Behavior of dense and porous hydroxyapatite implants and tissue response in rat femoral defects

Osteointegration of porous absorbable bone substitutes: A systematic review of the literature

Biomaterials' structural characteristics and the addition of osteoinductors influence the osteointegration capacity of bone substitutes. This study aims to identify the characteristics of porous and resorbable bone substitutes that influence new bone formation. An Internet search for studies reporting new bone formation rates in bone defects filled with porous and resorbable substitutes was performed in duplicate using the PubMed, Web of Science, Scielo, and University of São Paulo Digital Library databases. Metaphyseal or calvarial bone defects 4 to 10 mm in diameter from various animal models were selected. New bone formation rates were collected from the histomorphometry or micro-CT data. The following variables were analyzed: animal model, bone region, defect diameter, follow-up time after implantation, basic substitute material, osteoinductor addition, pore size and porosity. Of 3,266 initially identified articles, 15 articles describing 32 experimental groups met the inclusion criteria. There were no differences between the groups in the experimental model characteristics, except for the follow-up time, which showed a very weak to moderate correlation with the rate of new bone formation. In terms of the biomaterial and structural characteristics, only porosity showed a significant influence on the rate of new bone formation. Higher porosity is related to higher new bone formation rates. The influence of other characteristics could not be identified, possibly due to the large variety of experimental models and methodologies used to estimate new bone formation rates. We suggest the inclusion of standard control groups in future experimental studies to compare biomaterials.

Bone tissue engineering scaffolding: computer-aided scaffolding techniques

Tissue engineering is essentially a technique for imitating nature. Natural tissues consist of three components: cells, signalling systems (e.g. growth factors) and extracellular matrix (ECM). The ECM forms a scaffold for its cells. Hence, the engineered tissue construct is an artificial scaffold populated with living cells and signalling molecules. A huge effort has been invested in bone tissue engineering, in which a highly porous scaffold plays a critical role in guiding bone and vascular tissue growth and regeneration in three dimensions. In the last two decades, numerous scaffolding techniques have been developed to fabricate highly interconnective, porous scaffolds for bone tissue engineering applications. This review provides an update on the progress of foaming technology of biomaterials, with a special attention being focused on computer-aided manufacturing (Andrade et al. 2002) techniques. This article starts with a brief introduction of tissue engineering (Bone tissue engineering and scaffolds) and scaffolding materials (Biomaterials used in bone tissue engineering). After a brief reviews on conventional scaffolding techniques (Conventional scaffolding techniques), a number of CAM techniques are reviewed in great detail. For each technique, the structure and mechanical integrity of fabricated scaffolds are discussed in detail. Finally, the advantaged and disadvantage of these techniques are compared (Comparison of scaffolding techniques) and summarised (Summary).

Processing and characterization of innovative scaffolds for bone tissue engineering

A new protocol, based on a modified replication method, is proposed to obtain bioactive glass scaffolds. The main feature of these samples, named "shell scaffolds", is their external surface that, like a compact and porous shell, provides both high permeability to fluids and mechanical support. In this work, two different scaffolds were prepared using the following slurry components: 59 % water, 29 % 45S5 Bioglass(®) and 12 % polyvinylic binder and 51 % water, 34 % 45S5 Bioglass(®), 10 % polyvinylic binder and 5 % polyethylene. All the proposed samples were characterized by a widespread microporosity and an interconnected macroporosity, with a total porosity of 80 % vol. After immersion in a simulated body fluid (SBF), the scaffolds showed strong ability to develop hydroxyapatite, enhanced by the high specific surface of the porous systems. Moreover preliminary biological evaluations suggested a promising role of the shell scaffolds for applications in bone tissue regeneration. As regards the mechanical behaviour, the shell scaffolds could be easily handled without damages, due to their resistant external surface. More specifically, they possessed suitable mechanical properties for bone regeneration, as proved by compression tests performed before and after immersion in SBF.

Macroporous bioceramics: A remarkable material for bone regeneration

This review summarises the major developments of macroporous bioceramics used mainly for repairing bone defects. Porous bioceramics have been receiving attention ever since their larger surface area was reported to be beneficial for the formation of more rigid bonds with host tissues. The study of porous bioceramics is important to overcome the less favourable bonds formed between dense bioceramics and host tissues, especially in healing bone defects. Macroporous bioceramics, which have been studied extensively, include hydroxyapatite, tricalcium phosphate, alumina, and zirconia. The pore size and interconnections both have significant effects on the growth rate of bone tissues. The optimum pore size of hydroxyapatite scaffolds for bone growth was found to be 300 µm. The existence of interconnections between pores is critical during the initial stage of tissue ingrowth on porous hydroxyapatite scaffolds. Furthermore, pore formation on β-tricalcium phosphate scaffolds also allowed the impregnation of growth factors and cells to improve bone tissues growth significantly. The formation of vascularised tissues was observed on macroporous alumina but did not take place in the case of dense alumina due to its bioinert nature. A macroporous alumina coating on scaffolds was able to improve the overall mechanical properties, and it enabled the impregnation of bioactive materials that could increase the bone growth rate. Despite the bioinertness of zirconia, porous zirconia was useful in designing scaffolds with superior mechanical properties after being coated with bioactive materials. The pores in zirconia were believed to improve the bone growth on the coated system. In summary, although the formation of pores in bioceramics may adversely affect mechanical properties, the advantages provided by the pores are crucial in repairing bone defects.

Effects of ethanol on the osteogenesis around porous hydroxyapatite implants

Alcohol consumption compromises bone tissue, and thus may either impair or stop the fixation and maintenance of osseointegrated implants. To evaluate the effects of 5% and 15% ethanol on bone neoformation around porous hydroxiapatite implants. Fifteen rats were separated into 3 groups of 5 animals each: control (CT); 5% alcohol (A); and 15% alcohol (AA). After four weeks of ethanol consumption, the rats received porous hydroxiapatite implants into surgically made cavities in the femur. After surgery, the animals continued to consume ethanol until day 90 of the experiment, when they were euthanised and their femurs removed for histological processing. Bone tissue was found around the ceramic specimens of all the animals. The largest volume of neoformed bone around ceramic specimens occurred in the CT group, and the smallest in the AA group, followed by the A group. It was concluded that ethanol consumption produced a negative effect on osteogenesis around hydroxyapatite implants. Even small doses, such as the 5% ethanol dilution can interfere with bone repair.

A New Highly Bioactive Composite for Scaffold Applications: A Feasibility Study

Hydroxyapatite (HA) has been widely investigated as scaffolding material for bone tissue engineering, mainly for its excellent biocompatibility. Presently, there is an increasing interest in the composites of hydroxyapatite with bioactive glasses, with the aim to obtain systems with improved bioactivity or mechanical properties. Moreover, modifying the ratio between bioactive glass and hydroxyapatite results in the possibility of controlling the reaction rate of the composite scaffold in the human body. However, high temperature treatments are usually required in order to sinter HA-based composites, causing the bioactive glass to crystallize into a glass-ceramic, with possible negative effects on its bioactivity. In the present research work, a glass composition belonging to the Na₂O-CaO-P₂O₅-SiO₂ system, with a reduced tendency to crystallize, is applied to realize HA-based composites. The novel samples can be sintered at a relative low temperature (750 °C) compared to the widely studied HA/45S5 Bioglass^® composites. This fact greatly helps to preserve the amorphous nature of the glass, with excellent effects in terms of bioactivity, according to in vitro tests. As a first application, the obtained composites are also tested to realize highly porous scaffolds by means of the standard burning out method.

Clinical result of sintered bovine hydroxyapatite bone substitute: analysis of the interface reaction between tissue and bone substitute

BACKGROUND

Autogenic bone graft is the first choice for managing bone defects. However, donor site-associated morbidity and limited bone volume are constraints in clinical applications. Allografts can provide sufficient amounts for bone defects but have a high risk of infection. Bone substitute composed of hydroxyapatite (HA) is an alternative material for avoiding the aforementioned risks. Sintered bovine bone is a naturally occurring HA that has been proved to have excellent bioactivity for inducing osteoblastic expression and new bone formation in animal studies. The objective of this study was to evaluate the interactions between the tissue and the bone substitute composed of HA (sintered from bovine bone) in the human body.

METHODS

From 2003 to 2005, a total of 33 patients were enrolled to receive the sintered bovine HA as a bone substitute. Inclusion criteria were fractures with bony defects, benign bone tumors with a cavity, and spinal fusions. Bone healing was monitored by a series of radiographs, and bone microstructure was checked by scanning electron microscopy (SEM) and von Kossa staining.

RESULTS

In 81.8% (27/33) of cases, significant fusion mass formation was visible in the radiographs after 6-12 months. New bone formation on the surface of the sintered bovine HA was seen under microscopic observation. Tight bonding between the interface of the bone and the sintered bovine HA was shown with SEM/energy-dispersive spectroscopy and von Kossa staining.

CONCLUSIONS

Sintered bovine HA is a suitable material as a bone substitute to provide bone growth and promote bone healing.

Effects of granule size on the osteoconductivity of bovine and synthetic hydroxyapatite: a histologic and histometric study in dogs

Two bovine hydroxyapatites (BHAs), one with granule size of 150 to 200 microm and one with granule size of 300 to 329 micro, and 2 synthetic hydroxyapatites (SHAs), with granule size of 150 and 300 microm, respectively, were compared for effectiveness in repairing circumferential bone defects in dogs. The hydroxyapatites (HAs) were characterized through powder x-ray diffraction (XRD) analysis and scanning electron microscopy (SEM). Three trephined bone defects (5.0 mm wide x 4 mm long) were created in the humeruses of 8 dogs. In a random manner, the defects on each side were treated with either BHA with small granules (BHA[s]), BHA with large granules (BHA[L]), SHA with small granules (SHA[s]), SHA with large granules (SHA[L]), or left to heal unaided (bilateral control). Four dogs were sacrificed after 6 and 12 postoperative weeks, respectively. Ground sections of each defect were submitted to histologic and histomorphometric analysis (percentage of area occupied by bone, bone marrow, and biomaterial). As a rule, the HA granules exhibited direct bone contact, regardless of the origin and the size of the granules. Control sites were related and had an increased amount of connective tissue infiltration. At 12 weeks, BHA(s) exhibited improved bone formation compared with SHA(s) and SHA(L). The SHA(s) delivered reduced amounts of bone compared with the remaining groups (control included). The area of bone measured in BHA(s) sites was significantly higher at 12 weeks than 6 weeks. The XRD revealed the tested HA samples to be highly crystalline, while BHA appeared with rougher surface at SEM analysis. The BHA(s) performed better than the SHA(s) and SHA(L), as assessed by the amount of bone measured in both implantation sites at 12 weeks. The BHA's material characteristic itself rather than granules size accounted for the distinctive biological behavior. The increased roughness of the BHAs' surface, as assessed through SEM, seemed to benefit the osteoconduction process.

Repair of Cranial Bone Defects With Calcium Phosphate Ceramic Implant or Autogenous Bone Graft

Autogenous bone grafts have frequently been used in the treatment of bone defects; however, this procedure can cause clinical complications after surgery. Besides, the amount of available bone is sometimes insufficient. Therefore, synthetic biomaterials have been researched as an alternative to autogenous bone graft implants. The objective of this study was to evaluate the repair of bone defects treated with compact autogenous bone graft or porous calcium phosphate ceramics. Three defects 3 mm in diameter were produced in the skull of 21 rats. One the defects was produced in the frontal bone, which remained empty, while the others were produced in the right and left parietal bones, which were filled respectively with ceramics and autogenous bone graft. The animals were sacrificed 1, 2, 4, and 24 weeks after surgery and analyzed by light microscopy and radiography. In the twenty-fourth week, the defects filled with autogenous bone graft and ceramics had similar volumes of newly formed bone tissue. The ceramics offered favorable conditions to bone tissue growth. Thus, we concluded that the calcium phosphate ceramic implant proved to be effective in repairing defects produced in the skull of rats.

Macroporous bioactive glass-ceramic scaffolds for tissue engineering

Highly bioactive scaffolds for tissue engineering were synthesized using a glass belonging to the SiO2-CaO-K2O (SCK) system. The glass SCK was prepared by a traditional melting-quenching route and its bioactivity was assessed by in vitro tests in a simulated body fluid (SBF). The glass was ground and sieved to obtain powders of specific size that were subsequently mixed with polyethylene particles of two different dimensions. The powders were then uniaxially pressed to obtain a crack free green compact that was thermally treated to remove the organic component and to sinter the inorganic phase. The obtained biomaterial was characterised by means of X-ray Diffraction, SEM equipped with EDS, mercury intrusion porosimetry, density measurements, image analysis, mechanical tests and in vitro evaluations. A glass-ceramic macroporous scaffold with a homogenously distributed and highly interconnected porosity was obtained. The amount and size of the introduced porosity could be tailored using various amounts of polyethylene powders of different size.

The structure of the bond between bone and porous silicon-substituted hydroxyapatite bioceramic implants

The significance of micrometer-sized strut porosity in promoting bone ingrowth into porous hydroxyapatite (HA) scaffolds has only recently been noted. In this study, silicon-substituted HA (0.8 wt % Si-HA) with approximately 8.5% of the total porosity present as microporosity within the struts of the implant was prepared for high-resolution transmission electron microscopy (HR-TEM) via both ultramicrotomy and focused ion beam milling. Between the struts of the porous Si-HA, pores with varying shapes and sizes (1-10 microm in diameter) were characterized. Within the struts, the Si-HA contained features such as grain boundaries and triple-junction grain boundaries. Bone ingrowth and dissolution from a Si-HA implant were studied using HR-TEM after 6 weeks in vivo. Minor local dissolution occurred within several pores within the struts. Organized, mineralized collagen fibrils had grown into the strut porosity at the interface between the porous Si-HA implant and the surface of the surrounding bone. In comparison, deeper within the implant, disorganized and poorly mineralized fibers were observed within the strut porosity. These findings provide valuable insight into the development of bone around porous Si-HA implants.

Evaluation of substitutes for bone: comparison of microradiographic and histological assessments

We created defects of standard size in the frontal bones of adult pigs and filled them with four different materials. On six occasions (at 1, 2, 4, 8, 12, and 26 weeks), samples were harvested, and evaluated by computing microradiographic images. We examined the specimens histologically as controls. After insertion of anorganic materials, microradiographic evaluation was easy and precise, and there were no significant differences between them and the histological controls (p=0.2). A quantitative evaluation of chemically sterilised bone by computer was not possible for more than 4 weeks.

How we do it: modified Wehrs incus ossiculoplasty

Keypoints * Ossiculoplasty is commonly performed as part of tympanoplasty. Hydroxyapatite is a favoured material for ossicular protheses. * A modification to the Wehrs incus prosthesis is described. * Twenty-one procedures were performed on 20 patients and the results are reported. * On average there was a 4-5 dB closure of the air-bone gap (ABG), with patients having a hearing gain procedure averaging 11 dB closure. Air-bone gap closure to <or=20 dB was achieved between 78% (0.5, 1, 2 kHz average) and 60% (0.5, 1, 2, 4 kHz average) of patients and this was stable during long-term follow-up of the ABG. * Wehrs incus prosthesis ossiculoplasty provides a reliable result following ossiculoplasty when autograft incus is not available.

Small-animal models for testing macroporous ceramic bone substitutes

The aim of this study was to compare the bone colonization of a macroporous biphasic calcium phosphate (MBCP) ceramic in different sites (femur, tibia, and calvaria) in two animal species (rats and rabbits). A critical size defect model was used in all cases with implantation for 21 days. Bone colonization in the empty and MBCP-filled defects was measured with the use of backscattered electron microscopy (BSEM). In the empty cavities, bone healing remained on the edges, and did not bridge the critical size defects. Bone growth was observed in all the implantation sites in rats (approximately 13.6-36.6% of the total defect area, with ceramic ranging from 46.1 to 51.9%). The bone colonization appeared statistically higher in the femur of rabbits (48.5%) than in the tibia (12.6%) and calvaria (22.9%) sites. This slightly higher degree of bone healing was related to differences in the bone architecture of the implantation sites. Concerning the comparison between animal species, bone colonization appeared greater in rabbits than in rats for the femoral site (48.5% vs. 29.6%). For the other two sites (the tibia and calvaria), there was no statistically significant difference. The increased bone ingrowth observed in rabbit femurs might be due to the large bone surface area in contact with the MBCP ceramics. The femoral epiphysis of rabbits is therefore a favorable model for testing the bone-bonding capacity of materials, but a comparison with other implantation sites is subject to bias. This study shows that well-conducted and fully validated models with the use of small animals are essential in the development of new bone substitutes.