective management involves appropriate antimicrobial therapy, surgical interventions, foreign body removal, and robust infection control practices to curtail spread within healthcare environments.

Silver-integrated EDM processing of TiAl6V4 implant material has antibacterial capacity while optimizing osseointegration

Periprosthetic joint infections (PJI) are a common reason for orthopedic revision surgeries. It has been shown that the silver surface modification of a titanium alloy (Ti-6Al-4V) by PMEDM (powder mixed electrical discharge machining) exhibits an antibacterial effect on Staphylococcus spp. adhesion. Whether the thickness of the silver-modified surface influences the adhesion and proliferation of bacteria as well as the ossification processes and in-vivo antibacterial capacity has not been investigated before. Therefore, the aim of this work is to investigate the antibacterial effect as well as the in vitro ossification process depending on the thickness of PMEDM silver modified surfaces. The attachment of S. aureus on the PMEDM modified surfaces was significantly lower than on comparative control samples, independently of the tested surface properties. Bacterial proliferation, however, was not affected by the silver content in the surface layer. We observed a long-term effect of antibacterial capacity in vitro, as well as in vivo. An induction of ROS, as indicator for oxidative stress, was observed in the bacteria, but not in osteoblast-like cells. No influence on the in vitro osteoblast function was observed, whereas osteoclast formation was drastically reduced on the silver surface. No changes in cell death, the metabolic activity and oxidative stress was measured in osteoblasts. We show that already small amounts of silver exhibit a significant antibacterial capacity while not influencing the osteoblast function. Therefore, PMEDM using silver nano-powder admixed to the dielectric represents a promising technology to shape and concurrently modify implant surfaces to reduce infections while at the same time optimizing bone ingrowth of endoprosthesis.

The Intraoperative Use of Defensive Antibacterial Coating (DAC®) in the Form of a Gel to Prevent Peri-Implant Infections in Orthopaedic Surgery: A Clinical Narrative Review

Periprosthetic joint infections (PJIs) in arthroplasty and osteosynthesis-associated infections (OAIs) in reconstructive surgery still represent a challenging complication in orthopaedics and traumatology causing a burden worsening the patient's quality of life, for caregiver and treating physicians, and for healthcare systems. PJIs and OAIs are the result of bacterial adhesion over an implant surface with subsequent biofilm formation. Therefore, the clinical pathological outcome is a difficult-to-eradicate persistent infection. Strategies to treat PJIs and OAIs involve debridement, the replacement of internal fixators or articular prostheses, and intravenous antibiotics. However, long treatments and surgical revision cause discomfort for patients; hence, the prevention of PJIs and OAIs represents a higher priority than treatment. Local antibiotic treatments through coating-release systems are becoming a smart approach to prevent this complication. Hydrophilic coatings, loaded with antibiotics, simultaneously provide a barrier effect against bacterial adhesion and allow for the local delivery of an antibiotic. The intraoperative use of a hyaluronan (HY)-derivative coating in the form of a gel, loaded with antibiotics to prevent PJI, has recently raised interest in orthopaedics. Current evidence supports the use of this coating in the prophylaxis of PJI and IRIs in terms of clinical outcomes and infection reduction. Thus, the purpose of this narrative review is to assess the use of a commercially available HY derivative in the form of a gel, highlighting the characteristics of this biomaterial, which makes it attractive for the management of PJIs and IRIs in orthopaedics and traumatology.

Optimizing vancomycin release from novel carbon fiber-reinforced polymer implants with small holes: periprosthetic joint infection treatment

Periprosthetic joint infection (PJI) is a catastrophic complication after total hip arthroplasty. A new drug-loaded carbon fiber-reinforced polymer (CFRP) prosthesis with a sustained drug-release mechanism is being developed for one-stage surgery. We aimed to examine the diffusion dynamics of vancomycin from vancomycin paste-loaded CFRP implants. The differences in the in vitro diffusion dynamics of vancomycin paste were investigated using the elution test by varying parameters. These included the mixing ratio of vancomycin and distilled water (1:0.8, 1:1.2, and 1:1.4) for vancomycin paste, and hole diameter (1 mm and 2 mm) on the container. The in vivo diffusion dynamics were investigated using a rabbit model with vancomycin-loaded CFRP implants placed subcutaneously. The in vitro experiments showed that the diffusion effect of vancomycin was highest in the parameters of vancomycin paste with distilled water mixed in a ratio of 1:1.4, and with a 2 mm hole diameter. The in vivo experiments revealed diffusion dynamics similar to those observed in the in vitro study. The drug diffusion effect tended to be high for vancomycin paste with a large water ratio, and a large diameter of holes. These results indicate that the drug diffusion dynamics from a CFRP implant with holes can be adjusted by varying the water ratio of the vancomycin paste, and the hole size on the CFRP implant.

Interactions between Macrophages and Biofilm during Staphylococcus aureus-Associated Implant Infection: Difficulties and Solutions

Staphylococcus aureus (S. aureus) biofilm is the major cause of failure of implant infection treatment that results in heavy social and economic burden on individuals, families, and communities. Planktonic S. aureus attaches to medical implant surfaces where it proliferates and is wrapped by extracellular polymeric substances, forming a solid and complex biofilm. This provides a stable environment for bacterial growth, infection maintenance, and diffusion and protects the bacteria from antimicrobial agents and the immune system of the host. Macrophages are an important component of the innate immune system and resist pathogen invasion and infection through phagocytosis, antigen presentation, and cytokine secretion. The persistence, spread, or clearance of infection is determined by interplay between macrophages and S. aureus in the implant infection microenvironment. In this review, we discuss the interactions between S. aureus biofilm and macrophages, including the effects of biofilm-related bacteria on the macrophage immune response, roles of myeloid-derived suppressor cells during biofilm infection, regulation of immune cell metabolic patterns by the biofilm environment, and immune evasion strategies adopted by the biofilm against macrophages. Finally, we summarize the current methods that support macrophage-mediated removal of biofilms and emphasize the importance of considering multi-dimensions and factors related to implant-associated infection such as immunity, metabolism, the host, and the pathogen when developing new treatments.

Nanoscale Polishing Technique of Biomedical Grade NiTi Wire by Advanced MAF Process: Relationship between Surface Roughness and Bacterial Adhesion

Nitinol (NiTi), an alloy of nickel and titanium, wires are an important biomedical material that has been used in catheter tubes, guidewires, stents, and other surgical instruments. As such wires are temporarily or permanently inserted inside the human body, their surfaces need to be smoothed and cleaned in order to prevent wear, friction, and adhesion of bacteria. In this study, NiTi wire samples of micro-scale diameters (i.e., Ø 200 μm and Ø 400 μm) were polished by an advanced magnetic abrasive finishing (MAF) process using a nanoscale polishing method. Furthermore, bacterial adhesion (i.e., Escherichia coli (E. coli), and Staphylococcus aureus (S. aureus)) to the initial and final surfaces of NiTi wires were investigated and compared in order to assess the impact of surface roughness on bacterial adhesion to the surfaces of NiTi wires. The finding revealed that the surfaces of NiTi wires were clean and smooth with a lack of particle impurities and toxic components on the final surface polished using the advanced MAF process. The surface roughness Ra values of the Ø 200 μm and Ø 400 μm NiTi wires were smoothly enhanced to 20 nm and 30 nm from the 140 nm and 280 nm initial surface roughness values. Importantly, polishing the surfaces of a biomedical material such as NiTi wire to nano-level roughness can significantly reduce bacterial adhesion on the surface by more than 83.48% in the case of S. aureus, while in the case of E. coli was more than 70.67%.

Strategies to Mitigate and Treat Orthopaedic Device-Associated Infections

Orthopaedic device implants play a crucial role in restoring functionality to patients suffering from debilitating musculoskeletal diseases or to those who have experienced traumatic injury. However, the surgical implantation of these devices carries a risk of infection, which represents a significant burden for patients and healthcare providers. This review delineates the pathogenesis of orthopaedic implant infections and the challenges that arise due to biofilm formation and the implications for treatment. It focuses on research advancements in the development of next-generation orthopaedic medical devices to mitigate against implant-related infections. Key considerations impacting the development of devices, which must often perform multiple biological and mechanical roles, are delineated. We review technologies designed to exert spatial and temporal control over antimicrobial presentation and the use of antimicrobial surfaces with intrinsic antibacterial activity. A range of measures to control bio-interfacial interactions including approaches that modify implant surface chemistry or topography to reduce the capacity of bacteria to colonise the surface, form biofilms and cause infections at the device interface and surrounding tissues are also reviewed.

Antimicrobial peptide in polymethylmethacrylate bone cement as a prophylaxis of infectious complications in orthopedics-an experiment in a murine model

Polymethylmethacrylate (PMMA) bone cement mixed with antibiotics is used in orthopedic surgery to cope with implant-related infections which are typically associated with the formation of bacterial biofilms. Taking into account the growing bacterial resistance to current antibiotics, we examined here the efficacy of a selected antimicrobial peptide (AMP) mixed into the bone cement to inhibit bacterial adhesion and the consequent biofilm formation on its surface. In particular, we followed the formation of bacterial biofilms of methicillin-resistant Staphylococcus aureus (MRSA) on implants made from PMMA bone cement loaded with AMP composed of 12 amino acid residues. This was evaluated by CFU counting of bacteria released by sonication from the biofilms formed on their surfaces after these implants were retrieved from the infected murine femoral canals. The AMP loaded in these model implants prevented adhesion of MRSA and the subsequent formation of MRSA biofilm on the surfaces of more than 80% of these implants, whereas biofilms did form on control implants made from the plain cement. The results of our experiments performed in the murine femoral canal indicate the potential for this murine osteomyelitis model to mimic actual operations in orthopedics.

Functionalized Self-Assembled Monolayers: Versatile Strategies to Combat Bacterial Biofilm Formation

Bacterial infections due to biofilms account for up to 80% of bacterial infections in humans. With the increased use of antibiotic treatments, indwelling medical devices, disinfectants, and longer hospital stays, antibiotic resistant infections are sharply increasing. Annual deaths are predicted to outpace cancer and diabetes combined by 2050. In the past two decades, both chemical and physical strategies have arisen to combat biofilm formation on surfaces. One such promising chemical strategy is the formation of a self-assembled monolayer (SAM), due to its small layer thickness, strong covalent bonds, typically facile synthesis, and versatility. With the goal of combating biofilm formation, the SAM could be used to tether an antibacterial agent such as a small-molecule antibiotic, nanoparticle, peptide, or polymer to the surface, and limit the agent’s release into its environment. This review focuses on the use of SAMs to inhibit biofilm formation, both on their own and by covalent grafting of a biocidal agent, with the potential to be used in indwelling medical devices. We conclude with our perspectives on ongoing challenges and future directions for this field.

Antimicrobial potential and osteoblastic cell growth on electrochemically modified titanium surfaces with nanotubes and selenium or silver incorporation

Titanium nanotube surfaces containing silver, zinc, and copper have shown antimicrobial effects without decreasing osteoblastic cell growth. In this in-vitro study we present first results on the biological evaluation of surface modifications by incorporating selenium and silver compounds into titanium-dioxide (TiO₂) nanotubes by electrochemical deposition. TiO₂-nanotubes (TNT) and Phosphate-doped TNT (pTNT) were grown on the surface of Ti6Al4V discs by anodization. Hydroxyapatite (HA), selenium (Se) and silver (Ag) compounds were incorporated by electrochemical deposition. Colony forming units of Staphylococcus epidermidis (DSM 3269) were significantly decreased in SepTNT (0.97 ± 0.18 × 10⁶ CFU/mL), SepTNT-HA (1.2 ± 0.39 × 10⁶ CFU/mL), AgpTNT (1.36 ± 0.42 × 10⁶ CFU/mL) and Ag₂SepTNT (0.999 ± 0.12 × 10⁶ CFU/mL) compared to the non-modified control (2.2 ± 0.21 × 10⁶ CFU/mL). Bacterial adhesion was calculated by measuring the covered area after fluorescence staining. Adhesion was lower in SepTNT (37.93 ± 12%; P = 0.004), pTNT (47.3 ± 6.3%, P = 0.04), AgpTNT (24.9 ± 1.8%; P < 0.001) and Ag₂SepTNT (14.9 ± 4.9%; P < 0.001) compared to the non-modified control (73.7 ± 11%). Biofilm formation and the growth of osteoblastic cells (MG-63) was observed by using Crystal Violet staining. Biofilm formation was reduced in SepTNT (22 ± 3%, P = 0.02) and Ag₂SepTNT discs (23 ± 11%, P = 0.02) compared to the non-modified control (54 ± 8%). In comparison with the non-modified control the modified SepTNT-HA and pTNT surfaces showed a significant higher covered area with osteoblastic MG-63-cells. Scanning electron microscope (SEM) images confirmed findings regarding bacterial and osteoblastic cell growth. These findings show a potential synergistic effect by combining selenium and silver with titanium nanotubes.

Surface Roughness of Titanium Orthopedic Implants Alters the Biological Phenotype of Human Mesenchymal Stromal Cells

Metal orthopedic implants are largely biocompatible and generally achieve long-term structural fixation. However, some orthopedic implants may loosen over time even in the absence of infection. In vivo fixation failure is multifactorial, but the fundamental biological defect is cellular dysfunction at the host-implant interface. Strategies to reduce the risk of short- and long-term loosening include surface modifications, implant metal alloy type, and adjuvant substances such as polymethylmethacrylate cement. Surface modifications (e.g., increased surface rugosity) can increase osseointegration and biological ingrowth of orthopedic implants. However, the localized responses of cells to implant surface modifications need to be better characterized. As an in vitro model for investigating cellular responses to metallic orthopedic implants, we cultured mesenchymal stromal/stem cells on clinical-grade titanium disks (Ti6Al4V) that differed in surface roughness as high (porous structured), medium (grit blasted), and low (bead blasted). Topological characterization of clinically relevant titanium (Ti) materials combined with differential mRNA expression analyses (RNA-seq and real-time quantitative polymerase chain reaction) revealed alterations to the biological phenotype of cells cultured on titanium structures that favor early extracellular matrix production and observable responses to oxidative stress and heavy metal stress. These results provide a descriptive model for the interpretation of cellular responses at the interface between native host tissues and three-dimensionally printed modular orthopedic implants, and will guide future studies aimed at increasing the long-term retention of such materials after total joint arthroplasty. Impact statement Using an in vitro model of implant-to-cell interactions by culturing mesenchymal stromal cells (MSCs) on clinically relevant titanium materials of varying topological roughness, we identified mRNA expression patterns consistent with early extracellular matrix (ECM) production and responses to oxidative/heavy metal stress. Implants with high surface roughness may delay the differentiation and ECM formation of MSCs and alter the expression of genes sensitive to reactive oxygen species and protein kinases. In combination with ongoing animal studies, these results will guide future studies aimed at increasing the long-term retention of widely used titanium materials after total joint arthroplasty.

Superinfection with Difficult-to-Treat Pathogens Significantly Reduces the Outcome of Periprosthetic Joint Infections

Periprosthetic joint infection (PJI) is a serious complication after total joint arthroplasty. In the course of a PJI, superinfections with pathogens that do not match the primary infecting micro-organism may occur. To our knowledge, there are no published data on the outcome of such infections in the literature. The aim of this study was to assess the outcome of PJI with superinfections with a difficult-to-treat (DTT) pathogen. Data of 169 consecutive patients with PJI were retrospectively analyzed in this single-center study. Cases were categorized into: Group 1 including non-DTT-PJI without superinfection, Group 2 DTT-PJI without superinfection, Group 3 non-DTT-PJI with DTT superinfection, and Group 4 non-DTT-PJI with non-DTT superinfection. Group 3 comprised 24 patients and showed, after a mean follow-up of 13.5 ± 10.8 months, the worst outcome with infection resolution in 17.4% of cases (p = 0.0001), PJI-related mortality of 8.7% (p = 0.0001), mean revision rate of 6 ± 3.6 (p < 0.0001), and duration of antibiotic treatment of 71.2 ± 45.2 days (p = 0.0023). PJI caused initially by a non-DTT pathogen with a superinfection with a DTT pathogen is significantly associated with the worst outcome in comparison to non-DTT-PJI, PJI caused initially by a DTT pathogen, and to non-DTT-PJI with a non-DTT superinfection.

Endogenous nitric oxide-generating surfaces via polydopamine-copper coatings for preventing biofilm dispersal and promoting microbial killing

INTRODUCTION

Peri-implantitis is a bacterially induced inflammatory disease which affects the hard and soft tissues around a dental implant. Microbial biofilm formation is an important causative factor in peri-implantitis. The aim of this study is to develop an effective multifunctional surface coating for antimicrobial property and to counteract oral biofilm-associated infections via a single polydopamine copper coating (PDAM@Cu) on titanium implant surface to regulate endogenous nitric oxide (NO) generation.

METHODS

PDAM@Cu coatings were made with different concentrations of CuCl₂ on titanium surfaces with a simple dip coating technique. Coatings were characterised to evaluate Cu concentrations as well as NO release rates from the coatings. Further, salivary biofilms were made on the coatings using Brain Heart Infusion (BHI) media in an anaerobic chamber. Biofilms were prepared with three different mixtures, one of which was saliva only, the second had an addition of sheep's blood, and the third was prepared with NO donors S-nitrosoglutathione (GSNO) and L-glutathione (GSH) in the mixture of saliva and blood to evaluate the effects of endogenously produced NO on biofilms. The effectiveness of coated surfaces on biofilms were assessed using four different methods, namely, crystal violet assay, scanning electron microscopy imaging, 2,3-bis (2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino) carbonyl]-2H-tetrazolium hydroxide (XTT) metabolic assay, and live/dead staining.

RESULTS

NO release rates could be controlled with different Cu concentration in PDAM@Cu coatings. NO generated from the PDAM@Cu coatings effectively induced dispersal of biofilms shown by the reduction in biofilm biomass as well as reduced biofilm attachment in samples prepared with blood and NO donors. Cu ions released from the PDAM@Cu coatings resulted in killing of the dispersed bacteria, which was evidenced by the live/dead cell staining and reduced metabolic activity noted from the XTT assay. In contrast, samples prepared with saliva showed no significant reduction in biofilms, indicating the important effect of endogenously generated NO on biofilm dispersal.

CONCLUSION

In conclusion, PDAM@Cu coatings with NO generating surfaces have a dual anti-biofilm function, with a synergistic effect on biofilm dispersal from regulated NO generation and bactericidal effects from Cu ions from the coatings.

Biomaterials and technologies in the management of periprosthetic infection after total hip arthroplasty: An updated review

Although total hip arthroplasty (THA) is considered one of the most efficacious procedures for managing various hip conditions, failures due to different mechanisms are still being reported. Periprosthetic joint infection (PJI) is one of the devastating causes of failure and revision of THA. PJI carries a burden on the patient, the surgeon, and the health-care system. The diagnosis and management of PJIs carry many morbidities and increased treatment costs. The development of PJI is multifactorial, including issues related to the patient’s general condition, the surgeon’s efficiency, surgical technique, and the implants used. Recent advances in the area of diagnosis and predicting PJI as well as introducing new technologies and biomaterials update for the prevention and treatment of PJI. Local implant coatings, advancement in the bearing surfaces technologies, and new technologies such as immunotherapy and bacteriophage therapy were introduced and suggested as contemporary PJI eradication solutions. In this review, we aimed at discussing some of the newly introduced materials and technologies for the sake of PJI control.

Use of Plasma Technologies for Antibacterial Surface Properties of Metals

Bacterial infections of medical devices present severe problems connected with long-term antibiotic treatment, implant failure, and high hospital costs. Therefore, there are enormous demands for innovative techniques which would improve the surface properties of implantable materials. Plasma technologies present one of the compelling ways to improve metal's antibacterial activity; plasma treatment can significantly alter metal surfaces' physicochemical properties, such as surface chemistry, roughness, wettability, surface charge, and crystallinity, which all play an important role in the biological response of medical materials. Herein, the most common plasma treatment techniques like plasma spraying, plasma immersion ion implantation, plasma vapor deposition, and plasma electrolytic oxidation as well as novel approaches based on gaseous plasma treatment of surfaces are gathered and presented. The latest results of different surface modification approaches and their influence on metals' antibacterial surface properties are presented and critically discussed. The mechanisms involved in bactericidal effects of plasma-treated surfaces are discussed and novel results of surface modification of metal materials by highly reactive oxygen plasma are presented.

Silver-coated megaprosthesis in prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about efficacy and toxicity in primary and revision surgery

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.

Bacterial adhesion on orthopedic implants

Orthopedic implants are routinely used for fixation of fractures, correction of deformities, joint replacements, and soft tissue anchorage. Different biomaterials have been engineered for orthopedic implants. Previously, they were designed merely as mechanical devices, now new strategies to enhance bone healing and implant osteointegration via local delivery of molecules and via implant coatings are being developed. These biological coatings should enhance osteointegration and reduce foreign body response or infection. This article reviews current and future orthopedic implants, materials and surface characteristics, biocompatibility, and mechanisms of bacterial adhesion. Additionally, the review is addressing implant-related infection, the main strategies to prevent it and suggest possible future research that may control implant related-infection.

Long acting anti-infection constructs on titanium

Peri-prosthetic joint infections (PJI) are a serious adverse event following joint replacement surgeries; antibiotics are usually added to bone cement to prevent infection offset. For uncemented prosthesis, alternative antimicrobial approaches are necessary in order to prevent PJI; however, despite elution of drug from the surface of the device being shown one of the most promising approach, no effective antimicrobial eluting uncemented device is currently available on the market. Consequently, there is a clinical need for non-antibiotic antimicrobial uncemented prosthesis as these devices present numerous benefits, particularly for young patients, over cemented artificial joints. Moreover, non-antibiotic approaches are driven by the need to address the growing threat posed by antibiotic resistance. We developed a multilayers functional coating on titanium surfaces releasing chlorhexidine, a well-known antimicrobial agent used in mouthwash products and antiseptic creams, embedding the drug between alginate and poly-beta-amino-esters. Chlorhexidine release was sustained for almost 2 months and the material efficacy and safety was proven both in vitro and in vivo. The coatings did not negatively impact osteoblast and fibroblast cells growth and were capable of reducing bacterial load and accelerating wound healing in an excisional wound model. As PJI can develop weeks and months after the initial surgery, these materials could provide a viable solution to prevent infections after arthroplasty in uncemented prosthetic devices and, simultaneously, help the fight against antibiotic resistance.

A Review of In-Situ Grown Nanocomposite Coatings for Titanium Alloy Implants

Composite coatings are commonly applied to medical metal implants in order to improve biocompatibility and/or bioactivity. In this context, two types of titanium-based composite coatings have been reviewed as biocompatible and anti-bacterial coatings. The different composites can be synthesised on the surface of titanium using various methods, which have their own advantages and disadvantages. Moving with the smart and nanotechnology, multifunctional nanocomposite coatings have been introduced on implants and scaffolds for tissue engineering with the aim of providing more than one properties when required. In this context, titanium dioxide (TiO2) nanotubes have been shown to enhance the properties of titanium-based implants as part of nanocomposite coatings.

Synthesis and characterization of antibacterial drug loaded β-tricalcium phosphate powders for bone engineering applications

Powders of β-tricalcium phosphate [β-TCP, β-Ca₃(PO₄)₂] and composite powders of β-TCP and polyvinyl alcohol (PVA) were synthesized by using wet precipitation methods. First, the conditions for the preparation of single phase β-TCP have been delineated. In the co-precipitation procedure, calcium nitrate and diammonium hydrogen phosphate were used as calcium and phosphorous precursors, respectively. The pH of the system was varied in the range 7-11 by adding designed amounts of ammonia solution. The filtered cakes were desiccated at 80 °C and subsequently calcined at different temperatures in the range between 700-1100 °C. Later on, rifampicin form II was used to produce drug-loaded β-TCP and PVA/β-TCP powders. All the synthesized materials have been characterized from morphological (by scanning electron microscopy) and structural-chemical (by X-ray diffraction and Fourier transform infrared spectroscopy) point of view. The drug loading capacity of the selected pure β-TCP powder has been assessed. The biological performance (cytocompatibility in fibroblast cell culture and antibacterial efficacy against Escherichia coli and Staphylococcus aureus) has been tested with promising results. Application perspectives of the designed drug-bioceramic-polymer blends are advanced and discussed.

Fabricating Laser-Induced Periodic Surface Structures on Medical Grade Cobalt–Chrome–Molybdenum: Tribological, Wetting and Leaching Properties

Hip-implants structured with anti-bacterial textures should show a low-friction coefficient and should not leach hazardous substances into the human body. The surface of a typical material used for hip-implants, namely Cobalt–Chrome–Molybdenum (CoCrMo) was textured with different types of laser-induced periodic surface structures (LIPSS)—i.e., low spatial frequency LIPSS (LSFL), hierarchical structures consisting of grooves superimposed with high spatial frequency LIPSS (HSFL) and Triangular shaped Nanopillars (TNP)—using a picosecond pulsed laser source. The effect of LIPSS on the wettability, friction, as well as wear of the structures, when slid against a polyethylene (PE) counter surface and biocompatibility was analyzed. Surfaces covered with LSFL show superhydrophobicity and grooves with superimposed HSFL, as well as TNP, show hydrophobic behavior. The coefficient of friction (CoF) of LIPSS against a polyethylene (PE) counter surface was found to be higher (ranging from 0.40 to 0.66) than the CoF of (polished) CoCrMo, which was found to equal 0.22. It was found that the samples release cobalt within biocompatible limits. Compared to polished reference surfaces, LIPSS cause higher friction of CoCrMo against PE contact. However, the wear of the PE counter surface only increased significantly for the LSFL textures. For these reasons, it is concluded that LIPSS are not suitable for a heavily loaded metal-on-plastic bearing contact.

Partial two-stage exchange at the site of periprosthetic hip joint infections

INTRODUCTION

In the past 10 years an increasing number of studies about partial two-stage exchange arthroplasty in the management of periprosthetic hip infections have been published. The aim of the present work was to systematically review the current knowledge about this procedure, and critically verify the success as well as the complications of this treatment option.

MATERIALS-METHODS

A literature search was performed through PubMed until June 2018. Search terms were "partial two stage hip" and "partial retention hip", and "retaining well fixed hip".

RESULTS

A total of 7 studies reporting on a total of 80 patients could be identified. All studies had a level of evidence IV. The great majority of the studies reported on the isolated removal of the acetabular cup and placement of an antibiotic-loaded cement spacer head onto the retained, well-fixed stem. Most of the periprosthetic infections were caused by staphylococci. The infection eradication rate varied between 81.3 and 100% at a mean follow-up between 19 and 70 months. Poor outcome was observed at the site of MRSA infections.

CONCLUSIONS

The partial two-stage exchange arthroplasty appears to be a possible option in the management of PJI when one prosthetic component is well-fixed so that their removal might result in significant bone loss and compromise of fixation at the time of the later prosthesis reimplantation, and the causative organisms are not multiresistant. The small numbers published about this protocol does not allow for a generalization of application and should be only applied in highly selected patients. Future studies with larger collectives and longer follow-ups are welcome to evaluate the clinical success of this option and its possible role in the management of PJI.

Antimicrobial peptides prevent bacterial biofilm formation on the surface of polymethylmethacrylate bone cement

PURPOSE

Antibiotic-loaded polymethylmethacrylate-based bone cement has been implemented in orthopaedics to cope with implant-related infections associated with the formation of bacterial biofilms. In the context of emerging bacterial resistance to current antibiotics, we examined the efficacy of short antimicrobial peptide-loaded bone cement in inhibiting bacterial adhesion and consequent biofilm formation on its surface.

METHODOLOGY

The ability of α-helical antimicrobial peptides composed of 12 amino acid residues to prevent bacterial biofilm [methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, Pseudomonas aeruginosa and Escherichia coli] formation on the surface of model implants made from polymethylmethacrylate-based bone cement was evaluated by colony-forming unit (c.f.u.) counting of bacteria released by sonication from the biofilms formed on their surfaces. The biofilms on model implant surfaces were also visualized by light microscopy after staining with tetrazolium dye (MTT) and by scanning electron microscopy.

RESULTS

When incorporated in the implants, these peptides caused a mean reduction in the number of bacterial cells attached to implants' surfaces (by five orders of magnitude), and 88 % of these implants showed no bacterial adhesion after being exposed to growth media containing various bacteria.

CONCLUSION

The results showed that the antibiofilm activity of these peptides was comparable to that of the antibiotics, but the peptides exhibited broader specificity than the antibiotics. Given the rapid development of antibiotic resistance, antimicrobial peptides show promise as a substitute for antibiotics for loading into bone cements.

An antibiofilm coating of 5-aryl-2-aminoimidazole covalently attached to a titanium surface

Biofilms, especially those formed by Staphylococcus aureus, play a key role in the development of orthopedic implant infections. Eradication of these infections is challenging due to the elevated tolerance of biofilm cells against antimicrobial agents. In this study, we developed an antibiofilm coating consisting of 5-(4-bromophenyl)-N-cyclopentyl-1-octyl-1H-imidazol-2-amine, designated as LC0024, covalently bound to a titanium implant surface (LC0024-Ti). We showed in vitro that the LC0024-Ti surface reduces biofilm formation of S. aureus in a specific manner without reducing the planktonic cells above the biofilm, as evaluated by plate counting and fluorescence microscopy. The advantage of compounds that only inhibit biofilm formation without affecting the viability of the planktonic cells, is that reduced development of bacterial resistance is expected. To determine the antibiofilm activity of LC0024-Ti surfaces in vivo, a biomaterial-associated murine infection model was used. The results indicated a significant reduction in S. aureus biofilm formation (up to 96%) on the LC0024-Ti substrates compared to pristine titanium controls. Additionally, we found that the LC0024-Ti substrates did not affect the attachment and proliferation of human cells involved in osseointegration and bone repair. In summary, our results emphasize the clinical potential of covalent coatings of LC0024 on titanium implant surfaces to reduce the risk of orthopedic implant infections. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1908-1919, 2019.

Current Options and Emerging Biomaterials for Periprosthetic Joint Infection

PURPOSE OF REVIEW

Infection in the setting of total joint arthroplasty, referred to as periprosthetic joint infection (PJI), is a devastating complication requiring prolonged and costly treatment. The unique environment around an artificial joint and ability of surrounding tissues to sequester bacteria collectively make prevention, diagnosis, and treatment of this condition challenging. In light of the unique pathogenesis of PJI, this review explores the limitations of contemporary treatments and discusses novel treatment options.

RECENT FINDINGS

Recent advancements in local antibiotic delivery platforms for preventing and treating PJI include titanium nanotube arrays, synthetic polymers, resorbable hydrogels, and cyclodextrin-based drug delivery options. In particular, cyclodextrins have facilitated great advancements in other clinical disorders and have demonstrated early promise as a future option in the arena of PJI. Novel treatment modalities for PJI optimize the implant surfaces to prevent bacterial biofilm formation or provide prolonged intra-articular antibiotic dosing to eradicate bacteria.

Initial peri- and postoperative antibiotic treatment of infected nonunions: results from 212 consecutive patients after mean follow-up of 34 months

PURPOSE

Infected nonunions of the long bones belong to the most feared complications in the field of orthopedic and trauma surgery. Optimal antibiotic therapy should start early with the first revision surgery. Therefore, the aim of this study was to evaluate our peri- and postoperative antibiotic regime in context with the microbial spectrum and antibiotic resistances of patients with infected nonunions and to assess the possible impact on healing rates.

METHODS

We included all patients with first revision surgery during 2010-2015 due to nonunion of long bones with a clinical history of infection treated with radical debridement, local application of a gentamicin-impregnated bone cement, and systemic cefuroxime. Mean follow-up was 34.2 months. Data collection was performed retrospectively using a computerized databank with information about microbial species from intraoperatively acquired tissue samples and respective antibiograms. Bone fusion rates were evaluated based on findings of the latest X-rays and computed tomography scans.

RESULTS

Two hundred and twelve patients with nonunion and history of infection were selected; 171 patients had positive intraoperative microbial evidence of infection. Bacterial testing was mostly positive in fractures of the tibia (47.4%) and the femur (27.5%). Coagulase-negative Staphylococcus spp. were the most frequently detected (44.4%) followed by mixed infections (18.7%) and Staphylococcus aureus (10.5%). Antibiograms revealed that 62.6% of our cases were cefuroxime sensitive; 87.7% were gentamicin sensitive. Only 10.5% showed resistance to both cefuroxime and gentamicin. There was no statistically significant difference of fusion rates between patients with different microbial species or different antibiograms.

CONCLUSION

Our data suggest that besides the high variety of different detected species, initial antibiotic treatment with a combination of systemic cefuroxime and local gentamicin-loaded bone cement is effective and in almost 90% the later determined microbial infection was sensitive to this treatment. Therefore, we recommend initial treatment according to this algorithm until specific antibiograms are available from intraoperatively acquired tissue samples.

Multidrug-Resistant Organisms in the Setting of Periprosthetic Joint Infection-Diagnosis, Prevention, and Treatment

BACKGROUND

Periprosthetic joint infection (PJI) is a rare yet challenging problem in total hip and knee arthroplasties. The management of PJI remains difficult primarily due to the evolution of resistance by the infecting organisms.

METHODS

This review profiles acquired mechanisms of bacterial resistance and summarizes established and emerging techniques in PJI diagnosis, prevention, and treatment.

RESULTS

New techniques in PJI diagnosis and prevention continue to be explored. Antibiotics combined with 1 or 2-stage revision are associated with the higher success rates and remain the mainstay of treatment.

CONCLUSION

With higher prevalence of antibiotic-resistant organisms, novel antibiotic implant and wound care materials, improved methods for organism identification, and well-defined organism-specific treatment algorithms are needed to optimize outcomes of PJI.

Antimicrobial 3D Porous Scaffolds Prepared by Additive Manufacturing and Breath Figures

We describe herein a novel strategy for the fabrication of efficient 3D printed antibacterial scaffolds. For this purpose, both the surface topography as well as the chemical composition of 3D scaffolds fabricated by additive manufacturing were modified. The scaffolds were fabricated by fused deposition modeling (FDM) using high-impact polystyrene (HIPS) filaments. The surface of the objects was then topographically modified providing materials with porous surfaces by means of the Breath Figures approach. The strategy involves the immersion of the scaffold in a polymer solution during a precise period of time. This approach permitted the modification of the pore size varying the immersion time as well as the solution concentration. Moreover, by using polymer blend solutions of polystyrene and polystyrene-b-poly(acrylic acid) (PS₂₃-b-PAA₁₈) and a quaternized polystyrene-b-poly(dimethylaminoethyl methacrylate) (PS₄₂-b-PDMAEMAQ₁₇), the scaffolds were simultaneously chemically modified. The surfaces were characterized by scanning electron microscopy and infrared spectroscopy. Finally, the biological response toward bacteria was explored. Porous surfaces prepared using quaternized PDMAEMA as well as those prepared using PAA confer antimicrobial activity to the films, i.e., were able to kill on contact Staphylococcus aureus employed as model bacteria.

Backscattered electron imaging and electron backscattered diffraction in the study of bacterial attachment to titanium alloy structure

The application of secondary electron (SE) imaging, backscattered electron imaging (BSE) and electron backscattered diffraction (EBSD) was investigated in this work to study the bacterial adhesion and proliferation on a commercially pure titanium (cp Ti) and a Ti6Al4V alloy (Ti 64) with respect to substrate microstructure and chemical composition. Adherence of Gram-positive Staphylococcus epidermidis 11047 and Streptococcus sanguinis GW2, and Gram-negative Serratia sp. NCIMB 40259 and Escherichia coli 10418 was compared on cp Ti, Ti 64, pure aluminium (Al) and vanadium (V). The substrate microstructure and the bacterial distribution on these metals were characterised using SE, BSE and EBSD imaging. It was observed that titanium alloy-phase structure, grain boundaries and grain orientation did not influence bacterial adherence or proliferation at microscale. Adherence of all four strains was similar on cp Ti and Ti 64 surfaces whilst inhibited on pure Al. This work establishes a nondestructive and straight-forward statistical method to analyse the relationship between microbial distribution and metal alloy structure.

Advances in the local and targeted delivery of anti-infective agents for management of osteomyelitis

INTRODUCTION

Osteomyelitis, a common and debilitating invasive infection of bone, is a frequent complication following orthopedic surgery and causes pathologic destruction of skeletal tissues. Bone destruction during osteomyelitis results in necrotic tissue, which is poorly penetrated by antibiotics and can serve as a nidus for relapsing infection. Osteomyelitis therefore frequently necessitates surgical debridement procedures, which provide a unique opportunity for targeted delivery of antimicrobial and adjunctive therapies. Areas covered: Following surgical debridement, tissue voids require implanted materials to facilitate the healing process. Antibiotic-loaded, non-biodegradable implants have been the standard of care. However, a new generation of biodegradable, osteoconductive materials are being developed. Additionally, in the face of widespread antimicrobial resistance, alternative therapies to traditional antibiotic regimens are being investigated, including bone targeting compounds, antimicrobial surface modifications of orthopedic implants, and anti-virulence strategies. Expert commentary: Recent advances in biodegradable drug delivery scaffolds make this technology an attractive alternative to traditional techniques for orthopedic infection that require secondary operations for removal. Advances in novel treatment methods are expanding the arsenal of viable antimicrobial treatment strategies in the face of widespread drug resistance. Despite a need for large scale clinical investigations, these strategies offer hope for future treatment of this difficult invasive disease.

Local Cellular Responses to Titanium Dioxide from Orthopedic Implants

We evaluated recently published articles relevant to the biological effects of titanium dioxide (TiO₂) particles on local endogenous cells required for normal bone homeostasis, repair, and implant osseointegration. Structural characteristics, size, stability, and agglomeration of TiO₂ particles alter the viability and behavior of multiple bone-related cell types. Resulting shifts in bone homeostasis may increase bone resorption and lead to clinical incidents of osteolysis, implant loosening, and joint pain. TiO₂ particles that enter cells (through endocytosis or Trojan horse mechanism) may further disrupt implant retention. We propose that cellular responses to titanium-based nanoparticles contribute to pathological mechanisms underlying the aseptic loosening of titanium-based metal implants.

Zinc Pyrithione Improves the Antibacterial Activity of Silver Sulfadiazine Ointment

Topical antimicrobial ointments ostensibly mitigate bacterial wound disease and reliance on systemic antibiotics. Yet studies have called into question the therapeutic benefits of several traditional topical antibacterials, accentuating the need for improved next-generation antimicrobial ointments. Yet the development of such agents consisting of a new chemical entity is a time-consuming and expensive proposition. Considering that drug combinations are a mainstay therapeutic strategy for the treatment of other therapeutic indications, one alternative approach is to improve the performance of conventional antimicrobial ointments by the addition of a well-characterized and FDA-approved agent. Here we report data that indicate that the antimicrobial properties of silver sulfadiazine ointments can be significantly improved by the addition of the antifungal zinc pyrithione, suggesting that such combinations may provide an improved therapeutic option for the topical treatment of wound infections.

Pseudomonas aeruginosa, Acinetobacter baumannii, and Staphylococcus aureus are commonly associated with biofilm-associated wound infections that are recalcitrant to conventional antibiotics. As an initial means to identify agents that may have a greater propensity to improve clearance of wound-associated bacterial pathogens, we screened a Food and Drug Administration-approved drug library for members that display bactericidal activity toward 72-h-established P. aeruginosa biofilms using an adenylate kinase reporter assay for bacterial cell death. A total of 34 compounds displayed antibiofilm activity. Among these, zinc pyrithione was also shown to reduce levels of A. baumannii and S. aureus biofilm-associated bacteria and exhibited an additive effect in combination with silver sulfadiazine, a leading topical therapeutic for wound site infections. The improved antimicrobial activity of zinc pyrithione and silver sulfadiazine was maintained in an ointment formulation and led to improved clearance of P. aeruginosa, A. baumannii, and S. aureus in a murine model of wound infection. Taken together, these results suggest that topical zinc pyrithione and silver sulfadiazine combination formulations may mitigate wound-associated bacterial infections and disease progression.

IMPORTANCE Topical antimicrobial ointments ostensibly mitigate bacterial wound disease and reliance on systemic antibiotics. Yet studies have called into question the therapeutic benefits of several traditional topical antibacterials, accentuating the need for improved next-generation antimicrobial ointments. Yet the development of such agents consisting of a new chemical entity is a time-consuming and expensive proposition. Considering that drug combinations are a mainstay therapeutic strategy for the treatment of other therapeutic indications, one alternative approach is to improve the performance of conventional antimicrobial ointments by the addition of a well-characterized and FDA-approved agent. Here we report data that indicate that the antimicrobial properties of silver sulfadiazine ointments can be significantly improved by the addition of the antifungal zinc pyrithione, suggesting that such combinations may provide an improved therapeutic option for the topical treatment of wound infections.

Silver Nanocoating Technology in the Prevention of Prosthetic Joint Infection

Prosthetic joint infection (PJI) is a feared complication of total joint arthroplasty associated with increased morbidity and mortality. There is a growing body of evidence that bacterial colonization and biofilm formation are critical pathogenic events in PJI. Thus, the choice of biomaterials for implanted prostheses and their surface modifications may significantly influence the development of PJI. Currently, silver nanoparticle (AgNP) technology is receiving much interest in the field of orthopaedics for its antimicrobial properties and a strong anti-biofilm potential. The great advantage of AgNP surface modification is a minimal release of active substances into the surrounding tissue and a long period of effectiveness. As a result, a controlled release of AgNPs could ensure antibacterial protection throughout the life of the implant. Moreover, the antibacterial effect of AgNPs may be strengthened in combination with conventional antibiotics and other antimicrobial agents. Here, our main attention is devoted to general guidelines for the design of antibacterial biomaterials protected by AgNPs, its benefits, side effects and future perspectives in PJI prevention.

Osteogenic potential of human adipose-tissue-derived mesenchymal stromal cells cultured on 3D-printed porous structured titanium

Integration of porous metal prosthetics, which restore form and function of irreversibly damaged joints, into remaining healthy bone is critical for implant success. We investigated the biological properties of adipose-tissue-derived mesenchymal stromal/stem cells (AMSCs) and addressed their potential to alter the in vitro microenvironment of implants. We employed human AMSCs as a practical source for musculoskeletal applications because these cells can be obtained in large quantities, are multipotent, and have trophic paracrine functions. AMSCs were cultured on surgical-grade porous titanium disks as a model for orthopedic implants. We monitored cell/substrate attachment, cell proliferation, multipotency, and differentiation phenotypes of AMSCs upon osteogenic induction. High-resolution scanning electron microscopy and histology revealed that AMSCs adhere to the porous metallic surface. Compared to standard tissue culture plastic, AMSCs grown in the porous titanium microenvironment showed differences in temporal expression for genes involved in cell cycle progression (CCNB2, HIST2H4), extracellular matrix production (COL1A1, COL3A1), mesenchymal lineage identity (ACTA2, CD248, CD44), osteoblastic transcription factors (DLX3, DLX5, ID3), and epigenetic regulators (EZH1, EZH2). We conclude that metal orthopedic implants can be effectively seeded with clinical-grade stem/stromal cells to create a pre-conditioned implant.

Progranulin suppresses titanium particle induced inflammatory osteolysis by targeting TNFα signaling

Aseptic loosening is a major complication of prosthetic joint surgery, characterized by chronic inflammation, pain, and osteolysis surrounding the bone-implant interface. Progranulin (PGRN) is known to have anti-inflammatory action by binding to Tumor Necrosis Factor (TNF) receptors and antagonizing TNFα. Here we report that titanium particles significantly induced PGRN expression in RAW264.7 cells and also in a mouse air-pouch model of inflammation. PGRN-deficiency enhanced, whereas administration of recombinant PGRN effectively inhibited, titanium particle-induced inflammation in an air pouch model. In addition, PGRN also significantly inhibited titanium particle-induced osteoclastogenesis and calvarial osteolysis in vitro, ex vivo and in vivo. Mechanistic studies demonstrated that the inhibition of PGRN on titanium particle induced-inflammation is primarily via neutralizing the titanium particle-activated TNFα/NF-κB signaling pathway and this is evidenced by the suppression of particle-induced IκB phosphorylation, NF-κB p65 nuclear translocation, and activity of the NF-κB-specific reporter gene. Collectively, these findings not only demonstrate that PGRN plays an important role in inhibiting titanium particle-induced inflammation, but also provide a potential therapeutic agent for the prevention of wear debris-induced inflammation and osteolysis.