Use of intra-operative fluorescence imaging in periprosthetic joint infection: State of the art and future perspectives

BACKGROUND

In periprosthetic joint infections (PJIs), the surgeon's role becomes pivotal in addressing the infection locally, necessitating the surgical removal of infected and necrotic tissue. Opportunity to enhance the visualization of infected tissue during surgery could represent a game-changing innovation.

OBJECTIVE

The aim of this narrative review is to delineate the application of intraoperative fluorescence imaging for targeting infected tissues in PJIs.

METHODS

A systematic review, adhering to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, was carried out. The search included multiple online database; MEDLINE, Scopus, and Web of Science. For data extraction the following were evaluated: (i) diagnosis of musculoskeletal infection; (ii) use of intraoperative fluorescence imaging; (iii) infected or necrotic tissues as target.

RESULTS

Initially, 116 studies were identified through online database searches and reference investigations. The search was narrowed down to a final list of 5 papers for in-depth analysis at the full-text level. Subsequently, 2 studies were included in the review. The study included a total of 13 patients, focusing on cases of fracture-related infections of the lower limbs.

CONCLUSION

The primary and crucial role for orthopedic surgeons in PJIs is the surgical debridement and precise removal of necrotic and infected tissue. Technologies that enable clear and accurate visualization of the tissue to be removed can enhance the eradication of infections, thereby promoting healing. A promising avenue for the future involves the potential application of intraoperative fluorescence imaging in pursuit of this objective.

Preoperative MRSA screening using a simple questionnaire prior elective total joint replacement

INTRODUCTION

The purpose of this study was to evaluate the management and results of our standarized protocol for preoperative identification of MRSA colonisation in patients undergoing primary total hip and knee replacement procedures.

METHODS

Following hospital protocol, between January 2016 and June 2019 37,745 patients awaiting elective joint replacement underwent a standardized questionnaire to assess the risk of MRSA infection, identifying patients requiring preoperative MRSA screening. An evaluation of the questionnaire identified effective questions for identifying infected patients. Furthermore, an analysis evaluated the impact of comorbidities or Charlson Comorbidity Index scores on positive MRSA colonization. Additionally, we evaluated the cost savings of targeted testing compared to testing all surgery patients.

RESULTS

Of the 37,745 patients, 8.057 (21.3%) were swabbed, with a total of 65 (0.81%) positive tests. From this group 27 (36.48%) who were treated were negative before surgery. Some of the questionnaire results were consistently associated with a higher chance of colonization, including hospitalization during the past year (47,7%), previous history of MRSA (44,6%), and agriculture or cattle farming related work (15,4%). By selectively testing high-risk patients identified through the questionnaire, we achieved a 79% reduction in costs compared to universal MRSA screening.

CONCLUSION

Our results suggest that the simple and standardized questionnaire is a valuable tool for preoperative screening, effectively identifying high-risk patients prone to MRSA colonisation. The risk of periprosthetic joint infection (PJI) and its associated sequelae may be reduced by this approach.

The anatomical shape of the proximal femur correlates with the distal femur anatomy

PURPOSE

In the case of stemmed implants for lower limb joint arthroplasty procedures, implant stability and survivorship generally rely on the strength of fixation in the medullary canal regardless of whether the procedure is primary or revision surgery. This study aimed to investigate the relationship between the proximal (Dorr classification) and distal (Citak classification) femoral canal geometry classification systems.

METHODS

A total of 200 patients who received standing long leg radiographs (hip to ankle) at our institution were identified using our institutional electronic radiology database. Patients were recruited into 4 groups. There were 100 male and 100 female patients with each of those being split into 50 right-sided and 50 left-sided long-leg standing anteroposterior (AP) radiographs. Two independent, blinded observers reviewed each radiograph on two separate occasions, with a minimum of a one-week interval between sittings to review each respective radiograph.

RESULTS

No statistically significant correlation was found between demographic data and clinical measurements. A statistically significant correlation was found between the patient's age and BMI results and Citak and Dorr measurements. There was excellent inter-observer and intra-observer agreement for the Citak and Dorr Classifications. The mean Cronbach's α coefficient was 0.96 (range 0.93-0.98) for the Citak Classification and 0.95 (range 0.83-0.97) for the Dorr Classification. There was also an excellent intra-observer agreement with 95% average pairwise per cent agreement for the Citak Classification and 95% average pairwise per cent agreement for the Dorr classification. A statistically significant positive correlation was found between Dorr Calcar Isthmus and Citak Ratio (p < 0.05).

CONCLUSION

In this study, the Dorr and Citak classifications are put into relation to each other for the first time. The morphology of the femur was investigated in its entirety and it was shown that there was a positive correlation between the anatomical shape of the proximal and distal medullary canals.

Anatomical risk factors for aseptic loosening of full hinge knee prosthesis in primary and revision TKAs

INTRODUCTION

Risk factors (RF) associated with aseptic loosening (AL) in total knee arthroplasty (TKA) are poorly understood. Therefore, the aim of this study was to investigate the anatomical shape variations in relation to the inner-diameter of the femur and the tibia as prognostic RF for AL of full hinge prosthesis (FHP) in primary and revision TKA.

MATERIALS AND METHODS

We retrospectively examined all patients, who underwent revision surgery (2003-2018) due to AL of the FHP in primary (n = 38) and revision TKA (n = 46). Diagnosis-appropriate controls without AL at minimum follow-up of 24 months were randomly collected for each group. Besides other risk factors, we also measured the inner diameter of the femur according to the Citak classification and of the tibia on anteroposterior radiographies.

RESULTS

RF for AL are younger age in primary and revision as well as > 1 previous surgeries in revision TKA. The femoral index was shown to be a RF for AL in revision TKA (p = 0.001), but not in primary TKA. The novel tibial index was associated with AL in primary with AUC 0.776 (95% CI 0.67, 0.88), 65.8% sensitivity, 86.6% specificity and in revision TKA with AUC 0.817 (95% CI 0.73, 0.91), 82.6% sensitivity and 71.7% specificity.

CONCLUSION

This is the first study to calculate the tibial measurements and the tibial index according to Citak et al. and to identify them as prognostic RF for AL of the full hinge knee prosthesis in TKA and confirm the femoral index as a RF for AL also in revision full hinge knee prosthesis. Therefore, the preoperative radiological evaluation should include the analysis of the anatomical shape variants in order to select the appropriate prosthesis design with a possibly enhanced prognosis.

The anatomical shape of the distal femur is an independent risk factor for aseptic loosening following one-stage septic knee revision using rotating hinge knee prosthesis

PURPOSE

Aseptic loosening (AL) is the second most common reason for failure after one-stage septic knee revision. In this context, the goal of the study is to identify risk factors for AL following one-stage septic knee revision using rotating hinge implants. We aimed to answer the following research question: How does the anatomical shape of the distal femur represent an independent risk factor for AL following one-stage septic knee revision arthroplasty?

METHODS

Patients, who had undergone re-revision surgery due to AL of the rotating hinge knee prosthesis after one-stage septic knee revision arthroplasty between January 2008 and December 2018, were included. For this purpose, 41 patients with AL after one-stage septic knee revision using rotating hinge implants and 37 controls without any revision surgery at latest follow-up were included in this study. Using standardized anteroposterior (AP) views of the knee in all patients, we measured the inner diameter of the femur 20 cm proximally from the joint line and at a point 2 cm proximally from the adductor tubercle.

RESULTS

Among the vast majority of AL cases, we identified an isolated loosening of the femoral component. The AL group showd a high distribution of the Type C according to the Citak classification with 75.7%. Contrary to this, with 24.3% (p < 0.001) the amount of Type C cases was relatively low in the control group. Consequently, Type C configurations of the distal femur represent an independent risk factor for AL with an approximately sevenfold higher risk for AL compareed to Type A and Type B.

CONCLUSIONS

The novel radiological classification system of the distal femur shows that the Type C subtype is an independent and main risk factor for AL after one-stage septic knee revision using rotating hinge knee implants.

Agonistic and antagonistic targeting of immune checkpoint molecules differentially regulate osteoclastogenesis

Introduction

Immune checkpoint inhibitors are used in the treatment of various cancers and have been extensively researched with regard to inflammatory and autoimmune diseases. However, this revolutionary therapeutic strategy often provokes critical auto-inflammatory adverse events, such as inflammatory reactions affecting the cardiovascular, gastrointestinal, nervous, and skeletal systems. Because the function of these immunomodulatory co-receptors is highly cell-type specific and the role of macrophages as osteoclast precursors is widely published, we aimed to analyze the effect of immune checkpoint inhibitors on these bone-resorbing cells.

Methods

We established an in vitro model of osteoclastogenesis using human peripheral blood mononuclear cells, to which various immune checkpoints and corresponding antagonistic antibodies were administered. Formation of osteoclasts was quantified and cell morphology was analyzed via immunofluorescence staining, cell size measurements, and calculation of cell numbers in a multitude of samples.

Results

These methodical approaches for osteoclast research achieved objective, comparable, and reproducible results despite the great heterogeneity in the form, size, and number of osteoclasts. In addition to the standardization of experimental analyses involving osteoclasts, our study has revealed the substantial effects of agonistic and antagonistic checkpoint modulation on osteoclastogenesis, confirming the importance of immune checkpoints in bone homeostasis.

Discussion

Our work will enable more robust and reproducible investigations into the use of immune checkpoint inhibitors in conditions with diminished bone density such as osteoporosis, aseptic loosening of endoprostheses, cancer, as well as the side effects of cancer therapy, and might even pave the way for novel individualized diagnostic and therapeutic strategies.

Twenty-year results of a neck-preserving short-stem prosthesis in primary total hip arthroplasty

PURPOSE

The use of short-stemmed femoral components with preservation of the femoral neck has been advocated for younger and more active patients undergoing joint replacement. This study reports the long-term outcomes of the Collum Femoris-Preserving (CFP) prosthesis on a previous report.

METHODS

Between January 1999 and December 2000, a total of 149 patients underwent total hip arthroplasty procedure using the CFP stem in a single institution. At latest follow-up, 79 patients were available and were included in this study. The mean age of the cohort was 73.4 (range, 44-92 years) with a mean follow-up of 20.7 years (range 20-21). The average age was 52.1 years at index procedure (range, 21-71 years).

RESULTS

The Kaplan-Meier survivorship free from revision for any cause at 5, 10 and 20 years was 93.2% (87.8-96.3%), 93.2% (87.8-96.3%) and 83.0% (75.7-88.3%), respectively. At 20 years follow-up, the revision for any cause occurred in 26.6% (21 of 79) of patients. The most common causes for revision surgery were aseptic loosening, dislocation, and polyethylene wear with 6.3% (5 out of 79), respectively. Periprosthetic fracture occurred in four patients (5.1%) followed by periprosthetic joint infection in two patients (2.5%). Revision surgery of the femoral stem was required in four patients (5.1%). There was a statistically significant improvement of the Harris Hip Scores from 53 to 83.7 (range 56-91).

CONCLUSION

The long-term outcomes of the CFP stem are excellent, demonstrating a low rate of aseptic loosening with an excellent survivorship within 2 decades.

What is the rate of reinfection with different and difficult-to-treat bacteria after failed one-stage septic knee exchange?

PURPOSE

Re-operation after septic failure of a one-stage exchange for prosthetic joint infection (PJI) of the knee is a highly challenging procedure with concerns over residual bone stock, soft tissues, and stability. The associated changes in microbiology in cases of reinfection are still largely unknown.

METHODS

A comprehensive analysis was performed of all patients treated at our tertiary institution between 2001 and 2017 who developed reinfection after a one-stage exchange for PJI of the knee. Prerequisites for inclusion were a certain diagnosis of PJI according to the ICM criteria and a minimum follow-up of three years. Data on comorbidities, previous surgical interventions, microbiological findings at the time of the initial one-stage exchange and at the time of reinfection, detection methods, and antibiotic resistance patterns were retrospectively studied.

RESULTS

Sixty-six patients were identified that met the inclusion criteria. Reinfection occurred after a mean time interval of 27.7 months (SD ± 33.9, range 1-165). Ten types of bacteria were found that were not present before the one-stage exchange. The causative pathogen remained identical in 22 patients (33%) and additional microorganisms were detected in ten patients (15%). Half of the reinfections were however due to (a) completely different microorganism(s). A significant increase in the number of PJIs on the basis of high-virulent (23 vs 30, p = 0.017) and difficult-to-treat bacteria (13 vs 24, p = 0.035) was found.

CONCLUSION

The present study provides a novel insight into the microbiological changes following septic failure after one-stage exchange for PJI of the knee. A higher prevalence of more difficult-to-treat bacteria might increase the complexity of subsequent procedures. Also, a longer follow-up of these patients than previously suggested seems in order.

In situ Forming Hyperbranched PEG-Thiolated Hyaluronic Acid Hydrogels With Honey-Mimetic Antibacterial Properties

The rapidly increasing resistance of bacteria to currently approved antibiotic drugs makes surgical interventions and the treatment of bacterial infections increasingly difficult. In recent years, complementary strategies to classical antibiotic therapy have, therefore, gained importance. One of these strategies is the use of medicinal honey in the treatment of bacterially colonized wounds. One of the several bactericidal effects of honey is based on the in situ generation of hydrogen peroxide through the activity of the enzyme glucose oxidase. The strategy underlying this work is to mimic this antibacterial redox effect of honey in an injectable, biocompatible, and rapidly forming hydrogel. The hydrogel was obtained by thiol–ene click reaction between hyperbranched polyethylene glycol diacrylate (HB PEGDA), synthesized using reversible addition-fragmentation chain transfer (RAFT) polymerization, and thiolated hyaluronic acid (HA-SH). After mixing 500 µL HB PEGDA (10%, w/w) and 500 µL HA-SH (1%, w/w) solutions, hydrogels formed in ∼60 s (HB PEGDA/HA-SH 10.0–1.0), as assessed by the tube inverting test. The HB PEGDA/HA-SH 10.0–1.0 hydrogel (200 µL) was resistant to in vitro dissolution in water for at least 64 days, absorbing up to 130 wt% of water. Varying glucose oxidase (GO) amounts (0–500 U/L) and constant glucose content (2.5 wt%) were loaded into HB PEGDA and HA-SH solutions, respectively, before hydrogel formation. Then, the release of H₂O₂ was evaluated through a colorimetric pertitanic acid assay. The GO content of 250 U/L was selected, allowing the formation of 10.8 ± 1.4 mmol H₂O₂/L hydrogel in 24 h, under static conditions. The cytocompatibility of HB PEGDA/HA-SH 10.0–1.0 hydrogels loaded with different GO activities (≤ 500 U/L) at a constant glucose amount (2.5 wt%) was investigated by in vitro assays at 24 h with L929 and HaCaT cell lines, according to DIN EN ISO 10993-5. The tests showed cytocompatibility for GO enzyme activity up to 250 U/L for both cell lines. The antibacterial activity of HB PEGDA/HA-SH 10.0–1.0 hydrogels loaded with increasing amounts of GO was demonstrated against various gram-positive bacteria (S. aureus and S. epidermidis), antibiotic-resistant gram-positive bacteria (MRSA and MRSE), gram-negative bacteria (P. aeruginosa, E. coli, and A. baumanii), and antibiotic-resistant gram-negative strains (P. aeruginosa and E. coli) using agar diffusion tests. For all gram-positive bacterial strains, increasing efficacy was measured with increasing GO activity. For the two P. aeruginosa strains, efficacy was shown only from an enzyme activity of 125 U/L and for E. coli and A. baumanii, efficacy was shown only from 250 U/L enzyme activity. HB PEGDA/HA-SH 10.0–1.0 hydrogels loaded with ≤250 U/L GO and 2.5 wt% glucose are promising formulations due to their fast-forming properties, cytocompatibility, and ability to produce antibacterial H₂O₂, warranting future investigations for bacterial infection treatment, such as wound care.

What Is the Mid-term Survivorship of Infected Rotating-hinge Implants Treated with One-stage-exchange?

BACKGROUND

Despite the growing number of studies reporting on periprosthetic joint infection (PJI), there is little information on one-stage exchange arthroplasty for the revision of infected rotating-hinge prostheses, which can be among the most difficult PJI presentations to treat.

QUESTIONS/PURPOSES

After one-stage direct exchange revision for an infected rotating-hinge TKA prosthesis, and using a multimodal approach for infection control, we asked: (1) What is the survivorship free from repeat revision for infection and survivorship free from reoperation for any cause? (2) What is the clinical outcome, based on the Oxford Knee Score, of these patients at the latest follow-up?

METHODS

Between January 2011 and December 2017, we treated 101 patients with infected rotating-hinge knee prostheses at our hospital. All patients who underwent a one-stage exchange using another rotating-hinge implant were potentially eligible for this retrospective study. During that period, we generally used a one-stage approach when treating PJIs. Eighty-three percent (84 of 101) of patients were treated with one-stage exchange, and the remainder were treated with two-stage exchange. Of the 84 treated with one-stage exchange, eight patients died of unrelated causes and were therefore excluded, one patient declined to participate in the study, and another eight patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, leaving 80% (67 of 84) for analysis in this study. The included study population consisted of 60% males (40 of 67) with a mean age of 64 ± 8 years and a mean (range) BMI of 30 ± 6 kg/m2 (21 to 40). The mean number of prior surgeries was 4 ± 2 (1 to 9) on the affected knee. Fifteen percent (10 of 67) of knees had a preoperative joint communicating sinus tract, and 66% (44 of 67) had experienced a prior PJI on the affected knee. The antimicrobial regimen was chosen based on the advice of our infectious disease consultant and individually adapted for the organism cultured. The mean follow-up duration was 6 ± 2 years. Kaplan-Meier survivorship analysis was performed using the endpoints of survivorship free from repeat revision for infection and survivorship free from all-cause revision. The functional outcome was assessed using the Oxford Knee Score (on a 12- to 60-point scale, with lower scores representing less pain and greater function), obtained by interviewing patients for this study at their most recent follow-up visit. Preoperative scores were not obtained.

RESULTS

The Kaplan-Meier analysis demonstrated an overall survivorship free from reoperation for any cause of 75% (95% CI 64% to 87%) at the mean follow-up of 6 years postoperatively. Survivorship free from any repeat operative procedure for infection was 90% (95% CI 83% to 97%) at 6 years. The mean postoperative Oxford Knee Score was 37 ± 11 points.

CONCLUSION

With an overall revision rate of about 25% at 6 years and the limited functional results based on the poor Oxford Knee Scores, patients should be counseled to have modest expectations concerning postoperative pain and function level after one-stage exchange of an infected rotating-hinge arthroplasty. Nevertheless, patients may be informed about a reasonable chance of PJI eradication and might opt for this approach as a means to try to avoid high transfemoral amputation or joint arthrodesis, which in this population often is associated with the inability to ambulate at all. Regarding the relatively high number of patients with aseptic loosening, future studies might focus on implant design of revision knee systems as well. A longer course of oral antibiotics after such procedures may also be warranted to limit the chance of reinfection but requires further study.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Resection of the proximal femur during one-stage revision for infected hip arthroplasty : risk factors and effectiveness

AIMS

One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions.

METHODS

In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups.

RESULTS

Patients who required resection of the proximal femur were found to have a higher all-cause re-revision rate (29.8% vs 10.5%; p = 0.018), largely due to reinfection (15.8% vs 0%; p = 0.003), and dislocation (8.8% vs 10.5%; p = 0.762), and showed higher rate of in-hospital wound haematoma requiring aspiration or evacuation (p = 0.013), and wound revision (p = 0.008). The use of of dual mobility components/constrained liner in the resection group was higher than that of controls (94.7% vs 36.8%; p < 0.001). The presence and removal of additional metal hardware (odds ratio (OR) = 7.2), a sinus tract (OR 4), ten years' time interval between primary implantation and index infection (OR 3.3), and previous hip revision (OR 1.4) increased the risk of proximal femoral resection. A sinus tract (OR 9.2) and postoperative dislocation (OR 281.4) were associated with increased risk of subsequent re-revisions.

CONCLUSION

Proximal femoral resection during one-stage revision hip arthroplasty for PJI may be required to reduce the risk of of recurrent or further infection. Patients with additional metalware needing removal or transcortical sinus tracts and chronic osteomyelitis are particularly at higher risk of needing proximal femoral excision. However, radical resection is associated with higher surgical complications and increased re-revision rates. The use of constrained acetabular liners and dual mobility components maintained an acceptable dislocation rate. These results, including identified risk factors, may aid in preoperative planning, patient consultation and consent, and intraoperative decision-making. Cite this article: Bone Joint J 2021;103-B(11):1678-1685.

Regeneration of Bone Defects in a Rabbit Femoral Osteonecrosis Model Using 3D-Printed Poly (Epsilon-Caprolactone)/Nanoparticulate Willemite Composite Scaffolds

Steroid-associated osteonecrosis (SAON) is a chronic disease that leads to the destruction and collapse of bone near the joint that is subjected to weight bearing, ultimately resulting in a loss of hip and knee function. Zn2+ ions, as an essential trace element, have functional roles in improving the immunophysiological cellular environment, accelerating bone regeneration, and inhibiting biofilm formation. In this study, we reconstruct SAON lesions with a three-dimensional (3D)-a printed composite made of poly (epsilon-caprolactone) (PCL) and nanoparticulate Willemite (npW). Rabbit bone marrow stem cells were used to evaluate the cytocompatibility and osteogenic differentiation capability of the PCL/npW composite scaffolds. The 2-month bone regeneration was assessed by a Micro-computed tomography (micro-CT) scan and the expression of bone regeneration proteins by Western blot. Compared with the neat PCL group, PCL/npW scaffolds exhibited significantly increased cytocompatibility and osteogenic activity. This finding reveals a new concept for the design of a 3D-printed PCL/npW composite-based bone substitute for the early treatment of osteonecrosis defects.

Cytocompatibility Evaluation of a Novel Series of PEG-Functionalized Lactide-Caprolactone Copolymer Biomaterials for Cardiovascular Applications

Although the use of bioresorbable materials in stent production is thought to improve long-term safety compared to their durable counterparts, a recent FDA report on the 2-year follow-up of the first FDA-approved bioresorbable vascular stent showed an increased occurrence of major adverse cardiac events and thrombosis in comparison to the metallic control. In order to overcome the issues of first generation bioresorbable polymers, a series of polyethylene glycol-functionalized poly-L-lactide-co-ε-caprolactone copolymers with varying lactide-to-caprolactone content is developed using a novel one-step PEG-functionalization and copolymerization strategy. This approach represents a new facile way toward surface enhancement for cellular interaction, which is shown by screening these materials regarding their cyto- and hemocompatibility in terms of cytotoxicity, hemolysis, platelet adhesion, leucocyte activation and endothelial cell adhesion. By varying the lactide-to-caprolactone polymer composition, it is possible to gradually affect endothelial and platelet adhesion which allows fine-tuning of the biological response based on polymer chemistry. All polymers developed were non-cytotoxic, had acceptable leucocyte activation levels and presented non-hemolytic (<2% hemolysis rate) behavior except for PLCL-PEG 55:45 which presented hemolysis rate of 2.5% ± 0.5. Water contact angles were reduced in the polymers containing PEG functionalization (PLLA-PEG: 69.8° ± 2.3, PCL-PEG: 61.2° ± 7.5) versus those without (PLLA: 79.5° ± 3.2, PCL: 76.4° ± 10.2) while the materials PCL-PEG550, PLCL-PEG550 90:10 and PLCL-PEG550 70:30 demonstrated best endothelial cell adhesion. PLLA-PEG550 and PLCL-PEG550 70:30 presented as best candidates for cardiovascular implant use from a cytocompatibility perspective across the spectrum of testing completed. Altogether, these polymers are excellent innovative materials suited for an application in stent manufacture due to the ease in translation of this one-step synthesis strategy to device production and their excellent in vitro cyto- and hemocompatibility.

The 2018 International Consensus Meeting Minor Criteria for Chronic Hip and Knee Periprosthetic Joint Infection: Validation From a Single Center

BACKGROUND

Recently, a revised definition of the minor criteria scoring system for diagnosing periprosthetic joint infection (PJI) was developed by the second International Consensus Meeting on musculoskeletal infection. The new system combines preoperative and intraoperative findings, reportedly achieving high sensitivity and specificity. We aimed to validate the modified scoring system at a high-volume center.

METHODS

We retrospectively reviewed patients who underwent a revision total hip or knee arthroplasty at our institution from May 2015 to August 2018. Serum C-reactive protein, synovial white blood cell count and polymorphonuclear percentage, leukocyte esterase test, alpha-defensin, microbiological and histologic results, and documented existence of sinus tract and intraoperative purulence were available for all patients. Cases with at least 1 major criterion were considered as infected. Using the new minor criteria, a score of ≥6 reflects PJI, while a score <3 can be considered as noninfected. Sensitivity, specificity, mean accuracy (ACC), positive predictive value (PPV), and negative predictive value (NPV) were analyzed.

RESULTS

A total of 345 cases were included. A cutoff score of ≥6 points had the following diagnostic performance: area under the curve (AUC) = 0.90; ACC = 0.88; sensitivity = 0.96; specificity = 0.84; PPV = 0.70; NPV = 0.98. Diagnostic performance was better for the hip (AUC = 0.92; ACC = 0.90; sensitivity = 0.96; specificity = 0.86; PPV = 0.81; NPV = 0.98) than the knee (AUC = 0.89; ACC = 0.85; sensitivity = 0.95; specificity = 0.83; PPV = 0.59; NPV = 0.98).

CONCLUSION

The modified scoring system proposed by the 2018 International Consensus Meeting in diagnosing PJI showed high sensitivity and a good performance, especially as rule-out diagnostic criteria. The cutoff level seems to be different between the hip and knee. Further validation studies considering the acknowledged limitations are recommended.

Improved treatment strategies can result in better outcomes following one-stage exchange surgery for MRSA periprosthetic joint infection

Introduction. Periprosthetic joint infections caused by methicillin-resistant Staphylococcus aureus (MRSA-PJIs) are rare, with only a few studies reporting the treatment outcomes and even fewer reporting outcomes with one-stage exchange.Aim. This study aims to analyse the outcomes of one-stage exchange in the management of MRSA-PJIs.Methodology. Patients with MRSA-PJI of the hip and knee, who were treated with a one-stage exchange between 2001 and 2018 were enrolled in this study. The final cohort comprised of 29 patients, which included 23 hips and six knees. The mean follow-up was 5.3 years (1-9 years). Reinfection and complications rates after the one-stage exchange were analysed.Results. Overall infection control could be achieved in 93.1 % (27 out of 29 patients). The overall revision rate was 31.0% (9 patients), with three patients requiring an in-hospital revision (10.3 %). Six patients had to be revised after hospital discharge (20.7 %). Of the two reinfections, one had a growth of MRSA while the other was of methicillin-sensitive Staphyloccocus epidermidis.Conclusion. One-stage exchange surgery using current techniques could improve surgical outcomes with excellent results in the management of MRSA-PJIs.

Activated Polyhydroxyalkanoate Meshes Prevent Bacterial Adhesion and Biofilm Development in Regenerative Medicine Applications

Regenerative medicine has become an extremely valuable tool offering an alternative to conventional therapies for the repair and regeneration of tissues. The re-establishment of tissue and organ functions can be carried out by tissue engineering strategies or by using medical devices such as implants. However, with any material being implanted inside the human body, one of the conundrums that remains is the ease with which these materials can get contaminated by bacteria. Bacterial adhesion leads to the formation of mature, alive and complex three-dimensional biofilm structures, further infection of surrounding tissues and consequent development of complicated chronic infections. Hence, novel tissue engineering strategies delivering biofilm-targeted therapies, while at the same time allowing tissue formation are highly relevant. In this study our aim was to develop surface modified polyhydroxyalkanoate-based fiber meshes with enhanced bacterial anti-adhesive and juvenile biofilm disrupting properties for tissue regeneration purposes. Using reactive and amphiphilic star-shaped macromolecules as an additive to a polyhydroxyalkanoate spinning solution, a synthetic antimicrobial peptide, Amhelin, with strong bactericidal and anti-biofilm properties, and Dispersin B, an enzyme promoting the disruption of exopolysaccharides found in the biofilm matrix, were covalently conjugated to the fibers by addition to the solution before the spinning process. Staphylococcus epidermidis is one of the most problematic pathogens responsible for tissue-related infections. The initial antibacterial screening showed that Amhelin proved to be strongly bactericidal at 12 μg/ml and caused >50% reductions of biofilm formation at 6 μg/ml, while Dispersin B was found to disperse >70% of pre-formed biofilms at 3 μg/ml. Regarding the cytotoxicity of the agents toward L929 murine fibroblasts, a CC50 of 140 and 115 μg/ml was measured for Amhelin and Dispersin B, respectively. Optimization of the electrospinning process resulted in aligned fibers. Surface activated fibers with Amhelin and Dispersin B resulted in 83% reduction of adhered bacteria on the surface of the fibers. Additionally, the materials developed were found to be cytocompatible toward L929 murine fibroblasts. The strategy reported in this preliminary study suggests an alternative approach to prevent bacterial adhesion and, in turn biofilm formation, in materials used in regenerative medicine applications such as tissue engineering.

Response of Human Macrophages to Clinically Applied Wound Dressings Loaded With Silver

Wound infections constitute an increasing clinical problem worldwide. To reverse this trend, several wound dressings with antimicrobial properties have been developed. Considering the increasing presence of antibiotic-resistant microorganisms, product developers have been focusing their efforts in introducing antibiotic-free antibacterial wound dressings to the market, with silver being the most commonly incorporated antimicrobial agent. In this scenario, gaining information about the microbial and eukaryotic cells’ response to these dressings is needed for a proper selection of antimicrobial dressings for the different cases of infected wounds. In particular, one insufficiently explored parameter is the effect of the dressings on the immunomodulation of macrophages, the main immune cell population participating in the repair process, because of their pivotal role in the transition of the inflammation to the proliferation phase of wound healing. In this work, three different clinically applied antimicrobial, silver impregnated wound dressings were selected: Atrauman^® Ag, Biatain^® Alginate Ag and PolyMem WIC Silver^® Non-adhesive. Antimicrobial susceptibility tests (disk diffusion and broth dilution), cell viability evaluation (CellTiter-Blue^®) and experiments to determine macrophage polarization (e.g., flow cytometry, ELISA and glucose uptake) were performed after 24 h of incubation. Among all products tested, Biatain^® Alginate Ag induced the most evident bactericidal effect on Gram-positive and Gram-negative bacteria, followed by PolyMem WIC Silver^® Non-adhesive, but did not show good cytocompatibility in vitro. On the other hand, Atrauman^® Ag showed excellent cytocompatibility on L929 fibroblasts, HaCaT keratinocytes and THP-1 derived macrophages, but no significant antimicrobial activity was observed. Overall, it was confirmed that macrophages initiate, in fact, an alteration of their metabolism and phenotype in response to wound dressings of different composition in a short period of contact (24 h). M0 resting state macrophages common response to all silver-containing dressings used in this study was to increase the production of the anti-inflammatory cytokine TGF-β, which indicates an acquisition of M2-like macrophages characteristics.

Synchronous Periprosthetic Joint Infections: The Need for All Artificial Joints to Be Aspirated Routinely

BACKGROUND

Periprosthetic joint infection (PJI) is a severe complication with increasing incidence. However, we are not aware of any robust data on patients having PJI at the same time in ≥2 joints that had undergone total joint arthroplasty, referred to as synchronous PJI throughout this article. The aims of this study were to investigate the probability of the development of synchronous PJI of another prosthetic joint and to identify possible clinical risk factors for the development of synchronous PJI. In addition, we aimed to determine whether routine aspiration of all other prosthetic joints was warranted after a diagnosis of PJI in a single joint.

METHODS

A total of 2,532 septic revision procedures were performed during the study period. In the final analysis, 644 patients (26 with synchronous PJI and 618 with non-synchronous PJI) with 1,508 prosthetic joints were included. The mean age (and standard deviation) was 71 ± 9.6 years. Using bivariate analyses, we calculated the odds of synchronous PJI as a function of various demographic and clinical variables.

RESULTS

A suspicious clinical presentation of the non-primary joint had the strongest association with synchronous PJI (odds ratio [OR], 58.5 [95% confidence interval (CI), 22.4 to 152.8]). Additional associations with synchronous PJI were detected for a history of neoplasia (OR, 12 [95% CI, 3.9 to 37.2]), the use of immune-modulating therapy (OR, 9.5 [95% CI, 3.4 to 26.2]), the presence of systemic inflammatory response syndrome or sepsis (OR, 8.4 [95% CI, 2.8 to 25]), and having ≥3 prosthetic joints (OR, 3.0 [95% CI, 1.37 to 6.64]).

CONCLUSIONS

Synchronous PJI is a rare but very serious complication and every prosthetic joint should be investigated meticulously. Suspicious clinical presentation, a history of neoplasia, sepsis, immune-modulating therapy, and ≥3 prosthetic joints were identified as risk factors and should increase the physician's vigilance. In the case of PJI, aspiration of each joint that had undergone total joint arthroplasty should be considered.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Impact of α-Defensin Test in Diagnosing Periprosthetic Infection After Total Ankle Arthroplasty

Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a serious complication, and a reliable diagnostic test to identify PJI is needed. The purpose of this study was to investigate the use of synovial α-defensin levels in identifying PJI of the ankle. Data from 33 patients were retrospectively collected between September 2015 and May 2018. Patients who had pain or suspected loosening after TAA and who had undergone joint aspiration were included in the study. Aspiration was performed in a semisterile theatre. Synovial fluid was processed in descending order for microbiological cultures, α-defensin, leukocyte esterase strip test, and cell count. A periprosthetic infection was defined by Musculoskeletal Infection Society criteria. The sensitivity, specificity, and overall accuracy were calculated, and based on a receiver operating characteristic curve, the quality of the α-defensin test was determined. The calculated area under the curve was 0.97 ± 0.32. Two of 33 patients fulfilled the 2014 Musculoskeletal Infection Society criteria and were scheduled for septic revision arthroplasty. Sensitivity, specificity, and overall accuracy of the α-defensin test were 100% (95% confidence interval [CI], 15.8% to 100%), 93.5% (95% CI, 78.6% to 99.2%), and 93.9% (95% CI, 79.8% to 99.3%), respectively. The positive predictive value was 50% (95% CI, 20.7% to 79.3%), and the negative predictive value was 100%. The α-defensin test seems to be the best available synovial test to detect a late-onset PJI after total ankle arthroplasty. Further prospective studies with a larger number of patients are required.

Macrophage immunomodulation: An indispensable tool to evaluate the performance of wound dressing biomaterials

A major burden of the healthcare system resides in providing proper medical treatment for all types of chronic wounds, which are usually treated with dressings to induce a faster regeneration. Hence, to reduce healing time and improve the patient's quality of life, it is extremely important to select the most appropriate constituent material for a specific wound dressing. A wide range of wound dressings exist but their mechanisms of action are poorly explored, especially concerning the immunomodulatory effects that occur from the interactions between immune cells and the biomaterial. Tissue-resident and monocyte-derived recruited macrophages are key regulators of wound repair. These phagocytic immune cells exert specific functions during the different stages of wound healing. The recognition of the substantial role of macrophages in the outcome of the wound healing process requires specific understanding of the immunomodulatory effects of commercially available or newly developed wound dressings. For a precise intervention, it is necessary to obtain more knowledge on macrophage polarization in different phases of wound healing in the presence of the dressings. The main purpose of this review is to collect clinical cases in which macrophage immunomodulation was taken into consideration as an indicator of the performances of novel or mainstream wound dressing materials, including those provided with antimicrobial properties.

Risk Factors for Failure After 1-Stage Exchange Total Knee Arthroplasty in the Management of Periprosthetic Joint Infection

BACKGROUND

One-stage exchange arthroplasty in the management of periprosthetic joint infection was introduced at our institution. The purpose of this study was to analyze the risk factors of failure after periprosthetic joint infection following total knee arthroplasty treated with 1-stage exchange.

METHODS

Ninety-one patients who underwent failed treatment following 1-stage exchange total knee arthroplasty due to periprosthetic joint infection from January 2008 to December 2017 were included. From the same period, we randomly selected a 1:1 matched control group without a subsequent revision surgical procedure. Bivariate analyses, including preoperative, intraoperative, and postoperative factors, as well as logistic regression, were performed to identify risk factors for failure.

RESULTS

Bivariate analysis yielded 10 predictors (variables with significance at p < 0.05) for failure involving re-revision for any reason and 11 predictors for failure involving re-revision for reinfection. The binary logistic regression model revealed the following risk factors for re-revision for any reason: history of a 1-stage exchange for infection (odds ratio [OR], 26.706 [95% confidence interval (CI), 5.770 to 123.606]; p < 0.001), history of a 2-stage exchange (OR, 3.948 [95% CI, 1.869 to 8.339]; p < 0.001), and isolation of enterococci (OR, 16.925 [95% CI, 2.033 to 140.872]; p = 0.009). The risk factors for reinfection in the binary logistic regression analysis were history of 1-stage or 2-stage exchange arthroplasty, isolation of enterococci, and isolation of streptococci (OR, 6.025 [95% CI, 1.470 to 24.701]; p = 0.013).

CONCLUSIONS

We identified several risk factors of failure after 1-stage exchange arthroplasty for periprosthetic joint infection, most of which were not related to the patient comorbidities. Among them, previous exchange due to periprosthetic joint infection and the isolation of Enterococcus or Streptococcus species were associated with a higher risk of failure. Besides a multidisciplinary approach, being aware of the identified risk factors when evaluating patients with periprosthetic joint infection could lead to better outcomes.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Differential mineralization of human dental pulp stem cells on diverse polymers

In tissue engineering, biomaterials are used as scaffolds for spatial distribution of specific cell types. Biomaterials can potentially influence cell proliferation and extracellular matrix formation, both in positive and negative ways. The aim of the present study was to investigate and compare mineralized matrix production of human dental pulp stem cells (DPSC), cultured on 17 different well-characterized polymers. Osteogenic differentiation of DPSC was induced for 21 days on biomaterials using dexamethasone, L-ascorbic-acid-2-phosphate, and sodium β-glycerophosphate. Success of differentiation was analyzed by quantitative RealTime PCR, alkaline phosphatase (ALP) activity, and visualization of calcium accumulations by alizarin red staining with subsequent quantification by colorimetric method. All of the tested biomaterials of an established biomaterial bank enabled a mineralized matrix formation of the DPSC after osteoinductive stimulation. Mineralization on poly(tetrafluoro ethylene) (PTFE), poly(dimethyl siloxane) (PDMS), Texin, LT706, poly(epsilon-caprolactone) (PCL), polyesteramide type-C (PEA-C), hyaluronic acid, and fibrin was significantly enhanced (p<0.05) compared to standard tissue culture polystyrene (TCPS) as control. In particular, PEA-C, hyaluronic acid, and fibrin promoted superior mineralization values. These results were confirmed by ALP activity on the same materials. Different biomaterials differentially influence the differentiation and mineralized matrix formation of human DPSC. Based on the present results, promising biomaterial candidates for bone-related tissue engineering applications in combination with DPSC can be selected.

Surface patterning of a novel PEG-functionalized poly-l-lactide polymer to improve its biocompatibility: Applications to bioresorbable vascular stents

Today, research in the field of bioresorbable vascular stents (BVS) not only focusses on a new material being nontoxic but also tries to enhance its biocompatibility in terms of endothelialization potential and hemocompatibility. To this end, we used picosecond laser ablation technology as a single‐step and contactless method for surface microstructuring of a bioresorbable polymer which can be utilized in stent manufacture. The method works on all materials via fast material removal, can be easily adapted for micropatterning of tubular or more complex sample shapes and scaled up by means of micropatterning of metal molds for manufacturing. Here, picosecond laser ablation was applied to a bioresorbable, biologically inactive and polyethylene glycol‐modified poly‐l‐lactide polymer (PEGylated PLLA) to generate parallel microgrooves with varying geometries. The different patterns were thoroughly evaluated by a series of cyto‐ and hemocompatibility tests revealing that all surfaces were non‐toxic and non‐hemolytic. More importantly, patterns with 20 to 25 µm wide and 6 to 7 µm deep grooves significantly enhanced endothelial cell adhesion in comparison to samples with smaller grooves. Here, human cardiac microvascular endothelial cells were found to align along the groove direction, which is thought to encourage endothelialization of intraluminal surfaces of BVS. © 2018 The Authors Journal of Biomedical Materials Research Part B: Applied Biomaterials Published by Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 00B: 000–000, 2018. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 624–634, 2019.

Validation of in vitro assays in three-dimensional human dermal constructs

Three-dimensional cell culture systems are urgently needed for cytocompatibility testing of biomaterials. This work aimed at the development of three-dimensional in vitro dermal skin models and their optimization for cytocompatibility evaluation. Initially “murine in vitro dermal construct” based on L929 cells was generated, leading to the development of “human in vitro dermal construct” consisting of normal human dermal fibroblasts in rat tail tendon collagen type I. To assess the viability of the cells, different assays CellTiter-Blue^®, RealTime-Glo^™ MT, and CellTiter-Glo^® (Promega) were evaluated to optimize the best-suited assay to the respective cell type and three-dimensional system. Z-stack imaging (Live/Dead and Phalloidin/DAPI-Promokine) was performed to visualize normal human dermal fibroblasts inside matrix revealing filopodia-like morphology and a uniform distribution of normal human dermal fibroblasts in matrix. CellTiter-Glo was found to be the optimal cell viability assay among those analyzed. CellTiter-Blue reagent affected the cell morphology of normal human dermal fibroblasts (unlike L929), suggesting an interference with cell biological activity, resulting in less reliable viability data. On the other hand, RealTime-Glo provided a linear signal only with a very low cell density, which made this assay unsuitable for this system. CellTiter-Glo adapted to three-dimensional dermal construct by optimizing the “shaking time” to enhance the reagent penetration and maximum adenosine triphosphate release, indicating 2.4 times higher viability value by shaking for 60 min than for 5 min. In addition, viability results showed that cells were viable inside the matrix. This model would be further advanced with more layers of skin to make a full thickness model.

Heterotopic ossification mimicking infection in patients with traumatic spinal cord injury

BACKGROUND

Heterotopic ossification (HO) is a common concominant condition in patients with traumatic spinal cord injury (SCI). In this context, we report on patients with heterotopic ossification causing infection like symptoms as a first manifestation of HO subsequent to traumatic SCI.

OBJECTIVE

The objective of the study was to analyse possible ``early-indicator symptoms'' in patients suffering from heterotopic ossification following SCI with special focus on elevated serum CRP, serum CK and body temperature.

METHODS

All eligible patients treated between January 2004 and December 2013 because of a SCI and heterotopic ossification have been enrolled in this retrospective study. An age below 18 years and the absence of the combination of elevated serum CRP, CK and elevated body temperature (> 38.5 °C) were defined as exclusion criteria. The presence of another infection, led to exclusion. Fifteen out of 235 patients (6.4%) met the inclusion criteria and were included in the final data analysis.

RESULTS

The patient cohort consists of 13 male and two female patients with a mean age of 30.6 years (range from 18 to 56 years; SD = 13.5). The mean time interval between HO development and the injury was 49.4 days (range from 16 to 131 days; SD = 34.3). Focussing on laboratory parameters, mean serum CRP level was 10.2 mg/dl (range from 1.3 to 24.4 mg/dl; SD = 9.6). Mean serum CK was 1365 U/l (range from 255 to 4729 U/l; SD = 1491). Worth mentioning, in 9 cases (60%) serum CK was higher than 500 U/l. Mean body temperature was 38.7 °C (range from 38.0 to 39.4; SD = 0.4). CT scans of the thorax, abdomen and pelvis revealed no further pathologies besides the heterotopic ossification. Urinary tract infections were ruled out, using urine tests as a standard procedure in all cases.

CONCLUSIONS

Elevated levels of serum CRP, serum CK and high body temperature in acute SCI may be considered as indicators for a concominant HO diagnosis.

Expansion and differentiation of germline-derived pluripotent stem cells on biomaterials

Stem cells with broad differentiation potential, such as the recently described germline-derived pluripotent stem cells (gPS cells), are an appealing source for tissue engineering strategies. Biomaterials can inhibit, support, or induce proliferation and differentiation of stem cells. Here we identified (1) polymers that maintain self-renewal and differentiation potential of gPS cells for feeder-free expansion and (2) polymers supporting the cardiomyogenic fate of gPS cells by analyzing a panel of polymers of an established biomaterial bank previously used to assess growth of diverse stem cell types. Identification of cytocompatible gPS cell/biomaterial combinations required analysis of several parameters, including morphology, viability, cytotoxicity, apoptosis, proliferation, and differentiation potential. Pluripotency of gPS cells was visualized by the endogenous Oct4-promoter-driven GFP and by Sox2 and Nanog immunofluorescence. Viability assay, proliferation assay, and flow cytometry showed that gPS cells efficiently adhere and are viable on synthetic polymers, such as Resomer(®) LR704 (poly(L-lactic-D,L-lactic acid), poly(tetrafluor ethylene) (PTFE), poly(vinylidene fluoride) (PVDF), and on gelatine-coated tissue culture polystyrene. Expansion experiments showed that Resomer LR704 is an alternative substrate for feeder-free gPS cell maintenance. Resomer LR704, PTFE, and PVDF were found to be suitable for gPS cell differentiation. Spontaneous beating in embryoid bodies cultured on Resomer LR704 occurred already on day 8 of differentiation, much earlier compared to the other surfaces. This indicates that Resomer LR704 supports spontaneous cardiomyogenic differentiation of gPS cells, which was also confirmed on molecular, protein and functional level.

Integrin α4 impacts on differential adhesion of preadipocytes and stem cells on synthetic polymers

Stem cells represent an ideal cell source for tissue engineering and regenerative medicine, because they can be readily isolated, expanded, differentiated and transplanted. For stem cell-based therapies, biomaterials are required to allow for a spatial distribution of the stem cells within a defined area in the body. In our recent studies, we analysed the interaction of a large panel of stem cell types with an array of biomaterials and demonstrated that a rational prediction of stem cell behaviour on a specific biomaterial is so far not possible. Interestingly, even ontogenetically related stem cell types, such as mesenchymal stem cells (MSCs), preadipocytes and dental pulp stem cells (DPSCs), exhibit distinct adhesion properties on the very same biomaterial surface. Therefore, we investigated integrin and extracellular matrix (ECM) protein expression of stem cells to relate gene expression to adhesion behaviour. MSCs, preadipocytes and DPSCs were cultured on selected synthetic polymers, such as Texin, a thermoplastic polyurethane, poly(dimethyl siloxane) (PDMS), poly-d,l-lactic acid (PDLLA) and l-lactic acid-trimehylene carbonate (Resomer® LT706). Integrins and ECM proteins were analysed by RT-PCR, real-time PCR and immunohistochemistry. Analysis of several adhesion molecules yielded that only one molecule, integrin α4, might play a significant role in differential adhesion on polymers for preadipocytes compared to DPSCs and MSCs. Thus, our studies on the molecular interactions of stem cells and polymers are expected to lead to a more profound understanding of the stem cell-biomaterial interactions to eventually allow for a rational biomaterial design.

Transcriptome analysis of MSC and MSC-derived osteoblasts on Resomer® LT706 and PCL: impact of biomaterial substrate on osteogenic differentiation

Background

Mesenchymal stem cells (MSC) represent a particularly attractive cell type for bone tissue engineering because of their ex vivo expansion potential and multipotent differentiation capacity. MSC are readily differentiated towards mature osteoblasts with well-established protocols. However, tissue engineering frequently involves three-dimensional scaffolds which (i) allow for cell adhesion in a spatial environment and (ii) meet application-specific criteria, such as stiffness, degradability and biocompatibility.

Methodology/Principal Findings

In the present study, we analysed two synthetic, long-term degradable polymers for their impact on MSC-based bone tissue engineering: PLLA-co-TMC (Resomer® LT706) and poly(ε-caprolactone) (PCL). Both polymers enhance the osteogenic differentiation compared to tissue culture polystyrene (TCPS) as determined by Alizarin red stainings, scanning electron microscopy, PCR and whole genome expression analysis. Resomer® LT706 and PCL differ in their influence on gene expression, with Resomer® LT706 being more potent in supporting osteogenic differentiation of MSC. The major trigger on the osteogenic fate, however, is from osteogenic induction medium.

Conclusion

This study demonstrates an enhanced osteogenic differentiation of MSC on Resomer® LT706 and PCL compared to TCPS. MSC cultured on Resomer® LT706 showed higher numbers of genes involved in skeletal development and bone formation. This identifies Resomer® LT706 as particularly attractive scaffold material for bone tissue engineering.

Fibroblasts facilitate the engraftment of embryonic stem cell-derived cardiomyocytes on three-dimensional collagen matrices and aggregation in hanging drops

There is growing interest in the use of cardiomyocytes purified from embryonic stem (ES) cells for tissue engineering and cardiomyoplasty. However, most transplanted cells are lost shortly after transplantation due to the lack of integration into the host tissue and subsequent apoptosis. Here we examine whether murine embryonic fibroblasts (MEFs) can support the integration of purified murine ES cell-derived cardiomyocytes in a 3-dimensional tissue culture model based on a freezed-dryed collagen matrix with tubular structure. Collagen matrix was seeded either with cardiomyocytes alone or in combination with MEFs. The collagen sponges that were transplanted with cardiomyocytes alone showed neither morphological nor functional integration of viable cells. Cardiomyocytes also did not appear to be capable of attaching quantitatively to any of 16 different 2-dimensional biomaterials. However, cardiomyocytes co-cultured with MEFs formed fiber-like structures of rod-shaped cells with organized sarcomeric structure that contracted spontaneously. Electrical coupling between cardiomyocytes was suggested by strong expression of connexin 43. In addition, MEFs as well as cardiac fibroblasts supported re-aggregation of dissociated cardiomyocytes in hanging drops in the absence of collagen matrix. We conclude that fibroblasts promote cardiomyocyte engraftment and formation of functional 3-dimensional tissue in vitro. Elucidation of the mechanism of this phenomenon may help improve the integration of cardiomyocytes in vivo.

Cytocompatibility of high strength non-oxide ceramics

Oxide ceramic materials like alumina (Al(2)O(3)) and zirconia (ZrO(2)) are frequently used for medical applications like implants and prostheses because of their excellent biocompatibility and high wear resistance. Unfortunately, oxide ceramics cannot be used for minimal invasive thin-walled implants like resurfacing hip prostheses because of their limited strength. The hypothesis of this study is that non-oxide ceramics like silicon nitride (Si(3)N(4)) and silicon carbide (SiC)-not previously used in the medical field-are not only high strength and mechanically reliable ceramic materials due to their high amount of covalent bonds, but also exhibit a suitable biocompatibility for use as medical implants and prostheses. Mechanical investigations and cell culture tests with mouse fibroblast cells (L929) and human mesenchymal stem cells (hMSC) were performed on the ceramics. An excellent cytocompatibility was demonstrated by live/dead stainings for both L929 cells and hMSC. HMSC were able to differentiate towards osteoblasts on all tested ceramics. The determined strength of silicon nitride and silicon carbide was shown as significantly higher than that of oxide ceramics. Our results indicate that the high strength non-oxide ceramics are material candidates in the future especially for highly loaded, thin-walled implants like ceramic resurfacing hip prostheses.

Bio-functionalized star PEG-coated PVDF surfaces for cytocompatibility-improved implant components

Unmodified and GRGDS peptide-modified six arm PEG star based hydrogels (Star PEG) have been applied as a multifunctional, easy to handle coating system for textile polyvinylidene fluoride (PVDF) structures, which prevent unspecific protein and cell adsorption and control-specific cell adhesion. The reactive isocyanate-terminated Star PEG has been successfully applied to ammonia-plasma treated two- and three-dimensional PVDF surfaces. Easy modification of the surface hydrogel by mixing in of GRGDS peptide during the coating step or subsequent coupling of GRGDS was determined by TOF-SIMS. Unmodified and GRGDS-functionalized hydrogel surfaces show distinct protein repellency, as demonstrated by fluorescence microscopy after incubation with fluorescent labeled proteins and Surface MALDI-TOF-Mass Spectroscopy. Cell culture experiments with primary human dermal fibroblasts, primary fetal rat fibroblasts, and human osteoblasts on GRGDS and/or KRSR Star PEG-modified two- and three-dimensional substrates show advancement in cell adhesion and proliferation compared with untreated PVDF surfaces, whereas pure star PEG-coated surfaces show no cell adhesion. The combination of protein and cell repellent properties with specific biofunctionality and easy application of the coatings will enable their application for 3D-scaffolds.

Long-term survival and bipotent terminal differentiation of human mesenchymal stem cells (hMSC) in combination with a commercially available three-dimensional collagen scaffold

Researchers working in the field of tissue engineering ideally combine autologous cells and biocompatible scaffolds to replace defect tissues/organs. Due to their differentiation capacity, mesenchym-derived stem cells, such as human mesenchymal stem cells (hMSC), are a promising autologous cell source for the treatment of human diseases. As natural precursors for mesenchymal tissues, hMSC are particularly suitable for bone, cartilage, and adipose tissue replacement. In this study a detailed histological and ultrastructural analysis of long-term cultured and terminally differentiated hMSC on 3D collagen scaffolds was performed. Standardized 2D differentiation protocols for hMSC into adipocytes and osteoblasts were adapted for long-term 3D in vitro cultures in porous collagen matrices. After a 50-day culture period, large numbers of mature adipocytes and osteoblasts were clearly identifiable within the scaffolds. The adipocytes exhibited membrane free lipid vacuoles. The osteoblasts were arranged in close association with hydroxyapatite crystals, which were deposited on the surrounding fibers. The collagen matrix was remodeled and adopted a contracted and curved form. Human MSC survive long-term culture within these scaffolds and could be terminally differentiated into adipocytes and osteoblasts. Thus, the combination of hMSC and this particular collagen scaffold is a possible candidate for bone and adipose tissue replacement strategies.

Control of protein adsorption on functionalized electrospun fibers

Electrospun fibers that are protein resistant and functionalized with bioactive signals were produced by solution electrospinning amphiphilic block copolymers. Poly (ethylene glycol)-block-poly(D,L-lactide) (PEG-b-PDLLA) was synthesized in two steps, with a PEG segment of 10 kDa, while the PDLLA block ranged from 20 to 60 kDa. Depending on the PEG and PDLLA segment ratio, as well as solvent selection, the hydrophilicity and protein adsorption could be altered on the electrospun mesh. Furthermore, an alpha-acetal PEG-b-PDLLA was synthesized that allowed the conjugation of active molecules, resulting in surface functionalization of the electrospun fiber. Electrospun material with varying morphologies and diameter were electrospun from 10, 20, and 30 wt.% solutions. Sessile drop measurements showed a reduction in the contact angle from 120 degrees for pure poly(D,L-lactide) with increasing PEG/PDLLA ratio. All electrospun block PEG-b-PDLLA fibers had hydrophilic properties, with contact angles below 45 degrees . The fibers were collected onto six-arm star-poly(ethylene glycol) (star-PEG) coated silicon wafers and incubated with fluorescently labeled proteins. All PEG-b-PDLLA fibers showed no detectable adsorption of bovine serum albumin (BSA) independent of their composition while a dependence between hydrophobic block length was observed for streptavidin adsorption. Fibers of block copolymers with PDLLA blocks smaller than 39 kDa showed no adsorption of BSA or streptavidin, indicating good non-fouling properties. Fibers were surface functionalized with N(epsilon)-(+)-biotinyl-L-lysine (biocytin) or RGD peptide by attaching the molecule to the PEG block during synthesis. Protein adsorption measurements, and the controlled interaction of biocytin with fluorescently labeled streptavidin, showed that the electrospun fibers were both resistant to protein adsorption and are functionalized. Fibroblast adhesion was contrasting between the unfunctionalized and RGD-coupled electrospun fabrics, confirming that the surface of the fibers was functionalized. The PEG-b-PDLLA surface functionalized electrospun fibers are promising substrates for controlling cell-material interactions, particularly for tissue-engineering applications.

Biofunctionalized poly(ethylene glycol)-block-poly(epsilon-caprolactone) nanofibers for tissue engineering

Electrospun fibers with contrasting cell adhesion properties provided non-woven substrates with enhanced in vitro acceptance and controllable cell interactions. Poly(ethylene glycol)-block-poly(epsilon-caprolactone) (PEG-b-PCL) block copolymers with varying segment lengths were synthesized in two steps and characterized by NMR and GPC. A cell adhesive peptide sequence, GRGDS, was covalently coupled to the PEG segment of the copolymer in an additional step. The suitability of polymers with molecular weights ranging from 10 to 30 kDa for electrospinning and the influences of molecular weight, solvent, and concentration on the resulting morphologies were investigated. Generally, electrospun fibers were obtained by electrospinning polymers with molecular weight larger than 25 kDa and concentrations of 10 wt%. Methanol/chloroform (25/75, v/v) mixtures proved to be good solvent systems for electrospinning the PEG-b-PCL and resulted in hydrophilic, non-woven fiber meshes (contact angle 30 degrees ). The mesh without cell adhesive GRGDS ligands showed no attachment of human dermal fibroblasts after 24 h cell culture demonstrating that the particular combination of the material and electrospinnig conditions yielded protein and cell repellent properties. The GRGDS immobilized mesh showed excellent cellular attachment with fibroblasts viable after 24 h with spread morphology. Electrospun nanofibers based on block copolymers have been produced which are capable of specifically targeting cell receptor binding and are a promising material for tissue engineering and controlling cell material interactions.

Three-dimensional nonwoven scaffolds from a novel biodegradable poly(ester amide) for tissue engineering applications

Biodegradable polyesters are established biomaterials in medicine due to their chemical characteristics and options for material processing. A main problem, however, is the release of acid degradation products during biodegradation with severe local pH-drops and inflammatory reactions. Polyesteramides, in contrast, show a less prominent pH-drop during degradation. In this study, we developed a simple, reproducible synthesis of the poly(ester amide) (PEA) type C starting from epsilon-caprolactame, 1,4-butanediol, and adipic acid in a one-batch two-step reaction and conducted the manufacturing of PEA-derived 3D textile scaffolds applicable for tissue engineering purposes. The thermal and mechanical properties of PEA-type C were analysed and the structural conformity of different batches was confirmed by NMR spectroscopy and size exclusion chromatography. The polymer was formed into nonwovens by textile manufacturing. Cytotoxicity tests and X-ray photoelectron spectroscopy (XPS) were used to analyze the effect of scaffold extraction before cell seeding. The manufactured carriers were seeded with human preadipocytes and examined for cellular proliferation and differentiation. The production of PEA type C successfully occurred via simultaneous ring-opening polymerization of epsilon-caprolactame and polycondensation with 1,4-butanediol and adipic acid at 250 degrees C under high-vacuum. Soxhlet extraction allowed optimal cleaning of nonwoven scaffolds. Extracted PEA-derived matrices were capable of allowing good adherence, proliferation, and differentiation of preadipocytes. These results are encouraging and guidance towards an optimally prepared nonwoven carrier applicable for clinical use.

Surface Grafting of PEO-Based Star-Shaped Molecules for Bioanalytical and Biomedical Applications

This article reviews surface grafting of star-shaped PEO. The use of star-shaped polymers is compared to linear PEO chains regarding the layer preparation and the ability of the resulting surfaces to resist protein adsorption. We then focus on the use of end-functionalized, star-shaped, PEO-based prepolymers that are able to form covalent crosslinks and functional polymer networks on the substrate. Examples are given for specific protein adsorption as well as for cell adhesion on such layers by covalent embedding of biofunctional molecules. The possibility of coating biomedically relevant polymer substrates in three-dimensional geometries is discussed and examples are shown for poly(ethylene terephthalate) monofilament constructs.

Influence of different ECM mimetic peptide sequences embedded in a nonfouling environment on the specific adhesion of human-skin keratinocytes and fibroblasts on deformable substrates

Mechanical stress is a decisive factor for the differentiation, proliferation, and general behavior of cells. However, the specific signaling of mechanotransduction is not fully understood. One basic problem is the clear distinction between the different extracellular matrix (ECM) constituents that participate in cellular adhesion and their corresponding signaling pathways. Here, a system is proposed that enables mechanical stimulation of human-skin-derived keratinocytes and human dermal fibroblasts that specifically interact with peptide sequences immobilized on a non-interacting but deformable substrate. The peptide sequences mimic fibronectin, laminin, and collagen type IV, three major components of the ECM. To achieve this, PDMS is activated using ammonia plasma and coated with star-shaped isocyanate-terminated poly(ethylene glycol)-based prepolymers, which results in a functional coating that prevents unspecific cell adhesion. Specific cell adhesion is achieved by functionalization of the layers with the peptide sequences in different combinations. Moreover, a method that enables the decoration of deformable substrates with cell-adhesion peptides in extremely defined nanostructures is presented. The distance and clustering of cell adhesion molecules below 100 nm has been demonstrated to be of utmost importance for cell adhesion. Thus we present a new toolbox that allows for the detailed analysis of the adhesion of human-skin-derived cells on structurally and biochemically decorated deformable substrates.

Polyesteramide-Derived Nonwovens as Innovative Degradable Matrices Support Preadipocyte Adhesion, Proliferation, and Differentiation

Extended soft tissue defects resulting from injuries or tumor resections are still an unresolved problem in plastic and reconstructive surgery because adequate reconstruction is difficult. Immature adipogenic precursor cells, called preadipocytes, which are located between mature adipocytes in adipose tissue, represent a powerful tool for soft tissue engineering because of their ability to proliferate and differentiate into adipose tissue after transplantation. In previous studies, we compared preadipocyte-loaded hyaluronan or collagen biomaterials and their applicability for adipose tissue engineering. Our findings demonstrated successful de novo formation of adipose tissue in vivo but pore size and stiffness were limiting factors not allowing for sufficient cell distribution in the construct. This study presents a nonwoven made of novel bioabsorbable co-poly(ester amide) based on e-caprolactam, adipic acid, and 1,4-butanediol in an innovative 3-dimensional architecture. The material was formed into nonwovens by textile manufacturing using an aerodynamic web formation process and a needle felting technique. Carriers were seeded with human preadipocytes and examined for cellular proliferation and differentiation. In addition, methods of preparing scaffolds for optimal cell interaction were evaluated. Our findings show that polyesteramide-derived nonwovens allow good adherence, proliferation, and differentiation of preadipocytes. These results are promising guidance toward an optimally designed scaffold for in vivo use.

Direct in Vitro Electrospinning with Polymer Melts

The electrospinning of polymer melts can offer an advantage over solution electrospinning, in the development of layered tissue constructs for tissue engineering. Melt electrospinning does not require a solvent, of which many are cytotoxic in nature, and the use of nonwater soluble polymers allows the collection of fibers on water or onto cells. In this article, melt electrospinning of a blend of PEO-block-PCL with PCL was performed with in vitro cultured fibroblasts as the collection target. The significant parameters governing electrospinning polymer melts were determined before electrospinning directly onto fibroblasts. In general, a high electric field resulted in the most homogeneous and smallest fibers, although it is important that an optimal pump rate to the spinneret needs to be determined for different configurations. Many parameters governing melt electrospinning differ to those reported for solution electrospinning: the pump rate was a magnitude lower and the viscosity a magnitude higher than successful parameters for solution electrospinning. Cell vitality was maintained throughout the electrospinning process. Six days after electrospinning, fibroblasts adhered to the electrospun fibers and appeared to detach from the underlying flat substrate. The morphology of the fibroblasts changed from spread and flat, to long and spindle-shaped as adherence onto the fiber progressed. Therefore, an important step for producing layer-on-layer tissue constructs of cells and polymers in view of scaffold construction for tissue engineering was successfully demonstrated. The process of using cultured cells as the collection target was termed "direct in vitro electrospinning".