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Aboona F, Bou-Akl T, Miller AJ, Fry M, Wu B, Pawlitz P, Ren W, Markel DC. Effects of Vancomycin/Tobramycin-Doped Ceramic Composite (Polyvinyl Alcohol Composite-Vancomycin/Tobramycin-Polymeric Dicalcium Phosphate Dihydrate) in a Rat Femur Model Implanted With Contaminated Porous Titanium Cylinders. J Arthroplasty 2024:S0883-5403(24)00424-8. [PMID: 38718912 DOI: 10.1016/j.arth.2024.04.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) remains common and problematic. We hypothesized that using a bioceramic that provided rapid release of the antibiotics (vancomycin [VAN] or VAN and tobramycin [VAN and TOB]) from a polyvinyl-alcohol-composite (PVA) combined with a delayed and sustained antibiotic release from polymeric-dicalcium-phosphate-dihydrate (PDCPD) ceramic would inhibit S. aureus-associated implant infections. METHODS A total of 50 male Sprague Dawley rats were randomly divided into 5 groups-I: negative control; II: bacteria only; III: bacteria + saline wash; IV: bacteria + PVA-VAN-PDCPD, and V: bacteria + PVA-VAN-TOB-PDCPD. A porous titanium (Ti) implant was press-fit into the rat knee. S. aureus-containing broth was added into the joint space creating a PJI. After 1 week, the joints from groups III to V were washed with saline and the fluid collected for bacterial quantification. This was followed by saline irrigation treatment (groups III to V) and application of the antibiotic-loaded PVA-PDCPD bioceramic (groups IV and V). On day 21, joint fluid was collected, and the implants harvested for bacterial quantification. RESULTS No bacteria were isolated from the negative control (group I). The positive control (group II) was positive on both days 7 and 21. Bacteria were still present on day 21 in the fluid and implant in group III. Groups (IV and V) showed a decrease in the bacterial burden in the fluid and implant on day 21. There were significant differences in bacteria levels in the collected wash fluid and on the implant at day 21 between the saline wash (group III) and treatment groups (IV and V). CONCLUSIONS In this animal model of acute periprosthetic infection, treatment with PVA-VAN-PDCPD and PVA-VAN/TOB-PDCPD reduced bacterial load in the infected joint and the infected Ti implant. Application of PVA-VAN-PDCPD and/or PVA-VAN/TOB-PDCPD after saline irrigation could be used as an addition to the treatment of PJI.
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Affiliation(s)
- Fadi Aboona
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Therese Bou-Akl
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Adam J Miller
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Mike Fry
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Bin Wu
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Paula Pawlitz
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan
| | - Weiping Ren
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan; Virotech Co., Inc., Troy, Michigan
| | - David C Markel
- Section of Orthopaedic Surgery, Ascension-Providence Hospital, Southfield, Michigan; The Core Institute, Novi, Michigan
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Gupta TT, Zumpano B, Opalinski J, Ritchey R, Winter N, Nodzo SR, Canty M. Cathodic voltage-controlled electrical stimulation and betadine decontaminate nosocomial pathogens from implant surfaces. mSphere 2024; 9:e0058323. [PMID: 38299852 PMCID: PMC10900904 DOI: 10.1128/msphere.00583-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/21/2023] [Indexed: 02/02/2024] Open
Abstract
Periprosthetic joint infection (PJI) after total joint arthroplasty is a major concern requiring multiple surgeries and antibiotic interventions. Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli are the predominant causes of these infections. Due to biofilm formation, antibiotic treatment for patients with PJI can prolong resistance, further complicating the use of current treatments. Previous research has shown that cathodic voltage-controlled electrical stimulation (CVCES) is an effective technique to prevent/treat implant-associated biofilm infections on titanium (Ti) surfaces. This study thus evaluated the efficacy of CVCES via the use of 10% betadine alone and in combination with CVCES to eradicate lab-grown biofilms on cemented and cementless cobalt-chromium (CoCr) and Ti surfaces. CVCES treatment alone for 24 hours demonstrated no detectable CFU for E. coli and P. aeruginosa biofilms on cementless CoCr implants. In the presence of cement, E. coli biofilms had 106 CFUs/implant remaining after CVCES treatment alone; however, P. aeruginosa biofilms on cemented implants were reduced to below detectable limits. The use of 10% betadine treatment for 3 minutes followed by 24-hour CVCES treatment brought CFU levels to below detectable limits in E. coli and P. aeruginosa. The same was true for S. aureus biofilms on cementless patellofemoral implants as well as femoral and tibial implants. These treatment methods were not sufficient for eradication of S. aureus biofilms on cemented implants. These results suggest that CVCES alone and CVCES with 10% betadine are effective approaches to treating biofilms formed by certain bacterial species potentially leading to the treatment of PJI.IMPORTANCEPeriprosthetic joint infections (PJIs) are problematic due to requiring multiple surgeries and antibiotic therapies that are responsible for increased patient morbidity and healthcare costs. These infections become resistant to antibiotic treatment due to the formation of biofilms on the orthopedic surfaces. Cathodic voltage-controlled electrical stimulation (CVCES) has previously been shown to be an effective technique to prevent and treat biofilm infections on different surfaces. This study shows that CVCES can increase the efficacy of 10% betadine irrigation used in debridement, antibiotics, and implant retention by 99.9% and clear infection to below detection limits. PJI treatments are at times limited, and CVCES could be a promising technology to improve patient outcomes.
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Affiliation(s)
| | | | | | - Riley Ritchey
- Garwood Medical Devices, LLC, Buffalo, New York, USA
| | - Nathan Winter
- Department of Orthopedics & Sports Medicine, University at Buffalo, Buffalo, New York, USA
| | - Scott R Nodzo
- Department of Orthopedics & Sports Medicine, University at Buffalo, Buffalo, New York, USA
| | - Mary Canty
- Garwood Medical Devices, LLC, Buffalo, New York, USA
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Tong K, Wei J, Liu Z, Yang X, Hu Y. The early infection characterization of septic arthritis by Staphylococcus aureus after anterior cruciate ligament reconstruction in a novel rat model. J Orthop Surg Res 2023; 18:522. [PMID: 37481547 PMCID: PMC10362564 DOI: 10.1186/s13018-023-03969-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/01/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND The present study aimed to explore the time of maximum bacterial load and main colonization knee site in bacterial infection process based on a novel rat model of septic arthritis (SA) after anterior cruciate ligament reconstruction (ACLR). METHODS Ninety-five Wistar rats with unilateral ACLR, random enrolled into control surgery (CS) group; joint inject (JI) group; presoaking (PS) group, were injected with 30 μl sterile saline or 30 μl × 107 colony forming units/ml Staphylococcus aureus via the knee joint or graft with presoaked Staphylococcus aureus during ACLR, respectively. At 1, 4, 7, 11, and 14 days postoperatively, samples were harvested to evaluate progress of knee joint infection by postoperative body weight, body temperature, knee temperature, knee width, scales of tissue damage, serum inflammatory markers, microbiological counting, microcomputed tomography (Micro-CT), digital radiography, magnetic resonance imaging (MRI) examination, and scanning electron microscopy (SEM). RESULTS No systemic infection was observed in all rats. Comparing with serum inflammatory markers, tissue scores of inflammatory reactions, bacterial counts in the CS group, these data were significantly elevated in the JI group and PS group. The bone mass around the bone tunnel was lower and the soft tissue of knee showed more obvious swelling on MRI in the infection groups than that in the CS group at 7 and 14 days postoperatively. Staphylococcus aureus clusters on the surface of screw and graft were observed in the infection group. The whole colony forming units of Staphylococcus aureus maintained a continuous upward trend peaking 7 and 11 days followed by a balanced curve in the infection groups. Bone and soft tissue were found to have more bacterial counts than graft and screws. CONCLUSION This animal model effectively mimics the acute knee infection after ACLR. We found that the bacterial colonization exhibited the peak of acute infection between 7 and 11 days postoperatively, with the major bacteria loads found in the bone, soft tissue.
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Affiliation(s)
- Kai Tong
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Jian Wei
- Department of Joint Orthopedics, Liuzhou People's Hospital, Liuzhou, China
| | - Zilin Liu
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuchang District, Wuhan, 430060, China
| | - Xiaoming Yang
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuchang District, Wuhan, 430060, China.
| | - Yong Hu
- Department of Orthopedics, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuchang District, Wuhan, 430060, China.
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Sabater-Martos M, Verdejo MA, Morata L, Muñoz-Mahamud E, Guerra-Farfan E, Martinez-Pastor JC, Soriano A. Antimicrobials in polymethylmethacrylate: from prevention to prosthetic joint infection treatment: basic principles and risk of resistance. ARTHROPLASTY 2023; 5:12. [PMID: 36864538 PMCID: PMC9983184 DOI: 10.1186/s42836-023-00166-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/16/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Excellent revisions about antibiotic-loaded bone cement (ALBC) have been recently published. In the present article, we review the principles and limitations of local antibiotic delivery in the context of recent advances in the pathogenesis of prosthetic joint infections (PJI), with particular attention paid to the potential association between ALBC and antimicrobial resistance. MAIN BODY Recalcitrance of PJI is related to the ability of pathogens to adapt to particular environments present in bone tissue and protect themselves from host immunity in different ways. Accordingly, delivery of high local antimicrobial concentrations using ALBC is needed. Most relevant clinical data showing the efficacy of ALBC for PJI prophylaxis and treatment are reviewed, and we dissected the limitations on the basis of the recent findings from animal models and suggested that aminoglycosides, in particular, could not be the best option. One of the major concerns associated with ALBC is the emergence of resistance because of theoretical prolonged exposure to low antibiotic concentrations. We summarize the mechanisms for the selection of resistant microorganisms, and we critically reviewed the evidence from animal models and clinical data from observational and registry studies and concluded that there is no evidence to support this association. CONCLUSION While waiting for better evidence from well-designed clinical trials, ALBC shows a beneficial effect as a prophylaxis in arthroplasty, and to avoid the colonization of spacers used for two-stage revision in patients with PJI. Experimental models and clinical evidence suggest the need to achieve high local antimicrobial concentrations to obtain the highest prophylactic and therapeutic effect. The current evidence does not support the risk of increasing resistance with use of ALBC. In the future, it is necessary to evaluate new carriers and different antimicrobials to improve clinical outcomes.
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Affiliation(s)
- Marta Sabater-Martos
- Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain.
| | - Miguel A. Verdejo
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Laura Morata
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Muñoz-Mahamud
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Guerra-Farfan
- grid.411083.f0000 0001 0675 8654Department of Orthopedics and Traumatology, Hospital Vall d’Hebron of Barcelona, Passeig de la Vall d’Hebron 119, 08035 Barcelona, Spain
| | - Juan C. Martinez-Pastor
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain. .,University of Barcelona, CIBERINF, Carrer Casanova 143, 08036, Barcelona, Spain.
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Hipfl C, Karczewski D, Oronowicz J, Pumberger M, Perka C, Hardt S. Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement. Arch Orthop Trauma Surg 2023; 143:19-28. [PMID: 34097122 PMCID: PMC9886611 DOI: 10.1007/s00402-021-03981-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/26/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The optimal treatment of patients with a degenerative joint disease secondary to an active or chronic septic arthritis of the hip is unclear. The aim of the present study was to report on our experience with two-stage total hip arthroplasty (THA) using a contemporary treatment protocol without spacer insertion. MATERIALS AND METHODS Our prospective institutional database was used to identify all patients with degenerative septic arthritis treated with a non-spacer two-stage protocol between 2011 and 2017. Clinical outcomes included interim revision, periprosthetic infection (PJI) and aseptic revision rates. Restoration of leg-length and offset were assessed radiographically. Modified Harris hip score (mHHS) were obtained. Treatment success was defined using the modified Delphi consensus criteria. Mean follow-up was 62 months (13-110). RESULTS A total of 33 patients with a mean age of 60 years (13-85) were included. 55% of the cohort was male and average Charlson Comorbidity Index (CCI) was 3.7 (0-12). 21 patients (64%) had an active/acute infection and 12 patients (36%) were treated for chronic/quiescent septic arthritis. Overall, 11 patients (33%) had treatment failure, including 5 patients who failed to undergo THA, 2 interim re-debridement for persistent infection, and 4 patients who developed PJI after an average of 7 months (0.3-13) following THA. The most common identified pathogen was Staphylococcus aureus (42.4%). No aseptic revision was recorded following THA. Leg-length and offset were successfully restored. Mean mHHS improved from 35.2 points to 73.4 points. CONCLUSION Two-stage THA without spacer placement is a viable treatment option for destructive septic arthritis of the hip, demonstrating comparable rates of infection control and functional outcome. However, definitive resection arthroplasty is not uncommon in these often critically ill patients.
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Affiliation(s)
- Christian Hipfl
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Daniel Karczewski
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jakub Oronowicz
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Matthias Pumberger
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Carsten Perka
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Sebastian Hardt
- grid.6363.00000 0001 2218 4662Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Tseng TH, Chang CH, Chen CL, Chiang H, Hsieh HY, Wang JH, Young TH. A simple method to improve the antibiotic elution profiles from polymethylmethacrylate bone cement spacers by using rapid absorbable sutures. BMC Musculoskelet Disord 2022; 23:916. [PMID: 36242041 PMCID: PMC9563514 DOI: 10.1186/s12891-022-05870-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Antibiotic-loaded bone cement beads and spacers have been widely used for orthopaedic infection. Poor antibiotic elution is not capable of eradicating microbial pathogens and could lead to treatment failure. The elution profiles differ among different cement formulations. Although Simplex P cement has the least release amount, it is widely used due to its ready availability. Previous methods aiming to improve the elution profiles were not translated well to clinical practice. We sought to address this by using easily available materials to improve the elution profile of antibiotics from PMMA, which allows clinicians to implement the method intraoperatively. METHODS Vancomycin was mixed with Simplex P cement. We used Vicryl Rapide sutures to fabricate sustained-release cement beads by repetitively passing the sutures through the beads and/or mixing suture segments into the cement formulation. Vancomycin elution was measured for 49 days. The mechanism of antibiotic release was observed with gross appearance and scanning electron microscopic images. The antimicrobial activities against MRSA were tested using an agar disk diffusion bioassay. RESULTS Passing Vicryl Rapide sutures through cement beads significantly improved the elution profiles in the 7-week period. The increased ratios were 9.0% on the first day and 118.0% from the 2nd day to the 49th day. Addition of suture segments did not increase release amount. The Vicryl Rapide sutures completely degraded at the periphery and partially degraded at the center. The antibiotic particles were released around the suture, while antibiotic particles kept densely entrapped in the control group. The antimicrobial activities were stronger in passing suture groups. CONCLUSION Passing fast absorbable sutures through PMMA cement is a feasible method to fabricate sustained-release antibiotic bone cement. Intra-cement tunnels can be formed, and the effect can last for at least 7 weeks. It is suitable for a temporary spacer between two stages of a revision surgery.
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Affiliation(s)
- Tzu-Hao Tseng
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan.,Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan
| | - Chih-Hao Chang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan.,Department of Orthopaedic Surgery, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
| | - Chien-Lin Chen
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan
| | - Hongsen Chiang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan.,Department of Biomedical Engineering, National Taiwan University Hospital, Taipei City, Taiwan
| | - Hao-Ying Hsieh
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan
| | - Jyh-Horng Wang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, 7 Chungsan South Road, 10002, Taipei, Taiwan.
| | - Tai-Horng Young
- Department of Biomedical Engineering, National Taiwan University, No.1 Jen Ai road section 1, 10002, Taipei, Taiwan.
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Li J, Cheung WH, Chow SK, Ip M, Leung SYS, Wong RMY. Current therapeutic interventions combating biofilm-related infections in orthopaedics : a systematic review of in vivo animal studies. Bone Joint Res 2022; 11:700-714. [PMID: 36214177 PMCID: PMC9582863 DOI: 10.1302/2046-3758.1110.bjr-2021-0495.r3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims Biofilm-related infection is a major complication that occurs in orthopaedic surgery. Various treatments are available but efficacy to eradicate infections varies significantly. A systematic review was performed to evaluate therapeutic interventions combating biofilm-related infections on in vivo animal models. Methods Literature research was performed on PubMed and Embase databases. Keywords used for search criteria were “bone AND biofilm”. Information on the species of the animal model, bacterial strain, evaluation of biofilm and bone infection, complications, key findings on observations, prevention, and treatment of biofilm were extracted. Results A total of 43 studies were included. Animal models used included fracture-related infections (ten studies), periprosthetic joint infections (five studies), spinal infections (three studies), other implant-associated infections, and osteomyelitis. The most common bacteria were Staphylococcus species. Biofilm was most often observed with scanning electron microscopy. The natural history of biofilm revealed that the process of bacteria attachment, proliferation, maturation, and dispersal would take 14 days. For systemic mono-antibiotic therapy, only two of six studies using vancomycin reported significant biofilm reduction, and none reported eradication. Ten studies showed that combined systemic and topical antibiotics are needed to achieve higher biofilm reduction or eradication, and the effect is decreased with delayed treatment. Overall, 13 studies showed promising therapeutic potential with surface coating and antibiotic loading techniques. Conclusion Combined topical and systemic application of antimicrobial agents effectively reduces biofilm at early stages. Future studies with sustained release of antimicrobial and biofilm-dispersing agents tailored to specific pathogens are warranted to achieve biofilm eradication. Cite this article: Bone Joint Res 2022;11(10):700–714.
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Affiliation(s)
- Jie Li
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing-Hoi Cheung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Simon K. Chow
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Margaret Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong, China
| | - Sharon Y. S. Leung
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China
| | - Ronald M. Y. Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China, Ronald Man Yeung Wong. E-mail:
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Melicherčík P, Kotaška K, Jahoda D, Landor I, Čeřovský V. Antimicrobial peptide in polymethylmethacrylate bone cement as a prophylaxis of infectious complications in orthopedics-an experiment in a murine model. Folia Microbiol (Praha) 2022; 67:785-791. [PMID: 35612699 DOI: 10.1007/s12223-022-00979-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/18/2022] [Indexed: 12/29/2022]
Abstract
Polymethylmethacrylate (PMMA) bone cement mixed with antibiotics is used in orthopedic surgery to cope with implant-related infections which are typically associated with the formation of bacterial biofilms. Taking into account the growing bacterial resistance to current antibiotics, we examined here the efficacy of a selected antimicrobial peptide (AMP) mixed into the bone cement to inhibit bacterial adhesion and the consequent biofilm formation on its surface. In particular, we followed the formation of bacterial biofilms of methicillin-resistant Staphylococcus aureus (MRSA) on implants made from PMMA bone cement loaded with AMP composed of 12 amino acid residues. This was evaluated by CFU counting of bacteria released by sonication from the biofilms formed on their surfaces after these implants were retrieved from the infected murine femoral canals. The AMP loaded in these model implants prevented adhesion of MRSA and the subsequent formation of MRSA biofilm on the surfaces of more than 80% of these implants, whereas biofilms did form on control implants made from the plain cement. The results of our experiments performed in the murine femoral canal indicate the potential for this murine osteomyelitis model to mimic actual operations in orthopedics.
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Affiliation(s)
- Pavel Melicherčík
- Department of Orthopaedics, First Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Karel Kotaška
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - David Jahoda
- Department of Orthopaedics, First Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Ivan Landor
- Department of Orthopaedics, First Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, Prague 5, 150 06, Czech Republic
| | - Václav Čeřovský
- Institute of Organic Chemistry and Biochemistry of the Czech Academy of Sciences, Flemingovo nám. 2, Prague 6, 166 10, Czech Republic.
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9
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Levack AE, Turajane K, Driscoll DA, Yang X, Miller AO, Bostrom MP, Wellman DS, Carli AV. Identifying alternative antibiotics that elute from calcium sulfate beads for treatment of orthopedic infections. J Orthop Res 2022; 40:1143-1153. [PMID: 34191350 PMCID: PMC8716667 DOI: 10.1002/jor.25135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/17/2021] [Accepted: 06/25/2021] [Indexed: 02/04/2023]
Abstract
There has been increasing interest in the use of a synthetic absorbable calcium sulfate (CaSO4 ) for local antibiotic delivery in orthopaedic infections. The purpose of this study was to quantify elution kinetics of six antibiotics (amikacin, meropenem, fosfomycin, minocycline, cefazolin, and dalbavancin) from a clinically relevant CaSO4 bead model and compare elution and antimicrobial activity to the current clinical gold standards: vancomycin and tobramycin. Antibiotic-loaded synthetic CaSO4 beads were immersed in phosphate buffered saline and incubated at 37°C. Eluent was harvested at eight time points over 28 days. Antibiotic concentrations were measured by high performance liquid chromatography to quantify elution rates. CaSO4 beads demonstrated burst release kinetics. Dalbavancin, cefazolin, and minocycline all demonstrated similar elution profiles to vancomycin. Amikacin and meropenem demonstrated favorable elution profiles and durations of above-minimum inhibitory concentration when compared to tobramycin. Clinical Significance: This study provides important novel data regarding the utility of amikacin, meropenem and dalbavancin as alternative choices to place in CaSO4 carriers when treating orthopaedic infections.
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Affiliation(s)
- Ashley E. Levack
- Orthopaedic Trauma Service, Hospital for Special Surgery; New York, NY, USA,Loyola University Medical Center, Maywood, IL, USA
| | - Kathleen Turajane
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA
| | - Daniel A. Driscoll
- Orthopaedic Trauma Service, Hospital for Special Surgery; New York, NY, USA
| | - Xu Yang
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA
| | - Andy O. Miller
- Infectious Diseases, Hospital for Special Surgery; New York, NY, USA
| | - Mathias P. Bostrom
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA,Adult Reconstruction, Hospital for Special Surgery; New York, NY, USA
| | - David S. Wellman
- Orthopaedic Trauma Service, Hospital for Special Surgery; New York, NY, USA,Westchester Medical Center, Valhalla NY, USA
| | - Alberto V. Carli
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA,Adult Reconstruction, Hospital for Special Surgery; New York, NY, USA
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10
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Sokhi UK, Xia Y, Sosa B, Turajane K, Nishtala SN, Pannellini T, Bostrom MP, Carli AV, Yang X, Ivashkiv LB. Immune Response to Persistent Staphyloccocus Aureus Periprosthetic Joint Infection in a Mouse Tibial Implant Model. J Bone Miner Res 2022; 37:577-594. [PMID: 34897801 PMCID: PMC8940655 DOI: 10.1002/jbmr.4489] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 12/27/2022]
Abstract
Staphyloccocus aureus is one of the major pathogens in orthopedic periprosthetic joint infection (PJI), a devastating complication of total joint arthroplasty that often results in chronic and persistent infections that are refractory to antibiotics and require surgical interventions. Biofilm formation has been extensively investigated as a reason for persistent infection. The cellular composition, activation status, cytokine profile, and role of the immune response during persistent S. aureus PJI are incompletely understood. In this study, we used histology, multiparametric flow cytometry, and gene expression analysis to characterize the immune response in a clinically relevant orthopedic PJI model. We tested the hypothesis that persistent S. aureus infection induces feedback mechanisms that suppress immune cell activation, thereby affecting the course of infection. Surprisingly, persistent infection was characterized by strikingly high cytokine gene expression indicative of robust activation of multiple components of innate and adaptive immunity, along with ongoing severe neutrophil-dominated inflammation, in infected joint and bone tissues. Activation and expansion of draining lymph nodes and a bone marrow stress granulopoiesis reaction were also maintained during late phase infection. In parallel, feedback mechanisms involving T-cell inhibitory receptors and exhaustion markers, suppressive cytokines, and regulatory T cells were activated and associated with decreased T-cell proliferation and tissue infiltration during the persistent phase of infection. These results identify the cellular and molecular components of the mouse immune response to persistent S. aureus PJI and indicate that neutrophil infiltration, inflammatory cytokine responses, and ongoing lymph node and bone marrow reactions are insufficient to clear infection and that immune effector mechanisms are suppressed by feedback inhibitory pathways. These immune-suppressive mechanisms are associated with diminished T-cell proliferation and tissue infiltration and can be targeted as part of adjuvant immunotherapeutic strategies in combination with debridement of biofilm, antibiotics, and other therapeutic modalities to promote eradication of infection. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Upneet K Sokhi
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY, USA
| | - Yunwei Xia
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY, USA
| | - Branden Sosa
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,Arthroplasty Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Kathleen Turajane
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,Arthroplasty Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Sita N Nishtala
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,Arthroplasty Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Tania Pannellini
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,Department of Pathology, Hospital for Special Surgery, New York, NY, USA
| | - Mathias P Bostrom
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,Arthroplasty Research Laboratory, Hospital for Special Surgery, New York, NY, USA.,Department of Orthopaedics, Weill Cornell Medicine, New York, NY, USA
| | - Alberto V Carli
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,Arthroplasty Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Xu Yang
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,Arthroplasty Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Lionel B Ivashkiv
- Research Institute, Hospital for Special Surgery, New York, NY, USA.,David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY, USA.,Department of Medicine, Weill Cornell Medicine, New York, NY, USA.,Immunology and Microbial Pathogenesis Program, Weill Cornell Medicine, New York, NY, USA
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11
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Tong K, Wei J, Li Z, Wang H, Wen Y, Chen L. Evaluation of the Efficacy of Vancomycin-Soaked Autograft to Eliminate Staphylococcus aureus Contamination After Anterior Cruciate Ligament Reconstruction: Based on an Infected Rat Model. Am J Sports Med 2022; 50:932-942. [PMID: 35099312 DOI: 10.1177/03635465211068114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vancomycin-soaked autograft application in anterior cruciate ligament reconstruction (ACLR) significantly reduces postoperative infection rates. However, the optimal vancomycin concentrations and time of vancomycin presoaking of autografts for preventing infection are still unknown. PURPOSE To evaluate the efficacy of vancomycin-soaked autografts in preventing infection in rats with ACLR. STUDY DESIGN Controlled laboratory study. METHODS A total of 102 tendons of Wistar rats were harvested under sterile conditions from fresh cadaveric legs. Contamination with 2.0 × 104 colony forming units per milliliter of Staphylococcus aureus and soaking in different vancomycin concentrations for different soaking times was performed in vitro. In vivo, after being contaminated with S. aureus and soaked with optimal vancomycin solution treatment and sterile saline, the grafts were implanted in rat knees to finish ACLR surgery. At 2, 4, and 12 weeks after surgery, samples were harvested to observe signs of infection and tendon-bone incorporation via general postoperative conditions, serum inflammatory markers, microbiological counting, knee radiographs, micro-computed tomography, histologic staining, scanning electron microscopy, and biomechanical testing. RESULTS Bacterial contamination was eliminated when at least 5 or 10 mg/mL of vancomycin was applied for 30 minutes in vitro. Rats in the vancomycin-soaked graft group (5 mg/mL of vancomycin for 30 minutes) showed no significant signs of infection and fewer positive cultures than did those without presoaking. The vancomycin-soaked graft group had reduced serum inflammatory markers, tissue scores, inflammatory reactions in the joint tissue, and radiographic evidence of periarticular osseous destruction compared with the control group. At postoperative week 12, the vancomycin-soaked graft group showed good outcomes in tendon-bone incorporation via micro-computed tomography, histologic staining, and biomechanical testing. CONCLUSION In a rat model of infection after ACLR, presoaking grafts in a 5-mg/mL vancomycin solution for 30 minutes could effectively prevent S. aureus contamination without affecting tendon-bone incorporation and knee function. CLINICAL RELEVANCE The present study could provide a specific solution for the use of vancomycin in the prevention of infection after ACLR clinically.
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Affiliation(s)
- Kai Tong
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center Wuhan University, Wuhan University, Wuhan, China
| | - Jian Wei
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center Wuhan University, Wuhan University, Wuhan, China
| | - Zhenyu Li
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center Wuhan University, Wuhan University, Wuhan, China
| | - Hui Wang
- Department of Pharmacology, Department of Basic Medicine, Wuhan University, Wuhan, China
| | - Yinxian Wen
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center Wuhan University, Wuhan University, Wuhan, China
| | - Liaobin Chen
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China.,Joint Disease Research Center Wuhan University, Wuhan University, Wuhan, China
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12
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One-Stage Hip Revision Arthroplasty Using Megaprosthesis in Severe Bone Loss of The Proximal Femur Due to Radiological Diffuse Osteomyelitis. Trop Med Infect Dis 2021; 7:tropicalmed7010005. [PMID: 35051121 PMCID: PMC8780561 DOI: 10.3390/tropicalmed7010005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/23/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022] Open
Abstract
Managing substantial proximal and/or distal femoral bone defects is one of the biggest challenges in chronic hip periprosthetic joint infection. Most authors use two-stage arthroplasty with a temporary antibiotic-loaded cement spacer for the management of these patients. In this study, we show our experience with one-stage exchange arthroplasty in managing severe bone defects due to radiological-extensive proximal femoral osteomyelitis. Two patients were included in the study. They showed radiological-extensive proximal femoral osteomyelitis, and they were treated with one-stage exchange arthroplasty using megaprosthesis. Diffuse osteomyelitis was confirmed in both cases; in one case, the histology was compatible with osteomyelitis, and the other case had a positive culture identified in a bone sample. At a minimum of a four-year follow-up, the patients did not reveal any clinical, radiological or laboratory signs of infection. In conclusion, one-stage exchange arthroplasty and megaprosthesis is an option for the treatment of chronic hip periprosthetic joint infection associated with radiological-diffuse proximal femoral osteomyelitis.
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13
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Extended Trochanteric Osteotomy with Intermediate Resection Arthroplasty Is Safe for Use in Two-Stage Revision Total Hip Arthroplasty for Infection. J Clin Med 2021; 11:jcm11010036. [PMID: 35011776 PMCID: PMC8745126 DOI: 10.3390/jcm11010036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 12/03/2022] Open
Abstract
Background: This study sought to compare the results of two-stage revision total hip arthroplasty (THA) for periprosthetic infection (PJI) in patients with and without the use of an extended trochanteric osteotomy (ETO) for removal of a well-fixed femoral stem or cement. Methods: Thirty-two patients who had undergone an ETO as part of a two-stage revision without spacer placement were matched 1:2 with a cohort of sixty-four patients of the same sex and age who had stem removal without any osteotomy. Clinical outcomes including interim revision, reinfection and aseptic failure rates were evaluated. Modified Harris hip scores (mHHS) were calculated. Minimum follow-up was two years. Results: Patients undergoing ETO had a significantly lower rate of interim re-debridement compared to non-ETO patients (0% vs. 14.1%, p = 0.026). Reinfection following reimplantation was similar in both groups (12.5% in ETO patients vs. 9.4% in non-ETO patients, p = 0.365). Revision for aseptic reason was necessary in 12.5% in the ETO group and 14.1% in the non-ETO group (p = 0.833). Periprosthetic femoral fractures were seen in three patients (3.1%), of which all occurred in non-ETO patients. Dislocation was the most common complication, which was equally distributed in both groups (12.5%). The mean mHHS was 37.7 in the ETO group and 37.3 in the non-ETO group, and these scores improved significantly in both groups following reimplantation (p < 0.01). Conclusion: ETO without the use of spacer is a safe and effective method to manage patients with well-fixed femoral stems and for thorough cement removal in two-stage revision THA for PJI. While it might reduce the rate of repeated debridement in the interim period, the use of ETO appears to lead to similar reinfection rates following reimplantation.
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14
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Cyphert EL, Zhang N, Learn GD, Hernandez CJ, von Recum HA. Recent Advances in the Evaluation of Antimicrobial Materials for Resolution of Orthopedic Implant-Associated Infections In Vivo. ACS Infect Dis 2021; 7:3125-3160. [PMID: 34761915 DOI: 10.1021/acsinfecdis.1c00465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
While orthopedic implant-associated infections are rare, revision surgeries resulting from infections incur considerable healthcare costs and represent a substantial research area clinically, in academia, and in industry. In recent years, there have been numerous advances in the development of antimicrobial strategies for the prevention and treatment of orthopedic implant-associated infections which offer promise to improve the limitations of existing delivery systems through local and controlled release of antimicrobial agents. Prior to translation to in vivo orthopedic implant-associated infection models, the properties (e.g., degradation, antimicrobial activity, biocompatibility) of the antimicrobial materials can be evaluated in subcutaneous implant in vivo models. The antimicrobial materials are then incorporated into in vivo implant models to evaluate the efficacy of using the material to prevent or treat implant-associated infections. Recent technological advances such as 3D-printing, bacterial genomic sequencing, and real-time in vivo imaging of infection and inflammation have contributed to the development of preclinical implant-associated infection models that more effectively recapitulate the clinical presentation of infections and improve the evaluation of antimicrobial materials. This Review highlights the advantages and limitations of antimicrobial materials used in conjunction with orthopedic implants for the prevention and treatment of orthopedic implant-associated infections and discusses how these materials are evaluated in preclinical in vivo models. This analysis serves as a resource for biomaterial researchers in the selection of an appropriate orthopedic implant-associated infection preclinical model to evaluate novel antimicrobial materials.
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Affiliation(s)
- Erika L. Cyphert
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Ningjing Zhang
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Greg D. Learn
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Christopher J. Hernandez
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York 14853, United States
- Hospital for Special Surgery, New York, New York 10021, United States
| | - Horst A. von Recum
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
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15
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Gunn NJ, Zelmer AR, Kidd SP, Solomon LB, Roscioli E, Yang D, Atkins GJ. A Human Osteocyte Cell Line Model for Studying Staphylococcus aureus Persistence in Osteomyelitis. Front Cell Infect Microbiol 2021; 11:781022. [PMID: 34805001 PMCID: PMC8597899 DOI: 10.3389/fcimb.2021.781022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022] Open
Abstract
Infectious osteomyelitis associated with periprosthetic joint infections is often recalcitrant to treatment and has a high rate of recurrence. In the case of Staphylococcus aureus, the most common pathogen in all forms of osteomyelitis, this may be attributed in part to residual intracellular infection of host cells, yet this is not generally considered in the treatment strategy. Osteocytes represent a unique cell type in this context due to their abundance, their formation of a syncytium throughout the bone that could facilitate bacterial spread and their relative inaccessibility to professional immune cells. As such, there is potential value in studying the host-pathogen interactions in the context of this cell type in a replicable and scalable in vitro model. Here, we examined the utility of the human osteosarcoma cell line SaOS2 differentiated to an osteocyte-like stage (SaOS2-OY) as an intracellular infection model for S. aureus. We demonstrate that S. aureus is capable of generating stable intracellular infections in SaOS2-OY cells but not in undifferentiated, osteoblast-like SaOS2 cells (SaOS2-OB). In SaOS2-OY cells, S. aureus transitioned towards a quasi-dormant small colony variant (SCV) growth phenotype over a 15-day post-infection period. The infected cells exhibited changes in the expression of key immunomodulatory mediators that are consistent with the infection response of primary osteocytes. Thus, SaOS2-OY is an appropriate cell line model that may be predictive of the interactions between S. aureus and human osteocytes, and this will be useful for studying mechanisms of persistence and for testing the efficacy of potential antimicrobial strategies.
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Affiliation(s)
- Nicholas J Gunn
- Centre for Orthopaedic & Trauma Research, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Anja R Zelmer
- Centre for Orthopaedic & Trauma Research, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Stephen P Kidd
- Australian Centre for Antimicrobial Resistance Ecology, University of Adelaide, Adelaide, SA, Australia.,Research Centre for Infectious Disease, School of Biological Science, University of Adelaide, Adelaide, SA, Australia
| | - Lucian B Solomon
- Centre for Orthopaedic & Trauma Research, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Eugene Roscioli
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Department of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Dongqing Yang
- Centre for Orthopaedic & Trauma Research, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Gerald J Atkins
- Centre for Orthopaedic & Trauma Research, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
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16
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Liu J, Kang H, Lu J, Dai Y, Wang F. Experimental study of the effects of hypoxia simulator on osteointegration of titanium prosthesis in osteoporotic rats. BMC Musculoskelet Disord 2021; 22:944. [PMID: 34763682 PMCID: PMC8588664 DOI: 10.1186/s12891-021-04777-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 10/06/2021] [Indexed: 12/27/2022] Open
Abstract
Background Poor osseointegration is the key reason for implant failure after arthroplasty,whether under osteoporotic or normal bone conditions. To date, osseointegration remains a major challenge. Recent studies have shown that deferoxamine (DFO) can accelerate osteogenesis by activating the hypoxia signaling pathway. The purpose of this study was to test the following hypothesis: after knee replacement, intra-articular injection of DFO will promote osteogenesis and osseointegration with a 3D printed titanium prosthesis in the bones of osteoporotic rats. Materials and methods Ninety female Sprague–Dawley rats were used for the experiment. Ten rats were used to confirm the successful establishment of the osteoporosis model: five rats in the sham operation group and five rats in the ovariectomy group. After ovariectomy and knee arthroplasty were performed, the remaining 80 rats were randomly divided into DFO and control groups (n = 40 per group). The two groups were treated by intraarticular injection of DFO and saline respectively. After 2 weeks, polymerase chain reaction (PCR) and immunohistochemistry were used to evaluate the levels of HIF-1a, VEGF, and CD31. HIF-1a and VEGF have been shown to promote angiogenesis and bone regeneration, and CD31 is an important marker of angiogenesis. After 12 weeks, the specimens were examined by micro-computed tomography (micro-CT), biomechanics, and histopathology to evaluate osteogenesis and osseointegration. Results The results of PCR showed that the mRNA levels of VEGF and CD31 in the DFO group were significantly higher than those in the control group. The immunohistochemistry results indicated that positive cell expression of HIF-1a, VEGF, and CD31 in the DFO group was also higher. Compared with the control group, the micro-CT parameters of BMD, BV/TV, TB. N, and TB. Th were significantly higher. The maximal pull-out force and the bone-to-implant contact value were also higher. Conclusions The local administration of DFO, which is used to activate the HIF-1a signaling pathway, can promote osteogenesis and osseointegration with a prosthesis in osteoporotic bone.
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Affiliation(s)
- Jiangfeng Liu
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Huijun Kang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Jiangfeng Lu
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Yike Dai
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China
| | - Fei Wang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Ziqiang Road 139, Shijiazhuang, 050051, China.
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17
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Lin TL, Tsai CH, Fong YC, Shie MY, Chen HY, Chen YW. Cruciate-Retaining vs Posterior-Stabilized Antibiotic Cement Articulating Spacers for Two-Stage Revision of Prosthetic Knee Infection: A Retrospective Cohort Study. J Arthroplasty 2021; 36:3750-3759.e2. [PMID: 34284935 DOI: 10.1016/j.arth.2021.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/17/2021] [Accepted: 06/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Antibiotic cement articulating spacers are recommended during 2-stage revision for prosthetic knee infection because of increased range of motion (ROM) and improved function; however, spacer mechanical complications have been reported. We aimed to determine the association between different constraints of articulating spacers and the rate of complications and infection eradication, functional outcomes, and ROM. METHODS A retrospective study of prosthetic knee infection using cruciate-retaining (CR) or posterior-stabilized (PS) spacers was conducted between 2011 and 2018. The rate of spacer mechanical complications, infection eradication after reimplantation and reoperation, Hospital of Special Surgery (HSS) knee score, and ROM during the interim stage were analyzed. All patients were regularly followed up for 2 years. RESULTS One hundred forty-one patients were included, with 66 CR and 75 PS spacers. Overall mechanical complication rate was lower in PS (9.3%) than in CR spacers (45.5%) (P < .001), especially in joint dislocation (1.3% vs 30.3%, respectively, P < .001). Overall reoperation rate was lower in PS (16.0%) than in CR spacers (36.4%) (P < .001), especially for mechanical complications (1.3% vs 24.2%, respectively, P < .001). HSS knee score was higher in PS (72.3) than in CR spacers (63.8) (P < .001). ROM was greater in PS (90.3°) than in CR spacers (80.6°) (P = .005), especially at maximum flexion (102.4° vs 89.6°, respectively, P = .003). Infection eradication was comparable between the spacers. CONCLUSION Both spacers can control infection; however, PS spacers had a lower rate of mechanical complications and reoperation, better HSS knee scores, and greater ROM than CR spacers.
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Affiliation(s)
- Tsung-Li Lin
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan
| | - Yi-Chin Fong
- Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan; Department of Sports Medicine, College of Health Care, China Medical University, Taichung, Taiwan; Department of Orthopedics, China Medical University Beigang Hospital, Yunlin, Taiwan
| | - Ming-You Shie
- X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; School of Dentistry, China Medical University, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
| | - Hui-Yi Chen
- Department of Radiology, China Medical University Hospital, Taichung, Taiwan
| | - Yi-Wen Chen
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan; X-Dimension Center for Medical Research and Translation, China Medical University Hospital, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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18
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Levack AE, Turajane K, Yang X, Miller AO, Carli AV, Bostrom MP, Wellman DS. Thermal Stability and in Vitro Elution Kinetics of Alternative Antibiotics in Polymethylmethacrylate (PMMA) Bone Cement. J Bone Joint Surg Am 2021; 103:1694-1704. [PMID: 33857030 DOI: 10.2106/jbjs.20.00011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Amikacin, meropenem, minocycline, and fosfomycin have potential clinical utility for orthopaedic infections; however, their suitability for use in polymethylmethacrylate (PMMA) is poorly understood. The purpose of this study was (1) to quantify the thermal stability of these antibiotics at clinically relevant temperatures and (2) to determine the elution pharmacodynamics of these alternative antibiotics in vitro from PMMA beads of different sizes. METHODS Polymerization temperatures of 10-mm PMMA beads were measured over time to generate a simulated heating curve. Aqueous solutions of tobramycin, amikacin, meropenem, minocycline, and fosfomycin were subjected to the temperature curves, followed by incubation at 37°C. Minimum inhibitory concentrations of each antibiotic were evaluated against Staphylococcus aureus, Escherichia coli, and Acinetobacter baumannii. High-dose 4.5-mm, 6-mm, and 10-mm antibiotic-laden PMMA beads (10% antibiotic by weight) were submerged individually in a phosphate-buffered saline solution and incubated at 37°C. Antibiotic elution was determined with use of high-performance liquid chromatography with mass spectrometry. RESULTS Tobramycin, amikacin, and fosfomycin demonstrated thermal stability and maintained antimicrobial activity for 28 days. Minocycline and meropenem lost antimicrobial activity against all 3 organisms after 48 hours and 7 days, respectively. Elution concentrations, rates, and cumulative drug mass for tobramycin, amikacin, and meropenem were orders of magnitude higher than minocycline and fosfomycin at each time point. CONCLUSIONS This study identified notable differences in thermal stability and elution among antibiotics used to treat infections. Amikacin exhibited activity similarly to tobramycin. Meropenem demonstrated favorable elution kinetics and thermal stability in the initial 7-day period. CLINICAL RELEVANCE Amikacin and meropenem show pharmacologic promise as potential acceptable alternatives for local delivery in PMMA for treatment of orthopaedic infections. Further work to establish clinical relevance and utility is needed.
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Affiliation(s)
- Ashley E Levack
- Orthopaedic Trauma Service (A.E.L. and D.S.W.), Musculoskeletal Integrity Program (K.T., X.Y, A.V.C., and M.P.B.), Infectious Diseases (A.O.M.), and Adult Reconstruction (A.V.C. and M.P.B.), Hospital for Special Surgery, New York, NY.,Loyola University Medical Center, Maywood, Illinois
| | - Kathleen Turajane
- Orthopaedic Trauma Service (A.E.L. and D.S.W.), Musculoskeletal Integrity Program (K.T., X.Y, A.V.C., and M.P.B.), Infectious Diseases (A.O.M.), and Adult Reconstruction (A.V.C. and M.P.B.), Hospital for Special Surgery, New York, NY
| | - Xu Yang
- Orthopaedic Trauma Service (A.E.L. and D.S.W.), Musculoskeletal Integrity Program (K.T., X.Y, A.V.C., and M.P.B.), Infectious Diseases (A.O.M.), and Adult Reconstruction (A.V.C. and M.P.B.), Hospital for Special Surgery, New York, NY
| | - Andy O Miller
- Orthopaedic Trauma Service (A.E.L. and D.S.W.), Musculoskeletal Integrity Program (K.T., X.Y, A.V.C., and M.P.B.), Infectious Diseases (A.O.M.), and Adult Reconstruction (A.V.C. and M.P.B.), Hospital for Special Surgery, New York, NY
| | - Alberto V Carli
- Orthopaedic Trauma Service (A.E.L. and D.S.W.), Musculoskeletal Integrity Program (K.T., X.Y, A.V.C., and M.P.B.), Infectious Diseases (A.O.M.), and Adult Reconstruction (A.V.C. and M.P.B.), Hospital for Special Surgery, New York, NY
| | - Mathias P Bostrom
- Orthopaedic Trauma Service (A.E.L. and D.S.W.), Musculoskeletal Integrity Program (K.T., X.Y, A.V.C., and M.P.B.), Infectious Diseases (A.O.M.), and Adult Reconstruction (A.V.C. and M.P.B.), Hospital for Special Surgery, New York, NY
| | - David S Wellman
- Orthopaedic Trauma Service (A.E.L. and D.S.W.), Musculoskeletal Integrity Program (K.T., X.Y, A.V.C., and M.P.B.), Infectious Diseases (A.O.M.), and Adult Reconstruction (A.V.C. and M.P.B.), Hospital for Special Surgery, New York, NY.,Westchester Medical Center, Valhalla, New York
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19
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Hipfl C, Carganico T, Leopold V, Perka C, Müller M, Hardt S. Two-Stage Revision Total Hip Arthroplasty Without Spacer Placement: A Viable Option to Manage Infection in Patients With Severe Bone Loss or Abductor Deficiency. J Arthroplasty 2021; 36:2575-2585. [PMID: 33750632 DOI: 10.1016/j.arth.2021.02.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/06/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND High rates of spacer-related complications in two-stage exchange total hip arthroplasty (THA) have been reported. Patients with advanced bone defects and abductor deficiency may benefit from a nonspacer two-stage revision. This study reports on the clinical course of a contemporary two-stage exchange for periprosthetic hip infection without spacer insertion. METHODS We reviewed 141 infected THAs with extensive bone loss or abductor damage who underwent two-stage exchange without spacer placement. The mean duration from resection arthroplasty to reimplantation was 9 weeks (2-29). Clinical outcomes included interim revision, reinfection, and aseptic revision rates. Restoration of leg-length and offset was assessed radiographically. Modified Harris hip scores were calculated. Mean follow-up was 5 years (3-7). Treatment success was defined using the modified Delphi consensus criteria. RESULTS Thirty-four patients (24%) had treatment failure, including 13 reinfections, 16 interim redebridements for persistent infection, 2 antibiotic suppressive therapies, and 3 prosthetic joint infection-related deaths. Aseptic rerevision after reimplantation was necessary in 14 patients (10%). Dislocation accounted for most aseptic complications, with 20 dislocations occurring in 15 patients (11%). Leg-length and offset were restored to preoperative measures. Mean modified Harris hip scores significantly improved from 35 points to 67 points. CONCLUSION A nonspacer two-stage exchange is a viable option for managing chronically infected THA with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection. Cementless reimplantation demonstrates good midterm survivorship with comparable functional outcomes and leg-length restoration. However, dislocation continues to be a major concern.
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Affiliation(s)
- Christian Hipfl
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Teresa Carganico
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Vincent Leopold
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Carsten Perka
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Michael Müller
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
| | - Sebastian Hardt
- Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany
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Sukhonthamarn K, Cho J, Chisari E, Goswami K, Arnold WV, Parvizi J. N-acetylcysteine use as an adjuvant to bone cement to fight periprosthetic joint infections: A preliminary in vitro efficacy and biocompatibility study. J Orthop Res 2021; 39:356-364. [PMID: 33179364 DOI: 10.1002/jor.24910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/08/2020] [Indexed: 02/04/2023]
Abstract
When antibiotic laden bone cement is used to manage periprosthetic joint infection (PJI), failure still occurs with its use in up to 30% of cases. Therefore, we designed an in vitro study to assess the bactericidal effect of N-acetylcysteine (NAC), an antibacterial adjuvant, in cement against planktonic and biofilm forms of common PJI pathogens. NAC (10%, 20%, 30%, 40%, and 50% w/v) added to polymethyl methacrylate (PMMA) and incubated in broth at 36°C. PMMA-alone and/or culture bacteria alone were used as a negative control. Aliquots of cement elution from each group were taken at 1 day and 1 week and then were investigated for antimicrobial efficacy against the planktonic-form and the biofilm-form of Staphylococcus aureus and Escherichia coli. The primary outcome was the residual colony-forming unit count. The cytotoxicity and mechanical properties of the NAC-PMMA cement-blocks were also assessed. NAC-PMMA efficacy against the planktonic bacteria was demonstrated at a minimum of 30% at Day 1 and a minimum of 20% at 1 week after (p < .001). NAC-PMMA cement was effective against biofilm at a minimum of 30% of NAC at 1 day and 1 week of cement immersion (p < .001). The PMMA alone group was identified as having the highest cytotoxicity (p < .001). NAC decreased the stiffness (p = .004) and maximum load breaking point of the cement (p = .029). NAC is an effective and biocompatible adjuvant to PMMA in terms of antibacterial activity against Staphylococcus aureus and Escherichia coli. The broad antibacterial spectrum of NAC, its low expense, and minimal cytotoxicity makes it an ideal agent for addition to PMMA cement.
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Affiliation(s)
| | - Jeongeun Cho
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | | | - Karan Goswami
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | | | - Javad Parvizi
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
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21
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The utility of dithiothreitol treatment of periprosthetic tissues and explanted implants in the diagnosis of prosthetic joint infection. Indian J Med Microbiol 2020; 39:179-183. [PMID: 33966858 DOI: 10.1016/j.ijmmb.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/16/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE The methods used for the processing of periprosthetic tissues and explanted implants to improve culture outcome especially in biofilm mediated prosthetic joint infections (PJIs) are still debated upon. Studies have reported that Dithiothreitol (DTT) pretreatment of infected devices gives similar results as sonication. However, none of them evaluated the DTT treatment of periprosthetic tissues and explanted implants in the same cohort. We evaluated the diagnostic utility of DTT treatment of periprosthetic tissue and explanted implants, as compared to the normal saline treatment of periprosthetic tissues and sonication of explanted implants for the diagnosis of PJI. METHODS Seventy-three revision arthroplasty cases were prospectively included in this study. Three to five tissue specimens and the explanted implants were collected from each patient. Periprosthetic tissue samples were processed by both normal saline and DTT treatments. Explanted implants were subjected to both DTT treatment and sonication. Musculoskeletal Infection Society (MSIS) PJI criteria was used as the reference standard for the diagnosis of PJI. RESULTS Of the 73 cases enrolled, 34 had PJI and 39 were aseptic failures. The sensitivity of DTT treated periprosthetic tissue culture (PTC) and saline treated PTC was similar (66.6% vs 58.8%, P = 0.25). The specificity of both was 100%. Sonication and DTT treatment of explanted implants showed comparable sensitivity (85.3% vs 82.4%) and specificity (100% vs 97.4%), P > 0.99. Compared to DTT treated PTC, culture of DTT treated explanted implants significantly improved the diagnosis of PJI (P = 0.03). CONCLUSIONS We could verify that DTT can be used to improve culture outcome in laboratories where biofilm detaching sonication techniques are not available for infected implants. In addition, we showed that it is possible to use DTT for treating tissue biopsies, but larger studies are required to confirm our findings.
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22
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Xu YM, Peng HM, Feng B, Weng XS. Progress of antibiotic-loaded bone cement in joint arthroplasty. Chin Med J (Engl) 2020; 133:2486-2494. [PMID: 32960839 PMCID: PMC7575178 DOI: 10.1097/cm9.0000000000001093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Indexed: 11/26/2022] Open
Abstract
Bone cement, consisting of polymethyl methacrylate, is a bioinert material used for prothesis fixation in joint arthroplasty. To treat orthopedic infections, such as periprosthetic joint infection, antibiotic-loaded bone cement (ALBC) was introduced into clinical practice. Recent studies have revealed the limitations of the antibacterial effect of ALBC. Moreover, with the increase in high infection risk patients and highly resistant microbes, more researches and modification of ALBC are required. This paper reviewed latest findings about ALBC for most popular and destructive pathogens, summarized the influence of antibiotic kind, drug dosage, application method, and environment towards characteristic of ALBC. Subsequently, new cement additives and clinical applications of ALBC in joint arthroplasty were also discussed.
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Affiliation(s)
- Yi-Ming Xu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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23
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Abstract
Bone is a dynamic tissue with a quarter of the trabecular and a fifth of the cortical bone being replaced continuously each year in a complex process that continues throughout an individual's lifetime. Bone has an important role in homeostasis of minerals with non-stoichiometric hydroxyapatite bone mineral forming the inorganic phase of bone. Due to its crystal structure and chemistry, hydroxyapatite (HA) and related apatites have a remarkable ability to bind molecules. This review article describes the accretion of trace elements in bone mineral giving a historical perspective. Implanted HA particles of synthetic origin have proved to be an efficient recruiting moiety for systemically circulating drugs which can locally biomodulate the material and lead to a therapeutic effect. Bone mineral and apatite however also act as a waste dump for trace elements and drugs, which significantly affects the environment and human health. Cite this article: Bone Joint Res 2020;9(10):709-718.
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Affiliation(s)
| | | | | | - K Elizabeth Tanner
- School of Engineering and Materials Science and Institute of Bioengineering, Queen Mary University of London, London, UK
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Jie K, Deng P, Cao H, Feng W, Chen J, Zeng Y. Prosthesis design of animal models of periprosthetic joint infection following total knee arthroplasty: A systematic review. PLoS One 2019; 14:e0223402. [PMID: 31581252 PMCID: PMC6776332 DOI: 10.1371/journal.pone.0223402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The number of periprosthetic joint infections (PJI) after total knee arthroplasty (TKA) is increasing annually. Animal models have been used to clarify their clinical characteristics and the infection mechanism of pathogenic bacteria, However, since the prosthesis design of animal models is not uniform, it is difficult to simulate the environment of clinical PJI. OBJECTIVES To retrospect the progress on the prosthesis design of animal models of PJI after TKA and to summarize the criteria for evaluating a clinically representative model of PJI. METHODS This systematic review was reported on the basis of Systematic Reviews and Meta-Analyzes (PRISMA). Pubmed, EMbase, Cochrane Library, Web of Science, Wanfang Data and China National Knowledge Infrastructure were researched for animal models of PJI after TKA from database establishment to April 2019 according to Chinese and English retrieval words, including "periprosthetic joint infections and total knee arthroplasty," "periprosthetic joint infections and model," "periprosthetic joint infections and biofilm," and "total knee arthroplasty and model." RESULTS A total of 12 quantitative studies were enrolled in our study finally: 8 representative studies described prosthesis designs used in PJI animal models, 4 studies described prosthesis designs in non-infected animal models which were suitable for infection models. The major problems need to be dealed with were prosthesis, installation location, material, the function of separating the articular and medullary cavity, fixation manner, and the procedure of preserving the posterior cruciate ligament. CONCLUSION A highly representative design of the animal prosthesis of PJI should meet the following criteria: the surface of the prosthesis is smooth with the formation of biofilm, composed of titanium-6Al-4V or cobalt-chromium-molybdenum alloy; prosthesis can bear weight and is highly stable; and it can connect the joint cavity and medullary cavity simultaneously. To reach a more reliable conclusion, further experiments and improvements are required.
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Affiliation(s)
- Ke Jie
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Peng Deng
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Houran Cao
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Wenjun Feng
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Jinlun Chen
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Yirong Zeng
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
- * E-mail:
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Morris JL, Letson HL, Grant A, Wilkinson M, Hazratwala K, McEwen P. Experimental model of peri-prosthetic infection of the knee caused by Staphylococcus aureus using biomaterials representative of modern TKA. Biol Open 2019; 8:8/9/bio045203. [PMID: 31533935 PMCID: PMC6777360 DOI: 10.1242/bio.045203] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Prosthetic joint infection (PJI) following total knee arthroplasty (TKA) remains the leading cause for revision surgery, with Staphylococcus aureus the bacterium most frequently responsible. We describe a novel rat model of implant-associated S. aureus infection of the knee using orthopaedic materials relevant to modern TKA. Male Sprague-Dawley rats underwent unilateral knee implant surgery, which involved placement of a cementless, porous titanium implant into the femur, and an ultra-highly cross-linked polyethyelene (UHXLPE) implant into the proximal tibia within a mantle of gentamicin-laden bone cement. S. aureus biofilms were established on the surface of titanium implants prior to implantation into the femur of infected animals, whilst control animals received sterile implants. Compared to controls, the time taken to full weight-bear and recover pre-surgical body weight was greater in the infected group. Neutrophils and C-reactive protein levels were significantly higher in infected compared to control animals at day 5 post surgery, returning to baseline levels for the remainder of the 28-day experimental period. Blood cultures remained negative and additional plasma inflammatory markers were comparable for control and infected animals, consistent with the clinical presentation of delayed-onset PJI. S. aureus was recovered from joint tissue and implants at day 28 post surgery from all animals that received pre-seeded titanium implants, despite the use of antibiotic-laden cement. Persistent localised infection was associated with increased inflammatory responses and radiological changes in peri-implant tissue. The availability of a preclinical model that is reproducible based on the use of current TKA materials and consistent with clinical features of delayed-onset PJI will be valuable for evaluation of innovative therapeutic approaches.
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Affiliation(s)
- Jodie L Morris
- Orthopaedic Research Institute of Queensland, Townsville 4812, Australia .,College of Medicine, Division of Tropical Health and Medicine, James Cook University, Townsville 4811, Australia
| | - Hayley L Letson
- College of Medicine, Division of Tropical Health and Medicine, James Cook University, Townsville 4811, Australia
| | - Andrea Grant
- Orthopaedic Research Institute of Queensland, Townsville 4812, Australia
| | - Matthew Wilkinson
- Orthopaedic Research Institute of Queensland, Townsville 4812, Australia
| | - Kaushik Hazratwala
- Orthopaedic Research Institute of Queensland, Townsville 4812, Australia
| | - Peter McEwen
- Orthopaedic Research Institute of Queensland, Townsville 4812, Australia
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A preliminary study of the novel antibiotic-loaded cement computer-aided design-articulating spacer for the treatment of periprosthetic knee infection. J Orthop Surg Res 2019; 14:136. [PMID: 31096988 PMCID: PMC6521453 DOI: 10.1186/s13018-019-1175-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/29/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In comparison to static spacers, articulating spacers have been shown to result in a similar infection eradication rate in two-stage revision of periprosthetic knee infections. However, the optimal construct for articulating spacers has not been identified yet. The aim of this study was to present a preliminary result of treatment for periprosthetic knee infection using a novel computer-aided design (CAD)-articulating spacer. METHODS We retrospectively reviewed 32 consecutive cases of chronic periprosthetic knee infection occurring from January 2015 to December 2015. In these cases, we used an antibiotic-loaded, optimized CAD-articulating spacer based on the retrieved knee prosthesis. Evaluation included infection eradication rate, the Hospital of Special Surgery (HSS) knee score, range of motion (ROM), and spacer-related mechanical complications. All cases were regularly followed-up for 2 years minimum. RESULTS Twenty-eight of 32 patients (87.5%) had infection eradication; 18 patients (56.3%) received reimplantation successfully. The mean interval between spacer insertion and reimplantation was 8.8 months (range 4.0-12.5 months). The mean HSS knee score and ROM significantly increased during each interval (p < 0.0001 for both). The mean HSS knee scores were 31.2 (range 20-48) at initial visit, 65.4 (range 60-78.8) at 1 month after spacer insertion, and 84.2 (range 78-90) at 3 months after reimplantation (p < 0.0001). The mean ROM were 72.0° (range 15-100°), 85.6° (range 35-110°), and 102.0° (range 80-122°), respectively (p = 0.002). Two (6.3%) spacer-related mechanical complications occurred. CONCLUSIONS The CAD-articulating spacer in two-staged revision of periprosthetic knee infection significantly controlled infection, improved clinical outcomes, increased ROM, and decreased mechanical complications in the preliminary study. Further larger clinical studies are needed to confirm the findings presented here.
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27
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Suchý T, Šupová M, Sauerová P, Hubálek Kalbáčová M, Klapková E, Pokorný M, Horný L, Závora J, Ballay R, Denk F, Sojka M, Vištejnová L. Evaluation of collagen/hydroxyapatite electrospun layers loaded with vancomycin, gentamicin and their combination: Comparison of release kinetics, antimicrobial activity and cytocompatibility. Eur J Pharm Biopharm 2019; 140:50-59. [PMID: 31055065 DOI: 10.1016/j.ejpb.2019.04.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 04/23/2019] [Accepted: 04/30/2019] [Indexed: 12/20/2022]
Abstract
The aim of this study was to develop a biodegradable nanostructured electrospun layer based on collagen (COL), hydroxyapatite nanoparticles (HA), vancomycin hydrochloride (V), gentamicin sulphate (G) and their combination (VG) for the treatment of prosthetic joint infections and the prevention of infection during the joint replacement procedure. COL/HA layers containing different amounts of HA (0, 5 and 15 wt%) were tested for the in vitro release kinetics of antibiotics, antimicrobial activity against MRSA, gentamicin-resistant Staphylococcus epidermidis and Enterococcus faecalis isolates and cytocompatibility using SAOS-2 bone-like cells. The results revealed that the COL/HA layers released high concentrations of vancomycin and gentamicin for 21 days and performed effectively against the tested clinically-relevant bacterial isolates. The presence of HA in the collagen layers was found not to affect the release kinetics of the vancomycin from the layers loaded only with vancomycin or its combination with gentamicin. Conversely, the presence of HA slowed down the release of gentamicin from the COL/HA layers loaded with gentamicin and its combination with vancomycin. The combination of both antibiotics exerted a positive effect on the prolongation of the conversion of vancomycin into its degradation products. All the layers tested with different antibiotics exhibited potential antibacterial activity with respect to both the tested staphylococci isolates and enterococci. The complemental effect of vancomycin was determined against both gentamicin-resistant Staphylococcus epidermidis and Enterococcus faecalis in contrast to the application of gentamicin as a single agent. This combination was also found to be more effective against MRSA than is vancomycin as a single agent. Importantly, this combination of vancomycin and gentamicin in the COL/HA layers exhibited sufficient cytocompatibility to SAOS-2, which was independent of the HA content. Conversely, only gentamicin caused the death of SAOS-2 independently of HA content and only vancomycin stimulated SAOS-2 behaviour with an increased concentration of HA in the COL/HA layers. In conclusion, COL/HA layers with 15 wt% of HA impregnated with vancomycin or with a combination of vancomycin and gentamicin offer a promising treatment approach and the potential to prevent infection during the joint replacement procedures.
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Affiliation(s)
- Tomáš Suchý
- Department of Composites and Carbon Materials, Institute of Rock Structure and Mechanics, Academy of Sciences of the Czech Republic, Prague 8, Czech Republic; Faculty of Mechanical Engineering, Czech Technical University in Prague, Prague 6, Czech Republic; Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic.
| | - Monika Šupová
- Department of Composites and Carbon Materials, Institute of Rock Structure and Mechanics, Academy of Sciences of the Czech Republic, Prague 8, Czech Republic; Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Pavla Sauerová
- Institute of Pathological Physiology, 1(st) Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Marie Hubálek Kalbáčová
- Institute of Pathological Physiology, 1(st) Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Eva Klapková
- Department of Medical Chemistry and Clinical Biochemistry, Charles University, 2(nd) Medical School and University Hospital Motol, Prague 5, Czech Republic
| | - Marek Pokorný
- Contipro a.s., R&D Department, Dolni Dobrouc, Czech Republic
| | - Lukáš Horný
- Faculty of Mechanical Engineering, Czech Technical University in Prague, Prague 6, Czech Republic; Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Jan Závora
- Clinical Microbiology and ATB Centre, Institute of Medical Biochemistry and Laboratory Diagnostics, 1(st) Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague 2, Czech Republic
| | - Rastislav Ballay
- 1(st) Department of Orthopaedics, 1(st) Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague 5, Czech Republic
| | - František Denk
- Department of Composites and Carbon Materials, Institute of Rock Structure and Mechanics, Academy of Sciences of the Czech Republic, Prague 8, Czech Republic
| | - Martin Sojka
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic; Institute ofMicrobiology, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - Lucie Vištejnová
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
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