Antibiotic-Loaded Polymethylmethacrylate Beads and Spacers in Treatment of Orthopedic Infections and the Role of Biofilm Formation

Abstract

Polymethylmethacrylate (PMMA) also referred as (acrylic) bone cement is a non-degradable biomaterial that has been used in clinical orthopedic practice for several decades. PMMA can be used in a plain formulation, but is often used in an antibiotic-loaded formulation in (primary and revision) arthroplasty and in treatment of orthopedic infections as prosthetic joint infections (PJI) and chronic osteomyelitis. In treatment of PJIs antibiotic-loaded PMMA is often used as a carrier material for local antibiotic delivery in addition to treatment with systemic antibiotics. In this case, the antibiotic-loaded PMMA is often used as a spacer or as a bead chain. Since the introduction of PMMA as an antibiotic carrier there is a tremendous amount of scientific and clinical papers published, which studied numerous different aspects of antibiotic-loaded PMMA. This paper will review the research regarding basic principles of antibiotic-loaded PMMA as mechanism of action, antibiotic-release capacities, choice of antibiotics and influences on mechanical properties of PMMA. Subsequently, concerns regarding the application of antibiotic-loaded PMMA, biofilm formation, antibiotic resistance and local or systemic toxicity will be discussed. In addition to these subjects, the role of antibiotic loaded PMMA in clinical treatment of PJIs and chronic osteomyelitis is discussed in the final part of this paper.

Developments in Antibiotic-Eluting Scaffolds for the Treatment of Osteomyelitis

“…The most popular local treatment is an antibiotic-eluting material called polymethyl methacrylate (PMMA) or 'bone cement' [17]. This has been referred to as the gold-standard of chronic osteomyelitis treatment [17,18]. Experimental studies have shown that PMMA can deliver in the order of 200 times the amount that systemic antibiotics are able to [19].…”

“…In addition, the high temperatures generated during the preparation of PMMA can degrade its antibiotic content and induce thermal necrosis. This means certain antibiotics such as tetracyclines cannot be used [18]. Others have described a rare 'bone cement implantation syndrome' with PMMA use [24].…”

Garlic extract in prosthesis-related infections: a literature review

“…As the number of total joint replacements increases, so does the risk of infection around the prosthesis. 2,3 PJI can be divided into bacterial and fungal infections according to the different pathogenic organisms involved. The main bacterial pathogens are Staphylococcus aureus and S. epidermidis, 5 while the most common fungal pathogen is Candida albicans.…”

“…2,3 Due to the protection provided by the biofilm, the bacteria inside the biofilm are very difficult to kill. 2 Therefore, effectively destroying the biofilm becomes a key aim of the treatment of PJI. Many studies have shown that GE, as a naturally occurring antibacterial substance, has a good antibiofilm effect.…”

“…The most important reason is the prevalence of multi-drug resistant (MDR) bacteria, also known as 'superbugs', and the formation of bacterial biofilms, which significantly reduces the efficacy of antibiotics or even renders them ineffective. 2 Alternative treatments, therefore, especially for biofilm-associated infections need to be developed urgently.…”