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Tsikopoulos K, Meroni G, Kaloudis P, Pavlidou E, Gravalidis C, Tsikopoulos I, Drago L, Romano CL, Papaioannidou P. Is nanomaterial- and vancomycin-loaded polymer coating effective at preventing methicillin-resistant Staphylococcus aureus growth on titanium disks? An in vitro study. INTERNATIONAL ORTHOPAEDICS 2023; 47:1415-1422. [PMID: 36976333 DOI: 10.1007/s00264-023-05757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Periprosthetic joint infections induced by methicillin-resistant Staphylococcus aureus (MRSA) pose a major socioeconomic burden. Given the fact that MRSA carriers are at high risk for developing periprosthetic infections regardless of the administration of eradication treatment pre-operatively, the need for developing new prevention modalities is high. METHODS The antibacterial and antibiofilm properties of vancomycin, Al2O3 nanowires, and TiO2 nanoparticles were evaluated in vitro using MIC and MBIC assays. MRSA biofilms were grown on titanium disks simulating orthopedic implants, and the infection prevention potential of vancomycin-, Al2O3 nanowire-, and TiO2 nanoparticle-supplemented Resomer® coating was evaluated against biofilm controls using the XTT reduction proliferation assay. RESULTS Among the tested modalities, high- and low-dose vancomycin-loaded Resomer® coating yielded the most satisfactory metalwork protection against MRSA (median absorbance was 0.1705; [IQR = 0.1745] vs control absorbance 0.42 [IQR = 0.07]; p = 0.016; biofilm reduction was 100%; and 0.209 [IQR = 0.1295] vs control 0.42 [IQR = 0.07]; p < 0.001; biofilm reduction was 84%, respectively). On the other hand, polymer coating alone did not provide clinically meaningful biofilm growth prevention (median absorbance was 0.2585 [IQR = 0.1235] vs control 0.395 [IQR = 0.218]; p < 0.001; biofilm reduction was 62%). CONCLUSIONS We advocate that apart from the well-established preventative measures for MRSA carriers, loading implants with bioresorbable Resomer® vancomycin-supplemented coating may decrease the incidence of early post-op surgical site infections with titanium implants. Of note, the payoff between localized toxicity and antibiofilm efficacy should be considered when loading polymers with highly concentrated antimicrobial agents.
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Affiliation(s)
- Konstantinos Tsikopoulos
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki (AUTh), Thessaloniki, Greece, 54124.
| | - Gabriele Meroni
- One Health Unit, Department of Biomedical Surgical and Dental Sciences, School of Medicine, Università degli Studi di Milano, Milan, Italy
| | - Panagiotis Kaloudis
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki (AUTh), Thessaloniki, Greece, 54124
| | - Eleni Pavlidou
- Condensed Matter and Materials Section, Department of Physics, Faculty of Exact Sciences, Aristotle University of Thessaloniki (AUTh), Thessaloniki, Greece, 54124
| | - Christoforos Gravalidis
- Condensed Matter and Materials Section, Department of Physics, Faculty of Exact Sciences, Aristotle University of Thessaloniki (AUTh), Thessaloniki, Greece, 54124
| | - Ioannis Tsikopoulos
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki (AUTh), Thessaloniki, Greece, 54124
| | - Lorenzo Drago
- Laboratory of Clinical Microbiology and Microbiome, Department of Biomedical Sciences for Health. School of Medicine, University of Milan, Milan, Italy
| | | | - Paraskevi Papaioannidou
- 1st Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki (AUTh), Thessaloniki, Greece, 54124
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Strategies to Mitigate and Treat Orthopaedic Device-Associated Infections. Antibiotics (Basel) 2022; 11:antibiotics11121822. [PMID: 36551479 PMCID: PMC9774155 DOI: 10.3390/antibiotics11121822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/03/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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The editor endeavours, aims and standards in a surgery journal: our experience with "International Orthopaedics" and the Société Internationale de Chirurgie Orthopédique et de Traumatologie publications. INTERNATIONAL ORTHOPAEDICS 2022; 46:1211-1213. [PMID: 35551436 DOI: 10.1007/s00264-022-05424-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sandhu AK, Yang Y, Li WW. In Vivo Antibacterial Efficacy of Antimicrobial Peptides Modified Metallic Implants─Systematic Review and Meta-Analysis. ACS Biomater Sci Eng 2022; 8:1749-1762. [PMID: 35412810 PMCID: PMC9171719 DOI: 10.1021/acsbiomaterials.1c01307] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Biomaterial-associated infection is difficult to detect and brings consequences that can lead to morbidity and mortality. Bacteria can adhere to the implant surface, grow, and form biofilms. Antimicrobial peptides (AMPs) can target and kill bacterial cells using a plethora of mechanisms of action such as rupturing the cell membrane by creating pores via depolarization with their cationic and amphipathic nature. AMPs can thus be coated onto metal implants to prevent microbial cell adhesion and growth. The aim of this systematic review was to determine the potential clinical applications of AMP-modified implants through in vivo induced infection models. Following a database search recently up to 22 January 2022 using PubMed, Web of Science and Cochrane databases, and abstract/title screening using the PRISMA framework, 24 studies remained, of which 18 were used in the random effects meta-analysis of standardized mean differences (SMD) to get effect sizes. Quality of studies was assessed using SYRCLE's risk of bias tool. The data from these 18 studies showed that AMPs carry antibacterial effects, and the meta-analysis confirmed the favorited antibacterial efficacy of AMP-coated groups over controls (SMD -1.74, 95%CI [-2.26, -1.26], p < 0.00001). Subgroup analysis showed that the differences in effect size are random, and high heterogeneity values suggested the same. HHC36 and vancomycin were the most common AMPs for surface modification and Staphylococcus aureus, the most tested bacterium in vivo. Covalent binding with polymer brush coating and physical layer-by-layer incorporation of AMPs were recognized as key methods of incorporation to achieve desired densities. The use of fusion peptides seemed admirable to incorporate additional benefits such as osteointegration and wound healing and possibly targeting more microbe strains. Further investigation into the incorporation methods, AMP activity against different bacterial strains, and the number of AMPs used for metal implant surface modification is needed to progress toward potential clinical application.
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Affiliation(s)
- Amrit Kaur Sandhu
- School of Pharmacy and Bioengineering, Keele University, Thornburrow Drive, Stoke-on-Trent, ST4 7QB, United Kingdom
| | - Ying Yang
- School of Pharmacy and Bioengineering, Keele University, Thornburrow Drive, Stoke-on-Trent, ST4 7QB, United Kingdom
| | - Wen-Wu Li
- School of Pharmacy and Bioengineering, Keele University, Thornburrow Drive, Stoke-on-Trent, ST4 7QB, United Kingdom
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Tsikopoulos K, Sidiropoulos K, Kitridis D, Moulder E, Ahmadi M, Drago L, Lavalette D. Preventing Staphylococcus aureus stainless steel-associated infections in orthopedics. A systematic review and meta-analysis of animal literature. J Orthop Res 2021; 39:2615-2637. [PMID: 33527485 DOI: 10.1002/jor.24999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/17/2021] [Accepted: 01/25/2021] [Indexed: 02/04/2023]
Abstract
Surgical site infection in the presence of orthopedic implants poses significant healthcare and socioeconomic burden. To assess the potential of various prevention strategies against Staphylococcus-induced stainless steel-associated infections, a review of animal evidence was designed. The databases of PubMed, Embase, and CENTRAL were searched until March 10, 2020, for articles including animal models with stainless steel instrumentation and techniques to prevent Staphylococcus infection. We conducted a random-effects meta-analysis of standardized mean differences (SMD) with subgroup analysis linked to various protection strategies and we recorded complications. Quality was assessed with the SYRCLE's risk of bias tool. Twenty-five studies were included. Combined active coating (featuring organic antibacterial compound release) and degradable passive finishing (lipid- or polymer-based structure modification reducing bacterial adhesion) was favored over untreated controls (SMDs for methicillin-sensitive Staphylococcus aureus [MSSA] and methicillin-resistant Staphylococcus aureus [MRSA] were -3.46, 95% CI [-4.53 to -2.4], p < .001 [n = 4 head-to-head comparisons]; and -6.67, 95% CI [-10.53 to -3], p < .001 [n = 5 head-to-head comparisons], respectively). Systemic vitamin D supplementation and systemic antibiotic administration with or without local antibiotics demonstrated favorable outcomes against MSSA infection. On the contrary, no benefit was seen following vaccination. Of note, no side effects were documented. On the basis of data gathered from eight studies, which comprised 294 animals, a bioresorbable polymer- or lipid-based surface modification supplemented with organic coating yielded improved infection-related outcomes against MSSA and MRSA stainless steel infections, and therefore, this strategy could be further investigated in human research.
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Affiliation(s)
| | | | - Dimitrios Kitridis
- 1st Orthopedic Department, G. Papanikolaou General Hospital, Aristotle University, Thessaloniki, Greece
| | - Elizabeth Moulder
- Orthopedic Department, Hull Limb Reconstruction Unit, Hull Royal Infirmary, Hull, UK
| | - Milad Ahmadi
- Orthopaedic Department, Leeds General Infirmary, Leeds, UK
| | - Lorenzo Drago
- Laboratory of Clinical Microbiology, Department of Biochemical Sciences for Health, University of Milan, Milan, Italy
| | - David Lavalette
- Orthopedic Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
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Abstract
Implant-associated infections (IAIs) are among the most intractable and costly complications in implant surgery. They can lead to surgery failure, a high economic burden, and a decrease in patient quality of life. This manuscript is devoted to introducing current antimicrobial strategies for additively manufactured (AM) titanium (Ti) implants and fostering a better understanding in order to pave the way for potential modern high-throughput technologies. Most bactericidal strategies rely on implant structure design and surface modification. By means of rational structural design, the performance of AM Ti implants can be improved by maintaining a favorable balance between the mechanical, osteogenic, and antibacterial properties. This subject becomes even more important when working with complex geometries; therefore, it is necessary to select appropriate surface modification techniques, including both topological and chemical modification. Antibacterial active metal and antibiotic coatings are among the most commonly used chemical modifications in AM Ti implants. These surface modifications can successfully inhibit bacterial adhesion and biofilm formation, and bacterial apoptosis, leading to improved antibacterial properties. As a result of certain issues such as drug resistance and cytotoxicity, the development of novel and alternative antimicrobial strategies is urgently required. In this regard, the present review paper provides insights into the enhancement of bactericidal properties in AM Ti implants.
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Tsikopoulos K, Sidiropoulos K, Kitridis D, Drago L, Ebnezar R, Lavalette D. Rationalising animal research synthesis in orthopaedic literature. World J Methodol 2021; 11:75-80. [PMID: 34026580 PMCID: PMC8127423 DOI: 10.5662/wjm.v11.i3.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 02/05/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
Systematic reviews in orthopaedic literature are frequently criticised for offering inconsistent conclusions. On top of that, high-quality randomized human evidence on crucial orthopaedic topics is more often than not lacking. In this situation, pooling animal literature could offer an excellent insight into unanswered critical clinical questions, thus potentially improving healthcare. In this paper, we sought to present the rationale and basic principles governing meta-analysis of animal research. More specifically, we elaborated on the available evidence-based methods to achieve a scientifically sound animal data synthesis. In addition, we discussed result interpretation, strength of recommendations and clinical implications based on the results of these meta-analytic modalities.
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Affiliation(s)
- Konstantinos Tsikopoulos
- Orthopaedic Department, Harrogate and District Foundation Trust, Harrogate HG2 7SX, North Yorkshire, United Kingdom
| | | | - Dimitrios Kitridis
- First Orthopedic Department of Aristotle University, G. Papanikolaou General Hospital, Thessaloniki 55210, Greece
| | - Lorenzo Drago
- Laboratory of Clinical Microbiology, Department of Biochemical Sciences for Health, University of Milan, Milan 20164, Italy
| | - Rakesh Ebnezar
- Orthopaedic Department, Harrogate and District Foundation Trust, Harrogate HG2 7SX, North Yorkshire, United Kingdom
| | - David Lavalette
- Orthopaedic Department, Harrogate and District Foundation Trust, Harrogate HG2 7SX, North Yorkshire, United Kingdom
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Antolič V, Bumbaširević M, Pećina M. Central and Eastern Europe actual orthopaedics profile. INTERNATIONAL ORTHOPAEDICS 2021; 45:811-814. [PMID: 33738518 PMCID: PMC7971353 DOI: 10.1007/s00264-021-05000-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Vane Antolič
- University Medical Centre Ljubljana, Zaloska 9 Street, 1000 Ljubljana, Slovenia
| | - Marko Bumbaširević
- Clinic of Orthopedic Surgery and Traumatology, Clinical Centre of Serbia, 26 Visegradska Street, 11 000 Belgrade, Serbia
| | - Marko Pećina
- University of Zagreb, School of Medicine, Salata 3, 10000 Zagreb, Croatia
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Zoccali C, Scoccianti G, Biagini R, Daolio PA, Giardina FL, Campanacci DA. Antibacterial hydrogel coating in joint mega-prosthesis: results of a comparative series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1647-1655. [PMID: 33547509 DOI: 10.1007/s00590-021-02884-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Joint mega-prosthesis after bone tumors, severe trauma or infection is associated with high rates of post-surgical septic complications. A fast-resorbable antibacterial hydrogel coating (DAC®, Defensive Antibacterial Coating) has previously been shown to be able to significantly reduce surgical site infection in various clinical settings. Aim of the present study was to evaluate the safety and efficacy of the DAC hydrogel coating to prevent early periprosthetic joint infection after joint mega-prosthesis. METHODS In this three-centers, case-control study, 43 patients, treated with an antibacterial hydrogel coated mega-prosthesis for oncological (N = 39) or non-oncological conditions (N = 4), were retrospectively compared with 43 matched controls, treated with mega-implants without the coating. Clinical, laboratory and radiographic examinations were performed to evaluate the occurrence of post-surgical infection, complications and adverse events. RESULTS At a mean follow-up of 2 years, no evidence of infection or adverse events were observed in the DAC-treated group, compared to six cases of post-surgical infection in the control group. CONCLUSION This matched case-control study shows that a fast-resorbable, antibiotic-loaded coating can be safely used to protect joint mega-prosthesis, providing a reduction of early surgical site infections with no side effects. Larger prospective trials with longer follow-ups are warranted to confirm this report. TRIAL REGISTRATION RS1229/19 (Regina Elena National Cancer Institute Experimental Registry Number).
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Affiliation(s)
- Carmine Zoccali
- Oncological Orthopedics Department, IFO - Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
| | - Guido Scoccianti
- Department of Orthopaedic Oncology and Reconstructive Surgery, University of Florence, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla, 3, 50134, Florence, Italy
| | - Roberto Biagini
- Oncological Orthopedics Department, IFO - Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Primo Andrea Daolio
- Oncologic Surgery Centre, Gaetano Pini Orthopedic Institute, Via Quadronno, 25, 20122, Milan, Italy
| | - Fabio Luca Giardina
- Oncologic Surgery Centre, Gaetano Pini Orthopedic Institute, Via Quadronno, 25, 20122, Milan, Italy
| | - Domenico Andrea Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, University of Florence, Azienda Ospedaliera Universitaria Careggi, Largo Brambilla, 3, 50134, Florence, Italy
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