This study was performed to investigate the concentration of silver ions release up to a time of 9 weeks as well as the antimicrobial activity of silver sulfate and Nano-silver mixed bone cement on Candida albicans, in expectation of a new way of therapy in manner of a time limited application – a silverions releasing bone cement spacer.

Two different kinds of silver products were used and mixed with polymethylmetacrylate (PMMA, De Puy) bone cement:

Nano-silver with a particle size of 5–50 nm and active surface of 4 m2/ g. (Nanonet Styria, Austria)

Concentrations of 0.1%, 0.5%, 1% and 5% of the Nano-silver and the silver-salt by weight were mixed with the dry powder portion of the cement. To test the silver-ions release from the silver-containing bone cement two models of elution, a static model and a dynamic model were created. To test the antifungal effectiveness of the various concentrations of Ag-PMMA the bone cement samples were tested by agar diffusion assay.

With respect to minimal inhibition concentration (MIC) the sample containing 0.5 % silver sulfate showed required concentration at the dynamic elution model but none of the nano-silver samples did. In static elution model we measured the maximum concentration of 466.5 µg/l at the 0.5 % silver sulfate sample which is much below the toxic concentration. Agar diffusion assay showed no zone of inhibition from Nano-silver samples. In contrast, silver sulfate containing samples showed a zone of inhibition exactly growing, depending on the samples silver sulfate concentration.

According to results, silver sulfate addition to PMMA might be another approach in treatment of candida associated periprosthetic joint infection.

The aims of this study were to evaluate the incidence of local argyria in patients with silver-coated megaprostheses and to identify a possible association between argyria and elevated levels of silver both locally and in the blood. Between 2004 and 2011, 32 megaprostheses with silver coatings were implanted in 20 female and 12 male patients following revision arthroplasty for infection or resection of a malignant tumour, and the levels of silver locally in drains and seromas and in the blood were determined. The mean age of the patients was 46 years (10 to 81); one patient died in the immediate post-operative period and was excluded.

Seven patients (23%) developed local argyria after a median of 25.7 months (interquartile range 2 to 44.5). Patients with and without local argyria had comparable levels of silver in the blood and aspiration fluids. The length of the implant did not influence the development of local argyria. Patients with clinical evidence of local argyria had no neurological symptoms and no evidence of renal or hepatic failure. Thus, we conclude that the short-term surveillance of blood silver levels in these patients is not required.

Cite this article: Bone Joint J 2013;95-B:988–92.

Introduction: Chronic infection after total joint arthroplasty is a complication of major concern to orthopaedic surgeons, especially if patients suffer from any type of immunodeficiency. But for extensive surgical and systemic treatment recurrence rates are high.

Silver is a long known local antimicrobial agent. The use of silver coated prostheses is a valuable option in some cases.

Yet there are patients for whom the permanent implantation of large amounts of silver does not seem to be the perfect solution.

Methods: From 02/2004 to 12/2005 nine patients with severe deep infections after multiple revisions following total joint replacement underwent two-stage revision and implantation of silver coated megaendoprostheses (MUTARS®).

From 04/2004 to 01/2006 seventeen patients of slightly less impaired disposition were treated by a comparable two-stage procedure using silver-augmented cemented spacer prostheses or cement fills.

Patients are closely observed regarding toxic side effects.

Concentration of silver in blood and puncture samples are measured using an argon plasma mass spectrometer.

Results: To date eight of nine patients with silver coated megaendoprostheses are free of infection. One patient with known cellular and humoral immunodeficiency recently developed a fistula, puncture showing superinfection by coag. neg. staphylococci.

In the second group one patient of seventeen actually shows a persisting infection, but cannot be matched properly as he primarily suffered from a long-term infected knee arthrodesis.

Silver concentrations ranged from a maximum of 1010 to 243 μg/kg (ppb) to a minimum of 84 to 304 μg/kg (ppb) with silver coating, and a maximum of 380 to 22,9 μg/kg (ppb) to a minimum of 76 to 5,02 μg/kg (ppb) with silver spacers.

There are large individual differences in both groups.

We found no signs of argyrosis or recently developed neurological deficits.

Discussion: The use of silver in the treatment of severely infected joint prostheses is a promising approach, but it is not without risks and throwbacks. Strict indication and surveillance are needed to keep possible side effects under control. It ought not to be used out of specialized centres.