Adherent antimicrobial coatings for orthopaedic implants - A narrative review

There is a broad consensus among orthopaedic and trauma surgeons, as well as infection specialists, that antibacterial coatings represent an important tool for both the prevention and management of fracture-related infections. Nonetheless, the choice of commercially available implants fitted with an antibacterial coating remains limited. Intramedullary nails with resorbable, antibiotic eluting coatings have been commercially available for over a decade. Although multiple case series have shown evidence of efficacy of antimicrobial orthopaedic implants, randomized controlled trials are still lacking and their uptake in everyday clinical practice has been slow. More recently, nails with galvanic noble metal coatings were introduced, with encouraging clinical results. The most widely used coatings with the longest clinical track record are silver coated joint replacement endoprostheses, which have been successfully employed in revision surgeries and in patients undergoing tumor-related procedures. Silver coated plates are on the verge of market introduction and will represent the first of their kind to be broadly available. Overall, adherent antibacterial coatings are showing beneficial outcomes in terms of safety and efficacy. Health-technology assessments show cost effectiveness, demonstrating that in higher risk patient populations, the additional cost of using a coated implant is significantly less than the cost of treating an infection. Regulatory hurdles remain high, especially in the USA, where, to be best of our knowledge, coated implants have not been approved yet. Driven by the clear clinical need, we anticipate a dynamic near future in this field, with progress moving toward establishing coated implants as the standard of care for appropriate patient populations and expanding the range of available coating solutions. Such developments will ultimately benefit patients, surgeons, and the overall healthcare system.