1
|
Alimohammadi M, Mirzabozorg H, Farahmand F, Kim S, Baril C, Ploeg HL. Statistical distribution of micro and macro pores in acrylic bone cement- effect of amount of antibiotic content. J Mech Behav Biomed Mater 2024; 150:106297. [PMID: 38100980 DOI: 10.1016/j.jmbbm.2023.106297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/02/2023] [Accepted: 12/02/2023] [Indexed: 12/17/2023]
Abstract
Aseptic loosening due to mechanical failure of bone cement is considered to be a leading cause of revision of joint replacement systems. Detailed quantified information on the number, size and distribution pattern of pores can help to obtain a deeper understanding of the bone cement's fatigue behavior. The objective of this study was to provide statistical descriptions for the pore distribution characteristics of laboratory bone cement specimens with different amounts of antibiotic contents. For four groups of bone cement (Palacos) specimens, containing 0.3, 0.6, 1.2 and 2.4 wt/wt% of telavancin antibiotic, seven samples per group were micro computed tomography scanned (38.97 μm voxel size). The images were first preprocessed in Mimics and then analyzed in Dragonfly, with the level of threshold being set such that single-pixel pores become visible. The normalized pore volume data of the specimens were then used to extract the logarithmic histograms of the pore densities for antibiotic groups, as well as their three-parameter Weibull probability density functions. Statistical comparison of the pore distribution data of the antibiotic groups using the Mann-Whitney non-parametric test revealed a significantly larger porosity (p < 0.05) in groups with larger added antibiotic contents (2.4 and 0.6 wt/wt% vs 0.3 wt/wt%). Further analysis revealed that this effect was associated with the significantly larger frequency of micropores of 0.1-0.5 mm diameter (p < 0.05) in groups with larger antibiotic content (2.4 wt/wt% vs and 0.6 and 0.3 wt/wt%), implying that the elution of the added antibiotic produces micropores in this diameter range mainly. Based on this observation and the fatigue test results in the literature, it was suggested that micropore clusters have a detrimental effect on the mechanical properties of bone cement and play a major role in initiating fatigue cracks in highly antibiotic added specimens.
Collapse
Affiliation(s)
- Mahsa Alimohammadi
- Civil Engineering Department, KN Toosi University of Technology, Tehran, Iran; Department of Mechanical and Materials Engineering, Queen's University, Kingston, ON, Canada
| | - Hassan Mirzabozorg
- Civil Engineering Department, KN Toosi University of Technology, Tehran, Iran
| | - Farzam Farahmand
- Mechanical Engineering Department, Sharif University of Technology, Tehran, Iran
| | - Sunjung Kim
- Department of Orthopaedic Surgery, University of Illinois Chicago, Chicago, IL, USA
| | - Caroline Baril
- Department of Mechanical and Materials Engineering, Queen's University, Kingston, ON, Canada
| | - Heidi-Lynn Ploeg
- Department of Mechanical and Materials Engineering, Queen's University, Kingston, ON, Canada.
| |
Collapse
|
2
|
Hollyer I, Ivanov D, Kappagoda S, Lowenberg DW, Goodman SB, Amanatullah DF. Selecting a high-dose antibiotic-laden cement knee spacer. J Orthop Res 2023; 41:1383-1396. [PMID: 37127938 DOI: 10.1002/jor.25570] [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: 03/14/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft-tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA.
Collapse
Affiliation(s)
- Ian Hollyer
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - David Ivanov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Shanthi Kappagoda
- Division of Infectious Diseases and Geographic Medicine, Stanford Univeristy, Stanford, California, USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| |
Collapse
|
3
|
von Hertzberg-Boelch SP, Luedemann M, Rudert M, Steinert AF. PMMA Bone Cement: Antibiotic Elution and Mechanical Properties in the Context of Clinical Use. Biomedicines 2022; 10:biomedicines10081830. [PMID: 36009376 PMCID: PMC9404960 DOI: 10.3390/biomedicines10081830] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 12/04/2022] Open
Abstract
This literature review discusses the use of antibiotic loaded polymethylmethacrylate bone cements in arthroplasty. The clinically relevant differences that have to be considered when antibiotic loaded bone cements (ALBC) are used either for long-term implant fixation or as spacers for the treatment of periprosthetic joint infections are outlined. In this context, in vitro findings for antibiotic elution and material properties are summarized and transferred to clinical use.
Collapse
Affiliation(s)
- Sebastian Philipp von Hertzberg-Boelch
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
- Correspondence:
| | - Martin Luedemann
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
| | - Andre F. Steinert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
- Rhön Klinikum, Campus Bad Neustadt, EndoRhoen Center for Joint Replacement, Teaching Hospital of the Phillipps University Marburg, Von Guttenberg Str. 11, 97616 Bad Neustadt, Germany
| |
Collapse
|
4
|
Feng F, Chen M, Wang X, Zhang H, Nie H, Tang H. Translation of a spinal bone cement product from bench to bedside. Bioact Mater 2021; 10:345-354. [PMID: 34901551 PMCID: PMC8636668 DOI: 10.1016/j.bioactmat.2021.08.011] [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: 07/01/2021] [Revised: 08/01/2021] [Accepted: 08/09/2021] [Indexed: 01/18/2023] Open
Abstract
Spinal acrylic bone cements (ABCs) are used clinically for percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) to treat osteoporotic vertebral compression fractures. Product translation of spinal ABC products followed the design control processes including design verification and validation. The bench to bedside translation of the first Chinese spinal ABC product (Alliment®, namely Alliment Cement) approved by National Medical Products Administration of China was investigated and another commercial product served as the control (Osteopal®V, namely Osteopal V Cement). Results of non-clinical bench performance verification tests of compression, bending and monomer release showed that the newly marketed Alliment Cement is similar to the Osteopal V Cement with properties of both meeting the criteria specified by standards. The Alliment Cement demonstrated good biocompatibility during the 26 weeks’ bone implantation test. Porcine cadaver validation tests further revealed that the Alliment Cement satisfied the needs for both PVP and PKP procedures. A post-approval, retrospective clinical investigation further demonstrated the safety and efficacy of the Alliment Cement, with a significant reduction of pain and the improved stability of the fractured vertebral bodies. A successful translation of biomaterial medical products needs close collaborations among academia, industry, healthcare professionals and regulatory agencies. Bench-to-bedside research of the first Chinese spinal acrylic bone cement product. •Pre- & clinical investigations demonstrate the product's safety and efficacy. •Translation of biomaterial medical products follows regulated processes.
Collapse
Affiliation(s)
- Fei Feng
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Rd, Xi Cheng District, Beijing, 100050, China
| | - Mengmeng Chen
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Rd, Xi Cheng District, Beijing, 100050, China
| | - Xuan Wang
- Beijing Bonsci Technology Co Ltd, No.100, 6th Kechuang Street, Beijing Economic and Technological Development Area, Beijing, 100176, China
| | - Hongwei Zhang
- Beijing Bonsci Technology Co Ltd, No.100, 6th Kechuang Street, Beijing Economic and Technological Development Area, Beijing, 100176, China
| | - Hongtao Nie
- Beijing Bonsci Technology Co Ltd, No.100, 6th Kechuang Street, Beijing Economic and Technological Development Area, Beijing, 100176, China
| | - Hai Tang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Rd, Xi Cheng District, Beijing, 100050, China
| |
Collapse
|
5
|
Paz E, Ballesteros Y, Abenojar J, Dunne N, del Real JC. Advanced G-MPS-PMMA Bone Cements: Influence of Graphene Silanisation on Fatigue Performance, Thermal Properties and Biocompatibility. NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:E139. [PMID: 33435593 PMCID: PMC7826625 DOI: 10.3390/nano11010139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/16/2022]
Abstract
The incorporation of well-dispersed graphene (G) powder to polymethyl methacrylate (PMMA) bone cement has been demonstrated as a promising solution to improving its mechanical performance. However, two crucial aspects limit the effectiveness of G as a reinforcing agent: (1) the poor dispersion and (2) the lack of strong interfacial bonds between G and the matrix of the bone cement. This work reports a successful functionalisation route to promote the homogenous dispersion of G via silanisation using 3-methacryloxypropyltrimethoxy silane (MPS). Furthermore, the effects of the silanisation on the mechanical, thermal and biocompatibility properties of bone cements are presented. In comparison with unsilanised G, the incorporation of silanised G (G_MPS1 and G_MPS2) increased the bending strength by 17%, bending modulus by 15% and deflection at failure by 17%. The most impressive results were obtained for the mechanical properties under fatigue loading, where the incorporation of G_MPS doubled the Fatigue Performance Index (I) value of unsilanised G-bone cement-meaning a 900% increase over the I value of the cement without G. Additionally, to ensure that the silanisation did not have a negative influence on other fundamental properties of bone cement, it was demonstrated that the thermal properties and biocompatibility were not negatively impacted-allowing its potential clinical progression.
Collapse
Affiliation(s)
- Eva Paz
- Institute for Research in Technology, ICAI, Comillas Pontifical University, Santa Cruz de Marcenado, 26, 28015 Madrid, Spain; (Y.B.); (J.C.d.R.)
- Mechanical Engineering Department, ICAI, Comillas Pontifical University, Alberto Aguilera 25, 28015 Madrid, Spain
| | - Yolanda Ballesteros
- Institute for Research in Technology, ICAI, Comillas Pontifical University, Santa Cruz de Marcenado, 26, 28015 Madrid, Spain; (Y.B.); (J.C.d.R.)
- Mechanical Engineering Department, ICAI, Comillas Pontifical University, Alberto Aguilera 25, 28015 Madrid, Spain
| | - Juana Abenojar
- In-Service Material Performance Group, Materials Science and Engineering and Chemical Engineering Department, “Álvaro Alonso Barba” Institute of Chemistry and Materials Technology, Universidad Carlos III de Madrid. Av. Universidad, 30, 28911 Leganés, Spain;
| | - Nicholas Dunne
- Centre for Medical Engineering Research, School of Mechanical and Manufacturing Engineering, Dublin City University, Stokes Building, Collins Avenue, D09 E432 Dublin 9, Ireland
- School of Mechanical and Manufacturing Engineering, Dublin City University, D09 E432 Dublin 9, Ireland
- School of Pharmacy, Queen’s University of Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
- Department of Mechanical and Manufacturing Engineering, School of Engineering, Trinity College Dublin, D02 PN40 Dublin 2, Ireland
- Advanced Manufacturing Research Centre (I-Form), School of Mechanical and Manufacturing Engineering, Dublin City University, Glasnevin, D09 E432 Dublin 9, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Trinity College Dublin, D02 PN40 Dublin 2, Ireland
- Advanced Processing Technology Research Centre, Dublin City University, D09 E432 Dublin 9, Ireland
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, D02 PN40 Dublin 2, Ireland
| | - Juan C. del Real
- Institute for Research in Technology, ICAI, Comillas Pontifical University, Santa Cruz de Marcenado, 26, 28015 Madrid, Spain; (Y.B.); (J.C.d.R.)
- Mechanical Engineering Department, ICAI, Comillas Pontifical University, Alberto Aguilera 25, 28015 Madrid, Spain
| |
Collapse
|
6
|
Effect of Physiological Saline Solution Contamination on Selected Mechanical Properties of Seasoned Acrylic Bone Cements of Medium and High Viscosity. MATERIALS 2020; 14:ma14010110. [PMID: 33383870 PMCID: PMC7796448 DOI: 10.3390/ma14010110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 12/29/2022]
Abstract
Bone cements play a key role in present-day surgery, including the implantation of hip and knee joint endoprostheses. The correct and durable bonding of the prosthesis to the bone is affected by both the static strength characteristics determined in accordance with ISO 5833:2002 and the resistance to long-term exposure to an aggressive environment of the human body and the impurities that may be introduced into the cement during implementation. The study attempts to demonstrate statistically significant degradation of cement as a result of the seasoning of cement samples in Ringer’s solution with simultaneous contamination of the material with saline solution, which is usually present in the surgical field (e.g., during the fixing of endoprostheses). The results of statistical analysis showed the nature of changes in compressive strength and microhardness due to seasoning time and degree of contamination.
Collapse
|
7
|
Affiliation(s)
- René A Monzón
- Adult Reconstruction, Department of Orthopaedics, University of California-Davis Medical Center, Sacramento, California
| | - John G Coury
- Department of Orthopaedic Surgery, Doctors Medical Center, Valley Consortium for Medical Education, Modesto, California
| | - Gregory D Disse
- Adult Reconstruction, Department of Orthopaedics, University of California-Davis Medical Center, Sacramento, California
| | - Zachary C Lum
- Adult Reconstruction, Department of Orthopaedics, University of California-Davis Medical Center, Sacramento, California
| |
Collapse
|
8
|
Ajit Singh V, Chun Haw B, Haseeb A, Shuan Ju Teh C. Hand-mixed vancomycin versus commercial tobramycin cement revisited: A study on mechanical and antibacterial properties. J Orthop Surg (Hong Kong) 2020; 27:2309499019839616. [PMID: 30943842 DOI: 10.1177/2309499019839616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Arthroplasty-related infection has grown worldwide. Revision procedures for infection are associated with longer operating time, superior amounts of blood loss, and substantial economic encumbrance. To overcome cost, many surgeons opt for hand-mixed vancomycin into the bone cement. The objective of this research was to assess the biomechanical strength and antibacterial properties of hand-mixed vancomycin bone cement at different concentrations with commonly used industrial preblended antibiotic bone cement and plain cement. The target was to determine the ideal concentration of antibiotics that can be used in the preparation of hand-mixed vancomycin cement that delivers maximum antibiotics concentration without compromising its biomechanical properties. MATERIALS AND METHODS Vancomycin-impregnated polymethyl methacrylate (PMMA) specimen was hand prepared in varying concentrations (1-4 g). The authors tested three-point bending strength to determine 'maximum bending load' and stiffness and its antibacterial activity by looking into the zone of inhibition on methicillin-resistant Staphylococcus aureus-impregnated agar plate. These were compared with the industrial preblended Simplex™ P with 1 g tobramycin. RESULTS This study exhibited that vancomycin-PMMA disk that contained higher concentration of antibiotics had significantly higher antibacterial activity. The control group (plain cement) and industrial PMMA with preblended antibiotic (tobramycin) showed stable mechanical strength, while the hand-mixed antibiotic cement (HMAC) had variable mechanical strength varying on the concentration of antibiotics used. CONCLUSION It was effectively concluded that HMAC is advantageous as a cement spacer; however, it is not recommended for primary arthroplasty and second-stage revision arthroplasty. The recommended maximum concentration of vancomycin based on this study is 2 g/pack (40 g) of cement. Industrial preblended antibiotic cement is superior to hand-mixed cement.
Collapse
Affiliation(s)
- Vivek Ajit Singh
- 1 Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Bong Chun Haw
- 1 Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Amber Haseeb
- 1 Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cindy Shuan Ju Teh
- 2 Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
9
|
Bowman EC, Malkani AL. Point/Counterpoint: Static vs Articulating Spacers-Static Spacers for Resection Arthroplasty of the Knee. J Arthroplasty 2020; 35:S35-S39. [PMID: 32046829 DOI: 10.1016/j.arth.2019.10.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/17/2019] [Accepted: 10/19/2019] [Indexed: 02/01/2023] Open
Abstract
Antibiotic spacers play a significant role in the treatment of periprosthetic joint infections. They help maintain soft-tissue tension and provide delivery of high dose of antibiotics to the local tissue. The use of static or dynamic spacers is based on multiple factors including the extent of soft-tissue, ligamentous and bone compromise, overall patient function, comorbid conditions, and virulence of the organism. There is no difference in reinfection incidence between static vs dynamic spacers following two-stage reimplantation. Static spacers can be customized to treat all cases of periprosthetic total knee infections and offer intraoperative flexibility to vary the cement quantity and amount of antibiotics in the spacer to provide high-dose local delivery of antibiotics to address the dead space, bone loss, and soft-tissue compromise. Static spacers are especially advantageous in cases of extensor mechanism and ligamentous compromise where articulating spacers may not be able to provide adequate stability.
Collapse
Affiliation(s)
- Erik C Bowman
- Department of Orthopedics, University of Louisville, Louisville, KY
| | - Arthur L Malkani
- Department of Orthopedics, University of Louisville, Louisville, KY
| |
Collapse
|
10
|
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.
Collapse
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;
| |
Collapse
|
11
|
Rava A, Bruzzone M, Cottino U, Enrietti E, Rossi R. Hip Spacers in Two-Stage Revision for Periprosthetic Joint Infection: A Review of Literature. JOINTS 2019; 7:56-63. [PMID: 31879732 PMCID: PMC6930843 DOI: 10.1055/s-0039-1697608] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/06/2019] [Indexed: 02/06/2023]
Abstract
Infection after total hip arthroplasty (THA) is a devastating complication with significant consequences for patients. In literature, single and two-stage revision, irrigation and debridement, Girdlestone resection arthroplasty, and arthrodesis and amputation are reported as possible treatments. Recently, two-stage revision has become popular as the gold standard treatment for chronic hip joint infections after THA. In this review, we evaluate the current literature about microbiology of periprosthetic joint infections and the use of antibiotic-loaded cement spacers. We aim to give an overview about indications, clinical results, and mechanical complications for spacers implantation, evaluating also selection criteria, pharmacokinetic properties, and systemic safety of the most frequently used antibiotics.
Collapse
Affiliation(s)
- Alessandro Rava
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Torino, Torino, Italy
| | - Matteo Bruzzone
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
| | - Umberto Cottino
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
| | - Emilio Enrietti
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Torino, Torino, Italy
| | - Roberto Rossi
- SC Ortopedia e Traumatologia, AO Ospedale Mauriziano Umberto I, Torino, Italy
| |
Collapse
|
12
|
Shen SC, Letchmanan K, Chow PS, Tan RBH. Antibiotic elution and mechanical property of TiO2 nanotubes functionalized PMMA-based bone cements. J Mech Behav Biomed Mater 2019; 91:91-98. [DOI: 10.1016/j.jmbbm.2018.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/16/2018] [Accepted: 11/19/2018] [Indexed: 11/26/2022]
|
13
|
Ikeda S, Uchiyama K, Minegishi Y, Ohno K, Nakamura M, Yoshida K, Fukushima K, Takahira N, Takaso M. Double-layered antibiotic-loaded cement spacer as a novel alternative for managing periprosthetic joint infection: an in vitro study. J Orthop Surg Res 2018; 13:322. [PMID: 30572903 PMCID: PMC6302504 DOI: 10.1186/s13018-018-1033-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 12/06/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Previous studies comparing antibiotic-loaded calcium phosphate cement to polymethylmethacrylate cement reported that although the former has higher elution volumes over a longer period, it is mechanically weak when used alone. To counter this problem, a double-layered antibiotic-loaded cement spacer in which calcium phosphate cement is coated with polymethylmethacrylate cement was created. METHODS In this study, we compared the double-layered spacer to the polymethylmethacrylate cement spacer in terms of eluent antibiotic concentration, bioactivity against methicillin-resistant Staphylococcus aureus, and mechanical strength. Double-layered and polymethylmethacrylate cement spacers that were loaded with vancomycin (VCM) were prepared and immersed in phosphate buffer for 84 days. To facilitate VCM elution from calcium phosphate cores in double-layered spacers, we also drilled multiple holes into the calcium phosphate layer from the spacer surface. RESULTS We found that VCM concentrations in double-layered spacer eluents were higher than those in polymethylmethacrylate cement spacer eluents. The double-layered spacer also had higher bioactivity than the polymethylmethacrylate cement spacer. Although the polymethylmethacrylate cement spacer eluent lost the ability to inhibit bacterial growth on day 56, the double-layered spacer eluent maintained this ability for the duration of our study. Finally, the double-layered spacer retained high mechanical strength throughout the study period. CONCLUSIONS The beneficial biomechanical and drug-eluting properties of the double-layered spacer might qualify it to serve as a promising biomaterial that could be used for managing periprosthetic joint infections.
Collapse
Affiliation(s)
- Shinsuke Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374 Japan
| | - Katsufumi Uchiyama
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374 Japan
| | - Yojiro Minegishi
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374 Japan
| | - Keiko Ohno
- Department of Medication Use Analysis and Clinical Research, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose-shi, Tokyo, 204-8588 Japan
| | - Masaki Nakamura
- Department of Microbiology, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373 Japan
| | - Kazuhiro Yoshida
- Department of Medical Engineering, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373 Japan
| | - Kensuke Fukushima
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374 Japan
| | - Naonobu Takahira
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374 Japan
- Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373 Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374 Japan
| |
Collapse
|
14
|
Comparison of Elution Characteristics and Compressive Strength of Biantibiotic-Loaded PMMA Bone Cement for Spacers: Copal® Spacem with Gentamicin and Vancomycin versus Palacos® R+G with Vancomycin. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4323518. [PMID: 30410931 PMCID: PMC6206524 DOI: 10.1155/2018/4323518] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/24/2018] [Accepted: 09/26/2018] [Indexed: 12/19/2022]
Abstract
Purpose Copal® spacem is a new PMMA bone cement for fabricating spacers. This study compares elution of gentamicin, elution of vancomycin, and compressive strength of Copal® spacem and of Palacos® R+G at different vancomycin loadings in the powder of the cements. We hypothesized that antibiotic elution of Copal® spacem is superior at comparable compressive strength. Methods Compression test specimens were fabricated using Copal® spacem manually loaded with 0.5 g gentamicin and additionally 2 g, 4 g, and 6 g of vancomycin per 40 g of cement powder (COP specimens) and using 0.5 g gentamicin premixed Palacos® R+G manually loaded with 2 g, 4 g, and 6 g of vancomycin per 40 g of cement powder (PAL specimens). These specimens were used for determination of gentamicin and vancomycin elution (in fetal calf serum, at 22°C) and for determination of compressive strength both prior and following the elution tests. Results Cumulative gentamicin concentrations (p < 0.005) and gentamicin concentration after 28 days (p ≤ 0.043) were significantly lower for COP specimens compared to PAL specimens. Cumulative vancomycin concentrations were significantly higher (p ≤ 0.043) for COP specimens after the second day. Vancomycin concentrations after 28 days were not significantly higher for the Copal specimens loaded with 2 g and 4 g of vancomycin. Compressive strength was not significantly different between COP specimens and PAL specimens before elution tests. Compressive strength after the elution tests was significantly lower (p = 0.005) for COP specimens loaded with 2 g of vancomycin. Conclusion We could not demonstrate consistent superior antibiotic elution from Copal® spacem compared to Palacos® R+G for fabricating gentamicin and vancomycin loaded spacers. The results do not favor Copal® spacem over Palacos® R+G for the use as a gentamicin and vancomycin biantibiotic-loaded spacer.
Collapse
|
15
|
Martínez-Moreno J, Merino V, Nácher A, Rodrigo JL, Climente M, Merino-Sanjuán M. Antibiotic-loaded Bone Cement as Prophylaxis in Total Joint Replacement. Orthop Surg 2018; 9:331-341. [PMID: 29178309 DOI: 10.1111/os.12351] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/10/2017] [Indexed: 12/14/2022] Open
Abstract
One of its most serious complications associated with arthroplasty is the development of infections. Although its prevalence is only between 0.5% and 3%, in some cases it can lead to death. Therefore, an important challenge in joint surgery is the prevention of infections when an arthroplasty is performed. The use of antibiotic-loaded cements could be a suitable tool due to numerous advantages. The main advantage of the use of antibiotic loading into bone cement derives directly from antibiotic release in the effect site, allowing achievement of high concentrations at the site of action, and minimal or no systemic toxicity. This route of administration was first described by Buchholz and Engelbrecht. In the case of infection treatment, this is an established method and its good results have been confirmed. However, its role in infection prevention, and, therefore, the use of these systems in clinical practice, has proved controversial because of the uncertainty about the development of possible antibiotic resistance after prolonged exposure time, their effectiveness, the cost of the systems, toxicity and loosening of mechanical properties. This review discusses all these topics, focusing on effectiveness and safety, antibiotic decisions, cement type, mixing method, release kinetics and future perspectives. The final objective is to provide the orthopaedic surgeons the right information in their clinical practice based on current evidence.
Collapse
Affiliation(s)
- Javier Martínez-Moreno
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain.,Pharmacy Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Virginia Merino
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
| | - Amparo Nácher
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
| | - José Luis Rodrigo
- Traumatology Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Mónica Climente
- Pharmacy Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Matilde Merino-Sanjuán
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
| |
Collapse
|
16
|
Sa Y, Yang F, Wang Y, Wolke JGC, Jansen JA. Modifications of Poly(Methyl Methacrylate) Cement for Application in Orthopedic Surgery. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1078:119-134. [DOI: 10.1007/978-981-13-0950-2_7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
17
|
Paz E, Forriol F, del Real J, Dunne N. Graphene oxide versus graphene for optimisation of PMMA bone cement for orthopaedic applications. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2017; 77:1003-1011. [DOI: 10.1016/j.msec.2017.03.269] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 03/28/2017] [Indexed: 01/26/2023]
|
18
|
Boelch SP, Jordan MC, Arnholdt J, Rudert M, Luedemann M, Steinert AF. Loading with vancomycin does not decrease gentamicin elution in gentamicin premixed bone cement. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:104. [PMID: 28534287 DOI: 10.1007/s10856-017-5915-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/10/2017] [Indexed: 06/07/2023]
Abstract
Antibiotic loaded bone cements are used as drug delivery systems for the treatment of periprosthetic joint infections. They can be loaded with antibiotics during industrial component production (premixing) and during cement preparation (manually blending). Although double premixed antibiotic loaded bone cements are available, manually blending of a gentamicin premixed antibiotic loaded bone cement with vancomycin is still popular. We compared in vitro antibiotic elution and compressive strength of 0.5 g gentamicin premixed bone cement (PALACOS® R + G), 0.5 g gentamicin premixed bone cement (PALACOS® R + G) manually blended with 2.0 g vancomycin, 0.5 g gentamicin and 2.0 g vancomycin premixed bone cement (COPAL® G + V), 1 g gentamicin and clindamycin premixed bone cement (COPAL® G + C) and bone cement without an antibiotic (PALACOS® R) as control. Antibiotic concentration measurements were performed for 6 weeks and then compression strength was tested. Concentrations of gentamicin showed no significant differences between PALACOS® R + G, PALACOS® R + G with vancomycin and COPAL G® + V. After 48 h COPAL G® + C produced significantly higher gentamicin concentrations than the other formulations. After 12 h PALACOS® R + G with vancomycin produced significantly higher vancomycin concentrations, but had the lowest compression strength. We found no influence of vancomycin addition on gentamicin elution, irrespectively of the loading method. However, the manually vancomycin blended ALBC produced higher vancomycin concentrations. Compression strength after aging is reduced by loading with vancomycin.
Collapse
Affiliation(s)
- Sebastian P Boelch
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany.
| | - Martin C Jordan
- Julius-Maximilians University Wuerzburg, Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, 6 Oberduerrbacher Strasse, D-97080, Wuerzburg, Germany
| | - Joerg Arnholdt
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Martin Luedemann
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Andre F Steinert
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
- Hospital Agatharied, Department of Orthopaedic and Trauma Surgery, Norbert-Kerkel Platz, 83734, Hausham, Germany
| |
Collapse
|
19
|
Shields D, Kong R, Gupta S, Mahendra A. A Novel Antibiotic Spacer for Significant Proximal Femoral Loss - Surgical Technique. Open Orthop J 2017; 11:508-516. [PMID: 28694890 PMCID: PMC5481614 DOI: 10.2174/1874325001711010508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 02/21/2017] [Accepted: 02/23/2017] [Indexed: 11/22/2022] Open
Abstract
Background: Infections of proximal femora with prosthetic implants in situ have long been a major concern in orthopedic surgery. The gold standard in the management of infected proximal femurs in the presence of prosthetic implants has traditionally been a two-stage revision. However, this is challenging in the setting of extensive bone loss. Methods: A 3 case series of such infections leading to extensive loss of the proximal femur is presented. We specifically describe our technique of debriding the infected segments as well as utilization of a trochanteric slide osteotomy to resect the femur.We also demonstrate preparation of the “pseudoacetabulum” and femoral component with an antibiotic spacer. Conclusion: The high cost of such a procedure is offset by reduction in time spent in hospital. The spacer also helps to allow mobilization by partial weight bearing on a stable femoral component and provide pain control which improves quality of life as compared to prolonged intravenous antimicrobial therapy.
Collapse
Affiliation(s)
- David Shields
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| | - Roderick Kong
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| | - Sanjay Gupta
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| | - Ashish Mahendra
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0ET Scotland, United Kingdom
| |
Collapse
|
20
|
Custom-Made Antibiotic Cement Nails in Orthopaedic Trauma: Review of Outcomes, New Approaches, and Perspectives. BIOMED RESEARCH INTERNATIONAL 2015; 2015:387186. [PMID: 26509153 PMCID: PMC4609780 DOI: 10.1155/2015/387186] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 05/18/2015] [Accepted: 05/20/2015] [Indexed: 01/26/2023]
Abstract
Since the first description in 2002 by Paley and Herzenberg, antibiotic bone cement nails (ACNs) have become an effective tool in the orthopaedic trauma surgeons' hands. They simultaneously elute high amounts of antibiotics into medullary canal dead space and provide limited stability to the debrided long bone. In this paper, we perform a systematic review of current evidence on ACNs in orthopaedic trauma and provide an up-to-date review of the indications, operative technique, failure mechanisms, complications, outcomes, and outlooks for the ACNs use in long bone infection.
Collapse
|
21
|
McManamon C, de Silva JP, Delaney P, Morris MA, Cross GLW. Characteristics, interactions and coating adherence of heterogeneous polymer/drug coatings for biomedical devices. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2015; 59:102-108. [PMID: 26652354 DOI: 10.1016/j.msec.2015.09.103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 11/25/2022]
Abstract
With this rise in surgical procedures it is important to focus on the mobility and safety of the patient and reduce the infections that are associated with hip replacements. We examine the mechanical properties of gentamicin sulphate as a model antimicrobial layer for titanium-alloy based prosthetic hips to help prevent methicillin-resistant Staphylococcus aureus infection after surgery. A top layer of poly(lactic-co-glycolic acid) is added to maintain the properties of the gentamicin sulphate as well as providing a drug delivery system. Through the use of nanoindentation and micro-scratch techniques it is possible to determine the mechanical and adhesive properties of this system. Nanoindentation determined the modulus values for the poly(lactic-co-glycolic acid) and gentamicin sulphate materials to be 8.9 and 5.2GPa, respectively. Micro-scratch established that the gentamicin sulphate layer is strongly adhered to the Ti alloy and forces of 30N show no cohesive or adhesive failure. It was determined that the poly(lactic-co-glycolic acid) is ductile in nature and delaminates from the gentamicin sulphate layer of at 0.5N.
Collapse
Affiliation(s)
- Colm McManamon
- Centre for Research on Adaptive Nanostructures and Nanodevices (CRANN), Trinity College Dublin, Dublin 2, Ireland
| | - Johann P de Silva
- Centre for Research on Adaptive Nanostructures and Nanodevices (CRANN), Trinity College Dublin, Dublin 2, Ireland; School of Physics, Trinity College Dublin, Dublin 2, Ireland
| | - Paul Delaney
- Department of Chemistry, Supercritical Fluid Centre and Materials Section, University College Cork, Cork, Ireland
| | - Michael A Morris
- Centre for Research on Adaptive Nanostructures and Nanodevices (CRANN), Trinity College Dublin, Dublin 2, Ireland; Department of Chemistry, Supercritical Fluid Centre and Materials Section, University College Cork, Cork, Ireland
| | - Graham L W Cross
- Centre for Research on Adaptive Nanostructures and Nanodevices (CRANN), Trinity College Dublin, Dublin 2, Ireland; School of Physics, Trinity College Dublin, Dublin 2, Ireland.
| |
Collapse
|
22
|
Local antibiotic therapy strategies in orthopaedic trauma: Practical tips and tricks and review of the literature. Injury 2015; 46:1447-56. [PMID: 26007616 DOI: 10.1016/j.injury.2015.05.008] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/01/2015] [Indexed: 02/02/2023]
Abstract
The use of local antibiotics for the prevention of infection in the setting of open fractures and as part of the treatment of osteomyelitis is well established. Antibiotics are most commonly incorporated into polymethylmethacrylate (PMMA) cement, which can then be formed into beads, moulded to fit a bone defect or used to coat a guide wire or IM nail. Newer delivery vehicles and techniques are being evaluated to improve upon these methods. Many factors influence how local antibiotics are applied. Treatment strategies are challenging to standardise due to the variability of clinical presentations. The presence of hardware, upper versus lower extremity, healed versus non-healed fracture and quality of soft tissues overlying the affected bone, as well as patients' comorbidities all need to be considered. Despite the accepted use of local antibiotic therapy in orthopaedic trauma, high-quality evidence regarding the use of local antibiotics is lacking. Indications, techniques, dosages, types of antibiotics, elution properties and pharmacokinetics are poorly defined in the clinical setting. The purpose of our manuscript is to review current strategies and provide practical tips for local application of antibiotics in orthopaedic trauma. We focus on delivery vehicles, types of antibiotics, dosage recommendations when mixed with PMMA and indications.
Collapse
|
23
|
Martínez-Moreno J, Mura C, Merino V, Nácher A, Climente M, Merino-Sanjuán M. Study of the Influence of Bone Cement Type and Mixing Method on the Bioactivity and the Elution Kinetics of Ciprofloxacin. J Arthroplasty 2015; 30:1243-9. [PMID: 25743107 DOI: 10.1016/j.arth.2015.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/20/2015] [Accepted: 02/11/2015] [Indexed: 02/01/2023] Open
Abstract
The objectives of this study were to examine ciprofloxacin release from three trademarks of bone cements (Simplex®, Lima® and Palacos®) and its bioactivity using as variables, the mixing method, the chemical form of the antibiotic and the antibiotic combination. The antibiotic amount released in base form represents 35% of antibiotic amount released when hydrochloride form is incorporated. Moreover, the combination (vancomycin and ciprofloxacin) shows a stronger release (132%) than hydrochloride ciprofloxacin alone. Three cements show equal drug release profile (P > 0.05). A bioactivity simulation exercise showed that until 72 hours post-surgery, ciprofloxacin concentrations in the implant would be higher than 0.1 μg/mL in 100% of the patients. After drain removal, it is expected that bioactivity would increase since drug clearance from implant would decrease.
Collapse
Affiliation(s)
- Javier Martínez-Moreno
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnológico, Centro Mixto Universidad Politécnica de Valencia-Universidad de Valencia, Spain; Servicio de Farmacia, Hospital Universitario Doctor Peset de Valencia, Spain
| | - Carla Mura
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnológico, Centro Mixto Universidad Politécnica de Valencia-Universidad de Valencia, Spain
| | - Virginia Merino
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnológico, Centro Mixto Universidad Politécnica de Valencia-Universidad de Valencia, Spain
| | - Amparo Nácher
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnológico, Centro Mixto Universidad Politécnica de Valencia-Universidad de Valencia, Spain
| | - Mónica Climente
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Valencia, Spain; Servicio de Farmacia, Hospital Universitario Doctor Peset de Valencia, Spain
| | - Matilde Merino-Sanjuán
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnológico, Centro Mixto Universidad Politécnica de Valencia-Universidad de Valencia, Spain
| |
Collapse
|
24
|
Lee HS, Chang JH. Antimicrobial spine-bone cement with caffeic acid phenethyl ester for controlled release formulation and in vivo biological assessments. MEDCHEMCOMM 2015. [DOI: 10.1039/c4md00272e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The work reports the preparation of antimicrobial spine-bone-cement with a highly controlled release formulation that was subjected to tests, involvingin vitroandin vivobiological assessments such as antimicrobial effects, a cytotoxicity test, a bacterial reverse mutation (Ames) assay, a micronucleus assay, and implantation analysis.
Collapse
Affiliation(s)
- Hye Sun Lee
- Korea Institute of Ceramic Engineering and Technology
- Seoul 153-801
- Korea
| | - Jeong Ho Chang
- Korea Institute of Ceramic Engineering and Technology
- Seoul 153-801
- Korea
| |
Collapse
|
25
|
Mechanical evaluation of hip cement spacer reinforcement with stainless steel Kirschner wires, titanium and carbon rods, and stainless steel mesh. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 25:489-96. [DOI: 10.1007/s00590-014-1567-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
|
26
|
Brochu ABW, Matthys OB, Craig SL, Reichert WM. Extended fatigue life of a catalyst free self-healing acrylic bone cement using microencapsulated 2-octyl cyanoacrylate. J Biomed Mater Res B Appl Biomater 2014; 103:305-12. [PMID: 24825796 DOI: 10.1002/jbm.b.33199] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/30/2014] [Accepted: 04/12/2014] [Indexed: 11/12/2022]
Abstract
The tissue adhesive 2-octyl cyanoacrylate (OCA) was encapsulated in polyurethane microshells and incorporated into bone cement to form a catalyst free, self-healing bone cement comprised of all clinically approved components. The bending strength, modulus, and fatigue lifetime were investigated in accordance with ASTM and ISO standards for the testing of PMMA bone cement. The bending strength of bone cement specimens decreased with increasing wt % capsules content for capsules without or with OCA, with specimens of <5 wt % capsule content showing minimal effect. In contrast, bone cement bending modulus was insensitive to capsule content. Load controlled fatigue testing was performed in air at room temperature on capsule free bone cement (0 wt %), bone cement with 5 wt % OCA-free capsules (5 wt % No OCA), and 5 wt % OCA-containing capsules (5 wt % OCA). Specimens were tested at a frequency of 5 Hz at maximum stresses of 90%, 80%, 70%, and 50% of each specimen's bending strength until failure. The 5 wt % OCA exhibited significant self-healing at 70% and 50% of its reference strength (p < 0.05). Fatigue testing of all three specimen types in air at 22 MPa (50% of reference strength of the 5 wt % OCA specimens) showed that the cycles to failure of OCA-containing specimens was increased by two-fold compared with the OCA-free and capsule-free specimens. This study represents the first demonstration of dynamic, catalyst free self-healing in a biomaterial formulation.
Collapse
Affiliation(s)
- Alice B W Brochu
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, 27708
| | | | | | | |
Collapse
|
27
|
Sanz-Ruiz P, Paz E, Abenojar J, Carlos del Real J, Vaquero J, Forriol F. Effects of vancomycin, cefazolin and test conditions on the wear behavior of bone cement. J Arthroplasty 2014; 29:16-22. [PMID: 23702270 DOI: 10.1016/j.arth.2013.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 04/08/2013] [Accepted: 04/11/2013] [Indexed: 02/01/2023] Open
Abstract
Antibiotic cement has been recommended in the treatment of prosthetic infections. The purpose of this study was to investigate the mechanical behavioral changes in cement loaded with two antibiotics, vancomycin and cefazolin, in dry and liquid medium. Six groups and four study conditions were established according to the doses of antibiotic used and the ageing (immersion in phosphate buffered saline) of the samples. Properties evaluated were friction coefficient and wear. Samples in dry medium showed higher wears than in liquid. Antibiotic selection did not influence wear properties tested in dry conditions, however, in liquid medium, there were higher frictional coefficients and wear for cefazolin loaded cement after one week and for vancomycin and cefazolin after one month. The results suggest that antibiotic cements behave differently in liquid and that the molecular characteristics of antibiotics are essential for determining this influence.
Collapse
Affiliation(s)
- Pablo Sanz-Ruiz
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
| | | | | | | | | | | |
Collapse
|
28
|
Sanz-Ruiz P, Paz E, Abenojar J, del Real J, Forriol F, Vaquero J. Influence of the physiological medium on the mechanical properties of bone cement: Can current studies be extrapolated? ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.recote.2014.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
29
|
Sanz-Ruiz P, Paz E, Abenojar J, Del Real JC, Forriol F, Vaquero J. [Influence of the physiological medium on the mechanical properties of bone cement: can current studies be extrapolated?]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 58:3-10. [PMID: 24295826 DOI: 10.1016/j.recot.2013.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 09/07/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE The use of bone cement is widespread in orthopaedic surgery. Most of the mechanical tests are performed in dry medium, making it difficult to extrapolate the results. The objective of this study is to assess if the mechanical properties of polymethylmethacrylate (PMMA), obtained in previous reports, are still present in a liquid medium. MATERIAL AND METHOD An experimental study was designed with antibiotic (vancomycin) loaded PMMA. Four groups were defined according to the medium (dry or liquid) and the pre-conditioning in liquid medium (one week or one month). Wear and flexural strength tests were performed according to ASTM and ISO standards. Volumetric wear, friction coefficient, tensile strength, and Young's modulus were analyzed. All samples were examined by scanning electron microscopy. RESULTS The samples tested in liquid medium showed lower wear and flexural strength values (P<.05). The kind of wear was modified from abrasive to adhesive in those samples studied in liquid medium. The samples with a pre-conditioning time showed lower values of wear (P<.05). CONCLUSIONS Caution is recommended when extrapolating the results of previous PMMA results. The different mechanical strength of the cement in a liquid medium, observed in saline medium, is much closer to the clinical situation.
Collapse
Affiliation(s)
- P Sanz-Ruiz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - E Paz
- Instituto para la investigación tecnológica, Departamento de ingeniería mecánica, Universidad Pontificia Comillas, Madrid, España
| | - J Abenojar
- Grupo desarrollo materiales, Departamento de ingeniería y ciencia de materiales, Universidad Carlos III, Madrid, España
| | - J C Del Real
- Instituto para la investigación tecnológica, Departamento de ingeniería mecánica, Universidad Pontificia Comillas, Madrid, España
| | - F Forriol
- Facultad de Medicina, Universidad San Pablo CEU, Madrid, España
| | - J Vaquero
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, España
| |
Collapse
|
30
|
Antibiotic-loaded acrylic bone cements: an in vitro study on the release mechanism and its efficacy. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2013; 33:3025-32. [PMID: 23623128 DOI: 10.1016/j.msec.2013.03.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 01/22/2013] [Accepted: 03/18/2013] [Indexed: 11/22/2022]
Abstract
An in vitro study was carried out in order to investigate the antibiotic release mechanism and the antibacterial properties of commercially (Palacos® R+G and Palacos® LV+G) and manually (Palacos® R+GM and Palacos® LV+GM) blended gentamicin-loaded bone cements. Samples were characterized by means of scanning electron microscopy (SEM) and compression strength was evaluated. The antibiotic release was investigated by dipping sample in simulated body fluid (SBF) and periodically analyzing the solution by means of high pressure liquid chromatography (HPLC). Different antibacterial tests were performed to investigate the possible influence of blending technique on antibacterial properties. Only some differences were observed between gentamicin manually added and commercial ones, in the release curves, while the antibacterial effect and the mechanical properties seem to not feel the blending technique.
Collapse
|
31
|
|
32
|
Shearwood-Porter N, Browne M, Sinclair I. Micromechanical characterisation of failure in acrylic bone cement: The effect of barium sulphate agglomerates. J Mech Behav Biomed Mater 2012; 13:85-92. [DOI: 10.1016/j.jmbbm.2012.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 04/05/2012] [Accepted: 04/12/2012] [Indexed: 11/16/2022]
|
33
|
Giavaresi G, Bertazzoni Minelli E, Sartori M, Benini A, Parrilli A, Maltarello MC, Salamanna F, Torricelli P, Giardino R, Fini M. New PMMA-based composites for preparing spacer devices in prosthetic infections. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2012; 23:1247-1257. [PMID: 22359213 DOI: 10.1007/s10856-012-4585-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 02/10/2012] [Indexed: 05/31/2023]
Abstract
Even though the systemic antibiotic therapy is usually applied after prosthetic infections surgical treatments, it is unable to reach the infection site in sufficient concentrations to eradicate bacteria. Delivering antibiotics locally with the use of custom made device (spacer or nail coating) might eradicate or reduce the infection and the risk of recolonization, providing a very high concentration of antibiotic. PMMA-based (Mendec Spine) composites with BaSO(4) were enriched with β-tricalcium phosphate (Porosectan-TCP) or only a slightly higher BaSO(4) concentration (Porosectan-BaSO(4)) to obtain higher porosity. The aim of the study was to evaluate: (i) drug absorption capability and drug release kinetics in vitro soaking them with a combined solution of gentamicin and vancomycin, (ii) their in vitro and in vivo biocompatibility, and finally, (iii) they were tested preliminarily in an experimental model of bone infection. The simultaneous presence of β-TCP and BaSO(4) resulted in the formation of a texture of interconnecting channels with different diameters, from a few microns to several hundred microns, which totally filled the material. The porosity, determined by microcomputed tomography, was significantly higher in both tested plain composites (Porosectan-TCP: +17.3%; Porosectan-BaSO(4): +7.5%) in comparison to control composite material (Mendec Spine). The kinetics of antibiotic release from composites was rapid and complete, producing high drug concentrations for a short period of time. Both composites showed a good level of biocompatibility. The osteomyelitic model confirmed that both composites, soaked in antibiotic solution, were able to cure bone infection. These composites could be useful for preparing devices for prosthetic joint infections treatment also allowing the use of antibiotics solution at required concentrations.
Collapse
Affiliation(s)
- Gianluca Giavaresi
- Laboratory of Preclinical and Surgical Studies, Rizzoli Orthopaedic Institute IRCCS, via di Barbiano 1/10, 40136 Bologna, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Giavaresi G, Bertazzoni Minelli E, Sartori M, Benini A, Della Bora T, Sambri V, Gaibani P, Borsari V, Salamanna F, Martini L, Nicoli Aldini N, Fini M. Microbiological and pharmacological tests on new antibiotic-loaded PMMA-based composites for the treatment of osteomyelitis. J Orthop Res 2012; 30:348-55. [PMID: 21882237 DOI: 10.1002/jor.21531] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 07/29/2011] [Indexed: 02/04/2023]
Abstract
Local antibiotic diffusion in rabbit femurs from two new PMMA-based and nail-shaped composites, enriched with β-tricalcium phosphate (P-TCP) and BaSO(4) or only with BaSO(4) (P-BaSO(4) ), and soaked in a solution of gentamicin (G) and vancomycin (V) was studied. Nails were implanted into the intramedullary cavity of healthy and osteomyelitic femurs to study the resolution of infection and to quantify the antibiotic penetration into bone by microbiological, pharmacological, and histological tests. A significant progression of osteomyelitis was recorded 7 weeks after MRSA inoculation, whereas no bacteria were found in animals treated with antibiotic-loaded nails as confirmed by microbiology and histology (Smeltzer score). The release of both antibiotics from composites was high and prompt both in healthy and infected bone; the amount of V was higher than that of G in all bone samples. Antibiotics of both composites were still present in bone 3 weeks after nail implantation. The P-BaSO4 composite released a lower amount of antibiotics than did P-TCP. The G-V combination in vivo exerted a synergistic bactericidal effect, which was confirmed by microbiological, histological, and clinical results (no infection). These new porous PMMA composites, soaked in G-V solution in the operating room, might be an effective and useful drug delivery system for osteomyelitis treatment.
Collapse
Affiliation(s)
- Gianluca Giavaresi
- Laboratory of Preclinical and Surgical Studies, Rizzoli Orthopaedic Institute IRCCS, via di Barbiano 1/10, 40136, Bologna, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Laine JC, Nguyen TQD, Buckley JM, Kim HT. Effects of mixing techniques on vancomycin-impregnated polymethylmethacrylate. J Arthroplasty 2011; 26:1562-6. [PMID: 21474275 DOI: 10.1016/j.arth.2011.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 02/07/2011] [Indexed: 02/01/2023] Open
Abstract
The use of antibiotic-impregnated polymethylmethacrylate in joint arthroplasty is widespread. The Food and Drug Administration has approved commercially prepared antibiotic bone cement, but in a climate of increasingly drug-resistant bacteria, orthopedic surgeons often hand-mix their own. A recent study reported the effects on drug elution of different mixing methods designed to decrease antibiotic particle size and distribute those particles more uniformly. Theoretically, these mixing techniques could also improve antibiotic cement strength; however, the actual effects of these techniques on cement strength are undefined. In the present study, 3 different methods of mixing vancomycin with bone cement were compared. We conclude that the addition of vancomycin to polymethylmethacrylate at commonly accepted concentrations does substantially decrease cement strength and that more complex mixing techniques do not improve cement strength significantly.
Collapse
Affiliation(s)
- Jennifer C Laine
- Department of Orthopaedic Surgery, University of California, San Francisco, California 94143, USA
| | | | | | | |
Collapse
|
36
|
Pountos I, Georgouli T, Bird H, Kontakis G, Giannoudis PV. The effect of antibiotics on bone healing: current evidence. Expert Opin Drug Saf 2011; 10:935-45. [DOI: 10.1517/14740338.2011.589833] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
37
|
Bistolfi A, Massazza G, Verné E, Massè A, Deledda D, Ferraris S, Miola M, Galetto F, Crova M. Antibiotic-loaded cement in orthopedic surgery: a review. ISRN ORTHOPEDICS 2011; 2011:290851. [PMID: 24977058 PMCID: PMC4063209 DOI: 10.5402/2011/290851] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 05/27/2011] [Indexed: 01/05/2023]
Abstract
Infections in orthopaedic surgery are a serious issue. Antibiotic-loaded bone cement was developed for the treatment of infected joint arthroplasties and for prophylaxes in total joint replacement in selected cases. Despite the widespread use of the antibiotic-loaded bone cement in orthopedics, many issues are still unclear or controversial: bacterial adhesion and antibiotic resistance, modification of mechanical properties which follows the addition of the antibiotic, factors influencing the release of the antibiotic from the cement and the role of the surface, the method for mixing the cement and the antibiotic, the choice and the effectiveness of the antibiotic, the combination of two or more antibiotics, and the toxicity. This review discusses all these topics, focusing on properties, merits, and defects of the antibiotic loaded cement. The final objective is to provide the orthopaedic surgeons clear and concise information for the correct choice of cement in their clinical practice.
Collapse
Affiliation(s)
- Alessandro Bistolfi
- Department of Orthopedics and Traumatology, AO CTO Hospital, Turin, Italy ; c/o AO CTO/M. Adelaide, Via Zuretti 29, 10126 Torino, Italy
| | - Giuseppe Massazza
- Department of Orthopedics and Traumatology, AO CTO Hospital, Turin, Italy ; c/o AO CTO/M. Adelaide, Via Zuretti 29, 10126 Torino, Italy ; University of the Studies of Turin, Turin, Italy
| | - Enrica Verné
- Materials Science and Chemical Engineering Department, Polytechnic of Turin, C.so Duca degli Abruzzi, 24-10129 Turin, Italy
| | - Alessandro Massè
- University of the Studies of Turin, Turin, Italy ; Department of Clinical and Biological Sciences, c/o S. Luigi Hospital, Regione Gonzole, 10-10043 Orbassano, Italy
| | - Davide Deledda
- c/o AO CTO/M. Adelaide, Via Zuretti 29, 10126 Torino, Italy ; University of the Studies of Turin, Turin, Italy
| | - Sara Ferraris
- Materials Science and Chemical Engineering Department, Polytechnic of Turin, C.so Duca degli Abruzzi, 24-10129 Turin, Italy
| | - Marta Miola
- Materials Science and Chemical Engineering Department, Polytechnic of Turin, C.so Duca degli Abruzzi, 24-10129 Turin, Italy
| | - Fabrizio Galetto
- Department of Orthopedics and Traumatology, AO CTO Hospital, Turin, Italy ; c/o AO CTO/M. Adelaide, Via Zuretti 29, 10126 Torino, Italy
| | - Maurizio Crova
- Department of Orthopedics and Traumatology, AO CTO Hospital, Turin, Italy ; c/o AO CTO/M. Adelaide, Via Zuretti 29, 10126 Torino, Italy ; University of the Studies of Turin, Turin, Italy
| |
Collapse
|
38
|
Rogers BA, Middleton FR, Shearwood-Porter N, Kinch S, Roques A, Bradley NW, Browne M. Does cyclical loading affect the elution of antibiotics from articulating cement knee spacers? ACTA ACUST UNITED AC 2011; 93:914-20. [DOI: 10.1302/0301-620x.93b7.25890] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Two-stage revision surgery for infected total knee replacement offers the highest rate of success for the elimination of infection. The use of articulating antibiotic-laden cement spacers during the first stage to eradicate infection also allows protection of the soft tissues against excessive scarring and stiffness. We have investigated the effect of cyclical loading of cement spacers on the elution of antibiotics. Femoral and tibial spacers containing vancomycin at a constant concentration and tobramycin of varying concentrations were studied in vitro. The specimens were immersed and loaded cyclically to 250 N, with a flexion excursion of 45°, for 35 000 cycles. The buffered solution was sampled at set intervals and the antibiotic concentration was established so that the elution could be calculated. Unloaded samples were used as a control group for statistical comparison. The elution of tobramycin increased proportionately with its concentration in cement and was significantly higher at all sampling times from five minutes to 1680 minutes in loaded components compared with the control group (p = 0.021 and p = 0.003, respectively). A similar trend was observed with elution of vancomycin, but this failed to reach statistical significance at five, 1320 and 1560 minutes (p = 0.0508, p = 0.067 and p = 0.347, respectively). However, cyclically loaded and control components showed an increased elution of vancomycin with increasing tobramycin concentration in the specimens, despite all components having the same vancomycin concentration. The concentration of tobramycin influences both tobramycin and vancomycin elution from bone cement. Cyclical loading of the cement spacers enhanced the elution of vancomycin and tobramycin.
Collapse
Affiliation(s)
- B. A. Rogers
- Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, Canada M5G 1XS
| | - F. R. Middleton
- Kingston Hospital NHS Trust, Galsworthy Road, Kingston Upon Thames, Surrey KT2 7QB, UK
| | - N. Shearwood-Porter
- School of Engineering Sciences, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - S. Kinch
- School of Engineering Sciences, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - A. Roques
- Aurora Medical Ltd, Kenneth Dibben House, Enterprise Road, Southampton Science Park, Chilworth, Southampton SO16 7NS, UK
| | - N. W. Bradley
- The Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - M. Browne
- School of Engineering Sciences, University of Southampton, University Road, Southampton SO17 1BJ, UK
| |
Collapse
|
39
|
Patti BN, Lindeque BGP. Antibiotic-loaded acrylic bone cement in the revision of septic arthroplasty: where's the evidence? Orthopedics 2011; 34:210. [PMID: 21410104 DOI: 10.3928/01477447-20110124-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Brianna N Patti
- Department of Orthopedic Surgery, University of Colorado Health Sciences Center, Denver, Colorado, USA
| | | |
Collapse
|
40
|
Mori R, Nakai T, Enomoto K, Uchio Y, Yoshino K. Increased antibiotic release from a bone cement containing bacterial cellulose. Clin Orthop Relat Res 2011; 469:600-6. [PMID: 20945120 PMCID: PMC3018194 DOI: 10.1007/s11999-010-1626-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 09/30/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Major disadvantages of antibiotic bone cements include limited drug release and reduced strength resulting from the addition of high doses of antibiotics. Bacterial cellulose, a three-dimensional hydrophilic mesh, may retain antibiotics and release them gradually. We hypothesized that the addition of cellulose to antibiotic bone cement would improve mechanical strength and antibiotic release. QUESTIONS/PURPOSES We therefore examined the mechanical strength and antibiotic release of cellulose antibiotic cement. METHODS A high dose of antibiotics (5 g per 40 g cement powder) was incorporated into bacterial cellulose and then mixed with bone cement. We compared the compression strength, fracture toughness, fatigue life, and elution kinetics of this formulation with those of plain cement and a traditional antibiotic cement. RESULTS The average values for compression strength, fracture toughness, and fatigue life of the cellulose antibiotic cement were 97%, 97%, and 78% of the values obtained for plain cement, respectively. The corresponding values for the traditional antibiotic cement were 79%, 82%, and 17%, respectively. The cumulative elution over 35 days was 129% greater from the cellulose antibiotic cement than from the traditional antibiotic cement. CONCLUSIONS With a high dose of antibiotics, incorporating cellulose into the bone cement prevented compression and fracture fragility, improved fatigue life, and increased antibiotic elution. CLINICAL RELEVANCE Antibiotic cements containing cellulose may have applications in clinical situations that require high levels of antibiotic release and preservation of the mechanical properties of the cement.
Collapse
Affiliation(s)
- Ryuji Mori
- Research Project Promotion Institute, Shimane University, Izumo, Shimane 693-8501 Japan
| | - Takahisa Nakai
- Faculty of Science and Engineering, Shimane University, Matsue, Shimane Japan
| | - Koichi Enomoto
- Department of Neural and Muscular Physiology, Faculty of Medicine, Shimane University, Izumo, Shimane Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Faculty of Medicine, Shimane University, Izumo, Shimane Japan
| | - Katsumi Yoshino
- Research Project Promotion Institute, Shimane University, Izumo, Shimane 693-8501 Japan ,Shimane Institute for Industrial Technology, Matsue, Shimane Japan
| |
Collapse
|
41
|
Lewis G, Brooks JL, Courtney HS, Li Y, Haggard WO. An Approach for determining antibiotic loading for a physician-directed antibiotic-loaded PMMA bone cement formulation. Clin Orthop Relat Res 2010; 468:2092-100. [PMID: 20195806 PMCID: PMC2895843 DOI: 10.1007/s11999-010-1281-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND When a physician-directed antibiotic-loaded polymethylmethacrylate (PMMA) bone cement (ALBC) formulation is used in total hip arthroplasties (THAs) and total knee arthroplasties (TKAs), current practice in the United States involves arbitrary choice of the antibiotic loading (herein defined as the ratio of the mass of the antibiotic added to the mass of the cement powder). We suggest there is a need to develop a rational method for determining this loading. QUESTIONS/PURPOSES We propose a new method for determining the antibiotic loading to use when preparing a physician-directed ALBC formulation and illustrate this method using three in vitro properties of an ALBC in which the antibiotic was daptomycin. MATERIALS AND METHODS Daptomycin was blended with the powder of the cement using a mechanical mixer. We performed fatigue, elution, and activity tests on three sets of specimens having daptomycin loadings of 2.25, 4.50, and 11.00 wt/wt%. Correlational analyses of the results of these tests were used in conjunction with stated constraints and a nonlinear optimization method to determine the daptomycin loading to use. RESULTS With an increase in daptomycin loading, the estimated mean fatigue limit of the cement decreased, the estimated elution rate of the antibiotic increased, and the percentage inhibition of staphylococcal growth by the eluate remained unchanged at 100%. For a daptomycin-loaded PMMA bone cement we computed the optimum amount of daptomycin to mechanically blend with 40 g of cement powder is 1.36 g. CONCLUSIONS We suggest an approach that may be used to determine the amount of antibiotic to blend with the powder of a PMMA bone cement when preparing a physician-directed ALBC formulation, and highlighted the attractions and limitations of this approach. CLINICAL RELEVANCE When a physician-directed ALBC formulation is selected for use in a TKA or THA, the approach we detail may be employed to determine the antibiotic loading to use rather than the empirical approach that is taken in current clinical practice.
Collapse
Affiliation(s)
- Gladius Lewis
- Department of Mechanical Engineering, The University of Memphis, Memphis, TN USA
| | - Jennifer L. Brooks
- Department of Biomedical Engineering, The University of Memphis, Memphis, TN USA
| | - Harry S. Courtney
- Veterans Affairs Medical Center and Department of Medicine, University of Tennessee Health Science Center, Memphis, TN USA
| | - Yuan Li
- Department of Mechanical Engineering, The University of Memphis, Memphis, TN USA
| | - Warren O. Haggard
- Department of Biomedical Engineering, The University of Memphis, Memphis, TN USA
| |
Collapse
|
42
|
Abstract
Acrylic bone cements are in extensive use in joint replacement surgery. They are weight bearing and load transferring in the bone-cement-prosthesis complex and therefore, inter alia, their mechanical properties are deemed to be crucial for the overall outcome. In spite of adequate preclinical test results according to the current specifications (ISO, ASTM), cements with inferior clinical results have appeared on the market. The aim of this study was to investigate whether it is possible to predict the long term clinical performance of acrylic bone cement on the basis of mechanical in vitro testing. We performed in vitro quasistatic testing of cement after aging in different media and at different temperatures for up to 5 years. Dynamic creep testing and testing of retrieved cement were also performed. Testing under dry conditions, as required in current standards, always gave higher values for mechanical properties than did storage and testing under more physiological conditions. We could demonstrate a continuous increase in mechanical properties when testing in air, while testing in water resulted in a slight decrease in mechanical properties after 1 week and then levelled out. Palacos bone cement showed a higher creep than CMW3G and the retrieved Boneloc specimens showed a higher creep than retrieved Palacos. The strength of a bone cement develops more slowly than the apparent high initial setting rate indicates and there are changes in mechanical properties over a period of five years. The effect of water absorption is important for the physical properties but the mechanical changes caused by physical aging are still present after immersion in water. The established standards are in need of more clinically relevant test methods and their associated requirements need better definition. We recommend that testing of bone cements should be performed after extended aging under simulated physiological conditions. Simple quasistatic and dynamic creep tests seem unable to predict clinical performance of acrylic bone cements when the products under test are chemically very similar. However, such testing might be clinically relevant if the cements exhibit substantial differences.
Collapse
Affiliation(s)
- Markus Nottrott
- Centre for Bone- and Soft tissue Tumours, Department of Orthopaedic Surgery, Haukeland University Hospital, NO-5021 Bergen, Norway.
| |
Collapse
|
43
|
Abstract
Polymethylmethacrylate (PMMA) has been used in orthopaedics since the 1940s. Despite the development and popularity of new biomaterials, PMMA remains popular. Although its basic components remain the same, small proprietary and environmental changes create variations in its properties. PMMA can serve as a spacer and as a delivery vehicle for antibiotics, and it can be placed to eliminate dead space. Endogenous and exogenous variables that affect its performance include component variables, air, temperature, and handling and mixing. PMMA is used in hip arthroplasty and vertebral augmentation, notably, vertebroplasty and kyphoplasty. Cardiopulmonary complications have been reported.
Collapse
|
44
|
McLaren AC, Nugent M, Economopoulos K, Kaul H, Vernon BL, McLemore R. Hand-mixed and premixed antibiotic-loaded bone cement have similar homogeneity. Clin Orthop Relat Res 2009; 467:1693-8. [PMID: 19390905 PMCID: PMC2690765 DOI: 10.1007/s11999-009-0847-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 04/07/2009] [Indexed: 01/31/2023]
Abstract
Since low-dose antibiotic-loaded bone cement (ALBC) was approved by the FDA for second-stage reimplantation after infected arthroplasties in 2003, commercially premixed low-dose ALBC has become available in the United States. However, surgeons continue to mix ALBC by hand. We presumed hand-mixed ALBC was not as homogeneous as commercially premixed ALBC. We assessed homogeneity by determining the variation in antibiotic elution by location in a batch, from premixed and hand-mixed formulations of low-dose ALBC. Four hand-mixed methodologies were used: (1) suspension--antibiotic powder in the liquid monomer; (2) no-mix--antibiotic powder added but not mixed with the polymer powder before adding monomer; (3) hand-stirred--antibiotic powder stirred into the polymer powder before the monomer was added; and (4) bowl-mix--antibiotic powder mixed into polymer powder using a commercial mixing bowl before the monomer was added. Antibiotic elution was measured using the Kirby-Bauer bioassay. None of the mixing methods had consistently dissimilar homogeneity of antibiotic distribution from the others. Based upon our data we conclude hand-mixed low-dose ALBC is not less homogeneous than commercially premixed formulations.
Collapse
Affiliation(s)
- Alex C. McLaren
- Banner Good Samaritan Medical Center, 300 N 12th Street, Suite 620, Phoenix, AZ 85006
USA ,Center for Interventional Biomaterials, Harrington Department of Bioengineering, Arizona State University, Tempe, AZ USA
| | - Matt Nugent
- Banner Good Samaritan Medical Center, 300 N 12th Street, Suite 620, Phoenix, AZ 85006
USA
| | - Kostas Economopoulos
- Banner Good Samaritan Medical Center, 300 N 12th Street, Suite 620, Phoenix, AZ 85006
USA
| | - Himanshu Kaul
- Banner Good Samaritan Medical Center, 300 N 12th Street, Suite 620, Phoenix, AZ 85006
USA ,Center for Interventional Biomaterials, Harrington Department of Bioengineering, Arizona State University, Tempe, AZ USA
| | - Brent L. Vernon
- Center for Interventional Biomaterials, Harrington Department of Bioengineering, Arizona State University, Tempe, AZ USA
| | - Ryan McLemore
- Banner Good Samaritan Medical Center, 300 N 12th Street, Suite 620, Phoenix, AZ 85006
USA ,Center for Interventional Biomaterials, Harrington Department of Bioengineering, Arizona State University, Tempe, AZ USA
| |
Collapse
|
45
|
Abstract
STUDY DESIGN Three noncontiguous spinal implant sites in 1 rabbit were challenged with Staphylococcus aureus and local antibiotic prophylaxis was given with gentamicin in controlled-release microspheres (poly(lactic-coglycolic-acid) [PLGA]). Postoperative biomaterial-centered infection on and around the titanium rods was assessed using standard bacterial quantification essays. OBJECTIVE To assess surgical site and biomaterial-centered infection reduction with controlled release gentamicin from microspheres against S. aureus. SUMMARY OF BACKGROUND DATA A postoperative biomaterial-centered infection can be devastating after successful thoracolumbar spinal surgery and puts a high burden on patients, families, surgeons, and hospitals, endangering both our healthcare budget and our ability to perform challenging cases in patients with increasing numbers of comorbidities. Systemic antibiotics often do not reach "dead-space" hematomas where bacteria harbor after surgery, whereas local, controlled release gentamicin prophylaxis through PLGA microspheres showed favorable pharmacokinetics data to achieve local bactericidal concentrations for up to 7 days after surgery. METHODS A well published rabbit spinal implant model with systemic cephalosporin prophylaxis was challenged to create a baseline infection of approximately 70% in control sites. We then challenged 3 noncontiguous titanium rods inside the laminectomy defect with 10e6 colony forming units S. aureus and randomly treated 2 sites with gentamicin PLGA microspheres and 1 site with PLGA carrier only (control). Standard quantification techniques were used to assess biomaterial centered and soft tissue bacterial growth after 7 days. RESULTS After establishing reliable infection rates in control sites, the therapeutic arm of the study was started. Surgical site infections were found in 75% of control sites, whereas gentamicin microspheres reduced the incidence down to 38% in the same rabbits. Biomaterial-centered infection was reduced from 58% to 23% only in all sites challenged with 10e6 S. aureus. CONCLUSION Postoperative, biomaterial-centered infection was reduced at least 50% with intraoperative gentamicin microspheres in the face of systemic cephalosporin prophylaxis and high dose S. aureus in a laminectomy defect in rabbits. The data are statistically and clinically significant, and further animal testing is planned to confirm these results.
Collapse
|
46
|
Nottrott M, Mølster AO, Moldestad IO, Walsh WR, Gjerdet NR. Performance of bone cements: are current preclinical specifications adequate? Acta Orthop 2008; 79:826-31. [PMID: 19085502 DOI: 10.1080/17453670810016920] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Current specifications (standards) for preclinical testing of bone cements (ISO 5833: 2002, ASTM F451-99a) require simple mechanical testing after ageing for 24 h under dry conditions at 23 degrees C. Some bone cements have fulfilled the requirements in the specifications, and yet had inferior clinical results. Clinically, bone cements are subjected to complex loading patterns in a moist or wet environment at 37 degrees C. Thus, both the validity and the robustness of current standard testing protocols can be questioned. METHODS We examined the influence of temperature and storage medium on the properties of bone cement. We also compared the results of storage and testing under standard conditions of 23 degrees C in dry air, with the results obtained at 37 degrees C in water or plasma. RESULTS The dry specimens showed an increase in strength and elastic modulus with time, while the values of the wet ones decreased. There was no difference between specimens stored in water or in plasma. Ultimate compressive strength of dry specimens after 24 h was 1.16 times higher than that of the ones stored wet, increasing to 1.34 times after 1 month, and 1.46 times after 6 months (p<0.001 for all comparisons). INTERPRETATION Testing under dry conditions-as required in current standards-always gave higher values for mechanical properties than did storage and testing under more physiological conditions. The sensitivity of test values to different environments implies that testing conditions for bone cements should be scrutinized in order to develop more relevant testing protocols that reflect the in vivo environment more closely.
Collapse
Affiliation(s)
- Markus Nottrott
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
| | | | | | | | | |
Collapse
|
47
|
Lewis G. Properties of antibiotic‐loaded acrylic bone cements for use in cemented arthroplasties: A state‐of‐the‐art review. J Biomed Mater Res B Appl Biomater 2008; 89:558-574. [DOI: 10.1002/jbm.b.31220] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Gladius Lewis
- Department of Mechanical Engineering, The University of Memphis, Memphis, Tennessee 38152
| |
Collapse
|
48
|
Dunne NJ, Hill J, McAfee P, Kirkpatrick R, Patrick S, Tunney M. Incorporation of large amounts of gentamicin sulphate into acrylic bone cement: Effect on handling and mechanical properties, antibiotic release, and biofilm formation. Proc Inst Mech Eng H 2008; 222:355-65. [DOI: 10.1243/09544119jeim355] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Bacterial infection remains a significant complication following total joint replacement. If infection is suspected when revision surgery is being performed, a large dose of antibiotic, usually gentamicin sulphate, is often blended with the acrylic bone cement powder in an attempt to reduce the risk of recurrent infection. In this in-vitro study the effect of small and large doses of gentamicin sulphate on the handling and mechanical properties of the cement, gentamicin release from the cement, and in-vitro biofilm formation by clinical Staphylococcus spp. isolates on the cement was determined. An increase in gentamicin loading of 1, 2, 3, or 4 g, in a cement powder mass of 40 g, resulted in a significant decrease in the compressive and four-point bending strength, but a significant increase in the amount of gentamicin released over a 72 h period. When overt infection was modelled, using Staphylococcus spp. clinical isolates at an inoculum of 1×107 colony-forming units/ml, an increase in the amount of gentamicin (1, 2, 3, or 4 g) added to 40 g of poly(methyl methacrylate) cement resulted in an initial decrease in bacterial colonization but this beneficial effect was no longer apparent by 72 h, with the bacterial strains forming biofilms on the cements despite the release of high levels of gentamicin. The findings suggest that orthopaedic surgeons should carefully consider the clinical consequences of blending large doses (1 g or more per 40 g of poly(methyl methacrylate)) of gentamicin into Palacos® R bone cement for use in revision surgery as the increased gentamicin loading does not prevent bacterial biofilm formation and the effect on the mechanical properties could be important to the longevity of the prosthetic joint.
Collapse
Affiliation(s)
- N J Dunne
- School of Mechanical and Aerospace Engineering, Queen's University Belfast, Belfast, UK
| | - J Hill
- School of Mechanical and Aerospace Engineering, Queen's University Belfast, Belfast, UK
| | - P McAfee
- School of Mechanical and Aerospace Engineering, Queen's University Belfast, Belfast, UK
| | - R Kirkpatrick
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - S Patrick
- School of Medicine and Dentistry, Queen's University Belfast, Belfast, UK
| | - M Tunney
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| |
Collapse
|
49
|
Bodde EW, Kowalski RS, Spauwen PH, Jansen JA. No Increased Bone Formation around Alendronate or Omeprazole Loaded Bioactive Bone Cements in a Femoral Defect. Tissue Eng Part A 2008; 14:29-39. [DOI: 10.1089/ten.a.2007.0086] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Esther W.H. Bodde
- Department of Periodontology and Biomaterials, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | | | - Paul H.M. Spauwen
- Department of Plastic and Reconstructive Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - John A. Jansen
- Department of Periodontology and Biomaterials, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
50
|
Dunne N, Hill J, McAfee P, Todd K, Kirkpatrick R, Tunney M, Patrick S. In vitro study of the efficacy of acrylic bone cement loaded with supplementary amounts of gentamicin: effect on mechanical properties, antibiotic release, and biofilm formation. Acta Orthop 2007; 78:774-85. [PMID: 18236183 DOI: 10.1080/17453670710014545] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Infection remains a severe complication following a total hip replacement. If infection is suspected when revision surgery is being performed, additional gentamicin is often added to the cement on an ad hoc basis in an attempt to reduce the risk of recurrent infection. METHODS AND RESULTS In this in vitro study, we determined the effect of incorporating additional gentamicin on the mechanical properties of cement. We also determined the degree of gentamicin release from cement, and also the extent to which biofilms of clinical Staphylococcus spp. isolates form on cement in vitro. When gentamicin was added to unloaded cement (1-4 g), there was a significant reduction in the mechanical performance of the loaded cements compared to unloaded cement. A significant increase in gentamicin release from the cement over 72 h was apparent, with the amount of gentamicin released increasing significantly with each additional 1 g of gentamicin added. When overt infection was modeled, the incorporation of additional gentamicin did result in an initial reduction in bacterial colonization, but this beneficial effect was no longer apparent by 72 h, with the clinical strains forming biofilms on the cements despite the release of high levels of gentamicin. INTERPRETATION Our findings indicate that the addition of large amounts of gentamicin to cement is unlikely to eradicate bacteria present as a result of an overt infection of an existing implant, and could result in failure of the prosthetic joint because of a reduction in mechanical performance of the bone cement.
Collapse
Affiliation(s)
- Nicholas Dunne
- School of Mechanical and Aerospace Engineering, Queen's University, Belfast, UK.
| | | | | | | | | | | | | |
Collapse
|