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Background: It is widely acknowledged that peri-prosthetic joint infection (PJI) is the most devastating and challenging complication of total joint arthroplasty. As such, over the years, myriad aspects of this problem have been studied, among which are methods to increase the resistance of the arthroplasty to PJI by enhancing the profile of release of the antibiotic from an antibiotic-loaded poly(methyl methacrylate) bone cement (ALBC) when it is used to anchor the prosthesis to the bone.
Purpose: This was to conduct a detailed and critical state-of-the-art review of the literature on all aspects of enhancement methods, with a view to identify the most effective of these methods.
Methodology: Keywords, such as PJI, ALBC, and cemented arthroplasties, and publicly-available databases, such as Google Scholar and MEDLINE, were used to search for relevant English-language articles published in the open literature between January 1985 and August 2020.
Findings: From the results presented in the studies, a number of indices of enhancement were calculated. These included increases in 1) the cumulative amount of antibiotic released during the course of a release test, 2) the duration of the burst phase of release of the antibiotic, 3) the time at the start of the exhaustion phase of the release of the antibiotic and 4) effectiveness of the released antibiotic against microorganisms commonly found in PJI cases (herein, referred to as “clinically-relevant” bacterial strains), notably S. aureus. These calculated values indicated that the most effective enhancement method involves adding fillers to the cement powder.
Summary: An assortment of enhancement methods have been used, among which were adding fillers to the cement powder and ultrasonication of the cement specimen. Although many results were reported in the studies reviewed, the literature has a number of limitations.
Among these are a dearth of studies on determining activity of the released antibiotic against clinically-relevant bacterial strains and against biofilm formation. Expositions on these limitations lead to identification of potential areas for future research, such as studies of antibiotic enhancement from ALBCs that have innovative architecture and on relationship between an enhancement method and quorum quenching (a mechanism that is postulated to be involved in resistance to biofilm formation).
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