title: Hyaluronic Acid-Based Hydrogel Coating Does Not Affect Bone Apposition at the Implant Surface in a Rabbit Model.
abstract: BACKGROUND
  Uncemented orthopaedic implants rely on the bone-implant interface to provide stability, therefore it is essential that a coating does not interfere with the bone-forming processes occurring at the implant interface. In addition, local application of high concentrations of antibiotics for prophylaxis or treatment of infection may be toxic for osteoblasts and could impair bone growth.
  
  
  OBJECTIVE
  In this animal study, we investigated the effect of a commercially available hydrogel, either unloaded or loaded with 2% vancomycin. We asked, does unloaded hydrogel or hydrogel with vancomycin (1) interfere with bone apposition and timing of bone deposition near the implant surface; and (2) induce a local or systemic inflammatory reaction as determined by inflammation around the implant and hematologic parameters.
  
  
  METHODS
  In 18 New Zealand White rabbits, an uncoated titanium rod (n = 6), a rod coated with unloaded hydrogel (n = 6), or a rod coated with 2% vancomycin-loaded hydrogel (n = 6) was implanted in the intramedullary canal of the left tibia. After 28 days, the bone volume fraction near the implant was measured with microCT analysis, inflammation was semiquantitatively scored on histologic sections, and timing of bone apposition was followed by semiquantitative scoring of fluorochrome incorporation on histologic sections. Two observers, blinded to the treatment, scored the sections and reconciled their scores if there was a disagreement. The hematologic inflammatory reaction was analyzed by measuring total and differential leukocyte counts and erythrocyte sedimentation rates in blood. With group sizes of six animals per group, we had 79% power to detect a difference of 25% in histologic scoring for infection and inflammation.
  
  
  RESULTS
  No differences were found in the amount of bone apposition near the implant in the No Gel group (48.65% ± 14.95%) compared with the Gel group (59.97% ± 5.02%; mean difference [MD], 11.32%; 95% CI, -3.89% to 26.53%; p = 0.16) or for the Van2 group (56.12% ± 10.06%; MD, 7.46; 95% CI, -7.75 to 22.67; p = 0.40), with the numbers available. In addition, the scores for timing of bone apposition did not differ between the No Gel group (0.50 ± 0.55) compared with the Gel group (0.33 ± 0.52; MD, -0.17; 95% CI, -0.86 to 0.53; p = 0.78) or the Van2 group (0.83 ± 0.41; MD, 0.33; 95% CI, -0.36 to 1.03; p = 0.42). Furthermore, we detected no differences in the histopathology scores for inflammation in the No Gel group (2.33 ± 1.67) compared with the Gel group (3.17 ± 1.59; MD, 0.83; 95% CI, -0.59 to 2.26; p = 0.31) or to the Van2 group (2.5 ± 1.24; MD, 0.17; 95% CI, -1.26 to 1.59; p = 0.95). Moreover, no differences in total leukocyte count, erythrocyte sedimentation rate, and neutrophil, monocyte, eosinophil, basophil, and lymphocyte counts were present between the No Gel or Van2 groups compared with the Gel control group, with the numbers available.
  
  
  CONCLUSIONS
  The hydrogel coated on titanium implants, unloaded or loaded with 2% vancomycin, had no effect on the volume or timing of bone apposition near the implant, and did not induce an inflammatory reaction in vivo, with the numbers available.
  
  
  CONCLUSIONS
  Antibiotic-loaded hydrogel may prove to be a valuable option to protect orthopaedic implants from bacterial colonization. Future clinical safety studies will need to provide more evidence that this product does not impair bone formation near the implant and prove the safety of this product.
authors.affiliation: Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands. w.boot@umcutrecht.nl.
authors.forename: W
authors.identifier: http://orcid.org/0000-0001-7150-6007
authors.initials: W
authors.lastname: Boot
authors.affiliation: Department of Oral and Maxillofacial Surgery & Special Dental Care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: D
authors.initials: D
authors.lastname: Gawlitta
authors.affiliation: Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: P G J
authors.initials: PGJ
authors.lastname: Nikkels
authors.affiliation: Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: B
authors.initials: B
authors.lastname: Pouran
authors.affiliation: Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: M H P
authors.initials: MHP
authors.lastname: van Rijen
authors.affiliation: Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
authors.forename: W J A
authors.initials: WJA
authors.lastname: Dhert
authors.affiliation: Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: H Ch
authors.initials: HC
authors.lastname: Vogely
mesh_terms: D000818:Animals; D000069343:Bone-Implant Interface / Q000473:pathology*; D006820:Hyaluronic Acid / Q000494:pharmacology*; D020136:Hydrogel, Polyethylene Glycol Dimethacrylate / Q000494:pharmacology*; D023421:Models, Animal; D019736:Prostheses and Implants; D011817:Rabbits; D013977:Tibia / Q000601:surgery; D014025:Titanium; D014640:Vancomycin / Q000008:administration & dosage* / Q000494:pharmacology*
chemical_list: D020136:Hydrogel, Polyethylene Glycol Dimethacrylate; D014640:Vancomycin; D006820:Hyaluronic Acid; D014025:Titanium