Treatment of prosthetic osteoarticular infections

Bitter Taste Receptor as a Therapeutic Target in Orthopaedic Disorders

Non-gustatory, extraoral bitter taste receptors (T2Rs) are G-protein coupled receptors that are expressed throughout the body and have various functional responses when stimulated by bitter agonists. Presently, T2Rs have been found to be expressed in osteoclasts and osteocytes where osteoclasts were capable of detecting bacterial quorum-sensing molecules through the T2R38 isoform. In the innate immune system, stimulating T2Rs induces anti-inflammatory and anti-pathogenic effects through the phospholipase C/inositol triphosphate pathway, which leads to intracellular calcium release from the endoplasmic reticulum. The immune cells with functional responses to T2R activation also play a role in bone inflammation and orthopaedic disorders. Furthermore, increasing intracellular calcium levels in bone cells through T2R activation can potentially influence bone formation and resorption. With recent studies finding T2R expression in bone cells, we examine the potential of targeting this receptor to treat bone inflammation and to promote bone anabolism.

Development of a Novel Nanotextured Titanium Implant. An Experimental Study in Rats

This animal study evaluated the osseointegration level of a new nanotextured titanium surface produced by anodization. Ti-cp micro-implants (1.5 mm diameter by 2.5 mm in length) divided into two groups: titanium nanotextured surface treatment (Test Group) and acid etched surface treatment (Control Group). Surface characterization included morphology analysis using scanning electron microscopy and wettability by measuring contact angle. Sixteen Wistar rats were submitted to two micro implants surgical placement procedures. In each rat, one type of micro implant placed in each tibia. The animals sacrificed after two (T1) and six weeks (T2) post-implantation. After the euthanasia, tibias processed for histomorphometric analysis, which allowed the evaluation of bone to implant contact (BIC) and the bone area fraction occupancy between the threads (BAFO). Our surface analysis data showed that the Control Group exhibited an irregular and non-homogenous topography while the Test Group showed a nanotextured surface. The Test Group showed higher wettability (contact angle = 5.1 ± 0.7°) than the Control Group (contact angle = 75.5 ± 4.6°). Concerning the histomorphometric analysis results for T1, Control and Test groups showed BIC percentages of 41.3 ± 15.2% and 63.1 ± 8.7% (p < 0.05), respectively, and for BAFO, 28.7 ± 13.7% and 54.8 ± 7.5%, respectively (p < 0.05). For T2, the histomorphometric analysis for Control and Test groups showed BIC percentages of 51.2 ± 11.4% and 64.8 ± 7.4% (p < 0.05), respectively and for BAFO, 36.4 ± 10.3% and 57.9 ± 9.3% (p < 0.05), respectively. The findings of the current study confirmed that the novel nanotextured surface exhibited superior wettability, improved peri-implant bone formation, and expedited osseointegration.

Fabrication of alginate modified brushite cement impregnated with antibiotic: Mechanical, thermal, and biological characterizations

Treatment of postsurgical infections, associated with orthopedic surgeries, has been a major concern for orthopedics. Several strategies including systematic and local administration of antibiotics have been proposed to this regard. The present work focused on fabricating alginate (Alg) modified brushite (Bru) cements, which could address osteogeneration and local antibiotic demands. To find the proper method of drug incorporation, Gentamicin sulfate (Gen) was loaded into the samples in the form of solution or powder. Several characterization tests including compression test, morphology, cytotoxicity, and cell adhesion assays were carried out to determine the proper concentration of Alg as a modifier of the Bru cement. The results indicated that addition of 1 wt% Alg led to superior mechanical and biological properties of the cement. Moreover, Alg addition changed the morphology of the cement from plate and needle-like structures to petal-like structure. Fourier transform infrared spectroscopy results confirmed the successful loading of Gen on the cements, specifically when Gen solution was used, and X-Ray Diffractometer result indicated that Gen caused a decrease in crystalline size. Furthermore, thermal analysis revealed that Gen-loaded sample had more stable structure as the transformation temperature slightly shifted to a higher one. The stability study confirmed the chemical stability and adequate mechanical performance of the cements within 1 month of soaking time. Finally, the addition of Alg has a positive impact on the release behavior at low concentration of Gen solution so that 20% decrease within 2 weeks of release experiment was remarkably detected.

Immobilization of type I collagen/hyaluronic acid multilayer coating on enoxacin loaded titania nanotubes for improved osteogenesis and osseointegration in ovariectomized rats

Titania nanotubes (Ti-NTs) have been proven to be good drug carriers and can release drugs efficiently around implants. Enoxacin (EN) is a broad-spectrum antibiotic that has the ability of anti-osteoclastogenesis. Immobilization of extracellular matrix components on the surface of the material can greatly enhance the biological activity of the implant and slow down the release rate of the drug in Ti-NTs. In the present study, a material system that provided uniform drug release, promoted osteogenesis, and inhibited osteoclast was designed and developed. Scanning electron microscopy, X-ray photoelectron spectroscopy, and water contact angle measurements were used for material surface characterization. Enoxacin release was detected by high performance liquid chromatography. Alkaline phosphatase and Alizarin Red staining were used to evaluate the osteogenic differentiation of rat bone marrow mesenchymal stem cells. Tartrate-resistant acid phosphatase staining and bone absorption assay were applied to osteoclastogenesis experiments. A drug delivery system based on Ti-NTs and type I collagen /hyaluronic acid multilayer coating (Ti-NT+EN+Col/HyA) with predominant biocompatibility, osteogenic property, and anti-osteoclastogenesis ability was successfully constructed. These excellent biological properties were further validated in an ovariectomized rat model. The results of the study indicate that Ti-NT+EN+Col/HyA is a potential material for future orthopedic implants.

Antimicrobial activity of commercial calcium phosphate based materials functionalized with vanillin

Infections represent one of the most frequent causes of arthroplasty revision. Thus, design of new antimicrobial scaffolds to reduce implant rejections, bone infections and associated medical costs is highly desired. In recent years, essential oil components (EOCs) have merged as compounds with significant antimicrobial activity that can be attached to specific surfaces to enhance and prolong their antimicrobial effect. Herein calcium phosphate CaP regenerative materials have been coated with a vanillin derivative to combine its original bone regeneration properties with antimicrobial action of EOCs. Materials in form of microparticles and blocks were prepared and fully characterized. Clonogenic viability tests demonstrated that low concentrations of material (10 mg·mL^-1) resulted effective to kill 100% of E. coli DH5α bacteria. Additionally, vanillin containing scaffolds did not display any toxic effect over cells, yet they preserve the ability to express alkaline phosphatase (ALPL), collagen type 1, chain α1 (COL1A1) and bone gamma-carboxyglutamic acid-containing protein or osteocalcin (BGLAP), which are genes typically expressed by osteoblasts. These results demonstrate that commercially available scaffolds can be functionalized with EOCs, achieving antimicrobial activity and open up a new approach for the treatment and prevention of infection. STATEMENT OF SIGNIFICANCE: During the last years, the interest in bone regenerative materials with antibiotic properties has increased, since prosthesis infection is one of the most usual complications in implant surgery. In this work, we report a hybrid system composed by a calcium phosphate material (powders and scaffolds) functionalized with the derivative of an essential oil component (EOC). Our purpose was to provide the calcium phosphate material with antimicrobial activity without harming its bone regenerative capability. The obtained results were encouraging, which opens up the possibility of developing new modified materials for the prevention and treatment of bone infection.

State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty

Acute peri-prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a potentially devastating and undesired complication, with a prevalence of 0.3% to 2.9%. Its suspicion begins with a meticulous physical examination and anamnesis. Diagnosis should be made on the basis of the Musculoskeletal Infection Society criteria. Serum and synovial biomarkers are very useful tools when major criteria are absent.Although sometimes not possible due to medical conditions, surgery is usually the first line of treatment. Although its outcome is highly correlated with the isolated microorganism, irrigation and debridement with implant retention (DAIR) is the gold standard for treatment. Ideally, the prior approach should be proximally and distally extended to augment the field of view and remove all of the prosthetic modular components, that is, femoral head and acetabular insert.Given DAIR's unclear control of infection, with successful outcomes in the range of 30% to 95%, one- or two-stage revision protocols may play a role in certain cases of acute infections; nonetheless, further prospective, randomized studies are necessary to compare long-term outcomes between DAIR and revision surgeries.Following surgical treatment, length of antibiotherapy is in the range of six weeks to six months, without any difference in outcomes between short and long protocols. Treatment should be adjusted to the isolated bacteria and controlled further with post-operative serum biomarker levels. Cite this article: EFORT Open Rev 2018;3:434-441. DOI: 10.1302/2058-5241.3.170032.

Prevention of bacterial adhesion to zwitterionic biocompatible mesoporous glasses

Novel materials, based on Mesoporous Bioactive Glasses (MBGs) in the ternary system SiO₂-CaO-P₂O₅, decorated with (3-aminopropyl)triethoxysilane (APTES) and subsequently with amino acid Lysine (Lys), by post-grafting method on the external surface of the glasses (named MBG-NH₂ and MBG-Lys), are reported. The surface functionalization with organic groups did not damage the mesoporous network and their structural and textural properties were also preserved despite the high solubility of MBG matrices. The incorporation of Lys confers a zwitterionic nature to these MBG materials due to the presence of adjacent amine and carboxylic groups in the external surface. At physiologic pH, this coexistence of basic amine and carboxilic acid groups from anchored Lys provided zero surface charge named zwitterionic effect. This behaviour could give rise to potential applications of antibacterial adhesion. Therefore, in order to assess the influence of zwitterionic nature in in vitro bacterial adhesion, studies were carried out with Staphylococcus aureus. It was demonstrated that the efficient interaction of these zwitterionic pairs onto the MBG surfaces reduced bacterial adhesion up to 99.9% compared to bare MBGs. In order to test the suitability of zwitterionic MBGs materials as bone grafts, their cytocompatibility was investigated in vitro with MC3T3-E1 preosteoblasts. These findings suggested that the proposed surface functionalization strategy provided MBG materials with notable antibacterial adhesion properties, hence making these materials promising candidates for local bone infection therapy.

STATEMENT OF SIGNIFICANCE

The present research work is focused in finding a preventive treatment of bone infection based on Mesoporous Bioactive Glasses (MBGs) with antibacterial adhesion properties obtained by zwitterionic surface modification. MBGs exhibit unique nanostructural, textural and bioactive characteristics. The novelty and originality of this manuscript is based on the design and optimization of a straightforward functionalization method capable of providing MBGs with zwitterionic surfaces that are able to inhibit bacterial adhesion without affecting their cytocompatibility. This new characteristic enhanced the MBG properties to avoid the bacterial adherence onto the implant surfaces for bone tissue engineering applications. Subsequently, it could help to decrease the infection rates after implantation surgery, which represents one of the most serious complications associated to surgical treatments of bone diseases and fractures.

Hollow mesoporous carbon nanocarriers for vancomycin delivery: understanding the structure-release relationship for prolonged antibacterial performance

Mono-dispersed mesoporous hollow carbon (MHC) nanospheres with comparable structures have been designed as nanocarriers for the delivery of vancomycin (Van) to inhibit bacterial growth. It is demonstrated that MHC materials possess a Van loading capacity of 861 mg g^-1, much higher than that of any Van nanocarrier in previous reports. By comparing the drug loading, release and antibacterial performance of MHC nanospheres with controllable structures, it is shown that MHC with a pore size of 5.8 nm and a wall thickness of 25 nm exhibits compromising storage-release behaviour and achieves extended bactericidal activity of Van towards E. coli and S. epidermidis compared to free Van and other MHC nanocarriers. This study provides new knowledge about the rational design of carbon based nanocarriers to enhance the therapeutic efficacy of antibiotics.

Update on the Management of Pediatric Acute Osteomyelitis and Septic Arthritis

Acute osteomyelitis and septic arthritis are two infections whose frequencies are increasing in pediatric patients. Acute osteomyelitis and septic arthritis need to be carefully assessed, diagnosed, and treated to avoid devastating sequelae. Traditionally, the treatment of acute osteoarticular infection in pediatrics was based on prolonged intravenous anti-infective therapy. However, results from clinical trials have suggested that in uncomplicated cases, a short course of a few days of parenteral antibiotics followed by oral therapy is safe and effective. The aim of this review is to provide clinicians an update on recent controversies and advances regarding the management of acute osteomyelitis and septic arthritis in children. In recent years, the emergence of bacterial species resistant to commonly used antibiotics that are particularly aggressive highlights the necessity for further research to optimize treatment approaches and to develop new molecules able to fight the war against acute osteoarticular infection in pediatric patients.

Drug treatments for prosthetic joint infections in the era of multidrug resistance

INTRODUCTION

Despite many advances, the management of prosthetic joint infection is still a complex issue. Moreover, in recent years the problem of antimicrobial resistance has emerged as an important challenge.

AREAS COVERED

We analysed recent advances in different aspects of prosthetic joint infections. The importance of biofilms needs to be considered for antibiotic selection because, when embedded in these structures, bacteria acquire resistant behaviour. Moreover, the presence of resistance mechanisms in some species of organisms increases the difficulty of management. In this sense, the growing importance of methicillin-resistant staphylococci, multidrug-resistant Enterobacteriaceae or Pseudomonas aeruginosa is of increasing concern. Together with these organisms, others with constitutive resistance against most antibiotics (like Enterococcus sp., mycobacteria or fungi) represent a similar problem for selection of therapy. Research into new materials that can be used as drug carriers opens a new field for management of these infections and will likely come to the front line in the coming years.

EXPERT OPINION

Individualised therapies should carefully consider the aetiology, pathogenesis and antimicrobial susceptibility. Satisfactory clinical outcome could be further fostered by enhancing the multidisciplinary approach, with better collaboration in the antibiotic selection and the surgical management.

A commentary on the disparate perspectives of clinical microbiologists and surgeons: ad hoc antimicrobial use

Prosthetic joints and other orthopedic implants have improved quality of life for patients world-wide and the use of such devices is increasing. However, while infection rates subsequent to associated surgery are relatively low (<3%), the consequences of incidence are considerable, encompassing morbidity (including amputation) and mortality in addition to significant social and economic costs. Emphasis, therefore, has been placed on mitigating microbial risk, with clinical microbiologists and surgeons utilizing rapidly evolving molecular laboratory techniques in detection and diagnosis of infection, which still occurs despite sophisticated patient management. Multidisciplinary approaches are regularly adopted to achieve this. In this commentary, we describe an unusual case of Actinomyces infection in total hip arthroplasty and, in that context, describe the perspectives of the clinical microbiology and surgical teams and how they contrasted. More specifically, this case demonstrates an ad hoc approach to structured eradication of biofilms and intracellular bacteria related to biomaterials, as reflected in early usage of linezolid. This is a complex topic and, as described in this case, such accelerated treatment can be effective. This commentary focuses on the merits of such inadvisable use of potent antimicrobials amid the risk of diminishing valuable antimicrobial efficacy, albeit resulting in desirable patient outcomes.

In vitro antibacterial capacity and cytocompatibility of SiO2-CaO-P2O5 meso-macroporous glass scaffolds enriched with ZnO

Zn²⁺ ions exhibit osteogenic, angiogenic and antimicrobial properties. For this reason, they are often added in small amounts to bioceramics being investigated for bone tissue engineering. In this paper, the cytocompatibility and antibacterial properties of 80% SiO₂-15% CaO-5% P₂O₅ (mol%) mesoporous bioactive glass (MBG) scaffolds substituted with 4.0% and 7.0% of ZnO were studied and compared with the Zn-free scaffold. Cell proliferation, morphology, differentiation and cytotoxic effects of Zn²⁺ ions released from the samples were examined by culturing human osteoblast-like cells (HOS) osteoblasts both in the presence of sample extracts and on the scaffold surface. The bacterial inhibition capacity of the scaffolds was explored by using Gram-positive Stapylococcus aureus bacteria, responsible for numerous infections in orthopedic surgery, to simulate a severe infection. Our results show that the Zn-MBG scaffolds possess a hierarchical meso-macropore structure suitable for osteoblast growth. Furthermore, the amount of Zn²⁺ released from the scaffold with 4.0% ZnO was found to be more favorable for HOS cell development than that released from the scaffold including 7.0% ZnO. Zn²⁺ released to the medium from both scaffolds exhibited antibacterial properties against S. aureus. Thus, the cytocompatibility and the antibacterial ability exhibited by the MBG scaffold containing 4.0% ZnO make it a suitable candidate for bone regeneration applications.

Doped TiO2 anodic layers of enhanced antibacterial properties

Ti-6Al-4V joint replacement implants foster uncemented fixation in orthopaedic surgery. However, bacterial colonization competes with host cells and ultimately may produce implant-related difficult-to-treat infections, justifying the efforts to obtain infection-resistant materials. In a previous work, the authors demonstrated the antibacterial properties of anodic fluoride-TiO2 nanostructured layers on Ti-6Al-4V alloy. In this work, the anodizing bath has been modified in order to grow fluoride-TiO2 barrier layers (FBL). A bacterial adherence protocol, run with reference and six different clinical strains of Staphylococcus aureus and Staphylococcus epidermidis, showed a statistically significant decrease in the percentage of covered surface (p<0.0001, Kruskal-Wallis test) for FBL specimens when compared with non fluoride-containing specimens, i.e. chemically polished Ti-6Al-4V and F-free TiO2 barrier layers. The results obtained on the F-barrier layers allowed discrimination between the effects of the presence of fluoride in the layer and the layer nanostructure on bacterial adhesion.

Bacterial adherence to separated modular components in joint prosthesis: a clinical study

Bacterial adherence on total joint replacement implants may lead to biofilm formation and implant-related osteoarticular infection. It is unclear if different biomaterials in the prosthetic components are more prone to facilitate this bacterial adherence, although ultrahigh molecular weight polyethylene (UHMWPE) component exchange in modular systems has been clinically utilized in the early management of these infections. To clarify if the amount of clinically adhered microorganisms was related to the material or the component, we investigated retrieved implants from infected joint replacements. Thirty-two patients were revised after confirmed implant-related infection through positive cultures. Eighty-seven total joint components (hip and knee) were obtained and separately sonicated following a previously published protocol. Cultures were quantified, and detected colony forming units (CFU) were adjusted according to the component surface and compared based on the component material and location. Variable adherence of bacteria to chrome cobalt alloys, UHMWPE, hydroxyapatite coated components, and titanium alloys. The commonest isolated organisms were Staphylococcus epidermidis (23 of 87 components) and Staphylococcus aureus (10 of 87). Twelve components did not show any microorganism adhered despite location in an infected joint, with positive cultures in other components. A mixed linear model adjusted for random effects (the random effect being the infected patient) obtained convergence for the CFU/mm(2) variable, but could not confirm a significantly higher adherence to a particular component or to a particular biomaterial. Therefore, the bacterial adherence primarily depends on the infective microorganism and the response of each individual patient, rather than materials or components.

In vitro susceptibility of Staphylococcus aureus and Staphylococcus epidermidis isolated from prosthetic joint infections

Prosthetic joint infections (PJI) are severe complications in Orthopedics, with Staphylococcus aureus and Staphylococcus epidermidis being the most commonly isolated pathogens. The variable antimicrobial susceptibility found in these microorganisms, along with the increasing number of methicillin-resistant strains, increases the difficulty of antibiotic selection and makes it necessary to perform individual susceptibility studies to select the optimal antibiotic treatment. The aim of this study was to evaluate the in vitro susceptibility pattern of 35 clinical strains isolated from PJI (17 S. aureus and 18 S. epidermidis) against rifampin, vancomycin, tygecicline, clindamycin, cotrimoxazole, cloxacillin, ciprofloxacin, daptomycin and fosfomycin. In vitro susceptibility assays were performed using the broth microdilution method and agar dilution for fosfomycin. MBC was also determined. Tygecicline and daptomycin showed the highest antimicrobial activity with low MIC(90) values, and no resistant strains were detected. On the other hand, ciprofloxacin and cloxacillin exhibited a poor antimicrobial effect with a high percentage of nonsusceptible strains in both species. Bactericidal activity rates revealed the bacteriostatic behavior of rifampin, tygecicline, cotrimoxazole, fosfomycin and clindamycin, whereas vancomycin and cloxacillin showed species- and strain-dependent behavior. Daptomycin and ciprofloxacin were observed to be efficient bactericidal agents against the tested strains. According to our data, rifampin, tigecycline, daptomycin and fosfomycin showed high in vitro activity against most staphylococcal strains isolated from the PJIs tested, although daptomycin seems to be the best alternative to vancomycin therapy.

Biocompatible polymer coating of titania nanotube arrays for improved drug elution and osteoblast adhesion

Bacterial infection, extensive inflammation and poor osseointegration have been identified as the major reasons for [early] orthopaedic implant failures based on titanium. Creating implants with drug-eluting properties to locally deliver drugs is an appealing way to address some of these problems. To improve properties of titanium for orthopaedic applications, this study explored the modification of titanium surfaces with titaniananotube (TNT) arrays, and approach that combines drug delivery into bone and potentially improved bone integration. A titania layer with an array of nanotube structures (∼120 nm in diameter and 50 μm in length) was synthesized on titanium surfaces by electrochemical anodization and loaded with the water-insoluble anti-inflammatory drug indomethacin. A simple dip-coating process of polymer modification formed thin biocompatible polymer films over the drug-loaded TNTs to create TNTs with predictable drug release characteristics. Two biodegradable and antibacterial polymers, chitosan and poly(lactic-co-glycolic acid), were tested for their ability to extend the drug release time of TNTs and produce favourable bone cell adhesion properties. Dependent on polymer thickness, a significant improvement in the drug release characteristics was demonstrated, with reduced burst release (from 77% to >20%) and extended overall release from 4 days to more than 30 days. Excellent osteoblast adhesion and cell proliferation on polymer-coated TNTs compared with uncoated TNTs were also observed. These results suggest that polymer-modified implants with a TNT layer are capable of delivering a drug to a bone site over an extended period and with predictable kinetics. In addition, favourable bone cell adhesion suggests that such an implant would have good biocompatibility. The described approach is broadly applicable to a wide range of drugs and implants currently used in orthopaedic practice.