Incorporation of chitosan in acrylic bone cement: Effect on antibiotic release, bacterial biofilm formation and mechanical properties

Bacterial infection remains a significant problem following total joint replacement. Efforts to prevent recurrent implant infection, including the use of antibiotic-loaded bone cement for implant fixation at the time of revision surgery, are not always successful. In this in vitro study, we investigated whether the addition of chitosan to gentamicin-loaded Palacos® R bone cement increased antibiotic release and prevented bacterial adherence and biofilm formation by Staphylococcus spp. clinical isolates. Furthermore, mechanical tests were performed as a function of time post-polymerisation in pseudo-physiological conditions. The addition of chitosan to gentamicin-loaded Palacos® R bone cement significantly decreased gentamicin release and did not increase the efficacy of the bone cement at preventing bacterial colonisation and biofilm formation. Moreover, the mechanical performance of cement containing chitosan was significantly reduced after 28 days of saline degradation with the compressive and bending strengths not in compliance with the minimum requirements as stipulated by the ISO standard for PMMA bone cement. Therefore, incorporating chitosan into gentamicin-loaded Palacos® R bone cement for use in revision surgery has no clinical antimicrobial benefit and the detrimental effect on mechanical properties could adversely affect the longevity of the prosthetic joint.

In vitro study of the efficacy of acrylic bone cement loaded with supplementary amounts of gentamicin: Effect on mechanical properties, antibiotic release, and biofilm formation

Background: Infection remains a severe complication following a total hip replacement. If infection is suspected when revision surgery is being performed, additional gentamicin is often added to the cement on an ad hoc basis in an attempt to reduce the risk of recurrent infection.

Methods and results: In this in vitro study, we determined the effect of incorporating additional gentamicin on the mechanical properties of cement. We also determined the degree of gentamicin release from cement, and also the extent to which biofilms of clinical Staphylococcus spp. isolates form on cement in vitro. When gentamicin was added to unloaded cement (1–4 g), there was a significant reduction in the mechanical performance of the loaded cements compared to unloaded cement. A significant increase in gentamicin release from the cement over 72 h was apparent, with the amount of gentamicin released increasing significantly with each additional 1 g of gentamicin added. When overt infection was modeled, the incorporation of additional gentamicin did result in an initial reduction in bacterial colonization, but this beneficial effect was no longer apparent by 72 h, with the clinical strains forming biofilms on the cements despite the release of high levels of gentamicin.

Interpretation: Our findings indicate that the addition of large amounts of gentamicin to cement is unlikely to eradicate bacteria present as a result of an overt infection of an existing implant, and could result in failure of the prosthetic joint because of a reduction in mechanical performance of the bone cement.