钛合金表面抗菌涂层：抗菌能力及生物相容性

doi:10.3969/j.issn.2095-4344.2015.25.026

摘要/Abstract

摘要：

背景：钛合金材料因具有良好的生物相容性、耐腐蚀性和综合力学性能被广泛用于临床，如何赋予其优良的抗菌性以应对内植物相关感染是近年来的研究热点。
目的：综述了钛合金表面抗菌涂层的原理、技术、分类及优缺点。
方法：由第一作者检索1990年1月至2014年1月Scopus 数据库、中国科技期刊数据库(重庆维普)相关文献，检索关键词为“Titanium alloy，Plant，Antibacterial，Coating；钛合金，内植物，抗菌，涂层”。
结果与结论：根据涂层的种类可将其分为抗生素类涂层、非抗生素类有机抗菌剂涂层、无机抗菌剂类涂层、抗黏附性涂层、抗菌生物活性聚合物涂层，各种涂层均具有较好的生物相容性，但也有各自的局限，目前对抗菌涂层的研究主要集中于：如何增强抗菌涂层与基体的结合力，并获得良好的抗菌性、生物相容性、高耐磨性、持久性是需要研究的关键问题；抗菌相结构、分布对于细菌定植的研究，无论是合金整体添加抗菌元素还是表面涂层型钛合金，抗菌相的结构、分布是影响抗菌性能的关键因素。

中国组织工程研究杂志出版内容重点：生物材料；骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性；组织工程

关键词: 生物材料, 骨生物材料, 钛合金, 内植物, 抗菌, 涂层

Abstract:

BACKGROUND: Titanium alloy with good biocompatibility, corrosion resistance and mechanical properties have been widely used in clinic. How to give its excellent antibacterial properties so as to cope with plant-associated infections has become a research focus in recent years.
OBJECTIVE: To review the principle, techniques, classification and relative merits of antimicrobial coating.
METHODS: A computer-based search of Scopus database and VIP database was performed by the first author to retrieve relevant articles published from January 1990 to January 2014 using the keywords of “titanium alloy, plant, antibacterial, coating”.
RESULTS AND CONCLUSION: Coatings can be classified into antibiotic coating, non-antibiotic organic antimicrobial coating, inorganic antibacterial coating, anti-adhesion coating, antibacterial bioactive polymer coating, all of which have better biocompatibility, but also have their limitations. Current studies concerning antimicrobial coatings mainly focus on how to enhance the binding force between antimicrobial coating and the substrate as well as how to get a good anti-bacterial ability, biocompatibility, high wear resistance and persistence; antibacterial phase structure and distribution effects on the bacterial colonization. The antibacterial phase structure and distribution is the key factor for the antimicrobial properties of titanium alloys with either entirely added anti-bacterial elements or surface coating.

中国组织工程研究杂志出版内容重点：生物材料；骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性；组织工程

Key words: Biocompatible Materials, Titanium, Polymers

中图分类号:

R318

王家琦，尚剑，孙晔，韩昕光. 钛合金表面抗菌涂层：抗菌能力及生物相容性[J]. 中国组织工程研究, 2015, 19(25): 4069-4075.

Wang Jia-qi, Shang Jian, Sun Ye, Han Xin-guang. Titanium surface covered with antimicrobial coating: antibacterial ability and biocompatibility[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(25): 4069-4075.

图/表（结果） 2

根据涂层的种类可将其分为抗生素类涂层、非抗生素类有机抗菌剂涂层、无机抗菌剂类涂层、抗黏附性涂层、抗菌生物活性聚合物涂层。

2.1 抗生素类涂层全身预防性应用抗生素常应用于内植物手术中^[16]，而抗生素的全身给药有许多缺点，如局部有效药物浓度低及潜在的毒性和耐药性。因此，抗生素类涂层是抗菌材料的早期研究方向，具备抗菌作用快、持续时间长、毒性小等优点^[17]。

20世纪70年代初，抗生素已被融入骨水泥中，在全关节置换术中发挥局部抗菌作用^[18]。内植物涂层可以通过共价键载抗生素以预防感染^[19]。庆大霉素属于氨基糖苷类抗生素的家族，因其具有相对广泛的抗菌谱且是罕见的具有热稳定特性的抗生素，所以它是抗生素类涂层中应用最广泛的一个^[20]。其他具有广泛抗菌谱的抗生素，如头孢菌素、米诺环素、羧苄青霉素、阿莫西林、妥布霉素和万古霉素等已被用于抗菌内植物涂层^[21-23]。

磷酸钙是已知的具有良好生物相容性和骨整合生物活性分子的载体^[24]。抗生素可被加载到多孔羟基磷灰石钛内植物涂层上^[25]，而抗生素羟基磷灰石共聚涂层还存在一些问题，抗生素不能耐受非常高的温度，如高温高压消毒^[26]。钙磷酸盐的表面特性限制了抗生素的载药量和释放特性，即难以在局部稳定缓释有效剂量的抗生素^[27]。据研究表明，可通过磷酸钙晶体在钛内植物表面形成一层共沉淀涂层^[21]，此种方法虽然提高了抗生素的载药量，可以承载传统方法的10倍剂量，但相对于简单的等离子喷涂涂层等技术仍难以做到局部缓释抗生

素^[28-29]。这种聚合物通过溶胶-凝胶方法制备加载庆大霉素的聚乳酸缓释抗生素钛合金涂层，在第1个48 h内，聚乳酸缓释抗生素的速率比磷酸钙减慢80%左右^[30]，而载万古霉素二氧化硅的溶胶-凝胶涂层可以缓释万古霉素长达2周^[31]。

抗生素类涂层在临床应用中仍面临许多难题，内植物表面分离的细菌耐药性测试表明，细菌在内植物局部对抗生素的耐药性是一个问题^[32]。如何选择细菌敏感性强的抗生素负载到内植物表面，如何使其具备较长的抗生素有效缓释时间，如何防止其释放抗生素的浓度低于最低抑菌浓度均应考虑在内。最后，尽管抗生素被认为具有高度的生物相容性，但有些类型的抗生素仍可能损害细胞功能^[33-34]。

2.2 非抗生素类有机抗菌剂涂层相对于抗生素类涂层，非抗生素有机抗菌剂，如洗必泰、氯二甲酚、聚六亚甲基双胍体现出低耐药性的优势^[35-36]。因其广谱抗菌作用和较低耐药性的风险，氯己定在牙科中被广泛应用，例如使用明胶来治疗牙周感染和制备漱口水^[37]。研究表明，洗必泰可吸附到TiO₂层的钛表面且在一段时间内溶解吸收^[38]。有研究比较了几种钛合金负载洗必泰涂层的效果，结论是聚乙酸是相对较好的载药涂层，因为有良好的细胞相容性，相对较慢的药物缓释性，并具有良好的机械性能^[39]。表面诱发矿化技术已被用于制备洗必泰羟基磷灰石涂层外固定针^[40]，洗必泰涂层与抗生素类涂层相似，爆发释放后的一段时间内持续缓慢释放，也可通过离子相互作用，由聚阴离子胶原上的丙烯酸与洗必泰形成共价偶联的涂层^[41]。由于耐药性风险较低，非抗生素类有机抗菌剂可应用于体内相对更长的时间周期。然而有研究表明一些非抗生素类有机抗菌剂有可能导致细胞损伤，尚需要更全面的研究明确其与邻近组织的生物相容性^[42]。类似于抗生素类涂层，尚需研制可以加载这些非抗生素类有机抗菌剂适当的涂层材料，达到令人满意的载药量和受控的药物缓释方式。

2.3 无机抗菌剂类涂层从生物材料掺杂的角度来看无机抗菌剂具有相当大的研究价值，因其具有许多优点，如抗菌能力强，有良好的生物相容性及良好的稳定性。银在各种不同的无机杀菌剂中是最为熟知的，其优点如下：①抗菌谱广范，银在非常低的浓度下可抑制革兰阳性杆菌和革兰阴性杆菌和某些耐药菌^[43]。②银能抑制细菌附着到生物材料表面^[44]。③银的抗菌效果持久^[45]。④虽然机制仍未明确，但银不易产生耐药性^[46]。⑤体外研究表明，载银涂层具有优良的生物相容性，而无遗传毒性和细胞毒性^[47]。体内研究表明，载银涂层无局部或全身不良反应^[48]。⑥因为载银涂层是相对稳定的，可以通过许多公认的技术制备，如等离子体浸没离子注入^[49]、脉冲过滤阴极真空电弧沉积^[50]、物理气相沉积^[51]、磁控溅射^[52]、溶胶-凝胶法等^[53]。⑦银很容易与生物材料掺杂，包括聚合物、生物活性玻璃和陶瓷、金属等^[54]。由于这些优势，银被广泛用于提高钛合金的杀菌能力。如银被离子注入钛和钛-铝-铌合金，以提高其抗菌和磨损性能^[55]。此外，钛/银硬涂层可通过物理气相沉积技术沉积在钛表面^[56]，载银羟基磷灰石涂层通过磁控溅射于钛合金上。载银羟基磷灰石涂层对金黄色葡萄球菌及铜绿假单胞菌有明显抑制作用，无明显细胞毒性。

银能有效抑制细菌附着和生长而不影响成骨细胞和上皮细胞的活性^[56-57](图1)。有研究表明，与未涂覆银的内植物比较，载银内植物表面的细胞培养甚至显示出更好的播散和更高的细胞计数^[58]。另外，银的抗菌能力可通过其他条件(如氮气)进行扩充^[49]。如在用弱直流电阳极电极产生的银离子可以有效抑制细菌生长，阳极极化的镀银钛钉可防止内植物感染^[59]。所以在口腔、烧伤、整形外科、骨科等领域中将载银内植物阳极化处理以提高其抗菌性是可行的。银的抗菌性能是明确的，但其杀菌机制尚不十分明确，一般认为银、锌、铜等抗菌金属阳离子由库仑力的作用吸附于负电位的细菌细胞膜上，积累并破坏细菌细胞膜及细胞壁^[60-61]。这些金属离子可改变细菌细胞膜的通透性，破坏细菌细胞正常代谢，导致细菌死亡。当金属离子穿透细胞壁进入细菌内部后，抑制核酸合成，并使关键蛋白质变性，相关酶失活，也可导致细菌死亡^[62-63]。其他无机类抗菌剂，如铜、氟、钙、氮和锌也可制备于钛合金表面，但并没有像银一样被广泛地应用及研究^[64-65]。究其原因是为没有明显的抗菌性能，并且有相关有不良反应的产生，例如铜离子注入损害了钛的物理特性，诸如耐腐蚀性等^[66](图2)。

2.4 抗黏附性涂层植入物的表面特性，如粗糙度和化学特性、亲水性、表面能、表面电位和电导率等，在细菌的最初黏附和繁殖中发挥至关重要的作用^[67-69]。这些表面特性可以影响细菌数量和吸附的蛋白质，影响随后的细菌黏附和生物膜的形成^[70-71]。抗黏附性的涂层可通过改变这些表面特性来实现。

表面改性的抗黏附性涂层：表面改性是一个相对简单和经济的方式，通过其物理和化学表面性能以消除细菌定植。如紫外光处理的Ti6Al4V合金可良好抑制细菌黏附而不损害人体成骨细胞^[72]，实验表明，钛经紫外光预处理可大幅提高其骨传导能力及抗菌性能^[73]。另一种抗黏附性的涂层可通过改变其表面氧化层的晶体结构来实现。结晶的锐钛型钛氧化物层可显著减少细菌黏附并抑制细菌细胞的代谢活性，这种锐钛型氧化物层具有良好的骨传导能力，可以刺激磷灰石在体液中沉淀，且抗菌性能通过其光催化能力得到提高^[74]。研究证明，细菌黏附到导电表面与衬底的电阻率相关。高选择性吸收钛涂层(INOX)应用于钛合金，以改变其表面的导电性。约10⁴μ? cm的表面电阻率被发现在所有菌株中细菌黏附量最小^[75]，这是一个抗黏附性涂层新的研究方向。

抗黏附性聚合物涂层：可通过简单的方法制备某些聚合物钛合金涂层，例如亲水性聚甲基丙烯酸、聚氧化乙烯^[76]、氮化硅^[77]、聚乙二醇-丙烯酸微凝胶^[78]。这些涂层可显著降低金黄色葡萄球菌和表皮葡萄球菌的附着力，这些涂层拥有良好的抗菌能力且提高了生物活性分子，如丝胶和精氨酸-甘氨酸-天冬氨酸多肽的固化^[79-80]。这些抗黏附性聚合物涂层的主要作用是防止细菌黏附在内植物周围，阻碍生物被膜的形成。迄今未见报道关于通过改变钛合金表面的氧化物层结构来实现令人满意的抗黏附性能力。

2.5 生物活性聚合物涂层生物活性分子，如脱乙酰壳聚糖和透明质酸具有抗细菌黏附和杀菌能力^[81-82]。脱乙酰壳聚糖由壳聚糖的脱乙酰化得到，具备多种生物性质，包括生物相容性、生物降解、生理惰性、抗菌性、抑真菌、抗肿瘤及止血性等^[83]。壳聚糖可促进骨祖细胞的分化，提高其附着、生长、生存力、碱性磷酸酶活性及成骨细胞的表型表达^[84-85]。脱乙酰壳聚糖具有广泛的抗菌谱，因此它被广泛用于人工骨组织、伤口敷料、组织工程支架和各种活性剂的载体^[86]。脱乙酰壳聚糖通过层连接分子被结合到钛合金，可促进成骨细胞的附着和生长^[87]。体内研究表明，与磷酸钙和其他涂层相比，壳聚糖薄膜具有更好的促进骨整合作用^[88]。然而，脱乙酰壳聚糖的键合强度小于磷酸钙涂层^[84]。季胺类化合物与聚合物结合制备的内植物表面涂层，在破坏细菌细胞膜的同时不会损害正常细胞^[89]。一些材料表面纳米结构的功能已被证实能够破坏吸附细菌的蛋白质构象，同时起到对抗细菌黏附的作用^[90]。脱乙酰壳聚糖可以对纳米粒子表面进行修饰，进一步提其抗菌性能、降低细胞毒性^[91]。目前壳聚糖涂层的抗菌能力还没有得到详细评估，但其抗菌性能已被普遍接受。通过电沉积制备的混合磷酸钙/壳聚糖钛合金涂层，其中的壳聚糖可改变磷酸钙涂层的一些物理性质，但又不损害其良好的黏合强度。磷酸钙/壳聚糖涂层已被证实可为局部骨髓基质细胞增殖和成骨细胞分化提供一个良好的接触面，但该混合涂料的抗菌性能没有被详细评估^[92]。

为实现持久的抗菌能力，可通过层-层自组装制备脱乙酰壳多糖和透明质酸聚电解质多层涂层^[82]。与纯钛基相比，聚电解质多层涂层确实可减少细菌黏附约80%。因为透明质酸链的存在，使成骨细胞的黏附性变差，然而用额外的固定化细胞粘接精氨酸-甘氨酸-天冬氨酸多肽部分，可显著提高成骨细胞的黏附性碱性磷酸酶活性^[82]，其可同时提高内植物的抗菌性能和组织整合能力，因此抗菌生物活性聚合物涂层具有很高的研究价值因，然而其在体内的表现尚须进一步研究。

参考文献

[1] Geetha M,Singh AK,Asokamani R,et al.Ti based biomaterials, the ultimate choice for orthopaedic implantsea review. Prog Mater Sci.2009;54:397-425.

[2] 董桂香,李兴华,李慧琰,等.2007-2008年骨科细菌培养及药敏试验的分析[J].中国实用医药,2009,8(4):117-118.

[3] Cristina A.Biomaterial-centered infection:microbial adhesion versus tissue integration.Science.1987; 237(4822): 1588-1595.

[4] Campoccia D,Montanaro L,Arciola CR.The significance of infection related to orthopedic devices and issues of antibiotic resistance.Biomaterials.2006;27:2331-2339.

[5] Uçkay I,Hoffmeyer P,Lew D,et al.Prevention of surgical site infections in orthopaedic surgery and bone trauma: state-of-the-art update.J Hosp Infect.2013;84(1):5-12.

[6] Arciola CR,Campoccia D,Speziale P,et al.Biofilm formation in Staphylococcus implant infections. A review of molecular mechanisms and implications for biofilm-resistant materials. Biomaterials.2012;33(26):5967-5982.

[7] Andrej T,Werner Z.Antimicrobial Agents in orthopaedic Surgery. Drugs.2006; 66(5):1089-1105.

[8] Williams DL,Sinclair KD,Jeyapalina S,et al.Characterization of a novel active release coating to prevent biofilm implant- related infections.J Biomed Mater Res B Appl Biomater. 2013; 101(6):1078-1089.

[9] Monteiro DR,Gorup LF,Takamiya AS,et al.The growing importance of materials that prevent microbial adhesion: antimicrobial effect of medical devices containing silver. Int J Antimicrob Agents.2009;34:103-110.

[10] Speziale P,Pietrocola G,Rindi S,et al.Structural and functional role ofStaphylococcus aureussurface components recognizing adhesive matrix molecules of the host. Future Microbiol.2009;4(10):1337-1352.

[11] Campoccia D,Speziale P,Ravaioli S,et al.The presence of both bone sialoprotein-binding protein gene and collagen adhesin gene as a typical virulence trait of the major epidemic cluster in isolates from orthopedic implant infections. Biomaterials.2009;30(34):6621-6628.

[12] Buchmann R,Khoury F.The microflora recovered from the outer-surfaces of the Frialit-2 implanto-prosthetic connector.Clin Oral Implants Res.2003;14(1):28-34.

[13] Jahoda D,Nyc O,Pokorny D,et al.Antibiotictreatment forpreventionof infectiouscomplications injoint replacement. Acta Chir Orthop Traumatol Cech.2006; 73:108-114．

[14] Bos R,Van Der Mei HC,Busscher HJ.Physico-chemistry of initial microbial adhesive interactions- its mechanisms and methods for study.FEMS Microbiol Rev.1999;23:179-229.

[15] An YH,Friedman RJ,Draughn RA,et al.Rapid quanti?cation of staphylococci adhered to titanium surfaces using image analyzed epifluorescence microscopy.J Microbiol Methods. 1995;24:29-40.

[16] Jahoda D,Nyc O,Pokorny D,et al.Antibiotic treatment for prevention of infectious complications in joint replacement. Acta Chir Orthop Traumatol Cech.2006;73: 108-114.

[17] Hetrick EM,Schoenfisch MH.Reducing implant-related infections: active release strategies.Chem Soc Rev.2006; 35(9):780-789.

[18] Buchholz HW,Engelbrecht H.Uber die Depotwirkung einiger Antibiotika bei Vermischung mit dem Kunstharz Palacos. Chirurg.1970;41:511-515.

[19] Bernthal NM,Stavrakis AI,Billi F,et al.A mousemodel of post-arthroplasty Staphylococcus aureus joint infection to evaluate in vivo the ef?cacy of antimicrobial implant coatings. PLoS One.2010;5:12580.

[20] Alt V,Bitschnau A,Osterling J,et al.The effects of combined gentamicin-hydroxyapatite coating for cementless joint prostheses on the reduction of infection rates in a rabbit infection prophylaxis model.Biomaterials.2006;27:4627-4634.

[21] Stigter M,Bezemer J,de Groot K,et al.Incorporation of different antibiotics into carbonated hydroxyapatite coatings on titanium implants,release and antibiotic efficacy.J Control Release.2004;99:127-137.

[22] Darouiche BO,Mausouri MD,Zakarevicz D,et al.In vivo efficacy of antimicrobial-coated devices.J Bone Joint Surg Am.2007;89:792-797.

[23] Radin S,Campbell JT,Ducheyne P,et al.Calcium phosphate ceramic coatings as carriers of vancomycin.Biomaterials. 1997;18:777-782.

[24] Gautier H,Merle C,Auget JL,et al.Isostatic compression, a new process for incorporating vancomycin into biphasic calcium phosphate: Comparison with a classical method. Biomaterials.2000;21:243-249.

[25] Jahoda D,Nyc O,Pokorny D,et al.Antibiotic treatment for prevention of infectious complications in joint replacement. Acta Chir Orthop Traumatol Cech.2006;73:108-114.

[26] Taylor EN,Webster TJ.The use of superparamagnetic nanoparticles for prosthetic biofilm prevention.Int J Nanomedi. 2009;4:145-152.

[27] Maddikeri RR,Tosatti S,Schuler M,et al.Reduced medical infection related bacterial strains adhesion on bioactive RGD odified titanium surfaces: a first step toward cell selective surfaces．J Biomed Mater Res.2008;84A:425-435.

[28] Zilberman M,Elsner JJ.Antibiotic-eluting medical devices for various applications.J Controll Release.2008;130: 202-215.

[29] Aninwene GE,Yao C,Webster TJ.Enhanced osteoblast adhesion to drug-coated anodized nanotubular titanium surfaces.Int J Nanomedi.2008;3:257-264.

[30] Lucke M,Schmidmaier G,Sadoni S,et al.Gentamicin coating of metallic implants reduces implant-related osteomyelitis in rats.Bone.2003;32:521-531.

[31] Radin S,Ducheyne P.Controlled release of vancomycin from thin sol-gel films on titanium alloy fracture plate material. Biomaterials.2007;28:1721-1729.

[32] Tunney MM,Ramage G,Patrick S,et al. susceptibility of bacteria isolated from orthopedic implants following revision hip surgery.Antimicrob Agents Chemother.1998;42: 3002-3005。

[33] Antoci V Jr,Adams CS,Hickok NJ,et al.Antibiotics for local delivery systems cause skeletal cell toxicity in vitro. Clin Orthop Relat Res.2007;462:200-206.

[34] Ince A,Schutze N,Hendrich C,et al.In vitro investigation of orthopedic titanium-coated and brushite-coated surfaces using human osteoblasts in the presence of gentamycin.J Arthroplasty.2008;23:762-771.

[35] Kim WH,Lee SB,Oh KT,et al.The release behavior of CHX from polymer-coated titanium surfaces.Surf Interface Anal. 2008;40:202-204.

[36] Barbour ME,O’Sullivan DJ,Jagger DC.Chlorhexidine adsorption to anatase and rutile titanium dioxide.Colloids Surf A.2007;307:116-120.

[37] Heasman PA,Heasman L Stacey F,et al.Local delivery of chlorhexidine gluconate (PerioChip) in periodontal maintenance patients.J Clin Periodontol.2001;28:90-95.

[38] Kozlovsky A,Artzi Z,Moses O,et al.Interaction of chlorhexidine with smooth and rough types of titanium surfaces.J Periodontol. 2006;77:1194-1200.

[39] Harris LG,Mead L,Muller-Oberlander E,et al.Bacteria and cell cytocompatibility studies on coated medical grade titanium surfaces.J Biomed Mater Res A.2006;78:50-58.

[40] Campbell AA,Song L,Li XS,et al.Development, characterization, and anti-microbial efficacy of hydroxyapatite-chlorhexidine coatings produced by surface-induced mineralization. J Biomed Mater Res.2000;53: 400-407.

[41] Morra M,Cassinelli C,Cascardo G,et al.Adsorption of cationic antibacterial on collagen-coated titanium implant devices. Biomed Pharmacother.2004;58:418-422.

[42] Ince A,Schutze N,Hendrich C,et al.Effect of polyhexanide and gentamycin on human osteoblasts and endothelial cells.Swiss Med Wkly.2007;137:139-145.

[43] Lee D,Cohen RE,Rubner MF.Antibacterial properties of Ag nanoparticle loaded multilayers and formation of magnetically directed antibacterial microparticles. Langmuir.2005;21: 9651-9659.

[44] Li JX,Wang J,Shen LR,et al.The influence of polyethylene terephthalate surfaces modified by silver ion implantation on bacterial adhesion behavior. Surf Coat Technol. 2007;201: 8155-8159.

[45] Gosheger G,Hardes J,Ahrens H,et al.Silver-coated megaendoprostheses in a rabbit model-an analysis of the infection rate and toxicological side effects.Biomaterials. 2004;25:5547-56.

[46] Percival SL,Bowler PG,Russell D.Bacterial resistance to silver in wound care.J Hosp Infect.2005;60:1-7.

[47] Rojas IA,Slunt JB,Grainger DW.Polyurethane coatings release bioactive antibodies to reduce bacterial adhesion. J Control Release.2000;63:175-189.

[48] Hardes J,Ahrens H,Gebert C,et al.Lack of toxicological side-effects in silvercoated megaprostheses in humans. Biomaterials.2007;28:2869-2875.

[49] Zhang W,Luo Y,Wang H,et al.Ag and Ag/N(2) plasma modification of polyethylene for the enhancement of antibacterial properties and cell growth/proliferation.Acta Biomater.2008;4:2028-2036.

[50] Kwok SCH,Zhang W,Wan GJ,et al.Hemocompatibility and anti-bacterial properties of silver-doped diamond-like carbon prepared by pulsed filtered cathodic vacuum arc deposition.Diamond Relat Mater.2007;16:1353-1360.

[51] Ewald A,Gluckermann SK,Thull R,et al.Antimicrobial titanium/silver PVD coatings on titanium.Biomed Eng Online.2006;5:22.

[52] Chen W,Liu Y,Courtney HS,et al.In vitro anti-bacterial and biological properties of magnetron co-sputtered silver-containing hydroxyapatite coating.Biomaterials. 2006;27:5512-5517.

[53] Chung J,Hsieh MF,Huang CW,et al.Antimicrobial effects and human gingival biocompatibility of hydro-xyapatite sol-gel coatings.J Biomed Mater Res B. 2005;76:169-178.

[54] Vester H,Wildemann B,Schmidmaier Q,et al.Gentamycin delivered from a PDLLA coating of metallic implants in vivo and in vi-tro characterisation for local prophylaxis of implant-related osteo-myelitis.Injury.2010;41(10): 1053-1059.

[55] Wan YZ,Raman S,He F,et al.Surface modification of medical metals by ion implantation of silver and copper.Vacuum. 2007; 81:1114-1118.

[56] Ewald A,Gluckermann SK,Thull R,et al.Antimicrobial titanium/silver PVD coatings on titanium.Biomed Eng Online. 2006;5:22.

[57] Chen W,Oh S,Ong AP,et al.Antibacterial and osteogenic propeffies of silver-containing hydroxyapatite coatings produced using a sol gel process．J Biomed Mater Res A. 2007;82(4):899-906.

[58] Bosetti M,Masse A,Tobin E,et al.Silver coated materials for external fixation devices: In vitro biocompatibility and genotoxicity.Biomaterials.2002;23:887-892.

[59] Secinti KD,Ayten M,Kahilogullari G,et al.Antibacterial effects of electrically activated vertebral implants.J Clin Neurosci. 2008; 15:434-439.

[60] Feng QL,Wu J,Chen GQ,et al.A mechanistic study of the antibacterial effect of silver ions on Escherichia coli and Staphylococcus aureus.J Biomed Mater Res.2000;52: 662-668．

[61] Kim JS,Kuk E,Yu KN,et al.Antimicrobial effects of silver nanoparticles.Nanomedicine.2007;3:95-101.

[62] Li WR,Xie XB,Shi QS,et al.Antibacterial activity and mechanism of silver nanoparticles on Escherichia coli.Appl Microbiol Biotechnol.2010;85:1115-1122．

[63] Kim KJ,Sung WS,Suh BK,et al.Antifungal activity and mode of action of silver nano-particles on Candida albicans.Biometals. 2009;22:235-242．

[64] Yoshinari M,Oda Y,Kato T,et al.Influence of surface modifications to titanium on antibacterial activity in vitro. Biomaterials.2001;22:2043-2048.

[65] Petrini P,Arciola CR,Pezzali I,et al.Antibacterial activity of zinc modified titanium oxide surface.Int J Artif Organs.2006; 29: 434-442.

[66] Jeyachandran YL,Narayandass SK,Mangalaraj D,et al.A study on bacterial attachment on titanium and hydroxyapatite based films.Surf Coat Technol.2006;201:3462-3474.

[67] Wan YZ, Xiong GY, Liang H, et al.Modification of medical metals by ion implantation of copper. Appl Surf Sci 2007; 253:9426-9429.

[68] Chin MY,Sandham A,de Vries J,et al.Biofilm formation on surface characterized micro-implants for skeletal anchorage in orthodontics.Biomaterials.2007;28:2032-2040.

[69] Gottenbos B,van der Mei HC,Klatter F,et al.Positively charged biomaterials exert antimicrobial effects on gram-negative bacilli in rats.Biomaterials.2003;24:2707-2710.

[70] Verran J,Whitehead K.Factors affecting microbial adhesion to stainless steel and other materials used in medical devices.Int J Artif Organs.2005;28:1138-1145.

[71] Legeay G,Poncin-Epaillard F,Arciola CR.New surfaces with hydrophilic/hydrophobic characteristics in relation to (no)bioadhesion.Int J Artif Organs.2006;29:453-461.

[72] Gallardo-Moreno AM,Pacha-Olivenza MA,Saldana L,et al.In vitro biocompatibility and bacterial adhesion of physico- chemically modified Ti6Al4V surface by means of UV irradiation. Acta Biomater.2009;5:181-192.

[73] Aita H,Hori N,Takeuchi M,et al.The effect of ultraviolet functionalization of titanium on integration with bone. Biomaterials.2009;30:1015-1025.

[74] Del Curto B,Brunella MF,Giordano C,et al.Decreased bacterial adhesion to surface-treated titanium.Int J Artif Organs.2005;28:718-730.

[75] Koerner RJ,Butterworth LA,Mayer IV,et al.Bacterial adhesion to titanium-oxy-nitride(TiNOX) coatings with different resistivities: A novel approach for the development of biomaterials.Biomaterials.2002;23:2835-2840.

[76] Roosjen A,Kaper HJ,van der Mei HC,et al.Inhibition of adhesion of yeasts and bacteria by poly(ethylene oxide)-brushes on glass in a parallel plateflow chamber. Microbiology.2003;149(Pt 11):3239-3246.

[77] Gorth DJ,Puckett S,Ercan B,et al.Decreased bacteria activity on Si(3)N(4) surfaces compared with PEEK or titanium.Int J Nanomed.2012;7:4829-4840.

[78] Wang Q,Uzunoglu E,Wu Y,et al.Self-assembled poly(ethylene glycol)-co-acrylic acid microgels to inhibit bacterial colonization of synthetic surfaces.ACS Appl Mater Interfaces. 2012;4(5):2498-2506.

[79] Zhang F,Zhang Z,Zhu X,et al.Silk-functionalized titanium surfaces for enhancing osteoblast functions and reducing bacterial adhesion.Biomaterials.2008;29:4751-4759.

[80] Harris LG,Tosatti S,Wieland M,et al.Staphylococcus aureus adhesion to titanium oxide surfaces coated with non-functionalized and peptide-functionalized poly(L-lysine)- grafted-poly(ethylene glycol) copolymers.Biomaterials. 2004; 25:4135-4148.

[81] Singla AK,Chawla MM.Chitosan: Some pharmaceutical and biological aspects-AN update.J Pharm Pharmacol.2001;53: 1047-1067.

[82] Chua PH,Neoh KG,Kang ET,et al.Surface functionalization of titanium with hyaluronic acid/chitosan polyelectrolyte multilayers and RGD for promoting osteoblast functions and inhibiting bacterial adhesion.Biomaterials.2008;29: 1412-1421.

[83] Kim IY,Seo SJ,Moon HS,et al.Chitosan and its derivatives for tissue engineering applications. Biotechnol Adv.2008;26:1-21.

[84] Bumgardner JD,Wiser R,Gerard PD,et al.Chitosan:potential use as a bioactive coating for orthopaedic and craniofacial/ dental implants.J Biomater Sci Polym Ed. 2003;14:423-438.

[85] Lahiji A,Sohrabi A,Hungerford DS,et al.Chitosan supports the expression of extracellular matrix proteins in human osteoblasts and chondrocytes.J Biomed Mater Res.2000;51: 586-595.

[86] Khor E,Lim LY.Implantable applications of chitin and chitosan. Biomaterials. 2003;24:2339-2349.

[87] Martin HJ,Schulz KH,Bumgardner JD,et al.An XPS study on the attachment of triethoxsilylbutyraldehyde to two titanium surfaces as a way to bond chitosan.Appl Surf Sci.2008;254: 4599-4605.

[88] Bumgardner JD,Chesnutt BM,Yuan Y,et al.The integration of chitosan-coated titanium in bone: an in vivo study in rabbits. Implant Dent.2007;16:66-79.

[89] Milovic NM,Wang J,Lewis K,et al.Immobilized N-alkvlated polyethy- lenimine avidly kills bacteria by rupturing Cell membraves with no resistance developed.Bioeng.2005; 90:715-722．

[90] Montanaro L,Campoccia D,Arciola CR.Nanostructured materials for inhibition of bacterial adhesion in orthopedic implants: a minireview.Int J Artif Organs. 2008;31(9):771.

[91] Jena P,Mohanty S,Mallick R,et al.Toxicity and antibacterial assessment of chitosan-coated silver nanoparticles on human pathogens and macrophage cells.Int J Nanomed.2012;7: 1805-1818.

[92] Wang J,de Boer J,de Groot K.Proliferation and differentiation of MC3T3-E1 cells on calcium phosphate/chitosan coatings.J Dent Res.2008;87:650-654.

[93] Stefánsdóttir A,Johansson A,Lidgren L,et al. Bacterialcolonization and resistance patterns in 133 patients undergoing a primary hip- or knee replacement in Southern Sweden. Acta Orthop 2013;84(1).

[94] Yasunaga H,Tsuchiya K,Matsuyama Y,et al. Analysis of factors affecting operating time, postoperative complications, and length of stay for total knee arthroplasty: nationwide web-based survey. J Orthop Sci.2009;14(1):10-16.

[95] Ridgeway S,Wilson J,Charlet A,et al.Infection of the surgical site after arthroplasty of the hip.J Bone Joint Surg Br.2005; 87(6): 844-850.

[96] Hanssen AD.Managing the infected knee: As good as it gets.J Arthroplasty. 2002;17:98-101.

[97] Ehrlich GD,Stoodley P,Kathju S,et al.Engineering approaches for the detection and control of orthopaedic biofilm infections.Clin Orthop Relat Res.2005;437:59-66.

引言

随着医疗技术的进步和人们生活水平的不断提高，钛合金因其优良的力学性能、强度-质量比、耐腐蚀性及生物相容性，已是广泛应用于临床的内植物材料^[1]。在中国，仅骨折每年的内植物应用就超过500万例^[2]，而内植物相关感染是术后严重并发症之一，难以有效预防和治疗，进而增加了患者的痛苦，这类感染被称之为“生物材料相关感染^[3]”。平均来说，生物材料相关感染的发生率为0.5%-6%^[4]。虽然做了预防细菌污染的各种手术准备，但细菌入侵通常发生在术后。近几十年来，在无菌技术、无菌环境控制及围手术期预防性应用抗生素方面已取得改善的基础上，抗感染内植物材料正逐渐成为一种控制生物材料相关感染主要的手段^[5-6]。
内植物几乎均具有一定粗糙度的表面，以助于骨整合，但粗糙的表面使细菌更容易黏附，增加了机体对病原微生物的易感性，即内植物的存在使发生感染所需细菌的致病数量显著降低^[7]。感染的发生首先需要细菌黏附在内植物表面，形成生物被膜^[8]，细菌本身利用生物膜阻挡机体的免疫作用，而生物被膜形成后又很难被机体消除^[9]。内植物表面的细菌黏附通常通过以下两种方式：细菌、细胞以物理-化学表面相互作用方式被动吸附在内植物材料表面或细菌黏附素介导的活性机制^[10-11]。细菌在形成生物被膜后，常规抗生素治疗通常不能控制生物材料相关感染的发生，如外固定针和牙种植体更容易受到细菌污染，细菌可通过皮肤、黏膜和内植物表面侵入内植物周围的软组织，最终导致生物材料相关感染的发生^[12]。抑制生物被膜的形成，减少细菌在内植物表面的黏附，可有效控制内植物相关感染的发生。若感染已经发生，假体取出通常是根除问题的惟一有效途径^[13]。钛合金自身并不具备抗菌性能，如何将其表面进行抗菌修饰并提高其表面涂层的抗菌性成为近年来的研究热点。
抗菌钛合金涂层是指以钛合金为基体，通过喷涂、溶胶-凝胶、复合镀、离子注入、磁控溅射等工艺将具有抗菌功能的各种材料涂覆在基体上。抗菌钛合金的研究目前集中在以下方面：抗菌涂层随着应用会逐渐被磨耗，无法维持长期的抗菌功效，如何增强抗菌涂层与基体的结合力，并获得良好的抗菌性、生物相容性、高耐磨性、持久性是需要研究的关键问题^[14]；抗菌相结构、分布对于细菌定植的研究，无论是合金整体添加抗菌元素还是表面涂层型钛合金，抗菌相的结构、分布是影响抗菌性能的关键因素^[15-18]。

中国组织工程研究杂志出版内容重点：生物材料；骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性；组织工程