Antibacterial coating of implants: what surgeons should know

Background: Biofilm-associated infections represent a substantial burden in orthopedic and trauma surgery, with periprosthetic joint infection serving as a primary etiology for arthroplasty failure. Bacterial colonization and subsequent biofilm maturation occur within hours of implantation, creating a protective matrix that sequesters microorganisms from systemic antimicrobial agents and host immune responses.

Objective: This review examines the pathogenesis of implant-related infections and evaluates the classification, clinical efficacy, and limitations of current antibacterial coating technologies designed to inhibit bacterial adhesion and biofilm formation.

Key Points: Antibacterial strategies are categorized into passive surface modifications, active surface modifications, and local antibacterial carriers. Silver-coated megaprostheses demonstrate reduced infection rates in oncological reconstructions but face limitations regarding ion toxicity and incomplete implant coverage. Iodine-supported titanium implants show clinical safety in trauma and tumor cases. Antibiotic-loaded polymethylmethacrylate remains a standard for cemented fixations but is inapplicable to cementless components. A fast-resorbable hydrogel composed of hyaluronan and poly-L-lactic acid allows for intraoperative application across diverse biomaterials, including titanium and polyethylene. Preclinical and clinical data indicate that this hydrogel, when loaded with antibiotics, significantly reduces bacterial colonization and early postoperative infection rates without compromising osseointegration or bone healing.

Conclusion: Despite the rising incidence of septic complications, few antibacterial coating technologies have achieved widespread clinical adoption. Implementing these technologies, supported by robust post-marketing surveillance and specific reimbursement frameworks, is essential to reduce the clinical and economic burden of orthopedic infections.