The risk of biomaterial-associated infection after revision surgery due to an experimental primary implant infection

Metal-Phenolic Networks Assembled on TiO2 Nanospikes for Antimicrobial Peptide Deposition and Osteoconductivity Enhancement in Orthopedic Applications

The lack of antimicrobial and osteoconductive activities of titanium (Ti) for orthopedic implants has led to problems such as infection and structural looseness, which bring physical and psychological sufferings to patients as well as economic burden on the healthcare system. To endow Ti implants with anti-infective function and bioactivity, in this study, we successfully constructed TiO2 nanospike (TNS) structure on the surface of Ti followed by assembling metal-polyphenol networks (MPNs) and depositing antimicrobial peptides (AMPs). The TNSs' structure can disrupt the bacteria by physical puncture, and it was also proved to have excellent photothermal conversion performance upon near-infrared light irradiation. Furthermore, with the assistance of contact-active chemo bactericidal efficacy of AMPs, TNS-MPN-AMP nanocoating achieved physical/photothermal/chemo triple-synergistic therapy against pathogenic bacteria. The anti-infective efficiency of this multimodal treatment was obviously improved, with an antibacterial ratio of >99.99% in vitro and 95.03% in vivo. Moreover, the spike-like nanostructure of TNSs and the bioactive groups from MPNs and AMPs not only demonstrated desirable biocompatibility but also promoted the surface hydroxyapatite formation in simulated body fluid for further osseointegration enhancement. Altogether, this multifaceted TNS-MPN-AMP nanocoating endowed Ti implants with enhanced antibacterial activity, excellent cytocompatibility, and desirable osteoconductive ability.

Bacteria-targeted fluorescence imaging of extracted osteosynthesis devices for rapid visualization of fracture-related infections

PURPOSE

Fracture-related infection (FRI) is a serious complication in orthopedic trauma surgery worldwide. Especially, the distinction of infection from sterile inflammation and the detection of low-grade infection are highly challenging. The objective of the present study was to obtain proof-of-principle for the use of bacteria-targeted fluorescence imaging to detect FRI on extracted osteosynthesis devices as a step-up towards real-time image-guided trauma surgery.

METHODS

Extracted osteosynthesis devices from 13 patients, who needed revision surgery after fracture treatment, were incubated with a near-infrared fluorescent tracer composed of the antibiotic vancomycin and the fluorophore IRDye800CW (i.e., vanco-800CW). Subsequently, the devices were imaged, and vanco-800CW fluorescence signals were correlated to the results of microbiological culturing and to bacterial growth upon replica plating of the imaged devices on blood agar.

RESULTS

Importantly, compared to culturing, the bacteria-targeted fluorescence imaging of extracted osteosynthesis devices with vanco-800CW allows for a prompt diagnosis of FRI, reducing the time-to-result from days to less than 30 min. Moreover, bacteria-targeted imaging can provide surgeons with real-time visual information on the presence and extent of infection.

CONCLUSION

Here, we present the first clinical application of fluorescence imaging for the detection of FRI. We conclude that imaging with vanco-800CW can provide early, accurate, and real-time visual diagnostic information on FRI in the clinical setting, even in the case of low-grade infections.

Nanomaterials for bioprinting: functionalization of tissue-specific bioinks

Three-dimensional (3D) bioprinting is rapidly evolving, offering great potential for manufacturing functional tissue analogs for use in diverse biomedical applications, including regenerative medicine, drug delivery, and disease modeling. Biomaterials used as bioinks in printing processes must meet strict physiochemical and biomechanical requirements to ensure adequate printing fidelity, while closely mimicking the characteristics of the native tissue. To achieve this goal, nanomaterials are increasingly being investigated as a robust tool to functionalize bioink materials. In this review, we discuss the growing role of different nano-biomaterials in engineering functional bioinks for a variety of tissue engineering applications. The development and commercialization of these nanomaterial solutions for 3D bioprinting would be a significant step towards clinical translation of biofabrication.

Expression of a Shiga-Like Toxin during Plastic Colonization by Two Multidrug-Resistant Bacteria, Aeromonas hydrophila RIT668 and Citrobacter freundii RIT669, Isolated from Endangered Turtles (Clemmys guttata)

Aeromonas hydrophila RIT668 and Citrobacter freundii RIT669 were isolated from endangered spotted turtles (Clemmys guttata). Whole-genome sequencing, annotation and phylogenetic analyses of the genomes revealed that the closest relative of RIT668 is A. hydrophila ATCC 7966 and Citrobacter portucalensis A60 for RIT669. Resistome analysis showed that A. hydrophila and C. freundii harbor six and 19 different antibiotic resistance genes, respectively. Both bacteria colonize polyethylene and polypropylene, which are common plastics, found in the environment and are used to fabricate medical devices. The expression of six biofilm-related genes—biofilm peroxide resistance protein (bsmA), biofilm formation regulatory protein subunit R (bssR), biofilm formation regulatory protein subunit S (bssS), biofilm formation regulator (hmsP), toxin-antitoxin biofilm protein (tabA) and transcriptional activator of curli operon (csgD)—and two virulence factors—Vi antigen-related gene (viaB) and Shiga-like toxin (slt-II)—was investigated by RT-PCR. A. hydrophila displayed a > 2-fold increase in slt-II expression in cells adhering to both polymers, C. freundii adhering on polyethylene displayed a > 2-fold, and on polypropylene a > 6-fold upregulation of slt-II. Thus, the two new isolates are potential pathogens owing to their drug resistance, surface colonization and upregulation of a slt-II-type diarrheal toxin on polymer surfaces.

Real-Time Imaging of Bacteria/Osteoblast Dynamic Coculture on Bone Implant Material in an in Vitro Postoperative Contamination Model

Biomedical implants are an important part of evolving modern medicine but have a potential drawback in the form of postoperative pathogenic infection. Accordingly, the "race for surface" combat between invasive bacteria and host cells determines the fate of implants. Hence, proper in vitro systems are required to assess effective strategies to avoid infection. In this study, we developed a real time observation model, mimicking postoperative contamination, designed to follow E. coli proliferation on a titanium surface occupied by human osteoblastic progenitor cells (STRO). This model allowed us to monitor E. coli invasion of human cells on titanium surfaces coated and uncoated with fibronectin. We showed that the surface colonization of bacteria is significantly enhanced on fibronectin coated surfaces irrespective of whether areas were uncovered or covered with human cells. We further revealed that bacterial colonization of the titanium surfaces is enhanced in coculture with STRO cells. Finally, this coculture system provides a comprehensive system to describe in vitro and in situ bacterial and human cells and their localization but also to target biological mechanisms involved in adhesion as well as in interactions with surfaces, thanks to fluorescent labeling. This system is thus an efficient method for studies related to the design and function of new biomaterials.

Biofunctionalization of TiO2 Surfaces with Self-Assembling Layers of Oligopeptides Covalently Grafted to Chitosan

In the field of tissue engineering, a promising approach to obtain a bioactive, biomimetic, and antibiotic implant is the functionalization of a "classical" biocompatible material, for example, titanium, with appropriate biomolecules. For this purpose, we propose preparing self-assembling films of multiple components, allowing the mixing of different biofunctionalities "on demand". Self-assembling peptides (SAPs) are synthetic materials characterized by the ability to self-organize in nanostructures both in aqueous solution and as thin or thick films. Moreover, ordered layers of SAPs adhere on titanium surface as a scaffold coating to mimic the extracellular matrix. Chitosan is a versatile hydrophilic polysaccharide derived from chitin, with a broad antimicrobial spectrum to which Gram-negative and Gram-positive bacteria and fungi are highly susceptible, and is already known in the literature for the ability of its derivatives to firmly graft titanium alloys and show protective effects against some bacterial species, either alone or in combination with other antimicrobial substances such as antibiotics or antimicrobial peptides. In this context, we functionalized titanium surfaces with chitosan grafted to EAK16-II (a SAP), obtaining layer-by-layer structures of different degrees of order, depending on the preparative stoichiometry and path. The chemical composition, molecular structure, and arrangement of the obtained biofunctionalized surfaces were investigated by surface-sensitive techniques such as reflection-absorption infrared spectroscopy (RAIRS) and state-of-the-art synchrotron radiation-induced spectroscopies as X-ray photoemission spectroscopy (SR-XPS), and near-edge X-ray absorption fine structure (NEXAFS). Furthermore, was demonstrated that surfaces coated with EAK and Chit-EAK can support hNPs cell attachment and growth.

Design of surfaces for controlling hard and soft fouling

In this review, we present a framework to guide the design of surfaces which are resistant to solid fouling, based on the modulus and length scale of the fouling material. Solid fouling is defined as the undesired attachment of solid contaminants including ice, clathrates, waxes, inorganic scale, polymers, proteins, dust and biological materials. We first provide an overview of the surface design approaches typically applied across the scope of solid fouling and explain how these disparate research efforts can be united to an extent under a single framework. We discuss how the elastic modulus and the operating length scale of a foulant determine its ability or inability to elastically deform surfaces. When surface deformation occurs, minimization of the substrate elastic modulus is critical for the facile de-bonding of a solid contaminant. Foulants with low modulus or small deposition sizes cannot deform an elastic bulk material and instead de-bond more readily from surfaces with chemistries that minimize their interfacial free energy or induce a particular repellant interaction with the foulant. Overall, we review reported surface design strategies for the reduction in solid fouling, and provide perspective regarding how our framework, together with the modulus and length scale of a foulant, can guide future antifouling surface designs. This article is part of the theme issue 'Bioinspired materials and surfaces for green science and technology'.

Antibiofilm elastin-like polypeptide coatings: functionality, stability, and selectivity

Antimicrobial peptides (AMPs) are currently receiving interest as an alternative to conventional antibiotics to treat biomaterial-associated infection. However, the inherent instability of such peptides often limits their efficacy in intended clinical applications. Covalent immobilization of AMPs to surfaces is one strategy to increase the long-term stability and minimize the toxicity. In this work, an antimicrobial peptide, RRPRPRPRPWWWW-NH2 (RRP9W4N), was used to modify elastin-like polypeptide (ELP) surface coatings containing cell-adhesive peptide domains (RGD) using covalent chemistry. The AMP retained its antibacterial activity against Staphylococcus epidermidis, Staphylococcus aureus, and Pseudomonas aeruginosa when covalently bonded to ELP surfaces. Simultaneously, the AMP functionalization had insignificant effect on the viability, function, and differentiation of human osteosarcoma MG63 cells and human mesenchymal stem cells (hMSCs). Furthermore, stability of the immobilized AMP in human blood serum was investigated, and the results suggested that the AMP preserved its antibacterial activity up to 24 h. Combined, the results show that covalently attached AMPs onto RGD-containing ELP are an excellent candidate as an antimicrobial coating for medical devices. STATEMENT OF SIGNIFICANCE: Biomaterial associated infection, caused by adherent biofilm, is usually difficult to treat. There is a high demand for new materials and treatments to decrease the infection rates, especially with increasing threats concerning resistant bacteria. Formation of biofilms on medical devices lowers the bacteria susceptibility towards traditional antibiotics and also circumvent our immune system often resulting in revisional surgery and extensive use of antibiotics. One promising strategy is to develop surfaces having low bacterial attractiveness or bacterial killing properties, but still retaining the main function of the device. In this study, we have developed an implant coating that demonstrates a high antimicrobial effect and at the same time showing no negative affect on human cells.

Unveiling the fate of adhering bacteria to antimicrobial surfaces: expression of resistance-associated genes and macrophage-mediated phagocytosis

Since most antibacterial coatings reported to fight biomaterial-associated infections (BAI) fail in completely preventing bacterial colonization, it is crucial to know the impact of that small fraction of adhered bacteria in BAI recrudescence. This study aims to understand the fate of Staphylococcus aureus able to adhere to an antimicrobial coating previously developed, in terms of potential development of bacterial resistance and their macrophage-mediated phagocytosis. Antimicrobial coating comprised the co-immobilization of Palm peptide and DNase I onto polydimethylsiloxane. Expression of genes associated to resistance and virulence mechanisms showed that cells in contact with antimicrobial surfaces for a long period of 30 days, exhibit genes equally or less expressed, as compared to cells recovered from control surfaces. Recovered cells also exhibit the same susceptibility patterns, which strengthens the evidence of no resistance development. Remarkably, cells adhered to modified surfaces shows a reduced metabolic activity upon vancomycin treatment unlike the cells found on control surfaces, which can be identified as a clinical opportunity for prophylactically administration after implant surgery. Furthermore, results highlight that functionalization of PDMS with Palm and DNase I should not compromise the action of host immune cells. The overall results reinforce the potential of this antimicrobial strategy to fight BAI.

In vitro methods for the evaluation of antimicrobial surface designs

Bacterial adhesion and subsequent biofilm formation on biomedical implants and devices are a major cause of their failure. As systemic antibiotic treatment is often ineffective, there is an urgent need for antimicrobial biomaterials and coatings. The term "antimicrobial" can encompass different mechanisms of action (here termed "antimicrobial surface designs"), such as antimicrobial-releasing, contact-killing or non-adhesivity. Biomaterials equipped with antimicrobial surface designs based on different mechanisms of action require different in vitro evaluation methods. Available industrial standard evaluation tests do not address the specific mechanisms of different antimicrobial surface designs and have therefore been modified over the past years, adding to the myriad of methods available in the literature to evaluate antimicrobial surface designs. The aim of this review is to categorize fourteen presently available methods including industrial standard tests for the in vitro evaluation of antimicrobial surface designs according to their suitability with respect to their antimicrobial mechanism of action. There is no single method or industrial test that allows to distinguish antimicrobial designs according to all three mechanisms identified here. However, critical consideration of each method clearly relates the different methods to a specific mechanism of antimicrobial action. It is anticipated that use of the provided table with the fourteen methods will avoid the use of wrong methods for evaluating new antimicrobial designs and therewith facilitate translation of novel antimicrobial biomaterials and coatings to clinical use. The need for more and better updated industrial standard tests is emphasized.

STATEMENT OF SIGNIFICANCE

European COST-action TD1305, IPROMEDAI aims to provide better understanding of mechanisms of antimicrobial surface designs of biomaterial implants and devices. Current industrial evaluation standard tests do not sufficiently account for different, advanced antimicrobial surface designs, yet are urgently needed to obtain convincing in vitro data for approval of animal experiments and clinical trials. This review aims to provide an innovative and clear guide to choose appropriate evaluation methods for three distinctly different mechanisms of antimicrobial design: (1) antimicrobial-releasing, (2) contact-killing and (3) non-adhesivity. Use of antimicrobial evaluation methods and definition of industrial standard tests, tailored toward the antimicrobial mechanism of the design, as identified here, fulfill a missing link in the translation of novel antimicrobial surface designs to clinical use.

Influence of Antibiotic Pressure on Five Plasmid-based Bioluminescent Gram-negative Bacterial Strains

PURPOSE

The present study aims to develop five Gram-negative bacteria expressing bacterial luciferase for use to evaluate the influence of different antibiotics on bacterial bioluminescence.

PROCEDURES

The pBBR-lux plasmid was introduced into five Gram-negative bacteria; the bioluminescent signals and colony-forming unit (CFU)/ml of all the bioluminescent strains were monitored with six antibiotics at various concentrations.

RESULTS

Dose-dependent bioluminescence signals can be used for rapid bacterial antibiotic susceptibility test (AST). All five bioluminescent bacterial strains have similar bioluminescence and CFU enhancement at sub-minimum inhibitory concentration (MIC) of six different antibiotics.

CONCLUSION

The bioluminescent signals and CFU enhancement at sub-MIC antibiotic concentrations should be of value in the research of new antibiotic drugs and bioluminescent imaging.

SEM Analysis of Surface Impact on Biofilm Antibiotic Treatment

The aim of this work was to use scanning electron microscopy (SEM) to investigate the effect of ampicillin treatment on Escherichia coli biofilms formed on two surface materials with different properties, silicone (SIL) and glass (GLA). Epifluorescence microscopy (EM) was initially used to assess biofilm formation and killing efficiency on both surfaces. This technique showed that higher bacterial colonization was obtained in the hydrophobic SIL than in the hydrophilic GLA. It has also shown that higher biofilm inactivation was attained for GLA after the antibiotic treatment (7-log reduction versus 1-log reduction for SIL). Due to its high resolution and magnification, SEM enabled a more detailed analysis of the antibiotic effect on biofilm cells, complementing the killing efficiency information obtained by EM. SEM micrographs revealed that ampicillin-treated cells have an elongated form when compared to untreated cells. Additionally, it has shown that different materials induced different levels of elongation on cells exposed to antibiotic. Biofilms formed on GLA showed a 37% higher elongation than those formed on SIL. Importantly, cell elongation was related to viability since ampicillin had a higher bactericidal effect on GLA-formed biofilms. These findings raise the possibility of using SEM for understanding the efficacy of antimicrobial treatments by observation of biofilm morphology.

Bio-Inspired Coating Strategies for the Immobilization of Polymyxins to Generate Contact-Killing Surfaces

Microbial colonization of indwelling devices remains a major concern in modern healthcare. Developing approaches to prevent biomaterial-associated infections (BAI) is, therefore, in great demand. This study aimed to immobilize two antimicrobial peptides (polymyxins B and E) onto polydimethylsiloxane (PDMS) using two polydopamine (pDA)-based approaches: the conventional two-step method involving the deposition of a pDA layer to which biomolecules are immobilized, and a one-step method where peptides are dissolved together with dopamine before its polymerization. Surface characterization confirms the immobilization of polymyxins onto PDMS at a non-toxic concentration. Immobilization of polymyxins using a one-step pDA-based approach is able to prevent Pseudomonas aeruginosa adhesion and kill a significant fraction of the adherent ones. Living cells adhered to these modified surfaces exhibit the same susceptibility pattern as cells adhered to unmodified surfaces, highlighting no resistance development. Results suggest that polymyxins immobilization holds a great potential as an additional antimicrobial functionality in the design of biomaterials.

Polydopamine-Mediated Immobilization of Alginate Lyase to Prevent P. aeruginosa Adhesion

Given alginate's contribution to Pseudomonas aeruginosa virulence, it has long been considered a promising target for interventional therapies, which have been performed by using the enzyme alginate lyase. In this work, instead of treating pre-established mucoid biofilms, alginate lyase is immobilized onto a surface as a preventive measure against P. aeruginosa adhesion. A polydopamine dip-coating strategy is employed for functionalization of polycarbonate surfaces. Enzyme immobilization is confirmed by surface characterization. Surfaces functionalized with alginate lyase exhibit anti-adhesive properties, inhibiting the attachment of the mucoid strain. Moreover, surfaces modified with this enzyme also inhibit the adhesion of the tested non-mucoid strain. Unexpectedly, treatment with heat-inactivated enzyme also inhibits the attachment of mucoid and non-mucoid P. aeruginosa strains. These findings suggest that the antibacterial performance of alginate lyase functional coatings is catalysis-independent, highlighting the importance of further studies to better understand its mechanism of action against P. aeruginosa strains.

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.

Delivery of antibiotics from cementless titanium-alloy cubes may be a novel way to control postoperative infections

Bacterial colonisation and biofilm formation onto orthopaedic devices are difficult to eradicate. In most cases infection is treated by surgical removal of the implant and cleaning of the infected area, followed by extensive treatment with broad-spectrum antibiotics. Such treatment causes great discomfort, is expensive, and is not always successful. In this study we report on the release of vancomycin through polyethersulfone membranes from channels in cementless titanium-alloy cubes. The cubes were constructed with LaserCUSING from Ti6Al4V ELI powder. Vancomycin was released by non-Fickian anomalous (constraint) diffusion. Approximately 50% of the vancomycin was released within the first 17 h. However, sustained delivery of vancomycin for 100 h was possible by reinjecting the channels. Refillable implants may be a novel way to control postoperative infections.

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.

Quantification of the interaction between biomaterial surfaces and bacteria by 3-D modeling

It is general knowledge that bacteria/surface interactions depend on the surface topography. However, this well-known dependence has so far not been included in the modeling efforts. We propose a model for calculating interaction energies between spherical bacteria and arbitrarily structured 3-D surfaces, combining the Derjaguin, Landau, Verwey, Overbeek theory and an extended surface element integration method. The influence of roughness on the interaction (for otherwise constant parameters, e.g. surface chemistry, bacterial hydrophobicity) is quantified, demonstrating that common experimental approaches which consider amplitude parameters of the surface topography but which ignore spacing parameters fail to adequately describe the influence of surface roughness on bacterial adhesion. The statistical roughness profile parameters arithmetic average height (representing an amplitude parameter) and peak density (representing a spacing parameter) both exert a distinct influence on the interaction energy. The influence of peak density on the interaction energy increases with decreasing arithmetic average height and contributes significantly to the total interaction energy with an arithmetic average height below 70 nm. With the aid of the proposed model, different sensitivity ranges of the interaction between rough surfaces and bacteria are identified. On the nanoscale, the spacing parameter of the surface dominates the interaction, whereas on the microscale the amplitude parameter adopts the governing role.

Indications for implant removal following intra-articular calcaneal fractures and subsequent complications

INTRODUCTION

Implant removal following operative calcaneal fracture treatment has received little attention in the literature. The aim of the current retrospective cohort study was to assess the indications and number of wound complications following calcaneal plate removal.

METHODS

All consecutive adult patients who had their plate and screws removed following the operative treatment of a closed uni- or bilateral intra-articular calcaneal fracture using a stainless steel nonlocking calcaneal plate between 2000 and 2011 were included.

RESULTS

In 102 patients (46% of the total number of operated calcaneal fractures) implants were removed. Implant removal was performed in 75 patients for symptomatic reasons, in 10 patients due to implant malposition and in 19 patients because of a persistent wound infection or fistula. Following implant removal 17 (16%) patients had a wound complication (2 wound dehiscence, 15 culture positive wound infections). In 6 patients (9%) a wound complications was seen following implant removal after uncomplicated fracture surgery. Implant removal for active infection or plate fistula displayed an infection rate of 8 out of 19 (42%).

CONCLUSION

Implant removal after an intra-articular calcaneal fracture treated with open reduction and internal fixation via an extended lateral approach was followed by a wound complication in 1 of every 10 patients without a preexisting wound infection. Infection rates were especially high in patients in whom the implants were removed for an active wound problem.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Preparation of gentamicin-loaded electrospun coating on titanium implants and a study of their properties in vitro

PURPOSE

Implant-related infections are disastrous complications in the clinic, and there are no effective therapies. In this preliminary study, gentamicin-loaded coating on titanium implants was prepared using the electrospinning technique, and some properties of the coating titanium implants were studied.

METHODS

We adopted the electrospinning technique to prepare gentamicin-coated titanium implants. The surface structure of the coating implants was observed using scanning electron microscope. An elution study was performed to determine the release behavior of the gentamicin from the coating. The antibacterial efficacy and quantitative analysis of the bacterial adhesion of Staphylococcus aureus were evaluated in vitro, and the cytotoxicity of the coated titanium implants on osteoblasts was investigated in vitro.

RESULTS

The morphology of the gentamicin-coated titanium implants exhibited nanofibers, and the release of gentamicin showed an initial gentamicin burst followed by a slow release. The gentamicin-coated titanium implants had a persistent antibacterial efficacy for 1 week and significantly reduced the adhesion of the Staphylococcus aureus compared with bare titanium implants in vitro. There was no cytotoxicity observed in vitro for the gentamicin-coated implants.

CONCLUSION

The gentamicin-coated titanium implants, which were prepared using an electrospinning technique, present many advantages and may be considered to prevent and treat the implant-related infections.

Biofilm inhibition and drug-eluting properties of novel DMAEMA-modified polyethylene and silicone rubber surfaces

Poly(2-(dimethylaminoethyl) methacrylate) (pDMAEMA) was grafted to low density polyethylene (LDPE) and silicone rubber (SR) in order to make them less susceptible to microbial biofilm formation. The direct grafting of DMAEMA using γ-rays was an efficient and fast procedure for obtaining modified materials, which could be quaternized in a second step using methyl iodide. Raman spectroscopy showed that the grafting occurred only at the surface of the LDPE, but both at the surface and in the bulk of the SR. Consequently, the grafted chains caused changes in the surface-related features of the LDPE (water contact angle and viscoelastic behavior in the dry state) and in the bulk-related properties of the SR (swelling and viscoelasticity in the swollen state). The microbiological assays revealed that the grafted DMAEMA reduced Candida albicans biofilm formation (almost no biofilm on SR), while the quaternized surfaces inhibited C. albicans and Staphylococcus aureus biofilm by more than 99% compared to pristine materials. Modified LDPE and SR were capable of holding considerable amounts of nalidixic acid, an anionic antimicrobial drug, and sustained the release for several hours. In addition, the grafted materials were cytocompatible (fibroblast cell survival > 70%). In conclusion, these materials have the ability to inhibit microbial biofilm formation and at the same time act as drug-eluting systems, and for that reason may hold great promise for anti-biofouling applications.