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Kazum E, Maman E, Sharfman ZT, Wengier R, Sher O, Khoury A, Chechik O, Dolkart O. Development of a New Model of Humeral Hemiarthroplasty in Rats. J INVEST SURG 2023; 36:2162636. [PMID: 36592973 DOI: 10.1080/08941939.2022.2162636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE In vivo models are anatomically comparable to humans allowing to reproduce the patterns and progression of the disease and giving the opportunity to study the symptoms and responses to new treatments and materials. This study aimed to establish a valid and cost-effective in vivo rat model to assess the effects of implanted shoulder hemiarthroplasty materials on glenoid articular cartilage wear. METHODS Eight adult male Wistar rats underwent right shoulder hemi-arthroplasty. A stainless steel metal bearing was used as a shoulder joint prosthesis. X-rays were performed one week after surgery to verify correct implant position. Additional X-rays were performed 30 and 60 days post-implantation. Animals were sacrificed 24 weeks after implantation. All specimens were evaluated with micro-CT for cartilage and bone wear characteristics as well as histologically for signs of osteoarthritis. Samples were compared to the non-operated shoulders. RESULTS All animals recovered and resumed normal cage activity. All X-rays demonstrated correct implant positioning except for one in which the implant was displaced. Histologic evaluation demonstrated arthritic changes in the implanted shoulder. Decreased Trabecular thickness and Trabecular Spacing were documented among the implanted parties (p < .05). Bone Mineral Density and Tissue Mineral Density were reduced in the operated shoulder although not significantly (p = .07). CONCLUSIONS This study demonstrated significant glenoid cartilage wearing in the operated shoulder. Furthermore, the presence of an intra-articular hemiarthroplasty implant diminished underlying glenoid bone quality. This novel, in vivo-model will enable researchers to test implant materials and their effects on cartilage and bone tissue in a cost-effective reproducible rat model.
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Affiliation(s)
- Efi Kazum
- Division of Orthopaedic Surgery, Shoulder Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Maman
- Division of Orthopaedic Surgery, Shoulder Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zachary T Sharfman
- Department of Orthopaedic Surgery, Montefiore Medical Center, the University Hospital for Albert Einstein College of Medicine, New York, USA
| | - Reut Wengier
- Department of Orthopedic Surgery, Assuta Ashdod Medical Center and the Ben-Gurion University of the Negev, Ashdod, Israel
| | - Osnat Sher
- Pathology Institute, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amal Khoury
- Division of Orthopaedic Surgery, Shoulder Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Chechik
- Division of Orthopaedic Surgery, Shoulder Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oleg Dolkart
- Department of Orthopedic Surgery, Assuta Ashdod Medical Center and the Ben-Gurion University of the Negev, Ashdod, Israel
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Welling MM, Warbroek K, Khurshid C, van Oosterom MN, Rietbergen DDD, de Boer MGJ, Nelissen RGHH, van Leeuwen FWB, Pijls BG, Buckle T. A radio- and fluorescently labelled tracer for imaging and quantification of bacterial infection on orthopaedic prostheses : a proof of principle study. Bone Joint Res 2023; 12:72-79. [PMID: 36649933 PMCID: PMC9872039 DOI: 10.1302/2046-3758.121.bjr-2022-0216.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AIMS Arthroplasty surgery of the knee and hip is performed in two to three million patients annually. Periprosthetic joint infections occur in 4% of these patients. Debridement, antibiotics, and implant retention (DAIR) surgery aimed at cleaning the infected prosthesis often fails, subsequently requiring invasive revision of the complete prosthetic reconstruction. Infection-specific imaging may help to guide DAIR. In this study, we evaluated a bacteria-specific hybrid tracer (99mTc-UBI29-41-Cy5) and its ability to visualize the bacterial load on femoral implants using clinical-grade image guidance methods. METHODS 99mTc-UBI29-41-Cy5 specificity for Stapylococcus aureus was assessed in vitro using fluorescence confocal imaging. Topical administration was used to highlight the location of S. aureus cultured on femoral prostheses using fluorescence imaging and freehand single photon emission CT (fhSPECT) scans. Gamma counting and fhSPECT were used to quantify the bacterial load and monitor cleaning with chlorhexidine. Microbiological culturing helped to relate the imaging findings with the number of (remaining) bacteria. RESULTS Bacteria could be effectively stained in vitro and on prostheses, irrespective of the presence of biofilm. Infected prostheses revealed bacterial presence on the transition zone between the head and neck, and in the screw hole. Qualitative 2D fluorescence images could be complemented with quantitative 3D fhSPECT scans. Despite thorough chlorhexidine treatments, 28% to 44% of the signal remained present in the locations of the infection that were identified using imaging, which included 500 to 2,000 viable bacteria. CONCLUSION The hybrid tracer 99mTc-UBI29-41-Cy5 allowed effective bacterial staining. Qualitative real-time fluorescence guidance could be effectively combined with nuclear imaging that enables quantitative monitoring of the effectiveness of cleaning strategies.Cite this article: Bone Joint Res 2023;12(1):72-79.
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Affiliation(s)
- Mick M. Welling
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Kim Warbroek
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Chrow Khurshid
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Matthias N. van Oosterom
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Daphne D. D. Rietbergen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands,Department of Radiology, Section Nuclear Medicine, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G. J. de Boer
- Departments of Internal Medicine and Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | | | - Fijs W. B. van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Bart G. Pijls
- Department of Orthopedics, Leiden University Medical Center, Leiden, Netherlands
| | - Tessa Buckle
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, Netherlands, Tessa Buckle. E-mail:
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3
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Diez-Escudero A, Carlsson E, Andersson B, Järhult JD, Hailer NP. Trabecular Titanium for Orthopedic Applications: Balancing Antimicrobial with Osteoconductive Properties by Varying Silver Contents. ACS APPLIED MATERIALS & INTERFACES 2022; 14:41751-41763. [PMID: 36069272 PMCID: PMC9501801 DOI: 10.1021/acsami.2c11139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
Periprosthetic joint infection (PJI) and implant loosening are the most common complications after joint replacement surgery. Due to their increased surface area, additively manufactured porous metallic implants provide optimal osseointegration but they are also highly susceptible to bacterial colonization. Antibacterial surface coatings of porous metals that do not inhibit osseointegration are therefore highly desirable. The potential of silver coatings on arthroplasty implants to inhibit PJI has been demonstrated, but the optimal silver content and release kinetics have not yet been defined. A tight control over the silver deposition coatings can help overcome bacterial infections while reducing cytotoxicity to human cells. In this regard, porous titanium sputtered with silver and titanium nitride with increasing silver contents enabled controlling the antibacterial effect against common PJI pathogens while maintaining the metabolic activity of human primary cells. Electron beam melting additively manufactured titanium alloys, coated with increasing silver contents, were physico-chemically characterized and investigated for effects against common PJI pathogens. Silver contents from 7 at % to 18 at % of silver were effective in reducing bacterial growth and biofilm formation. Staphylococcus epidermidis was more susceptible to silver ions than Staphylococcus aureus. Importantly, all silver-coated titanium scaffolds supported primary human osteoblasts proliferation, differentiation, and mineralization up to 28 days. A slight reduction of cell metabolic activity was observed at earlier time points, but no detrimental effects were found at the end of the culture period. Silver release from the silver-coated scaffolds also had no measurable effects on primary osteoblast gene expression since similar expression of genes related to osteogenesis was observed regardless the presence of silver. The investigated silver-coated porous titanium scaffolds may thus enhance osseointegration while reducing the risk of biofilm formation by the most common clinically encountered pathogens.
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Affiliation(s)
- Anna Diez-Escudero
- Ortholab,
Department of Surgical Sciences—Orthopaedics, Uppsala University, Uppsala 751 85, Sweden
| | - Elin Carlsson
- Ortholab,
Department of Surgical Sciences—Orthopaedics, Uppsala University, Uppsala 751 85, Sweden
| | - Brittmarie Andersson
- Ortholab,
Department of Surgical Sciences—Orthopaedics, Uppsala University, Uppsala 751 85, Sweden
| | - Josef D. Järhult
- Zoonosis
Science Center, Department of Medical Sciences, Uppsala University, Uppsala 751 85, Sweden
| | - Nils P. Hailer
- Ortholab,
Department of Surgical Sciences—Orthopaedics, Uppsala University, Uppsala 751 85, Sweden
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Visperas A, Santana D, Ju M, Milbrandt NB, Tsai YH, Wickramasinghe S, Klika AK, Piuzzi NS, Samia ACS, Higuera-Rueda CA. Standardized quantification of biofilm in a novel rabbit model of periprosthetic joint infection. J Bone Jt Infect 2022; 7:91-99. [PMID: 35505905 PMCID: PMC9051660 DOI: 10.5194/jbji-7-91-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/06/2022] [Indexed: 12/02/2022] Open
Abstract
Periprosthetic joint infection (PJI) is one of the most
devastating complications of total joint arthroplasty. The underlying
pathogenesis involves the formation of bacterial biofilm that protects the
pathogen from the host immune response and antibiotics, making eradication
difficult. The aim of this study was to develop a rabbit model of knee PJI
that would allow reliable biofilm quantification and permit the study of
treatments for PJI. In this work,
New Zealand white rabbits (n=19) underwent knee joint arthrotomy,
titanium tibial implant insertion, and inoculation with Xen36 (bioluminescent
Staphylococcus aureus) or a saline control after capsule closure. Biofilm was quantified via
scanning electron microscopy (SEM) of the tibial explant 14 d after
inoculation (n=3 noninfected, n=2 infected). Rabbits underwent
debridement, antibiotics, and implant retention (DAIR) (n=6) or sham
surgery (n=2 noninfected, n=6 infected) 14 d after inoculation, and
they were sacrificed 14 d post-treatment. Tibial explant and periprosthetic tissues
were examined for infection.
Laboratory assays supported bacterial infection in infected
animals. No differences in weight or C-reactive protein (CRP) were detected after
DAIR compared to sham treatment. Biofilm coverage was significantly
decreased with DAIR treatment when compared with sham treatment (61.4 % vs.
90.1 %, p<0.0011) and was absent in noninfected control
explants. In summary, we have developed an experimental rabbit hemiarthroplasty knee
PJI model with bacterial infection that reliably produces quantifiable
biofilm and provides an opportunity to introduce treatments at 14 d. This
model may be used to better understand the pathogenesis of this condition
and to measure treatment strategies for PJI.
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Affiliation(s)
- Anabelle Visperas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Santana
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Minseon Ju
- Department of Chemistry, Case Western Reserve University, Cleveland, OH, USA
| | | | - Yu Hsin Tsai
- Department of Chemistry, Case Western Reserve University, Cleveland, OH, USA
| | | | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Cyphert EL, Zhang N, Learn GD, Hernandez CJ, von Recum HA. Recent Advances in the Evaluation of Antimicrobial Materials for Resolution of Orthopedic Implant-Associated Infections In Vivo. ACS Infect Dis 2021; 7:3125-3160. [PMID: 34761915 DOI: 10.1021/acsinfecdis.1c00465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
While orthopedic implant-associated infections are rare, revision surgeries resulting from infections incur considerable healthcare costs and represent a substantial research area clinically, in academia, and in industry. In recent years, there have been numerous advances in the development of antimicrobial strategies for the prevention and treatment of orthopedic implant-associated infections which offer promise to improve the limitations of existing delivery systems through local and controlled release of antimicrobial agents. Prior to translation to in vivo orthopedic implant-associated infection models, the properties (e.g., degradation, antimicrobial activity, biocompatibility) of the antimicrobial materials can be evaluated in subcutaneous implant in vivo models. The antimicrobial materials are then incorporated into in vivo implant models to evaluate the efficacy of using the material to prevent or treat implant-associated infections. Recent technological advances such as 3D-printing, bacterial genomic sequencing, and real-time in vivo imaging of infection and inflammation have contributed to the development of preclinical implant-associated infection models that more effectively recapitulate the clinical presentation of infections and improve the evaluation of antimicrobial materials. This Review highlights the advantages and limitations of antimicrobial materials used in conjunction with orthopedic implants for the prevention and treatment of orthopedic implant-associated infections and discusses how these materials are evaluated in preclinical in vivo models. This analysis serves as a resource for biomaterial researchers in the selection of an appropriate orthopedic implant-associated infection preclinical model to evaluate novel antimicrobial materials.
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Affiliation(s)
- Erika L. Cyphert
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Ningjing Zhang
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Greg D. Learn
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Christopher J. Hernandez
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York 14853, United States
- Hospital for Special Surgery, New York, New York 10021, United States
| | - Horst A. von Recum
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
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6
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Ghimire A, Song J. Anti-Periprosthetic Infection Strategies: From Implant Surface Topographical Engineering to Smart Drug-Releasing Coatings. ACS APPLIED MATERIALS & INTERFACES 2021; 13:20921-20937. [PMID: 33914499 PMCID: PMC8130912 DOI: 10.1021/acsami.1c01389] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Despite advanced implant sterilization and aseptic surgical techniques, periprosthetic bacterial infection remains a major challenge for orthopedic and dental implants. Bacterial colonization/biofilm formation around implants and their invasion into the dense skeletal tissue matrices are difficult to treat and could lead to implant failure and osteomyelitis. These complications require major revision surgeries and extended antibiotic therapies that are associated with high treatment cost, morbidity, and even mortality. Effective preventative measures mitigating risks for implant-related infections are thus in dire need. This review focuses on recent developments of anti-periprosthetic infection strategies aimed at either reducing bacterial adhesion, colonization, and biofilm formation or killing bacteria directly in contact with and/or in the vicinity of implants. These goals are accomplished through antifouling, quorum-sensing interfering, or bactericidal implant surface topographical engineering or surface coatings through chemical modifications. Surface topographical engineering of lotus leaf mimicking super-hydrophobic antifouling features and cicada wing-mimicking, bacterium-piercing nanopillars are both presented. Conventional physical coating/passive release of bactericidal agents is contrasted with their covalent tethering to implant surfaces through either stable linkages or linkages labile to bacterial enzyme cleavage or environmental perturbations. Pros and cons of these emerging anti-periprosthetic infection approaches are discussed in terms of their safety, efficacy, and translational potentials.
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Affiliation(s)
- Ananta Ghimire
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jie Song
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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7
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Motififard M, Nazem K, Meshkati M. Determining the relation between total knee arthroplasty surgery site drainage in two weeks after surgery with periprosthetic joint infection (PJI) in two years. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2021; 11:62-68. [PMID: 33824787 PMCID: PMC8012868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/28/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Prosthetic joint infection (PJI) is a devastating complication in total knee arthroplasty (TKA) surgeries and prompt diagnosis and treatment are vital; however, no study has been conducted to determine the relationship between characteristics and duration of surgical site discharge and PJI. METHODS This is a longitudinal observational study that was performed at Al-Zahra and Kashani and Sadi university hospitals from 2017 until 2019. A total of 961 elective TKA were performed on 850 consecutive patients. Patients were followed up for two years after surgery. Data regarding the occurrence of discharges, types of discharges, duration of discharges, the incidence of PJI and superficial infections were collected. RESULTS The rate of superficial and prosthetic joint infection was 0.3% and 0.3%. Patients with infections (either PJI or superficial) had a longer duration of discharge (14.6 days and 13.3 days in PJI and superficial infections respectively, compared to 7.7 days in all of the study population); Bloody-purulent discharge was associated with the development of prosthetic and superficial infections. CONCLUSION Bloody purulent discharge reaching seven days postsurgical in TKA patients is highly suggestive of an underlying infection (PJI or superficial infection) but type and duration of discharge could not be used to differentiate between PJI and superficial infection. Other risk factors for PJI or superficial infection include women's gender, longer surgical duration, longer hospitalization and longer discharge duration.
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Affiliation(s)
- Mehdi Motififard
- Department of Orthopedic and Trauma, Isfahan University of Medical ScienceIsfahan, Iran
| | - Khalilolah Nazem
- Department of Orthopedic and Trauma, Isfahan University of Medical ScienceIsfahan, Iran
| | - Mehdi Meshkati
- Department of Orthopedic Surgery, School of Medicine, Isfahan University of Medical SciencesIsfahan, Iran
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8
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Duan J, Yang Y, Zhang E, Wang H. Co-Cr-Mo-Cu alloys for clinical implants with osteogenic effect by increasing bone induction, formation and development in a rabbit model. BURNS & TRAUMA 2020; 8:tkaa036. [PMID: 33376752 PMCID: PMC7750714 DOI: 10.1093/burnst/tkaa036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/12/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
Background Co-Cr-Mo alloy has been widely used in clinical implants because of its excellent mechanical and anti-corrosion properties, but there is an urgent need to address its disadvantages, such as implant-related infections and implant loosening. We synthesized Co-Cr-Mo-Cu (Co-Cu) alloys with different Cu contents to modify implant performance to be suitable as a bone-compatible implant material. Methods Microstructure, phase content and mechanical properties of the Co-Cr-Mo alloy were characterized. Histological and immunohistochemical analyses were performed after implantation in rabbits. The experimental alloy was implanted on the lateral side of the lower tibial condyle and the tibial nodule. Results Phase content and mechanical properties revealed that the crystallographic structure and wear resistance were changed. Experimental implantation results demonstrated that osteogenic capability was markedly enhanced, ascribed to the excellent antibacterial and osseointegration capacities of Cu phases, and with the release of Cu ions. In particular, Co-Cu alloy containing 2 wt% Cu exhibited the best osteogenic performance among all samples. Conclusions The results indicated that osteogenic performance of the Co-Cr-Mo alloy could be enhanced by adding Cu. In particular, the Co-2Cu alloy exhibited the best properties according to both immunohistochemical and histological analyses. Our study not only provides deep insight into the osteogenic effect of Cu but presents a new Co-Cu alloy for clinical implants.
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Affiliation(s)
- Jingzhu Duan
- Department of Orthopaedic, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang 110004, China
| | - Yang Yang
- Department of Ophthalmology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang 110004, China
| | - Erlin Zhang
- Key Laboratory for Anisotropy and Texture of Materials, Education Ministry of China, School of Materials Science and Engineering, Northeastern University, No. 3-11 Wenhua Road, Heping District, Shenyang 110819, China
| | - Huan Wang
- Department of Orthopaedic, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang 110004, China
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9
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Paish ADM, Nikolov HN, Welch ID, El-Warrak AO, Teeter MG, Naudie DDR, Holdsworth DW. Image-based design and 3D-metal printing of a rat hip implant for use in a clinically representative model of joint replacement. J Orthop Res 2020; 38:1627-1636. [PMID: 32369210 DOI: 10.1002/jor.24706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/06/2020] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
Abstract
The aim of this study was to obtain micro-computed tomography derived measurements of the rat proximal femur, to create parameterized rat hip implants that could be surgically installed in a clinically representative small animal model of joint replacement. The proximal femoral anatomy of N = 25 rats (male, Sprague-Dawley, 390-605 g) was quantified. Key measurements were used to parameterize computer-aided design models of monoblock rat femoral implants. Linear regression analysis was used to determine if rat hip dimensions could be predicted from animal weight. A correlation analysis was used to determine how implants could be scaled to create a range of sizes. Additive manufacturing (3D printing) was used to create implants in medical-grade metal alloys. Linear regressions comparing rat weight to femoral head diameter and neck-head axis length revealed a significant nonzero slope (P < .05). Pearson's correlation analysis revealed five significant correlations between key measurements in the rat femur (P < .05). Implants were installed into both cadaveric and live animals; iterative design modifications were made to prototypes based on these surgical findings. Animals were able to tolerate the installation of implants and were observed ambulating on their affected limbs postoperatively. Clinical significance: We have developed a preclinical rat hip hemiarthroplasty model using image-based and iterative design techniques to create 3D-metal printed implants in medical-grade metal alloys. Our findings support further development of this model for use as a low-cost translational test platform for preclinical orthopaedic research into areas such as osseointegration, metal-on-cartilage wear, and periprosthetic joint infection.
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Affiliation(s)
- Adam D M Paish
- Bone and Joint Institute, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada
| | - Hristo N Nikolov
- Robarts Research Institute, Western University, London, Ontario, Canada
| | - Ian D Welch
- Animal Care Services, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander O El-Warrak
- Surgery Team, Premier Veterinary Group by Ethos Animal Health, Orland Park, Illinois
| | - Matthew G Teeter
- Bone and Joint Institute, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada.,Division of Orthopaedic Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Douglas D R Naudie
- Bone and Joint Institute, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada.,Division of Orthopaedic Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - David W Holdsworth
- Bone and Joint Institute, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Robarts Research Institute, Western University, London, Ontario, Canada.,Division of Orthopaedic Surgery, London Health Sciences Centre, London, Ontario, Canada
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10
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Is EDTA Irrigation Effective in Reducing Bacterial Infection in a Rat Model of Contaminated Intra-articular Knee Implants? Clin Orthop Relat Res 2020; 478:1111-1121. [PMID: 32012144 PMCID: PMC7170675 DOI: 10.1097/corr.0000000000001119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND To mitigate the possibility of infection after arthroplasty, intraoperative irrigation is essential to remove contaminating bacteria. Previous studies have demonstrated that irrigation with an EDTA solution before wound closure is superior to irrigation with normal saline in removing contaminating bacteria in a rat model of open fractures. However, the effectiveness of an EDTA solution in a model with a contaminated intra-articular implant remains unclear. QUESTIONS/PURPOSES (1) Does irrigation with an EDTA solution decrease the proportion of culture-positive joints compared with normal saline, benzalkonium chloride, and povidone iodine? (2) Is an EDTA solution toxic to cells resident in joints including chondrocytes, osteoblasts, and synovial fibroblasts? (3) Does irrigation with an EDTA solution have adverse effects including arthrofibrosis and hypocalcemia? METHODS We first established a model of contaminated intra-articular implants. Female Sprague-Dawley rats (n = 30 for each treatment group) underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. To simulate bacterial contamination, the inserted wire was inoculated with either Staphylococcus aureus or Escherichia coli. After 1 hour, the wound and implant were irrigated with normal saline, benzalkonium chloride, povidone iodine, or an EDTA solution (1 mM). The animals were euthanized 1 week later, and the distal femur, knee capsule, and implanted wire were harvested for bacterial culture using standard techniques. In this study, we used a well-established animal model of an intra-articular implant and inoculated the implant to simulate the clinical setting of intraoperative contamination. The proportion of culture-positive joints in normal saline, benzalkonium chloride, povidone-iodine, and EDTA groups were compared. The viable cell numbers (chondrocytes, osteoblasts, and synovial fibroblasts) were counted and compared after treatment with either solution. Measurement of blood calcium level and histological examination of the joint were performed to rule out hypocalcemia and arthrofibrosis after EDTA irrigation. RESULTS With S. aureus inoculation, EDTA irrigation resulted in fewer culture-positive joints than normal saline (37% [11 of 30] versus 70% [21 of 30]; p = 0.019), benzalkonium chloride (83% [25 of 30]; p < 0.001), and povidone iodine (83% [25 of 30]; p < 0.001) irrigation. Likewise, infection rates for implant inoculation with E. coli were also lower in the EDTA irrigation group (13% [four of 30]) than in the normal saline (60% [18 of 30]; p < 0.001), benzalkonium chloride (77% [23 of 30]; p < 0.001), and povidone iodine (80% [24 of 30]; p < 0.001) groups. Between normal saline control and EDTA, there were no differences in cell viability in chondrocytes (normal saline: 98% ± 18%; EDTA: 105% ± 18%; p = 0.127), osteoblasts (normal saline: 102 ± 19%, EDTA: 103 ± 14%; p = 0.835), and synovial fibroblasts (normal saline: 101% ± 21%, EDTA: 110% ± 13%; p = 0.073). EDTA irrigation did not result in hypocalcemia (before irrigation: 2.21 ± 0.32 mmol/L, after irrigation: 2.23 ± 0.34 mmol/L; p = 0.822); and we observed no arthrofibrosis in 30 histologic samples. CONCLUSIONS In a rat model of a bacteria-contaminated intra-articular implants, intraoperative irrigation with 1 mmol/L of an EDTA solution was superior to normal saline, 0.03% benzalkonium chloride, and 0.3% povidone iodine in preventing surgical-site infection and caused no adverse effects including death of resident cells, arthrofibrosis, and hypocalcemia. Future studies should seek to replicate our findings in other animal models, perhaps such as dog and goat. CLINICAL RELEVANCE If other animal models substantiate the efficacy and safety of the EDTA solution, clinical trials would be warranted to determine whether the use of an EDTA irrigation solution might reduce the risk of periprosthetic joint infections in patients compared with traditional irrigation solutions.
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