Infection prevention While seemingly insignificant, in England and
Wales in 2023, 281,109 arthroplasty procedures were performed.4
infected that means over 5000 new cases of PJI per year – a considerable number. This is then added to the additional burden of FRI - much harder to quantify given the marked heterogeneity in fracture injury populations, but again has been estimated at up to 2% (although much higher in open fracture).5
If
these parameters were to be overlain the only existing fracture database in England and Wales (the National Hip Fracture Database),6
then with
around 75,000 new operations annually on this injury group alone, this equates to at least 1,500 deep infections in this frail older population annually. The impact on patients with hip fracture having infection is profound – thirty-day mortality trebles.7 The impact of infection after implant surgery
is transparent both for the individual and the system of care in which they are managed. While data varies, the effect on the individual and the costs associated are accepted as profound. Therefore, any means for reducing infection
following surgery involving implants grows in importance and this topic is becoming central to scientific enquiry in implant care. To this end, we highlight the role of a surface applied hydrogel material in the prevention of deep infection in orthopaedic implant surgery. The only commercially available Hydrogel
to the authors is DAC (Defensive Antibacterial Coating) which is composed of two bioresorbable polymers and creates a protective barrier against bacterial adherence. The two constituent polymers are not novel, having a track record and established role in the surgical field. Hyaluronic acid (HA) is a natural polysaccharide. Already present in the human body, it constitutes the bulk of the extracellular matrix (ECM) of connective tissue. The second, Poly-lactic acid (PLA) is a
biodegradable and bioabsorbable synthetic polymer obtained from renewable sources
and from corn or other cereals, through the bacterial fermentation and polymerisation of lactic acid. PLA use is commonplace in orthopaedic surgery, most notably in suture construction. The hydrogel barrier formed carries out its
antimicrobial role by limiting the contact and adherence of bacteria to implants. In short, it impacts on the ability of a given bacteria to ‘stick’ to an implant. This seemingly benign process and its interruption is far from benign – it is central to implant infection. This adherence aids the ability of bacteria to evade host defence mechanisms, as well as treatments aimed at the bacteria themselves, such as debridement, lavage, and antibiotics. Central to understanding the action of
any hydrogel is an appreciation that it is the physical properties of its hydrogel polymers and the physical interaction between the polymer coating and the bacteria that impacts on bacterial adherence and resulting risk of deep infection. Surgeons may choose to add antibiotics to the hydrogel coating, but they contribute only one part of the efficacy – the physical barrier is the predominant impact. Research interest and the expanding field
Biofilm formation poses significant risks for patients with implants. 20
www.clinicalservicesjournal.com I October 2024
of implant coatings is focusing on preventing this early adherence of bacteria to implants. Bacteria can be seen to exist, where implants and infection are concerned, in vulnerable, planktonic, or free-floating states or as part of a protected, impregnable biofilm. The distinction is vital to understanding implant related infection, weaknesses in current and traditional management and the role of novel treatments including hydrogels. Bacteria are most vulnerable to host defences and medical treatment when exposed and free floating.
If 2% of these were to become
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