1
|
Emonde CK, Eggers ME, Wichmann M, Hurschler C, Ettinger M, Denkena B. Radiopacity Enhancements in Polymeric Implant Biomaterials: A Comprehensive Literature Review. ACS Biomater Sci Eng 2024; 10:1323-1334. [PMID: 38330191 PMCID: PMC10934286 DOI: 10.1021/acsbiomaterials.3c01667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/10/2024]
Abstract
Polymers as biomaterials possess favorable properties, which include corrosion resistance, light weight, biocompatibility, ease of processing, low cost, and an ability to be easily tailored to meet specific applications. However, their inherent low X-ray attenuation, resulting from the low atomic numbers of their constituent elements, i.e., hydrogen (1), carbon (6), nitrogen (7), and oxygen (8), makes them difficult to visualize radiographically. Imparting radiopacity to radiolucent polymeric implants is necessary to enable noninvasive evaluation of implantable medical devices using conventional imaging methods. Numerous studies have undertaken this by blending various polymers with contrast agents consisting of heavy elements. The selection of an appropriate contrast agent is important, primarily to ensure that it does not cause detrimental effects to the relevant mechanical and physical properties of the polymer depending upon the intended application. Furthermore, its biocompatibility with adjacent tissues and its excretion from the body require thorough evaluation. We aimed to summarize the current knowledge on contrast agents incorporated into synthetic polymers in the context of implantable medical devices. While a single review was found that discussed radiopacity in polymeric biomaterials, the publication is outdated and does not address contemporary polymers employed in implant applications. Our review provides an up-to-date overview of contrast agents incorporated into synthetic medical polymers, encompassing both temporary and permanent implants. We expect that our results will significantly inform and guide the strategic selection of contrast agents, considering the specific requirements of implantable polymeric medical devices.
Collapse
Affiliation(s)
- Crystal Kayaro Emonde
- Laboratory
for Biomechanics and Biomaterials (LBB), Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Max-Enno Eggers
- Institute
of Production Engineering and Machine Tools, Leibniz University Hannover, An der Universität 2, 30823 Garbsen, Hannover, Germany
| | - Marcel Wichmann
- Institute
of Production Engineering and Machine Tools, Leibniz University Hannover, An der Universität 2, 30823 Garbsen, Hannover, Germany
| | - Christof Hurschler
- Laboratory
for Biomechanics and Biomaterials (LBB), Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Max Ettinger
- Department
of Orthopedic Surgery − DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625 Hannover, Germany
| | - Berend Denkena
- Institute
of Production Engineering and Machine Tools, Leibniz University Hannover, An der Universität 2, 30823 Garbsen, Hannover, Germany
| |
Collapse
|
2
|
Lunz A, Schonhoff M, Omlor GW, Knappe K, Bangert Y, Lehner B, Renkawitz T, Jaeger S. Enhanced antibiotic release from bone cement spacers utilizing dual antibiotic loading with elevated vancomycin concentrations in two-stage revision for periprosthetic joint infection. INTERNATIONAL ORTHOPAEDICS 2023; 47:2655-2661. [PMID: 37566227 PMCID: PMC10602962 DOI: 10.1007/s00264-023-05922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Antibiotic loaded bone cement spacers provide high local antibiotic concentrations, preserve bone stock, and reduce soft tissue contractions. The objective of this in-vitro study was to compare antibiotic release from spacers, aiming to discover the most optimal preparation and identify modifiable factors that can further enhance antibiotic release. METHODS Six distinct spacer preparation were created using three different bone cements and manual incorporation of antibiotics. During a six-week period, the release of antibiotics from each spacer was measured individually at ten predetermined time points using a chemiluminescent immunoassay. RESULTS Manually adding 4 g of vancomycin to every 40 g of "Palacos R + G" yielded the most favorable release profile. Throughout all preparations, antibiotic release consistently and significantly decreased over the six-week period. When incorporating a higher concentration of vancomycin, a significantly higher cumulative release of vancomycin was observed, with varying effects on the release of gentamicin. The choice of bone cement had a significant impact on antibiotic release. CONCLUSION To enhance antibiotic release from spacers, surgeons should manually incorporate high antibiotic concentrations into the most appropriate bone cement and keep the interim period as short as possible. Specifically, we suggest manual incorporation of 4 g of vancomycin to every 40 g of gentamicin premixed "Palacos R + G" to create bone cement spacers.
Collapse
Affiliation(s)
- Andre Lunz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
| | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Georg W Omlor
- Center for Orthopedics and Joint Replacement, Marienhaus Hospital St. Wendel-Ottweiler, Am Hirschberg 1, 66606, St. Wendel, Germany
| | - Kevin Knappe
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Yannic Bangert
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Tobias Renkawitz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| |
Collapse
|
3
|
Steadman W, Chapman PR, Schuetz M, Schmutz B, Trampuz A, Tetsworth K. Local Antibiotic Delivery Options in Prosthetic Joint Infection. Antibiotics (Basel) 2023; 12:antibiotics12040752. [PMID: 37107114 PMCID: PMC10134995 DOI: 10.3390/antibiotics12040752] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Prosthetic Joint Infection (PJI) causes significant morbidity and mortality for patients globally. Delivery of antibiotics to the site of infection has potential to improve the treatment outcomes and enhance biofilm eradication. These antibiotics can be delivered using an intra-articular catheter or combined with a carrier substance to enhance pharmacokinetic properties. Carrier options include non-resorbable polymethylmethacrylate (PMMA) bone cement and resorbable calcium sulphate, hydroxyapatite, bioactive glass, and hydrogels. PMMA allows for creation of structural spacers used in multi-stage revision procedures, however it requires subsequent removal and antibiotic compatibility and the levels delivered are variable. Calcium sulphate is the most researched resorbable carrier in PJI, but is associated with wound leakage and hypercalcaemia, and clinical evidence for its effectiveness remains at the early stage. Hydrogels provide a versatile combability with antibiotics and adjustable elution profiles, but clinical usage is currently limited. Novel anti-biofilm therapies include bacteriophages which have been used successfully in small case series.
Collapse
Affiliation(s)
- William Steadman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Paul R Chapman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Herston Infectious Disease Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
| | - Michael Schuetz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- Faculty of Health, Queensland University of Technology, Brisbane 4059, Australia
| | - Beat Schmutz
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology, Brisbane 4000, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, Brisbane 4059, Australia
- Australian Research Council Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing, Queensland University of Technology, Brisbane 4059, Australia
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery, Septic Unit Charité-Universitätsmedizin, 10117 Berlin, Germany
| | - Kevin Tetsworth
- Department of Orthopaedics, Royal Brisbane and Women's Hospital, Herston, Brisbane 4029, Australia
- School of Medicine, University of Queensland, Brisbane 4029, Australia
| |
Collapse
|
4
|
Lunz A, Knappe K, Omlor GW, Schonhoff M, Renkawitz T, Jaeger S. Mechanical strength of antibiotic-loaded PMMA spacers in two-stage revision surgery. BMC Musculoskelet Disord 2022; 23:945. [PMID: 36309657 PMCID: PMC9617327 DOI: 10.1186/s12891-022-05895-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/14/2022] [Indexed: 11/30/2022] Open
Abstract
Background Antibiotic-loaded polymethylmethacrylate (PMMA) bone cement spacers provide high local antibiotic concentrations and patient mobility during the interim period of two-stage revision for periprosthetic joint infection (PJI). This study compares mechanical characteristics of six dual antibiotic-loaded bone cement (dALBC) preparations made from three different PMMA bone cements. The study`s main objective was to determine the effect of time and antibiotic concentration on mechanical strength of dALBCs frequently used for spacer fabrication in the setting of two-stage revision for PJI. Methods A total of 84 dual antibiotic-loaded bone cement specimens made of either Copal spacem, Copal G + V or Palacos R + G were fabricated. Each specimen contained 0.5 g of gentamicin and either 2 g (low concentration) or 4 g (high concentration) of vancomycin powder per 40 g bone cement. The bending strength was determined at two different timepoints, 24 h and six weeks after spacer fabrication, using the four-point bending test. Results Preparations made from Copal G + V showed the highest bending strength after incubation for 24 h with a mean of 57.6 ± 1.2 MPa (low concentration) and 50.4 ± 4.4 MPa (high concentration). After incubation for six weeks the bending strength had decreased in all six preparations and Palacos R + G showed the highest bending strength in the high concentration group (39.4 ± 1.6 MPa). All low concentration preparations showed superior mechanical strength compared to their high concentration (4 g of vancomycin) counterpart. This difference was statistically significant for Copal spacem and Copal G + V (both p < 0.001), but not for Palacos R + G (p = 0.09). Conclusions This study suggests that mechanical strength of antibiotic-loaded PMMA bone cement critically decreases even over the short time period of six weeks, which is the recommended interim period in the setting of two-stage revision. This potentially results in an increased risk for PMMA spacer fracture at the end of the interim period and especially in patients with prolonged interim periods. Finally, we conclude that intraoperative addition of 4 g of vancomycin powder per 40 g of gentamicin-premixed Palacos R + G (Group D) is mechanically the preparation of choice if a dual antibiotic-loaded bone cement spacer with high antibiotic concentrations and good stability is warranted. In any case the written and signed informed consent including the off-label use of custom-made antibiotic-loaded PMMA bone cement spacers must be obtained before surgery.
Collapse
|
5
|
von Hertzberg-Boelch SP, Luedemann M, Rudert M, Steinert AF. PMMA Bone Cement: Antibiotic Elution and Mechanical Properties in the Context of Clinical Use. Biomedicines 2022; 10:biomedicines10081830. [PMID: 36009376 PMCID: PMC9404960 DOI: 10.3390/biomedicines10081830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 12/04/2022] Open
Abstract
This literature review discusses the use of antibiotic loaded polymethylmethacrylate bone cements in arthroplasty. The clinically relevant differences that have to be considered when antibiotic loaded bone cements (ALBC) are used either for long-term implant fixation or as spacers for the treatment of periprosthetic joint infections are outlined. In this context, in vitro findings for antibiotic elution and material properties are summarized and transferred to clinical use.
Collapse
Affiliation(s)
- Sebastian Philipp von Hertzberg-Boelch
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
- Correspondence:
| | - Martin Luedemann
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
| | - Maximilian Rudert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
| | - Andre F. Steinert
- Department of Orthopaedic Surgery, University of Wuerzburg, Koenig-Ludwig-Haus, 11 Brettreichstrasse, 97074 Würzburg, Germany; (M.L.); (M.R.); (A.F.S.)
- Rhön Klinikum, Campus Bad Neustadt, EndoRhoen Center for Joint Replacement, Teaching Hospital of the Phillipps University Marburg, Von Guttenberg Str. 11, 97616 Bad Neustadt, Germany
| |
Collapse
|
6
|
Mensah LM, Love BJ. A meta-analysis of bone cement mediated antibiotic release: Overkill, but a viable approach to eradicate osteomyelitis and other infections tied to open procedures. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 123:111999. [PMID: 33812619 DOI: 10.1016/j.msec.2021.111999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/08/2021] [Accepted: 02/20/2021] [Indexed: 12/13/2022]
Abstract
A number of clinical studies have highlighted the success of antibiotics formulated at concentrations between 0 and 6% w/w into bone cements to address localized infections. Separately, some commercial manufacturers have produced gentamycin-infused bone cement mixtures as a countermeasure to infection. The anecdotal evidence suggests that antibiotic infused cements can help eradicate or delay the onset of infections. Quantifying the functionality of that response is more challenging. We have surveyed the literature to identify studies in which controlled drug release or mechanical behavioral assessments have been conducted on drug-infused cements. The focus here is on vancomycin (VAN) in part due to its higher potency relative to gentamycin and its more common usage for staph infections. Takeaways from the limited pool of research studies indicate that large fractions (>99%) of the infused vancomycin remain sequestered in the cement and aren't bioavailable after solidification. Antibiotic fluence ranged from 1 to 283 μg/cm2hr. The initial strength of the various antibiotic loaded samples as produced were 52-96 MPa. Simulated exposures in a fluid environment by submersion reduced the antibiotic loaded strengths between 3 and 29%. Some strength measurements were noted below the ASTM F451 standard for acrylic bone cement although drug releasing spacers likely have different requirements. The glassy behavior of the cured cement led to both vancomycin and gentamicin having low permeability and a burst response. Smaller drug molecules and more gel-like immobilization matrices with lower glass transition temperatures offer higher potential for larger and more comprehensive drug bioavailability.
Collapse
Affiliation(s)
- Lydia M Mensah
- Department of Materials Science and Engineering, The University of Michigan, 2300 Hayward St., Ann Arbor, MI 48109, United States of America
| | - Brian J Love
- Department of Materials Science and Engineering, The University of Michigan, 2300 Hayward St., Ann Arbor, MI 48109, United States of America; Department of Biomedical Engineering, The University of Michigan, 2300 Hayward St., Ann Arbor, MI 48109, United States of America; Macromolecular Science and Engineering Program, The University of Michigan, 2300 Hayward St., Ann Arbor, MI 48109, United States of America.
| |
Collapse
|
7
|
Abstract
Essential treatment methods for infected knee arthroplasty involve DAIR (debridement, antibiotics, and implant retention), and one and two-stage exchange arthroplasty. Aggressive debridement with the removal of all avascular tissues and foreign materials that contain biofilm is mandatory for all surgical treatment modalities. DAIR is a viable option with an acceptable success rate and can be used as a first surgical procedure for patients who have a well-fixed, functioning prosthesis without a sinus tract for acute-early or late-hematogenous acute infections with no more than four weeks (most favourable being < seven days) of symptoms. Surgeons must focus on the isolation of the causative organism with sensitivities to bactericidal treatment as using one-stage exchange. One-stage exchange is indicated when the patients have:minimal bone loss/soft tissue defect allowing primary wound closure, easy to treat micro-organisms, absence of systemic sepsis and absence of extensive comorbidities.
There are no validated serum or synovial biomarkers to determine optimal timing of re-implantation for two-stage exchange. Antibiotic-free waiting intervals and joint aspiration before the second stage are no longer recommended. The decision to perform aspiration should be made based on the index of suspicion for persistent infection. Re-implantation can be performed when the treating medical team feels that the clinical signs of infection are under control and serological tests are trending downwards.
Cite this article: EFORT Open Rev 2020;5:672-683. DOI: 10.1302/2058-5241.5.190069
Collapse
Affiliation(s)
- Ismail Remzi Tözün
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Vahit Emre Ozden
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Goksel Dikmen
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| | - Kayahan Karaytuğ
- Department of Orthopaedic Surgery and Traumatology, Acibadem Mehmet Ali Aydınlar University, School of Medicine, Acibadem Maslak Hospital, Sarıyer/Istanbul, Turkey
| |
Collapse
|
8
|
Comparison of Elution Characteristics and Compressive Strength of Biantibiotic-Loaded PMMA Bone Cement for Spacers: Copal® Spacem with Gentamicin and Vancomycin versus Palacos® R+G with Vancomycin. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4323518. [PMID: 30410931 PMCID: PMC6206524 DOI: 10.1155/2018/4323518] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/24/2018] [Accepted: 09/26/2018] [Indexed: 12/19/2022]
Abstract
Purpose Copal® spacem is a new PMMA bone cement for fabricating spacers. This study compares elution of gentamicin, elution of vancomycin, and compressive strength of Copal® spacem and of Palacos® R+G at different vancomycin loadings in the powder of the cements. We hypothesized that antibiotic elution of Copal® spacem is superior at comparable compressive strength. Methods Compression test specimens were fabricated using Copal® spacem manually loaded with 0.5 g gentamicin and additionally 2 g, 4 g, and 6 g of vancomycin per 40 g of cement powder (COP specimens) and using 0.5 g gentamicin premixed Palacos® R+G manually loaded with 2 g, 4 g, and 6 g of vancomycin per 40 g of cement powder (PAL specimens). These specimens were used for determination of gentamicin and vancomycin elution (in fetal calf serum, at 22°C) and for determination of compressive strength both prior and following the elution tests. Results Cumulative gentamicin concentrations (p < 0.005) and gentamicin concentration after 28 days (p ≤ 0.043) were significantly lower for COP specimens compared to PAL specimens. Cumulative vancomycin concentrations were significantly higher (p ≤ 0.043) for COP specimens after the second day. Vancomycin concentrations after 28 days were not significantly higher for the Copal specimens loaded with 2 g and 4 g of vancomycin. Compressive strength was not significantly different between COP specimens and PAL specimens before elution tests. Compressive strength after the elution tests was significantly lower (p = 0.005) for COP specimens loaded with 2 g of vancomycin. Conclusion We could not demonstrate consistent superior antibiotic elution from Copal® spacem compared to Palacos® R+G for fabricating gentamicin and vancomycin loaded spacers. The results do not favor Copal® spacem over Palacos® R+G for the use as a gentamicin and vancomycin biantibiotic-loaded spacer.
Collapse
|
9
|
Klinder A, Zaatreh S, Ellenrieder M, Redanz S, Podbielski A, Reichel T, Bösebeck H, Mittelmeier W, Bader R. Antibiotics release from cement spacers used for two-stage treatment of implant-associated infections after total joint arthroplasty. J Biomed Mater Res B Appl Biomater 2018; 107:1587-1597. [PMID: 30312529 PMCID: PMC6586059 DOI: 10.1002/jbm.b.34251] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/29/2018] [Accepted: 09/08/2018] [Indexed: 12/13/2022]
Abstract
Two‐stage revision arthroplasty is the treatment of choice for periprosthetic infection, a serious complication after knee or hip arthroplasty. Our prospective clinical trial aimed to investigate the concentrations of gentamicin and vancomycin in wound exudate and tissue in two‐stage revision arthroplasty. Wound exudate and periprosthetic membrane samples were collected from 18 patients (10 hip and eight knee patients), who were due for two‐stage treatment after a periprosthetic joint infection. Samples were taken during insertion of antibiotic‐impregnated spacers and after their removal. The concentrations of gentamicin and vancomycin in wound exudates and adjacent tissue were analyzed using high‐performance liquid chromatography mass spectrometry. Average time period of spacer implantation was 13.6 weeks (9.3–22.6 weeks). The concentration of vancomycin in wound exudate decreased from a median of 43.28 μg/mL (0.28–261.22) after implantation to 0.46 μg/mL (0.13–37.47) after the removal of the spacer. In the adjacent tissue, vancomycin concentration was mainly undetectable prior to spacer implantation (0.003 μg/g [0.003–0.261]) and increased to 0.318 μg/g [0.024–484.16] at the time of spacer removal. This was also observed for gentamicin in the tissue of patients who previously had cement‐free implants (0.008 μg/g [0.008–0.087] vs. 0.164 μg/g [0.048–71.75]) while in the tissue of patients with previously cemented prosthesis, baseline concentration was already high (8.451 μg/g [0.152–42.926]). Despite the rapid decrease in antibiotics release from spacer cement observed in vitro, in vivo antibiotics are much longer detectable, especially in the adjacent soft tissue. © 2018 The Authors. Journal of Biomedical Materials Research Part B: Applied Biomaterials Published By Wiley Periodicals, Inc. J Biomed Mater Res B Part B, 2019. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1587–1597, 2019.
Collapse
Affiliation(s)
- Annett Klinder
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Sarah Zaatreh
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Martin Ellenrieder
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Sylvio Redanz
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Andreas Podbielski
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany
| | | | | | - Wolfram Mittelmeier
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Rostock, Germany
| |
Collapse
|
10
|
Wear Performance of Calcium Carbonate-Containing Knee Spacers. MATERIALS 2017; 10:ma10070805. [PMID: 28773164 PMCID: PMC5551848 DOI: 10.3390/ma10070805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 12/28/2022]
Abstract
Articulating spacers should be wear-resistant and load-bearing to avoid prolonged immobilization of the patient and to reduce morbidity. However, due to the articulation of both components, a release of cement wear particles is to be expected. The aim of this study was to investigate the wear performance of a new spacer cement that contains calcium carbonate as a radio-opaque substance, in comparison to an established barium sulphate-containing spacer material, and also to characterize the amount, morphology, and size distributions of the released cement particles in detail. Force-controlled simulation was carried out on an AMTI knee simulator. The test parameters were in accordance with the standard ISO 14243-1 with a 50% reduced axial force. Tests were run for 500,000 cycles at a frequency of 1 Hz. For wear analysis, photographic documentation of the wear scars, gravimetric wear measurements and wear particle analysis were performed. The barium sulphate spacer material showed a total articular wear of 375.53 ± 161.22 mg. For the calcium carbonate-containing cement, reduced articular wear of 136.32 ± 37.58 mg was determined. Isolated cement wear particles of the barium sulphate-containing cement had a diameter of 0.429 ± 0.224 μm and were significantly larger compared to the calcium carbonate-containing cement (0.380 ± 0.216 μm, p = 0.02). The calcium carbonate-containing cement showed better wear performance in terms of gravimetric wear and particle release. Thus, calcium carbonate seems to be a promising material as a radio-opaque substrate in cement spacers.
Collapse
|
11
|
Antibiotic Elution from Hip and Knee Acrylic Bone Cement Spacers: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4657874. [PMID: 28656144 PMCID: PMC5474553 DOI: 10.1155/2017/4657874] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/09/2017] [Indexed: 12/17/2022]
Abstract
Knowledge about the elution from antibiotic-loaded cement spacers is an indispensable premise for guarantee of clinical success. A systematic literature search was performed through PubMed. Search terms were “antibiotic elution” and “antibiotic release” in combination with “spacer,” “hip spacer,” and “knee spacer,” respectively. A total of 11 studies could be identified. Seven studies reported on the release of antibiotics after spacer implantation, three studies at spacer removal, and one study on both time points. Seven studies reported on hip spacers, one study on knee spacers, and three studies on both. In eight studies, custom-made spacers have been implanted and in three prefabricated ones. In the majority of the studies, the cement has been loaded with an antibiotic combination, mostly consisting of aminoglycoside (either gentamicin or tobramycin) and vancomycin. Measured concentrations exceeded the minimal inhibitory concentration of the particular pathogen organisms in each case. However, large discrepancies were observed with regard to the height of the antibiotic concentration depending on the antibiotic combination and the antibiotic ratio used. Current literature data indicate a sufficient elution of antibiotics after spacer implantation and at spacer removal, respectively. Future studies are required to optimize the local antibiotic therapy at the site of spacer implantation.
Collapse
|