Fully porous 3D printed titanium femoral stem to reduce stress-shielding following total hip arthroplasty

Strain shielding effect analysis of solid and porous Ti-6Al-4V alloy implanted femur bone using finite element analysis

In the proposed work, strain shielding effect analysis of solid and porous Ti-6Al-4V alloy implanted femur bone using finite element analysis is carried out. Strain shielding is a significant concern during total hip arthroplasty (THA) since it reduces bone growth and results in aseptic implant loosening due to the mismatch of femur and implant characteristics. The study examined solid and porous implanted femur bone under three loading conditions: standing, walking and stair climbing. The results show that strains on bone due to porous implants as compared to solid implants have been increased by 31, 24.3% and reduced by 12.18% for standing, walking, and stair climbing human activities, respectively. The findings show that porous implants promote bone growth and reduce aseptic implant loosening by lowering the strain and stress shielding effect.

Mandibular Implants: A Metamaterial-Based Approach to Reducing Stress Shielding

Biomechanical complications, such as stress shielding, bone resorption, and reconstruction failure, are prevalently associated with solid titanium mandible reconstruction plates. This study evaluates the potential of metamaterial designs with porous gyroid microarchitectures, to enhance biomechanical stimulation and mitigate these complications. A novel metamaterial reconstruction plate is compared with solid titanium plates, both patient-specifically designed and fabricated from Ti6Al4 V alloy. Stress shielding is assessed through photoelasticity experiments and validated with finite element analysis (FEA). Transparent mandible models are loaded incrementally (0-1000 N) to analyze stress distributions in the implants, screws, and mandible segments. The metamaterial plate reduces stress concentrations in the distant mandibular regions from the defect, while increasing stress around the screws near the defect, favoring local mechanical stimulation. FEA confirms improved load distribution (p = 0.003). However, the metamaterial plate exhibited a lower load-bearing capacity, failing at 775 N, while the solid plate withstood 1800 N without failure. Yet, the metamaterial design effectively reduced stress shielding, thereby enhancing biomechanical function near critical mandibular regions. Hence, despite their reduced load-bearing capacity, they can, potentially, preserve bone integrity and prevent implant failure that should be validated in future (pre-)clinical studies.

Effectiveness of Stress Shielding Prevention Using a Low Young's Modulus Ti-33.6Nb-4Sn Stem: A 7-Year Follow-Up Study

BACKGROUND

Stress shielding (SS) after total hip arthroplasty (THA) leads to proximal femoral bone loss and increases the risk of complications such as implant loosening and periprosthetic fracture. While various low-stiffness stems have been developed to prevent SS, they often compromise mechanical stability. A novel femoral stem composed of Ti-33.6Nb-4Sn (TNS) alloy offers a gradually decreasing Young's modulus from proximal to distal regions, potentially improving load distribution and reducing SS. This study aimed to evaluate the mid-term clinical and radiographic outcomes of the TNS stem, with a particular focus on its effectiveness in suppressing SS.

METHODS

A prospective clinical study was conducted involving 35 patients who underwent THA using the TNS stem, with a minimum follow-up of 7 years. Twenty-one patients with Ti6Al4V metaphyseal-filling stems served as controls. Clinical outcomes were assessed using Japanese Orthopaedic Association (JOA) scores, and radiographic SS was graded using Engh's classification and analyzed in Gruen zones. Inter-examiner reliability and statistical comparisons between groups were performed using appropriate tests.

RESULTS

The TNS group showed significantly higher preoperative JOA scores than the control group, but no significant difference in final scores. Both groups demonstrated significant improvement postoperatively. Third-degree SS occurred in the TNS group, although the overall SS grade distribution was significantly lower than in the control group (p = 0.03). SS frequency was significantly reduced in Gruen Zones 2, 3, and 6 in the TNS group.

CONCLUSIONS

The TNS stem demonstrated a significant reduction in SS progression compared to conventional titanium stems over a 7-year period, with comparable clinical outcomes. However, the occurrence of third-degree SS indicates that material optimization alone may be insufficient, highlighting the need for further design improvements.

A Neural Network-Accelerated Approach for Orthopedic Implant Design and Evaluation Through Strain Shielding Analysis

The design of orthopedic implants is a complex challenge, requiring the careful balance of mechanical performance and biological integration to ensure long-term success. This study focuses on the development of a porous femoral stem implant aimed at reducing stiffness and mitigating stress shielding effects. To accelerate the design process, neural networks were trained to predict the optimal density distribution of the implant, enabling rapid optimization. Two initial design spaces were evaluated, revealing the necessity of incorporating the femur's anatomical features into the design process. The trained models achieved a median error near 0 for both conventional and extended design spaces, producing optimized designs in a fraction of the computational time typically required. Finite element analysis (FEA) was employed to assess the mechanical performance of the neural network-generated implants. The results demonstrated that the neural network predictions effectively reduced stress shielding compared to a solid model in 50% of the test cases. While the graded porosity implant design did not show significant differences in stress shielding prevention compared to a uniform porosity design, it was found to be significantly stronger, highlighting its potential for enhanced durability. This work underscores the efficacy of neural network-accelerated design in improving implant development efficiency and performance.

Latest advancements and trends in biomedical polymers for disease prevention, diagnosis, treatment, and clinical application

Biomedical polymers are at the forefront of medical advancements, offering innovative solutions in disease prevention, diagnosis, treatment, and clinical use due to their exceptional physicochemical properties. This review delves into the characteristics, classification, and preparation methods of these polymers, highlighting their diverse applications in drug delivery, medical imaging, tissue engineering, and regenerative medicine. We present a thorough analysis of the recent advancements in biomedical polymer research and their clinical applications, acknowledging the challenges that remain, such as immune response management, controlled degradation rates, and mechanical property optimization. Addressing these issues, we explore future directions, including personalization and the integration of nanotechnology, which hold significant potential for further advancing the field. This comprehensive review aims to provide a deep understanding of biomedical polymers and serve as a valuable resource for the development of innovative polymer materials in both fundamental research and clinical practice.

An integrated experimental and analytical approach for the analysis of the mechanical interaction between metal porous scaffolds and bone: implications for stress shielding in orthopedic implants

Introduction

Metal porous structures are becoming a standard design feature of orthopedic implants such as joint endoprostheses. The benefits of the pores are twofold: 1) help improve the cementless primary stabilization of the implant by increasing osteointegration and 2) reduce the overall stiffness of the metal implant thus minimizing stress-shielding. While the mechanical interaction between porous implants and bone has been extensively investigated via complex numerical and finite element models, scarce is the in vitro and in vivo data on the effect of porosity and materials on stress and strain distribution in the implant-bone compound.

Materials and methods

An integrated numerical and experimental approach was used to investigate the effect of material and porosity on the mechanical interaction in compression between porous metal scaffolds and bovine cortical bone. 18 × 18 × 6 mm cuboid samples were cut from fresh-frozen bovine cortical bones. A 9 × 6 × 6 cavity was obtained in each sample to allow insertion of CoCrMo porous and full density scaffolds. Digital Image Correlation analysis tracked bone strain during axial compression of the scaffold-bone samples up to bone failure. The experimental strain data were compared to those from finite element analysis (FEA) of the scaffold-bone compound. The effect of scaffold porosity and material - Ti6Al4V and CoCrMo - on bone strain distribution and reactions forces, with respect to full bone samples, was assessed via FEA and an analytical spring-based model of the bone-scaffold compound.

Results

The experimental data revealed that the porous scaffold resulted in bone strain closer to that of the intact bone with respect to full density scaffolds. FEA showed that Ti6Al4V scaffolds result in bone strain and reaction forces closer to the those in the intact bone with respect to those in CoCrMo scaffolds. The 1,000 µm pores scaffolds resulted significantly more effective in improving reaction forces with respect to the 500 µm pores scaffolds.

Conclusion

The present findings confirm that metal porous scaffolds help promote a more uniform distribution to the bone compared to full density implants. Ti6Al4V scaffolds demonstrated a more favorable mechanical interaction compared to CoCrMo. This integrated approach offers valuable insights into the design of orthopedic implants with optimized mechanical and osseointegration properties.

Comprehensive review of 3D printing techniques emphasizing thermal characterization in biomedical prototyping

The rapid advancement of 3D printing technology has revolutionized biomedical engineering, enabling the creation of complex and personalized prototypes. Thermal properties play a crucial role in the performance and safety of these biomedical devices. Understanding their thermal behavior is essential for ensuring their effectiveness, reliability, and compatibility with the human body. This review article aims to provide a comprehensive overview of the thermal properties of 3D printed biomedical prototypes. It categorizes these prototypes based on thermal characteristics, examines the thermal attributes of various 3D printing materials, explores the thermal considerations for different biomedical devices, and identifies the challenges and future prospects in this dynamic field.

The 3D-Printed Customized Femoral Short Stem Offers Improved Anatomical Parameters Restoration, Fitness and Biomechanical Performance Compared With Traditional Femoral Stem

OBJECTIVE

The traditional femoral stem is unsuitable for patients with severe proximal femoral bone defects or deformities. However, 3D-printed customized designs offer improved proximal femoral canal contact and enhance the initial stability of the femoral prosthesis. Therefore, this study aims to compare the anatomical parameters, contact parameters, and performance of the 3D-printed customized femoral short (CFS) stem with those of the traditional femoral stem following total hip arthroplasty (THA).

METHODS

An in vitro study simulating THA was performed using artificial femur models, with a 3D-printed CFS stem as the experimental group and a Trilock stem as the control group. Anatomical parameters, fitness, filling, micro-motion, and strain distribution were evaluated using artificial femoral models. Micro-motion and strain were recorded under different simulated bodyweight loading using a 3D digital image correlation measurement system.

RESULTS

The neck-shaft angles (NSA) and coronal femoral horizontal offset (CFHO) of the 3D-printed CFS stem (NSA: 125.22°, CFHO: 41.03 mm) were closer to those of the intact femur (NSA: 127.37°, CFHO: 43.27 mm) compare with the Trilock stem (NSA: 132.61°, CFHO: 32.98 mm). In addition, the 3D-printed CFS stem showed improved fitness at cross-sections (The top of the lesser trochanter: 6.31%, the middle of the lesser trochanter: 23.42%, the bottom of the lesser trochanter: 26.61%) and reduced micro-motion under different simulated bodyweight loads (1000: 0.043, 1375: 0.056, 2060 N: 0.061 mm).

CONCLUSIONS

The 3D-printed CFS stem provides improved restoration of anatomical parameters, enhanced fitness, and superior biomechanical performance compared with the Trilock stem.

High subsidence rate in primary total hip arthroplasty with a taper wedge stem featuring a three-dimensionally printed porous structure

INTRODUCTION

Femoral stem subsidence (FSS) following total hip arthroplasty (THA) can lead to complications such as aseptic loosening and early implant failure. This study evaluated the subsidence and clinical outcomes of the GS-Taper stem, a taper wedge stem using a three-dimensional (3D)-printed porous structure, in primary THA cases.

MATERIALS AND METHODS

This retrospective analysis was conducted in 112 hips that underwent THA using the GS-Taper stem between October 2020 and May 2023, with follow-up at 1 year postoperatively. The primary outcome was the evaluation of FSS and its relationship with neck length, canal fill ratio, and stem alignment. Secondary outcomes included clinical scores assessed using the modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and University of California, Los Angeles activity scores, as well as radiographic findings such as periprosthetic bone reactions, including stress shielding, radiolucent lines, and spot welds.

RESULTS

The mean subsidence at 1 year postoperatively was 3.4 ± 3.0 mm, with 55 hips showing subsidence ≥ 3 mm (FSS group) and 57 hips showing subsidence < 3 mm (non-FSS group). The FSS group demonstrated significantly shorter neck length, lower canal fill ratio, valgus positioning, and a higher proportion of medial gaps compared to the non-FSS group. Radiographic analysis revealed increased radiolucent lines and stress shielding in Gruen zone 1 in the FSS group. The FSS group had significantly worse clinical outcomes and a higher incidence of thigh pain than the non-FSS group.

CONCLUSIONS

The GS-Taper stem exhibited a high rate of subsidence, potentially due to its 3D-printed porous structure and micro-spike configuration. These findings highlight the need for design modifications to improve initial stability and biological fixation.

Developing porous hip implants implementing topology optimization based on the bone remodelling model and fatigue failure

In contemporary orthopaedic practice, total hip arthroplasty (THA) is a reliable surgical technique for hip joint replacement. However, introducing solid implants into human bone tissue can lead to complications, notably stress shielding and cortical hypertrophy. These issues often stem from mechanical mismatches, particularly stiffness disparities, between the solid implants and the bone tissue. A potential solution lies in adopting porous implant structures with lower stiffness and tuneable mechanical properties based on morphological parameters such as porosity, relative density, and unit cell sizes. This study, which is of significant importance to orthopaedic implant development, aims to develop porous implants that meet biological and manufacturing requirements, employing topology optimization methods to address the challenges associated with conventional solid implants. To achieve this objective, we conducted finite element analyses to compare the stress distribution within healthy bones with solid and newly developed porous implants under real-life loading conditions. The porous implants were designed with triply periodic minimal surface structures, featuring uniform relative density and gradient relative density mapping derived from topology optimization results considering additive manufacturing capabilities and biological constraints. Our findings provide critical insights into the impact on the bone's mechanical environment about the choice of implant. Specifically, solid implants significantly decrease applied stress within the cortical bone, leading to stress shielding and subsequent bone resorption, consistent with bone remodelling principles and Wolff's law. However, replacing the solid implant with uniform porosity with maximum compliance and employing gradient porous implants based on topology optimization methods significantly increases the strain energy density ratio. Specifically, the uniform gyroid, uniform diamond, gradient gyroid, and gradient diamond stems exhibited increases of 43%, 39%, 27%, and 25%, respectively, compared to the solid stem, effectively mitigating the stress shielding effect. However, amongst porous stems, only gradient designs could meet the mechanical strength requirements with a safety factor greater than one, rendering them suitable replacements for solid implants aimed at addressing associated complications. These results hold promise, particularly with the advancements in additive manufacturing methods capable of fabricating these porous implants with acceptable precision.

Complications and Long-Term Outcome in 30 Canine Total Hip Arthroplasties Using a Second-Generation Selective Laser Melted Screw Cup

OBJECTIVE

 The aim of this study was to report complications and outcomes of a cementless total hip arthroplasty (THA) system with a second-generation selective laser-melted screw cup (SCSL).

STUDY DESIGN

 All THA using the SCSL performed at a single institution between January 2017 and November 2022 were retrospectively evaluated. Patients with a minimum follow-up period of 12 months and complete medical records were included and analyzed for radiographic and clinical outcomes.

RESULTS

 Thirty THA with SCSL in 23 dogs were included in this study. Complications were observed in seven hips, comprising two minor and five major complications, with two hips experiencing two major complications. Among these seven major complications, six were associated with the femoral implant and one involved cup luxation. Of the 30 THA, 4 were explanted, while 26 remained in place for a median follow-up of 17.5 months (range, 12-38 months).

CONCLUSION

 No cases of late aseptic loosening were observed with SCSL. THA using SCSL helps reduce cup-associated complications and is appropriate for THA surgery, and the overall complication rate is comparable with that of other single-implant systems. Nevertheless, four hips were explanted.

Multi-scale topology optimisation design and mechanical property analysis of porous interbody fusion cage

BackgroundTitanium (Ti) and polyether ether ketone (PEEK) interbody fusion cages cause postoperative stress shielding problems. The porous cage design is one of the solutions advanced to mitigate this problem.ObjectiveExploring the mitigation of stress shielding with a porous interbody fusion cage after surgery for idiopathic scoliosis.MethodsThe porous interbody fusion cage was constructed based on the multiscale topology optimisation method, and the postoperative lumbar spine models implanted with it. The porous Ti and PEEK fusion cages were evaluated under physiological conditions to investigate their mechanical properties.ResultsThe volume of the porous fusion cage was reduced by 52.57%, and the stress was increased by 242.76% and 252.46% compared with the Ti and PEEK fusion cage; the modulus of elasticity of the porous fusion cage was reduced by 76.85%, and the strain was increased by 131.40%∼686.51% compared with the Ti cage; the porous fusion cage increased L3 cortical bone stress by 13.36% and 13.52% and cancellous bone by 82.93% and 76.72%, respectively, compared with the original interbody fusion cages.ConclusionThe porous interbody fusion cage has a much more lightweight design which facilitates growth of bone tissue. However, a frame structure should be constructed to minimize issues with stress peaks and localised stress concentrations. It also has a significantly lower stiffness which helps alleviate vertebral stress shielding, further fostering bone growth. The porous fusion cage thus meets the clinical requirements for better fusion outcomes.

Biomechanical properties of tetrahedral microstructure for design of the porous stem in total hip arthroplasty

Different internal strut architectures affect the biomechanical performance of porous lattice structures. This study aims to investigate these properties under various conditions using different methods.The finite element simulations of tetrahedral microstructures were conducted with varying internal strut thicknesses under different loads. The effective elastic modulus from compression tests aligned with the homogenization results. However, both the number and size of unit cells can influence the modulus at identical porosity levels. Smaller unit cell sizes demonstrated superior mechanical properties while utilizing less material.

Pathomorphological features of the proximal femur in crowe IV hips and their implication on stem selection during total hip arthroplasty

BACKGROUND

The best stem type and location for femoral shortening in high-riding developmental dysplasia of the hip (DDH) in not clear. We evaluated the morphology of the proximal femur on EOS™ images, focusing on the anatomical landmarks and measurements relevant to the stem selection in high-riding DDH. Our goal is to identify and define the differences in the anatomy of the proximal femur between patients with Crowe type IV DDH and normal individuals, in order to determine the appropriate neck cut location in these patients to increase the chances of successfully using a wedge femoral stem.

METHODS

EOS™ images of 40 hips with Crowe type-IV DDH and 40 normal hips were included. The distances between the tip of the greater trochanter and vastus ridge (GT-VR), vastus ridge and proximal border of lesser trochanter (VR-LT), greater- and lesser trochanters (GT-LT), base width of the LT, and the proportion of these distances to the femoral length were evaluated. Canal Flare Index (CFI) was also measured, at two different levels.

RESULTS

The mean GT-LT index was not different between the two groups (p = 0.46). The GT-VR index was smaller in the case group (p < 0.001), while the VR-LT index was greater (p < 0.001). The LT base width index was larger in the case group (P < 0.001). CFI was smaller at the LT level in dysplastic hips (P < 0.001), but the values were similar with a cut 1.5 cm above the LT (P = 0.67).

CONCLUSION

In Crowe IV hips, the GT height is shorter and the LT is located far more distally along the femoral metaphysis, resulting in a narrower canal width at the upper border of the lesser trochanter. Also, the CFI at the LT level is smaller, and to fit a wedge stem, the neck cut should be made at a higher level.

Calcium sulfate-based load-bearing bone grafts with patient-specific geometry

The treatment of bone defects with complex three-dimensional geometry presents challenges in terms of bone grafting and restoration. In this paper, we propose a rapid and effective method that uses 3D printing, ceramic casting, and the incorporation of mesh reinforcement to create load-bearing bone grafts with patient-specific three-dimensional geometry. Using two types of facial bones as examples, we show that this fabrication method has a high degree of geometrical fidelity. We also experimentally study the fracture behavior of six different architectures designed for the treatment of mandibular defects, one of the principal load-bearing facial bones. These design configurations include un-reinforced calcium sulfate samples, and samples reinforced with one or two layers of stainless steel, poly (lactic acid), and poly (L-lactic acid). The results suggested a trade-off between energy dissipation and maximum load based on the position of the metal mesh in the sample. Samples reinforced with one layer of metallic mesh at their lowermost margin exhibited a 17% higher stiffness and a 21.3% higher peak load, while samples with a layer of metal mesh embedded within dissipated 16% more energy. Samples with two layers of metallic mesh demonstrated the highest improvements among all samples, dissipating 5767.85% more energy and exhibiting a peak load 145.6% higher compared to plain CS. The improvements in stiffness for SD, SL, and S2 were 3%, 21.3%, and 21.9% respectively compared to the plain ceramic. In contrast, PLA mesh improved energy dissipation by 96.71% but reduced the peak load by 29.18%, while PLLA mesh decreased both the peak load and the dissipated energy by 13.05% and 35.31%, respectively. While PLA mesh reduced stiffness by 11% compared to plain CS, PLLA mesh-reinforced samples were slightly stiffer than pure CS by 1.6%.

Employing Polymer and Gel to Fabricate Scaffold-like Cancellous Orthopedic Screw: Polycaprolactone/Chitosan/Hydroxyapatite

Using metallic/polymeric orthopedic screws causes cavities in bone trauma after the attachment of broken bones, which prolongs the healing. Yet, it remains unknown how to overcome such a challenge. The main aim of this research was to use both polymers and gels to fabricate and study a new PCL/chitosan/hydroxyapatite scaffold-like orthopedic screw for cancellous bone trauma. This screw, because of its low stiffness and its scaffold-based matrix (due to the gel part), can facilitate bone healing. Different concentrations of PCL (60-95% w/v) and chitosan (0-5% w/v) were blended according to the Response Surface Methodology using the Central Composite Design. The screws were fabricated using the freeze-drying technique. The screws were assessed mechanically, physically, and biologically (cell viability, cell attachment, DAPI, ALP staining, and Alizarin Red staining), and in vivo (a rat subcutaneous implantation model). Based on the results, screws depending on the PCL and gel content depicted different but notable mechanical behavior (10-60 MPa of compressive strength and 100-600 N force). The gel part could affect the physical properties of screws including water uptake (120%), degradation (18% after 21 days), porosities (23%), and mechanical strength (elastic modulus = 59.47 Mpa). The results also demonstrated no cytotoxicity towards MC3T3 cells (>80% cell viability) with good cell attachment, cell concentration, and mineralization (>90%) that was justified by the gel content. The results also showed good in vivo biocompatibility. To sum up, fabricated scaffold-like screws with gel content can be a good candidate for cancellous-bone-based orthopedic purposes. However, more in vitro and in vivo studies are required to optimize the PCL:gel ratio.

Microplasma-Sprayed Titanium and Hydroxyapatite Coatings on Ti6Al4V Alloy: in vitro Biocompatibility and Corrosion Resistance: Part I

This two-part paper investigates the bioactivity and mechanical properties of coatings applied to Ti6Al4V, a common titanium alloy used in endoprosthetic implants. Coatings made from hydroxyapatite (HA) powder and commercially pure titanium (CP-Ti) wires were applied using microplasma spraying. The study focuses on the responses of rat mesenchymal stem cells (MSCs), which are essential for bone healing, to these coatings. Part I shows how adjusting the microplasma spraying process allows coatings with varying porosity and surface roughness to be achieved.

Comparing functional outcomes between 3D printed acetabular cups and traditional prosthetic implants in hip arthroplasty: a systematic review and meta analysis

OBJECTIVE

The primary research aim was to determine if the use of traditional or 3D printed prosthesis resulted in better functional outcome scores in hip arthroplasty.

METHODS

A systematic review and meta-analysis was conducted utilizing the PRISMA 2020 guidelines. Six databases (PubMed, Embase, Scopus, WebOfScience, and Cochrane Library, Google Scholar) were searched yielding 1117 article titles and abstracts. Rayyan.ai was used to detect duplicates (n = 246) and for manual screening for inclusion and exclusion criteria. Included were controlled studies of any publication time that assessed Harris Hip Score (HHS) at baseline and twelve months. Six papers were sought for full text review of which three studies totaling 195 hips met final inclusion.

RESULTS

Mean HHS in the control group went from 38.15 (± 6.02) at baseline to 80.30 (± 4.79) at twelve months follow-up, while the 3D group saw a change from 37.81 (± 5.84) to 90.60 (± 4.49). Significant and large improvements between time points were seen within the control group [p = .02, Cohen's d = 8.57 (1.48, 15.56)] and 3D group [p < 0.01, Cohen's d = 9.18 (3.50, 14.86)]. The HHS score of the 3D group improved by 10.64 points more than the HHS score of the control group, which is a statistically insignificant (p = 0.89) amount.

CONCLUSION

Group differences in pooled mean HHS scores at twelve months follow-up surpassed established minimum differences for clinical importance. High quality research should be further pursued to elucidate these findings.

Comprehensive Overview of Interface Strategies in Implant Osseointegration

With the improvement of implant design and the expansion of application scenarios, orthopedic implants have become a common surgical option for treating fractures and end‐stage osteoarthritis. Their common goal is rapidly forming and long‐term stable osseointegration. However, this fixation effect is limited by implant surface characteristics and peri‐implant bone tissue activity. Therefore, this review summarizes the strategies of interface engineering (osteogenic peptides, growth factors, and metal ions) and treatment methods (porous nanotubes, hydrogel embedding, and other load‐release systems) through research on its biological mechanism, paving the way to achieve the adaptation of both and coordination between different strategies. With the transition of the osseointegration stage, interface engineering strategies have demonstrated varying therapeutic effects. Especially, the activity of osteoblasts runs almost through the entire process of osseointegration, and their physiological activities play a dominant role in bone formation. Furthermore, diseases impacting bone metabolism exacerbate the difficulty of achieving osseointegration. This review aims to assist future research on osseointegration engineering strategies to improve implant‐bone fixation, promote fracture healing, and enhance post‐implantation recovery.

Designs and mechanical responses of 3D-printed Ti6Al4V porous structures based on triply periodic minimal surfaces with different iso-values

With the increasing applications of additive manufacturing in orthopaedic implants and numerous designs of porous structures available, there is a strong need and opportunity to optimize the structure designs for improved bone integration. Here we created a unique group of sheet structures based on triply periodic minimal surface (TPMS) by varying the iso-value and systematically examined how iso-value influences the mechanical performance of sheet diamond TPMS structures compared to the Octet truss structure. Four iso-values (C) 0, 0.25, 0.5, and 0.75 were designed for sheet Diamond (OSD) TPMS with varying porosity, and Ti6Al4V powder bed fusion was used to produce the porous structures. Compressive tests revealed that iso-value C significantly affected mechanical performance, and interestingly, the impact was porosity-dependent. At high relative density (>0.25), OSD0 (C = 0) displayed the highest elastic modulus and yield strength, whereas at low relative density (<0.25), OSD0.5 showed the highest among all OSD structures. Regarding failure mechanisms, OSD0, OSD0.25, and OSD0.75 showed a mixed domination of stretching and bending, while OSD0.5 was predominantly stretching-dominated. Finite Element Analysis (FEA) found that local yielding initiated at cell nodes upon loading, followed by surface bending and the formation of single or multiple shear bands near the cell nodes. This work demonstrated the feasibility of improving the mechanical performance of porous TPMS structures by simple adjustments in their governing trigonometric functions, serving as a starting point to customize porous structures for specific applications.

Exploring the frontiers of metal additive manufacturing in orthopaedic implant development

This paper provides a thorough analysis of recent advancements and emerging trends in the integration of metal additive manufacturing (AM) within orthopedic implant development. With an emphasis on the use of various metals and alloys, including titanium, cobalt-chromium, and nickel-titanium, the review looks at their characteristics and how they relate to the creation of various orthopedic implants, such as spinal implants, hip and knee replacements, and cranial-facial reconstructions. The study highlights how metal additive manufacturing (AM) can revolutionize the field by enabling customized implant designs that take patient anatomical variances into account. The review discusses the drawbacks of conventional manufacturing techniques and emphasizes the benefits of metal additive manufacturing (AM), such as increased design flexibility and decreased material waste. Important material selection factors, including mechanical qualities and biocompatibility, are covered in relation to metal additive manufacturing applications. The work ends with a summary of the issues facing metal AM today, such as surface finish and material certification, and suggestions for future developments, like the creation of advanced materials and the application of AI to design optimization.

A Systematic Review of the Contribution of Additive Manufacturing toward Orthopedic Applications

Human bone holds an inherent capacity for repairing itself from trauma and damage, but concerning the severity of the defect, the choice of implant placement is a must. Additive manufacturing has become an elite option due to its various specifications such as patient-specific custom development of implants and its easy fabrication rather than the conventional methods used over the years. Additive manufacturing allows customization of the pore size, porosity, various mechanical properties, and complex structure design and formulation. Selective laser melting, powder bed fusion, electron beam melting, and fused deposition modeling are the various AM methods used extensively for implant fabrication. Metals, polymers, biocrystals, composites, and bio-HEA materials are used for implant fabrication for various applications. A wide variety of polymer implants are fabricated using additive manufacturing for nonload-bearing applications, and β-tricalcium phosphate, hydroxyapatite, bioactive glass, etc. are mainly used as ceramic materials in additive manufacturing due to the biological properties that could be imparted by the latter. For decades metals have played a major role in implant fabrication, and additive manufacturing of metals provides an easy approach to implant fabrication with augmented qualities. Various challenges and setbacks faced in the fabrication need postprocessing such as sintering, coating, surface polishing, etc. The emergence of bio-HEA materials, printing of shape memory implants, and five-dimensional printing are the trends of the era in additive manufacturing.

Comparison of Stress between Three Different Functionally Graded Hip Stem Implants Made of Different Titanium Alloys and Composite Materials

This study aims to evaluate the mechanical behavior, by ways of the FEM, of three femoral stems made of a Ti-6Al-4V titanium alloy with transverse holes in the proximal zone and a stem made of a β-type titanium alloy with a stiffness varying from 65 GPa in the proximal zone to 110 GPa in the distal zone and the CFRP composite material. The purpose of the study was to evaluate the effect of stress shielding on an intact femoral bone. A three-dimensional model of the intact femur was created, and the three prostheses were inserted with perfect stem bone fit. Applying constraint conditions such as fixation in all directions of the distal part of the femur and the application of a static load simulating standing still during a gait cycle allowed the stresses of both the implants and the bone to be compared. Evaluating the stress shielding for the three proposed materials was possible by identifying the seven Gruen zones. We can see from the results obtained that the metal alloys produced observable stress shielding in all the Gruen zones. There was a difference for the β-type alloy which, as a result of its stiffness variation from the proximal to the distal zone, did not show any level of stress shielding in Gruen zones 1 and 2. The CFRP composite, in contrast, showed no stress shielding in all of the Gruen zones and is an excellent material for the fabrication of total hip replacements. Further in vitro and in vivo validation studies are needed to make the modeling more accurate and understand the biological effects of the use of the three materials.

Biomechanical design of a new proximal humerus fracture plate using alternative materials

Comminuted proximal humerus fractures are often repaired by metal plates, but potentially still experience bone refracture, bone "stress shielding," screw perforation, delayed healing, and so forth. This "proof of principle" investigation is the initial step towards the design of a new plate using alternative materials to address some of these problems. Finite element modeling was used to create design graphs for bone stress, plate stress, screw stress, and interfragmentary motion via three different fixations (no, 1, or 2 "kickstand" [KS] screws across the fracture) using a wide range of plate elastic moduli (EP = 5-200 GPa). Well-known design optimization criteria were used that could minimize bone, plate, and screw failure (i.e., peak stress < ultimate tensile strength), reduce bone "stress shielding" (i.e., bone stress under the new plate ≥ bone stress for an intact humerus, titanium plate, and/or steel plate "control"), and encourage callus growth leading to early healing (i.e., 0.2 mm ≤ axial interfragmentary motion ≤ 1 mm; shear/axial interfragmentary motion ratio <1.6). The findings suggest that a potentially optimal configuration involves the new plate being manufactured from a material with an EP of 5-41.5 GPa with 1 KS screw; but, using no KS screws would cause immediate bone fracture and 2 KS screws would almost certainly lead to delayed healing. A prototype plate might be fabricated using alternative materials suggested for orthopedics and other industries, like fiber-metal laminates, fiber-reinforced polymers, metal foams, pure polymers, shape memory alloys, or 3D-printed porous metals.

FixThePig: a custom 3D-printed femoral intramedullary nailing for preclinical research applications

Background

Critical-size bone defects (CSBDs) pose significant challenges in clinical orthopaedics and traumatology. Developing reliable preclinical models that accurately simulate human conditions is crucial for translational research. This study addresses the need for a reliable preclinical model by evaluating the design and efficacy of a custom-made 3D-printed intramedullary nail (IMN) specifically for CSBDs in minipigs. The study aims to answer the following questions: Can a custom-made 3D-printed IMN be designed for femoral osteosynthesis in minipigs? Does the use of the custom-made IMN result in consistent and reproducible surgical procedure, particularly in the creation and fixation of CSBDs? Can the custom-made IMN effectively treat and promote bone consolidation of CSBDs?

Hypothesis

The custom-made 3D-printed IMN can be designed to effectively create, fix and treat CSBDs in minipigs, resulting in consistent surgical outcomes.

Materials and Methods

The IMN was designed based on CT scans of minipig femurs, considering factors such as femoral curvature, length, and medullary canal diameters. It was 3D-printed in titanium and evaluated through both in vitro and in vivo testing. Female Aachen minipigs underwent bilateral femoral surgeries to create and fix CSBDs using the custom-made IMN. Post-operative follow-up included X-rays and CT scans every 2 weeks, with manual examination of explanted femurs to assess consolidation and mechanical stability after 3 months.

Results

The custom-made IMN effectively fitted the minipig femoral anatomy and facilitated reproducible surgical outcomes. Symmetric double osteotomies were successfully performed, and allografts showed minimal morphological discrepancies. However, proximal fixation faced challenges, leading to non-union in several cases, while most distal osteotomy sites achieved stable consolidation.

Discussion

The custom-made 3D-printed IMN demonstrated potential in modelling and treating CSBDs in minipigs. While the design effectively supported distal bone healing, issues with proximal fixation highlight the need for further refinements. Potential improvements include better screw placement, additional mechanical support, and adaptations such as a reduction clamp or a cephalic screw to enhance stability and distribute forces more effectively.

Advanced porous hip implants: A comprehensive review

The field of orthopaedic implants has experienced significant advancements in recent years, transforming the approach to orthopaedic treatments. Amongst these advancements, porous structures have emerged as a promising solution to address the limitations of traditional solid implants. This comprehensive review paper offers a thorough overview of the importance of advanced porous hip implants, focusing on three key areas bone morphology and biomechanical parameters, complications associated with solid implants, and the benefits of porous structures and porous implants. Understanding the intricate interplay between bone morphology and biomechanical parameters is crucial when designing orthopaedic implants. Mimicking the native bone structure ensures optimal osseointegration, load distribution, and long-term success. Porous implants closely resemble natural bone structures, facilitating improved integration and biomechanical compatibility. Complications with solid implants are a significant concern in orthopaedic procedures. Stress shielding, cortical hypertrophy, and micromotion can lead to implant failure or revision surgeries. By contrast, porous structures promise to mitigate these issues by promoting bone ingrowth, reducing stress concentrations, and providing stability at the bone-implant interface. The benefits of porous structures and porous implants go beyond addressing solid implant complications. These structures enhance bone in-growth potential, strengthening integration and long-term stability. The interconnected porosity promotes nutrient diffusion and new blood vessel formation, supporting healing and minimizing infection risk. Furthermore, porous implants exhibit improved mechanical properties, such as lower elastic modulus and higher energy absorption, that better match those of bone. This feature helps alleviate stress shielding and enhances the overall performance and longevity of the implant. In conclusion, advanced porous implants have tremendous potential in orthopaedics. By closely mimicking native bone structure and reducing complications associated with solid implants, they can revolutionize orthopaedic treatments. Further research and development are warranted to fully exploit the potential of these innovative solutions and improve patient outcomes.

Finite element analysis of a low modulus Ti-20Zr-3Mo-3Sn alloy designed to reduce the stress shielding effect of a hip prosthesis

After total hip arthroplasty, the stress shielding effect can occur due to the difference of stiffness between the metallic alloy of the stems and the host bone, which may cause a proximal bone loss. To overcome this problem, a low-modulus metastable β Ti-20Zr-3Mo-3Sn alloy composition has recently been designed to be potentially used for the cementless femoral hip stems. After having verified experimentally that the β alloy has a low modulus of around 50 GPa, a finite element analysis was performed on a Ti-20Zr-3Mo-3Sn alloy hip prosthesis model to evaluate the influence of a reduced modulus on stress shielding and stress fields in both stem and bone compared with the medical grade Ti-6Al-4V alloy whose elastic modulus reached 110 GPa. Our results show that the Ti-20Zr-3Mo-3Sn stem with low elastic modulus can effectively reduce the total stress shielding by 45.5% compared to the common Ti-6Al-4V prosthesis. Moreover, it is highlighted that the material elasticity affects the stress distribution in the implant, especially near the bone-stem interfaces.

Porous versus solid shoulder implants in humeri of different bone densities: A finite element analysis

Porous metallic prosthesis components can now be manufactured using additive manufacturing techniques, and may prove beneficial for promoting bony ingrowth, for accommodating drug delivery systems, and for reducing stress shielding. Using finite element modeling techniques, 36 scenarios (three porous stems, three bone densities, and four held arm positions) were analysed to assess the viability of porous humeral stems for use in total shoulder arthroplasty, and their resulting mechanobiological impact on the surrounding humerus bone. All three porous stems were predicted to experience stresses below the yield strength of Ti6Al4V (880 MPa) and to be capable of withstanding more than 10 million cycles of each loading scenario before failure. There was an indication that within an 80 mm region of the proximal humerus, there would be a reduction in bone resorption as stem porosity increased. Overall, this study shows promise that these porous structures are mechanically viable for incorporation into permanent shoulder prostheses to combat orthopedic infections.

Bone graft incorporation failure with inappropriate limb load transfer can lead to aseptic acetabular loosening of metal-on-metal prosthesis: A case report

BACKGROUND

Aseptic acetabular loosening can result from various factors that can be categorized into groups: patient-related, surgeon-related and implant-related. We present a case of a 63-year-old patient who at first underwent a total hip arthroplasty (THA) using a metal-on-metal bearing due to hip arthrosis. Follow-up visits revealed no complications after the procedure. Two years after the THA, acetabular component loosening occurred due to subsequent trauma of the opposite hip, necessitating a revision THA using a ceramic-on-ceramic bearing.

CASE SUMMARY

We aim to illustrate a rare case where the primary reason for undergoing THA revision was not only incomplete bone graft incorporation but also improper limb load distribution. Following the revision arthroplasty, a 9-year follow-up visit revealed improvements in all evaluation measures on questionnaire compared to the state before surgery: Harris Hip Score (before surgery: 15; after surgery: 95), Western Ontario and McMaster Universities Arthritis Index (before surgery: 96; after surgery: 0), and Visual Analogue Scale (before surgery: 10; after surgery: 1).

CONCLUSION

Opposite-hip trauma caused a weight transfer to the limb after a THA procedure. This process led to a stress shielding effect, resulting in acetabular component loosening.

Design of novel triply periodic minimal surface (TPMS) bone scaffold with multi-functional pores: lower stress shielding and higher mass transport capacity

Background: The bone repair requires the bone scaffolds to meet various mechanical and biological requirements, which makes the design of bone scaffolds a challenging problem. Novel triply periodic minimal surface (TPMS)-based bone scaffolds were designed in this study to improve the mechanical and biological performances simultaneously. Methods: The novel bone scaffolds were designed by adding optimization-guided multi-functional pores to the original scaffolds, and finite element (FE) method was used to evaluate the performances of the novel scaffolds. In addition, the novel scaffolds were fabricated by additive manufacturing (AM) and mechanical experiments were performed to evaluate the performances. Results: The FE results demonstrated the improvement in performance: the elastic modulus reduced from 5.01 GPa (original scaffold) to 2.30 GPa (novel designed scaffold), resulting in lower stress shielding; the permeability increased from 8.58 × 10-9 m2 (original scaffold) to 5.14 × 10-8 m2 (novel designed scaffold), resulting in higher mass transport capacity. Conclusion: In summary, the novel TPMS scaffolds with multi-functional pores simultaneously improve the mechanical and biological performances, making them ideal candidates for bone repair. Furthermore, the novel scaffolds expanded the design domain of TPMS-based bone scaffolds, providing a promising new method for the design of high-performance bone scaffolds.

Design, fabrication and clinical characterization of additively manufactured tantalum hip joint prosthesis

The joint prosthesis plays a vital role in the outcome of total hip arthroplasty. The key factors that determine the performance of joint prostheses are the materials used and the structural design of the prosthesis. This study aimed to fabricate a porous tantalum (Ta) hip prosthesis using selective laser melting (SLM) technology. The feasibility of SLM Ta use in hip prosthesis was verified by studying its chemical composition, metallographic structure and mechanical properties. In vitro experiments proved that SLM Ta exhibited better biological activities in promoting osteogenesis and inhibiting inflammation than SLM Ti6Al4V. Then, the topological optimization design of the femoral stem of the SLM Ta hip prosthesis was carried out by finite element simulation, and the fatigue performance of the optimized prosthesis was tested to verify the biomechanical safety of the prosthesis. A porous Ta acetabulum cup was also designed and fabricated using SLM. Its mechanical properties were then studied. Finally, clinical trials were conducted to verify the clinical efficacy of the SLM Ta hip prosthesis. The porous structure could reduce the weight of the prosthesis and stress shielding and avoid bone resorption around the prosthesis. In addition, anti-infection drugs can also be loaded into the pores for infection treatment. The acetabular cup can be custom-designed based on the severity of bone loss on the acetabular side, and the integrated acetabular cup can repair the acetabular bone defect while achieving the function of the acetabular cup.

Increased stability of short femoral stem through customized distribution of coefficient of friction in porous coating

Stress shielding and aseptic loosening are complications of short stem total hip arthroplasty, which may lead to hardware failure. Stems with increased porosity toward the distal end were discovered to be effective in reducing stress shielding, however, there is a lack of research on optimized porous distribution in stem's coating. This study aimed to optimize the distribution of the coefficient of friction of a metaphyseal femoral stem, aiming for reducing stress shielding in the proximal area. A finite element analysis model of an implanted, titanium alloy short-tapered wedge stem featuring a porous coating made of titanium was designed to simulate a static structural analysis of the femoral stem's behavior under axial loading in Analysis System Mechanical Software. For computational feasibility, 500 combinations of coefficients of friction were randomly sampled. Increased strains in proximal femur were found in 8.4% of the models, which had decreased coefficients of friction in middle medial areas of porous coating and increased in lateral proximal and lateral and medial distal areas. This study reported the importance of the interface between bone and middle medial and distal lateral areas of the porous coating in influencing the biomechanical behavior of the proximal femur, and potentially reducing stress shielding.

Modulate stress distribution with bio-inspired irregular architected materials towards optimal tissue support

Natural materials typically exhibit irregular and non-periodic architectures, endowing them with compelling functionalities such as body protection, camouflage, and mechanical stress modulation. Among these functionalities, mechanical stress modulation is crucial for homeostasis regulation and tissue remodeling. Here, we uncover the relationship between stress modulation functionality and the irregularity of bio-inspired architected materials by a generative computational framework. This framework optimizes the spatial distribution of a limited set of basic building blocks and uses these blocks to assemble irregular materials with heterogeneous, disordered microstructures. Despite being irregular and non-periodic, the assembled materials display spatially varying properties that precisely modulate stress distribution towards target values in various control regions and load cases, echoing the robust stress modulation capability of natural materials. The performance of the generated irregular architected materials is experimentally validated with 3D printed physical samples - a good agreement with target stress distribution is observed. Owing to its capability to redirect loads while keeping a proper amount of stress to stimulate bone repair, we demonstrate the potential application of the stress-programmable architected materials as support in orthopedic femur restoration.

A novel design of hip-stem with reduced strain-shielding

The use of uncemented stems in hip arthroplasty has been increasing, even in osteoporotic patients. The major concerns of uncemented hip-stems, however, are peri-prosthetic fracture, thigh pain, and proximal femoral stress-/strain-shielding. In this study, a novel design of uncemented hip-stem is proposed that will reduce such concerns, improve osseointegration, and benefit both osteoporotic and arthritic patients. The stem has a central titanium alloy core surrounded by a set of radial buttresses that are partly porous titanium, as is the stem tip. The aim of the study was to investigate the mechanical behaviour of the proposed partly-porous design, examining load transfer in the short-term, and comparing its strain-shielding behaviour with a solid metal implant. The long-term effect of implant-induced bone remodelling was also simulated. Computed tomography based three-dimensional finite element models of an intact proximal femur, and the same femur implanted with the proposed design, were developed. Peak hip contact and major muscle forces corresponding to level-walking and stair climbing were applied. The proposed partly-porous design had approximately 50% lower strain-shielding than the solid-metal counterpart. Results of bone remodelling simulation indicated that only 16% of the total bone volume is subjected to reduction of bone density. Strain concentrations were observed in the bone around the stem-tip for both solid and porous implants; however, it was less prominent for the porous design. Lower strain-shielding and reduced bone resorption are advantageous for long-term fixation, and the reduced strain concentration around the stem-tip indicates a lower risk of peri-prosthetic fracture.

Effect of density grading on the mechanical behaviour of advanced functionally graded lattice structures

Lattice structures have found significant applications in the biomedical field due to their interesting combination of mechanical and biological properties. Among these, functionally graded structures sparked interest because of their potential of varying their mechanical properties throughout the volume, allowing the design of biomedical devices able to match the characteristics of a graded structure like human bone. The aim of this works is the study of the effect of the density grading on the mechanical response and the failure mechanisms of a novel functionally graded lattice structure, namely Triply Arranged Octagonal Rings (TAOR). The mechanical behaviour was compared with the same lattice structures having constant density ratio. Electron Beam Melting technology was used to manufacture titanium alloy specimens with global relative densities from 10% to 30%. Functionally graded structures were obtained by increasing the relative density along the specimen, by individually designing the lattice's layers. Scanning electron and a digital microscopy were used to evaluate the dimensional mismatch between actual and designed structures. Compressive tests were carried out to obtain the mechanical properties and to evaluate the collapse modes of the structures in relation to their average relative density and lattice grading. Open-source Digital Image Correlation algorithm was applied to evaluate the deformation behaviour of the structures and to calculate their elastic moduli. The results showed that uniform density structures provide higher mechanical properties than functionally graded ones. The Digital Image Correlation results showed the possibility of effectively designing the different layers of functionally graded structures selecting desired local mechanical properties to mimic the different characteristics of cortical and cancellous bone.

Enhancing Hip Arthroplasty Outcomes: The Multifaceted Advantages, Limitations, and Future Directions of 3D Printing Technology

In the evolving field of orthopedic surgery, the integration of three-dimensional printing (3D printing) has emerged as a transformative technology, particularly in addressing the rising incidence of degenerative joint diseases. The integration of 3D printing technology in hip arthroplasty offers substantial advantages throughout the surgical process. In preoperative planning, 3D models enable meticulous assessments, aiding in accurate implant selection and precise surgical strategies. Intraoperatively, the technology contributes to precise prosthesis design, reducing operation duration, X-ray exposures, and blood loss. Beyond surgery, 3D printing revolutionizes medical equipment production, imaging, and implant design, showcasing benefits such as enhanced osseointegration and reduced stress shielding with titanium cups. Challenges include a higher risk of postoperative infection due to the porous surfaces of 3D-printed implants, technical complexities in the printing process, and the need for skilled manpower. Despite these challenges, the evolving nature of 3D printing technologies underscores the importance of relying on existing orthopedic surgical practices while emphasizing the need for standardized guidelines to fully harness its potential in improving patient care.

Debulking of the Femoral Stem in a Primary Total Hip Joint Replacement: A Novel Method to Reduce Stress Shielding

In current-generation designs of total primary hip joint replacement, the prostheses are fabricated from alloys. The modulus of elasticity of the alloy is substantially higher than that of the surrounding bone. This discrepancy plays a role in a phenomenon known as stress shielding, in which the bone bears a reduced proportion of the applied load. Stress shielding has been implicated in aseptic loosening of the implant which, in turn, results in reduction in the in vivo life of the implant. Rigid implants shield surrounding bone from mechanical loading, and the reduction in skeletal stress necessary to maintain bone mass and density results in accelerated bone loss, the forerunner to implant loosening. Femoral stems of various geometries and surface modifications, materials and material distributions, and porous structures have been investigated to achieve mechanical properties of stems closer to those of bone to mitigate stress shielding. For improved load transfer from implant to femur, the proposed study investigated a strategic debulking effort to impart controlled flexibility while retaining sufficient strength and endurance properties. Using an iterative design process, debulked configurations based on an internal skeletal truss framework were evaluated using finite element analysis. The implant models analyzed were solid; hollow, with a proximal hollowed stem; FB-2A, with thin, curved trusses extending from the central spine; and FB-3B and FB-3C, with thick, flat trusses extending from the central spine in a balanced-truss and a hemi-truss configuration, respectively. As outlined in the International Organization for Standardization (ISO) 7206 standards, implants were offset in natural femur for evaluation of load distribution or potted in testing cylinders for fatigue testing. The commonality across all debulked designs was the minimization of proximal stress shielding compared to conventional solid implants. Stem topography can influence performance, and the truss implants with or without the calcar collar were evaluated. Load sharing was equally effective irrespective of the collar; however, the collar was critical to reducing the stresses in the implant. Whether bonded directly to bone or cemented in the femur, the truss stem was effective at limiting stress shielding. However, a localized increase in maximum principal stress at the proximal lateral junction could adversely affect cement integrity. The controlled accommodation of deformation of the implant wall contributes to the load sharing capability of the truss implant, and for a superior biomechanical performance, the collared stem should be implanted in interference fit. Considering the results of all implant designs, the truss implant model FB-3C was the best model.

3D-Printed Personalized Lattice Implant as an Innovative Strategy to Reconstruct Geographic Defects in Load-Bearing Bones

OBJECTIVE

Geographic defect reconstruction in load-bearing bones presents formidable challenges for orthopaedic surgeon. The use of 3D-printed personalized implants presents a compelling opportunity to address this issue. This study aims to design, manufacture, and evaluate 3D-printed personalized implants with irregular lattice porous structures for geographic defect reconstruction in load-bearing bones, focusing on feasibility, osseointegration, and patient outcomes.

METHODS

This retrospective study involved seven patients who received 3D-printed personalized lattice implants for the reconstruction of geographic defects in load-bearing bones. Personalized implants were customized for each patient. Randomized dodecahedron unit cells were incorporated within the implants to create the porous structure. The pore size and porosity were analyzed. Patient outcomes were assessed through a combination of clinical and radiological evaluations. Tomosynthesis-Shimadzu metal artifact reduction technology (T-SMART) was utilized to evaluate osseointegration. Functional outcomes were assessed according to the Musculoskeletal Tumor Society (MSTS) 93 score.

RESULTS

Multiple pore sizes were observed in porous structures of the implant, with a wide distribution range (approximately 300-900 um). The porosity analysis results showed that the average porosity of irregular porous structures was around 75.03%. The average follow-up time was 38.4 months, ranging from 25 to 50 months. Postoperative X-rays showed that the implants matched the geographic bone defect well. Osseointegration assessments according to T-SMART images indicated a high degree of bone-to-implant contact, along with favorable bone density around the implants. Patient outcomes assessments revealed significant improvements in functional outcomes, with the average MSTS score of 27.3 (range, 26-29). There was no implant-related complication, such as aseptic loosening or structure failure.

CONCLUSION

3D-printed personalized lattice implants offer an innovative and promising strategy for geographic defect reconstruction in load-bearing bones. This approach has the potential to match the unique contours and geometry of the geographic bone defect and facilitate osteointegration.

Development of a density-based topology optimization of homogenized lattice structures for individualized hip endoprostheses and validation using micro-FE

Prosthetic implants, particularly hip endoprostheses, often lead to stress shielding because of a mismatch in compliance between the bone and the implant material, adversely affecting the implant's longevity and effectiveness. Therefore, this work aimed to demonstrate a computationally efficient method for density-based topology optimization of homogenized lattice structures in a patient-specific hip endoprosthesis. Thus, the root mean square error (RMSE) of the stress deviations between the physiological femur model and the optimized total hip arthroplasty (THA) model compared to an unoptimized-THA model could be reduced by 81 % and 66 % in Gruen zone (GZ) 6 and 7. However, the method relies on homogenized finite element (FE) models that only use a simplified representation of the microstructural geometry of the bone and implant. The topology-optimized hip endoprosthesis with graded lattice structures was synthesized using algorithmic design and analyzed in a virtual implanted state using micro-finite element (micro-FE) analysis to validate the optimization method. Homogenized FE and micro-FE models were compared based on averaged von Mises stresses in multiple regions of interest. A strong correlation (CCC > 0.97) was observed, indicating that optimizing homogenized lattice structures yields reliable outcomes. The graded implant was additively manufactured to ensure the topology-optimized result's feasibility.

Numerical design of open-porous titanium scaffolds for Powder Bed Fusion using Laser Beam (PBF-LB)

The paper concerns the numerical design of novel three-dimensional titanium scaffolds with complex open-porous structures and desired mechanical properties for the Powder Bed Fusion using Laser Beam (PBF-LB). The 60 structures with a broad range of porosity (38-78%), strut diameters (0.70-1.15 mm), and coefficients of pore volume variation, CV(Vp), 0.35-5.35, were designed using the Laguerre-Voronoi tessellations (LVT). Their Young's moduli and Poisson's ratios were calculated using Finite Element Model (FEM) simulations. The experimental verification was performed on the representative designs additively manufactured (AM) from commercially pure titanium (CP Ti) which, after chemical polishing, were subjected to uniaxial compression tests. Scanning Electron Microscopy (SEM) observations and microtomography (μ-CT) confirmed the removal of the support structures and unmelted powder particles. PBF-LB structures after chemical polishing were in close agreement with the CAD models' dimensions having 4-12% more volume. The computational and experimental results show that elastic properties were predicted in very close agreement for the low CV(Vp), and with even 30-40% discrepancies for CV(Vp) higher than 4.0, mainly due to PBF-LB scaffold architecture drawbacks rather than CAD inaccuracy. Our research demonstrates the possibility of designing the open-porous scaffolds with pore volume diversity and tuning their elastic properties for biomedical applications.

Build parameter influence on strut thickness and mechanical performance in additively manufactured titanium lattice structures

Additively manufactured lattices have been adopted in applications ranging from medical implants to aerospace components. For solid AM components, the effect of build parameters has been well studied but comparably little attention has been paid to the influence of build parameters on lattice performance. For this project, the main aim was to evaluate static compressive mechanical performance of regular and stochastic lattices as a function of build parameters. The second aim was to compare strut dimensions of the metal lattice structures as build parameters were changed. Both regular and stochastic lattices were fabricated with a designed strut diameter of either 200 μm or 300 μm on a laser powder bed fusion machine. A range of laser power (140-180 W), scan speed (1700-2100 mm/s), and laser offset (0-45 μm) were used in fabricating each lattice. Compression tests were performed following the ISO 13314 (2011) standard to measure modulus, yield strength, and ultimate compressive strength values. Laser power adjustments produced the most significant effect on lattice performance. A change of 50 W resulted in roughly a 2X increase in maximum load and modulus for both regular and stochastic lattice structures. Regular lattice structures had a higher mechanical response during the mechanical evaluation. Internal strut diameters varied between build parameters as well, with laser offset adjustments producing the most noticeable change in strut geometry between lattice samples. These findings suggest that build parameter optimization, in lieu of using OEM parameters developed for solid structures, is necessary to ensure the optimum mechanical performance of AM lattice structures.

Mechano-driven intervertebral bone bridging via oriented mechanical stimulus in a twist metamaterial cage: An in silico study

Stiffer cages provide sufficient mechanical support but fail to promote bone ingrowth due to stress shielding. It remains challenging for fusion cage to satisfy both bone bridging and mechanical stability. Here we designed a fusion cage based on twist metamaterial for improved bone ingrowth, and proved its superiority to the conventional diagonal-based cage in silico. The fusion process was numerically reproduced via an injury-induced osteogenesis model and the mechano-driven bone remodeling algorithm, and the outcomes fusion effects were evaluated by the morphological features of the newly-formed bone and the biomechanical behaviors of the bone-cage composite. The twist-based cages exhibited oriented bone formation in the depth direction, in comparison to the diagonal-based cages. The axial stiffness of the bone-cage composites with twist-based cages was notably higher than that with diagonal-based cages; meanwhile, the ranges of motion of the twist-based fusion segment were lower. It was concluded that the twist metamaterial cages led to oriented bone ingrowth, superior mechanical stability of the bone-cage composite, and less detrimental impacts on the adjacent bones. More generally, metamaterials with a tunable displacement mode of struts might provide more design freedom in implant designs to offer customized mechanical stimulus for osseointegration.

Functionalized biomimetic mineralized collagen promotes osseointegration of 3D-printed titanium alloy microporous interface

Mineralized collagen (MC) is the fundamental unit of natural bone tissue and can induce bone regeneration. Unmodified MC has poor mechanical properties and a single component, making it unable to cope with complex physiological environment. In this study, we introduced sodium alginate (SA) and vascular endothelial growth factor (VEGF) into the MC material to construct functionalized mineralized collagen (FMC) with good mechanical strength and the ability to continuously release growth factors. The FMC is filled into the pores of 3D printed titanium alloy scaffold to form a new organic-inorganic bioactive interface. With the continuous degradation of FMC, bone marrow mesenchymal stem cells (BMSCs) and vascular endothelial cells (VECs) in the surrounding environment are recruited to the surface of the scaffold to promote bone and vascular regeneration. After implanting the scaffold into the distal femoral defect of rabbits, Micro CT, histological, push-out, as well as immunohistochemical analysis showed that the composite interface can significantly promote osseointegration. These findings provide a new strategy for the development and application of mineralized collagen materials.

The application of custom 3D-printed prostheses with ultra-short stems in the reconstruction of bone defects: a single center analysis

Objective: Considering the advantages and widespread presence of 3D-printing technology in surgical treatments, 3D-printed porous structure prostheses have been applied in a wide range of the treatments of bone tumor. In this research, we aimed to assess the application values of the 3D-printed custom prostheses with ultra-short stems for restoring bone defects and maintaining arthrosis in malignant bone tumors of lower extremities in children. Methods: Seven cases of pediatric patients were included in this study. In all cases, the prostheses were porous titanium alloy with ultra-short stems. MSTS 93 (Musculoskeletal Tumor Society) scores were recorded for the functional recovery of the limbs. VAS (Visual analogue scale) scores were utilized to assess the degree of painfulness for the patients. X-ray and MRI (magnetic resonance imaging) were applied to evaluate the bone integration, prostheses aseptic loosening, prostheses fracture, wound healing, and tumor recurrence during follow-up. Results: During follow-up, none of the patients developed any postoperative complications, including prostheses aseptic loosening, prostheses fracture, or tumor recurrence. Radiological examinations during the follow-up showed that prostheses implanted into the residual bone were stably fitted and bone defects were effectively reconstructed. The MSTS 93 scores were 24.9 ± 2.9 (20-28). VAS scores were decreased to 5.8 ± 1.2 (4.0-7.0). No statistically significant differences in leg length discrepancy were observed at the time of the last follow-up. Conclusion: 3D-printing technology can be effectively applied throughout the entire surgical treatment procedures of malignant bone tumors, offering stable foundations for the initial stability of 3D-printed prostheses with ultra-short stems through preoperative design, intraoperative precision operation, and personalized prosthesis matching. With meticulous postoperative follow-up, close monitoring of postoperative complications was ensured. These favorable outcomes indicate that the utilization of 3D-printed custom prostheses with ultra-short stems is a viable alternative for reconstructing bone defects. However, further investigation is warranted to determine the long-term effectiveness of the 3D-printing technique.

Load, unload and repeat: Understanding the mechanical characteristics of zirconia in dentistry

OBJECTIVES

Zirconia-based dental restorations and implants are gaining attention due to their bioactivity, corrosion resistance and mechanical stability. Further, surface modification of zirconia implants has been performed at the macro-, micro- and nanoscale to augment bioactivity. While zirconia's physical and chemical characteristics have been documented, its relation to mechanical performance still needs to be explored. This extensive review aims to address this knowledge gap.

METHODS

This review critically compares and contrasts the findings from articles published in the domain of 'mechanical stability of zirconia\ in dentistry' based on a literature survey (Web of Science, Medline/PubMed and Scopus databases) and a review of the relevant publications in international peer-reviewed journals. Reviewing the published data, the mechanical properties of zirconia, such as fracture resistance, stress/tension, flexural strength, fatigue, and wear are detailed and discussed to understand the biomechanical compatibility of zirconia with the mechanical performance of modified zirconia in dentistry also explored.

RESULTS

A comprehensive insight into dental zirconia's critical fundamental mechanical characteristics and performance is presented. Further, research challenges and future directions in this domain are recommended.

SIGNIFICANCE

This review extends existing knowledge of zirconia's biomechanical performance and it they can be modulated to design the next generation of zirconia dental restorations and implants to withstand long-term constant loading.

The role of stiffness-matching in avoiding stress shielding-induced bone loss and stress concentration-induced skeletal reconstruction device failure

It is well documented that overly stiff skeletal replacement and fixation devices may fail and require revision surgery. Recent attempts to better support healing and sustain healed bone have looked at stiffness-matching of these devices to the desired role of limiting the stress on fractured or engrafted bone to compressive loads and, after the reconstructed bone has healed, to ensure that reconstructive medical devices (implants) interrupt the normal loading pattern as little as possible. The mechanical performance of these devices can be optimized by adjusting their location, integration/fastening, material(s), geometry (external and internal), and surface properties. This review highlights recent research that focuses on the optimal design of skeletal reconstruction devices to perform during and after healing as the mechanical regime changes. Previous studies have considered auxetic materials, homogeneous or gradient (i.e., adaptive) porosity, surface modification to enhance device/bone integration, and choosing the device's attachment location to ensure good osseointegration and resilient load transduction. By combining some or all of these factors, device designers work hard to avoid problems brought about by unsustainable stress shielding or stress concentrations as a means of creating sustainable stress-strain relationships that best repair and sustain a surgically reconstructed skeletal site. STATEMENT OF SIGNIFICANCE: Although standard-of-care skeletal reconstruction devices will usually allow normal healing and improved comfort for the patient during normal activities, there may be significant disadvantages during long-term use. Stress shielding and stress concentration are amongst the most common causes of failure of a metallic device. This review highlights recent developments in devices for skeletal reconstruction that match the stiffness, while not interrupting the normal loading pattern of a healthy bone, and help to combat stress shielding and stress concentration. This review summarises various approaches to achieve stiffness-matching: application of materials with modulus close to that of the bone; adaptation of geometry with pre-defined mechanical properties; and/or surface modification that ensures good integration and proper load transfer to the bone.

Titanium Alloy Implants with Lattice Structures for Mandibular Reconstruction

In recent years, the field of mandibular reconstruction has made great strides in terms of hardware innovations and their clinical applications. There has been considerable interest in using computer-aided design, finite element modelling, and additive manufacturing techniques to build patient-specific surgical implants. Moreover, lattice implants can mimic mandibular bone's mechanical and structural properties. This article reviews current approaches for mandibular reconstruction, their applications, and their drawbacks. Then, we discuss the potential of mandibular devices with lattice structures, their development and applications, and the challenges for their use in clinical settings.

Design of 3D-printed prostheses for reconstruction of periacetabular bone tumors using topology optimization

Background: Prostheses for the reconstruction of periacetabular bone tumors are prone to instigate stress shielding. The purpose of this study is to design 3D-printed prostheses with topology optimization (TO) for the reconstruction of periacetabular bone tumors and to add porous structures to reduce stress shielding and facilitate integration between prostheses and host bone. Methods: Utilizing patient CT data, we constructed a finite element analysis (FEA) model. Subsequent phases encompassed carrying out TO on the designated area, utilizing the solid isotropic material penalization model (SIMP), and this optimized removal area was replaced with a porous structure. Further analyses included preoperative FEA simulations to comparatively evaluate parameters, including maximum stress, stress distribution, strain energy density (SED), and the relative micromotion of prostheses before and after TO. Furthermore, FEA based on patients' postoperative CT data was conducted again to assess the potential risk of stress shielding subsequent to implantation. Ultimately, preliminary follow-up findings from two patients were documented. Results: In both prostheses, the SED before and after TO increased by 143.61% (from 0.10322 to 0.25145 mJ/mm3) and 35.050% (from 0.30964 to 0.41817 mJ/mm3) respectively, showing significant differences (p < 0.001). The peak stress in the Type II prosthesis decreased by 10.494% (from 77.227 to 69.123 MPa), while there was no significant change in peak stress for the Type I prosthesis. There were no significant changes in stress distribution or the proportion of regions with micromotion less than 28 μm before and after TO for either prosthesis. Postoperative FEA verified results showed that the stress in the pelvis and prostheses remained at relatively low levels. The results of follow-up showed that the patients had successful osseointegration and their MSTS scores at the 12th month after surgery were both 100%. Conclusion: These two types of 3D-printed porous prostheses using TO for periacetabular bone tumor reconstruction offer advantages over traditional prostheses by reducing stress shielding and promoting osseointegration, while maintaining the original stiffness of the prosthesis. Furthermore, in vivo experiments show that these prostheses meet the requirements for daily activities of patients. This study provides a valuable reference for the design of future periacetabular bone tumor reconstruction prostheses.

Perfusion Window Chambers Enable Interventional Analyses of Tumor Microenvironments

Intravital microscopy (IVM) allows spatial and temporal imaging of different cell types in intact live tissue microenvironments. IVM has played a critical role in understanding cancer biology, invasion, metastases, and drug development. One considerable impediment to the field is the inability to interrogate the tumor microenvironment and its communication cascades during disease progression and therapeutic interventions. Here, a new implantable perfusion window chamber (PWC) is described that allows high-fidelity in vivo microscopy, local administration of stains and drugs, and longitudinal sampling of tumor interstitial fluid. This study shows that the new PWC design allows cyclic multiplexed imaging in vivo, imaging of drug action, and sampling of tumor-shed materials. The PWC will be broadly useful as a novel perturbable in vivo system for deciphering biology in complex microenvironments.

Advancement in total hip implant: a comprehensive review of mechanics and performance parameters across diverse novelties

The UK's National Joint Registry (NJR) and the American Joint Replacement Registry (AJRR) of 2022 revealed that total hip replacement (THR) is the most common orthopaedic joint procedure. The NJR also noted that 10-20% of hip implants require revision within 1 to 10 years. Most of these revisions are a result of aseptic loosening, dislocation, implant wear, implant fracture, and joint incompatibility, which are all caused by implant geometry disparity. The primary purpose of this review article is to analyze and evaluate the mechanics and performance factors of advancement in hip implants with novel geometries. The existing hip implants can be categorized based on two parts: the hip stem and the joint of the implant. Insufficient stress distribution from implants to the femur can cause stress shielding, bone loss, excessive micromotion, and ultimately, implant aseptic loosening due to inflammation. Researchers are designing hip implants with a porous lattice and functionally graded material (FGM) stems, femur resurfacing, short-stem, and collared stems, all aimed at achieving uniform stress distribution and promoting adequate bone remodeling. Designing hip implants with a porous lattice FGM structure requires maintaining stiffness, strength, isotropy, and bone development potential. Mechanical stability is still an issue with hip implants, femur resurfacing, collared stems, and short stems. Hip implants are being developed with a variety of joint geometries to decrease wear, improve an angular range of motion, and strengthen mechanical stability at the joint interface. Dual mobility and reverse femoral head-liner hip implants reduce the hip joint's dislocation limits. In addition, researchers reveal that femoral headliner joints with unidirectional motion have a lower wear rate than traditional ball-and-socket joints. Based on research findings and gaps, a hypothesis is formulated by the authors proposing a hip implant with a collared stem and porous lattice FGM structure to address stress shielding and micromotion issues. A hypothesis is also formulated by the authors suggesting that the utilization of a spiral or gear-shaped thread with a matched contact point at the tapered joint of a hip implant could be a viable option for reducing wear and enhancing stability. The literature analysis underscores substantial research opportunities in developing a hip implant joint that addresses both dislocation and increased wear rates. Finally, this review explores potential solutions to existing obstacles in developing a better hip implant system.