Bingyun Li - Racing for the Surface: Pathogenesis of Implant Infection and Advanced Antimicrobial Strategies

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With the implantation of new devices and novel technologies to mitigate pain and improve function, unforeseen, sometimes serious complications are currently being observed that may limit the lifetime of the implant. In orthopedic surgery, chief amongst these adverse events is implant infection. Whether the implant is a permanent prosthesis (such as in joint replacement or a spinal device), or a biodegradable polymeric device (e.g., for fracture fixation or reconstruction of deficient ligaments), acute and chronic infection can occur. Infection of an implant induces local inflammation, subsequent pain and poor function, and may necessitate removal of the implant, aggressive debridement of the local tissues, and prolonged antibiotic treatment. Infections of orthopedic implants are a substantial burden to society and the healthcare system and a devastating financial and psychosocial event in the lives of patients and their families.

Are orthopedic implant infections common? In joint replacement surgery of the lower extremity, periprosthetic infection is the leading cause of failure of total knee replacements and is amongst the top three reasons for failure of total hip replacements. Given the fact that joint replacement of the hip and knee total more than one million cases per year in the USA alone, and the infection rate varies from about 0.5 to 10% or more depending on the complexity of the case, implant infection is a potential scenario that cannot be ignored. Substantial clinical and basic research has been performed to identify the causative organisms and provide antiseptics and antibiotics to accompany radical surgical debridement, and if necessary, implant removal. However, these secondary measures do not address the major challenge in this area, namely how to prevent the occurrence of infection primarily and in the longer term. These issues have great relevance to clinical practice. The population is aging and individuals want to remain active at all ages including in their later years of life. At the same time, the immune system ages, making the elderly more susceptible to infection, compared to younger individuals. Furthermore, advances in the treatment of chronic diseases such as diabetes, cancer, and others are enabling individuals to enjoy an extended life span despite a compromised and aging immune system. The possibility of late infection of an implant looms over these individuals because of their suboptimal immune status.

Thus, there are major challenges that present themselves to orthopedic clinicians, researchers, device manufacturers, government regulators, insurance companies, and other related parties. These challenges pertain to the selection and optimization of patients who will be receiving orthopedic implants, the appropriate use of peri-operative antibiotic prophylaxis, implant choice and surgical technique, and postoperative care to improve patient outcomes. Surgical devices need to have an established track record of safety, efficacy, and cost-effectiveness, and be relatively straightforward for the surgeon to implant. Recent studies have demonstrated that the properties of the device including its composition, shape, topography, and surface properties, as well as the addition of specialized treatments and coatings may have a major impact on the development of implant infection. In this regard, the compendium of chapters in this book on current developments in the field of orthopedic implant infection is both timely and indispensable to the broadening of our knowledge base on a subject that continues to plague orthopedic surgeons and patients alike.