Use of contemporary biomaterials in chronic osteomyelitis treatment: Clinical lessons learned and literature review

Research Progress in Medical Biomaterials for Bone Infections

Bone infection is a debilitating condition characterized by inflammation of the bone and its marrow. It poses significant challenges in clinical practice due to its recalcitrant nature and difficulty in eradicating the infecting microorganisms. Recent advancements in the field of medical biomaterials have shown hope in the treatment of bone infections. This article reviews the research progress of medical biomaterials for anti-osteomyelitis in recent years, focusing on the mechanism of action, unique advantages, and application backgrounds of various materials. At the same time, we pay attention to the need for materials used in the treatment of osteomyelitis to promote bone healing.

Long-term follow-up of chronic osteomyelitis after bone tumor resection

The standard treatment for chronic osteomyelitis after trauma is affected bone resection and bone and soft tissue defect reconstruction. However, few reports exist regarding chronic osteomyelitis after bone tumor surgery. We retrospectively reviewed five cases of chronic infection after bone tumor surgery, including their treatment strategy and clinical course. We reviewed three cases of giant cell tumors of bone and two cases of osteosarcoma. Reconstruction was performed after tumor resection in all cases. Despite careful management, fistula formation and chronic infection occurred. Two patients underwent radical surgery for chronic infection. After the infection subsided, reconstruction was performed again. However, in one case, the infection recurred, and consequently, amputation was performed. When radical surgery is performed, implant replacement is essential due to biofilm formation. Controlling soft tissue infection, besides bone and implant infection, is important. In some cases, however, radical surgery is undesirable, and patients choose to live with the chronic infection instead. Even when methicillin-resistant S. aureus (MRSA) was detected, anti-MRSA drugs were used only in the early stages, after which the infection was managed by switching to oral antibiotics, such as minocycline and sulfamethoxazole-trimethoprim combination drugs. Careful follow-up is necessary due to the risk of fistula cancer in conservative management.

Calcium phosphate-based anti-infective bone cements: recent trends and future perspectives

Bone infection remains a challenging condition to fully eradicate due to its intricate nature. Traditional treatment strategies, involving long-term and high-dose systemic antibiotic administration, often encounter difficulties in achieving therapeutic drug concentrations locally and may lead to antibiotic resistance. Bone cement, serving as a local drug delivery matrix, has emerged as an effective anti-infective approach validated in clinical settings. Calcium phosphate cements (CPCs) have garnered widespread attention and application in the local management of bone infections due to their injectable properties, biocompatibility, and degradability. The interconnected porous structure of calcium phosphate particles, not only promotes osteoconductivity and osteoinductivity, but also serves as an ideal carrier for antibacterial agents. Various antimicrobial agents, including polymeric compounds, antibiotics, antimicrobial peptides, therapeutic inorganic ions (TIIs) (and their nanoparticles), graphene, and iodine, have been integrated into CPC matrices in numerous studies aimed at treating bone infections in diverse applications such as defect filling, preparation of metal implant surface coatings, and coating of implant surfaces. Additionally, for bone defects and nonunions resulting from chronic bone infections, the utilization of calcium phosphate-calcium sulfate composite multifunctional cement loaded with antibacterial agents serves to efficiently deal with infection, stimulate new bone formation, and attain an optimal degradation rate of the bone cement matrix. This review briefly delves into various antibacterial strategies based on calcium phosphate cement for the prevention and treatment of bone infections, while also discussing the application of calcium phosphate-calcium sulfate composites in the development of multifunctional bone cement against bone infections.

Local Delivery of Exosomes and Antibiotics in Hydroxyapatite-Based Nanocement for Osteomyelitis Management

The management of bone and joint infections is a formidable challenge in orthopedics and poses a global health concern. While clinical management emphasizes infection prevention and complete eradication, an effective strategy for stabilizing skeletal tissue with adequate soft tissue coverage remains limited. In this study, we have employed a novel approach of using the local delivery of exosomes and antibiotics (rifampicin) using a hydroxyapatite-based nanocement carrier to manage the residual space created during debridement effectively. Additionally, we synthesized a periosteum-guiding antioxidant herbal membrane to leverage the inherent periosteum regeneration capability of the bone, facilitating bone callus repair and natural healing. The synthesized scaffolds were biocompatible and demonstrated potent antibacterial activity in vitro. When evaluated in vivo in the Staphylococcus aureus-induced rat tibial osteomyelitis model, the released drugs successfully cleared the residual bacteria and the released exosome promoted bone healing, resulting in 3-fold increase in bone volume as analyzed via micro-CT analysis. Immunofluorescence staining of periosteum-specific markers also indicated the complete formation of periosteal layers, thus highlighting the complete bone repair.

Ilizarov External Fixator Versus Orthofix LRS in Management of Femoral Osteomyelitis: A Propensity Score Matched Analysis

Purpose

Treatment of osteomyelitis (OM) is challenging. Ilizarov bone transport is a commonly used technique for management of OM. The recently introduced limb reconstruction system (LRS) has been effectively used for management of OM. It was suggested to be easier in use and less invasive. The present retrospective study aimed to compare LRS and Ilizarov bone transport in management of femoral OM using a propensity score matched analysis.

Methods

The present retrospective study included 80 consecutive patients with femoral OM. The studied patients were managed either using Ilizarov external fixator (n = 40) or Orthofix LRS (n = 40). The clinical outcome measurements included union time, limb length discrepancy, additional operative procedures, refracture and infection.

Results

Patients in the LRS group were exposed to significantly higher frequency of bone transport (30.0 versus 15.0%) and lower frequency of acute compression and lengthening (10.0 versus 32.5%). Patients in Ilizarov group had significantly higher frequency of tobramycin pellets as compared to their counterparts. The studied groups were comparable regarding the operative complications including pin-tract infection, non-union at docking site and refracture. Patients in the Ilizarov had significantly shorter time to union (8.2 ± 3.2 versus 11.0 ± 5.6 months, p = 0.012). No statistically significant differences were found between the studied groups regarding the quality-of-life domains.

Conclusions

Use of Ilizarov external fixator and Orthofix LRS devices proved to be effective and reliable. Their influences on patients' quality appear to be comparable.

Clinical outcomes and complications of S53P4 bioactive glass in chronic osteomyelitis and septic non-unions: a retrospective single-center study

INTRODUCTION

Dead space management following debridement surgery in chronic osteomyelitis or septic non-unions is one of the most crucial and discussed steps for the success of the surgical treatment of these conditions. In this retrospective clinical study, we described the efficacy and safety profile of surgical debridement and local application of S53P4 bioactive glass (S53P4 BAG) in the treatment of bone infections.

METHODS

A consecutive single-center series of 38 patients with chronic osteomyelitis (24) and septic non-unions (14), treated with bioactive glass S53P4 as dead space management following surgical debridement between May 2015 and November 2020, were identified and evaluated retrospectively.

RESULTS

Infection eradication was reached in 22 out of 24 patients (91.7%) with chronic osteomyelitis. Eleven out of 14 patients (78.6%) with septic non-union achieved both fracture healing and infection healing in 9.1 ± 4.9 months. Three patients (7.9%) developed prolonged serous discharge with wound dehiscence but healed within 2 months with no further surgical intervention. Average patient follow-up time was 19.8 months ± 7.6 months.

CONCLUSION

S53P4 bioactive glass is an effective and safe therapeutic option in the treatment of chronic osteomyelitis and septic non-unions because of its unique antibacterial properties, but also for its ability to generate a growth response in the remaining healthy bone at the bone-glass interface.

Synthesis and characterization of mesoporous bioactive glass nanoparticles loaded with peganum harmala for bone tissue engineering

Globally, there is an increase in a number of bone disorders including osteoarthritis (OA), osteomyelitis, bone cancer, and etc., which has led to a demand for bone tissue regeneration. In order to take use of the osteogenic potential of natural herbs, mesoporous bioactive glass nanoparticles (MBGNs) have the ability to deliver therapeutically active chemicals locally. MBGNs influence bioactivity and osteointegration of materials making them suitable for bone tissue engineering (BTE). In the present study, we developed Peganum Harmala (P. harmala) loaded MBGNs (PH-MBGNs) synthesized via modified Stöber process. The MBGNs were analyzed in terms of surface morphology, chemical make-up, amorphous nature, chemical interaction, pore size, and surface area before and after loading with P. harmala. A burst release of drug from PH-MBGNs was observed within 8 h immersion in phosphate buffer saline (PBS). PH-MBGNs effectively prevented Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) from spreading. Furthermore, PH-MBGNs developed a hydroxyapatite (HA) layer in the presence of simulated body fluid (SBF) after 21 days, which confirmed the in-vitro bioactivity of MBGNs. In conclusion, PH-MBGNs synthesized in this work are potential candidate for scaffolding or a constituent in the coatings for BTE applications.

Antibiotic artificial bone implantation for the treatment of infection after internal fixation of tibial plateau fractures

OBJECTIVE

To explore the clinical effect of antibiotic artificial bone (Calcium phosphate) in the treatment of infection after internal fixation of tibial plateau fractures.

METHODS

We retrospectively reviewed the clinical data of 32 patients with infection after internal fixation of tibial plateau fractures treating from March 2010 to October 2021. There were 18 males and 14 females, aged from 23 to 70 (average 49.66 ± 10.49), 19 cases of the left side and 13 cases of the right side. Among them, 7 cases were open fractures with initial injury and 25 cases were closed fractures. On the basis of thorough debridement and implanting antibiotic artificial bone, the internal fixation of 18 patients were tried to be preserved and the internal fixation of 14 patients were removed completely. In order to provide effective fixation, 14 patients also received external fixation. Postoperative wound healing, infection control, Hospital for Special Surgery knee scores (HSS), related inflammatory indicators and bone healing time were recorded and followed up.

RESULTS

Thirty-two patients were followed up for 12 ~ 82 months (average 36.09 ± 19.47 months). The redness, swelling and pain of pin site occurred in 2 patients, which returned to normal after applying antibiotics and continuous dressing change. One patient retained the internal fixation during the first-stage operation. Redness and swelling of incision, subcutaneous undulation occurred after two months. In order to avoid the recurrence of infection, the internal fixation was removed completely and antibiotic artificial bone was filled again. The infection was controlled and fracture healed. Four patients' wounds could not be closed directly due to soft tissue defect and was covered with skin flap. After the first-stage operation, 12 patients received second-stage autologous iliac bone grafting due to residual bone defects and poor healing of the fracture end. The bone healing time was 4 ~ 16 months (average 7.31 ± 2.79 months). Inflammatory indicators including CRP, ESR, and WBC returned to normal levels within 2 ~ 10 weeks (average 4.97 ± 2.58 weeks). The HSS of all patients were 54 ~ 86 points (average 73.06 ± 8.44 points) at the last follow-up.

CONCLUSION

Implantation of antibiotic artificial bone, retention or removal of internal fixation according to infection and fracture healing, application of external fixation timely is an effective method to treat infection after internal fixation of tibial plateau fractures, which can control infection effectively and promote functional recovery.

Fabrication and mechanical properties of newly developed triphasic blocks composed of gypsum-brushite-monetite for bone graft applications

Objective

A triphasic bone graft block composed of gypsum, brushite, and monetite is expected to be better for regenerating bone than a gypsum-hydroxyapatite-tricalcium phosphate block. Therefore, the aim of this study was to fabricate and evaluate the mechanical properties of a newly developed triphasic block composed of gypsum, brushite, and monetite.

Materials and method

Triphasic blocks were prepared by mixing calcium sulfate hemihydrate, brushite, and monetite powders with distilled water at a powder-to-liquid ratio of 0.5. The content of calcium sulfate hemihydrate was fixed at 50%, and the contents of brushite and monetite powders were varied. After molding and setting, the obtained blocks were characterized, and their mechanical properties were evaluated.

Results

The triphasic blocks were prepared and could maintain their shape without collapsing. The XRD characterization of the obtained triphasic blocks showed that only three phases existed in the block. Calcium sulfate hemihydrate was transformed into its dihydrate form and provided mechanical strength to the block through a setting mechanism. The transformation of calcium sulfate hemihydrate into its dihydrate crystals formed an interlocked structure that was disrupted in triphasic blocks, as observed in SEM images. The disruption of the interlocked structure resulted in lower mechanical strength of the obtained triphasic blocks compared to the set gypsum control. The variation in brushite and monetite composition did not affect the mechanical properties of the triphasic blocks.

Conclusion

The triphasic gypsum-brushite-monetite block was successfully prepared, and no other crystal phases were found. The triphasic blocks could maintain their shape after setting. The addition of brushite and monetite powders disrupted the interlocked structure of the set gypsum crystal, resulting in a decrease in mechanical strength. Furthermore, the variation in brushite and monetite powders did not affect the mechanical properties of the triphasic blocks.

Facile post modification synthesis of copper-doped mesoporous bioactive glass with high antibacterial performance to fight bone infection

Successful treatment of infected bone defects caused by multi-drug resistant bacteria (MDR) has become a major clinical challenge, stressing the urgent need for effective antibacterial bone graft substitutes. Mesoporous bioactive glass nanoparticles (MBGNs), a rapidly emerging class of nanoscale biomaterials, offer specific advantages for the development of biomaterials to treat bone infection due to endowed antibacterial features. Herein, we propose a facile post-modification sol-gel strategy to synthesize effective antibacterial MBGNs doped with copper ions (Cu-PMMBGNs). In this strategy, amine functional groups as chelating agents were introduced to premade mesoporous silica nanoparticles (MSNs) which further facilitate the incorporation of high content of calcium (∼17 mol%) and copper ions (∼8 mol%) without compromising nanoparticle shape, mesoporosity, and homogeneity. The resulting nanoparticles were degradable and showed rapidly induce abundant deposition of apatite crystals on their surface upon soaking in simulated body fluids (SBF) after 3 days. Cu-PMMBGNs exhibited a dose-dependent inhibitory effect on Methicillin-resistant Staphylococcus aureus (MRSA) bacteria, which are common pathogens causing severe bone infections. Most importantly, the nanoparticles containing 5 mol% copper ions at concentrations of 500 and 1000 μg.mL^-1 showed highly effective antibacterial performance as reflected by a 99.9 % reduction of bacterial viability. Nanoparticles at a concentration of 500 μg.mL^-1 showed no significant cytotoxicity toward preosteoblast cells (∼85-89 % cell viability) compared to the control group. In addition, the nanoscale properties of synthesized Cu-PMMBGNs (∼100 nm in size) facilitated their internalization into preosteoblast cells, which highlights their potential as intracellular carriers in combating intracellular bacteria. Therefore, these copper-doped nanoparticles hold strong promise for use as an antibacterial component in antibacterial bone substitutes such as hydrogels, nanocomposites, and coatings.

Mid-term clinical results of chronic cavitary long bone osteomyelitis treatment using S53P4 bioactive glass: a multi-center study

Introduction: Chronic osteomyelitis is a challenging condition in the orthopedic practice and traditionally treated using local and systemic antibiotics in a two-stage surgical procedure. With the introduction of the antimicrobial biomaterial S53P4 bioactive glass (Bonalive^®), chronic osteomyelitis can be treated in a one-stage procedure. This study evaluated the mid-term clinical results of patients treated with S53P4 bioactive glass for long bone chronic osteomyelitis. Methods: In this prospective multi-center study, patients from two different university medical centers in the Netherlands were included. One-stage treatment consisted of debridement surgery, implantation of S53P4 bioactive glass, and treatment with culture-based systemic antibiotics. If required, wound closure by a plastic surgeon was performed. The primary outcome was the eradication of infection, and a secondary statistical analysis was performed on probable risk factors for treatment failure. Results: In total, 78 patients with chronic cavitary long bone osteomyelitis were included. Follow-up was at least 12 months (mean 46; standard deviation, SD, 20), and 69 patients were treated in a one-stage procedure. Overall infection eradication was 85 %, and 1-year infection-free survival was 89 %. Primary closure versus local/muscular flap coverage is the only risk factor for treatment failure. Conclusion: With 85 % eradication of infection, S53P4 bioactive glass is an effective biomaterial in the treatment of chronic osteomyelitis in a one-stage procedure. A major risk factor for treatment failure is the necessity for local/free muscle flap coverage. These results confirm earlier published data, and together with the fundamentally different antimicrobial pathways without antibiotic resistance, S53P4 bioactive glass is a recommendable biomaterial for chronic osteomyelitis treatment and might be beneficial over other biomaterials.

LncRNA NONHSAT009968 inhibits the osteogenic differentiation of hBMMSCs in SA-induced inflammation via Wnt3a

Osteomyelitis is one of the most challenging diseases in the field of orthopedics for its complex pathogenesis and unsatisfactory treatment. The mechanism underlying its occurrence and development is still unclear. In our previous study, we found that long non-coding RNA (lncRNA) NONHSAT009968 inhibited the ability of osteogenic differentiation in staphylococcal protein A (SPA)-treated human bone marrow mesenchymal stem cells (hBMMSCs), but the underlying mechanism remains unclear. The current study was aimed at elucidating the possible mechanism of NONHSAT009968 in regulating osteogenic differentiation and bone defect repairability of hBMMSCs under infection. It was revealed that Wnt3a played a key role in promoting osteogenic differentiation of hBMMSCs treated with SPA in vitro. In addition, NONHSAT009968 inhibited osteogenic differentiation of hBMMSCs treated with SPA via Wnt3a, both in vivo and in vitro. In sum, the results suggested that lncNONHSAT009968 inhibited osteogenic differentiation of hBMMSCs in SA-induced inflammation through Wnt3a, which may have affected the occurrence and development of osteomyelitis. This study might provide novel insights regarding osteomyelitis and infectious bone defects.

Use of contemporary biomaterials in chronic osteomyelitis treatment: Clinical lessons learned and literature review

Chronic osteomyelitis has always been a therapeutic challenge for patient and surgeon due to the specific problems related with bone infection and bacterial biofilm eradication. Other than being the cause of infection or facilitating spread or persistence of infection, biomaterials are also becoming a tool in the treatment of infection. Certain novel biomaterials have unique and ideal properties that render them perfectly suited to combat infection and are therefore used more and more in the treatment of chronic bone infections. In case of infection treatment, there is still debate whether these properties should be focused on bone regeneration and/or their antimicrobial properties. These properties will be of even greater importance with the challenge of emerging antimicrobial resistance. This review highlights indications for use and specific material properties of some commonly used contemporary biomaterials for this indication as well as clinical experience and a literature overview.