Antibiotic-free antimicrobial poly (methyl methacrylate) bone cements: A state-of-the-art review

Abstract

Prosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty, this being because it is associated with, among other things, high morbidity and low quality of life, is difficult to prevent, and is very challenging to treat/manage. The many shortcomings of antibiotic-loaded poly (methyl methacrylate) (PMMA) bone cement (ALBC) as an agent for preventing and treating/ managing PJI are well-known. One is that microorganisms responsible for most PJI cases, such as methicillin-resistant S. aureus, have developed or are developing resistance to gentamicin sulfate, which is the antibiotic in the vast majority of approved ALBC brands. This has led to many research efforts to develop cements that do not contain gentamicin (or, for that matter, any antibiotic) but demonstrate excellent antimicrobial efficacy. There is a sizeable body of literature on these so-called “antibiotic-free antimicrobial” PMMA bone cements (AFAMBCs). The present work is a comprehensive and critical review of this body. In addition to summaries of key trends in results of characterization studies of AFAMBCs, the attractive features and shortcomings of the literature are highlighted. Shortcomings provide motivation for future work, with some ideas being formulation of a new generation of AFAMBCs by, example, adding a nanostructured material and/or an extract from a natural product to the powder and/or liquid of the basis cement, respectively.

Keywords: Periprosthetic joint infection; Poly (methyl methacrylate) bone cement; Antibiotic-loaded poly (methyl methacrylate) bone cement bone cement; Antibiotic-free antimicrobial poly (methyl methacrylate) bone cement bone cement

Core Tip: Although antibiotic-loaded poly (methyl methacrylate) (PMMA) bone cements are widely used both as prophylactic agent and in the treatment/management of prosthetic joint infection, there is dissatisfaction about the material. A new generation of antibiotic-free antimicrobial PMMA bone cements (AFAMBCs) is emerging. The present review is a critical appraisal of the literature on AFAMBCs, highlighting its strengths, shortcomings, and possible areas for future studies. The conclusion is that state-of-the-art on AFAMBC formulations is such that it is premature to comment on the potential of any of the formulations for clinical application.