Surgical site infection, ultraclean ventilated operating theatres and prosthetic joint surgery: where now?

A Review on Nano Ti-Based Oxides for Dark and Photocatalysis: From Photoinduced Processes to Bioimplant Applications

Catalysis on TiO₂ nanomaterials in the presence of H₂O and oxygen plays a crucial role in the advancement of many different fields, such as clean energy technologies, catalysis, disinfection, and bioimplants. Photocatalysis on TiO₂ nanomaterials is well-established and has advanced in the last decades in terms of the understanding of its underlying principles and improvement of its efficiency. Meanwhile, the increasing complexity of modern scientific challenges in disinfection and bioimplants requires a profound mechanistic understanding of both residual and dark catalysis. Here, an overview of the progress made in TiO₂ catalysis is given both in the presence and absence of light. It begins with the mechanisms involving reactive oxygen species (ROS) in TiO₂ photocatalysis. This is followed by improvements in their photocatalytic efficiency due to their nanomorphology and states by enhancing charge separation and increasing light harvesting. A subsection on black TiO₂ nanomaterials and their interesting properties and physics is also included. Progress in residual catalysis and dark catalysis on TiO₂ are then presented. Safety, microbicidal effect, and studies on Ti-oxides for bioimplants are also presented. Finally, conclusions and future perspectives in light of disinfection and bioimplant application are given.

Nanomechanical probing of bacterial adhesion to biodegradable Zn alloys

Bacterial infections on implants cause an inflammatory response and even implant failure. Bacterial adhesion is an initial and critical step during implant infection. The prevention of bacterial adhesion to implant materials has attracted much attention, especially for biodegradable metals. A deep understanding of the mechanisms of bacterial adhesion to biodegradable metals is urgently needed. In this work, a bacterial probe based on atomic force spectroscopy was employed to determine the bacterial adhesion to Zn alloy, which depended on surface charge, roughness, and wettability. Negative surface charges of Zn, Zn-0.5Li, and 316L generated electrostatic repulsion force towards bacteria. The surface roughness of Zn-0.5Li was significantly increased by localized corrosion. Bacterial adhesion forces on Zn, Zn-0.5Li, and 316L were 325.2 pN, 519.1 pN, and 727.7 pN, respectively. The density of attached bacteria (early-stage bacterial adhesion) on these samples exhibited a positive correlation with the bacterial adhesion force. The bacterial adhesion force and adhesion work provide a quantitative determination of the interactions between bacteria and biodegradable alloys. These results provide a deeper understanding of early bacterial adhesion on Zn alloys, which can further guide the antibacterial surface design of biodegradable materials for clinical application.

Surface coating of orthopedic implant to enhance the osseointegration and reduction of bacterial colonization: a review

The use of orthopedic implants in surgical technology has fostered restoration of physiological functions. Along with successful treatment, orthopedic implants suffer from various complications and fail to offer functions correspondent to native physiology. The major problems include aseptic and septic loosening due to bone nonunion and implant site infection due to bacterial colonization. Crucial advances in material selection in the design and development of coating matrixes an opportunity for the prevention of implant failure. However, many coating materials are limited in in-vitro testing and few of them thrive in clinical tests. The rate of implant failure has surged with the increasing rates of revision surgery creating physical and sensitive discomfort as well as economic burdens. To overcome critical pathogenic activities several systematic coating techniques have been developed offering excellent results that combat infection and enhance bone integration. This review article includes some more common implant coating matrixes with excellent in vitro and in vivo results focusing on infection rates, causes, complications, coating materials, host immune responses and significant research gaps. This study provides a comprehensive overview of potential coating technology, with functional combination coatings which are focused on ultimate clinical practice with substantial improvement on in-vivo tests. This includes the development of rapidly growing hydrogel coating techniques with the potential to generate several accurate and precise coating procedures.

Ultrasound Triggered Drug Release from Affinity-Based β-Cyclodextrin Polymers for Infection Control

This work demonstrates a slow, sustained drug delivery system that provides on-demand delivery bursts through the application of pulsed therapeutic ultrasound (TUS). Insoluble β-cyclodextrin-polymer (pCD) disks were loaded with a saturated antibiotic solution of rifampicin (RIF) and used for drug delivery studies. To obtain on-demand release from the implants, TUS was applied at an intensity of 1.8 W/cm². The therapeutic efficacy of the combination treatment was assessed in bacterial culture via an in vitro Staphylococcus aureus bioluminescence assay. The results demonstrated that the application of pulsed TUS at 3 MHz and 1.8 W/cm² to pCD implants leads to a significantly higher short-term burst in the drug release rate compared to samples not treated with TUS. The addition of TUS increased the drug release by 100% within 4 days. The pCD disk + RIF stimulated with TUS showed a comparatively higher bacterial eradication with CFU/mL of 4.277E+09, and 8.00E+08 at 1 and 24 h compared with control treated bacteria at 1.48E+10. Overall, these results suggest that the addition of pulsed TUS could be an effective technology to noninvasively expedite antibiotic release on demand at desired intervals.

Fast-resorbable antibiotic-loaded hydrogel coating to reduce post-surgical infection after internal osteosynthesis: a multicenter randomized controlled trial

BACKGROUND

Infection is one of the main reasons for failure of orthopedic implants. Antibacterial coatings may prevent bacterial adhesion and biofilm formation, according to various preclinical studies. The aim of the present study is to report the first clinical trial on an antibiotic-loaded fast-resorbable hydrogel coating (Defensive Antibacterial Coating, DAC®) to prevent surgical site infection, in patients undergoing internal osteosynthesis for closed fractures.

MATERIALS AND METHODS

In this multicenter randomized controlled prospective study, a total of 256 patients in five European orthopedic centers who were scheduled to receive osteosynthesis for a closed fracture, were randomly assigned to receive antibiotic-loaded DAC or to a control group (without coating). Pre- and postoperative assessment of laboratory tests, wound healing, clinical scores and X-rays were performed at fixed time intervals.

RESULTS

Overall, 253 patients were available with a mean follow-up of 18.1 ± 4.5 months (range 12-30). On average, wound healing, clinical scores, laboratory tests and radiographic findings did not show any significant difference between the two groups. Six surgical site infections (4.6%) were observed in the control group compared to none in the treated group (P < 0.03). No local or systemic side-effects related to the DAC hydrogel product were observed and no detectable interference with bone healing was noted.

CONCLUSIONS

The use of a fast-resorbable antibiotic-loaded hydrogel implant coating provides a reduced rate of post-surgical site infections after internal osteosynthesis for closed fractures, without any detectable adverse event or side-effects.

LEVEL OF EVIDENCE

2.

Does an Antibiotic-Loaded Hydrogel Coating Reduce Early Post-Surgical Infection After Joint Arthroplasty?

Background: Infection remains among the main reasons for joint prosthesis failure. Preclinical reports have suggested that antibacterial coatings of implants may prevent bacterial adhesion and biofilm formation. This study presents the results of the first clinical trial on an antibiotic-loaded fast-resorbable hydrogel coating (Defensive Antibacterial Coating, DAC^®) in patients undergoing hip or knee prosthesis. Methods: In this multicenter, randomized prospective study, a total of 380 patients, scheduled to undergo primary (n=270) or revision (n=110) total hip (N=298) or knee (N=82) joint replacement with a cementless or a hybrid implant, were randomly assigned, in six European orthopedic centers, to receive an implant either with the antibiotic-loaded DAC coating (treatment group) or without coating (control group). Pre- and postoperative assessment of clinical scores, wound healing, laboratory tests, and x-ray exams were performed at fixed time intervals. Results: Overall, 373 patients were available at a mean follow-up of 14.5 ± 5.5 months (range 6 to 24). On average, wound healing, laboratory and radiographic findings showed no significant difference between the two groups. Eleven early surgical site infections were observed in the control group and only one in the treatment group (6% vs. 0.6%; p=0.003). No local or systemic side effects related to the DAC hydrogel coating were observed, and no detectable interference with implant osteointegration was noted. Conclusions: The use of a fast-resorbable, antibiotic-loaded hydrogel implant coating can reduce the rate of early surgical site infections, without any detectable adverse events or side effects after hip or knee joint replacement with a cementless or hybrid implant.

Silver Nanocoating Technology in the Prevention of Prosthetic Joint Infection

Prosthetic joint infection (PJI) is a feared complication of total joint arthroplasty associated with increased morbidity and mortality. There is a growing body of evidence that bacterial colonization and biofilm formation are critical pathogenic events in PJI. Thus, the choice of biomaterials for implanted prostheses and their surface modifications may significantly influence the development of PJI. Currently, silver nanoparticle (AgNP) technology is receiving much interest in the field of orthopaedics for its antimicrobial properties and a strong anti-biofilm potential. The great advantage of AgNP surface modification is a minimal release of active substances into the surrounding tissue and a long period of effectiveness. As a result, a controlled release of AgNPs could ensure antibacterial protection throughout the life of the implant. Moreover, the antibacterial effect of AgNPs may be strengthened in combination with conventional antibiotics and other antimicrobial agents. Here, our main attention is devoted to general guidelines for the design of antibacterial biomaterials protected by AgNPs, its benefits, side effects and future perspectives in PJI prevention.

Antibacterial coating of implants in orthopaedics and trauma: a classification proposal in an evolving panorama

Implanted biomaterials play a key role in current success of orthopedic and trauma surgery. However, implant-related infections remain among the leading reasons for failure with high economical and social associated costs. According to the current knowledge, probably the most critical pathogenic event in the development of implant-related infection is biofilm formation, which starts immediately after bacterial adhesion on an implant and effectively protects the microorganisms from the immune system and systemic antibiotics. A rationale, modern prevention of biomaterial-associated infections should then specifically focus on inhibition of both bacterial adhesion and biofilm formation. Nonetheless, currently available prophylactic measures, although partially effective in reducing surgical site infections, are not based on the pathogenesis of biofilm-related infections and unacceptable high rates of septic complications, especially in high-risk patients and procedures, are still reported.In the last decade, several studies have investigated the ability of implant surface modifications to minimize bacterial adhesion, inhibit biofilm formation, and provide effective bacterial killing to protect implanted biomaterials, even if there still is a great discrepancy between proposed and clinically implemented strategies and a lack of a common language to evaluate them.To move a step forward towards a more systematic approach in this promising but complicated field, here we provide a detailed overview and an original classification of the various technologies under study or already in the market. We may distinguish the following: 1. Passive surface finishing/modification (PSM): passive coatings that do not release bactericidal agents to the surrounding tissues, but are aimed at preventing or reducing bacterial adhesion through surface chemistry and/or structure modifications; 2. Active surface finishing/modification (ASM): active coatings that feature pharmacologically active pre-incorporated bactericidal agents; and 3. Local carriers or coatings (LCC): local antibacterial carriers or coatings, biodegradable or not, applied at the time of the surgical procedure, immediately prior or at the same time of the implant and around it. Classifying different technologies may be useful in order to better compare different solutions, to improve the design of validation tests and, hopefully, to improve and speed up the regulatory process in this rapidly evolving field.

Preventing surgical-site infections: measures other than antibiotics

Surgical-site infections (SSIs) due to intra-operative contamination are chiefly ascribable to airborne particles carrying microorganisms, mainly Staphylococcus aureus, which settle on the surgeon's hands and instruments. SSI prevention therefore rests on minimisation of airborne contaminated particle counts, although these have not been demonstrated to correlate significantly with SSI rates. Maintaining clear air in the operating room classically involves the use of ultra clean ventilation systems combining laminar airflow and high-efficiency particulate air filters to create a physical barrier around the surgical table; in addition to a stringent patient preparation protocol, appropriate equipment, and strict operating room discipline on the part of the surgeon and other staff members. SSI rates in clean surgery, although influenced by the type of procedure and by patient-related factors, are consistently very low, of about 1% to 2%. These low rates, together with the effectiveness of prophylactic antibiotic therapy and the multiplicity of parameters influencing the SSI risk, are major obstacles to the demonstration that a specific measure is effective in decreasing SSIs. As a result, controversy surrounds the usefulness of many measures, including laminar airflow, body exhaust suits, patient preparation techniques, and specific surgical instruments. Impeccable surgical technique and operating room behaviour, in contrast, are clearly essential.

Antibacterial surface treatment for orthopaedic implants

It is expected that the projected increased usage of implantable devices in medicine will result in a natural rise in the number of infections related to these cases. Some patients are unable to autonomously prevent formation of biofilm on implant surfaces. Suppression of the local peri-implant immune response is an important contributory factor. Substantial avascular scar tissue encountered during revision joint replacement surgery places these cases at an especially high risk of periprosthetic joint infection. A critical pathogenic event in the process of biofilm formation is bacterial adhesion. Prevention of biomaterial-associated infections should be concurrently focused on at least two targets: inhibition of biofilm formation and minimizing local immune response suppression. Current knowledge of antimicrobial surface treatments suitable for prevention of prosthetic joint infection is reviewed. Several surface treatment modalities have been proposed. Minimizing bacterial adhesion, biofilm formation inhibition, and bactericidal approaches are discussed. The ultimate anti-infective surface should be “smart” and responsive to even the lowest bacterial load. While research in this field is promising, there appears to be a great discrepancy between proposed and clinically implemented strategies, and there is urgent need for translational science focusing on this topic.