Implants coating strategies for antibacterial treatment in fracture and defect models: A systematic review of animal studies

Objective

Fracture-related infection (FRI) remains a major concern in orthopaedic trauma. Functionalizing implants with antibacterial coatings are a promising strategy in mitigating FRI. Numerous implant coatings have been reported but the preventive and therapeutic effects vary. This systematic review aimed to provide a comprehensive overview of current implant coating strategies to prevent and treat FRI in animal fracture and bone defect models.

Methods

A literature search was performed in three databases: PubMed, Web of Science and Embase, with predetermined keywords and criteria up to 28 February 2023. Preclinical studies on implant coatings in animal fracture or defect models that assessed antibacterial and bone healing effects were included.

Results

A total of 14 studies were included in this systematic review, seven of which used fracture models and seven used defect models. Passive coatings with bacteria adhesion resistance were investigated in two studies. Active coatings with bactericidal effects were investigated in 12 studies, four of which used metal ions including Ag+ and Cu2+; five studies used antibiotics including chlorhexidine, tigecycline, vancomycin, and gentamicin sulfate; and the other three studies used natural antibacterial materials including chitosan, antimicrobial peptides, and lysostaphin. Overall, these implant coatings exhibited promising efficacy in antibacterial effects and bone formation.

Conclusion

Antibacterial coating strategies reduced bacterial infections in animal models and favored bone healing in vivo. Future studies of implant coatings should focus on optimal biocompatibility, antibacterial effects against multi-drug resistant bacteria and polymicrobial infections, and osseointegration and osteogenesis promotion especially in osteoporotic bone by constructing multi-functional coatings for FRI therapy.

The translational potential of this paper

The clinical treatment of FRI is complex and challenging. This review summarizes novel orthopaedic implant coating strategies applied to FRI in preclinical studies, and offers a perspective on the future development of orthopaedic implant coatings, which can potentially contribute to alternative strategies in clinical practice.

Active Osteoblasts or Quiescent Bone Lining Cells? Preosteoblasts Fate Orchestrated by Curvature and Stiffness of an In Vitro 2.5D Biomimetic Culture System

Biomimetic cell culture systems are required to provide more physiologically relevant microenvironments for bone cells. Here, a simple 2.5D culture platform is proposed, combining adjustable stiffness and surface features that mimic bone topography by using sandpaper grits as master molds with two stiffness formulations of polydimethylsiloxane (PDMS). The subsequent replicas perfectly conform the grits and reproduce the corresponding negative relief with cavities separated by convex edges. Biomimicry is also provided by an extracellular matrix (ECM)-like thin film coating, using the layer-by-layer (LbL) method. The topographical features, alternating concave, and convex structures drive preosteoblasts organization and morphology. Strikingly, curvature orchestrates the commitment of preosteoblasts, with i) maturation to active osteoblasts able to produce a dense collagenous matrix that ultimately mineralizes in the cavities, and ii) edges hosting quiescent cells that synthetize a very thin immature collagen layer with no mineralization. In summary, the present in vitro culture system model offers a cell-instructive 2.5D microenvironment that controls preosteoblasts fate, leading to two coexisting subpopulations: mature osteoblasts and bone lining cells (BLC). This promising culture system opens new avenues to advanced tissue-engineered modeling and can be applied to precellularized bone biomaterials.

Methacrylated Cellulose Nanocrystals as Fillers for the Development of Photo-Cross-Linkable Cytocompatible Biosourced Formulations Targeting 3D Printing

Cellulose nanocrystals (CNCs) from cotton were functionalized in aqueous medium using methacrylic anhydride (MA) to produce methacrylated cellulose nanocrystals (mCNCs) with a degree of methacrylation (DM) up to 12.6 ± 0.50%. Dispersible as-prepared CNCs and mCNCs were then considered as reinforcing fillers for aqueous 3D-printable formulations based on methacrylated carboxymethylcellulose (mCMC). The rheological properties of such photo-cross-linkable aqueous formulations containing nonmodified CNCs or mCNCs at 0.2 or 0.5 wt% in 2 wt% mCMC were fully investigated. The influence of the presence of nanoparticles on the UV-curing kinetics and dimensions of the photo-cross-linked hydrogels was probed and 13C CP-MAS NMR spectroscopy was used to determine the maximum conversion ratio of methacrylates as well as the optimized time required for UV postcuring. The viscoelasticity of cross-linked hydrogels and swollen hydrogels was also studied. The addition of 0.5 wt% mCNC with a DM of 0.83 ± 0.040% to the formulation yielded faster cross-linking kinetics, better resolution, more robust cross-linked hydrogels, and more stable swollen hydrogels than pure mCMC materials. Additionally, the produced cryogels showed no cytotoxicity toward L929 fibroblasts. This biobased formulation could thus be considered for the 3D printing of hydrogels dedicated to biomedical purposes using vat polymerization techniques, such as stereolithography or digital light processing.

Dual-functional antibacterial and osteogenic nisin-based layer-by-layer coatings

Implanted biomaterials can be regarded in a cornerstone in the domain of bone surgery. Their surfaces are expected to fulfil two particular requirements: preventing the settlement and the development of bacteria, and stimulating bone cells in view to foster osseointegration. Therefore, a modern approach consists in the design of dual functional coatings with both antibacterial and osteogenic features. To this end, we developed ultrathin Layer-by-Layer (LbL) coatings composed of biocompatible polyelectrolytes, namely chondroitin sulfate A (CSA) and poly-l-lysine (PLL). The coatings were crosslinked with genipin (GnP), a natural and biocompatible crosslinking agent, to increase their resistance against environmental changes, and to confer them adequate mechanical properties with regards to bone cell behaviors. Antibacterial activity was obtained with nisin Z, an antimicrobial peptide (AMP), which is active against gram-positive bacteria. The coatings had a significant bactericidal impact upon Staphylococcus aureus, with fully maintained bone cell adhesion, proliferation and osteogenic differentiation.

Nisin-based antibacterial and antiadhesive layer-by-layer coatings

Some removable medical devices such as catheters and cardiovascular biomaterials require antiadhesive properties towards both prokaryotic and eukaryotic cells in order to prevent the tissues from infections upon implantation and, from alteration upon removal. In order to inhibit cell adhesion, we developed ultrathin hydrated Layer-by-Layer (LbL) coatings composed of biocompatible polyelectrolytes, namely chondroitin sulfate A (CSA) and poly-l-lysine (PLL). The coatings were crosslinked with genipin (GnP), a natural and biocompatible crosslinking agent, to increase their resistance against environmental changes. In order to confer antibacterial activity to the coatings, we proceeded to the electrostatically-driven immobilization of nisin Z, an antimicrobial peptide (AMP) active against gram-positive bacteria. The nisin-enriched coatings had a significantly increased anti-proliferative impact on fibroblasts, as well as a strong contact-killing activity against Staphylococcus aureus in the short and long term.

Microgels Based on Carboxymethylpullulan Grafted with Ferulic Acid Obtained by Enzymatic Crosslinking in Emulsion for Drug Delivery Systems

Carboxymethylpullulan (CMP) grafted with ferulic acid (FA) is crosslinked with laccase by the reverse water-in-oil emulsion technique (with sunflower oil) to obtain microgels with size from 40 to 200 µm. It is demonstrated that laccase activity and dispersion time have an impact on microgels' size. Fluorescence spectroscopy of different probes (e.g., pyrene, Nile red, and curcumin) shows the nonpolar characteristics of hydrophobic microdomains formed by the FA moieties and its dimers forming the crosslinking nodes. Encapsulation and release of curcumin or lidocaine used as drug models are studied in different buffers. Curcumin is well encapsulated but retained in microgels, while lidocaine is released at 65-70% in 2 h and 30 min in buffer simulating the gastrointestinal tract and at 75-85% in 1 h in acetate buffer pH 5.6 or phosphate-buffered saline (PBS) pH 6.9.

Biomimetic layer-by-layer templates for calcium phosphate biomineralization

Carboxylated, sulfated and/or phosphorylated surfaces are admitted as potential optimal templates for biomimetic deposition of calcium phosphate (CaP) coatings in view of improving implants' osseointegration. Layer-by-layer films were built up consisting of anionic chondroitin sulfate (ChS), a biological carboxylated and sulfated polysaccharide and cationic poly(l-lysine) (PLL). The films were used as soft matrices to immobilize a model phosphoprotein, phosvitin (PhV). The respective roles of ChS, PLL and PhV terminal layers on the heterogeneous nucleation kinetics and the structure of CaP deposits obtained from supersaturated solutions were inspected. Critical supersaturation ratios and induction times preceding heterogeneous nucleation were precisely determined and interpreted within the framework of classical nucleation theory in order to derive the effective interfacial energies of CaP crystals. It was found that the potency of terminal layers toward CaP nucleation increased in the order: PLL<ChS<PhV. Beyond a supersaturation threshold, PhV-terminated films exerted unique influence on the nucleation kinetics, maintaining the induction time at a constant value owing to conformational change of the PhV molecules upon calcium bridging. Promisingly, all films templated the deposition of thin (a few micrometer thick) uniform coatings of octacalcium phosphate and possibly hydroxyapatite, the two most relevant biological phases of CaP.

Protein-triggered instant disassembly of biomimetic Layer-by-Layer films

Layer-by-Layer (LbL) coatings are promising tools for the biofunctionalization of biomaterials, as they allow stress-free immobilization of proteins. Here, we explore the possibility to immobilize phosvitin, a highly phosphorylated protein viewed as a model of bone phosphoproteins and, as such, a potential promotive agent of surface-directed biomineralization, into biomimetic LbL architectures. Two immobilization protocols are attempted, first, using phosvitin as the polyanionic component of phosvitin/poly-(L-lysine) films and, second, adsorbing it onto preformed chondroitin sulfate/poly-(L-lysine) films. Surprisingly, it is neither possible to embed phosvitin as the constitutive polyanion of the LbL architectures nor to adsorb it atop preformed films. Instead, phosvitin triggers instant massive film disassembly. This unexpected, incidentally detected behavior constitutes the first example of destructive interactions between LbL films and a third polyelectrolyte, a fortiori a protein, which might open a route toward new stimuli-responsive films for biosensing or drug delivery applications. Interestingly, additional preliminary results still indicate a promotive effect of phosvitin-containing remnant films on calcium phosphate deposition.

Sensitivity of alveolar macrophages to substrate mechanical and adhesive properties

In order to understand the sensitivity of alveolar macrophages (AMs) to substrate properties, we have developed a new model of macrophages cultured on substrates of increasing Young's modulus: (i) a monolayer of alveolar epithelial cells representing the supple (approximately 0.1 kPa) physiological substrate, (ii) polyacrylamide gels with two concentrations of bis-acrylamide representing low and high intermediate stiffness (respectively 40 kPa and 160 kPa) and, (iii) a highly rigid surface of plastic or glass (respectively 3 MPa and 70 MPa), the two latter being or not functionalized with type I-collagen. The macrophage response was studied through their shape (characterized by 3D-reconstructions of F-actin structure) and their cytoskeletal stiffness (estimated by transient twisting of magnetic RGD-coated beads and corrected for actual bead immersion). Macrophage shape dramatically changed from rounded to flattened as substrate stiffness increased from soft ((i) and (ii)) to rigid (iii) substrates, indicating a net sensitivity of alveolar macrophages to substrate stiffness but without generating F-actin stress fibers. Macrophage stiffness was also increased by large substrate stiffness increase but this increase was not due to an increase in internal tension assessed by the negligible effect of a F-actin depolymerizing drug (cytochalasine D) on bead twisting. The mechanical sensitivity of AMs could be partly explained by an idealized numerical model describing how low cell height enhances the substrate-stiffness-dependence of the apparent (measured) AM stiffness. Altogether, these results suggest that macrophages are able to probe their physical environment but the mechanosensitive mechanism behind appears quite different from tissue cells, since it occurs at no significant cell-scale prestress, shape changes through minimal actin remodeling and finally an AMs stiffness not affected by the loss in F-actin integrity.

Practice of a testing bench to study the effects of cyclic stretching on osteoblast-orthopaedic ceramic interactions

A new experimental method has been used to study the behaviour of human osteoblasts cultured on bioceramics subjected to mechanical strains. The ceramics were alumina, hydroxyapatite (HA) and a duplex system composed of hydroxyapatite-covered alumina. The system applied 400 microdeformations for a 6-h period with a cycle frequency of 0.5 Hz to osteoblasts growing on ceramic-covered disks. The effects of strains on short-term cell viability, cell growth, alkaline phosphatase (ALP) activity, and collagen biosynthesis were assessed. When possible, the parameters (lactate dehydrogenase) were studied along the experiment in samples of the culture medium, in the other cases by comparison of stretched and unstretched cultures on the same ceramics with the same cell line. In relationship with the coating, mechanical strains resulted in a decrease in DNA corresponding to cell number, an LDH release during straining, an unchanged (alumina) or decreased (HA and duplex) ALP activity, a decrease (HA and duplex) of collagen and total protein synthesis or an increase of it (alumina). The stress-producing device and its associated protocol are shown to be suitable for investigating the behaviour of cells, cultured on biomaterials subjected to mechanical strain.

Interaction of a plasma-sprayed hydroxyapatite coating in contact with human osteoblasts and culture medium

The loss of calcium from plasma-sprayed calcium phosphate ceramics (CPCs) on bioinert metal substrate (Ti-6Al-4V) immersed in cell culture medium with or without human osteoblast culture was measured. The ceramics were a CPC and a duplex system composed of a CPC layer on an alumina coating. The dissolution of calcium compounds was monitored by measuring the calcium leaked from the coatings into the culture medium in 15 days. Calcium was measured by flame photometry. The surfaces of the ceramics exposed to the culture medium and in contact with osteoblasts were analysed by X-ray diffraction (XRD). The dissolution process occurred in the first 6 days of contact, but the calcium released into the culture medium was only a small fraction of the calcium content of the coatings. The presence or absence of osteoblasts on the surface of the ceramics did not make significant difference for the calcium release. The XRD spectra of the ceramics before and after immersion and in contact with cells did not show a significant change in the compounds of the coatings.

A standardized parameter for the distribution of individual red blood cell deformability with the cell transit analyzer

The purpose of this study was to identify a parameter allowing the standardization of the Cell Transit Analyzer (CTA) in order to study the individual deformability of each explored Red Blood Cell (RBC). Using theoretical arguments based on the principle of the CTA, we calculated the thickness "x" of the crown of fluid surrounding each RBC during its entry phase into the micropore. A mathematical equation (x = 62.5/magnitude of dU) was established between the difference of potential (dU, mV) that occurs during this phase and the corresponding thickness ("x", micron) of the crown. By exploring fresh control RBCs of healthy subjects and assuming that the rigid RBCs proportion in a fresh blood sample of healthy subject is less than 3.5%, we performed a thresholding of "x" to distinguish rigid RBC from deformable ones. That thresholding was necessary to stamp the variability of counts linked to polycarbonate filters (PF) used to carry out measures. According to the PF, the value of the threshold "Tx" provided by the thresholding ranged between 0.222 and 0.246 micron. Using the values of "Tx", we counted approximately 10-25% rigid RBCs in the pathological samples of four patients with sickle cells SS disease and of one diabetic patient with splenomegaly. We observed in addition that the percentages of rigid RBCs counted after thresholding are identical from a filter to another one with an absolute error less than 2% in fresh RBCs (normal or pathological) samples. We concluded that the method of standardization by thresholding presented here could be used in clinic routine to count the rigid RBCs percentage contained in a given sample.

Effects of gamma-alumina and hydroxyapatite coatings on the growth and metabolism of human osteoblasts

The behavior of human osteoblasts cultivated on hydroxyapatite or alumina-coated disks of Ti6AL4V was studied in vitro. Cell anchorage and spreading were observed by scanning electron microscopy. Cell growth was monitored by counting cells and measuring DNA at 5 h and 2,5, and 10 days after cell seeding. Cells grown for 10 days were labeled with 14C-proline and total protein and collagen synthesis were measured; the type of collagen was also determined. Both ceramics showed excellent biocompatibility. At 10 days of culture the cells showed a higher rate of proliferation on alumina than on hydroxyapatite. Neither ceramic altered the collagen biosynthesis or the osteoblast-like properties of the cells, as indicated by the high percentage of type I collagen.

Association of polyacrylamide beads to polyethylene terephthalate prostheses

A method for the coupling of polyacrylamide beads to polyethylene terephthalate (PET) vascular prostheses is described. The reactional procedure used is performed along several steps; acrylic acid grafting on PET textile fibres, in order to introduce reactive carboxylic groups, introduction of terminal primary amine groups onto the beads, and then, attachment method which consists in coupling carboxylic groups of prostheses with amine groups of modified beads. The relative weight increase of the samples before and after the coupling reaction and, microscopic observations of beads distribution onto the prostheses surface demonstrate the binding feasibility of polyacrylamide matrices to PET prostheses. In the near future, authors expect to replace these beads by microcapsules with polyacrylamide wall and containing active compounds to improve the vascular prostheses biocompatibility.