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Listopadzki T, Chowdhury A, Kohut K, Haider MN, Crane JK, Duquin T, DiPaola M. The effect of different antibiotic combinations in calcium sulfate cement on the growth of Cutibacterium acnes and Staphylococcus periprosthetic shoulder infection isolates. J Shoulder Elbow Surg 2024; 33:1457-1464. [PMID: 38417732 DOI: 10.1016/j.jse.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/17/2023] [Accepted: 01/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Periprosthetic joint infections (PJI) of the shoulder are a devastating complication of shoulder arthroplasty and are commonly caused by Staphylococcus and Cutibacterium acnes. Absorbable calcium sulfate (CS) beads are sometimes used for delivering antibiotics in PJI. This study evaluates the in vitro effect of different combinations of gentamicin, vancomycin, and ertapenem in beads made from CS cement on the growth of C acnes and coagulase-negative Staphylococcus (CNS) strains. METHODS Three strains of C acnes and 5 strains of CNS from clinically proven shoulder PJI were cultured and plated with CS beads containing combinations of vancomycin, gentamicin, and ertapenem. Plates with C acnes were incubated anaerobically while plates with Staphylococcus were incubated aerobically at 37 °C. Zones of inhibition were measured at intervals of 3 and 7 days using a modified Kirby Bauer technique, and beads were moved to plates containing freshly streaked bacteria every seventh day. This process was run in triplicate over the course of 56 days. Statistical analysis was conducted using SPSS v. 28 with repeated measures analysis of variance (ANOVA) and pairwise comparisons with Tukey correction. RESULTS In experiments with C acnes, beads containing ertapenem + vancomycin and vancomycin alone formed the largest zones of inhibition over time (P < .001). In experiments with Staphylococcus, beads containing vancomycin alone formed the largest zones of inhibition over time for all 5 strains (P < .001). Zones of inhibition were 1.4x larger for C acnes than for Staphylococcus with beads containing vancomycin alone. For both C acnes and Staphylococcus, beads containing ertapenem had the strongest initial effect, preventing all bacterial growth in C acnes and almost all growth for Staphylococcus during the first week but dropping substantially by the second week. Beads containing gentamicin alone consistently created smaller zones of inhibition than beads containing vancomycin alone, with vancomycin producing zones 5.3x larger than gentamicin in C acnes and 1.3x larger in Staphylococcus (P < .001). DISCUSSION These data suggest that for both C acnes and Staphylococcal species, CS beads impregnated with vancomycin were most effective at producing a robust antibiotic effect. Additionally, ertapenem may be a viable supplement in order to create a more potent initial antibiotic effect but is not as effective as vancomycin when used alone. Gentamicin alone was not effective in maintaining consistent and long-term antibiotic effects. These results indicate that amongst the antibiotics currently commercially available to be used with CS, vancomycin is consistently superior to gentamicin in the setting of C. acnes and CNS.
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Affiliation(s)
- Thomas Listopadzki
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Allison Chowdhury
- Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Kevin Kohut
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Mohammad Nadir Haider
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - John K Crane
- Division of Infectious Disease, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Thomas Duquin
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Matthew DiPaola
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Science, University at Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA.
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Fraval A, Zhou Y, Parvizi J. Antibiotic-loaded cement in total joint arthroplasty: a comprehensive review. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05328-z. [PMID: 38687383 DOI: 10.1007/s00402-024-05328-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
This review evaluates the decision-making framework for using antibiotic-loaded cement (ALC) in the management of prosthetic joint infection (PJI). Drawing on available literature, we offer orthopaedic surgeons a guided discussion on several critical considerations. First, we explore the impact of antibiotic-loading on the mechanical properties of polymethylmethacrylate (PMMA) cement, assessing both strength and durability. We then explore the optimal antibiotic dosage to load into cement, aiming to achieve effective local concentrations for infection control without compromising mechanical stability. Furthermore, we explore how cement and antibiotic properties affect the overall antibiotic elution characteristics of ALC. Finally, we discuss risks of systemic toxicity, particularly acute kidney injury, when using ALC. The principal goal in this review is to provide a balanced approach based on best available evidence that optimises antibiotic elution from ALC whilst minimising potential harms associated with its use.
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Affiliation(s)
- Andrew Fraval
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Yushy Zhou
- Department of Orthopaedic Surgery, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
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Lekkala S, Inverardi N, Grindy SC, Hugard S, Muratoglu OK, Oral E. Irradiation Behavior of Analgesic and Nonsteroidal Anti-Inflammatory Drug-Loaded UHMWPE for Joint Replacement. Biomacromolecules 2024; 25:2312-2322. [PMID: 38456765 DOI: 10.1021/acs.biomac.3c01179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Local delivery of pain medication can be a beneficial strategy to address pain management after joint replacement, as it can decrease systemic opioid usage, leading to less side and long-term effects. In this study, we used ultrahigh molecular weight polyethylene (UHMWPE), commonly employed as a bearing material for joint implants, to deliver a wide set of analgesics and the nonsteroidal anti-inflammatory drug tolfenamic acid. We blended the drugs with UHMWPE and processed the blend by compression molding and sterilization by low-dose gamma irradiation. We studied the chemical stability of the eluted drugs, drug elution, tensile properties, and wear resistance of the polymer blends before and after sterilization. The incorporation of bupivacaine hydrochloride and tolfenamic acid in UHMWPE resulted in either single- or dual-drug loaded materials that can be sterilized by gamma irradiation. These compositions were found to be promising for the development of clinically relevant drug-eluting implants for joint replacement.
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Affiliation(s)
- Sashank Lekkala
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
| | - Nicoletta Inverardi
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Scott C Grindy
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Shannon Hugard
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts 02114, United States
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts 02114, United States
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Quinto ES, Reyes NP, Cutter BM, Paisner ND, Steimel JP, Lee J, Huish EG, Holmes W. Effects of vancomycin and tobramycin on compressive and tensile strengths of antibiotic bone cement: A biomechanical study. J Orthop 2024; 50:8-11. [PMID: 38214003 PMCID: PMC10777384 DOI: 10.1016/j.jor.2023.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024] Open
Abstract
Purpose This study aims to compare the compressive and tensile strengths of bone cement mixed with various concentrations of vancomycin, tobramycin, and combinations of the two. Methods 12 mm × 6 mm antibiotic bone cement samples were created by vacuum mixing 0-4 g of vancomycin, tobramycin, and combinations of the two in 0.5 g increments per one pouch (40 g) of Palacos LV cement. An Instron 3369 Universal Testing System was used to determine the compressive and tensile strengths. Results Compressive and tensile strengths of the bone cement without antibiotics were 118 ± 4 MPa and 30.3 ± 12 MPa, respectively. 4 g of vancomycin alone decreased the compressive strength to 108 ± 4 MPa (p-value 0.001) and decreased the tensile strength beginning at 2 g which yielded a strength of 28.1 ± 12 MPa (p-value 0.016). Tobramycin alone decreased the tensile strength beginning at 1.5 g yielding a strength of 27.7 ± 7 MPa (p-value 0.003). Although it decreased compressive strength at 1 g to 117 ± 7 MPa (p-value 0.002), it demonstrated variable effects with increasing concentrations. A combination of vancomycin and tobramycin decreased both the compressive (111 ± 5 MPa, p-value 0.014) and tensile (27.9 ± 8 MPa, p-value 0.007) strengths beginning at 1 g each. Conclusions Various combinations of vancomycin and tobramycin affect the compressive and tensile strengths of bone cement. Clinicians should be diligent when mixing these antibiotics in bone cement to prevent possible failure of the constructs.
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Affiliation(s)
| | | | | | | | - Joshua P. Steimel
- Department of Mechanical Engineering, California State Polytechnic University, Humboldt, Arcata, CA, USA
| | - JuEun Lee
- Department of Mechanical Engineering, California State Polytechnic University, Humboldt, Arcata, CA, USA
| | - Eric G. Huish
- VCME Orthopedic Surgery Residency, Modesto, CA, USA
- Division of Orthopedic Surgery, San Joaquin General Hospital, French Camp, CA, USA
| | - William Holmes
- VCME Orthopedic Surgery Residency, Modesto, CA, USA
- Division of Orthopedic Surgery, San Joaquin General Hospital, French Camp, CA, USA
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Laperche J, Barrett CC, Boduch A, Glasser J, Clippert D, Garcia DR, Antoci V. Mechanically stable rifampin antibiotic cement inhibits Pseudomonas aeruginosa biofilm surface growth. J Orthop Res 2024; 42:547-554. [PMID: 37884321 DOI: 10.1002/jor.25720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/07/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
Rifampin has been proven to be effective in the treatment of prosthetic infections due to its ability to intercalate into biofilms. The use of rifampin in antibiotic spacers is not well described, which would be especially important in the local periprosthetic environment where parenteral doses have poor penetration. The null hypothesis tests if rifampin use in polymethyl methacrylate (PMMA) cement will show no clinically significant impact on mechanical strength at antibiotic concentrations that remain bactericidal. Test antibiotic cement samples supplemented with 0, 30, 50, 100, 150, or 200 mg of rifampin into a standard 40 g bag were tested for compression to failure using published ASTM standards. The samples were then inoculated with Pseudomonas aeruginosa and either evaluated for lipopolysaccharide (LPS) presence as a marker of biofilm or tested by elution as the Kirby Bauer assay. Rifampin concentrations of 30 and 50 mg, showed no statistically different mechanical characteristics from control PMMA (p > 0.05). The 100-mg sample fell within the acceptable range of compressive strength and had significantly less LPS and bacterial presence compared to the control at 12 and 24 h. The ability of PMMA with 100 mg of rifampin to maintain its structural integrity and have significant bacterial inhibition at 12 and 24 h makes it a great candidate as an antibiotic bone cement additive. PMMA loaded with up to 100 mg of rifampin shows promise in the treatment and prevention of periprosthetic joint infection for total knee and total hip arthroplasty.
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Affiliation(s)
- Jacob Laperche
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | - Caitlin C Barrett
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
| | - Abigail Boduch
- Department of Orthopedic Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jillian Glasser
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
| | - Drew Clippert
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
| | - Dioscaris R Garcia
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Valentin Antoci
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
- Department of Orthopedic Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Warwick HS, Tan TL, Rangwalla K, Shau DN, Barry JJ, Hansen EN. Effect of Antibiotic Spacer Dosing on Treatment Success in Two-Stage Exchange for Periprosthetic Joint Infection. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202402000-00014. [PMID: 38385716 PMCID: PMC10883627 DOI: 10.5435/jaaosglobal-d-23-00103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION In two-stage exchange for periprosthetic joint infection (PJI), adding antibiotics to cement spacers is the standard of care; however, little is known about optimal dosage. There is emphasis on using >3.6 g of total antibiotic, including ≥2.0 g of vancomycin, per 40 g of cement, but these recommendations lack clinical evidence. We examined whether recommended antibiotic spacer doses affect treatment success. METHODS This was a retrospective review of 202 patients who underwent two-stage exchange for PJI from 2004 to 2020 with at least 1-year follow-up. Patients were separated into high (>3.6 g of total antibiotic per 40 g of cement) and low-dose spacer groups. Primary outcomes were overall and infectious failure. RESULTS High-dose spacers were used in 80% (162/202) of patients. High-dose spacers had a reduced risk of overall (OR, 0.37; P = 0.024) and infectious (OR, 0.35; P = 0.020) failure for infected primary arthroplasties, but not revisions. In multivariate analysis, vancomycin dose ≥2.0 g decreased the risk of infectious failure (OR, 0.31; P = 0.016), although not overall failure (OR, 0.51; P = 0.147). CONCLUSION During two-stage exchange for PJI, spacers with greater than 3.6 g of total antibiotic may reduce overall and infectious failure for infected primary arthroplasties. Furthermore, using at least 2.0 g of vancomycin could independently decrease the risk of infectious failure.
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Affiliation(s)
- Hunter S Warwick
- From the Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
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Kuris EO, Osorio C, Anderson GM, Younghein JA, McDonald CL, Daniels AH. Utilization of Antibiotic Bone Cement in Spine Surgery: Pearls, Techniques, and Case Review. Orthop Rev (Pavia) 2023; 15:90618. [PMID: 38116585 PMCID: PMC10727979 DOI: 10.52965/001c.90618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/11/2023] [Indexed: 12/21/2023] Open
Abstract
Vertebral osteomyelitis (VO) encompasses a spectrum of spinal infections ranging from isolated mild vertebral osteomyelitis to severe diffuse infection with associated epidural abscess and fracture. Although patients can often be treated with an initial course of intravenous antibiotics, surgery is sometimes required in patients with sepsis, spinal instability, neurological compromise, or failed medical treatment. Antibiotic bone cement (ABC) has been widely used in orthopedic extremity surgery for more than 150 years, both for prophylaxis and treatment of bacterial infection. However, relatively little literature exists regarding its utilization in spine surgery. This article describes ABC utilization in orthopedic surgery and explains the technique of ABC utilization in spine surgery. Surgeons can choose from multiple premixed ABCs with variable viscosities, setting times, and antibiotics or can mix in antibiotics to bone cements themselves. ABC can be used to fill large defects in the vertebral body or disc space or in some cases to coat instrumentation. Surgeons should be wary of complications such as ABC extravasation as well as an increased difficulty with revision. With a thorough understanding of the properties of the cement and the methods of delivery, ABC is a powerful adjunct in the treatment of spinal infections.
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Affiliation(s)
- Eren O Kuris
- Orthopedic Surgery Warren Alpert School of Medicine at Brown University
| | - Camilo Osorio
- Orthopedic Surgery Warren Alpert School of Medicine at Brown University
| | | | | | | | - Alan H Daniels
- Orthopedic Surgery Warren Alpert School of Medicine at Brown University
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Lunz A, Schonhoff M, Omlor GW, Knappe K, Bangert Y, Lehner B, Renkawitz T, Jaeger S. Enhanced antibiotic release from bone cement spacers utilizing dual antibiotic loading with elevated vancomycin concentrations in two-stage revision for periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2023; 47:2655-2661. [PMID: 37566227 PMCID: PMC10602962 DOI: 10.1007/s00264-023-05922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Antibiotic loaded bone cement spacers provide high local antibiotic concentrations, preserve bone stock, and reduce soft tissue contractions. The objective of this in-vitro study was to compare antibiotic release from spacers, aiming to discover the most optimal preparation and identify modifiable factors that can further enhance antibiotic release. METHODS Six distinct spacer preparation were created using three different bone cements and manual incorporation of antibiotics. During a six-week period, the release of antibiotics from each spacer was measured individually at ten predetermined time points using a chemiluminescent immunoassay. RESULTS Manually adding 4 g of vancomycin to every 40 g of "Palacos R + G" yielded the most favorable release profile. Throughout all preparations, antibiotic release consistently and significantly decreased over the six-week period. When incorporating a higher concentration of vancomycin, a significantly higher cumulative release of vancomycin was observed, with varying effects on the release of gentamicin. The choice of bone cement had a significant impact on antibiotic release. CONCLUSION To enhance antibiotic release from spacers, surgeons should manually incorporate high antibiotic concentrations into the most appropriate bone cement and keep the interim period as short as possible. Specifically, we suggest manual incorporation of 4 g of vancomycin to every 40 g of gentamicin premixed "Palacos R + G" to create bone cement spacers.
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Affiliation(s)
- Andre Lunz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Georg W Omlor
- Center for Orthopedics and Joint Replacement, Marienhaus Hospital St. Wendel-Ottweiler, Am Hirschberg 1, 66606, St. Wendel, Germany
| | - Kevin Knappe
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Yannic Bangert
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Tobias Renkawitz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
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Hoyt A, Lawler P, Bostrom M, Carli A, Levack A. Dalbavancin is thermally stable at clinically relevant temperatures against methicillin-sensitive Staphylococcus Aureus. J Bone Jt Infect 2023; 8:175-181. [PMID: 37727824 PMCID: PMC10506503 DOI: 10.5194/jbji-8-175-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/28/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction: While the rate of orthopaedic infections has remained constant over the years, the burden on healthcare systems continues to rise with an aging population. Local antibiotic delivery via polymethyl methacrylate bone cement is a common adjunct in treating bone and joint infections. Dalbavancin is a novel lipoglycopeptide antibiotic in the same class as vancomycin that has shown efficacy against Gram-positive organisms when used systemically but has not been investigated as a local antibiotic. This study aims to identify whether dalbavancin is thermally stable at the temperatures expected during the polymerization of polymethyl methacrylate cement. Methods: Stock solutions of dalbavancin were prepared and heated using a polymerase chain reaction machine based upon previously defined models of curing temperatures in two clinically relevant models: a 10 mm polymethyl methacrylate bead and a polymethyl methacrylate articulating knee spacer model. Aliquots of heated dalbavancin were then transferred to be incubated at core body temperature (37 ∘ C) and analyzed at various time points up to 28 d. The minimum inhibitory concentration at which 90 % of colonies were inhibited (MIC90 ) for each heated sample was determined against methicillin-sensitive Staphylococcus aureus (American Type Culture Collection, ATCC, 0173K) using a standard microbroth dilution assay. Results: The average MIC90 of dalbavancin was 1.63 µ g mL - 1 ± 0.49 against 0173K S. aureus. There were no significant differences in the relative MIC90 values after heating dalbavancin in either model compared to unheated control dalbavancin. Conclusions: Dalbavancin is thermally stable at the curing temperatures of polymethyl methacrylate cement and at human core body temperature over 28 d. Future in vitro and in vivo studies are warranted to further investigate the role of dalbavancin as a local antibiotic prior to its clinical use.
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Affiliation(s)
- Aaron K. Hoyt
- Department of Orthopaedic Surgery
& Rehabilitation, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Patrick Lawler
- Stritch School of Medicine, Loyola University, Maywood, IL 60153, USA
| | - Mathias Bostrom
- Musculoskeletal Integrity Program, Hospital for Special Surgery, New
York, NY 10021, USA
- Adult Reconstruction, Hospital for Special Surgery, New York, NY
10021, USA
| | - Alberto V. Carli
- Musculoskeletal Integrity Program, Hospital for Special Surgery, New
York, NY 10021, USA
- Adult Reconstruction, Hospital for Special Surgery, New York, NY
10021, USA
| | - Ashley E. Levack
- Department of Orthopaedic Surgery
& Rehabilitation, Loyola University Medical Center, Maywood, IL 60153, USA
- Stritch School of Medicine, Loyola University, Maywood, IL 60153, USA
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Rupp M, Walter N, Szymski D, Taeger C, Langer M, Alt V. The antibiotic bead pouch - a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery. J Bone Jt Infect 2023; 8:165-173. [PMID: 37818255 PMCID: PMC10561378 DOI: 10.5194/jbji-8-165-2023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/23/2023] [Indexed: 10/12/2023] Open
Abstract
Soft tissue defects resulting from trauma and musculoskeletal infections can complicate surgical treatment. Appropriate temporary coverage of these defects is essential to achieve the best outcomes for necessary plastic soft tissue defect reconstruction. The antibiotic bead pouch technique is a reasonable surgical approach for managing temporary soft tissue defects following adequate surgical debridement. This technique involves the use of small diameter antibiotic-loaded bone cement beads to fill the dead space created by debridement. By applying antibiotics to the bone cement and covering the beads with an artificial skin graft, high local dosages of antibiotics can be achieved, resulting in the creation of a sterile wound that offers the best starting position for soft tissue and bone defect reconstruction. This narrative review describes the rationale for using this technique, including its advantages and disadvantages, as well as pearls and pitfalls associated with its use in daily practice. In addition, the article provides a comprehensive overview of the literature that has been published since the technique was introduced in surgical practice.
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Affiliation(s)
- Markus Rupp
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christian Taeger
- Plastische Chirurgie & Ästhetik an der Isar, Widenmayerstraße 16, 80538 Munich, Germany
| | - Martin Franz Langer
- Department of Trauma, Hand and Reconstructive Surgery, Waldeyerstrasse 1, 48149 Muenster, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Fan W, Fu D, Zhang L, Xiao Z, Shen X, Chen J, Qi X. Enoxaparin sodium bone cement plays an anti-inflammatory immunomodulatory role by inducing the polarization of M2 macrophages. J Orthop Surg Res 2023; 18:380. [PMID: 37221568 DOI: 10.1186/s13018-023-03865-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/18/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVE The implantation of PMMA bone cement results in an immune response and the release of PMMA bone cement particles causes an inflammatory cascade. Our study discovered that ES-PMMA bone cement can induce M2 polarization of macrophages, which has an anti-inflammatory immunomodulatory effect. We also delved into the molecular mechanisms that underlie this process. METHODS In this study, we designed and prepared samples of bone cement. These included PMMA bone cement samples and ES-PMMA bone cement samples, which were implanted into the back muscles of rats. At 3, 7, and 14 days after the operation, we removed the bone cement and a small amount of surrounding tissue. We then performed immunohistochemistry and immunofluorescence to observe the polarization of macrophages and the expression of related inflammatory factors in the surrounding tissues. The RAW264.7 cells were exposed to lipopolysaccharide (LPS) for 24 h to establish the macrophage inflammation model. Then, each group was treated with enoxaparin sodium medium, PMMA bone cement extract medium, and ES-PMMA bone cement extract medium, respectively, and cultured for another 24 h. We collected cells from each group and used flow cytometry to detect the expressions of CD86 and CD206 in macrophages. Additionally, we performed RT-qPCR to determine the mRNA levels of three markers of M1 macrophages (TNF-α, IL-6, iNOS) and two M2 macrophage markers (Arg-1, IL-10). Furthermore, we analyzed the expression of TLR4, p-NF-κB p65, and NF-κB p65 through Western blotting. RESULTS The immunofluorescence results indicate that the ES-PMMA group exhibited an upregulation of CD206, an M2 marker, and a downregulation of CD86, an M1 marker, in comparison to the PMMA group. Additionally, the immunohistochemistry results revealed that the levels of IL-6 and TNF-α expression were lower in the ES-PMMA group than in the PMMA group, while the expression level of IL-10 was higher in the ES-PMMA group. Flow cytometry and RT-qPCR analyses revealed that the expression of M1-type macrophage marker CD86 was significantly elevated in the LPS group compared to the NC group. Additionally, M1-type macrophage-related cytokines TNF-α, IL-6, and iNOS were also found to be increased. However, in the LPS + ES group, the expression levels of CD86, TNF-α, IL-6, and iNOS were decreased, while the expression of M2-type macrophage markers CD206 and M2-type macrophage-related cytokines (IL-10, Arg-1) were increased compared to the LPS group. In comparison to the LPS + PMMA group, the LPS + ES-PMMA group demonstrated a down-regulation of CD86, TNF-α, IL-6, and iNOS expression levels, while increasing the expression levels of CD206, IL-10, and Arg-1. Western blotting results revealed a significant decrease in TLR4/GAPDH and p-NF-κB p65/NF-κB p65 in the LPS + ES group when compared to the LPS group. Additionally, the LPS + ES-PMMA group exhibited a decrease in TLR4/GAPDH and p-NF-κB p65/NF-κB p65 levels when compared to the LPS + PMMA group. CONCLUSION ES-PMMA bone cement is more effective than PMMA bone cement in down-regulating the expression of the TLR4/NF-κB signaling pathway. Additionally, it induces macrophages to polarize towards the M2 phenotype, making it a crucial player in anti-inflammatory immune regulation.
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Affiliation(s)
- Weiye Fan
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050035, People's Republic of China
| | - Dehao Fu
- Department of Orthopedics, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Li Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050035, People's Republic of China
| | - Zhihang Xiao
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050035, People's Republic of China
| | - Xiaoyu Shen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050035, People's Republic of China
| | - Jianchao Chen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050035, People's Republic of China
| | - Xiangbei Qi
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050035, People's Republic of China.
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12
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Determination of the Elution Capacity of Dalbavancin in Bone Cements: New Alternative for the Treatment of Biofilm-Related Peri-Prosthetic Joint Infections Based on an In Vitro Study. Antibiotics (Basel) 2022; 11:antibiotics11101300. [PMID: 36289958 PMCID: PMC9598415 DOI: 10.3390/antibiotics11101300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
Antibiotic-loaded bone cement is the most widely used approach for the treatment of biofilm-induced septic sequelae in orthopedic surgery. Dalbavancin is a lipoglycopeptide that acts against Gram-positive bacteria and has a long half-life, so we aimed to assess whether it could be a new alternative drug in antibiotic-loaded bone cement for the treatment of periprosthetic joint infections. We assessed the elution capacity of dalbavancin and compared it with that of vancomycin in bone cement. Palacos®R (Heraeus Medical GmbH, Wehrheim, Germany) bone cement was manually mixed with each of the antibiotics studied at 2.5% and 5%. Three cylinders were obtained from each of the mixtures; these were weighed and incubated in 5 mL phosphate-buffered saline at 37°C under shaking for 1 h, 2 h, 4 h, 8 h, 24 h, 48 h, 168 h, and 336 h. PBS was replenished at each time point. The samples were analyzed using high-performance liquid chromatography (vancomycin) and mass cytometry (dalbavancin). Elution was higher than the minimum inhibitory concentration (MIC)90 for both antibiotics after 14 days of study. The release of vancomycin at 14 days was higher than of dalbavancin at each concentration tested (p = 0.05, both). However, the cumulative release of 5% dalbavancin was similar to that of 2.5% vancomycin (p = 0.513). The elution capacity of dalbavancin reached a cumulative concentration similar to that of vancomycin. Moreover, considering that the MIC90 of dalbavancin is one third that of vancomycin (0.06 mg/L and 2 mg/L, respectively) and given the long half-life of dalbavancin, it may be a new alternative for the treatment of biofilm-related periprosthetic infections when loaded in bone cement.
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13
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Wei J, Tong K, Wang H, Wen Y, Chen L. Intra-articular versus systemic vancomycin for the treatment of periprosthetic joint infection after debridement and spacer implantation in a rat model. Bone Joint Res 2022; 11:371-385. [PMID: 35708551 PMCID: PMC9233408 DOI: 10.1302/2046-3758.116.bjr-2021-0319.r3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aims Treatment outcomes for methicillin-resistant Staphylococcus aureus (MRSA) periprosthetic joint infection (PJI) using systemic vancomycin and antibacterial cement spacers during two-stage revision arthroplasty remain unsatisfactory. This study explored the efficacy and safety of intra-articular vancomycin injections for PJI control after debridement and cement spacer implantation in a rat model. Methods Total knee arthroplasty (TKA), MRSA inoculation, debridement, and vancomycin-spacer implantation were performed successively in rats to mimic first-stage PJI during the two-stage revision arthroplasty procedure. Vancomycin was administered intraperitoneally or intra-articularly for two weeks to control the infection after debridement and spacer implantation. Results Rats receiving intra-articular vancomycin showed the best outcomes among the four treatment groups, with negative bacterial cultures, increased weight gain, increased capacity for weightbearing activities, increased residual bone volume preservation, and reduced inflammatory reactions in the joint tissues, indicating MRSA eradication in the knee. The vancomycin-spacer and/or systemic vancomycin failed to eliminate the MRSA infections following a two-week antibiotic course. Serum vancomycin levels did not reach nephrotoxic levels in any group. Mild renal histopathological changes, without changes in serum creatinine levels, were observed in the intraperitoneal vancomycin group compared with the intra-articular vancomycin group, but no changes in hepatic structure or serum alanine aminotransferase or aspartate aminotransferase levels were observed. No local complications were observed, such as sinus tract or non-healing surgical incisions. Conclusion Intra-articular vancomycin injection was effective and safe for PJI control following debridement and spacer implantation in a rat model during two-stage revision arthroplasties, with better outcomes than systemic vancomycin administration. Cite this article: Bone Joint Res 2022;11(6):371–385.
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Affiliation(s)
- Jian Wei
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Kai Tong
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Hui Wang
- Department of Pharmacology, Department of Basic Medicine, Wuhan University, Wuhan, China
| | - Yinxian Wen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
| | - Liaobin Chen
- Department of Joint Surgery and Sports Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center of Wuhan University, Wuhan, China
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14
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Ismat A, Walter N, Baertl S, Mika J, Lang S, Kerschbaum M, Alt V, Rupp M. Antibiotic cement coating in orthopedic surgery: a systematic review of reported clinical techniques. J Orthop Traumatol 2021; 22:56. [PMID: 34940945 PMCID: PMC8702599 DOI: 10.1186/s10195-021-00614-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 11/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Antibiotic-containing cement and bone graft substitute-coated orthopedic implants provide the advantages of simultaneous local antibiotic delivery and internal stable fixation, aiding in both infection eradication and osseous healing. Standardized protocols pertaining to implant coating techniques in various clinical and particularly intraoperative settings are scarce, and available literature is limited. This systematic review aims to provide a summary of the available current literature reporting on custom-made coating techniques of orthopedic implants, indications, outcomes, and associated complications in clinical use. Methods A systematic search of the literature in PubMed, Medline, Embase, and Cochrane Library databases was performed in accordance with PRISMA guidelines. Articles reporting specifically on custom-made coating techniques of orthopedic implants in a clinical setting were eligible. Results A total of 41 articles with a cumulative total number of 607 cases were included. Indications for treatment mostly involved intramedullary infections after previous plate osteosynthesis or nailing. A variety of implants ranging from intramedullary nails, plates, wires, and rods served as metal cores for coating. Polymethylmethacrylate (PMMA) bone cement was most commonly used, with vancomycin as the most frequently added antibiotic additive. Chest tubes and silicone tubes were most often used to mold. Common complications are cement debonding and breakage of the metallic implant. Conclusion Adequate coating techniques can reduce the burden of treatment and be associated with favorable outcomes. Lack of general consensus and heterogeneity in the reported literature indicate that the perfect all-in-one implant coating method is yet to be found. Further efforts to improve implant coating techniques are warranted. Level of evidence III.
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Affiliation(s)
- Abdullah Ismat
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Susanne Baertl
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Joerg Mika
- Experimental Rheumatology Unit, Department of Orthopedics, Jena University Hospital, Waldkliniken Eisenberg GmbH, Klosterlausnitzer Strasse 81, 07607, Eisenberg, Germany
| | - Siegmund Lang
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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15
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Wei J, Tong K, Zhou S, Wang H, Wen Y, Chen L. Intra-wound vancomycin powder for the eradication of periprosthetic joint infection after debridement and implant exchange: experimental study in a rat model. BMC Microbiol 2021; 21:333. [PMID: 34876010 PMCID: PMC8650465 DOI: 10.1186/s12866-021-02399-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/19/2021] [Indexed: 12/12/2022] Open
Abstract
Background Intra-wound vancomycin powder (VP) has been used in clinical practice to prevent periprosthetic joint infection (PJI) after primary knee/hip arthroplasty. The role of intra-wound VP in the setting of debridement and implant exchange after PJI remains undefined. This study aimed to explore the efficacy and safety of intra-wound VP in the control of methicillin-resistant S. aureus (MRSA) infection after debridement and implant exchange. Methods PJI modeling by knee prosthesis implantation and MRSA inoculation, debridement and implant exchange were performed in Wistar rats successively to mimic the one-stage exchange arthroplasty of PJI patients. Two weeks of systemic vancomycin (SV) or/and intraoperative intra-wound VP of single dosage were applied after revision surgery. Results No post-surgery deaths, incision complications and signs of drug toxicity were observed. The microbial counts of SV or intra-wound VP group were significantly reduced compared with the control group, while bacteria were still detected on the bone, soft-tissue and prosthesis. The elimination of bacterial counts, along with improvement of tissue inflammation and serum inflammatory markers, were observed in the rats with SV plus intra-wound VP. Serum levels of vancomycin in all groups were lower than that of causing nephrotoxicity, while no statistic difference was observed in the serum biochemical marker among the groups. Conclusions Intra-wound VP is effective after debridement and implant exchange in our current rat PJI model. Neither SV nor intra-wound VP alone could eradicate the bacteria within a two-weeks treatment course, while SV plus intra-wound VP could eliminate the MRSA infection, without notable hepatic or renal toxicity and any incision complications.
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Affiliation(s)
- Jian Wei
- Department of Joint Orthopedics, Affiliated Liutie Central Hospital of Guangxi Medical University, Liuzhou, 545007, China
| | - Kai Tong
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuhan, 430071, China
| | - Siqi Zhou
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuhan, 430071, China
| | - Hui Wang
- Department of pharmacology, Basic Medical School of Wuhan University, Wuhan, 430071, China
| | - Yinxian Wen
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuhan, 430071, China.
| | - Liaobin Chen
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, No.169, Donghu Road, Wuhan, 430071, China.
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16
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Additives Imparting Antimicrobial Properties to Acrylic Bone Cements. MATERIALS 2021; 14:ma14227031. [PMID: 34832430 PMCID: PMC8622877 DOI: 10.3390/ma14227031] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 12/16/2022]
Abstract
PMMA bone cements are mainly used to fix implanted prostheses and are introduced as a fluid mixture, which hardens over time. The problem of infected prosthesis could be solved due to the development of some new antibacterial bone cements. In this paper, we show the results obtained to develop four different modified PMMA bone cements by using antimicrobial additives, such as gentamicin, peppermint oil incorporated in hydroxyapatite, and silver nanoparticles incorporated in a ceramic glass matrix (2 and 4%). The structure and morphology of the modified bone cements were investigated by SEM and EDS. We perform experimental measurements on wettability, hydration degree, and degradation degree after immersion in simulated body fluid. The cytotoxicity was evaluated by MTT assay using the human MG-63 cell line. Antimicrobial properties were checked against standard strains Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. The addition of antimicrobial agents did not significantly affect the hydration and degradation degree. In terms of biocompatibility assessed by the MTT test, all experimental PMMA bone cements are biocompatible. The performance of bone cements with peppermint essential oil and silver nanoparticles against these two pathogens suggests that these antibacterial additives look promising to be used in clinical practice against bacterial infection.
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17
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Hoshino T, Watanabe T, Nakagawa Y, Katagiri H, Ozeki N, Ohara T, Shioda M, Kono Y, Sekiya I, Koga H. Clinical outcomes of two-stage revision total knee arthroplasty in infected cases with antibiotic-loaded cement spacers produced using a handmade silicone mold. Knee Surg Relat Res 2021; 33:27. [PMID: 34454632 PMCID: PMC8400397 DOI: 10.1186/s43019-021-00113-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/05/2021] [Indexed: 01/04/2023] Open
Abstract
Purpose This study assessed the clinical outcomes of periprosthetic joint infection patients who underwent two-stage revision total knee arthroplasty with antibiotic-loaded cement spacers fabricated using a handmade silicone mold. Materials and methods This study included seven patients (average age 77 years, average follow-up time 54 months) who underwent surgery at our hospital between 2009 and 2013. Clinical outcomes including knee scores, function scores, knee range of motion, and walking ability at the final observation, period from the primary total knee arthroplasty to implant removal, period from implant removal to revision total knee arthroplasty, and follow-up period after revision total knee arthroplasty were investigated. Results At the final follow-up, the average knee range of motion was 99°, with no significant differences at each stage; average knee and function scores were 84 and 77, respectively. With cement spacers, five patients were able to walk with a t-cane. No recurrence of infection was observed. Conclusions The clinical outcomes of the current case series demonstrated good knee function with preserved walking ability, without any recurrence of periprosthetic joint infection. This study suggests that using a handmade silicone mold could be an effective option for periprosthetic joint infection after a total knee arthroplasty.
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Affiliation(s)
- Takashi Hoshino
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshifumi Watanabe
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Second Department of Orthopaedic Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan.
| | - Yusuke Nakagawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Second Department of Orthopaedic Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan
| | - Nobutake Ozeki
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshiyuki Ohara
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Mikio Shioda
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yuji Kono
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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18
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Han W, Zhang L, Yu LJ, Wang JQ. Effect of Local Delivery of Vancomycin and Tobramycin on Bone Regeneration. Orthop Surg 2021; 13:1654-1661. [PMID: 34124847 PMCID: PMC8313164 DOI: 10.1111/os.13020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/18/2021] [Accepted: 03/21/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE A bone defect rat model was established to investigate the osteogenic effect of local delivery two antibiotics (vancomycin and tobramycin powder) on bone regeneration. METHODS Twenty-four Sprague-Dawley (SD) male rats (6 to 8 weeks, 200 to 250 g) were used in this study. All these rats were randomly divided into four groups. Based on dose conversion between rat and human via body surface area, the rat dose of two antibiotics was 88μg/g and 176 μg/g for vancomycin and tobramycin, respectively. Con group (no antibiotic), Van group (vancomycin, 88 μg/g), Tob group (tobramycin 176 μg/g), and Van+Tob group (vancomycin 88μg/g combined with tobramycin 176 μg/g). A 5.0-mm full-thickness standardized mandibular bone defect was performed with a drill in each rat and different antibiotic powders were placed over the bone defect space, respectively. All these animals were sacrificed after 12 weeks post-operation. The mandible bones were harvested for further radiographic and histologic analysis. The bone volume/total volume (BV/TV) ratio, bone volume (BV), and bone fractional area (BFA) in the defect area via micro-computed tomography (μCT scanning) were further analyzed. Then, we performed a histological assessment via hematoxylin and eosin (H&E) and Masson's trichrome staining to analyze bone regeneration and also analyze the number of osteoblasts per filed. RESULTS There were no postoperative deaths, signs of vancomycin-related or tobramycin-related toxicity, or signs of systemic illness in any of the four groups. All wounds healed well, and no complications or surgical site infection were observed in all rats. From the μCT scans analyses, there was less bone regeneration in the Van group than in the Con group (BV/TV: F = 64.29, R2 = 0.9602; P = 0.0052; BFA: F = 76.17, R2 = 0.9662, P = 0.0007; BV: F = 194.4, R2 = 0.9865, P = 0.0022). However, when the tobramycin and vancomycin were combined, an increase in bone defect re-ossification was found in the Van+Tob group than in the Van group (BV/TV: F = 64.29, R2 = 0.9602, P = 0.0033; BFA: F = 76.17, R2 = 0.9662, P = 0.0006; BV: F = 194.4, R2 = 0.9865, P = 0.0033). Routine H&E and Masson staining supported the finding of μCT scanning. Quantitative indices confirmed that both the bone regeneration and the number of osteoblasts per filed in the defect area was higher in the Van+Tob group than in the Van group (percentage of bone tissue: F = 145.7, R2 = 0.9562, P = 0.0008; number of osteoblasts per file; F = 67.3, R2 = 0.9098, P < 0.0001). There was no significant difference between the Con group and the Van+Tob group on the number of osteoblasts each field (F = 145.7, R2 = 0.9562, P > 0.9999). CONCLUSION For bone defect, local application of vancomycin combined with tobramycin was recommended over vancomycin alone. This animal study presents data suggesting that the use of local delivery of vancomycin and tobramycin should be investigated further in clinical studies.
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Affiliation(s)
- Wei Han
- Department of Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, China
| | - Ling-Jia Yu
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jun-Qiang Wang
- Department of Traumatology, Beijing Jishuitan Hospital, Beijing, China
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Elution Kinetics from Antibiotic-Loaded Calcium Sulfate Beads, Antibiotic-Loaded Polymethacrylate Spacers, and a Powdered Antibiotic Bolus for Surgical Site Infections in a Novel In Vitro Draining Knee Model. Antibiotics (Basel) 2021; 10:antibiotics10030270. [PMID: 33800299 PMCID: PMC8000420 DOI: 10.3390/antibiotics10030270] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/17/2022] Open
Abstract
Antibiotic-tolerant bacterial biofilms are notorious in causing PJI. Antibiotic loaded calcium sulfate bead (CSB) bone void fillers and PMMA cement and powdered vancomycin (VP) have been used to achieve high local antibiotic concentrations; however, the effect of drainage on concentration is poorly understood. We designed an in vitro flow reactor which provides post-surgical drainage rates after knee revision surgery to determine antibiotic concentration profiles. Tobramycin and vancomycin concentrations were determined using LCMS, zones of inhibition confirmed potency and the area under the concentration-time curve (AUC) at various time points was used to compare applications. Concentrations of antibiotcs from the PMMA and CSB initially increased then decreased before increasing after 2 to 3 h, correlating with decreased drainage, demonstrating that concentration was controlled by both release and flow rates. VP achieved the greatest AUC after 2 h, but rapidly dropped below inhibitory levels. CSB combined with PMMA achieved the greatest AUC after 2 h. The combination of PMMA and CSB may present an effective combination for killing biofilm bacteria; however, cytotoxicity and appropriate antibiotic stewardship should be considered. The model may be useful in comparing antibiotic concentration profiles when varying fluid exchange is important. However, further studies are required to assess its utility for predicting clinical efficacy.
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20
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Klosterman EL, Cotter EJ, Squire MW, Grogan BF. Creation of a Custom-Length, Humeral Antibiotic Cement Spacer for Use in Treatment of Shoulder Periprosthetic Joint Infection. Arthrosc Tech 2021; 10:e481-e486. [PMID: 33680782 PMCID: PMC7917196 DOI: 10.1016/j.eats.2020.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/21/2020] [Indexed: 02/03/2023] Open
Abstract
Periprosthetic joint infection of the shoulder is a challenging clinical situation to manage owing to the fastidious organisms often present and delayed clinical presentation. While several treatment options have been described, the mainstay of treatment remains a staged revision with the use of a humeral antibiotic cement spacer. Such spacers are commercially available or can be made by hand. When an extended humeral osteotomy is required to remove a well-fixed long stem humeral component, it may be advantageous to place an antibiotic spacer with a stem length approximately as long as the hardware being removed. This technique demonstrates creation of a custom length, humeral antibiotic cement spacer for use in treatment of shoulder periprosthetic joint infection.
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Affiliation(s)
- Emma L. Klosterman
- Address correspondence to Emma L. Klosterman, M.D., Orthopedic Surgery Resident, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave., 6th Floor, Madison, WI 53705.
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21
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Tetzel L, Guyard M. Saving the lower limb with GlassBONE™ - Successful surgical revision of pseudarthrosis after infected open proximal tibia fracture type IIIC with bioactive glass grafting - A case report. Trauma Case Rep 2020; 31:100382. [PMID: 33426259 PMCID: PMC7779823 DOI: 10.1016/j.tcr.2020.100382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 12/04/2022] Open
Abstract
Background The management of bone defect due to trauma or surgical debridement is a current problem in orthopedic trauma surgery, often complicated by infection and bone nonunion. The graft is one of the most challenging variables in surgical treatment. Bioactive Glass (BAG) as a biocompatible and osteogenic product is a promising bone substitute showing good results in maxillo-facial-, spine surgery and treatment of osteomyelitis. Surprisingly, there is very little data on BAG use in trauma surgery. Case presentation A 51-year-old male patient, involved in a motorcycle accident, suffered an open proximal tibia fracture, type IIIC, of the left leg. Patient was admitted in January of 2013 to a general orthopedic department for surgical treatment. After several surgical revisions due to infection, vascular damage, and bone nonunion, the patient was successfully treated with Masquelet therapy followed by GlassBONE™ grafting (GlassBONE™ 45S5; Norarker). The patient demonstrated excellent results over the course of a two-year follow-up. Conclusions In our experience, GlassBONE™ 45S5 has proven to be an effective bone substitute even in difficult grafting conditions, including multiple surgical revisions for bone nonunion and infection. In our case, at the end of 2 years and 3 months of follow-up, the patient reported no pain, and had no signs of infection. Bone union and full weight bearing was achieved. This case report is oriented by the CARE guidelines for clinical case reports; the patient gave consent for publication. GlassBONE™ 45S5 has proven to be an effective bone substitute even in difficult grafting conditions. Bone nonunion was successfully treated with Masquelet therapy followed by GlassBONE™ grafting. Bone loss due to fracture or surgical debridement is a current problem in orthopedic trauma surgery. Bone fractures are the most widespread trauma in humans.
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Affiliation(s)
- L Tetzel
- Orthopedic Department, University Children's Hospital Basel, Switzerland
| | - M Guyard
- Orthopedic Department, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France
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Muratlı SK, Karatosun V, Uzun B, Günal İ. Biomechanical comparison of tigecycline loaded bone cement with vancomycin and daptomycin loaded bone cements. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:535-540. [PMID: 33155566 DOI: 10.5152/j.aott.2020.19086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objectives of this study were "1" to analyze the compressive and tensile mechanical strength characteristics of tigecycline loaded bone cement and "2" to compare them with those of vancomycin and daptomycin loaded bone cements which are used in prosthetic joint infections complicated with resistant microorganisms. METHODS In this study, three experimental groups, which consisted of vancomycin (subgroups containing 1 g, 2 g, and 3 g vancomycin), daptomycin (subgroups containing 0.5 g, 1 g, and 1.5 g daptomycin), and tigecycline (subgroups containing 50 mg, 100 mg, and 150 mg tigecycline) and one control group without antibiotics were used. Using a standardized protocol, all antibiotic loaded bone cements were prepared. For each antibiotic group, including the control group, 10 samples were tested. All samples were biomechanically tested in terms of compressive strength and tensile strength. RESULTS Compression tests showed that all determined antibiotic concentrations resulted in a significant decrease when compared with the control group (p<0.0011). Vancomycin and daptomycin study groups demonstrated lower tensile strength than the control group (p<0.0011). However, comparison of tensile values of tigecycline study groups with the control group revealed no significant difference (p>0.0011). In addition, all statistically significant results from between groups comparisons revealed higher tensile and compressive mechanical strength values for the tigecycline groups (p<0.0011). CONCLUSION Evidence from this study has demonstrated that tigecycline loaded bone cement may have no mechanical disadvantage compared with vancomycin and daptomycin loaded bone cements in terms of mechanical strength when used at defined concentrations.
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Affiliation(s)
- Sedit Kıvanç Muratlı
- Department of Orthopedics and Traumatology, Çanakkale Onsekiz Mart University, Research and Training Hospital, Çanakkale, Turkey
| | - Vasfi Karatosun
- Department of Orthopedics and Traumatology, Dokuz Eylül University, School of Medicine Hospital, İzmir, Turkey
| | - Bora Uzun
- Department of Biomechanics, Dokuz Eylül University, School of Medicine Hospital, İzmir, Turkey
| | - İzge Günal
- Department of Orthopedics and Traumatology, Dokuz Eylül University, School of Medicine Hospital, İzmir, Turkey
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23
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Yu L, Fei Q, Lin J, Yang Y, Xu Y. The Osteogenic Effect of Local Delivery of Vancomycin and Tobramycin on Bone Marrow Stromal Cells. Infect Drug Resist 2020; 13:2083-2091. [PMID: 32753906 PMCID: PMC7351982 DOI: 10.2147/idr.s261767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/18/2020] [Indexed: 01/12/2023] Open
Abstract
Purpose Bone tissue infections are a difficult problem in orthopedic surgery. Topical application of vancomycin and tobramycin powder has been proved to significantly reduce infection rates. However, the osteogenic effect of the topical application of these two antibiotics is unclear. In this study, the osteogenic effect of local delivery antibiotics on bone regeneration was investigated in vitro. Methods Bone marrow stromal cells (BMSCs) were incubated in the presence of vancomycin (14.28μg/mL), tobramycin (28.57μg/mL), or vancomycin combined with tobramycin (vancomycin 14.28μg/mL and tobramycin 28.57μg/mL). Cell viability, proliferation, and migration were analyzed. The alizarin red staining as well as the alkaline phosphatase staining was investigated. Then, the quantitative real-time (qRT)-PCR of osteogenic mRNA expression levels were also evaluated. Results The results showed that vancomycin combined with tobramycin has no adverse effect on the viability and proliferation of BMSCs. The topical application of vancomycin alone may interfere with the bone regenerative processes. However, the tobramycin can promote the osteogenic differentiation of BMSCs and also rescue the osteogenic potential of BMSCs inhibited by vancomycin both in vitro. Conclusion From this in vitro study, local application of vancomycin combined with tobramycin does not affect the osteogenic potential of BMSCs.
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Affiliation(s)
- Lingjia Yu
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Qi Fei
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Jisheng Lin
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Yong Yang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, People's Republic of China
| | - Yisheng Xu
- Orthopedics Department, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong 510120, People's Republic of China
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Abstract
Osteomyelitis, or inflammation of bone, is most commonly caused by invasion of bacterial pathogens into the skeleton. Bacterial osteomyelitis is notoriously difficult to treat, in part because of the widespread antimicrobial resistance in the preeminent etiologic agent, the Gram-positive bacterium Staphylococcus aureus Bacterial osteomyelitis triggers pathological bone remodeling, which in turn leads to sequestration of infectious foci from innate immune effectors and systemically delivered antimicrobials. Treatment of osteomyelitis therefore typically consists of long courses of antibiotics in conjunction with surgical debridement of necrotic infected tissues. Even with these extreme measures, many patients go on to develop chronic infection or sustain disease comorbidities. A better mechanistic understanding of how bacteria invade, survive within, and trigger pathological remodeling of bone could therefore lead to new therapies aimed at prevention or treatment of osteomyelitis as well as amelioration of disease morbidity. In this minireview, we highlight recent developments in our understanding of how pathogens invade and survive within bone, how bacterial infection or resulting innate immune responses trigger changes in bone remodeling, and how model systems can be leveraged to identify new therapeutic targets. We review the current state of osteomyelitis epidemiology, diagnostics, and therapeutic guidelines to help direct future research in bacterial pathogenesis.
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Bistolfi A, Ferracini R, Albanese C, Vernè E, Miola M. PMMA-Based Bone Cements and the Problem of Joint Arthroplasty Infections: Status and New Perspectives. MATERIALS (BASEL, SWITZERLAND) 2019; 12:E4002. [PMID: 31810305 PMCID: PMC6926619 DOI: 10.3390/ma12234002] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Alessandro Bistolfi
- AO Citta’ della Salute e della Scienza. CTO Hospital, Department of Orthopedics. Via Zuretti 29, 10126 Turin, Italy; (A.B.); (C.A.)
| | - Riccardo Ferracini
- IRCCS Ospedale Policlinico San Martino, Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo R. Benzi 10, 16132 Genova, Italy;
| | - Carlo Albanese
- AO Citta’ della Salute e della Scienza. CTO Hospital, Department of Orthopedics. Via Zuretti 29, 10126 Turin, Italy; (A.B.); (C.A.)
| | - Enrica Vernè
- Department of Applied Science and Technology, PolitoBIOMed Lab, Politecnico di Torino, C.so Duca Degli Abruzzi 24, 10129 Torino, Italy;
| | - Marta Miola
- Department of Applied Science and Technology, PolitoBIOMed Lab, Politecnico di Torino, C.so Duca Degli Abruzzi 24, 10129 Torino, Italy;
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Li T, Fu L, Wang J, Shi Z. High dose of vancomycin plus gentamicin incorporated acrylic bone cement decreased the elution of vancomycin. Infect Drug Resist 2019; 12:2191-2199. [PMID: 31410038 PMCID: PMC6645360 DOI: 10.2147/idr.s203740] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/03/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose Low doses of vancomycin and gentamicin were commonly incorporated into acrylic bone cement (antibiotic-impregnated bone cement, AIBC) during revision arthroplasty. Previous studies showed that only a very small amount of antibiotics could be eluted from AIBC. Given the fact that a high dose of antibiotic would elute high concentration of antibiotic, this study investigated the influence of a high dose of dual-antibiotic loading on the properties of cement. Methods A total of 8 groups of AIBC containing either gentamicin or vancomycin or both with different amounts of antibiotics (1 g, 2 g and 4 g) were tested on material properties, elution profiles, antibacterial activity and cytological toxicity. Results A high dose of gentamicin and vancomycin AIBC (with 2 g gentamicin and 2 g vancomycin loaded) regiment showed acceptable compressive strength of 74.25±0.72 MPa. No cytotoxicity or antibacterial activity reduction was observed in any group tested in this study. The elution profiles indicated that incorporating 2 g vancomycin resulted in 4.77% (1049.57±3.74 μg) released after 28 days. However, after 2 g gentamicin was added, the vancomycin released was significantly reduced to 2.42% (532.24±1.77 μg) (p<0.001), approximately 50% reduction. No significant influence of vancomycin on gentamicin was observed. Conclusion These findings suggest that the addition of 2 g vancomycin and 2 g gentamicin into acrylic bone cement was preferred while considering this dual-antibiotic AIBC regiment with acceptably material properties and effective antibacterial activity. However, special attention should be drawn to the reduction of vancomycin elution when incorporated with gentamicin.
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Affiliation(s)
- Tao Li
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Lilan Fu
- Nanfang PET Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jian Wang
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
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Oliver RA, Lovric V, Christou C, Walsh WR. Evaluation of comparative soft tissue response to bone void fillers with antibiotics in a rabbit intramuscular model. J Biomater Appl 2019; 34:117-129. [PMID: 30987506 PMCID: PMC6587362 DOI: 10.1177/0885328219838382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Management of osseous and soft tissue dead space can be a significant challenge in the clinical setting. Calcium sulphate and calcium phosphate-based biomaterials are increasingly being used as alternatives to PMMA for local release of antibiotics, in particular to fill dead space following surgical debridement. This study aims to observe the in-vivo absorption characteristics and tissue response of three commercially available calcium sulphate-based materials combined with gentamicin in an established soft tissue rabbit model. The implant materials (1cc) were placed into four intramuscular sites in 18 New Zealand White rabbits (n = 6). In-life blood samples and radiographs were taken from each animal following implantation. Animals were sacrificed at 0, 1, 7, 21, 42 and 63 days post-operatively (n = 3) and implant sites analysed by micro-computed tomography and histology. Radiographically and histologically, recrystallized calcium sulphate (RCS) absorbed the fastest with complete absorption by day 21. Calcium sulphate/HA composite (CSHA) and Calcium sulphate/calcium carbonate (CSCC) absorbed slower and were detectable at day 63. Residual bead analysis revealed the presence of detectable gentamicin at 24 h and 7 days for CSHA and RCS but none in CSCC. Systemic levels of gentamicin were only detected between 1 h and 24 h. Serological inflammatory cytokine expression for IL-6, TNF-α and IL-1β indicated no unusual inflammatory response to the implanted materials. Calcium sulphate materials loaded with gentamicin are effective in resolving a surgically created dead space without eliciting any adverse host response.
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Affiliation(s)
- Rema A Oliver
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - Vedran Lovric
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - Chris Christou
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - William R Walsh
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
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