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Cianni L, Taccari F, Bocchi MB, Micheli G, Sangiorgi F, Ziranu A, Fantoni M, Maccauro G, Vitiello R. Characteristics and Epidemiology of Megaprostheses Infections: A Systematic Review. Healthcare (Basel) 2024; 12:1283. [PMID: 38998818 PMCID: PMC11241048 DOI: 10.3390/healthcare12131283] [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: 04/12/2024] [Revised: 05/18/2024] [Accepted: 06/18/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Megaprostheses were first employed in oncological orthopedic surgery, but more recently, additional applications have arisen. These implants are not without any risks and device failure is quite frequent. The most feared complication is undoubtedly the implants' infection; however, the exact incidence is still unknown. This systematic review aims to estimate in the current literature the overall incidence of megaprosthesis infections and to investigate possible risk/protective factors. METHODS We conducted a systematic search for studies published from July 1971 to December 2023 using specific keywords. To be included, studies needed to report either the megaprosthesis anatomical site, and/or whether the megaprosthesis was coated, and/or the surgical indication as oncological or non-oncological reasons. RESULTS The initial literature search resulted in 1281 studies. We evaluated 10,456 patients and the overall infection rate was 12%. In cancer patients, the infection rate was 22%, while in non-oncological patients, this was 16% (trauma 12%, mechanical failure 17%, prosthetic joint infections 26%). The overall infection rates comparing coated and uncoated implants were 10% and 12.5%, respectively. CONCLUSIONS The number of megaprosthesis implants is increasing considerably. In traumatological patients, the infection rate is lower compared to all the other subgroups, while the infection rate remains higher in the cancer patient group. As these devices become more common, focused studies exploring epidemiological data, clinical outcomes, and long-term complications are needed to address the uncertainties in prevention and management.
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Affiliation(s)
- Luigi Cianni
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco Taccari
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Beatrice Bocchi
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulia Micheli
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Flavio Sangiorgi
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Ziranu
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Ospedale Isola Tiberina-Gemelli Isola, 00186 Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giulio Maccauro
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Raffaele Vitiello
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Andreani L, Ipponi E, Varchetta G, Ruinato AD, De-Franco S, Campo FR, D'Arienzo A. Topical Application of Vancomycin Powder to Prevent Infections after Massive Bone Resection and the implantation of Megaprostheses in Orthopaedic Oncology Surgery. Malays Orthop J 2024; 18:125-132. [PMID: 38638658 PMCID: PMC11023351 DOI: 10.5704/moj.2403.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 10/06/2023] [Indexed: 04/20/2024] Open
Abstract
Introduction Periprosthetic joint infection (PJI) represents a serious burden in orthopaedic oncology. Through the years, several local expedients have been proposed to minimise the risk of periprosthetic infection. In this study, we report our outcomes using topical vancomycin powder (VP) with the aim to prevent PJIs. Materials and methods Fifty oncological cases treated with massive bone resection and the implant of a megaprosthesis were included in our study. Among them, 22 [(GGroup A) received one gram of vancomycin powder on the surface of the implant and another gram on the surface of the muscular fascia]. The remaining 28 did not receive such a treatment (Group B). The rest of surgical procedures and the follow-up were the same for the two groups. Patients underwent periodical outpatient visits, radiographs and blood exams' evaluations. Diagnosis of PJIs and adverse reactions to topical vancomycin were recorded. Results None of the cases treated with topical vancomycin developed infections, whereas 6 of the 28 cases (21.4%) who did not receive the powder suffered from PJIs. These outcomes suggest that cases treated with VP had a significantly lower risk of post-operative PJI (p=0.028). None of our cases developed acute kidney failures or any other complication directly or indirectly attributable to the local administration of VP. Conclusions The topical use of vancomycin powder on megaprosthetic surfaces and the overlying fascias, alongside with a correct endovenous antibiotic prophylaxis, can represent a promising approach in order to minimise the risk of periprosthetic infections in orthopaedic oncology surgery.
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Affiliation(s)
- L Andreani
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - E Ipponi
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - G Varchetta
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - A D Ruinato
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - S De-Franco
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - F R Campo
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - A D'Arienzo
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
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Andreani L, Ipponi E, Falcinelli F, Cordoni M, Bechini E, Vannucci L, D’Arienzo A, Capanna R. Proximal Femur Megaprostheses in Orthopedic Oncology: Evaluation of a Standardized Post-operative Rehabilitation Protocol. Indian J Orthop 2024; 58:323-329. [PMID: 38425819 PMCID: PMC10899131 DOI: 10.1007/s43465-023-01092-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/25/2023] [Indexed: 03/02/2024]
Abstract
Background Reconstructions of the proximal femur after massive resections represent one of the main challenges in orthopedic oncology. Among the possible treatments, megaprostheses represent one of the most used and reliable reconstructive approaches. Although literature about their outcomes has flourished through the last decades, a consensus rehabilitative treatment is still far from being established. Materials and methods We evaluated the functional results of all our oncologic cases treated between 2016 and 2022 that could follow our standardized post-operative rehabilitative approach, consisting in progressive hip mobilization and early weight-bearing. Results Twenty-two cases were included in our study. On average, their hospitalization lasted 15.1 days. The seated position was achieved on average within 3.7 days after surgery, the standing position reached 5.4 after surgery, while assisted deambulation was started 6.4 days after surgery. After a mean post-operative follow-up of 44.0 months, our patients' mean MSTS score was 23.2 (10-30). Our data suggested a statistically significant inverse linear correlation between post-operative functionality and patients' age, resection length, and the start of deambulation. Conclusions A correct rehabilitation, focused on early mobilization and progressive weight-bearing, is crucial to maximize patients' post-operative functional outcomes.
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Affiliation(s)
- Lorenzo Andreani
- Department of Orthopedics and Trauma Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Edoardo Ipponi
- Department of Orthopedics and Trauma Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Federico Falcinelli
- Department of Orthopedics and Trauma Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Martina Cordoni
- Department of Orthopedics and Trauma Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Elena Bechini
- Department of Orthopedics and Trauma Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Lorenzo Vannucci
- Physiotherapy and Rehabilitation Unit, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Antonio D’Arienzo
- Department of Orthopedics and Trauma Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Rodolfo Capanna
- Department of Orthopedics and Trauma Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
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Fiore M, Sambri A, Morante L, Bortoli M, Parisi SC, Panzavolta F, Alesi D, Neri E, Neri MP, Tedeschi S, Zamparini E, Cevolani L, Donati DM, Viale P, Campanacci DA, Zaffagnini S, De Paolis M. Silver-Coated Distal Femur Megaprosthesis in Chronic Infections with Severe Bone Loss: A Multicentre Case Series. J Clin Med 2023; 12:6679. [PMID: 37892817 PMCID: PMC10607434 DOI: 10.3390/jcm12206679] [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: 09/28/2023] [Revised: 10/20/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Periprosthetic joint infections (PJI) and fracture-related infections (FRI) of the distal femur (DF) may result in massive bone defects. Treatment options include articulated silver-coated (SC) megaprosthesis (MP) in the context of a two-stage protocol. However, there is limited evidence in the literature on this topic. A retrospective review of the prospectively maintained databases of three Institutions was performed. Forty-five patients were included. The mean follow-up time was 43 ± 17.1 months. Eight (17.8%) patients had a recurrent infection. The estimated recurrence-free survival rate was 91.1% (93.5% PJI vs. 85.7% FRI) 2 years following MP implantation, and 75.7% (83.2% PJI vs. 64.3% FRI; p = 0.253) after 5 years. No statistically relevant difference was found according to the initial diagnosis (PJI vs. FRI). Among possible risk factors, only resection length was found to significantly worsen the outcomes in terms of infection control (p = 0.031). A total of eight complications not related to infection were found after reimplantation, but only five of them required further surgery. Above-the-knee amputation was performed in two cases (4.4%), both for reinfection. Articulated DF SC MP in a two-stage protocol is a safe and effective treatment for chronic knee infection with severe bone loss.
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Affiliation(s)
- Michele Fiore
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.F.); (S.T.)
| | - Andrea Sambri
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.M.); (F.P.); (M.D.P.)
| | - Lorenzo Morante
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.M.); (F.P.); (M.D.P.)
| | - Marta Bortoli
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.M.); (F.P.); (M.D.P.)
| | - Stefania Claudia Parisi
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.M.); (F.P.); (M.D.P.)
| | - Francesco Panzavolta
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.M.); (F.P.); (M.D.P.)
| | - Domenico Alesi
- Second Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (D.A.); (S.Z.)
| | - Elisabetta Neri
- Orthopaedic Oncology Unit, Azienda Ospedaliera Universitaria Careggi, 50134 Firenze, Italy (D.A.C.)
| | - Maria Pia Neri
- Second Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (D.A.); (S.Z.)
| | - Sara Tedeschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.F.); (S.T.)
- Infectious Disease Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Eleonora Zamparini
- Infectious Disease Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Cevolani
- Third Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy (D.M.D.)
| | - Davide Maria Donati
- Third Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy (D.M.D.)
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.F.); (S.T.)
- Infectious Disease Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | | | - Stefano Zaffagnini
- Second Orthopaedic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (D.A.); (S.Z.)
| | - Massimiliano De Paolis
- Orthopaedics and Traumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.M.); (F.P.); (M.D.P.)
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Pressato D, Battista A, Govoni M, Vivarelli L, Dallari D, Pellegrini A. The Intraoperative Use of Defensive Antibacterial Coating (DAC ®) in the Form of a Gel to Prevent Peri-Implant Infections in Orthopaedic Surgery: A Clinical Narrative Review. MATERIALS (BASEL, SWITZERLAND) 2023; 16:5304. [PMID: 37570009 PMCID: PMC10420205 DOI: 10.3390/ma16155304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023]
Abstract
Periprosthetic joint infections (PJIs) in arthroplasty and osteosynthesis-associated infections (OAIs) in reconstructive surgery still represent a challenging complication in orthopaedics and traumatology causing a burden worsening the patient's quality of life, for caregiver and treating physicians, and for healthcare systems. PJIs and OAIs are the result of bacterial adhesion over an implant surface with subsequent biofilm formation. Therefore, the clinical pathological outcome is a difficult-to-eradicate persistent infection. Strategies to treat PJIs and OAIs involve debridement, the replacement of internal fixators or articular prostheses, and intravenous antibiotics. However, long treatments and surgical revision cause discomfort for patients; hence, the prevention of PJIs and OAIs represents a higher priority than treatment. Local antibiotic treatments through coating-release systems are becoming a smart approach to prevent this complication. Hydrophilic coatings, loaded with antibiotics, simultaneously provide a barrier effect against bacterial adhesion and allow for the local delivery of an antibiotic. The intraoperative use of a hyaluronan (HY)-derivative coating in the form of a gel, loaded with antibiotics to prevent PJI, has recently raised interest in orthopaedics. Current evidence supports the use of this coating in the prophylaxis of PJI and IRIs in terms of clinical outcomes and infection reduction. Thus, the purpose of this narrative review is to assess the use of a commercially available HY derivative in the form of a gel, highlighting the characteristics of this biomaterial, which makes it attractive for the management of PJIs and IRIs in orthopaedics and traumatology.
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Affiliation(s)
- Daniele Pressato
- Clinical and Scientific Affairs, Novagenit S.r.l., 38017 Mezzolombardo, Italy
| | - Angela Battista
- Quality Assurance and Regulatory Affairs, Novagenit S.r.l., 38017 Mezzolombardo, Italy;
| | - Marco Govoni
- Reconstructive Orthopaedic Surgery and Innovative Techniques—Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.V.); (D.D.)
| | - Leonardo Vivarelli
- Reconstructive Orthopaedic Surgery and Innovative Techniques—Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.V.); (D.D.)
| | - Dante Dallari
- Reconstructive Orthopaedic Surgery and Innovative Techniques—Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.V.); (D.D.)
| | - Antonio Pellegrini
- Reconstructive Surgery and Septic Complications Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy;
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Savvidou OD, Kaspiris A, Goumenos S, Trikoupis I, Melissaridou D, Kalogeropoulos A, Serenidis D, Georgoulis JD, Lianou I, Koulouvaris P, Papagelopoulos PJ. Knee Arthrodesis with a Modular Silver-Coated Endoprosthesis for Infected Total Knee Arthroplasty with Extensive Bone Loss: A Retrospective Case-Series Study. J Clin Med 2023; 12:jcm12103600. [PMID: 37240706 DOI: 10.3390/jcm12103600] [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: 04/11/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Knee arthrodesis is a limb salvage intervention for persistent periprosthetic joint infection (PJI) when revision total knee arthroplasty fails. Conventional arthrodesis techniques are associated with the increased rate of complications, especially in patients with extensive bone loss and extensor tendon deficiency. METHODS Eight patients with a modular silver-coated arthrodesis implant after failed exchange arthroplasty for infection, were retrospectively reviewed. All patients had significant bone loss, while 5 displayed extensor tendon deficiency. Survivorship, complications, leg length discrepancy, median Visual Analogue Scale (VAS) and Oxford Knee score (OKS) were evaluated. RESULTS The median follow up was 32 months (range 24-59 months). The survivorship rate of the prosthesis was 86% during the minimum time of follow up of 24 months. In one patient recurrence of the infection was observed and above-knee amputation was performed. The median postoperative leg length discrepancy was 2.07 ± 0.67 cm. Patients were able to ambulate with mild or no pain. The median VAS and OKS was 2.14 ± 0.9 and 34.7 ± 9.3, respectively. CONCLUSIONS The results of our study demonstrated that knee arthrodesis with a silver coated arthrodesis implant, performed for persistent PJI in patients with significant bone loss and extensor tendon deficit, provided a stable construct, allowed eradication of infection and was associated with good functional outcome.
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Affiliation(s)
- Olga D Savvidou
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology, School of Health Sciences, University of Patras, 26504 Patras, Greece
| | - Stavros Goumenos
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Ioannis Trikoupis
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dimitra Melissaridou
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | | | - Dimitris Serenidis
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Jim-Dimitris Georgoulis
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Ioanna Lianou
- Department of Orthopaedics, Rion University Hospital University of Patras, 26504 Patras, Greece
| | - Panagiotis Koulouvaris
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Panayiotis J Papagelopoulos
- Medical School, First Department of Orthopedics, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Li H, Wang D, Zhang W, Xu G, Xu C, Liu W, Li J. Potential side effects of antibacterial coatings in orthopaedic implants: A systematic review of clinical studies. Front Bioeng Biotechnol 2023; 11:1111386. [PMID: 36845182 PMCID: PMC9947536 DOI: 10.3389/fbioe.2023.1111386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
Objective: The systematic review aimed to determine the potential side effects of antibacterial coatings in orthopaedic implants. Methods: Publications were searched in the databases of Embase, PubMed, Web of Science and Cochrane Library using predetermined keywords up to 31 October 2022. Clinical studies reporting side effects of the surface or coating materials were included. Results: A total of 23 studies (20 cohort studies and three case reports) reporting the concerns about the side effects of antibacterial coatings were identified. Three types of coating materials, silver, iodine and gentamicin were included. All of studies raised the concerns regarding safety of antibacterial coatings, and the occurrence of adverse events was observed in seven studies. The main side effect of silver coatings was the development of argyria. For iodine coatings, only one anaphylactic case was reported as an adverse event. No systemic or other general side effects were reported for gentamicin. Conclusion: Clinical studies on the side effects of antibacterial coatings were limited. Based on the available outcomes, the most reported side effects of antibacterial coatings in clinical use were argyria with silver coatings. However, researchers should always pay attention to the potential side effects of antibacterial materials, such as systematic or local toxicity and allergy.
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Affiliation(s)
- Hua Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Daofeng Wang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Wupeng Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,School of Medicine, Nankai University, Tianjin, China
| | - Gaoxiang Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Cheng Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,*Correspondence: Cheng Xu, ; Wanheng Liu, ; Jiantao Li,
| | - Wanheng Liu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,*Correspondence: Cheng Xu, ; Wanheng Liu, ; Jiantao Li,
| | - Jiantao Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,*Correspondence: Cheng Xu, ; Wanheng Liu, ; Jiantao Li,
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Dong J, Wang W, Zhou W, Zhang S, Li M, Li N, Pan G, Zhang X, Bai J, Zhu C. Immunomodulatory biomaterials for implant-associated infections: from conventional to advanced therapeutic strategies. Biomater Res 2022; 26:72. [PMID: 36471454 PMCID: PMC9721013 DOI: 10.1186/s40824-022-00326-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/19/2022] [Indexed: 12/11/2022] Open
Abstract
Implant-associated infection (IAI) is increasingly emerging as a serious threat with the massive application of biomaterials. Bacteria attached to the surface of implants are often difficult to remove and exhibit high resistance to bactericides. In the quest for novel antimicrobial strategies, conventional antimicrobial materials often fail to exert their function because they tend to focus on direct bactericidal activity while neglecting the modulation of immune systems. The inflammatory response induced by host immune cells was thought to be a detrimental force impeding wound healing. However, the immune system has recently received increasing attention as a vital player in the host's defense against infection. Anti-infective strategies based on the modulation of host immune defenses are emerging as a field of interest. This review explains the importance of the immune system in combating infections and describes current advanced immune-enhanced anti-infection strategies. First, the characteristics of traditional/conventional implant biomaterials and the reasons for the difficulty of bacterial clearance in IAI were reviewed. Second, the importance of immune cells in the battle against bacteria is elucidated. Then, we discuss how to design biomaterials that activate the defense function of immune cells to enhance the antimicrobial potential. Based on the key premise of restoring proper host-protective immunity, varying advanced immune-enhanced antimicrobial strategies were discussed. Finally, current issues and perspectives in this field were offered. This review will provide scientific guidance to enhance the development of advanced anti-infective biomaterials.
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Affiliation(s)
- Jiale Dong
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China
| | - Wenzhi Wang
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China
| | - Wei Zhou
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China
| | - Siming Zhang
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China
| | - Meng Li
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China ,grid.263761.70000 0001 0198 0694Medical College, Soochow University, 215006 Suzhou, Jiangsu P. R. China
| | - Ning Li
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China
| | - Guoqing Pan
- grid.440785.a0000 0001 0743 511XInstitute for Advanced Materials, School of Materials Science and Engineering, Jiangsu University, 212013 Zhenjiang, China
| | - Xianzuo Zhang
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China
| | - Jiaxiang Bai
- grid.263761.70000 0001 0198 0694Medical College, Soochow University, 215006 Suzhou, Jiangsu P. R. China
| | - Chen Zhu
- grid.411395.b0000 0004 1757 0085Department of Orthopedic Surgery, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, 230001 Hefei, Anhui P. R. China
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9
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Damle A, Sundaresan R, Rajwade JM, Srivastava P, Naik A. A concise review on implications of silver nanoparticles in bone tissue engineering. BIOMATERIALS ADVANCES 2022; 141:213099. [PMID: 36088719 DOI: 10.1016/j.bioadv.2022.213099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/25/2022] [Accepted: 08/27/2022] [Indexed: 06/15/2023]
Abstract
Skeletal disorders represent a variety of degenerative diseases that affect bone and cartilage homeostasis. The regenerative capacity of bone is affected in osteoporosis, osteoarthritis, rheumatoid arthritis, bone fractures, congenital defects, and bone cancers. There is no viable, non-invasive treatment option and bone regeneration requires surgical intervention with the implantation of bone grafts. Incorporating nanoparticles in bone grafts have improved fracture healing by providing fine structures for bone tissue engineering. It is currently a revolutionary finding in the field of regenerative medicine. Silver nanoparticles (AgNPs) have garnered particular attention due to their well-known anti-microbial and potential osteoinductive properties. In addition, AgNPs have been demonstrated to regulate the proliferation and differentiation of mesenchymal stem cells (MSCs) involved in bone regeneration. Furthermore, AgNPs have shown toxicity towards cancer cells derived from bone. In the last decade, there have been multiple studies focusing on the effect of nanoparticles on the proliferation and/or differentiation of MSCs and bone cancer cells; however, the specific studies with AgNPs are limited. Although the reported investigations show promising in vitro and in vivo potential of AgNPs for application in bone regeneration, more studies are required to ensure their implications in bone tissue engineering. This review aims to highlight the current advances related to the production of AgNPs and their effect on MSCs and bone cancer cells, which will potentiate their possible implications in orthopedics. Moreover, this review article evaluates the future of AgNPs in bone tissue engineering.
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Affiliation(s)
- Atharva Damle
- School of BioSciences and Technology, Vellore Institute of Technology, Vellore 632014, Tamil Nadu, India
| | - Rajapriya Sundaresan
- School of BioSciences and Technology, Vellore Institute of Technology, Vellore 632014, Tamil Nadu, India
| | - Jyutika M Rajwade
- Nanobioscience Group, Agharkar Research Institute, Pune 411004, Maharashtra, India
| | - Priyanka Srivastava
- Centre for Nanobiotechnology, Vellore Institute of Technology, Vellore 632014, Tamil Nadu, India.
| | - Amruta Naik
- National Centre for Cell Science, S. P. Pune University Campus, Pune 411007, Maharashtra, India.
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10
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Smolle MA, Bergovec M, Scheipl S, Gössler W, Amerstorfer F, Glehr M, Leithner A, Friesenbichler J. Long-term changes in serum silver concentrations after extremity reconstruction with silver-coated megaprostheses. Sci Rep 2022; 12:13041. [PMID: 35906279 PMCID: PMC9338280 DOI: 10.1038/s41598-022-16707-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/14/2022] [Indexed: 12/02/2022] Open
Abstract
Silver-coated megaprostheses are considered to reduce infection rate following reconstruction of bone defects in tumour surgery or revision arthroplasty. However, little is known about systemic silver exposure and possible side effects. The aim of this study was to analyse serum silver concentrations in patients with silver-coated megaprostheses over a prolonged time period. Between 2004 and 2016, 46 patients (52.2% female, mean age at surgery 47.1 ± 24.2 years) received silver-coated megaprostheses for septic (n = 26) or oncological (n = 17; main implant since 2013) indications, or aseptic loosening (n = 3). Blood was drawn from all patients within the first few days following surgery (without silver ion levels) and thereafter every 6 months at the outpatient department (with silver ion levels). Inductively coupled plasma mass spectrometry was used to determine silver ion levels. Median follow-up was 47.3 months (IQR: 16.1–78.9). Overall, 29 revision surgeries became necessary in 20 patients, equivalent to a cumulative complication rate of 63.0%. Revisions were most commonly for periprosthetic joint infections (PJIs, n = 12) and instability/soft tissue problems (n = 10). Revision-free implant survival was 81.4%, 42.3% and 35.2% at one, 5 and 10 years. Incidence of local argyria was 8.7% (n = 4). Silver ion levels at two or more consecutive time points during follow-up were available for 26 patients. An increment of silver levels within the first months (“run-in”) was observed, followed by an unspecific undulating course. Median initial and latest follow-up (median, 49.5 months) serum silver ion levels were 16.0 ppb (IQR: 9.1–29.1) and 7.4 ppb (IQR: 2.7–14.1), respectively. According to the multivariate mixed linear random-effects model, development of PJI was associated with significantly higher silver ion levels over time (p = 0.002), irrespective of time from surgery (p = 0.274). In the current series, a cumulative complication rate of 63.0% was observed for patients receiving silver-coated megaprostheses for septic of oncological indications. An overall unspecific course of silver ion concentration was present. Development of PJI was significantly associated with increased silver ion levels over time. Yet, no systemic complication associated to high silver levels occurred. It can be concluded that silver-coated implants constitute a safe solution for megaprosthetic reconstruction, but monitoring of silver concentrations is recommended.
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Affiliation(s)
- Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Marko Bergovec
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Susanne Scheipl
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Walter Gössler
- Institute of Analytic Chemistry, Karl-Franzens University, Graz, Austria
| | - Florian Amerstorfer
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Mathias Glehr
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Jörg Friesenbichler
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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11
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de Avila ED, Nagay BE, Pereira MMA, Barão VAR, Pavarina AC, van den Beucken JJJP. Race for Applicable Antimicrobial Dental Implant Surfaces to Fight Biofilm-Related Disease: Advancing in Laboratorial Studies vs Stagnation in Clinical Application. ACS Biomater Sci Eng 2022; 8:3187-3198. [PMID: 35816289 DOI: 10.1021/acsbiomaterials.2c00160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Across years, potential strategies to fight peri-implantitis have been notoriously explored through the antimicrobial coating implant surfaces capable of interfering with the bacterial adhesion process. However, although experimental studies have significantly advanced, no product has been marketed so far. For science to reach the society, the commercialization of research outcomes is necessary to provide real advancement in the biomedical field. Therefore, the aim of this study was to investigate the challenges involved in the development of antimicrobial dental implant surfaces to fight peri-implantitis, through a systematic search. Research articles reporting antimicrobial dental implant surfaces were identified by searching PubMed, Scopus, Web of Science, The Cochrane Library, Embase, and System of Information on Grey Literature in Europe, between 2008 and 2020. A total of 1778 studies were included for quality assessment and the review. An impressive number of 1655 articles (93,1%) comprised in vitro studies, whereas 123 articles refer to in vivo investigations. From those 123, 102 refer to animal studies and only 21 articles were published on the clinical performance of antibacterial dental implant surfaces. The purpose of animal studies is to test how safe and effective new treatments are before they are tested in people. Therefore, the discrepancy between the number of published studies clearly reveals that preclinical investigations still come up against several challenges to overcome before moving forward to a clinical setting. Additionally, researchers need to recognize that the complex journey from lab to market requires more than a great idea and resources to develop a commercial invention; research teams must possess the skills necessary to commercialize an invention.
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Affiliation(s)
- Erica D de Avila
- Dental Research Division, Guarulhos University (UNG), Praça Tereza Cristina, 88 - Centro, Guarulhos, São Paulo 07023-070, Brazil.,Department of Dental Materials and Prosthodontics, School of Dentistry at Araraquara, Sao Paulo State University (UNESP), Rua Humaita, 1680, Araraquara, São Paulo 14801-903, Brazil
| | - Bruna E Nagay
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Av. Limeira, 901, Piracicaba, São Paulo 13414-903, Brazil
| | - Marta M A Pereira
- Department of Dental Materials and Prosthodontics, School of Dentistry at Araraquara, Sao Paulo State University (UNESP), Rua Humaita, 1680, Araraquara, São Paulo 14801-903, Brazil
| | - Valentim A R Barão
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Av. Limeira, 901, Piracicaba, São Paulo 13414-903, Brazil
| | - Ana Claudia Pavarina
- Department of Dental Materials and Prosthodontics, School of Dentistry at Araraquara, Sao Paulo State University (UNESP), Rua Humaita, 1680, Araraquara, São Paulo 14801-903, Brazil
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12
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Development of Silver-Containing Hydroxyapatite-Coated Antimicrobial Implants for Orthopaedic and Spinal Surgery. Medicina (B Aires) 2022; 58:medicina58040519. [PMID: 35454358 PMCID: PMC9029955 DOI: 10.3390/medicina58040519] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022] Open
Abstract
The prevention of surgical site infections is directly related to the minimization of surgical invasiveness, and is in line with the concept of minimally invasive spine therapy (MIST). In recent years, the incidence of postoperative infections has been increasing due to the increased use of spinal implant surgery in patients at high risk of infection, including the elderly and easily infected hosts, the limitations of poor bone marrow transfer of antibiotics, and the potential for contamination of surgical gloves and instruments. Thus, the development of antimicrobial implants in orthopedic and spinal surgery is becoming more and more popular, and implants with proven antimicrobial, safety, and osteoconductive properties (i.e., silver, iodine, antibiotics) in vitro, in vivo, and in clinical trials have become available for clinical use. We have developed silver-containing hydroxyapatite (Ag-HA)-coated implants to prevent post-operative infection, and increase bone fusion capacity, and have successfully commercialized antibacterial implants for hip prostheses and spinal interbody cages. This narrative review overviews the present status of available surface coating technologies and materials; describes how the antimicrobial, safety, and biocompatibility (osteoconductivity) of Ag-HA-coated implants have been demonstrated for commercialization; and reviews the clinical use of antimicrobial implants in orthopedic and spinal surgery, including Ag-HA-coated implants that we have developed.
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13
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Lex JR, Koucheki R, Stavropoulos NA, Michele JD, Toor JS, Tsoi K, Ferguson PC, Turcotte RE, Papagelopoulos PJ. Megaprosthesis anti-bacterial coatings: A comprehensive translational review. Acta Biomater 2022; 140:136-148. [PMID: 34879295 DOI: 10.1016/j.actbio.2021.11.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022]
Abstract
Periprosthetic joint infections (PJI) are catastrophic complications for patients with implanted megaprostheses and pose significant challenges in the management of orthopaedic oncology patients. Despite various preventative strategies, with the increasing rate of implanted orthopaedic prostheses, the number of PJIs may be increasing. PJIs are associated with a high rate of amputation. Therefore, novel strategies to combat bacterial colonization and biofilm formation are required. A promising strategy is the utilization of anti-bacterial coatings on megaprosthetic implants. In this translational review, a brief overview of the mechanism of bacterial colonization of implants and biofilm formation will be provided, followed by a discussion and classification of major anti-bacterial coatings currently in use and development. In addition, current in vitro outcomes, clinical significance, economic importance, evolutionary perspectives, and future directions of anti-bacterial coatings will also be discussed. Megaprosthetic anti-bacterial coating strategies will help reduce infection rates following the implantation of megaprostheses and would positively impact sarcoma care. STATEMENT OF SIGNIFICANCE: This review highlights the clinical challenges and a multitude of potential solutions to combating peri-prosthetic join infections in megaprotheses using anti-bacterial coatings. Reducing infection rates following the implantation of megaprostheses would have a major impact on sarcoma care and major trauma surgeries that require reconstruction of large skeletal defects.
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Affiliation(s)
- Johnathan R Lex
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Robert Koucheki
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | | | - Joseph Di Michele
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Toor
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Kim Tsoi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Canada; University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Peter C Ferguson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada; University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Robert E Turcotte
- Division of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Panayiotis J Papagelopoulos
- 1st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, Greece
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14
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One-Stage Hip Revision Arthroplasty Using Megaprosthesis in Severe Bone Loss of The Proximal Femur Due to Radiological Diffuse Osteomyelitis. Trop Med Infect Dis 2021; 7:tropicalmed7010005. [PMID: 35051121 PMCID: PMC8780561 DOI: 10.3390/tropicalmed7010005] [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: 11/29/2021] [Revised: 12/23/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022] Open
Abstract
Managing substantial proximal and/or distal femoral bone defects is one of the biggest challenges in chronic hip periprosthetic joint infection. Most authors use two-stage arthroplasty with a temporary antibiotic-loaded cement spacer for the management of these patients. In this study, we show our experience with one-stage exchange arthroplasty in managing severe bone defects due to radiological-extensive proximal femoral osteomyelitis. Two patients were included in the study. They showed radiological-extensive proximal femoral osteomyelitis, and they were treated with one-stage exchange arthroplasty using megaprosthesis. Diffuse osteomyelitis was confirmed in both cases; in one case, the histology was compatible with osteomyelitis, and the other case had a positive culture identified in a bone sample. At a minimum of a four-year follow-up, the patients did not reveal any clinical, radiological or laboratory signs of infection. In conclusion, one-stage exchange arthroplasty and megaprosthesis is an option for the treatment of chronic hip periprosthetic joint infection associated with radiological-diffuse proximal femoral osteomyelitis.
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15
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Hadrup N, Sharma AK, Jacobsen NR, Loeschner K. Distribution, metabolism, excretion, and toxicity of implanted silver: a review. Drug Chem Toxicol 2021; 45:2388-2397. [PMID: 34455878 DOI: 10.1080/01480545.2021.1950167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Some implantable medical devices contain silver. We aimed to assess at what amount implanted silver becomes toxic. Silver was elevated in bodily fluids and tissues surrounding silver-containing implants. Silver released from implants also distributes to blood and other tissues; there is evidence to suggest silver can pass the blood-brain-barrier. Silver can be deposited as nano-sized particles in various tissues. Such particles, in addition to silver, often contain other elements too, e.g., selenium and sulfur. Silver released from implants seems to stay in the body for long periods (years). Reported excretion pathways following implantation are urinary and fecal ones. Reported toxicological effects were virtually all local reactions surrounding the implants. Argyria is a blue-gray discoloration of the skin due to deposited silver granules. Localized argyria has been described after the implantation of acupuncture needles and silver-coated prostheses, although the presence of silver was tested only for and shown in the former. Other toxicological effects include local tissue reactivity and examples of neurotoxic and vascular effects. We did not include genotoxicity studies in the present publication as we recently evaluated silver to be genotoxic. Carcinogenicity studies were absent. We conclude that local toxicity of implanted silver can be foreseen in some situations.
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Affiliation(s)
- Niels Hadrup
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Anoop K Sharma
- Division for Diet, Disease Prevention and Toxicology, Group for Chemical Risk Assessment and GMO, National Food Institute, Technical University of Denmark, Lyngby, Denmark
| | - Nicklas R Jacobsen
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Katrin Loeschner
- Division for Food Technology, Research Group for Analytical Food Chemistry, National Food Institute, Technical University of Denmark, Lyngby, Denmark
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16
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17
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Abstract
Periprosthetic joint infection (PJI) is one of the most dreaded complications after arthroplasty surgery; thus numerous approaches have been undertaken to equip metal surfaces with antibacterial properties. Due to its antimicrobial effects, silver is a promising coating for metallic surfaces, and several types of silver-coated arthroplasty implants are in clinical use today. However, silver can also exert toxic effects on eukaryotic cells both in the immediate vicinity of the coated implants and systemically. In most clinically-used implants, silver coatings are applied on bulk components that are not in direct contact with bone, such as in partial or total long bone arthroplasties used in tumour or complex revision surgery. These implants differ considerably in the coating method, total silver content, and silver release rates. Safety issues, such as the occurrence of argyria, have been a cause for concern, and the efficacy of silver coatings in terms of preventing PJI is also controversial. The application of silver coatings is uncommon on parts of implants intended for cementless fixation in host bone, but this option might be highly desirable since the modification of implant surfaces in order to improve osteoconductivity can also increase bacterial adhesion. Therefore, an optimal silver content that inhibits bacterial colonization while maintaining osteoconductivity is crucial if silver were to be applied as a coating on parts intended for bone contact. This review summarizes the different methods used to apply silver coatings to arthroplasty components, with a focus on the amount and duration of silver release from the different coatings; the available experience with silver-coated implants that are in clinical use today; and future strategies to balance the effects of silver on bacteria and eukaryotic cells, and to develop silver-coated titanium components suitable for bone ingrowth. Cite this article: Bone Joint J 2021;103-B(3):423-429.
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Affiliation(s)
- Anna Diez-Escudero
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Nils P Hailer
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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18
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Betts HD, Whitehead C, Harris HH. Silver in biology and medicine: opportunities for metallomics researchers. Metallomics 2020; 13:6029133. [PMID: 33570135 DOI: 10.1093/mtomcs/mfaa001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 12/06/2020] [Indexed: 12/13/2022]
Abstract
The antibacterial properties of silver have been known for centuries and the threat of antibiotic-resistant bacteria has led to renewed focus on the noble metal. Silver is now commonly included in a range of household and medical items to imbue them with bactericidal properties. Despite this, the chemical fate of the metal in biological systems is poorly understood. Silver(I) is a soft metal with high affinity for soft donor atoms and displays much similarity to the chemistry of Cu(I). In bacteria, interaction of silver with the cell wall/membrane, DNA, and proteins and enzymes can lead to cell death. Additionally, the intracellular generation of reactive oxygen species by silver is posited to be a significant antimicrobial action. While the antibacterial action of silver is well known, bacteria found in silver mines display resistance against it through use of a protein ensemble thought to have been specifically developed for the metal, highlighting the need for judicious use. In mammals, ∼10-20% of ingested silver is retained by the body and thought to predominantly localize in the liver or kidneys. Chronic exposure can result in argyria, a condition characterized by blue staining of the skin, resulting from subdermal deposition of silver [as Ag(0)/sulfides], but more insidious side effects, such as inclusions in the brain, seizures, liver/kidney damage, and immunosuppression, have also been reported. Here, we hope to highlight the current understanding of the biological chemistry of silver and the necessity for continued study of these systems to fill existing gaps in knowledge.
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Affiliation(s)
- Harley D Betts
- Department of Chemistry, The University of Adelaide, North Terrace, SA 5005, Australia
| | - Carole Whitehead
- Department of Chemistry, The University of Adelaide, North Terrace, SA 5005, Australia
| | - Hugh H Harris
- Department of Chemistry, The University of Adelaide, North Terrace, SA 5005, Australia
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19
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Fiore M, Sambri A, Zucchini R, Giannini C, Donati DM, De Paolis M. Silver-coated megaprosthesis in prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about efficacy and toxicity in primary and revision surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:201-220. [PMID: 32889672 DOI: 10.1007/s00590-020-02779-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/28/2020] [Indexed: 01/02/2023]
Abstract
AIM Prosthetic joint infection (PJI) is a common complication following orthopedic megaprosthetic implantations (EPR), estimated up to 50%. Silver coatings were introduced in order to reduce the incidence of PJI, by using the antibacterial activity of silver. Three different silver coatings are available: MUTARS® (Implantcast), Agluna® (Accentus Medical), PorAg® (Waldemar Link). The aim of this review is to provide an overview on efficacy and safety of silver-coated EPR both in primary and revision surgery, comparing infection rate according to the type of implant. METHODS Through an electronic systematic search, we reviewed the articles concerning silver-coated EPRs. Infection rate, silver-related complications, local and blood concentrations of the silver were evaluated. Meta-analyses were performed to compare results from each study included. RESULTS Nineteen studies were included. The overall infection rate in patients with silver-coated implants was 17.6% (133/755). Overall infection rate in primary silver-coated EPR was been 9.2% (44/445), compared to 11.2% (57/507) of non-silver-coated implants. The overall infection rate after revisions was 13.7% (25/183) in patients with silver-coated EPR and 29.2% (47/161) when uncoated EPR were used, revealing a strength statistically significative utility of silver coatings in preventing infections in this group (p: 0.019). Generally, the use of MUTARS® EPR had produced an almost constant decrease in the incidence of primary PJI but there are few data on the effectiveness in revisions. The results from the use of Agluna® in both primary and revisions implants are inconstant. Conversely, PorAg® had proven to be effective both in PJI prevention but, especially, when used in PJI revision settings. Local argyria was reported in 8 out of 357 patients (2.2%), while no systemic complications were described. Local and blood concentrations of silver were always reported very far to the threshold of toxicity, with the lowest concentration found using PorAg®. CONCLUSIONS Silver-coated EPRs are safe and effective in reduction in PJI and re-infection rate, in particular when used in higher risk patients and after two-stage revisions to fight PJI.
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Affiliation(s)
- Michele Fiore
- IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136, Bologna, Italy.
| | - Andrea Sambri
- Azienda ospedaliera Sant'Orsola Malpighi, Bologna, Italy.,Alma mater studiorum - University of Bologna, Bologna, Italy
| | - Riccardo Zucchini
- IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136, Bologna, Italy
| | - Claudio Giannini
- IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136, Bologna, Italy
| | - Davide Maria Donati
- IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136, Bologna, Italy.,Alma mater studiorum - University of Bologna, Bologna, Italy
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20
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Silver-coated (PorAg ®) endoprosthesis can be protective against reinfection in the treatment of tumor prostheses infection. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1345-1353. [PMID: 32449080 DOI: 10.1007/s00590-020-02705-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/13/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We aim to evaluate the use of silver (PorAg®) coated compared to uncoated prosthesis in two-stage revision for prosthetic joint infection (PJI) of distal femur and proximal tibia megaprosthesis in oncological patients. MATERIALS AND METHODS In total, 68 patients were retrospectively evaluated. Median age was 30 years (range 14-83). In total, 29 patients were re-implanted with PorAg® prosthesis and 39 with uncoated prosthesis (Megasystem C®, Waldemar Link GmbH & Co. KG, Hamburg, Germany). All patients had PJI confirmed according to Musculoskeletal Infection Society (MSIS) criteria. In 10 cases, no microorganism was identified at the time of first-stage revision, but all had a sinus communicating with the prosthesis. Successful eradication of the infection was defined by the absence of clinical/serologic evidence of infection at 6 months after the second stage or at latest follow-up. Infection was again defined according to the MSIS criteria. RESULTS At 3-year follow-up, estimated reinfection rate in the silver group was slightly lower than in uncoated EPR (10.3% vs. 17.5%, p = 0.104). Among reinfected patients, only one out of three patients (33%) in the silver group required an amputation compared to 80% in the nonsilver group (p = 0.047). CONCLUSIONS Our results show the efficacy of PorAg® coating in the two-stage revision of knee EPR. PorAg®-coated EPR may have possible advantages over this traditional strategy, in particular when applied to patients with a higher risk of reinfection.
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21
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Does a Competing Risk Analysis Show Differences in the Cumulative Incidence of Revision Surgery Between Patients with Oncologic and Non-oncologic Conditions After Distal Femur Replacement? Clin Orthop Relat Res 2020; 478:1062-1073. [PMID: 31895069 PMCID: PMC7170673 DOI: 10.1097/corr.0000000000001106] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Distal femur replacement is frequently used for limb salvage after bone tumor resections. It is also used in patients with severe bone loss because of traumatic conditions or revision TKA. Some studies on distal femur replacement reported on revision-free survival without distinguishing between patients with oncologic diagnoses and those without, although these patients might be incomparable because of their differences in important patient- and disease-specific characteristics. This may lead to an inaccurate and undifferentiated interpretation of the results of survival analyses. QUESTIONS/PURPOSES (1) What is the overall cumulative incidence of revision surgery after cemented and cementless distal femoral replacement, as determined with a competing risk analysis? (2) Does the cumulative incidence of revision surgery change over time? (3) Are there differences in the cumulative incidence of revision surgery between patients with oncologic conditions and those without who are treated with cemented or cementless distal femoral replacement? METHODS A total of 403 patients were possible candidates for distal femoral replacement. Of these, 56 patients elected to undergo different procedures, 83 were excluded because an expendable growing prosthesis was implanted, and 28 were lost to follow-up. Therefore, 229 patients who underwent distal femoral replacement for oncologic or non-oncologic reasons between 1983 and 2016 were retrospectively included in this study. The type of fixation method (cemented or cementless) was obtained from the patients' medical records, operation reports, and radiographic analyses from plain radiographs. All radiographs were standardized and obtained at standard time intervals in our institution. No algorithm regarding the fixation approach was followed. According to our data, patients receiving cementless fixation were younger and therefore likely to be more active than those receiving cemented fixation. The median follow-up duration of the overall cohort was 85 months (range 0.1-391 months). Patients who died or had revision surgery before the 2-year minimum follow-up interval were adequately considered using competing risk calculation. The reasons for revision surgery were classified using the classification system proposed by the International Society for Limb Salvage. A competing risk analysis was performed to estimate the cumulative incidence function of revision, accounting for death as a competing event. To evaluate the influence of potential prognostic factors, including diagnosis (oncologic versus non-oncologic), fixation (cemented versus cementless), year of distal femoral replacement, age, and sex on the occurrence of revision surgery, univariate and multivariable Fine and Gray models were applied. RESULTS The competing risks analysis revealed cumulative incidences of revision surgery for any cause (Types 1 to 5) of 26% (95% CI, 20.3%-31.9%) at 12 months, 37.9% (95% CI, 31.3%-44.4%) at 24 months, 52.6% (95% CI, 45.1%-59.5%) at 5 years, and 58.2% (95% CI, 50.1%-65.4%) at 10 years for all patients. Rotating hinge-type prostheses showed a lower cumulative incidence of revision surgery (41.6%; 95% CI, 31.8%-51%) than fixed-hinge prostheses did (64%; 95% CI, 50.5%-74.5% ) at 5 years (Gray's test: p = 0.01). According to the multivariate Fine and Gray model, the year of surgery did not have any effect on the risk of revision surgery (1994 to 2003: hazard ratio 0.70; 95% CI, 0.46-1.07); 2004 to 2016: HR 0.83; 95% CI, 0.52-1.34; p = 0.26). The multivariate analysis, adjusted for disease, sex, age, cementation, and year of surgery, revealed a difference in the risk of revision surgery between patients with oncologic disease and those with non-oncologic disease (HR 0.44 for oncologic versus non-oncologic; 95% CI, 0.22-0.87; p = 0.02) and a reduction in the risk of overall revision with cemented fixation in patients with oncologic disease (HR 0.53; 95% CI, 0.29-0.98; p = 0.03). CONCLUSION This study indicates that even with newer implants, there was a high incidence of revision surgery after distal femoral replacement. According to our analysis, patients with oncologic diagnoses have a lower likelihood of revision when the stem is cemented whereas the type of fixation did not impact patients with non-oncologic diagnoses. Because of differences in patient demographics (age, etiology of disease, and use of chemotherapy) and outcomes of fixation, oncologic and non-oncologic patients should be analyzed separately in survival studies about distal femoral replacement. LEVEL OF EVIDENCE Level III, therapeutic study.
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Arens D, Zeiter S, Nehrbass D, Ranjan N, Paulin T, Alt V. Antimicrobial silver-coating for locking plates shows uneventful osteotomy healing and good biocompatibility results of an experimental study in rabbits. Injury 2020; 51:830-839. [PMID: 32164954 DOI: 10.1016/j.injury.2020.02.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 02/02/2023]
Abstract
Infections after internal fixation of fractures remain a challenge. Silver is known for its antimicrobial activity, including activity against multi-resistant strains. The aim of the current study was to analyze the biocompatibility and potential influence on the osteotomy healing process of a silver-coating technology for locking plates compared to silver-free locking plates in an established rabbit model. The implants used in this study were 7-hole titanium locking plates, and plasma electrolytic oxidation (PEO) silver-coated equivalents. A total of 24 rabbits were used in this study (12 coated, 12 non-coated). An osteotomy of the midshaft of the humerus was created and the humerus stabilized with the 7-hole locking plates with a total of 6 screws. Radiographs were taken on day 0, week 2, 4, 6, 8, and 10 for continuous radiographical evaluation. All animals were euthanized after 10 weeks and further assessment was performed using X-rays, micro-CT, non-destructive four-point bending biomechanical testing and semi-quantitative histopathological evaluation. Furthermore, silver concentration was measured in the blood, kidney, liver, spleen, brain, feces and soft tissue around the plate. Radiographs showed normal undisturbed and completed healing of the osteotomy in all animals without any differences between the two groups over the entire observation period. Micro-CT analysis revealed overall tissue volume as well as tissue density to be comparable between the two groups. Mechanical testing showed comparable stiffness with an average stiffness relative to contralateral bones of 75.7 ± 16.1% in the silver-free control group compared to 69.7 ± 18.5% (p-value: 0.46). Semi-quantitative histopathological evaluation showed no remarkable difference in the analysis of the osteotomy gap healing or in the surrounding soft tissue area. There were detectable silver concentrations in the soft tissue around the plate after 10 weeks. Silver in the blood was only found in 3 animals within the first two weeks and all animals were free of silver afterwards. There were no detectable silver concentrations in the brain, liver, spleen, axillary lymph nodes and kidney. This study shows undisturbed osteotomy healing of the presented antimicrobial silver surface coating and a good biocompatibility in this rabbit model.
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Affiliation(s)
- Daniel Arens
- AO Research Institute Davos, Davos Platz, Switzerland
| | | | - Dirk Nehrbass
- AO Research Institute Davos, Davos Platz, Switzerland
| | | | | | - Volker Alt
- Department of Trauma Surgery, University Medical Centre, Regensburg, Germany.
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Fabritius M, Al-Munajjed AA, Freytag C, Jülke H, Zehe M, Lemarchand T, Arts JJ, Schumann D, Alt V, Sternberg K. Antimicrobial Silver Multilayer Coating for Prevention of Bacterial Colonization of Orthopedic Implants. MATERIALS (BASEL, SWITZERLAND) 2020; 13:E1415. [PMID: 32245004 PMCID: PMC7143109 DOI: 10.3390/ma13061415] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
Due to increasing rates of periprosthetic joint infections (PJI), new approaches are needed to minimize the infection risk. The first goal of this study was to modify a well-established infection model to test surface-active antimicrobial systems. The second goal was to evaluate the antimicrobial activity of a silver multilayer (SML) coating. In vitro tests with SML items showed a >4 Log reduction in a proliferation assay and a 2.2 Log reduction in an agar immersion test (7 d). In the in vivo model blank and SML coated K-wires were seeded with ~2 × 104 CFU of a methicillin-sensitive Staphylococcus epidermidis (MSSE) and inserted into the intramedullary tibial canal of rabbits. After 7 days, the animals were sacrificed and a clinical, microbiological and histological analysis was performed. Microbiology showed a 1.6 Log pathogen reduction on the surface of SML items (p = 0.022) and in loosely attached tissue (p = 0.012). In the SML group 7 of 12 SML items were completely free of pathogens (cure rate = 58%, p = 0.002), while only 1 of 12 blank items were free of pathogens (cure rate = 8%, p = 0.110). No silver was detected in the blood or urine of the SML treated animals and only scarcely in the liver or adjacent lymph nodes. In summary, an in vivo infection model to test implants with bacterial pre-incubation was established and the antimicrobial activity of the SML coating was successfully proven.
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Affiliation(s)
- Martin Fabritius
- Aesculap AG, Research and Development, Am Aesculap-Platz, 78532 Tuttlingen, Germany; (D.S.); (K.S.)
| | | | | | | | - Markus Zehe
- QualityLabs, Neumeyerstr. 46a, 90411 Nuremberg, Germany;
| | | | - Jacobus J. Arts
- Department of Orthopedic Surgery, Research School CAPHRI, Maastricht University Medical Centre, 6202 Maastricht, The Netherlands;
| | - Detlef Schumann
- Aesculap AG, Research and Development, Am Aesculap-Platz, 78532 Tuttlingen, Germany; (D.S.); (K.S.)
| | - Volker Alt
- Department of Trauma Surgery, University of Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany;
| | - Katrin Sternberg
- Aesculap AG, Research and Development, Am Aesculap-Platz, 78532 Tuttlingen, Germany; (D.S.); (K.S.)
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Borcherding K, Marx D, Gätjen L, Bormann N, Wildemann B, Specht U, Salz D, Thiel K, Grunwald I. Burst Release of Antibiotics Combined with Long-Term Release of Silver Targeting Implant-Associated Infections: Design, Characterization and in vitro Evaluation of Novel Implant Hybrid Surface. MATERIALS (BASEL, SWITZERLAND) 2019; 12:E3838. [PMID: 31766488 PMCID: PMC6926566 DOI: 10.3390/ma12233838] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/18/2019] [Accepted: 11/19/2019] [Indexed: 02/06/2023]
Abstract
Implant-associated infections represent a serious risk in human medicine and can lead to complications, revisions and in worst cases, amputations. To target these risks, the objective was to design a hybrid implant surface that allows a local burst release of antibiotics combined with long-term antimicrobial activity based on silver. The efficacy should be generated with simultaneous in vitro cytocompatibility. The investigations were performed on titanium K-wires and plates and gentamicin was selected as an illustrative antibiotic. A gentamicin depot (max 553 µg/cm2) was created on the surface using laser structuring. The antibiotic was released within 15 min in phosphate buffered saline (PBS) or agar medium. Metallic silver particles (4 µg/cm2) in a titanium dioxide layer were deposited using plasma vapor deposition (PVD). About 16% of the silver was released within 28 days in the agar medium. The local efficacy of the incorporated silver was demonstrated in a direct contact assay with a reduction of more than 99.99% (Escherichia coli). The local efficacy of the hybrid surface was confirmed in a zone of inhibition (ZOI) assay using Staphylococcus cohnii. The biocompatibility of the hybrid surface was proven using fibroblasts and osteoblasts as cell systems. The hybrid surface design seems to be promising as treatment of implant-associated infections, considering the achieved amount and release behavior of the active ingredients (gentamicin, silver). The generated in vitro results (efficacy, biocompatibility) proofed the concept. Further in vivo studies will be necessary translate the hybrid surface towards clinical applied research.
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Affiliation(s)
- Kai Borcherding
- Department of Adhesive Bonding Technology and Surfaces, Fraunhofer Institute for Manufacturing Technology and Advanced Materials (IFAM), 28359 Bremen, Germany; (D.M.); (L.G.); (U.S.); (D.S.); (K.T.)
| | - Dennis Marx
- Department of Adhesive Bonding Technology and Surfaces, Fraunhofer Institute for Manufacturing Technology and Advanced Materials (IFAM), 28359 Bremen, Germany; (D.M.); (L.G.); (U.S.); (D.S.); (K.T.)
| | - Linda Gätjen
- Department of Adhesive Bonding Technology and Surfaces, Fraunhofer Institute for Manufacturing Technology and Advanced Materials (IFAM), 28359 Bremen, Germany; (D.M.); (L.G.); (U.S.); (D.S.); (K.T.)
| | - Nicole Bormann
- Julius Wolff Institute, BIH Center for Regenerative Therapies, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (N.B.); (B.W.)
| | - Britt Wildemann
- Julius Wolff Institute, BIH Center for Regenerative Therapies, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 13353 Berlin, Germany; (N.B.); (B.W.)
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, 07747 Jena, Germany
| | - Uwe Specht
- Department of Adhesive Bonding Technology and Surfaces, Fraunhofer Institute for Manufacturing Technology and Advanced Materials (IFAM), 28359 Bremen, Germany; (D.M.); (L.G.); (U.S.); (D.S.); (K.T.)
| | - Dirk Salz
- Department of Adhesive Bonding Technology and Surfaces, Fraunhofer Institute for Manufacturing Technology and Advanced Materials (IFAM), 28359 Bremen, Germany; (D.M.); (L.G.); (U.S.); (D.S.); (K.T.)
| | - Karsten Thiel
- Department of Adhesive Bonding Technology and Surfaces, Fraunhofer Institute for Manufacturing Technology and Advanced Materials (IFAM), 28359 Bremen, Germany; (D.M.); (L.G.); (U.S.); (D.S.); (K.T.)
| | - Ingo Grunwald
- Industrial and Environmental Biology, Hochschule Bremen-City University of Applied Sciences, Neustadswall 30, 28199 Bremen, Germany;
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[Erratum to: Silver coating on tumour prostheses]. DER ORTHOPADE 2019; 48:1057. [PMID: 31728568 DOI: 10.1007/s00132-019-03835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Liu P, Fu K, Zeng X, Chen N, Wen X. Fabrication and Characterization of Composite Meshes Loaded with Antimicrobial Peptides. ACS APPLIED MATERIALS & INTERFACES 2019; 11:24609-24617. [PMID: 31199612 DOI: 10.1021/acsami.9b07246] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Biomaterials-centered infection or implant-associated infection plays critical roles in all areas of medicine with implantable devices. The widespread over use of antibiotics has caused severe bacterial resistance and even super bugs. Therefore, the development of anti-infection implantable devices with non-antibiotic-based new antimicrobial agents is indeed a priority for all of us. In this study, antimicrobial composite meshes were fabricated with broad-spectrum antimicrobial peptides (AMPs). Macroporous polypropylene meshes with poly-caprolactone electrospun nanosheets were utilized as a substrate to load AMPs and gellan gum presented as a media to gel with AMPs. Different amounts of AMPs were loaded onto gellan gum to determine the appropriate dose. The surface morphologies, Fourier-transform infrared spectroscopy spectra, in vitro release profiles, mechanical performances, in vitro antimicrobial properties, and cytocompatibility of composite scaffolds were evaluated. Results showed that AMPs were loaded into the meshes successfully, the in vitro release of AMPs in phosphate-buffered saline was prolonged, and less than 60% peptides were released in 10 days. The mechanical properties of composite meshes were also within the scope of several commercial surgical meshes. Composite meshes with the AMP loading amount of over 3 mg/cm2 showed inhibition against both Gram-negative and Gram-positive bacteria effectively, while they presented no toxicity to mammalian cells even at a loading amount of 10 mg/cm2. These results demonstrate a new simple and practicable method to offer antimicrobial properties to medical devices for hernia repair.
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Affiliation(s)
- Pengbi Liu
- College of Textiles , Donghua University , Shanghai 201620 , P. R. China
- Department of Chemical and Life Science Engineering, School of Engineering , Virginia Commonwealth University , Richmond , Virginia 23284 , United States
| | - Kun Fu
- Department of Chemical and Life Science Engineering, School of Engineering , Virginia Commonwealth University , Richmond , Virginia 23284 , United States
- Department of Stomatology , The First Affiliated Hospital of Zhengzhou University , Zhengzhou , Henan 450052 , P. R. China
| | - Xiaomei Zeng
- Department of Chemical and Life Science Engineering, School of Engineering , Virginia Commonwealth University , Richmond , Virginia 23284 , United States
| | - Nanliang Chen
- College of Textiles , Donghua University , Shanghai 201620 , P. R. China
| | - Xuejun Wen
- Department of Chemical and Life Science Engineering, School of Engineering , Virginia Commonwealth University , Richmond , Virginia 23284 , United States
- Beijing Ditan Hospital , Capital Medical University , Beijing 100015 , P. R. China
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Friesenbichler J, Bergovec M, Maurer-Ertl W, Reinbacher P, Maier M, Amerstorfer F, Leithner A. [Silver coating on tumour prostheses]. DER ORTHOPADE 2019; 48:598-604. [PMID: 30927028 DOI: 10.1007/s00132-019-03720-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Modular endoprostheses, so-called "tumour or megaprostheses" are mainly used for limb salvage surgery after resection of malignant soft tissue or a bone tumour. Sometimes, this type of prosthesis is also used for revision surgeries after failed primary joint arthroplasty. Despite continuously improving techniques and quality management systems, periprosthetic infection is one of the most serious complications. AIM OF THE STUDY Review of the literature in the PubMed data base with the main focus on silver coatings in joint arthroplasty and their effect on infection rate, outcome and patients' safety. RESULTS The current literature shows that there is a beneficial role of silver coatings in megaprostheses in terms of revision rates for septic complications, especially following tumour resection with bad soft tissue coverage or in (multimorbid) high-risk patients, compared to uncoated implants. DISCUSSION Based on the results of previous publications examining blood or serum silver concentrations or silver levels in urine, silver coatings do not appear to have side effects, except for local argyria. Continuous monitoring of silver levels in blood or serum is still recommended, and additional long-term studies will be necessary to verify the effectiveness and safety of silver coatings.
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Affiliation(s)
- J Friesenbichler
- Univ. Klinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich.
| | - M Bergovec
- Univ. Klinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - W Maurer-Ertl
- Univ. Klinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - P Reinbacher
- Univ. Klinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - M Maier
- Univ. Klinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - F Amerstorfer
- Univ. Klinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - A Leithner
- Univ. Klinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
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Alaee F, Angerame M, Bradbury T, Blackwell R, Booth RE, Brekke AC, Courtney PM, Frenkel T, Grieco Silva FR, Heller S, Hube R, Ismaily S, Jennings J, Lee M, Noble PC, Ponzio D, Saxena A, Simpson H, Smith BM, Smith EB, Stephens S, Vasarhelyi E, Wang Q, Yeo SJ. General Assembly, Prevention, Operating Room - Surgical Technique: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S139-S146. [PMID: 30348556 DOI: 10.1016/j.arth.2018.09.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Wyatt MC, Foxall-Smith M, Roberton A, Beswick A, Kieser DC, Whitehouse MR. The use of silver coating in hip megaprostheses: a systematic review. Hip Int 2019; 29:7-20. [PMID: 30442019 DOI: 10.1177/1120700018811070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Retrospective studies of silver-coated hip implants have demonstrated promising results and safety profile, however, the potential benefits are so far unproven in prospective studies. Silver-coated implants may have a role in patients undergoing revision or primary surgery with a high risk of infection but as yet there are no human studies investigating silver in primary hip arthroplasty. Adequately powered robust prospective studies are needed in this area to determine if silver-coated implants would be efficacious and cost-effective. The purpose of this systematic review article is to review the current literature regarding the use of silver in hip arthroplasty. Our review showed that there is some encouraging evidence that silver coatings can reduce infection.
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Affiliation(s)
- Michael C Wyatt
- 1 Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, New Zealand
| | - Michael Foxall-Smith
- 2 Musculoskeletal Research Unit, Southmead Hospital, Bristol, UK.,3 North Devon District Hospital, Barnstaple, UK
| | - Andrew Roberton
- 2 Musculoskeletal Research Unit, Southmead Hospital, Bristol, UK.,3 North Devon District Hospital, Barnstaple, UK
| | - Andrew Beswick
- 2 Musculoskeletal Research Unit, Southmead Hospital, Bristol, UK
| | - David C Kieser
- 1 Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch, New Zealand
| | - Michael R Whitehouse
- 4 National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK.,5 Faculty of Health Sciences, University of Bristol, UK
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One-stage exchange with antibacterial hydrogel coated implants provides similar results to two-stage revision, without the coating, for the treatment of peri-prosthetic infection. Knee Surg Sports Traumatol Arthrosc 2018; 26:3362-3367. [PMID: 29549387 DOI: 10.1007/s00167-018-4896-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/12/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Aim of this study was to verify the hypothesis that a one-stage exchange procedure, performed with an antibiotic-loaded, fast-resorbable hydrogel coating, provides similar infection recurrence rate than a two-stage procedure without the coating, in patients affected by peri-prosthetic joint infection (PJI). METHODS In this two-center case-control, study, 22 patients, treated with a one-stage procedure, using implants coated with an antibiotic-loaded hydrogel [defensive antibacterial coating (DAC)], were compared with 22 retrospective matched controls, treated with a two-stage revision procedure, without the coating. RESULTS At a mean follow-up of 29.3 ± 5.0 months, two patients (9.1%) in the DAC group showed an infection recurrence, compared to three patients (13.6%) in the two-stage group. Clinical scores were similar between groups, while average hospital stay and antibiotic treatment duration were significantly reduced after one-stage, compared to two-stage (18.9 ± 2.9 versus 35.8 ± 3.4 and 23.5 ± 3.3 versus 53.7 ± 5.6 days, respectively). CONCLUSIONS Although in a relatively limited series of patients, our data shows similar infection recurrence rate after one-stage exchange with DAC-coated implants, compared to two-stage revision without coating, with reduced overall hospitalization time and antibiotic treatment duration. These findings warrant further studies in the possible applications of antibacterial coating technologies to treat implant-related infections. LEVEL OF EVIDENCE III.
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Jin S, Li J, Wang J, Jiang J, Zuo Y, Li Y, Yang F. Electrospun silver ion-loaded calcium phosphate/chitosan antibacterial composite fibrous membranes for guided bone regeneration. Int J Nanomedicine 2018; 13:4591-4605. [PMID: 30127608 PMCID: PMC6091484 DOI: 10.2147/ijn.s167793] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The purpose of this study is to construct a guided bone regeneration membrane that is similar to bone components and structurally resembles the native extracellular matrix with sufficient antibacterial properties. MATERIALS AND METHODS A novel type of biomimetic and bioactive silver ion-loaded calcium phosphate/chitosan (Ag-CaP/CS) membrane with antibacterial ability was successfully developed by incorporation of silver ion-loaded CaP via a one-step electrospinning method and subsequently crosslinked with vanillin. RESULTS Evaluation of the physicochemical properties revealed that the fabricated fibrous membranes mimicked the extracellular matrix structure and the addition of CaP significantly increased the mineralization ability of the membranes. Importantly, the Ag-CaP/CS membranes exhibited a sustainable release of Ag+, which in turn inhibited the adhesion and growth of Staphylococcus mutans. The results of cell adhesion and MTT assay revealed that the Ag-CaP/CS membranes were cytocompatible with bone marrow stromal cells. CONCLUSION The fabricated electrospinning Ag-CaP/CS nanofiber membranes with excellent biocompatibility and strong antimicrobial properties have great potential to be used for guided bone regeneration.
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Affiliation(s)
- Shue Jin
- Research Center for Nano-Biomaterials, Analytical and Testing Center, Sichuan University, Chengdu 610064, China,
| | - Jidong Li
- Research Center for Nano-Biomaterials, Analytical and Testing Center, Sichuan University, Chengdu 610064, China,
| | - Jian Wang
- Research Center for Nano-Biomaterials, Analytical and Testing Center, Sichuan University, Chengdu 610064, China,
| | - Jiaxing Jiang
- Research Center for Nano-Biomaterials, Analytical and Testing Center, Sichuan University, Chengdu 610064, China,
| | - Yi Zuo
- Research Center for Nano-Biomaterials, Analytical and Testing Center, Sichuan University, Chengdu 610064, China,
| | - Yubao Li
- Research Center for Nano-Biomaterials, Analytical and Testing Center, Sichuan University, Chengdu 610064, China,
| | - Fang Yang
- Department of Biomaterials, Radboud University Medical Center, Nijmegen, the Netherlands,
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Economic Evaluation of Antibacterial Coatings on Healthcare Costs in First Year Following Total Joint Arthroplasty. J Arthroplasty 2018. [PMID: 29530518 DOI: 10.1016/j.arth.2018.01.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Antibacterial coatings (ABCs) of implants have proven safe and effective to reduce postsurgical infection, but little is known about their possible economic impact on large-scale use. This study evaluated the point of economic balance, during the first year after surgery, and the potential overall annual healthcare cost savings of 3 different antibacterial technologies applied to joint arthroplasty: a dual-antibiotic-loaded bone cement (COPAL G + C), an antibacterial hydrogel coating (DAC), and a silver coating (Agluna). METHODS The variables included in the algorithm were average cost and number of primary joint arthroplasties; average cost per patient of the ABC; incidence of periprosthetic joint infections and expected reduction using the ABCs; average cost of infection treatment and expected number of cases. RESULTS The point of economic balance for COPAL G + C, DAC, and Agluna in the first year after surgery was reached in patient populations with an expected postsurgical infection rate of 1.5%, 2.6%, and 19.2%, respectively. If applied on a national scale, in a moderately high-risk population of patients with a 5% expected postsurgical infection rate, COPAL G + C and DAC hydrogel would provide annual direct cost savings of approximately €48,800,000 and €43,200,000 (€1220 and €1080 per patient), respectively, while the silver coating would be associated with an economic loss of approximately €136,000,000. CONCLUSION This economic evaluation shows that ABC technologies have the potential to decrease healthcare costs primarily by decreasing the incidence of surgical site infections, provided that the technology is used in the appropriate risk class of patients.
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Schmidt-Braekling T, Streitbuerger A, Gosheger G, Boettner F, Nottrott M, Ahrens H, Dieckmann R, Guder W, Andreou D, Hauschild G, Moellenbeck B, Waldstein W, Hardes J. Silver-coated megaprostheses: review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:483-489. [PMID: 28265758 DOI: 10.1007/s00590-017-1933-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/26/2017] [Indexed: 01/06/2023]
Abstract
Periprosthetic infection remains one of the most serious complications following megaendoprostheses. Despite a large number of preventive measures that have been introduced in recent years, it has not been possible to further reduce the rate of periprosthetic infection. With regard to metallic modification of implants, silver in particular has been regarded as highly promising, since silver particles combine a high degree of antimicrobial activity with a low level of human toxicity. This review provides an overview of the history of the use of silver as an antimicrobial agent, its mechanism of action, and its clinical application in the field of megaendoprosthetics. The benefits of silver-coated prostheses could not be confirmed until now. However, a large number of retrospective studies suggest that the rate of periprosthetic infections could be reduced by using silver-coated megaprostheses.
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Affiliation(s)
- Tom Schmidt-Braekling
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany.
| | - Arne Streitbuerger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | - Markus Nottrott
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Helmut Ahrens
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Ralf Dieckmann
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Wiebke Guder
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Dimosthenis Andreou
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Gregor Hauschild
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Burkhard Moellenbeck
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
| | - Wenzel Waldstein
- Department of Orthopedics, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Jendrik Hardes
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, Germany
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Modular Endoprostheses for Nonneoplastic Conditions: Midterm Complications and Survival. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2606521. [PMID: 28050552 PMCID: PMC5165145 DOI: 10.1155/2016/2606521] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/26/2016] [Accepted: 11/03/2016] [Indexed: 11/20/2022]
Abstract
The use of modular endoprostheses is a viable option to manage both tumor resection and severe bone loss due to nonneoplastic conditions such as fracture sequelae, failed osteoarticular grafts, arthroplasty revisions, and periprosthetic fractures. We sought to investigate both midterm complications and failures occurred in 87 patients who underwent a megaprosthetic reconstruction in a nonneoplastic setting. After a mean follow-up of 58 (1–167) months, overall failure-free survival was 91.5% at 1 year, 80% at 2 years, 71.6% at 5 years, and 69.1% at 5 and 10 years. There was no significant difference in the survival rate according to the diagnosis at the index procedure (p = 0.921), nor to the reconstruction site (p = 0.402). The use of megaprostheses in a postneoplastic setting did not affect survival rate in comparison with endoprosthetic reconstruction of pure nonneoplastic conditions (p = 0.851). Perimegaprosthetic infection was the leading complication, occurring in 10 (11.5%) patients and implying a megaprosthetic revision in all but one case. Physicians should consider these results when discussing with patients desired outcomes of endoprosthetic reconstructions of a nonneoplastic disease.
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