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Hamilton JL, Gianotti S, Fischer J, Della Fara G, Impergre A, De Vecchi F, AbuAlia M, Fischer A, Markovics A, Wimmer MA. Electrophoretic Deposition of Gentamicin Into Titania Nanotubes Prevents Evidence of Infection in a Mouse Model of Periprosthetic Joint Infection. J Orthop Res 2025; 43:671-681. [PMID: 39741387 DOI: 10.1002/jor.26029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 09/05/2024] [Revised: 11/15/2024] [Accepted: 12/04/2024] [Indexed: 01/03/2025]
Abstract
Periprosthetic joint infection (PJI) is a leading cause and major complication of joint replacement failure. As opposed to standard-of-care systemic antibiotic prophylaxis for PJI, we developed and tested titanium femoral intramedullary implants with titania nanotubes (TNTs) coated with the antibiotic gentamicin and slow-release agent chitosan through electrophoretic deposition (EPD) in a mouse model of PJI. We hypothesized that these implants would enable local gentamicin delivery to the implant surface and surgical site, effectively preventing bacterial colonization. In the mouse PJI model, C57BL/6 mice received implants with TNTs coated with chitosan (chitosan group; control group) or with TNTs coated with chitosan and gentamicin (chitosan + gentamicin group; experimental group). Following implant placement, the surgical site was inoculated with 1 × 103 CFUs of Xen36 bioluminescent Staphylococcus aureus. All the mice in the chitosan group and none in the chitosan + gentamicin group had evidence of infection based on CFU analysis and bioluminescence imaging through the 14-day assessment postsurgery. Correspondingly, scanning electron microscopy analysis at the implant surface demonstrated bacterial biofilm only in the chitosan group. Furthermore, periosteal reaction and peri-implant bone loss at the femur were significantly reduced in the chitosan + gentamicin group. The chitosan + gentamicin group had reduced pain behavior, improved weight-bearing, and increased weight compared to the chitosan-control group. This study provides preclinical evidence supporting the efficacy of implants with TNTs coated with chitosan and gentamicin through EPD for preventing bacterial colonization and biofilm formation in a mouse model of PJI.
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Affiliation(s)
- John L Hamilton
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Sofia Gianotti
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Julia Fischer
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Greta Della Fara
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Amandine Impergre
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Francesca De Vecchi
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Mohammed AbuAlia
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Alfons Fischer
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Department of Microstructure Physics and Alloy Design, Max-Planck-Institute for Sustainable Materials, Duesseldorf, Germany
| | - Adrienn Markovics
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Markus A Wimmer
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Straub J, Baertl S, Verheul M, Walter N, Wong RMY, Alt V, Rupp M. Antimicrobial resistance: Biofilms, small colony variants, and intracellular bacteria. Injury 2024; 55 Suppl 6:111638. [PMID: 39482024 DOI: 10.1016/j.injury.2024.111638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 03/27/2024] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 11/03/2024]
Abstract
Soft tissue and bone infections continue to be a serious complication in orthopedic and trauma surgery. Both can lead to a high burden for the patients and the healthcare system. Musculoskeletal infections can be induced by intraoperative contamination, bacterial contamination of open wounds or hematogenous bacterial spread. During the recent decades, advances were achieved in the understanding of pathogenesis and antibiotic resistance. Despite some progress in the diagnosis and advancing of therapeutic concepts, groundbreaking successful improvement of treatment concepts is still missing. Current therapy concepts are based on the two pillars consisting of surgical debridement with joint or bone reconstruction as well as prolonged antibiotic therapy. An improved understanding of both host and pathogen-related factors leading to treatment failure is essential in musculoskeletal infections. Therefore, this review aims to give an overview of pathogen-related pathophysiology in musculoskeletal infections. It describes defense strategies of pathogens such as (1) biofilm, its development, characteristics, and treatment options. In addition, (2) characteristics of small colony variants and (3) intracellular bacteria are highlighted. Lastly (4) an outlook for potential and promising future therapeutic strategies is provided.
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Affiliation(s)
- Josina Straub
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Susanne Baertl
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Marielle Verheul
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Nike Walter
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Ronald Man Yeung Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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Hosseini Hooshiar M, Mozaffari A, Hamed Ahmed M, Abdul Kareem R, Jaber Zrzo A, Salah Mansoor A, H Athab Z, Parhizgar Z, Amini P. Potential role of metal nanoparticles in treatment of peri-implant mucositis and peri-implantitis. Biomed Eng Online 2024; 23:101. [PMID: 39396020 PMCID: PMC11470642 DOI: 10.1186/s12938-024-01294-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 06/24/2024] [Accepted: 09/16/2024] [Indexed: 10/14/2024] Open
Abstract
Peri-implantitis (PI), a pathological condition associated with plaque, affects the tissues around dental implants. In addition, peri-implant mucositis (PIM) is a precursor to the destructive inflammatory PI and is an inflammation of the soft tissues surrounding the dental implant. It is challenging to eradicate and regulate the PI treatment due to its limited effectiveness. Currently, there is a significant interest in the development and research of additional biocompatible materials to prevent the failure of dental implants. Nanotechnology has the potential to address or develop solutions to the significant challenge of implant failure caused by cytotoxicity and biocompatibility in dentistry. Nanoparticles (NPs) may be used as carriers for the release of medicines, as well as to make implant coatings and supply appropriate materials for implant construction. Furthermore, the bioactivity and therapeutic efficacy of metal NPs in peri-implant diseases (PID) are substantiated by a plethora of in vitro and in vivo studies. Furthermore, the use of silver (Ag), gold (Au), zinc oxide, titanium oxide (TiO2), copper (Cu), and iron oxide NPs as a cure for dental implant infections brought on by bacteria that have become resistant to several medications is the subject of recent dentistry research. Because of their unique shape-dependent features, which enhance bio-physio-chemical functionalization, antibacterial activity, and biocompatibility, metal NPs are employed in dental implants. This study attempted to provide an overview of the application of metal and metal oxide NPs to control and increase the success rate of implants while focusing on the antimicrobial properties of these NPs in the treatment of PID, including PIM and PI. Additionally, the study reviewed the potential benefits and drawbacks of using metal NPs in clinical settings for managing PID, with the goal of advancing future treatment strategies for these conditions.
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Affiliation(s)
| | - Asieh Mozaffari
- Department of Periodontics, Faculty of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | | | - Athmar Jaber Zrzo
- Collage of Pharmacy, National University of Science and Technology, Dhi Qar, 64001, Iraq
| | | | - Zainab H Athab
- Department of Pharmacy, Al-Zahrawi University College, Karbala, Iraq
| | - Zahra Parhizgar
- Resident of Periodontology, Department of Periodontics, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Parisa Amini
- Department of Periodontology, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.
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Mannala GK, Rupp M, Walter N, Youf R, Bärtl S, Riool M, Alt V. Repetitive combined doses of bacteriophages and gentamicin protect against Staphylococcus aureus implant-related infections in Galleria mellonella. Bone Joint Res 2024; 13:383-391. [PMID: 39089687 PMCID: PMC11293943 DOI: 10.1302/2046-3758.138.bjr-2023-0340.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 08/04/2024] Open
Abstract
Aims Bacteriophages infect, replicate inside bacteria, and are released from the host through lysis. Here, we evaluate the effects of repetitive doses of the Staphylococcus aureus phage 191219 and gentamicin against haematogenous and early-stage biofilm implant-related infections in Galleria mellonella. Methods For the haematogenous infection, G. mellonella larvae were implanted with a Kirschner wire (K-wire), infected with S. aureus, and subsequently phages and/or gentamicin were administered. For the early-stage biofilm implant infection, the K-wires were pre-incubated with S. aureus suspension before implantation. After 24 hours, the larvae received phages and/or gentamicin. In both models, the larvae also received daily doses of phages and/or gentamicin for up to five days. The effect was determined by survival analysis for five days and quantitative culture of bacteria after two days of repetitive doses. Results In the haematogenous infection, a single combined dose of phages and gentamicin, and repetitive injections with gentamicin or in combination with phages, resulted in significantly improved survival rates. In the early-stage biofilm infection, only repetitive combined administration of phages and gentamicin led to a significantly increased survival. Additionally, a significant reduction in number of bacteria was observed in the larvae after receiving repetitive doses of phages and/or gentamicin in both infection models. Conclusion Based on our results, a single dose of the combination of phages and gentamicin is sufficient to prevent a haematogenous S. aureus implant-related infection, whereas gentamicin needs to be administered daily for the same effect. To treat early-stage S. aureus implant-related infection, repetitive doses of the combination of phages and gentamicin are required.
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Affiliation(s)
- Gopala K. Mannala
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
- Department for Psychosomatic Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Raphaelle Youf
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Susanne Bärtl
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martijn Riool
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
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Albavera-Gutierrez RR, Espinosa-Ramos MA, Rebolledo-Bello E, Paredes-Herrera FJ, Carballo-Lucero D, Valencia-Ledezma OE, Castro-Fuentes CA. Prevalence of Staphylococcus aureus Infections in the Implantation of Orthopedic Devices in a Third-Level Hospital: An Observational Cohort Study. Pathogens 2024; 13:620. [PMID: 39204221 PMCID: PMC11357249 DOI: 10.3390/pathogens13080620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 06/17/2024] [Revised: 07/19/2024] [Accepted: 07/24/2024] [Indexed: 09/03/2024] Open
Abstract
Using orthopedic devices or prosthetic joints to treat various conditions is expected in a Traumatology and Orthopedics Unit. Recently, the materials used to build these different devices have evolved; however, pathogens can still infect these materials. Additionally, the immune system has limitations when defending against these pathogens, which results in bacterial infections like Staphylococcus aureus, Methicillin-susceptible Staphylococcus aureus (MSSA) and Methicillin-resistant Staphylococcus aureus (MRSA). A total of 276 patients who attended the Traumatology and Orthopedics Unit of our hospital from 1 June 2018 to 1 June 2019, were included in the present study. Our study analyzed the incidence of S. aureus and other bacterial pathogens in the surgical sites of patients with orthopedic implants, as well as the most used types of implants and implant materials. The specimens obtained from the surgical sites of the patients were cultured in anaerobic and aerobic media for subsequent identification using their phenotypic characteristics. Subsequently, antibiotic susceptibility tests were performed to establish the appropriate treatment. The primary pathogens identified were Staphylococcus aureus (26.4%), followed by Escherichia coli (21.0%) and Staphylococcus epidermidis (15.8%). The most commonly used implants were plates (41.7%), followed by endomedullary nails (20%), Kirschner wires (14.1%), and fixators (10.1%). As for the anatomical regions of the implants, the most frequent sites were the legs, followed by the thighs, wrists, and ankles. The pathogens were more susceptible to ciprofloxacin (95%), clindamycin (89%), and cefotaxime (86%). S. aureus is the primary infectious agent in our hospital, with an incidence of 26.4% after the placement of orthopedic implants. Although its incidence was lower compared to other tertiary hospitals, it is necessary to improve aseptic techniques in such a way as to reduce the incidence of this pathogen further.
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Affiliation(s)
- Roberto Renan Albavera-Gutierrez
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico
| | - Manuel A Espinosa-Ramos
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico
| | - Ernesto Rebolledo-Bello
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico
| | - Francisco Javier Paredes-Herrera
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico
| | - Daniel Carballo-Lucero
- Traumatology and Orthopedics Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico
| | - Omar Esteban Valencia-Ledezma
- Research Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico
| | - Carlos Alberto Castro-Fuentes
- Research Unit, Hospital Regional de Alta Especialidad de Ixtapaluca, IMSS-BIENESTAR. Calle Gustavo E. Campa 54, Col. Guadalupe Inn, Alcaldía Álvaro Obregón, Ciudad de México C.P. 01020, Mexico
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6
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Jaekel C, Windolf CD, Bieler D, Oezel L, Seiler LF, Lakomek FN, Beyersdorf C, Mertens J, Steuwe A, Windolf J, Grassmann JP. Efficacy of lysostaphin-coated titanium plates on implant-associated MRSA osteitis in minipigs. Eur J Trauma Emerg Surg 2024; 50:887-895. [PMID: 38265442 PMCID: PMC11249774 DOI: 10.1007/s00068-024-02448-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 11/26/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Abstract
PURPOSE The growing incidence of implant-associated infections (IAIs) caused by biofilm-forming Staphylococcus aureus in combination with an increasing resistance to antibiotics requires new therapeutic strategies. Lysostaphin has been shown to eliminate this biofilm. Own studies confirm the effectiveness in a murine model. The current study characterizes the effects of lysostaphin-coated plates in an IAI minipig model. METHODS The femur of 30 minipigs was stabilized with a five-hole plate, a bone defect was created, and in 20 cases methicillin-resistant Staphylococcus aureus was applied. Ten animals served as control group. After 14 days, local debridement, lavage, and plate exchange (seven-hole plate) were performed. Ten of the infected minipigs received an uncoated plate and 10 a lysostaphin-coated plate. On day 84, the minipigs were again lavaged, followed by euthanasia. Bacterial load was quantified by colony-forming units (CFU). Immunological response was determined by neutrophils, as well as interleukins. Fracture healing was assessed radiologically. RESULTS CFU showed significant difference between infected minipigs with an uncoated plate and minipigs with a lysostaphin-coated plate (p = 0.0411). The infection-related excessive callus formation and calcification was significantly greater in the infected animals with an uncoated plate than in animals with a lysostaphin-coated plate (p = 0.0164/p = 0.0033). The analysis of polymorphonuclear neutrophils and interleukins did not reveal any pioneering findings. CONCLUSION This study confirms the minipig model for examining IAI. Furthermore, coating of plates using lysostaphin could be a promising tool in the therapeutic strategies of IAI. Future studies should focus on coating technology of implants and on translation into a clinical model.
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Affiliation(s)
- Carina Jaekel
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Ceylan D Windolf
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Dan Bieler
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
- Department of Trauma Surgery and Orthopedics, Reconstructive Surgery, Hand Surgery and Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Lisa Oezel
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Lars F Seiler
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Felix N Lakomek
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christoph Beyersdorf
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jann Mertens
- Department of Trauma Surgery, Orthopaedics and Hand Surgery, Städtisches Klinikum Solingen, Solingen, Germany
| | - Andrea Steuwe
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Joachim Windolf
- Department of Orthopaedics and Trauma Surgery, Medical Faculty and University Hospital, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jan P Grassmann
- Department of Trauma, Hand and Reconstructive Surgery, Klinikum Osnabrück GmbH, Osnabrück, Germany
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Graziani G, Ghezzi D, Boi M, Baldini N, Sassoni E, Cappelletti M, Fedrizzi G, Maglio M, Salamanna F, Tschon M, Martini L, Zaffagnini S, Fini M, Sartori M. Ionized jet deposition of silver nanostructured coatings: Assessment of chemico-physical and biological behavior for application in orthopedics. BIOMATERIALS ADVANCES 2024; 159:213815. [PMID: 38447383 DOI: 10.1016/j.bioadv.2024.213815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Academic Contribution Register] [Received: 07/19/2023] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
Infection is one of the main issues connected to implantation of biomedical devices and represents a very difficult issue to tackle, for clinicians and for patients. This study aimed at tackling infection through antibacterial nanostructured silver coatings manufactured by Ionized Jet Deposition (IJD) for application as new and advanced coating systems for medical devices. Films composition and morphology depending on deposition parameters were investigated and their performances evaluated by correlating these properties with the antibacterial and antibiofilm efficacy of the coatings, against Escherichia coli and Staphylococcus aureus strains and with their cytotoxicity towards human cell line fibroblasts. The biocompatibility of the coatings, the nanotoxicity, and the safety of the proposed approach were evaluated, for the first time, in vitro and in vivo by rat subcutaneous implant models. Different deposition times, corresponding to different thicknesses, were selected and compared. All silver coatings exhibited a highly homogeneous surface composed of nanosized spherical aggregates. All coatings having a thickness of 50 nm and above showed high antibacterial efficacy, while none of the tested options caused cytotoxicity when tested in vitro. Indeed, silver films impacted on bacterial strains viability and capability to adhere to the substrate, in a thickness-dependent manner. The nanostructure obtained by IJD permitted to mitigate the toxicity of silver, conferring strong antibacterial and anti-adhesive features, without affecting the coatings biocompatibility. At the explant, the coatings were still present although they showed signs of progressive dissolution, compatible with the release of silver, but no cracking, delamination or in vivo toxicity was observed.
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Affiliation(s)
- Gabriela Graziani
- BST-NaBi Biomedical Science and Technologies Laboratory and Nanobiotechnology, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
| | - Daniele Ghezzi
- BST-NaBi Biomedical Science and Technologies Laboratory and Nanobiotechnology, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy; Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 42, 40126 Bologna, Italy.
| | - Marco Boi
- BST-NaBi Biomedical Science and Technologies Laboratory and Nanobiotechnology, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
| | - Nicola Baldini
- BST-NaBi Biomedical Science and Technologies Laboratory and Nanobiotechnology, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Via Massarenti 9, 40128 Bologna, Italy
| | - Enrico Sassoni
- Department of Civil, Chemical, Environmental and Materials Engineering, University of Bologna, Via Terracini 28, 40131 Bologna, Italy.
| | - Martina Cappelletti
- Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 42, 40126 Bologna, Italy.
| | - Giorgio Fedrizzi
- Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia-Romagna (IZSLER), Reparto Chimico degli Alimenti, Via Pietro Fiorini 5, 40127 Bologna, Italy.
| | - Melania Maglio
- Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
| | - Francesca Salamanna
- Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
| | - Matilde Tschon
- Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
| | - Lucia Martini
- Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
| | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, via Pupilli 1, 40136 Bologna, Italy.
| | - Milena Fini
- Scientific Direction, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
| | - Maria Sartori
- Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy.
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Onorato F, Masoni V, Gagliardi L, Comba LC, Rivera F. What to Know about Antimicrobial Coatings in Arthroplasty: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:574. [PMID: 38674220 PMCID: PMC11052078 DOI: 10.3390/medicina60040574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Academic Contribution Register] [Received: 01/21/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024]
Abstract
Periprosthetic joint infections (PJIs) are one of the most worrying complications orthopedic surgeons could face; thus, methods to prevent them are evolving. Apart from systemic antibiotics, targeted strategies such as local antimicrobial coatings applied to prosthetics have been introduced. This narrative review aims to provide an overview of the main antimicrobial coatings available in arthroplasty orthopedic surgery practice. The search was performed on the PubMed, Web of Science, SCOPUS, and EMBASE databases, focusing on antimicrobial-coated devices used in clinical practice in the arthroplasty world. While silver technology has been widely adopted in the prosthetic oncological field with favorable outcomes, recently, silver associated with hydroxyapatite for cementless fixation, antibiotic-loaded hydrogel coatings, and iodine coatings have all been employed with promising protective results against PJIs. However, challenges persist, with each material having strengths and weaknesses under investigation. Therefore, this narrative review emphasizes that further clinical studies are needed to understand whether antimicrobial coatings can truly revolutionize the field of PJIs.
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Affiliation(s)
- Francesco Onorato
- Department of Orthopedics and Traumatology, University of Turin, Via Zuretti, 29, 10126 Turin, Italy; (F.O.); (V.M.); (L.G.)
| | - Virginia Masoni
- Department of Orthopedics and Traumatology, University of Turin, Via Zuretti, 29, 10126 Turin, Italy; (F.O.); (V.M.); (L.G.)
| | - Luca Gagliardi
- Department of Orthopedics and Traumatology, University of Turin, Via Zuretti, 29, 10126 Turin, Italy; (F.O.); (V.M.); (L.G.)
- Department of Orthopedics and Traumatology, Ospedale SS Annunziata, ASL CN1, Via Ospedali, 9, 12038 Savigliano, Italy;
| | - Luca Costanzo Comba
- Department of Orthopedics and Traumatology, Ospedale SS Annunziata, ASL CN1, Via Ospedali, 9, 12038 Savigliano, Italy;
| | - Fabrizio Rivera
- Department of Orthopedics and Traumatology, Ospedale SS Annunziata, ASL CN1, Via Ospedali, 9, 12038 Savigliano, Italy;
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Burchard R, Graw J. Use of a silver-coated plate to treat a postoperative infection after high tibial osteotomy - a case report. J Bone Jt Infect 2024; 9:117-119. [PMID: 38779580 PMCID: PMC11110801 DOI: 10.5194/jbji-9-117-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 08/18/2023] [Accepted: 01/26/2024] [Indexed: 05/25/2024] Open
Abstract
Unilateral osteoarthritis of the knee can be treated by osteotomy. In case of postoperative infection after high tibial osteotomy, treatment can be challenging and often requires implant removal with the risk of loss of reduction. In the presented case, a 47-year old patient suffered postoperative infection after high tibial osteotomy using an angular stable plate with the need for multiple revision surgeries and anti-infective therapy. Implant exchange to a silver-coated angular plate led to infection control with undisturbed wound healing and further bone consolidation. Full bone consolidation could be achieved radiographically 12 months after the last revision surgery. One-step implant exchange using silver-coated implants could be a promising approach to address postoperative infections after high tibial osteotomy.
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Affiliation(s)
- Rene Burchard
- University of Marburg, Marburg 35037, Germany
- Department of Orthopaedics and Trauma Surgery, University Hospital of Giessen and Marburg, Marburg 35043, Germany
- Department of Orthopaedics and Trauma Surgery, Lahn-Dill-Kliniken, Dillenburg 35683, Germany
| | - Jan A. Graw
- Department of Anesthesiology and Intensive Care Medicine, Ulm University Hospital, Ulm 89081, Germany
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10
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Graziani G, Ghezzi D, Nudelman F, Sassoni E, Laidlaw F, Cappelletti M, Boi M, Borciani G, Milita S, Bianchi M, Baldini N, Falini G. A natural biogenic fluorapatite as a new biomaterial for orthopedics and dentistry: antibacterial activity of lingula seashell and its use for nanostructured biomimetic coatings. J Mater Chem B 2024; 12:2083-2098. [PMID: 38284627 DOI: 10.1039/d3tb02454g] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 01/30/2024]
Abstract
Calcium phosphates are widely studied in orthopedics and dentistry, to obtain biomimetic and antibacterial implants. However, the multi-substituted composition of mineralized tissues is not fully reproducible from synthetic procedures. Here, for the first time, we investigate the possible use of a natural, fluorapatite-based material, i.e., Lingula anatina seashell, resembling the composition of bone and enamel, as a biomaterial source for orthopedics and dentistry. Indeed, thanks to its unique mineralization process and conditions, L. anatina seashell is among the few natural apatite-based shells, and naturally contains ions having possible antibacterial efficacy, i.e., fluorine and zinc. After characterization, we explore its deposition by ionized jet deposition (IJD), to obtain nanostructured coatings for implantable devices. For the first time, we demonstrate that L. anatina seashells have strong antibacterial properties. Indeed, they significantly inhibit planktonic growth and cell adhesion of both Gram-positive Staphylococcus aureus and Gram-negative Escherichia coli. The two strains show different susceptibility to the mineral and organic parts of the seashells, the first being more susceptible to zinc and fluorine in the mineral part, and the second to the organic (chitin-based) component. Upon deposition by IJD, all films exhibit a nanostructured morphology and sub-micrometric thickness. The multi-doped, complex composition of the target is maintained in the coating, demonstrating the feasibility of deposition of coatings starting from biogenic precursors (seashells). In conclusion, Lingula seashell-based coatings are non-cytotoxic with strong antimicrobial capability, especially against Gram-positive strains, consistently with their higher susceptibility to fluorine and zinc. Importantly, these properties are improved compared to synthetic fluorapatite, showing that the films are promising for antimicrobial applications.
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Affiliation(s)
- Gabriela Graziani
- Biomedical Science, Technologies, and Nanobiotecnology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy. gabriela.graziani(at)polimi.it
| | - Daniele Ghezzi
- Biomedical Science, Technologies, and Nanobiotecnology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy. gabriela.graziani(at)polimi.it
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Fabio Nudelman
- EaStCHEM School of Chemistry, The University of Edinburgh, Edinburgh, UK
| | - Enrico Sassoni
- Department of Civil, Chemical, Environmental and Materials Engineering, University of Bologna, Bologna, Italy
| | - Fraser Laidlaw
- School of Physics and Astronomy, The University of Edinburgh, Edinburgh, UK
| | - Martina Cappelletti
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Marco Boi
- Biomedical Science, Technologies, and Nanobiotecnology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy. gabriela.graziani(at)polimi.it
| | - Giorgia Borciani
- Biomedical Science, Technologies, and Nanobiotecnology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy. gabriela.graziani(at)polimi.it
| | - Silvia Milita
- CNR-Institute for Microelectronic and Microsystems, Bologna, Italy
| | - Michele Bianchi
- Department of Life Sciences, Università di Modena e Reggio Emilia, Modena, Italy
| | - Nicola Baldini
- Biomedical Science, Technologies, and Nanobiotecnology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy. gabriela.graziani(at)polimi.it
- University of Bologna, Department of Biomedical and Neuromotor Sciences, Bologna, Italy
| | - Giuseppe Falini
- Department of Chemistry "Giacomo Ciamician", University of Bologna, Bologna, Italy. giuseppe.falini(at)unibo.it
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11
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Zhou W, Liang J, Huang X, Weir MD, Masri R, Oates TW, Xu HHK, Cheng L. Novel antibacterial titanium implant healing abutment with dimethylaminohexadecyl methacrylate to combat implant-related infections. Dent Mater 2024; 40:244-253. [PMID: 37981511 DOI: 10.1016/j.dental.2023.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 07/06/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE Implant-related infections from the adhesion and proliferation of dental plaque are a major challenge for dental implants. The objectives of this study were to: (1) develop novel antibacterial titanium (Ti) healing abutment; (2) investigate the inhibition of implant infection-related pathogenic bacteria and saliva-derived biofilm, and evaluate the biocompatibility of the new material for the first time. METHODS Dimethylaminohexadecyl methacrylate (DMAHDM) and hydroxyapatite (HAP) were polymerized via polydopamine (PDA) on Ti. Staphylococcus aureus (S. aureus), Streptococcus sanguinis (S. sanguinis) and human saliva-derived biofilms were tested. After 4 weeks of DMAHDM release, the antibacterial efficacy of the DMAHDM remaining on Ti surface and the DMADHM in medium was tested. Biocompatibility was determined using human gingival fibroblasts (HGFs) and periodontal ligament stem cells (PDLSCs). RESULTS The DMAHDM-loaded coating filled into the nano-voids in Ti surfaces. The modified Ti showed potent antibacterial activity, reducing the CFU of S. aureus, S. sanguinis and saliva-derived biofilms by 8, 7 and 4 log, respectively (P < 0.05). After 4 weeks of release, the modified Ti was still able to reduce S. aureus and S. sanguinis biofilm CFU by 1-3 log (P < 0.05). This provided strong antibacterial function for more than 4 weeks, which were the high-risk period for implant infections. The new material showed excellent biocompatibility when compared to control (P > 0.05). CONCLUSION Novel DMAHDM-loaded Ti healing abutment had strong antibacterial effects, reducing biofilm CFUs by orders of magnitude, and lasting for over four weeks to cover the high-risk period for implant infections. The novel antibacterial Ti is promising to combat implant-related infections in dental, craniofacial and orthopedic applications.
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Affiliation(s)
- Wen Zhou
- Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou 350002, China; State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China; Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Jingou Liang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China; Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Xiaoyu Huang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China; Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA; Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Hangzhou, China
| | - Michael D Weir
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Radi Masri
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Thomas W Oates
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA
| | - Hockin H K Xu
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD 21201, USA.
| | - Lei Cheng
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China.
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12
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Rupp M, Walter N, Bärtl S, Heyd R, Hitzenbichler F, Alt V. Fracture-Related Infection-Epidemiology, Etiology, Diagnosis, Prevention, and Treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:17-24. [PMID: 37970721 PMCID: PMC10916768 DOI: 10.3238/arztebl.m2023.0233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Academic Contribution Register] [Received: 06/11/2023] [Revised: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Fracture-related infection (FRI) is a challenge to physicians and other workers in health care. In 2018, there were 7253 listed cases of FRI in Germany, corresponding to an incidence of 10.7 cases per 100 000 persons per year. METHODS This review is based on pertinent publications retrieved from a search in PubMed with the search terms "fracture," "infection," "guideline," and "consensus." Aside from the primary literature, international guidelines and consensus recommendations were evaluated as well. RESULTS FRI arise mainly from bacterial contamination of the fracture site. Staphylococcus aureus is the most commonly detected pathogen. The treatment is based on surgery and antibiotics and should be agreed upon by an interdisciplinary team; it is often difficult because of biofilm formation. Treatment options include implant-preserving procedures and single-stage, two-stage, or multi-stage implant replacement. Treatment failure occurs in 10.3% to 21.4% of cases. The available evidence on the efficacy of various treatment approaches is derived mainly from retrospective cohort studies (level III evidence). Therefore, periprosthetic joint infections and FRI are often discussed together. CONCLUSION FRI presents an increasing challenge. Preventive measures should be optimized, and the treatment should always be decided upon by an interdisciplinary team. Only low-level evidence is available to date to guide diagnostic and treatment decisions. High-quality studies are therefore needed to help us meet this challenge more effectively.
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Affiliation(s)
- Markus Rupp
- These authors share first authorship
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Nike Walter
- These authors share first authorship
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Susanne Bärtl
- Department for Trauma surgery, University Hospital Regensburg, Germany
| | - Robert Heyd
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany
| | - Florian Hitzenbichler
- Department for Hospital hygiene and Infectiology, University Hospital Regensburg, Germany
| | - Volker Alt
- Department for Trauma surgery, University Hospital Regensburg, Germany
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13
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Berberich C, Kühn KD, Alt V. [Bone cement as a local antibiotic carrier]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:981-991. [PMID: 37831092 DOI: 10.1007/s00132-023-04447-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Academic Contribution Register] [Accepted: 09/01/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND There is widespread consensus that adjuvant local use of antimicrobial agents in combination with their systemic administration can better prevent and treat implant-associated musculoskeletal infections. The advantage of local antibiotics lies in their particular pharmacokinetics with initially high antibiotic concentrations at the implant site with only low systemic uptake. AIM OF TREATMENT The aim of local application is to protect the foreign bodies directly at the implantation site from bacterial colonization and biofilm formation (prophylaxis) and to support the eradication of an already established infection after surgical debridement (treatment). Since the observations of Prof. Buchholz, bone cement has been the most frequently used local carrier system. APPLICATION In cases of infection, surgeons should ideally work together with microbiologists, infectiologists or clinical pharmacists to determine which anti-infective agents are indicated systemically for the patient and which ones are indicated locally with PMMA cement, based on the pathogen(s) and antibiograms. However, for the anti-infective agents administered with bone cement, there is still uncertainty about which agents can be added to this carrier material and at what concentrations. Accordingly, the authors of this review article not only summarize the rationale and evidence for local antibiotic use but also elaborate on the points that must be considered for admixing these agents to the cement.
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Affiliation(s)
- Christof Berberich
- Heraeus Medical GmbH, Philipp-Reis-Str. 8/11, 61273, Wehrheim, Deutschland.
| | - Klaus-Dieter Kühn
- Heraeus Medical GmbH, Philipp-Reis-Str. 8/11, 61273, Wehrheim, Deutschland
- Universitätsklinik für Orthopädie und Orthopädische Chirurgie, Medizinische Universität Graz, Graz, Österreich
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
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14
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Lin T, Zhang J, Huo D, Yang F, Zhang J, Huang L, Deng SP, Tan S, Chen H. Silk fibroin-based coating with pH-dependent controlled release of Cu 2+ for removal of implant bacterial infections. J Colloid Interface Sci 2023; 650:1893-1906. [PMID: 37517189 DOI: 10.1016/j.jcis.2023.07.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 02/20/2023] [Revised: 07/18/2023] [Accepted: 07/22/2023] [Indexed: 08/01/2023]
Abstract
The implantation of medical devices is frequently accompanied by the invasion of bacteria, which may lead to implant failure. Therefore, an intelligent and responsive coating seems particularly essential in hindering implant-associated infections. Herein, a self-defensive antimicrobial coating, accompanied by silk fibroin as a valve, was successfully prepared on the titanium (Ti-Cu@SF) for pH-controlled release of Cu2+. The results showed that the layer could set free massive Cu2+ to strive against E. coli and S. aureus for self-defense when exposed to a slightly acidic condition. By contrary, a little Cu2+ was released in the physiological situation, which could avoid damage to the normal cells and showed excellent in vitro pH-dependent antibiosis. Besides, in vivo experiment confirmed that Ti-Cu@SF could work as an antibacterial material to kill S. aureus keenly and display negligible toxicity in vivo. Consequently, the design provided support for endowing the layer with outstanding biocompatibility and addressing the issue of bacterial infection during the implantation of Ti substrates.
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Affiliation(s)
- Tongyao Lin
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China
| | - Jinglin Zhang
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China; School of Light Industry and Materials, Guangdong Polytechnic, Foshan 528041, China
| | - Dongliang Huo
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China
| | - Fengjuan Yang
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China
| | - Jingxian Zhang
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China
| | - Langhuan Huang
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China
| | - Sui-Ping Deng
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China
| | - Shaozao Tan
- Guangdong Engineering & Technology Research Centre of Graphene-like Materials and Products, Department of Chemistry, College of Chemistry and Materials Science, Jinan University, Guangzhou 510632, China; Guangdong Jianpai New Materials Co., Ltd., Foshan 528500, China.
| | - Huifang Chen
- College of Pharmacy, Guangdong Lingnan Institute of Technology, Guangzhou 510663, China.
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15
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Kotsarinis G, Wakefield SM, Kanakaris NK, Giannoudis PV. Stabilization of Tibial Fractures at Risk of Complications With the Bactiguard Intramedullary Nail: Early to Medium Results With a Novel Metal-Coated Device. J Orthop Trauma 2023; 37:S12-S17. [PMID: 37828696 DOI: 10.1097/bot.0000000000002688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Accepted: 08/08/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications. DESIGN This is a retrospective case series with prospectively collected data. SETTING Level I Trauma Centre in the United Kingdom. PATIENTS AND INTERVENTION Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up. MAIN OUTCOME MEASUREMENTS The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions. RESULTS Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; [19.3%]) required reinterventions [2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection). CONCLUSIONS The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Georgios Kotsarinis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Sophia M Wakefield
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; and
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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16
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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] [Academic Contribution 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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17
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Weber J, Henssler L, Zeman F, Pfeifer C, Alt V, Nerlich M, Huber M, Herbst T, Koller M, Schneider-Brachert W, Kerschbaum M, Holzmann T. Nanosilver/DCOIT-containing surface coating effectively and constantly reduces microbial load in emergency room surfaces. J Hosp Infect 2023; 135:90-97. [PMID: 36958698 DOI: 10.1016/j.jhin.2023.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 10/12/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Colonization of near-patient surfaces in hospitals plays an important role as a source of healthcare-associated infections. Routine disinfection methods only result in short-term elimination of pathogens. AIM To investigate the efficiency of a newly developed antimicrobial coating containing nanosilver in long-term reduction of bacterial burden in hospital surfaces to close the gap between routine disinfection cycles. METHODS In this prospective, double-blinded trial, frequently touched surfaces of a routinely used treatment room in an emergency unit of a level-I hospital were treated with a surface coating (nanosilver/DCOIT-coated surface, NCS) containing nanosilver particles and another organic biocidal agent (4,5-dichloro-2-octyl-4-isothiazolin-3-one, DCOIT), whereas surfaces of another room were treated with a coating missing both the nanosilver- and DCOIT-containing ingredient and served as control. Bacterial contamination of the surfaces was examined using contact plates and liquid-based swabs daily for a total trial duration of 90 days. After incubation, total microbial counts and species were assessed. FINDINGS In a total of 2880 antimicrobial samples, a significant reduction of the overall bacterial load was observed in the NCS room (median: 0.31 cfu/cm2; interquartile range: 0.00-1.13) compared with the control coated surfaces (0.69 cfu/cm2; 0.06-2.00; P < 0.001). The nanosilver- and DCOIT-containing surface coating reduced the relative risk of a critical bacterial load (defined as >5 cfu/cm2) by 60% (odds ratio 0.38, P < 0.001). No significant difference in species distribution was detected between NCS and control group. CONCLUSION Nanosilver-/DCOIT-containing surface coating has shown efficiency for sustainable reduction of bacterial load of frequently touched surfaces in a clinical setting.
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Affiliation(s)
- J Weber
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - L Henssler
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - F Zeman
- Center of Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - C Pfeifer
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany; Department of Orthopedic Trauma and Hand Surgery, Innklinikum Altötting-Mühldorf, Altötting, Germany
| | - V Alt
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Nerlich
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Huber
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - T Herbst
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Koller
- Center of Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - W Schneider-Brachert
- Institute of Medical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - M Kerschbaum
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - T Holzmann
- Institute of Medical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
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18
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Ghezzi D, Boi M, Sassoni E, Valle F, Giusto E, Boanini E, Baldini N, Cappelletti M, Graziani G. Customized biofilm device for antibiofilm and antibacterial screening of newly developed nanostructured silver and zinc coatings. J Biol Eng 2023; 17:18. [PMID: 36879323 PMCID: PMC9987098 DOI: 10.1186/s13036-023-00326-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 10/30/2022] [Accepted: 01/19/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Bacterial colonisation on implantable device surfaces is estimated to cause more than half of healthcare-associated infections. The application of inorganic coatings onto implantable devices limits/prevents microbial contaminations. However, reliable and high-throughput deposition technologies and experimental trials of metal coatings for biomedical applications are missing. Here, we propose the combination of the Ionized Jet Deposition (IJD) technology for metal-coating application, with the Calgary Biofilm Device (CBD) for high-throughput antibacterial and antibiofilm screening, to develop and screen novel metal-based coatings. RESULTS The films are composed of nanosized spherical aggregates of metallic silver or zinc oxide with a homogeneous and highly rough surface topography. The antibacterial and antibiofilm activity of the coatings is related with the Gram staining, being Ag and Zn coatings more effective against gram-negative and gram-positive bacteria, respectively. The antibacterial/antibiofilm effect is proportional to the amount of metal deposited that influences the amount of metal ions released. The roughness also impacts the activity, mostly for Zn coatings. Antibiofilm properties are stronger on biofilms developing on the coating than on biofilms formed on uncoated substrates. This suggests a higher antibiofilm effect arising from the direct contact bacteria-coating than that associated with the metal ions release. Proof-of-concept of application to titanium alloys, representative of orthopaedic prostheses, confirmed the antibiofilm results, validating the approach. In addition, MTT tests show that the coatings are non-cytotoxic and ICP demonstrates that they have suitable release duration (> 7 days), suggesting the applicability of these new generation metal-based coatings for the functionalization of biomedical devices. CONCLUSIONS The combination of the Calgary Biofilm Device with the Ionized Jet Deposition technology proved to be an innovative and powerful tool that allows to monitor both the metal ions release and the surface topography of the films, which makes it suitable for the study of the antibacterial and antibiofilm activity of nanostructured materials. The results obtained with the CBD were validated with coatings on titanium alloys and extended by also considering the anti-adhesion properties and biocompatibility. In view of upcoming application in orthopaedics, these evaluations would be useful for the development of materials with pleiotropic antimicrobial mechanisms.
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Affiliation(s)
- Daniele Ghezzi
- Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136, Bologna, Italy
| | - Marco Boi
- Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136, Bologna, Italy
| | - Enrico Sassoni
- Department of Civil, University of Bologna, Chemical, Environmental and Materials Engineering, Via Terracini 28, 40131, Bologna, Italy
| | - Francesco Valle
- Institute of Nanostructured Materials, National Research Council (ISMN-CNR), Via Piero Gobetti, 101, 40129, Bologna, Italy
| | - Elena Giusto
- Blizard Institute, Queen Mary University of London, 4 Newark St, London, E1 2AT, UK
| | - Elisa Boanini
- Department of Chemistry, University of Bologna, Giacomo Ciamician", Via Selmi 2, Bologna, Italy
| | - Nicola Baldini
- Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Via Massarenti 9, 40128, Bologna, Italy
| | - Martina Cappelletti
- Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 42, 40126, Bologna, Italy.
| | - Gabriela Graziani
- Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via Di Barbiano 1/10, 40136, Bologna, Italy.
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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] [Academic Contribution 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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20
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Bottagisio M, Palombella S, Lopa S, Sangalli F, Savadori P, Biagiotti M, Sideratou Z, Tsiourvas D, Lovati AB. Vancomycin-nanofunctionalized peptide-enriched silk fibroin to prevent methicillin-resistant Staphylococcus epidermidis-induced femoral nonunions in rats. Front Cell Infect Microbiol 2023; 12:1056912. [PMID: 36683682 PMCID: PMC9851397 DOI: 10.3389/fcimb.2022.1056912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 09/29/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Implant-related infections and infected fractures are significant burdens in orthopedics. Staphylococcus epidermidis is one of the main causes of bone infections related to biofilm formation upon implants. Current antibiotic prophylaxis/therapy is often inadequate to prevent biofilm formation and results in antibiotic resistance. The development of bioactive materials combining antimicrobial and osteoconductive properties offers great potential for the eradication of microorganisms and for the enhancement of bone deposition in the presence of infections. The purpose of this study is to prevent the development of methicillin-resistant S. epidermidis (MRSE)-infected nonunion in a rat model. Methods To this end, a recently developed in our laboratories bioactive material consisting of antibiotic-loaded nanoparticles based on carboxylic acid functionalized hyperbranched aliphatic polyester (CHAP) that are integrated into peptide-enriched silk fibroin sponges with osteoconductive properties (AFN-PSF) was employed, whose biocompatibility and microbiological tests provided proof of its potential for the treatment of both orthopedic and dental infections. In particular, non-critical femoral fractures fixed with plates and screws were performed in Wistar rats, which were then randomly divided into three groups: 1) the sham control (no infection, no treatment); 2) the control group, infected with MRSE and treated with peptide-enriched silk fibroin sponges incorporating non-drug-loaded functionalized nanoparticles (PSF); 3) the treated group, infected with MRSE and treated with peptide-enriched silk fibroin sponges incorporating vancomycin-loaded functionalized nanoparticles (AFN-PSF). After 8 weeks, bone healing and osteomyelitis were clinically assessed and evaluated by micro-CT, microbiological and histological analyses. Results The sham group showed no signs of infection and complete bone healing. The PSF group failed to repair the infected fracture, displaying 75% of altered bone healing and severe signs of osteomyelitis. The AFN-PSF treated group reached 70% of fracture healing in the absence of signs of osteomyelitis, such as abscesses in the cortical and intraosseous compartments and bone necrosis with sequestra. Discussion AFN-PSF sponges have proven effective in preventing the development of infected nonunion in vivo. The proposed nanotechnology for local administration of antibiotics can have a significant impact on patient health in the case of orthopedic infections.
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Affiliation(s)
- Marta Bottagisio
- IRCCS Istituto Ortopedico Galeazzi, Laboratory of Clinical Chemistry and Microbiology, Milan, Italy
| | - Silvia Palombella
- IRCCS Istituto Ortopedico Galeazzi, Cell and Tissue Engineering Laboratory, Milan, Italy
| | - Silvia Lopa
- IRCCS Istituto Ortopedico Galeazzi, Cell and Tissue Engineering Laboratory, Milan, Italy
| | - Fabio Sangalli
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Laboratory of Renal Biophysics, Department of Biomedical Engineering, Bergamo, Italy
| | - Paolo Savadori
- IRCCS Istituto Ortopedico Galeazzi, Department of Endodontics, Milan, Italy
| | | | - Zili Sideratou
- National Centre for Scientific Research "Demokritos", Institute of Nanoscience and Nanotechnology, Aghia Paraskevi, Greece
| | - Dimitris Tsiourvas
- National Centre for Scientific Research "Demokritos", Institute of Nanoscience and Nanotechnology, Aghia Paraskevi, Greece
| | - Arianna B Lovati
- IRCCS Istituto Ortopedico Galeazzi, Cell and Tissue Engineering Laboratory, Milan, Italy
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21
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Costa RC, Nagay BE, Dini C, Borges MHR, Miranda LFB, Cordeiro JM, Souza JGS, Sukotjo C, Cruz NC, Barão VAR. The race for the optimal antimicrobial surface: perspectives and challenges related to plasma electrolytic oxidation coating for titanium-based implants. Adv Colloid Interface Sci 2023; 311:102805. [PMID: 36434916 DOI: 10.1016/j.cis.2022.102805] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 06/15/2022] [Revised: 10/01/2022] [Accepted: 10/20/2022] [Indexed: 01/24/2023]
Abstract
Plasma electrolytic oxidation (PEO) is a low-cost, structurally reliable, and environmentally friendly surface modification method for orthopedic and dental implants. This technique is successful for the formation of porous, corrosion-resistant, and bioactive coatings, besides introducing antimicrobial compounds easily. Given the increase in implant-related infections, antimicrobial PEO-treated surfaces have been widely proposed to surmount this public health concern. This review comprehensively discusses antimicrobial implant surfaces currently produced by PEO in terms of their in vitro and in vivo microbiological and biological properties. We present a critical [part I] and evidence-based [part II] review about the plethora of antimicrobial PEO-treated surfaces. The mechanism of microbial accumulation on implanted devices and the principles of PEO technology to ensure antimicrobial functionalization by one- or multi-step processes are outlined. Our systematic literature search showed that particular focus has been placed on the metallic and semi-metallic elements incorporated into PEO surfaces to facilitate antimicrobial properties, which are often dose-dependent, without leading to cytotoxicity in vitro. Meanwhile, there are concerns over the biocompatibility of PEO and its long-term antimicrobial effects in animal models. We clearly highlight the importance of using clinically relevant infection models and in vivo long-term assessments to guarantee the rational design of antimicrobial PEO-treated surfaces to identify the 'finish line' in the race for antimicrobial implant surfaces.
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Affiliation(s)
- Raphael C Costa
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, Sāo Paulo 13414-903, Brazil
| | - Bruna E Nagay
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, Sāo Paulo 13414-903, Brazil
| | - Caroline Dini
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, Sāo Paulo 13414-903, Brazil
| | - Maria H R Borges
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, Sāo Paulo 13414-903, Brazil
| | - Luís F B Miranda
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, Sāo Paulo 13414-903, Brazil
| | - Jairo M Cordeiro
- Department of Dentistry, Centro Universitário das Faculdades Associadas de Ensino (UNIFAE), Sāo Joāo da Boa Vista, Sāo Paulo 13870-377, Brazil
| | - Joāo G S Souza
- Dental Research Division, Guarulhos University, Guarulhos, Sāo Paulo 07023-070, Brazil; Dentistry Science School (Faculdade de Ciências Odontológicas - FCO), Montes Claros, Minas Gerais 39401-303, Brazil
| | - Cortino Sukotjo
- Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL 60612, USA
| | - Nilson C Cruz
- Laboratory of Technological Plasmas, Institute of Science and Technology, Sāo Paulo State University (UNESP), Sorocaba, Sāo Paulo 18087-180, Brazil
| | - Valentim A R Barão
- Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, Sāo Paulo 13414-903, Brazil.
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Choi S, Lee H, Hong R, Jo B, Jo S. Application of Multi-Layered Temperature-Responsive Polymer Brushes Coating on Titanium Surface to Inhibit Biofilm Associated Infection in Orthopedic Surgery. Polymers (Basel) 2022; 15:polym15010163. [PMID: 36616511 PMCID: PMC9823637 DOI: 10.3390/polym15010163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 12/01/2022] [Revised: 12/25/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Infection associated with biomedical implants remains the main cause of failure, leading to reoperation after orthopedic surgery. Orthopedic infections are characterized by microbial biofilm formation on the implant surface, which makes it challenging to diagnose and treat. One potential method to prevent and treat such complications is to deliver a sufficient dose of antibiotics at the onset of infection. This strategy can be realized by coating the implant with thermoregulatory polymers and triggering the release of antibiotics during the acute phase of infection. We developed a multi-layered temperature-responsive polymer brush (MLTRPB) coating that can release antibiotics once the temperature reaches a lower critical solution temperature (LCST). The coating system was developed using copolymers composed of diethylene glycol methyl ether methacrylate and 2-hydroxyethyl methacrylate by alternatively fabricating monomers layer by layer on the titanium surface. LCST was set to the temperature of 38-40 °C, a local temperature that can be reached during infection. The antibiotic elution characteristics were investigated, and the antimicrobial efficacy was tested against S. aureus species (Xen29 ATCC 29 213) using one to four layers of MLTRPB. Both in vitro and in vivo assessments demonstrated preventive effects when more than four layers of the coating were applied, ensuring promising antibacterial effects of the MLTRPB coating.
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Affiliation(s)
- Sookyung Choi
- School of Medicine, Chosun University Medical School, Gwangju 61452, Republic of Korea
| | - Hyeonjoon Lee
- Department of Orthopedic Surgery, Chosun University Hospital, Gwangju 61453, Republic of Korea
| | - Ran Hong
- School of Medicine, Chosun University Medical School, Gwangju 61452, Republic of Korea
- Department of Pathology, Chosun University Hospital, Gwangju 61453, Republic of Korea
| | - Byungwook Jo
- School of Engineering, Chosun University, Gwangju 61452, Republic of Korea
| | - Suenghwan Jo
- School of Medicine, Chosun University Medical School, Gwangju 61452, Republic of Korea
- Department of Orthopedic Surgery, Chosun University Hospital, Gwangju 61453, Republic of Korea
- Correspondence: ; Tel.: +82-62-220-3147
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23
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Ghezzi D, Sassoni E, Boi M, Montesissa M, Baldini N, Graziani G, Cappelletti M. Antibacterial and Antibiofilm Activity of Nanostructured Copper Films Prepared by Ionized Jet Deposition. Antibiotics (Basel) 2022; 12:55. [PMID: 36671256 PMCID: PMC9854604 DOI: 10.3390/antibiotics12010055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 12/02/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Metal coatings represent good strategies to functionalize surfaces/devices and limit bacterial contamination/colonization thanks to their pleiotropic activity and their ability to prevent the biofilm formation. Here, we investigated the antibacterial and antibiofilm capacity of copper coatings deposited through the Ionized Jet Deposition (IJD) on the Calgary Biofilm Device (CBD) against the growth of two gram-negative and two gram-positive pathogenic strains. Three areas (i.e., (+)Cu, (++)Cu, and (+++)Cu based on the metal amount) on the CBD were obtained, presenting nanostructured coatings with high surface homogeneity and increasing dimensions of aggregates from the CBD periphery to the centre. The coatings in (++)Cu and (+++)Cu were efficient against the planktonic growth of the four pathogens. This antibacterial effect decreased in (+)Cu but was still significant for most of the pathogens. The antibiofilm efficacy was significant for all the strains and on both coated and uncoated surfaces in (+++)Cu, whereas in (++)Cu the only biofilms forming on the coated surfaces were inhibited, suggesting that the decrease of the metal on the coatings was associated to a reduced metal ion release. In conclusion, this work demonstrates that Cu coatings deposited by IJD have antibacterial and antibiofilm activity against a broad range of pathogens indicating their possible application to functionalize biomedical devices.
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Affiliation(s)
- Daniele Ghezzi
- BST Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Enrico Sassoni
- Department of Civil, Chemical, Environmental and Materials Engineering, University of Bologna, Via Terracini 28, 40131 Bologna, Italy
| | - Marco Boi
- BST Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Matteo Montesissa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via Massarenti 9, 40128 Bologna, Italy
| | - Nicola Baldini
- BST Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via Massarenti 9, 40128 Bologna, Italy
| | - Gabriela Graziani
- BST Biomedical Science and Technologies and Nanobiotechnology Lab, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - Martina Cappelletti
- Department of Pharmacy and Biotechnology, University of Bologna, Via Irnerio 42, 40126 Bologna, Italy
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24
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Schoder S, Lafuente M, Alt V. Silver-coated versus uncoated locking plates in subjects with fractures of the distal tibia: a randomized, subject and observer-blinded, multi-center non-inferiority study. Trials 2022; 23:968. [PMID: 36456987 PMCID: PMC9714230 DOI: 10.1186/s13063-022-06919-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 05/02/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Antimicrobial coatings of implants are of interest to reduce infection rate in orthopedic surgery. Demonstration of clinical effectiveness of such coated implants to obtain market approval is challenging. The objective of this article is to define a design for a randomized controlled trial to evaluate the clinical performance of a silver-coating for locking plates for fracture treatment. METHODS The study design has to respect different criteria, such as feasibility, focus on overall complications, such as functional impairment, fracture healing, and particularly on infection rates. Distal tibia fractures were chosen due to the high prevalence of infections in this type of injuries, which warrants a particular benefit of antimicrobial prophylaxis and thus might allow to see a statistical trend in favor of the coated product. The study design was defined as a randomized, controlled, subject and observer-blinded, multi-center study in subjects with fractures of the distal tibia with a total of 226 patients. A number of 113 patients are planned for each of the two treatment arms with treatment of the fracture with a silver-coated device (first arm) or with an uncoated device (second arm). Inclusion criteria are closed fractures of the distal tibia according to the Tscherne-Oestern classification or open fractures of the distal tibia according to the Gustilo-Anderson classification in subjects older than 18 years. Primary outcome parameter is the Anticipated Adverse Device Effects (AADE) including all typical complications of this type of injury, such as functional impairment of the affected limb, non-union, and infections based on a non-inferiority study design. Also, silver-typical complications, such as argyria, are included. Secondary parameters are infection rates and fracture healing. Follow-up of patients includes five visits with clinical and X-ray evaluations with a follow-up time of 12 months. DISCUSSION Demonstration of clinical effectiveness of antimicrobial coatings of fracture fixation devices remains a challenge. Definition of a prospective randomized pre-market trial design and recruitment of clinical sites for such a study is possible. A confirmative proof of the expected clinical benefit in terms of reduction of device-related infections will be addressed with a prospective post-market clinical follow-up study in a second step due to the large sample size required. TRIAL REGISTRATION ClinicalTrials.gov NCT05260463. Registered on 02 March 2022.
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Affiliation(s)
- S. Schoder
- grid.508869.a0000 0004 0477 4388aap Implantate AG, Lorenzweg 5, 12099 Berlin, Germany
| | - M. Lafuente
- grid.508869.a0000 0004 0477 4388aap Implantate AG, Lorenzweg 5, 12099 Berlin, Germany
| | - V. Alt
- grid.411941.80000 0000 9194 7179Universitätsklinikum Regensburg, Klinik und Poliklinik für Unfallchirurgie, Franz-Josef-Strauß-Allee 111, 93042 Regensburg, Germany
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25
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Alt V, Pfeifer C, Rupp M, Walter N. Treatment of a Gustilo-Anderson type II open tibia shaft fracture with an ultrathin silver plasma-coated plate: A case report. Trauma Case Rep 2022; 42:100715. [PMID: 36299855 PMCID: PMC9589016 DOI: 10.1016/j.tcr.2022.100715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Accepted: 10/15/2022] [Indexed: 10/31/2022] Open
Abstract
The treatment of open tibia fractures with plate fixation bears a high risk for the development of a fracture-related infection. Here we present a case of an 80-year-old female with a Gustilo-Anderson type II open distal tibial shaft fracture with an indwelling knee prosthesis. The case was successfully treated with a 2-stage procedure with initial external fixation and subsequent open reduction and plate fixation with a custom-made ultrathin silver plasma-coated locking plate. Plate fixation was the preferred method as the indwelling knee prosthesis prevented the use of a standard intramedullary tibia nail. The fracture healed uneventfully without any signs of infections and the patient achieved full weight-bearing with a normal gait and without any pain after three months. Radiographical full bridging of the initial fracture area was seen after 5 months without any signs of infection or fracture healing disturbances. After an overall follow-up of 12 months, there were no signs of silver associated or other adverse events. Thus, ultrathin silver plasma coating seems to be helpful in the treatment open fractures with plate fixation to prevent fracture-related infections.
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Affiliation(s)
- Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christian Pfeifer
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Nike Walter
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
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26
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Ricciardi BF. CORR Insights®: A Novel Nanostructured Surface on Titanium Implants Increases Osseointegration in a Sheep Model. Clin Orthop Relat Res 2022; 480:2251-2253. [PMID: 36001013 PMCID: PMC9556014 DOI: 10.1097/corr.0000000000002365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 07/18/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Benjamin F Ricciardi
- Orthopaedic Surgeon, Assistant Professor, University of Rochester Medical Center, Rochester, NY, USA
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27
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Walter N, Rupp M, Krückel J, Alt V. Individual and commercially available antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions - a systematic review. Injury 2022; 53 Suppl 3:S74-S80. [PMID: 35613970 DOI: 10.1016/j.injury.2022.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 03/09/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
The treatment of infected non-unions of the femur and the tibia remains difficult and requires control of the infection and successful bone healing. Antimicrobial coating of intramedullary nails promises both infection control and stabilization for subsequent bone healing. Both results for custom-made and commercially available antimicrobial coating for intramedullary nails have been published in the past mainly consisting of retrospective case series. The purpose of this work is to review the published literature on techniques and clinical outcome of antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions. A systematic literature research in Medline, PubMed, Embase and Cochrane Library was performed in accordance to the PRISMA guidelines. Articles reporting on antimicrobial-coated intramedullary nails for the treatment of infected long bone non-unions were eligible for inclusion. In total, 22 publications were found reporting on 506 infected non-unions of the tibia and femur treated with an antimicrobial-coated nail. Most of them consisted of retrospective case series (72.7%). 469 and 37 patients were treated with an individual antibiotic-loaded PMMA-coating and commercially available gentamicin-coating for intramedullary nails, respectively. The overall infection eradication rate was 90.0% (range 68.7-100%) and the bone consolidation rate was 85.5% (range 57.9-100%). Coating specific side effects were not reported. In conclusion, the treatment of infected long bone non-unions with antimicrobial-coated nails is associated with a high infection control and bone consolidation rate and seems to be a reasonable treatment options with minimal side effects. However, scientific quality of the publications is low and randomized controlled trials are needed.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany
| | - Jonas Krückel
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre, Franz-Josef-Strauss Allee 11, Regensburg 93053, Germany.
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Alt V. [Infection management]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:788-791. [PMID: 36040514 DOI: 10.1007/s00113-022-01233-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Academic Contribution Register] [Accepted: 07/20/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
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Lu Y, Cai WJ, Ren Z, Han P. The Role of Staphylococcal Biofilm on the Surface of Implants in Orthopedic Infection. Microorganisms 2022; 10:1909. [PMID: 36296183 PMCID: PMC9612000 DOI: 10.3390/microorganisms10101909] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 08/17/2022] [Revised: 09/11/2022] [Accepted: 09/20/2022] [Indexed: 08/27/2023] Open
Abstract
Despite advanced implant sterilization and aseptic surgical techniques, implant-associated infection remains a major challenge for orthopedic surgeries. The subject of bacterial biofilms is receiving increasing attention, probably as a result of the wide acknowledgement of the ubiquity of biofilms in the clinical environment, as well as the extreme difficulty in eradicating them. Biofilm can be defined as a structured microbial community of cells that are attached to a substratum and embedded in a matrix of extracellular polymeric substances (EPS) that they have produced. Biofilm development has been proposed as occurring in a multi-step process: (i) attachment and adherence, (ii) accumulation/maturation due to cellular aggregation and EPS production, and (iii) biofilm detachment (also called dispersal) of bacterial cells. In all these stages, characteristic proteinaceous and non-proteinaceous compounds are expressed, and their expression is strictly controlled. Bacterial biofilm formation around implants shelters the bacteria and encourages the persistence of infection, which could lead to implant failure and osteomyelitis. These complications need to be treated by major revision surgeries and extended antibiotic therapies, which could lead to high treatment costs and even increase mortality. Effective preventive and therapeutic measures to reduce risks for implant-associated infections are thus in urgent need.
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Affiliation(s)
| | | | | | - Pei Han
- Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Miwa S, Yamamoto N, Hayashi K, Takeuchi A, Igarashi K, Tsuchiya H. Surgical Site Infection after Bone Tumor Surgery: Risk Factors and New Preventive Techniques. Cancers (Basel) 2022; 14:cancers14184527. [PMID: 36139686 PMCID: PMC9497226 DOI: 10.3390/cancers14184527] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 08/07/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
The management of malignant bone tumors requires multidisciplinary interventions including chemotherapy, radiation therapy, and surgical tumor resection and reconstruction. Surgical site infection (SSI) is a serious complication in the treatment of malignant bone tumors. Compared to other orthopedic surgeries, the surgical treatment of malignant bone tumors is associated with higher rates of SSIs. In patients with SSIs, additional surgeries, long-term administrations of antibiotics, extended hospital stays, and the postponement of scheduled adjuvant treatments are required. Therefore, SSI may adversely affect functional and oncological outcomes. To improve surgical outcomes in patients with malignant bone tumors, preoperative risk assessments for SSIs, new preventive techniques against SSIs, and the optimal use of prophylactic antibiotics are often required. Previous reports have demonstrated that age, tumor site (pelvis and tibia), extended operative time, implant use, body mass index, leukocytopenia, and reconstruction procedures are associated with an increased risk for SSIs. Furthermore, prophylactic techniques, such as silver and iodine coatings on implants, have been developed and proven to be efficacious and safe in clinical studies. In this review, predictive factors of SSIs and new prophylactic techniques are discussed.
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Walter N, Baertl S, Lang S, Szymski D, Weber J, Alt V, Rupp M. Treatment of Periprosthetic Joint Infection and Fracture-Related Infection With a Temporary Arthrodesis Made by PMMA-Coated Intramedullary Nails – Evaluation of Technique and Quality of Life in Implant-Free Interval. Front Surg 2022; 9:917696. [PMID: 36117826 PMCID: PMC9478367 DOI: 10.3389/fsurg.2022.917696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 04/11/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background Antimicrobial coating of intramedullary nails with polymethyl methacrylate (PMMA) bone cement promises infection control and stabilization for subsequent bone healing. However, when removing the implant, bone cement can debond and remain in the medullary cavity of the long bones, representing a nidus for reinfection. This work presents a technique comprising reinforcement of PMMA-coated intramedullary nails with cerclage wire to prevent such problems in patients treated for fracture-related infection (FRI) or knee periprosthetic joint infection (PJI) with a static spacer as temporary arthrodesis allowing weight-bearing in the implant-free interval. Outcomes of this surgical treatment were evaluated in terms of (i) associated complications and (ii) patient-reported quality of life. Methods In this retrospective case series, 20 patients with PJI (n = 14, 70%) and FRI (n = 6, 30%) treated with PMMA-coated intramedullary nails reinforced with cerclage wire between January 2021 and July 2021 were included. Quality of life during the implant-free interval was evaluated with the EQ-5D, SF-36, and an ICD-10 based psychological symptom rating and compared with previously analyzed cohorts of successfully treated PJI and FRI patients in whom eradication of infection and stable bone consolidation was achieved. Results Complications during the implant-free interval comprised a broken nail in one case (5.0%) and a reinfection in one case (5.0%). Coating-specific side effects and cement debonding during removal did not occur. The mean physical health component score of SF-36 was 26.1 ± 7.6, and the mean mental health component score reached a value of 47.1 ± 18.6. The mean EQ-5D index value was 0.36 ± 0.32 and the mean EQ-5D visual analogue scale rating was 47.4 ± 19.4. The scores were significantly lower than those in the successfully treated FRI cohort but not in the PJI cohort. The mean ICD-10-based symptom rating scores revealed psychological symptom burden on the depression scale and enhanced levels of anxiety in comparison with healed FRI and PJI patients. Conclusion Reinforcement of PMMA bone cement-coated implants seems to be a reasonable treatment option to create a temporary arthrodesis, preventing detachment of the bone cement when the implant was removed. Level of Evidence: IV.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
- Department of Psychosomatic Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Susanne Baertl
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Siegmund Lang
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Johannes Weber
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
- Correspondence: Markus Rupp
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The State of Research in Fracture-Related Infection—A Bibliometric Analysis. Medicina (B Aires) 2022; 58:medicina58091170. [PMID: 36143847 PMCID: PMC9506014 DOI: 10.3390/medicina58091170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 07/05/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: Fracture-related infection (FRI) is a challenging complication in trauma surgery. A consensus definition of FRI has only recently been published. Therefore, the purpose of this study was to evaluate the state of research related to FRI. Material and Methods: A systemic literature review was conducted on research on FRI published between 2017 and 2020. The Web of Science database was used, and a bibliometric analysis was performed. To provide robust evidence regarding the impact of publications, the behavior of publications in non-traditional dissemination channels was analyzed. For this, the Research Interest Score and the Altmetric Score were combined. The Research Interest Score was calculated from information extracted from ResearchGate, while Altmetric Score includes information from different websites and apps with a significant volume of traffic, such as Twitter. Results: A total of 131 published papers were identified. The most significant contribution came from the United States and European countries. The most relevant articles were published by the journal Injury—International Journal of the Care of the Injured. A positive correlation was observed between the number of citations and Research Interest Scores, whereas the number of citations and Altmetric Score showed no correlation. The social media platform most used by FRI researchers was Twitter. Conclusions: By evaluating the status of publications for FRI between 2017 and 2020, an upward trend in the number of publications was evident. This could be related to the increasing acceptance of the long-needed definition for FRI and the implications it carries for daily clinical practice.
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Use of antibiotic-cement coated locking plates in the setting of periprosthetic infection and infected nonunion. Injury 2022; 53:2567-2572. [PMID: 35365348 DOI: 10.1016/j.injury.2022.03.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 09/05/2021] [Revised: 02/28/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In the setting of periprosthetic total hip and knee arthroplasty (THA/TKA) infection, plating of the femur may be necessary for fracture fixation, prophylactic fixation of the femur, poor bone quality, or infected femoral shaft nonunion. The purpose of this study was to investigate infection control rates and fracture healing in patients receiving antibiotic cement coated plates in the setting of infected nonunion and periprosthetic infections. METHODS We retrospectively reviewed a series of ten patients who had an antibiotic coated plate placed in the setting of periprosthetic infection or infected nonunion with a minimum follow-up of six months. 80 g of Simplex bone cement (Stryker, Mahwah, NJ) were mixed with 4 g of powdered vancomycin and 4.8 g of powdered tobramycin and applied to a dynamic compression plate with locking screw guides in every hole. The antibiotic loaded cement was allowed to harden before implantation. Outcome measures were designed to assess for fracture healing defined as three out of four cortices united on radiographs along with bearing full weight without pain and evidence of infection control defined as normalized erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the absence of antibiotic treatment with no clinical signs of infection. RESULTS Ten patients were treated with an antibiotic cement coated plate in the settings of infectious nonunion and periprosthetic infection and followed for an average of three years (mean 21.4 months, seven months to 61 months). Eight patients (80%) went on to successful control of infection after initial procedure. Two patients developed chronic drainage and had a second antibiotic spacer with antibiotic cement coated plate placed before the infection was controlled. All patients obtained successful control of infection at latest follow-up showing no clinical signs of infection, normalized laboratory markers, and negative culture results. There were no reported mechanical failures of the implant, fractures of the femur, or soft tissue complications. CONCLUSION An antibiotic cement coated plating technique is a viable option for periprosthetic THA and TKA infections requiring plating of the femur or in patients with an infected nonunion.
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Masters EA, Ricciardi BF, Bentley KLDM, Moriarty TF, Schwarz EM, Muthukrishnan G. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nat Rev Microbiol 2022; 20:385-400. [PMID: 35169289 PMCID: PMC8852989 DOI: 10.1038/s41579-022-00686-0] [Citation(s) in RCA: 228] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Accepted: 01/07/2022] [Indexed: 12/13/2022]
Abstract
Osteomyelitis remains one of the greatest risks in orthopaedic surgery. Although many organisms are linked to skeletal infections, Staphylococcus aureus remains the most prevalent and devastating causative pathogen. Important discoveries have uncovered novel mechanisms of S. aureus pathogenesis and persistence within bone tissue, including implant-associated biofilms, abscesses and invasion of the osteocyte lacuno-canalicular network. However, little clinical progress has been made in the prevention and eradication of skeletal infection as treatment algorithms and outcomes have only incrementally changed over the past half century. In this Review, we discuss the mechanisms of persistence and immune evasion in S. aureus infection of the skeletal system as well as features of other osteomyelitis-causing pathogens in implant-associated and native bone infections. We also describe how the host fails to eradicate bacterial bone infections, and how this new information may lead to the development of novel interventions. Finally, we discuss the clinical management of skeletal infection, including osteomyelitis classification and strategies to treat skeletal infections with emerging technologies that could translate to the clinic in the future.
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Affiliation(s)
- Elysia A Masters
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin F Ricciardi
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Karen L de Mesy Bentley
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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Alt V. Treatment of an infected nonunion with additional fresh fracture of the femur with a silver-coated intramedullary nail: A case report. Trauma Case Rep 2022; 39:100641. [PMID: 35345781 PMCID: PMC8957057 DOI: 10.1016/j.tcr.2022.100641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Accepted: 03/19/2022] [Indexed: 01/26/2023] Open
Abstract
Infected non-unions of the femur can be difficult to treat with a high risk of reinfection and persisting nonunion. Here we demonstrate a case of a 66-year-old female with a chronic infected nonunion of the left femur. The patient fell during temporary external fixation of the infected nonunion and sustained an additional proximal femur shaft fracture. The case was successfully managed with a low-amount silver coating of a long proximal femur nail and an additional augmentation locking plate along with local and systemic antibiotics. After a follow-up of 26 months, both the fracture and also the infected nonunion healed completely without recurrence of infection and without any signs of adverse events in response to the silver coating. In conclusion, silver coated fracture fixation devices can be helpful in difficult to treat infection cases without adverse events.
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Affiliation(s)
- Volker Alt
- Department of Trauma Surgery, University Hsopital Regensburg, Germany
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36
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Bläsius F, Delbrück H, Hildebrand F, Hofmann UK. Surgical Treatment of Bone Sarcoma. Cancers (Basel) 2022; 14:cancers14112694. [PMID: 35681674 PMCID: PMC9179414 DOI: 10.3390/cancers14112694] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 04/10/2022] [Revised: 05/22/2022] [Accepted: 05/24/2022] [Indexed: 12/24/2022] Open
Abstract
Bone sarcomas are rare primary malignant mesenchymal bone tumors. The three main entities are osteosarcoma, chondrosarcoma, and Ewing sarcoma. While prognosis has improved for affected patients over the past decades, bone sarcomas are still critical conditions that require an interdisciplinary diagnostic and therapeutic approach. While radiotherapy plays a role especially in Ewing sarcoma and chemotherapy in Ewing sarcoma and osteosarcoma, surgery remains the main pillar of treatment in all three entities. After complete tumor resection, the created bone defects need to be reconstructed. Possible strategies are implantation of allografts or autografts including vascularized bone grafts (e.g., of the fibula). Around the knee joint, rotationplasty can be performed or, as an alternative, the implantation of (expandable) megaprostheses can be performed. Challenges still associated with the implantation of foreign materials are aseptic loosening and infection. Future improvements may come with advances in 3D printing of individualized resection blades/implants, thus also securing safe tumor resection margins while at the same time shortening the required surgical time. Faster osseointegration and lower infection rates may possibly be achieved through more elaborate implant surface structures.
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Affiliation(s)
- Felix Bläsius
- Department of Orthopaedic, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany; (F.B.); (H.D.); (F.H.)
- Centre for Integrated Oncology Aachen Bonn Köln Düsseldorf (CIO), 52074 Aachen, Germany
| | - Heide Delbrück
- Department of Orthopaedic, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany; (F.B.); (H.D.); (F.H.)
- Centre for Integrated Oncology Aachen Bonn Köln Düsseldorf (CIO), 52074 Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany; (F.B.); (H.D.); (F.H.)
- Centre for Integrated Oncology Aachen Bonn Köln Düsseldorf (CIO), 52074 Aachen, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany; (F.B.); (H.D.); (F.H.)
- Centre for Integrated Oncology Aachen Bonn Köln Düsseldorf (CIO), 52074 Aachen, Germany
- Correspondence: ; Tel.: +49-(0)241-80-89350
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Szczęsny G, Kopec M, Politis DJ, Kowalewski ZL, Łazarski A, Szolc T. A Review on Biomaterials for Orthopaedic Surgery and Traumatology: From Past to Present. MATERIALS 2022; 15:ma15103622. [PMID: 35629649 PMCID: PMC9145924 DOI: 10.3390/ma15103622] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Academic Contribution Register] [Received: 04/07/2022] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 02/04/2023]
Abstract
The principal features essential for the success of an orthopaedic implant are its shape, dimensional accuracy, and adequate mechanical properties. Unlike other manufactured products, chemical stability and toxicity are of increased importance due to the need for biocompatibility over an implants life which could span several years. Thus, the combination of mechanical and biological properties determines the clinical usefulness of biomaterials in orthopaedic and musculoskeletal trauma surgery. Materials commonly used for these applications include stainless steel, cobalt-chromium and titanium alloys, ceramics, polyethylene, and poly(methyl methacrylate) (PMMA) bone cement. This study reviews the properties of commonly used materials and the advantages and disadvantages of each, with special emphasis on the sensitivity, toxicity, irritancy, and possible mutagenic and teratogenic capabilities. In addition, the production and final finishing processes of implants are discussed. Finally, potential directions for future implant development are discussed, with an emphasis on developing advanced personalised implants, according to a patient’s stature and physical requirements.
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Affiliation(s)
- Grzegorz Szczęsny
- Department of Orthopaedic Surgery and Traumatology, Medical University, 4 Lindleya Str., 02-005 Warsaw, Poland; (G.S.); (A.Ł.)
| | - Mateusz Kopec
- Institute of Fundamental Technological Research, Polish Academy of Sciences, 5B Pawińskiego Str., 02-106 Warsaw, Poland; (Z.L.K.); (T.S.)
- Correspondence:
| | - Denis J. Politis
- Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia 20537, Cyprus;
| | - Zbigniew L. Kowalewski
- Institute of Fundamental Technological Research, Polish Academy of Sciences, 5B Pawińskiego Str., 02-106 Warsaw, Poland; (Z.L.K.); (T.S.)
| | - Adam Łazarski
- Department of Orthopaedic Surgery and Traumatology, Medical University, 4 Lindleya Str., 02-005 Warsaw, Poland; (G.S.); (A.Ł.)
| | - Tomasz Szolc
- Institute of Fundamental Technological Research, Polish Academy of Sciences, 5B Pawińskiego Str., 02-106 Warsaw, Poland; (Z.L.K.); (T.S.)
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Polymeric Coatings and Antimicrobial Peptides as Efficient Systems for Treating Implantable Medical Devices Associated-Infections. Polymers (Basel) 2022; 14:polym14081611. [PMID: 35458361 PMCID: PMC9024559 DOI: 10.3390/polym14081611] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 03/15/2022] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023] Open
Abstract
Many infections are associated with the use of implantable medical devices. The excessive utilization of antibiotic treatment has resulted in the development of antimicrobial resistance. Consequently, scientists have recently focused on conceiving new ways for treating infections with a longer duration of action and minimum environmental toxicity. One approach in infection control is based on the development of antimicrobial coatings based on polymers and antimicrobial peptides, also termed as “natural antibiotics”.
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Basu B, Gowtham N, Xiao Y, Kalidindi SR, Leong KW. Biomaterialomics: Data science-driven pathways to develop fourth-generation biomaterials. Acta Biomater 2022; 143:1-25. [PMID: 35202854 DOI: 10.1016/j.actbio.2022.02.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 12/07/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
Conventional approaches to developing biomaterials and implants require intuitive tailoring of manufacturing protocols and biocompatibility assessment. This leads to longer development cycles, and high costs. To meet existing and unmet clinical needs, it is critical to accelerate the production of implantable biomaterials, implants and biomedical devices. Building on the Materials Genome Initiative, we define the concept 'biomaterialomics' as the integration of multi-omics data and high-dimensional analysis with artificial intelligence (AI) tools throughout the entire pipeline of biomaterials development. The Data Science-driven approach is envisioned to bring together on a single platform, the computational tools, databases, experimental methods, machine learning, and advanced manufacturing (e.g., 3D printing) to develop the fourth-generation biomaterials and implants, whose clinical performance will be predicted using 'digital twins'. While analysing the key elements of the concept of 'biomaterialomics', significant emphasis has been put forward to effectively utilize high-throughput biocompatibility data together with multiscale physics-based models, E-platform/online databases of clinical studies, data science approaches, including metadata management, AI/ Machine Learning (ML) algorithms and uncertainty predictions. Such integrated formulation will allow one to adopt cross-disciplinary approaches to establish processing-structure-property (PSP) linkages. A few published studies from the lead author's research group serve as representative examples to illustrate the formulation and relevance of the 'Biomaterialomics' approaches for three emerging research themes, i.e. patient-specific implants, additive manufacturing, and bioelectronic medicine. The increased adaptability of AI/ML tools in biomaterials science along with the training of the next generation researchers in data science are strongly recommended. STATEMENT OF SIGNIFICANCE: This leading opinion review paper emphasizes the need to integrate the concepts and algorithms of the data science with biomaterials science. Also, this paper emphasizes the need to establish a mathematically rigorous cross-disciplinary framework that will allow a systematic quantitative exploration and curation of critical biomaterials knowledge needed to drive objectively the innovation efforts within a suitable uncertainty quantification framework, as embodied in 'biomaterialomics' concept, which integrates multi-omics data and high-dimensional analysis with artificial intelligence (AI) tools, like machine learning. The formulation of this approach has been demonstrated for patient-specific implants, additive manufacturing, and bioelectronic medicine.
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Hellwinkel JE, Working ZM, Certain L, García AJ, Wenke JC, Bahney CS. The intersection of fracture healing and infection: Orthopaedics research society workshop 2021. J Orthop Res 2022; 40:541-552. [PMID: 35076097 PMCID: PMC9169242 DOI: 10.1002/jor.25261] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 07/11/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
Infection is a common cause of impaired fracture healing. In the clinical setting, definitive fracture treatment and infection are often treated separately and sequentially, by different clinical specialties. The ability to treat infection while promoting fracture healing will greatly reduce the cost, number of procedures, and patient morbidity associated with infected fractures. In order to develop new therapies, scientists and engineers must understand the clinical need, current standards of care, pathologic effects of infection on fractures, available preclinical models, and novel technologies. One of the main causes of poor fracture healing is infection; unfortunately, bone regeneration and infection research are typically approached independently and viewed as two separate disciplines. Here, we aim to bring these two groups together in an educational workshop to promote research into the basic and translational science that will address the clinical challenge of delayed fracture healing due to infection. Statement of clinical significance: Infection and nonunion are each feared outcomes in fracture care, and infection is a significant driver of nonunion. The impact of nonunions on patie[Q2]nt well-being is substantial. Outcome data suggests a long bone nonunion is as impactful on health-related quality of life measures as a diagnosis of type 1 diabetes and fracture-related infection has been shown to significantly l[Q3]ower a patient's quality of life for over 4 years. Although they frequently are associated with one another, the treatment approaches for infections and nonunions are not always complimentary and cannot be performed simultaneously without accepting tradeoffs. Furthermore, different clinical specialties are often required to address the problem, the orthopedic surgeon treating the fracture and an infectious disease specialist addressing the sources of infection. A sequential approach that optimizes treatment parameters requires more time, more surgeries, and thus confers increased morbidity to the patient. The ability to solve fracture healing and infection clearance simultaneously in a contaminated defect would benefit both the patient and the health care system.
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Affiliation(s)
- Justin E Hellwinkel
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
| | - Zachary M Working
- Department of Orthopaedic Surgery and Rehabilitation, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Laura Certain
- Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
- George E. Wahlen VA Medical Center, Salt Lake City, Utah, USA
| | - Andrés J García
- Woodruff School of Mechanical Engineering and Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Joseph C Wenke
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas, USA
- 7Shriners Children's Texas, Galveston, TX
| | - Chelsea S Bahney
- Center for Regenerative and Personalized Medicine, The Steadman Clinic & Steadman Philippon Research Institute, Vail, Colorado, USA
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF), San Francisco, California, USA
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Baertl S, Walter N, Engelstaedter U, Ehrenschwender M, Hitzenbichler F, Alt V, Rupp M. What Is the Most Effective Empirical Antibiotic Treatment for Early, Delayed, and Late Fracture-Related Infections? Antibiotics (Basel) 2022; 11:287. [PMID: 35326751 PMCID: PMC8944514 DOI: 10.3390/antibiotics11030287] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 01/21/2022] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 12/28/2022] Open
Abstract
Antibiotic treatment strategies for fracture-related infections (FRI) are often extrapolated from periprosthetic joint infections (PJI), although, in contrast to PJI, detailed analysis of pathogens and their antibiotic resistance is missing. Therefore, this study aimed to investigate antibiotic susceptibility profiles to identify effective empiric antibiotic treatment for early-, delayed-, and late-onset FRI. Patients treated for FRI from 2013 to 2020 were grouped into early (<2 weeks), delayed (3−10 weeks), and late (>10 weeks) onset of infection. Antibiotic susceptibility profiles were examined with respect to broadly used antibiotics and antibiotic combinations. In total, 117 patients (early n = 19, delayed n = 60, late n = 38) were enrolled. In early-onset FRI, 100.0% efficacy would be achieved by meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide, ciprofloxacin + glycopeptide and piperacillin/tazobactam + glycopeptide. For patients with delayed FRI, the highest susceptibility was revealed for meropenem + vancomycin, gentamicin + vancomycin and ciprofloxacin + glycopeptide (96.7%). Meropenem + vancomycin was the most effective empiric antimicrobial in patients with late-onset of infection with 92.1% coverage. No subgroup differences in antibiotic sensitivity profiles were observed except for the combination ciprofloxacin + glycopeptide, which was significantly superior in early FRI (F = 3.304, p = 0.04). Across all subgroups meropenem + vancomycin was the most effective empiric treatment in 95.7% of patients with confirmed susceptibility. Meropenem + vancomycin, gentamicin + vancomycin, co-amoxiclav + glycopeptide are the best therapeutic options for FRI, regardless of the onset of infection. To avoid multidrug resistance, established antibiotic combinations such as co-amoxiclav with a glycopeptide seem to be reasonable as a systemic antibiotic therapy, while vancomycin + gentamicin could be implemented in local antibiotic therapy to reduce adverse events during treatment.
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Affiliation(s)
- Susanne Baertl
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
| | - Nike Walter
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
- Department for Psychosomatic Medicine, University Hospital, 93053 Regensburg, Germany
| | - Ulrike Engelstaedter
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
| | - Martin Ehrenschwender
- Institute of Laboratory Medicine, Microbiology and Hygiene, Hospital of the Order of St. John, 93053 Regensburg, Germany;
| | - Florian Hitzenbichler
- Department of Infection Prevention and Infectious Diseases, University Hospital, 93053 Regensburg, Germany;
| | - Volker Alt
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
| | - Markus Rupp
- Department for Trauma Surgery, University Hospital, 93053 Regensburg, Germany; (S.B.); (N.W.); (U.E.); (V.A.)
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Shi L, Tang Z, Tao P, Li X, Guo S, Wei X, Yu X, Liu W, Guo Z. The anti-infective outcomes of the distal femoral replacement coated with antibiotic cement in limb salvage surgery: A randomized clinical trial. Medicine (Baltimore) 2022; 101:e28648. [PMID: 35089205 PMCID: PMC8797527 DOI: 10.1097/md.0000000000028648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 04/08/2021] [Accepted: 12/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The aim of this study was to observe the anti-infective effect of the distal femoral tumor prosthesis coated with antibiotic cement during limb salvage treatment, and evaluate its potential prospect in clinic. METHODS In this randomized controlled trial, the en bloc resection and reconstruction were performed in 36 patients with distal femoral primary bone tumor. Patients were divided into 2 groups randomly according to the application of antibiotic bone cement coating, which included antibiotic cement coating group (16 cases) and control group (18 cases). There were 10 men and 6 women in anti-infection group, aged from 18 to 54 years (23.47 ± 3.53), and there were 12 men and 6 women in control group, aged from 19 to 56 years (24.16 ± 4.32). The tumor type, age, sex, and Enneking stage were enrolled with well-matched of the 2 groups of patients. There was no difference between bundles and routine standard care for each group. The antibiotic cement was coated on the surface of polyethylene jacket with punched holes during operation. The peri-prosthetic infection, local recurrence and distant metastasis were followed up and limb functions were evaluated by Musculoskeletal Tumor Society 93 (MSTS93) scoring system. RESULTS Patients were followed up till 34.7 months (range 18∼62 months). There was no periprosthetic infection in anti-infection group. Four cases in control group showed deep infection. Infection rate had significant differences between the 2 groups (P < .05). Infection-related prosthesis mortality was 0% (0/16) in anti-infection group and 16.67% (3/18) in control group. Local recurrence and distant metastasis occurred in 7 of 34 patients with primary malignant bone tumor, wherein 2 cases of local recurrence and 1 cases of distant metastasis occurred in anti-infective group; 2 cases of local recurrence and 2 cases of distant metastasis occurred in the control group. During a latest follow-up, MSTS93 function scoring revealed a mean of 25.6 ± 4.2 in anti-infection group and 18.5 ± 3.3 in control group. The survival rate of anti-infective group is 75%, and the survival rate of control group is 61.11%. CONCLUSION The antibiotic cement-coated technique on the surface of the polyethylene jacket of custom-made distal femoral prosthesis is simple and effective in controlling the periprosthetic infection after tumor prosthesis reconstruction.
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Affiliation(s)
- Lei Shi
- Orthopedic Oncology Department, Xijing Hospital, the Fourth Military Medical University, Xi’an, China
| | - Zhen Tang
- Orthopedic Oncology Department, Xijing Hospital, the Fourth Military Medical University, Xi’an, China
| | - Pengfei Tao
- Department of Spine Surgery, Wuhan No. 1 Hospital, Wuhan, Hubei, P.R. China
| | - Xiaokang Li
- Department of Orthopedics, Tangdu Hospital, the Fourth Military Medical University, Xi’an, China
| | - Shuo Guo
- Department of Orthopedics, Tangdu Hospital, the Fourth Military Medical University, Xi’an, China
| | - Xinghui Wei
- Orthopedic Oncology Department, Xijing Hospital, the Fourth Military Medical University, Xi’an, China
| | - Xiaodi Yu
- Orthopedic Oncology Department, Xijing Hospital, the Fourth Military Medical University, Xi’an, China
| | - Wenwen Liu
- Department of Orthopedics, Tangdu Hospital, the Fourth Military Medical University, Xi’an, China
| | - Zheng Guo
- Department of Orthopedics, Tangdu Hospital, the Fourth Military Medical University, Xi’an, China
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Zhou W, Wang X, Li Z, Zhao H, Weir MD, Cheng L, Xu HHK, Huang X. Novel dual-functional implants via oxygen non-thermal plasma and quaternary ammonium to promote osteogenesis and combat infections. Dent Mater 2021; 38:169-182. [PMID: 34924200 DOI: 10.1016/j.dental.2021.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 08/23/2021] [Revised: 11/08/2021] [Accepted: 12/02/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Implant-related infections are a primary reason for implant failures that affect millions of patients. It is of paramount importance to develop novel implants that possess the dual functions of osteogenesis-promotion and antibacterial activity. The objectives of this study were to: (1) develop novel dual-functional titanium (Ti) implants by combining oxygen non-thermal plasma and covalent bonding of antibacterial organosilicon quaternary ammonium monomers; (2) investigate the physicochemical properties, bioactivity and antibacterial effects of the modified implants for the first time. METHODS Surface characteristics of the modified Ti surfaces were tested. Adherence and viability of rat bone marrow-derived stem cells (rBMSCs) on the surface were evaluated. Metabolic activity of biofilm on the surfaces were measured. The stability of the dual-function after 5000 thermal cycles was also evaluated. RESULTS The presence of chemical bonding between Ti and organosilicon monomers demonstrated covalent immobilization of the antibacterial agents. The water contact angle of the treated Ti surfaces decreased from 70.98 ± 3.68° to 59.86 ± 4.91°. The adhesion and proliferation of rBMSCs on the modified Ti were increased by 40%, compared to control group (P < 0.05). The metabolic level of biofilms on modified Ti were reduced by more than half, compared to control (P < 0.05). The modified Ti implants exhibited cell-promotion and antibacterial stability after thermal cycles. SIGNIFICANCE The new dual-functional Ti implant is promising to promote osteogenesis while simultaneously preventing infections. Furthermore, the novel surface modification and processing methods have applicability to enhancing a wide range of other implants to improve bioactivity and combat infections.
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Affiliation(s)
- Wen Zhou
- Postdoctoral workstation & Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou 350002, China; Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD, 21201, USA; State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China
| | - Xianlong Wang
- Department of Bioinformatics, Fujian Key Laboratory of Medical Bioinformatics, Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350122 Fujian, China
| | - Zhen Li
- Postdoctoral workstation & Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou 350002, China
| | - Hongyan Zhao
- Postdoctoral workstation & Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou 350002, China
| | - Michael D Weir
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD, 21201, USA
| | - Lei Cheng
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, National Clinical Research Center for Oral Diseases & Department of Operative Dentistry and Endodontics, West China School of Stomatology, Sichuan University, Chengdu 610041, China.
| | - Hockin H K Xu
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD, 21201, USA.
| | - Xiaojing Huang
- Postdoctoral workstation & Fujian Key Laboratory of Oral Diseases & Fujian Provincial Engineering Research Center of Oral Biomaterial & Stomatological Key Lab of Fujian College and University, School and Hospital of Stomatology, Fujian Medical University, Fuzhou 350002, China.
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Decker S, Kunisch E, Moghaddam A, Renkawitz T, Westhauser F. Molybdenum trioxide enhances viability, osteogenic differentiation and extracellular matrix formation of human bone marrow-derived mesenchymal stromal cells. J Trace Elem Med Biol 2021; 68:126827. [PMID: 34371328 DOI: 10.1016/j.jtemb.2021.126827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Received: 04/02/2021] [Revised: 07/01/2021] [Accepted: 07/30/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Metals and their ions allow specific modifications of the biological properties of bioactive materials that are intended for application in bone tissue engineering. While there is some evidence about the impact of particles derived from orthopedic Cobalt-Chromium-Molybdenum (Co-Cr-Mo) alloys on cells, there is only limited data regarding the influence of the essential trace element Mo and its ions on the viability, osteogenic differentiation as well as on the formation and maturation of the primitive extracellular matrix (ECM) of primary human bone marrow-derived stromal cells (BMSCs) available so far. METHODS In this study, the influence of a wide range of molybdenum (VI) trioxide (MoO3), concentrations on BMSC viability was evaluated via measurement of fluorescein diacetate metabolization. Thereafter, the impact of three non-cytotoxic concentrations of MoO3 on the cellular osteogenic differentiation as well as on ECM formation and maturation of BMSCs was assessed. RESULTS MoO3 had no negative influence on BMSC viability in most tested concentrations, as viability was in fact even enhanced. Only the highest concentration (10 mM) of MoO3 showed cytotoxic effects. Cellular osteogenic differentiation, measured via the marker enzyme alkaline phosphatase was enhanced by the presence of MoO3 in a concentration-dependent manner. Furthermore, MoO3 showed a positive influence on the expression of relevant marker genes for osteogenic differentiation (osteopontin, osteocalcin and type I collagen alpha 1) and on the formation and maturation of the primitive ECM, as measured by collagen deposition and ECM calcification. CONCLUSION MoO3 is considered as an attractive candidate for supplementation in biomaterials and qualifies for further research.
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Affiliation(s)
- S Decker
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - E Kunisch
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - A Moghaddam
- Orthopedic and Trauma Surgery, Frohsinnstraße 12, 63739, Aschaffenburg, Germany
| | - T Renkawitz
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - F Westhauser
- Center of Orthopedics, Traumatology, and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany.
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Diez-Escudero A, Andersson B, Carlsson E, Recker B, Link H, Järhult JD, Hailer NP. 3D-printed porous Ti6Al4V alloys with silver coating combine osteocompatibility and antimicrobial properties. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 133:112629. [DOI: 10.1016/j.msec.2021.112629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Academic Contribution Register] [Received: 09/21/2021] [Revised: 12/02/2021] [Accepted: 12/19/2021] [Indexed: 12/23/2022]
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Kilb MF, Moos Y, Eckes S, Braun J, Ritz U, Nickel D, Schmitz K. An Additively Manufactured Sample Holder to Measure the Controlled Release of Vancomycin from Collagen Laminates. Biomedicines 2021; 9:biomedicines9111668. [PMID: 34829897 PMCID: PMC8615449 DOI: 10.3390/biomedicines9111668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 10/21/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
The controlled release of antibiotics prevents the spread of pathogens and thereby improves healing processes in regenerative medicine. However, high concentrations may interfere with healing processes. It is therefore advantageous to use biodegradable materials for a controlled release. In particular, multilayer materials enable differential release at different surfaces. For this purpose, collagen sheets of different properties can be bonded by photochemical crosslinking. Here, we present the development and application of an easily accessible, additively manufactured sample holder to study the controlled release of vancomycin from modularly assembled collagen laminates in two directions. As proof-of-concept, we show that laminates of collagen sheets covalently linked by rose bengal and green light crosslinking (RGX) can be tightly inserted into the device without leakage from the upper to lower cavity. We used this sample holder to detect the release of vancomycin from symmetrically and asymmetrically loaded two-layer and three-layer collagen laminates into the upper and lower cavity of the sample holder. We show that these collagen laminates are characterized by a collagen type-dependent vancomycin release, enabling the control of antibiotic release profiles as well as the direction of antibiotic release.
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Affiliation(s)
- Michelle Fiona Kilb
- Clemens-Schöpf-Institute of Organic Chemistry and Biochemistry, Technical University of Darmstadt, Alarich-Weiss-Straße 8, 64287 Darmstadt, Germany; (M.F.K.); (S.E.)
| | - Yannik Moos
- Akademische Motorsportgruppe Darmstadt e.V., c/o Institut für Verbrennungskraftmaschinen und Fahrzeugantriebe, Otto-Berndt-Straße 2, 64287 Darmstadt, Germany;
| | - Stefanie Eckes
- Clemens-Schöpf-Institute of Organic Chemistry and Biochemistry, Technical University of Darmstadt, Alarich-Weiss-Straße 8, 64287 Darmstadt, Germany; (M.F.K.); (S.E.)
| | - Joy Braun
- Department of Orthopaedics and Traumatology, BiomaTiCS, University Medical Center, Johannes Gutenberg University, Langenbeckstraße 1, 55131 Mainz, Germany; (J.B.); (U.R.)
| | - Ulrike Ritz
- Department of Orthopaedics and Traumatology, BiomaTiCS, University Medical Center, Johannes Gutenberg University, Langenbeckstraße 1, 55131 Mainz, Germany; (J.B.); (U.R.)
| | - Daniela Nickel
- Berufsakademie Sachsen–Staatliche Studienakademie Glauchau, University of Cooperative Education, Kopernikusstraße 51, 08371 Glauchau, Germany;
| | - Katja Schmitz
- Clemens-Schöpf-Institute of Organic Chemistry and Biochemistry, Technical University of Darmstadt, Alarich-Weiss-Straße 8, 64287 Darmstadt, Germany; (M.F.K.); (S.E.)
- Correspondence: ; Tel.: +49-6151-16-21015
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Infections @ Trauma/Orthopedic Implants: Recent Advances on Materials, Methods, and Microbes-A Mini-Review. MATERIALS 2021; 14:ma14195834. [PMID: 34640231 PMCID: PMC8510481 DOI: 10.3390/ma14195834] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Academic Contribution Register] [Received: 08/16/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 12/22/2022]
Abstract
Implants and materials are indispensable in trauma and orthopedic surgery. The continuous improvements of implant design have resulted in an optimized mechanical function that supports tissue healing and restoration of function. One of the still unsolved problems with using implants and materials is infection. Trauma and material implantation change the local inflammatory situation and enable bacterial survival and material colonization. The main pathogen in orthopedic infections is Staphylococcus aureus. The research efforts to optimize antimicrobial surfaces and to develop new anti-infective strategies are enormous. This mini-review focuses on the publications from 2021 with the keywords S. aureus AND (surface modification OR drug delivery) AND (orthopedics OR trauma) AND (implants OR nails OR devices). The PubMed search yielded 16 original publications and two reviews. The original papers reported the development and testing of anti-infective surfaces and materials: five studies described an implant surface modification, three developed an implant coating for local antibiotic release, the combination of both is reported in three papers, while five publications are on antibacterial materials but not metallic implants. One review is a systematic review on the prevention of stainless-steel implant-associated infections, the other addressed the possibilities of mixed oxide nanotubes. The complexity of the approaches differs and six of them showed efficacy in animal studies.
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Dip- and Spray-coating of Schanz pin with PLA and PLA nanosphere for prolonged antibacterial activity. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 02/07/2023]
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Goh GS, Tornetta P, Parvizi J. Facilitating the Approval Process of Anti-Infective Technologies and Advancing Them to the Market: Insights from an FDA Workshop on Orthopaedic Device-Related Infections. J Bone Joint Surg Am 2021; 103:e57. [PMID: 34357892 DOI: 10.2106/jbjs.21.00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Academic Contribution Register] [Indexed: 02/01/2023]
Abstract
Orthopaedic device-related infection is one of the most devastating complications in orthopaedic and trauma surgery. With increasing life expectancies as well as the lifelong risk of bacterial seeding on an implant, the prevention and treatment of device-related infection remains an important area for research and development. To facilitate information exchange and enhance collaboration among various stakeholders in the orthopaedic community, the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) organized an inaugural workshop on orthopaedic device-related infections, exploring the regulatory challenges that are faced when proceeding from the bench level to marketing and clinical implementation of new infection-control devices and products. This article summarizes the perspectives of scientists, clinicians, and industry partners on the current regulatory approval process for orthopaedic anti-infective technologies as well as the proposed strategies to overcome these regulatory challenges.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Kumaravel V, Nair KM, Mathew S, Bartlett J, Kennedy JE, Manning HG, Whelan BJ, Leyland NS, Pillai SC. Antimicrobial TiO 2 nanocomposite coatings for surfaces, dental and orthopaedic implants. CHEMICAL ENGINEERING JOURNAL (LAUSANNE, SWITZERLAND : 1996) 2021; 416:129071. [PMID: 33642937 PMCID: PMC7899925 DOI: 10.1016/j.cej.2021.129071] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Academic Contribution Register] [Received: 12/14/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 05/03/2023]
Abstract
Engineering of self-disinfecting surfaces to constrain the spread of SARS-CoV-2 is a challenging task for the scientific community because the human coronavirus spreads through respiratory droplets. Titania (TiO2) nanocomposite antimicrobial coatings is one of the ideal remedies to disinfect pathogens (virus, bacteria, fungi) from common surfaces under light illumination. The photocatalytic disinfection efficiency of recent TiO2 nanocomposite antimicrobial coatings for surfaces, dental and orthopaedic implants are emphasized in this review. Mostly, inorganic metals (e.g. copper (Cu), silver (Ag), manganese (Mn), etc), non-metals (e.g. fluorine (F), calcium (Ca), phosphorus (P)) and two-dimensional materials (e.g. MXenes, MOF, graphdiyne) were incorporated with TiO2 to regulate the charge transfer mechanism, surface porosity, crystallinity, and the microbial disinfection efficiency. The antimicrobial activity of TiO2 coatings was evaluated against the most crucial pathogenic microbes such as Escherichia coli, methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Bacillus subtilis, Legionella pneumophila, Staphylococcus aureus, Streptococcus mutans, T2 bacteriophage, H1N1, HCoV-NL63, vesicular stomatitis virus, bovine coronavirus. Silane functionalizing agents and polymers were used to coat the titanium (Ti) metal implants to introduce superhydrophobic features to avoid microbial adhesion. TiO2 nanocomposite coatings in dental and orthopaedic metal implants disclosed exceptional bio-corrosion resistance, durability, biocompatibility, bone-formation capability, and long-term antimicrobial efficiency. Moreover, the commercial trend, techno-economics, challenges, and prospects of antimicrobial nanocomposite coatings are also discussed briefly.
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Affiliation(s)
- Vignesh Kumaravel
- Nanotechnology and Bio-Engineering Research Group, Department of Environmental Science, School of Science, Institute of Technology Sligo, Ash Lane, Sligo, Ireland
- Centre for Precision Engineering, Materials and Manufacturing Research (PEM), Institute of Technology Sligo, Ash Lane, Sligo, Ireland
| | - Keerthi M Nair
- Nanotechnology and Bio-Engineering Research Group, Department of Environmental Science, School of Science, Institute of Technology Sligo, Ash Lane, Sligo, Ireland
- Centre for Precision Engineering, Materials and Manufacturing Research (PEM), Institute of Technology Sligo, Ash Lane, Sligo, Ireland
| | - Snehamol Mathew
- Nanotechnology and Bio-Engineering Research Group, Department of Environmental Science, School of Science, Institute of Technology Sligo, Ash Lane, Sligo, Ireland
- Centre for Precision Engineering, Materials and Manufacturing Research (PEM), Institute of Technology Sligo, Ash Lane, Sligo, Ireland
| | - John Bartlett
- Nanotechnology and Bio-Engineering Research Group, Department of Environmental Science, School of Science, Institute of Technology Sligo, Ash Lane, Sligo, Ireland
- Centre for Precision Engineering, Materials and Manufacturing Research (PEM), Institute of Technology Sligo, Ash Lane, Sligo, Ireland
| | | | | | | | | | - Suresh C Pillai
- Nanotechnology and Bio-Engineering Research Group, Department of Environmental Science, School of Science, Institute of Technology Sligo, Ash Lane, Sligo, Ireland
- Centre for Precision Engineering, Materials and Manufacturing Research (PEM), Institute of Technology Sligo, Ash Lane, Sligo, Ireland
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