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Silver-coated megaprosthesis in prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about efficacy and toxicity in primary and revision surgery

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Abstract

Aim

Prosthetic joint infection (PJI) is a common complication following orthopedic megaprosthetic implantations (EPR), estimated up to 50%. Silver coatings were introduced in order to reduce the incidence of PJI, by using the antibacterial activity of silver. Three different silver coatings are available: MUTARS® (Implantcast), Agluna® (Accentus Medical), PorAg® (Waldemar Link). The aim of this review is to provide an overview on efficacy and safety of silver-coated EPR both in primary and revision surgery, comparing infection rate according to the type of implant.

Methods

Through an electronic systematic search, we reviewed the articles concerning silver-coated EPRs. Infection rate, silver-related complications, local and blood concentrations of the silver were evaluated. Meta-analyses were performed to compare results from each study included.

Results

Nineteen studies were included. The overall infection rate in patients with silver-coated implants was 17.6% (133/755). Overall infection rate in primary silver-coated EPR was been 9.2% (44/445), compared to 11.2% (57/507) of non-silver-coated implants. The overall infection rate after revisions was 13.7% (25/183) in patients with silver-coated EPR and 29.2% (47/161) when uncoated EPR were used, revealing a strength statistically significative utility of silver coatings in preventing infections in this group (p: 0.019). Generally, the use of MUTARS® EPR had produced an almost constant decrease in the incidence of primary PJI but there are few data on the effectiveness in revisions. The results from the use of Agluna® in both primary and revisions implants are inconstant. Conversely, PorAg® had proven to be effective both in PJI prevention but, especially, when used in PJI revision settings. Local argyria was reported in 8 out of 357 patients (2.2%), while no systemic complications were described. Local and blood concentrations of silver were always reported very far to the threshold of toxicity, with the lowest concentration found using PorAg®.

Conclusions

Silver-coated EPRs are safe and effective in reduction in PJI and re-infection rate, in particular when used in higher risk patients and after two-stage revisions to fight PJI.

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Authors and Affiliations

  1. IRCCS Istituto Ortopedico Rizzoli, Via G.C. Pupilli 1, 40136, Bologna, Italy

    Michele Fiore, Riccardo Zucchini, Claudio Giannini & Davide Maria Donati

  2. Azienda ospedaliera Sant’Orsola Malpighi, Bologna, Italy

    Andrea Sambri & Massimiliano De Paolis

  3. Alma mater studiorum - University of Bologna, Bologna, Italy

    Andrea Sambri & Davide Maria Donati

Authors
  1. Michele Fiore
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  2. Andrea Sambri
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  3. Riccardo Zucchini
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  4. Claudio Giannini
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  5. Davide Maria Donati
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  6. Massimiliano De Paolis
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Contributions

MDP conceived the study and revised the paper; MF and AS drafted the manuscript and collected and interpreted the data; RZ, CG and DMD participated in planning and revising the manuscript. All the authors read and approved the final manuscript.

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Correspondence to Michele Fiore.

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Fiore, M., Sambri, A., Zucchini, R. et al. Silver-coated megaprosthesis in prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about efficacy and toxicity in primary and revision surgery. Eur J Orthop Surg Traumatol 31, 201–220 (2021). https://doi.org/10.1007/s00590-020-02779-z

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