Effectiveness of strontium/silver-based titanium surface coatings in improving antibacterial and osteogenic implant characteristics: a systematic review of in-vitro studies

Introduction: Due to the high incidence of implant failures, dual functionalization of titanium surfaces with antibacterial and osteogenic agents, like silver (Ag) and strontium (Sr), has gained significant attention in recent years. However, so far, the combined antibacterial and osteoinductive effectiveness of Ag/Sr-based titanium surface coatings has only been analyzed in individual studies. Methods: This systematic review aims to evaluate the existing scientific literature regarding the PICOS question "Does dual incorporation of strontium/silver enhances the osteogenic and anti-bacterial characteristics of Ti surfaces in vitro?". As a result of a web-based search adhering to the PRISMA Guidelines using three electronic databases (PubMed, Scopus, and Web of Science) until March 31, 2023, a total of 69 publications were identified as potentially relevant and 17 of which were considered appropriate for inclusion into this review. Results and Discussion: In all included publications, the use of Sr/Ag combination showed enhanced osteogenic and antibacterial effects, either alone or in combination with other agents. Moreover, the combination of Sr and Ag shows potential to synergistically enhance these effects. Nevertheless, further studies need to validate these findings under clinically more relevant conditions and evaluate the mechanism of antimicrobial and osteogenic activity of Sr/Ag combination.

Innovative Coatings of Metallic Alloys Used as Bioactive Surfaces in Implantology: A Review

Metallic implants are widely used in the field of implantology, but there are still problems leading to implant failures due to weak osseointegration, low mechanical strength for the implant, inadequate antibacterial properties, and low patient satisfaction. Implant failure can be caused by bacterial infections and poor osteointegration. To improve the implant functionalization, many researchers focus on surface modifications to prepare the proper physical and chemical conditions able to increase biocompatibility and osteointegration between implant and bone. Improving the antibacterial performance is also a key factor to avoid the inflammation in the human body. This paper is a brief review for the types of coatings used to increase osseointegration and biocompatibility for the successful use of metal alloys in the field of implantology.

Study on Effects of Titanium Surface Microporous Coatings Containing Zinc on Osteoblast Adhesion and Its Antibacterial Activity

Metal surface structure/biomedical function integration is the current research focus. In previous studies, we have successfully prepared the microporous coatings containing zinc on the pure titanium surface by MAO. In the study, osteoblasts were seeded on the surface of the microporous coatings containing zinc and the adhesion of osteoblasts were evaluated, and the antibacterial activity of the microporous coatings containing zinc is observed through in vitro bacterial experiments. The result indicates that the adhesion ability of osteoblasts on the surface of microporous coatings containing zinc was very good, and the coatings could obviously inhibit the growth of Staphylococcus aureus and had good antibacterial activity. In conclusion, the microporous coatings containing zinc on titanium surface have good osteogenic and antibacterial properties and have good application prospect.

Silver doped hydroxyapatite coatings by sacrificial anode deposition under magnetic field

Uniform distribution of silver (Ag) in the hydroxyapatite (HA) coated Ti surface has been a concern for which an attempt has been made to dope Ag in HA coating with and without magnetic field. Cathodic deposition technique was employed to coat Ag incorporated hydroxyapatite coating using a sacrificial silver anode method by using NdFeB bar magnets producing 12 Tesla magnetic field. While uniform deposition of Ag was observed in the coatings under magnetic field, dense coating was evident in the coating without magnetic field conditions. Uniformly distributed Ag incorporated HA in the present study has potential to fight microorganism while providing osseoconduction properties of the composite coating.

Antibacterial and bioactive coatings on titanium implant surfaces

Various surface modifications have been tried for enhancing osseointegration of the dental implants like mechanical and/or chemical treatments and deposition of calcium phosphate coatings. The objective of this research was to develop calcium-phosphate based thin coatings with antibacterial and bioactive properties for potential application in dental implants. Titanium (Ti) discs were immersed in different calcifying solutions: CaP (positive control), F-CaP, Zn-CaP, and FZn-CaP and incubated for 24 h. Negative control was uncoated Ti discs. Coated surfaces were characterized using X-ray diffraction, scanning electron microscopy and energy dispersive spectroscopy. Antibacterial properties were tested using Porphyromonas gingivalis because of its strong association with periodontal and peri-implant infections. Bacterial adhesion and colonization were studied at different timepoints. The coated surfaces had compositional characteristics similar to that of bone mineral and they inhibited the growth, colonization and adherence of P. gingivalis, resulted in reduced thickness of biofilms and bacterial inhibition in the culture medium as compared to the positive and negative controls (p < 0.05). There was no significant difference between the experimental groups (p > 0.05). It has been previously demonstrated that these coatings have excellent in vitro bioactivity (formed carbonate hydroxyapatite when immersed in a simulated body fluid). Such coatings can enhance osseointegration and prevent infection in implants, thereby improving the success rates of implants. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 2218-2227, 2017.

Silver-nanoparticles-modified biomaterial surface resistant to staphylococcus: new insight into the antimicrobial action of silver

Titanium implants are widely used clinically, but postoperative implant infection remains a potential severe complication. The purpose of this study was to investigate the antibacterial activity of nano-silver(Ag)-functionalized Ti surfaces against epidemic Staphylococcus from the perspective of the regulation of biofilm-related genes and based on a bacteria-cell co-culture study. To achieve this goal, two representative epidemic Staphylococcus strains, Staphylococcus epidermidis (S. epidermidis, RP62A) and Staphylococcus aureus (S. aureus, USA 300), were used, and it was found that an Ag-nanoparticle-modified Ti surface could regulate the expression levels of biofilm-related genes (icaA and icaR for S. epidermidis; fnbA and fnbB for S. aureus) to inhibit bacterial adhesion and biofilm formation. Moreover, a novel bacteria-fibroblast co-culture study revealed that the incorporation of Ag nanoparticles on such a surface can help mammalian cells to survive, adhere and spread more successfully than Staphylococcus. Therefore, the modified surface was demonstrated to possess a good anti-infective capability against both sessile bacteria and planktonic bacteria through synergy between the effects of Ag nanoparticles and ion release. This work provides new insight into the antimicrobial action and mechanism of Ag-nanoparticle-functionalized Ti surfaces with bacteria-killing and cell-assisting capabilities and paves the way towards better satisfying the clinical needs.

Tetracycline tethered to titanium inhibits colonization by Gram-negative bacteria

As peri-prosthetic infection is one of the most devastating complications associated with implant placement, we have reasoned that such infection can be largely subverted by development of antibacterial implants. Our previous work demonstrated that covalent coupling of vancomycin to titanium alloy prevented colonization by the Gram-positive pathogens, Staphylococcus aureus and Staphylococcus epidermidis. Some orthopedic devices, including permanent prosthesis anchors, and most dental implants are transcutaneous or transmucosal and can be prone to colonization by Gram-negative pathogens. We report here the successful covalent coupling of the broad-spectrum antibiotic, tetracycline (TET), to titanium surfaces (Ti-TET) to retard Gram-negative colonization. Synthetic progress was followed by changes in water contact angle, while the presence of TET was confirmed by immunofluorescence. Ti-TET actively prevented colonization in the presence of bathing Escherichia coli, both by fluorescence microscopy and direct counting. Finally, the Ti-TET surface supported osteoblastic cell adhesion and proliferation over a 72-h period. Thus, this new surface offers a powerful means to protect transcutaneous implants from adhesion of Gram-negative pathogens, decreasing the need for replacement of this hardware.

Quaternized chitosan as an antimicrobial agent: antimicrobial activity, mechanism of action and biomedical applications in orthopedics

Chitosan (CS) is a linear polysaccharide with good biodegradability, biocompatibility and antimicrobial activity, which makes it potentially useful for biomedical applications, including an antimicrobial agent either alone or blended with other polymers. However, the poor solubility of CS in most solvents at neutral or high pH substantially limits its use. Quaternary ammonium CS, which was prepared by introducing a quaternary ammonium group on a dissociative hydroxyl group or amino group of the CS, exhibited improved water solubility and stronger antibacterial activity relative to CS over an entire range of pH values; thus, this quaternary modification increases the potential biomedical applications of CS in the field of anti-infection. This review discusses the current findings on the antimicrobial properties of quaternized CS synthesized using different methods and the mechanisms of its antimicrobial actions. The potential antimicrobial applications in the orthopedic field and perspectives regarding future studies in this field are also considered.

Physical characterization and osteogenic activity of the quaternized chitosan-loaded PMMA bone cement

Gentamicin-loaded polymethylmethacrylate (PMMA), widely used for primary cemented arthroplasty and revision surgery for preventing or treating infections, may lead to the evolution of antibiotic-resistant bacteria and dysfunction of osteogenic cells, which further influence the osteointegration of bone cement. In a previous study, we reported that a new quaternized chitosan derivative (hydroxypropyltrimethyl ammonium chloride chitosan, HACC) that was loaded into PMMA significantly inhibited the formation of biofilms caused by methicillin-resistant Staphylococcus strains. In the present study, we further investigated the surface morphology, hydrophilicity, apatite formation ability and osteogenic activity of HACC-loaded PMMA. Chitosan-loaded PMMA, gentamicin-loaded PMMA and PMMA without antibiotic were also investigated and compared. The results showed that, compared to other PMMA-based cements, HACC-loaded PMMA had improved properties such as a lower polymerization temperature, prolonged setting time, porous structures after immersion in phosphate-buffered saline, higher hydrophilicity, more apatite formation on the surface after immersion in simulated body fluid, and better attachment and spreading of the human-marrow-derived mesenchymal stem cells. We also found better stem cell proliferation, osteogenic differentiation, and osteogenesis-associated genes expression on the surface of the HACC-loaded PMMA compared to the gentamicin-loaded PMMA. Therefore, this new anti-infective bone cement had improved physical properties and osteogenic activity, which may lead to better osteointegration of the bone cement in cemented arthroplasty.

The use of quaternised chitosan-loaded PMMA to inhibit biofilm formation and downregulate the virulence-associated gene expression of antibiotic-resistant staphylococcus

Biomaterial-associated infections remain a serious complication in orthopaedic surgery. Treatments, including the local use of antibiotic-loaded polymethylmethacrylate (PMMA) bone cement, are not always successful because of multiantibiotic-resistant organisms. In this study, we synthesised a new quaternised chitosan derivative (hydroxypropyltrimethyl ammonium chloride chitosan, HACC) that contains a series of substitutions of quaternary ammonium and demonstrated that HACC with a 26% degree of substitution (DS; referred to as 26%HACC) had a strong antibacterial activity and simultaneously good biocompatibility with osteogenic cells. We loaded 26%HACC at 20% by weight into PMMA bone cement to investigate whether HACC in PMMA prevents bacterial biofilm formation on the surface of bone cements. Chitosan-loaded PMMA (at the same weight ratio), gentamicin-loaded PMMA and PMMA with no antibiotic were also investigated and compared. Two clinical isolates, Staphylococcus epidermidis 389 and methicillin-resistant S. epidermidis (MRSE287), and two standard strains, S. epidermidis (ATCC35984) and methicillin-resistant Staphylococcus aureus (ATCC43300), were selected to evaluate the bacterial biofilm formation at 6, 12 and 24 h using the spread plate method, confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM). The results showed that 26%HACC-loaded PMMA inhibited biofilm formation on its surface, while the PMMA control and chitosan-loaded PMMA were unable to inhibit biofilm formation. The gentamicin-loaded PMMA decreased the number of viable methicillin-resistant Staphylococcus strains, but its ability to inhibit biofilm formation was lower than 26%HACC-loaded PMMA. Real-time PCR demonstrated that 26%HACC-loaded PMMA markedly downregulated the expression of icaAD, which encodes essential enzymes for polysaccharide intercellular adhesion (PIA) biosynthesis, upregulated the expression level of icaR, which negatively mediates icaAD expression, and also downregulated the expression of MecA, which encodes membrane-bound enzymes known to be penicillin-binding proteins. Our study indicates that 26%HACC-loaded PMMA prevents biofilm formation of Staphylococcus, including antibiotic-resistant strains, on the surface of bone cement, and downregulates the virulence-associated gene expression of antibiotic-resistant staphylococcus, thus providing a promising new strategy for combating implant infections and osteomyelitis.

A watertight acrylic-free titanium recording chamber for electrophysiology in behaving monkeys

Neurophysiological recording in alert monkeys requires the creation of a permanent aperture in the skull for repeated insertion of microelectrodes. Most laboratories use polymethyl methacrylate to attach a recording chamber over the skull opening. Here, we describe a titanium chamber that fastens to the skull with screws, using no polymethyl methacrylate. The gap between the base of the chamber and the skull is filled with hydroxyapatite, forming a watertight gasket. As the chamber base osseointegates with the skull, the hydroxyapatite is replaced with bone. Rather than having a finite lifetime, the recording chamber becomes more firmly anchored the longer it is in place. It has a small footprint, low profile, and needs little maintenance to control infection. Toilette consists of occasional application of betadine to clean the scalp margin, followed by application of neomycin, polymyxin, and bacitracin ointment. Antibiotic is also placed inside the chamber to suppress bacterial proliferation. Thickening of the dura within the chamber can be prevented by regular application of mitocycin C and/or bevacizumab, an antibody against vascular endothelial growth factor. By conducting an e-mail survey, this protocol for chamber maintenance was compared with procedures used in 37 other vision research laboratories. Refinement of appliances and techniques used for recordings in awake monkeys promises to increase the pace of scientific discovery and to benefit animal welfare.

Nano-Ag-loaded hydroxyapatite coatings on titanium surfaces by electrochemical deposition

Hydroxyapatite (HA) coatings on titanium (Ti) substrates have attracted much attention owing to the combination of good mechanical properties of Ti and superior biocompatibility of HA. Incorporating silver (Ag) into HA coatings is an effective method to impart the coatings with antibacterial properties. However, the uniform distribution of Ag is still a challenge and Ag particles in the coatings are easy to agglomerate, which in turn affects the applications of the coatings. In this study, we employed pulsed electrochemical deposition to co-deposit HA and Ag simultaneously, which realized the uniform distribution of Ag particles in the coatings. This method was based on the use of a well-designed electrolyte containing Ag ions, calcium ions and l-cysteine, in which cysteine acted as the coordination agent to stabilize Ag ions. The antibacterial and cell culture tests were used to evaluate the antibacterial properties and biocompatibility of HA/Ag composite coatings, respectively. The results indicated the as-prepared coatings had good antibacterial properties and biocompatibility. However, an appropriate silver content should be chosen to balance the biocompatibility and antibacterial properties. Heat treatments promoted the adhesive strength and enhanced the biocompatibility without sacrificing the antibacterial properties of the HA/Ag coatings. In summary, this study provided an alternative method to prepare bioactive surfaces with bactericidal ability for biomedical devices.