CORRInsights®: Hyaluronic Acid-based Hydrogel Coating Does Not Affect Bone Apposition at the Implant Surface in a Rabbit Model

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The National Hospital Discharge Survey documented more than 1 million primary and revision hip and knee procedures in 2009 [5] and those numbers are projected to grow over the next decade [6]. Approximately 1% to 2% of primary arthroplasties develop a surgical site infection (SSI) [1, 2], and the risk of infection is much higher in patients who undergo revision arthroplasty due to trauma. The prevention and treatment of deep/organ space infections around prosthetic joints remains an area of concern among orthopaedic surgeons.
While a variety of approaches involving premade antibiotic-containing spacers, beads, and synthetic materials are used to treat patients with prosthetic joint infections, these approaches must be used in concert with intravenous antibiotics to achieve clinical effectiveness. The Minimum Biofilm Eradication Concentration can be 100 to 1000 times the Minimum Inhibitory Concentration necessary to control planktonic bacteria with antimicrobials, and requires exposure times on the order of 24 to 48 hours at those concentrations.
One strategy for preventing infection is to protect the surface of implants so that bacteria cannot attach. There have been “race to the surface” paradigms, where low-dose antimicrobial cement is thought to protect the surrounding implant from bacterial colonization. A number of other techniques have also been tried, or are in development, including chemically bonding antimicrobials to the surface of the implant (vancomycin-bone) [10], silver and gold nanoparticles to create antibacterial microcurrent, and poly(lactic-co-glycolic acid) coatings [4] (among others). Most of these approaches require considerable modification to the implant-manufacturing process, are damaged by scratches or rough handling, and would add substantial cost and difficulty to the use of devices in orthopaedic surgery. Several groups, including my own, [7, 8] have advanced the idea of hydrogel-based, high-dose delivery for antimicrobials. These hydrogels are intended to be space filling, provide different amounts of chemical release, and degrade or dissolve once their payload has been delivered. Ideally, the gels would be compatible with any implant design and procedure, and could be widely used in orthopaedic surgery, plastic surgery, and other disciplines to prevent SSIs.
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