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Table 2 Classification of antibacterial implant protection strategies

From: Antibacterial coating of implants in orthopaedics and trauma: a classification proposal in an evolving panorama

Strategy

Features

Examples

Development stage

Limits

Passive surface finishing/modifications (PSM)

Prevention of bacterial adhesion

Hydrophilic surface

Preclinical

Limited antibacterial and antibiofilm activity

Super-hydrophobic surface

Anti-adhesive polymers

Possible interference with osteointegration

Nano-patterned surface

Albumin

Unknown long-term effects

Hydrogels

Regulatory issues

Biosurfactants

Active surface finishing/modifications (ASM)

Inorganic

Silver ions and nanoparticles

Market

Incomplete implant coating

Questionable long-term toxicity

Limited versatility and applicability

Limited large-scale applications

Possible bacterial resistance induction

Costs

Other metals (copper, zinc, titanium dioxide etc.)

Preclinical

Questionable long-term toxicity

Regulatory issues

Non-metals: Iodine

Clinical

Incomplete implant coating

Questionable long-term toxicity

Challenging large-scale application

Regulatory issues

Other non-metal ions (selenium, grapheme, etc.)

Preclinical

Poorly studied compounds

Coating resistance to press-fit insertion

Questionable long-term toxicity

Challenging large-scale application

Regulatory issues

Organic

Coated/linked antibiotics

Market

Unique application to nail coating

Long-term effects on osteointegration

Single antibiotic (gentamicin)

Covalently linked antibiotics

Preclinical

Incomplete implant coating.

Questionable long-term toxicity

Challenging large-scale application

Regulatory issues

Antimicrobial peptides

No data on in vivo or clinical effects

Cytokines

Coating resistance to press-fit insertion

Enzymes and biofilm disrupting agents

Questionable long-term toxicity

Challenging large-scale application

Chitosan derivatives

Synthetic

Non-antibiotic antimicrobial compounds

Regulatory issues

“Smart” coatings

Combined

Multilayer coating

Peri-operative antibacterial local carriers or coatings (LCC)

Not-biodegradable

Antibiotic-loaded polymethylmetacrylate

Market

Resistance and small-colony variants induction

No antibiofilm effect

Incomplete implant coating

May not be used for cementless implants

Biodegradable

Antibiotic-loaded bone grafts and substitutes

Market

Limited availability

Not proven efficacy as implant coating

Cost

Fast-resorbable hydrogel

Market

Early clinical use and results