In Vivo Response of Laser Processed Porous Titanium Implants for Load-Bearing Implants. Ann Biomed Eng. 2017;45:249-260. [PMID: 27307009 DOI: 10.1007/s10439-016-1673-8]

Utilization of 3D-Printed Customized Uncemented Stem Prostheses for Revision of Aseptic Loosening in the Distal Femoral Cemented Prostheses: Case Series and Literature Review

OBJECTIVE

Aseptic loosening (AL) is a common mechanical complication following reconstruction of the distal femoral cemented prosthesis (DFCP), often resulting in severe bone loss, which complicates prosthesis revision. 3D-printed personalized implants represent an emerging solution for the reconstruction of complex bone defects. This study aimed to investigate the early therapeutic effects of using a 3D-printed, customized, uncemented stem prosthesis for revising aseptic AL in DFCP.

METHODS

From June 2021 to December 2022, a retrospective review was conducted on six consecutive patients who underwent revision surgery due to AL of the DFCP with a 3D-printed customized uncemented stem prosthesis. The study included four male and two female patients, with an average age of 58 ± 11 (range: 46-75) years. All six patients had previously undergone limb salvage surgery using a cemented megaprosthesis after tumor resection. Preoperative imaging evaluation was performed for all patients, and the personalized design of the prostheses was achieved through 3D printing based on CT imaging data. Regular clinical and radiographic follow-up was conducted postoperatively, with the main outcome measures being oncological outcomes, prosthesis survival, osseointegration, complications, and lower limb function.

RESULTS

All patients successfully underwent surgery and were followed up for a mean duration of 30.33 ± 6.15 (range: 24-38) months. All patients were alive at the last follow-up, with no tumor recurrence or distant metastasis. No complications such as infection, loosening, or fracture of the prosthesis occurred. Osseointegration was satisfactory, with a mean MSTS score of 26 (range: 20-28) points.

CONCLUSION

3D-printed, customized, uncemented stem prosthesis exhibit immediate initial stability and reliable biocompatibility. Early clinical outcomes are satisfactory, making them an effective method for revision AL of DFCP.

Surface treatment of PET multifilament textile for biomedical applications: roughness modification and fibroblast viability assessment

OBJECTIVES

The aim of this study was to investigate the potential of tuning the topography of textile surfaces for biomedical applications towards modified cell-substrate interactions.

METHODS

For that purpose, a supercritical Nitrogen N2 jet was used to spray glass particles on multi-filament polyethylene terephthalate (PET) yarns and on woven fabrics. The influence of the jet projection parameters such as the jet pressure (P) and the standoff distance (SoD) on the roughness was investigated.

RESULTS

The impact of the particles created local filament ruptures on the treated surfaces towards hairiness increase. The results show that the treatment increases the roughness by up to 17 % at P 300 bars and SoD 300 mm while the strength of the material is slightly decreased. The biological study brings out that proliferation can be slightly limited on a more hairy surface, and is increased when the surface is more flat. After 10 days of fibroblast culture, the cells covered the entire surface of the fabrics and had mainly grown unidirectionally, forming cell clusters oriented along the longitudinal axis of the textile yarns. Clusters were generated at yarn crossings.

CONCLUSIONS

This approach revealed that the particle projection technology can help tuning the cell proliferation on a textile surface.

Porous metal implants: processing, properties, and challenges

Porous and functionally graded materials have seen extensive applications in modern biomedical devices-allowing for improved site-specific performance; their appreciable mechanical, corrosive, and biocompatible properties are highly sought after for lightweight and high-strength load-bearing orthopedic and dental implants. Examples of such porous materials are metals, ceramics, and polymers. Although, easy to manufacture and lightweight, porous polymers do not inherently exhibit the required mechanical strength for hard tissue repair or replacement. Alternatively, porous ceramics are brittle and do not possess the required fatigue resistance. On the other hand, porous biocompatible metals have shown tailorable strength, fatigue resistance, and toughness. Thereby, a significant interest in investigating the manufacturing challenges of porous metals has taken place in recent years. Past research has shown that once the advantages of porous metallic structures in the orthopedic implant industry have been realized, their biological and biomechanical compatibility-with the host bone-has been followed up with extensive methodical research. Various manufacturing methods for porous or functionally graded metals are discussed and compared in this review, specifically, how the manufacturing process influences microstructure, graded composition, porosity, biocompatibility, and mechanical properties. Most of the studies discussed in this review are related to porous structures for bone implant applications; however, the understanding of these investigations may also be extended to other devices beyond the biomedical field.

Nanoscale Morphologies on the Surface of 3D-Printed Titanium Implants for Improved Osseointegration: A Systematic Review of the Literature

Three-dimensional (3D) printing is serving as the most promising approach to fabricate personalized titanium (Ti) implants for the precise treatment of complex bone defects. However, the bio-inert nature of Ti material limits its capability for rapid osseointegration and thus influences the implant lifetime in vivo. Despite the macroscale porosity for promoting osseointegration, 3D-printed Ti implant surface morphologies at the nanoscale have gained considerable attention for their potential to improve specific outcomes. To evaluate the influence of nanoscale surface morphologies on osseointegration outcomes of 3D-printed Ti implants and discuss the available strategies, we systematically searched evidence according to the PRISMA on PubMed, Embase, Web of Science, and Cochrane (until June 2022). The inclusion criteria were in vivo (animal) studies reporting the osseointegration outcomes of nanoscale morphologies on the surface of 3D-printed Ti implants. The risk of bias (RoB) was assessed using the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE's) tool. The quality of the studies was evaluated using the Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines. (PROSPERO: CRD42022334222). Out of 119 retrieved articles, 9 studies met the inclusion criteria. The evidence suggests that irregular nano-texture, nanodots and nanotubes with a diameter of 40-105nm on the surface of porous/solid 3D-printed Ti implants result in better osseointegration and vertical bone ingrowth compared to the untreated/polished ones by significantly promoting cell adhesion, matrix mineralization, and osteogenic differentiation through increasing integrin expression. The RoB was low in 41.1% of items, unclear in 53.3%, and high in 5.6%. The quality of the studies achieved a mean score of 17.67. Our study demonstrates that nanostructures with specific controlled properties on the surface of 3D-printed Ti implants improve their osseointegration. However, given the small number of studies, the variability in experimental designs, and lack of reporting across studies, the results should be interpreted with caution.

Tubular nanomaterials for bone tissue engineering

Nanomaterial composition, morphology, and mechanical performance are critical parameters for tissue engineering. Within this rapidly expanding space, tubular nanomaterials (TNs), including carbon nanotubes (CNTs), titanium oxide nanotubes (TNTs), halloysite nanotubes (HNTs), silica nanotubes (SiNTs), and hydroxyapatite nanotubes (HANTs) have shown significant potential across a broad range of applications due to their high surface area, versatile surface chemistry, well-defined mechanical properties, excellent biocompatibility, and monodispersity. These include drug delivery vectors, imaging contrast agents, and scaffolds for bone tissue engineering. This review is centered on the recent developments in TN-based biomaterials for structural tissue engineering, with a strong focus on bone tissue regeneration. It includes a detailed literature review on TN-based orthopedic coatings for metallic implants and composite scaffolds to enhance in vivo bone regeneration.

Osseointegration in additive-manufactured titanium implants: A systematic review of animal studies on the need for surface treatment

The objective of the systematic review is to find an answer to a question: "Do surface treatments on titanium implants produced by additive manufacturing improve osseointegration, compared to untreated surfaces?". This review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA 2020) and was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022321351). Searches were performed in PubMed, Scopus, Science Direct, Embase, and Google Scholar databases on March 22nd, 2022. Articles were chosen in 2 steps by 2 blinded reviewers based on previously selected inclusion criteria: articles in animals that addressed the influence of surface treatments on osseointegration in implants produced by additive manufacturing. Articles were excluded that (1) did not use titanium surface, 2) that did not evaluate surface treatments, 3) that did not described osseointegration, 4) Studies with only in vitro analyses, clinical studies, systematic reviews, book chapters, short communications, conference abstracts, case reports and personal opinions.). 1003 articles were found and, after applying the eligibility criteria, 17 were used for the construction of this review. All included studies found positive osseointegration results from performing surface treatments on titanium. The risk of bias was analyzed using the SYRCLE assessment tool. Surface treatments are proposed to promote changes in the microstructure and composition of the implant surface to favor the adhesion of bone cells responsible for osseointegration. It is observed that despite the benefits generated by the additive manufacturing process in the microstructure of the implant surface, surface treatments are still indispensable, as they can promote more suitable characteristics for bone-implant integration. It can be concluded that the surface treatments evaluated in this systematic review, performed on implants produced by additive manufacturing, optimize osseointegration, as it allows the creation of a micro-nano-textured structure that makes the surface more hydrophilic and allows better contact bone-implant.

Improving Biocompatibility for Next Generation of Metallic Implants

The increasing need for joint replacement surgeries, musculoskeletal repairs, and orthodontics worldwide prompts emerging technologies to evolve with healthcare's changing landscape. Metallic orthopaedic materials have a shared application history with the aerospace industry, making them only partly efficient in the biomedical domain. However, suitability of metallic materials in bone tissue replacements and regenerative therapies remains unchallenged due to their superior mechanical properties, eventhough they are not perfectly biocompatible. Therefore, exploring ways to improve biocompatibility is the most critical step toward designing the next generation of metallic biomaterials. This review discusses methods of improving biocompatibility of metals used in biomedical devices using surface modification, bulk modification, and incorporation of biologics. Our investigation spans multiple length scales, from bulk metals to the effect of microporosities, surface nanoarchitecture, and biomolecules such as DNA incorporation for enhanced biological response in metallic materials. We examine recent technologies such as 3D printing in alloy design and storing surface charge on nanoarchitecture surfaces, metal-on-metal, and ceramic-on-metal coatings to present a coherent and comprehensive understanding of the subject. Finally, we consider the advantages and challenges of metallic biomaterials and identify future directions.

Immediate, non-submerged, three-dimensionally printed, one-piece mandibular molar porous root-analogue titanium implants: A 2-year prospective study involving 18 patients

This study prospectively evaluated non-submerged, three-dimensionally printed, one-piece molar porous root-analogue titanium implants. A total of 18 non-restorable multiple-rooted teeth in 18 patients, aged 22-64 years, were included in this study. A series of computed tomography images of the mandible were selected and rendered into a digital model. The non-restorable mandibular molars were digitally separated from the surrounding alveolar bone, and served as the template on which the porous root-analogue titanium implants (RAIs) were designed with computer-aided design (CAD) software. The porous molar RAIs were fabricated with the selective laser melting technique (average particle size 20 μm) and inserted into the alveolar sockets after extraction of the non-restorable molars. Definitive restorations were placed after 3 months of uninterrupted healing. Peri-implant clinical and radiographic measurements were obtained 2 years later. All patients functioned well following 2 years of functional loading, and peri-implant clinical and radiographic measurements demonstrated implant stability. No implants were lost at the 2-year follow-up, and the survival rate was 100%. Three-dimensionally printed one-piece molar porous RAIs may be a promising option for the replacement of non-restorable molars that are planned for extraction. Additional studies are required to evaluate the long-term survival of implants fabricated using this technique.

Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges

The uses of implantable medical devices are safer and more common since sterilization methods and techniques were established a century ago; however, device-associated infections (DAIs) are still frequent and becoming a leading complication as the number of medical device implantations keeps increasing. This urges the world to develop instructive prevention and treatment strategies for DAIs, boosting the studies on the design of antibacterial surfaces. Every year, studies associated with DAIs yield thousands of publications, which here are categorized into four groups, i.e., antibacterial surfaces with long-term efficacy, cell-selective capability, tailored responsiveness, and immune-instructive actions. These innovations are promising in advancing the solution to DAIs; whereas most of these are normally quite preliminary “proof of concept” studies lacking exact clinical scopes. To help identify the flaws of our current antibacterial designs, clinical features of DAIs are highlighted. These include unpredictable onset, site-specific incidence, and possibly involving multiple and resistant pathogenic strains. The key point we delivered is antibacterial designs should meet the specific requirements of the primary functions defined by the “intended use” of an implantable medical device. This review intends to help comprehend the complex relationship between the device, pathogens, and the host, and figure out future directions for improving the quality of antibacterial designs and promoting clinical translations.

Applications of Titanium Dioxide Nanostructure in Stomatology

Breakthroughs in the field of nanotechnology, especially in nanochemistry and nanofabrication technologies, have been attracting much attention, and various nanomaterials have recently been developed for biomedical applications. Among these nanomaterials, nanoscale titanium dioxide (nano-TiO₂) has been widely valued in stomatology due to the fact of its excellent biocompatibility, antibacterial activity, and photocatalytic activity as well as its potential use for applications such as dental implant surface modification, tissue engineering and regenerative medicine, drug delivery carrier, dental material additives, and oral tumor diagnosis and treatment. However, the biosafety of nano-TiO₂ is controversial and has become a key constraint in the development of nano-TiO₂ applications in stomatology. Therefore, in this review, we summarize recent research regarding the applications of nano-TiO₂ in stomatology, with an emphasis on its performance characteristics in different fields, and evaluations of the biological security of nano-TiO₂ applications. In addition, we discuss the challenges, prospects, and future research directions regarding applications of nano-TiO₂ in stomatology that are significant and worthy of further exploration.

Effect of Angiogenesis in Bone Tissue Engineering

The reconstruction of large skeletal defects is still a tricky challenge in orthopedics. The newly formed bone tissue migrates sluggishly from the periphery to the center of the scaffold due to the restrictions of exchange of oxygen and nutrition impotent cells osteogenic differentiation. Angiogenesis plays an important role in bone reconstruction and more and more studies on angiogenesis in bone tissue engineering had been published. Promising advances of angiogenesis in bone tissue engineering by scaffold designs, angiogenic factor delivery, in vivo prevascularization and in vitro prevascularization are discussed in detail. Among all the angiogenesis mode, angiogenic factor delivery is the common methods of angiogenesis in bone tissue engineering and possible research directions in the future.

Influence of strut-size and cell-size variations on porous Ti6Al4V structures for load-bearing implants

Mechanical properties of porous metal coatings in load-bearing implants play a critical role in determining the in vivo lifetime. However, there is a knowledge gap in measuring the shear strength of porous metal coatings at the porous-dense interface. This study evaluated pore morphology dependence and strut-size on compression, shear deformation, and in vitro response of additively manufactured porous Ti6Al4V structures. Selective laser melting (SLM)-based additive manufacturing (AM) technique was used to process two types of structures with honeycomb cell design-one with constant cell-size of ∼470 μm with mean strut-size varying from 92 to 134 μm, and denoted as strut-size variation (SSV); and the other with a constant strut-size of ∼135 μm with mean cell-size varying from 580 to 740 μm, denoted as cell-size variation (CSV). It was observed that under compressive loading, changes in elastic modulus were more sensitive to variations in strut-size over cell-size. Under shear loading at the porous-dense interface, strength enhancement and material hardening were observed in both SSV and CSV samples due to pore-collapsing. Our results show that for hexagonal cell designs, shear behavior is more sensitive to variations in cell-size over strut-size, although elastic modulus is more sensitive to changes in strut-size for porous metallic structures. From in vitro hFOB analysis, it was observed that pore size of 670 μm demonstrated the highest osteoblast cell viability among porous structures with evidence of pore-bridging by cells. P. aeruginosa bacterial culture showed that bacterial cell viability was higher for porous structures than dense Ti, with evidence of pore-bridging by bacterial cells.

Synthesis of Ti-Al-xNb Ternary Alloys via Laser-Engineered Net Shaping for Biomedical Application: Densification, Electrochemical and Mechanical Properties Studies

The lives of many people around the world are impaired and shortened mostly by cardiovascular diseases (CVD). Despite the fact that medical interventions and surgical heart transplants may improve the lives of patients suffering from cardiovascular disease, the cost of treatments and securing a perfect donor are aspects that compel patients to consider cheaper and less invasive therapies. The use of synthetic biomaterials such as titanium-based implants are an alternative for cardiac repair and regeneration. In this work, an in situ development of Ti-Al-xNb alloys were synthesized via laser additive manufacturing for biomedical application. The effect of Nb composition on Ti-Al was investigated. The microstructural evolution was characterized using a scanning electron microscope (SEM) equipped with energy dispersive spectroscopy (EDS). A potentiodynamic polarization technique was utilized to investigate the corrosion behavior of TiAl-Nb in 3.5% NaCl. The microhardness and corrosion behaviour of the synthesized Ti-Al-Nb alloys were found to be dependent on laser-processing parameters. The microhardness performance of the samples increased with an increase in the Nb feed rate to the Ti-Al alloy system. Maximum microhardness of 699.8 HVN was evident at 0.061 g/min while at 0.041 g/min the microhardness was 515.8 HVN at Nb gas carrier of 1L/min, respectively.

Photothermal and Enhanced Photocatalytic Therapies Conduce to Synergistic Anticancer Phototherapy with Biodegradable Titanium Diselenide Nanosheets

Nanomaterial-based photothermal and photocatalytic therapies are effective against various types of cancers. However, combining two or more materials is considered necessary to achieve the synergistic anticancer effects of photothermal and photocatalytic therapy, which made the preparation process complicated. Herein, the authors describe simple 2D titanium diselenide (TiSe₂ ) nanosheets (NSs) that can couple photothermal therapy with photocatalytic therapy. The TiSe₂ NSs are prepared using a liquid exfoliation method. They show a layered structure and possess high photothermal conversion efficiency (65.58%) and good biocompatibility. Notably, upon near-infrared irradiation, these NSs exhibit good photocatalytic properties with enhanced reactive oxygen species generation and H₂ O₂ decomposition in vitro. They can also achieve high temperatures, with heat improving their catalytic ability to further amplify oxidative stress and glutathione depletion in cancer cells. Furthermore, molecular mechanism studies reveal that the synergistic effects of photothermal and enhanced photocatalytic therapy can simultaneously lead to apoptosis and necrosis in cancer cells via the HSP90/JAK3/NF-κB/IKB-α/Caspase-3 pathway. Systemic exploration reveals that the TiSe₂ NSs has an appreciable degradation rate and accumulates passively in tumor tissue, where they facilitate photothermal and photocatalytic effects without obvious toxicity. Their study thus indicates the high potential of biodegradable TiSe₂ NSs in synergistic phototherapy for cancer treatment.

Evolution of anodised titanium for implant applications

Anodised titanium has a long history as a coating structure for implants due to its bioactive and ossified surface, which promotes rapid bone integration. In response to the growing literature on anodised titanium, this article is the first to revisit the evolution of anodised titanium as an implant coating. The review reports the process and mechanisms for the engineering of distinctive anodised titanium structures, the significant factors influencing the mechanisms of its formation, bioactivity, as well as recent pre- and post-surface treatments proposed to improve the performance of anodised titanium. The review then broadens the discussion to include future functional trends of anodised titanium, ranging from the provision of higher surface energy interactions in the design of biocomposite coatings (template stencil interface for mechanical interlock) to techniques for measuring the bone-to-implant contact (BIC), each with their own challenges. Overall, this paper provides up-to-date information on the impacts of the structure and function of anodised titanium as an implant coating in vitro and in/ex vivo tests, as well as the four key future challenges that are important for its clinical translations, namely (i) techniques to enhance the mechanical stability and (ii) testing techniques to measure the mechanical stability of anodised titanium, (iii) real-time/in-situ detection methods for surface reactions, and (iv) cost-effectiveness for anodised titanium and its safety as a bone implant coating.

Additively manufactured titanium scaffolds and osteointegration - meta-analyses and moderator-analyses of in vivo biomechanical testing

Introduction

Maximizing osteointegration potential of three-dimensionally-printed porous titanium (3DPPT) is an ongoing focus in biomaterial research. Many strategies are proposed and tested but there is no weighted comparison of results.

Methods

We systematically searched Pubmed and Embase to obtain two pools of 3DPPT studies that performed mechanical implant-removal testing in animal models and whose characteristics were sufficiently similar to compare the outcomes in meta-analyses (MAs). We expanded these MAs to multivariable meta-regressions (moderator analysis) to verify whether statistical models including reported scaffold features (e.g., “pore-size”, “porosity”, “type of unit cell”) or post-printing treatments (e.g., surface treatments, adding agents) could explain the observed differences in treatment effects (expressed as shear strength of bone-titanium interface).

Results

“Animal type” (species of animal in which the 3DPPT was implanted) and “type of post-treatment” (treatment performed after 3D printing) were moderators providing statistically significant models for differences in mechanical removal strength. An interaction model with covariables “pore-size” and “porosity” in a rabbit subgroup analysis (the most reported animal model) was also significant. Impact of other moderators (including “time” and “location of implant”) was not statistically significant.

Discussion/conclusion

Our findings suggest a stronger effect from porosity in a rat than in a sheep model. Additionally, adding a calcium-containing layer does not improve removal strength but the other post-treatments do. Our results provide overview and new insights, but little narrowing of existing value ranges. Consequent reporting of 3DPPT characteristics, standardized comparison, and expression of porosity in terms of surface roughness could help tackle these existing dilemmas.

Graphical abstract

Advancing of titanium medical implants by surface engineering: recent progress and challenges

Introduction:Titanium (Ti) and their alloys are used as main implant materials in orthopedics and dentistry for decades having superior mechanical properties, chemical stability and biocompatibility. Their rejections due lack of biointegration and bacterial infection are concerning with considerable healthcare costs and impacts on patients. To address these limitations, conventional Ti implants need improvements where the use of surface nanoengineering approaches and the development of a new generation of implants are recognized as promising strategies.Areas covered:This review presents an overview of recent progress on the application of surface engineering methods to advance Ti implants enable to address their key limitations. Several promising surface engineering strategies are presented and critically discussed to generate advanced surface properties and nano-topographies (tubular, porous, pillars) able not only to improve their biointegration, antibacterial performances, but also to provide multiple functions such as drug delivery, therapy, sensing, communication and health monitoring underpinning the development of new generation and smart medical implants.Expert opinion:Recent advances in cell biology, materials science, nanotechnology and additive manufacturing has progressively influencing improvements of conventional Ti implants toward the development of the next generation of implants with improved performances and multifunctionality. Current research and development are in early stage, but progressing with promising results and examples of moving into in-vivo studies an translation into real applications.

Osseointegration of porous titanium and tantalum implants in ovariectomized rabbits: A biomechanical study

BACKGROUND

Today, biological fixation of uncemented press-fit acetabular components plays an important role in total hip arthroplasty. Long-term stable fixation of these implants depends on the osseointegration of the acetabular cup bone tissue into the acetabular cup implant, and their ability to withstand functional loads.

AIM

To compare the strength of bone-implant osseointegration of four types of porous metal implants in normal and osteoporotic bone in rabbits.

METHODS

The study was performed in 50 female California rabbits divided into non-ovariectomized (non-OVX) and ovariectomized groups (OVX) at 6 mo of age. Rabbits were sacrificed 8 wk after the implantation of four biomaterials [TTM, CONCELOC, Zimmer Biomet's Trabecular Metal (TANTALUM), and ATLANT] in a 5-mm diameter defect created in the left femur. A biomechanical evaluation of the femur was carried out by testing implant breakout force. The force was gradually increased until complete detachment of the implant from the bone occurred.

RESULTS

The breakout force needed for implant detachment was significantly higher in the non-OVX group, compared with the OVX group for all implants (TANTALUM, 194.7 ± 6.1 N vs 181.3 ± 2.8 N; P = 0.005; CONCELOC, 190.8 ± 3.6 N vs 180.9 ± 6.6 N; P = 0.019; TTM, 186.3 ± 1.8 N vs 172.0 N ± 11.0 N; P = 0.043; and ATLANT, 104.9 ± 7.0 N vs 78.9 N ± 4.5 N; P = 0.001). In the OVX group, The breakout forces in TANTALUM, TTM, and CONCELOC did not differ significantly (P = 0.066). The breakout force for ATLANT in the OVX group was lower by a factor of 2.3 compared with TANTALUM and CONCELOC, and by 2.2 compared with TTM (P = 0.001). In the non-OVX group, the breakout force for ATLANT was significantly different from all other implants, with a reduction in fixation strength by a factor of 1.9 (P = 0.001).

CONCLUSION

TANTALUM, TTM, and CONCELOC had equal bone-implant osseointegration in healthy and in osteoporotic bone. ATLANT had significantly decreased osseointegration (P = 0.001) in healthy and in osteoporotic bone.

Histological and Histomorphometric Comparison of Innovative Dental Implants Laser Obtained: Animal Pilot Study

OBJECTIVE

Evaluation of the in vivo bone response of two innovative titanium surfaces ytterbium laser active fiber obtained (L1-L2) compared to a sandblasted and acid etched (SBAE) during early phase of osseointegration.

MATERIAL AND METHODS

Three implant groups with the same macroscopic features were obtained (L1-L2-SBAE) to promote specific surface characteristics. Scanning electron microscopy, profilometric evaluation, X-ray spectrometry, and diffraction analysis were performed. For each group, six implants were placed in the tibiae of three Peli Buey sheep, and histologic, histomorphometric analysis, bone to implant contact (BIC), and the Dynamic Osseointegration index (DOI) were performed.

RESULTS

During the early phases of osseointegration, the histological and histomorphometric results showed significant differences between L1-L2-SBAE implants. At 15 and 30 days, histological analysis detected a newly bone formation around all specimens with an higher vital bone in L2 compared to L1 and SBAE both in cortical and in poor-quality marrow bone. At same time, histomorphometric analysis showed significantly higher BIC values in L2 (42.1 ± 2.6 and 82.4 ± 2.2) compared to L1 (5.2 ± 3.1 and 56.2 ± 1.3) and SBAE (23.3 ± 3.9 and 77.3 ± 0.4). DOI medium value showed a higher rate in L2 (2.83) compared to SBAE (2.60) and L1 (1.91).

CONCLUSIONS

With the limitations of this pilot study, it is possible to assess that the titanium surface characteristics, and not the technologies used to obtain the modification, played a crucial role during the osseointegration process. Histological, histomorphometric, BIC, and DOI evaluation showed a significantly higher rate in L2 specimens compared to others, confirming that the implant surface could increase the bone response in cortical or marrow poor quality bone during the initial phases of osseointegration.

Mixed oxide nanotubes in nanomedicine: A dead-end or a bridge to the future?

Nanomedicine has seen a significant rise in the development of new research tools and clinically functional devices. In this regard, significant advances and new commercial applications are expected in the pharmaceutical and orthopedic industries. For advanced orthopedic implant technologies, appropriate nanoscale surface modifications are highly effective strategies and are widely studied in the literature for improving implant performance. It is well-established that implants with nanotubular surfaces show a drastic improvement in new bone creation and gene expression compared to implants without nanotopography. Nevertheless, the scientific and clinical understanding of mixed oxide nanotubes (MONs) and their potential applications, especially in biomedical applications are still in the early stages of development. This review aims to establish a credible platform for the current and future roles of MONs in nanomedicine, particularly in advanced orthopedic implants. We first introduce the concept of MONs and then discuss the preparation strategies. This is followed by a review of the recent advancement of MONs in biomedical applications, including mineralization abilities, biocompatibility, antibacterial activity, cell culture, and animal testing, as well as clinical possibilities. To conclude, we propose that the combination of nanotubular surface modification with incorporating sensor allows clinicians to precisely record patient data as a critical contributor to evidence-based medicine.

In vivo performance of Al2O3-Ti bone implants in the rat femur

Background

Alumina-titanium (Al₂O₃-Ti) biocomposites have been recently developed with improved mechanical properties for use in heavily loaded orthopedic sites. Their biological performance, however, has not been investigated yet.

Methods

The aim of the present study was to evaluate the in vivo biological interaction of Al₂O₃-Ti. Spark plasma sintering (SPS) was used to fabricate Al₂O₃-Ti composites with 25 vol.%, 50 vol.%, and 75 vol.% Ti content. Pure alumina and titanium were also fabricated by the same procedure for comparison. The fabricated composite disks were cut into small bars and implanted into medullary canals of rat femurs. The histological analysis and scanning electron microscopy (SEM) observation were carried out to determine the bone formation ability of these materials and to evaluate the bone-implant interfaces.

Results

The histological observation showed the formation of osteoblast, osteocytes with lacuna, bone with lamellar structures, and blood vessels indicating that the healing and remodeling of the bone, and vasculature reconstruction occurred after 4 and 8 weeks of implantation. However, superior bone formation and maturation were obtained after 8 weeks. SEM images also showed stronger interfaces at week 8. There were differences between the composites in percentages of bone area (TB%) and the number of osteocytes. The 50Ti composite showed higher TB% at week 4, while 25Ti and 75Ti represented higher TB% at week 8. All the composites showed a higher number of osteocytes compared to 100Ti, particularly 75Ti.

Conclusions

The fabricated composites have the potential to be used in load-bearing orthopedic applications.

3D X-ray micro-computed tomography imaging for the microarchitecture evaluation of porous metallic implants and scaffolds

As an advanced microscopy technology with strong sample adaptability and non-destructive three-dimensional (3D) characteristics, X-ray micro-computed tomography (Micro-CT) can establish the overall connection between various microarchitecture parameters and accelerate the research process of porous metallic implants and scaffolds. In this review, the Micro-CT based quantitative evaluation methods of microarchitecture and bone formation are investigated. To ensure reliability of the results, the Micro-CT setup is discussed briefly and the essential image processing algorithms are introduced in detail. The significance and limitations of Micro-CT are analyzed in the context of research on porous metallic implants. We also discuss the future development of Micro-CT technology in the field of biological tissue engineering.

3D printed titanium scaffolds with homogeneous diamond-like structures mimicking that of the osteocyte microenvironment and its bone regeneration study

Biofabrication of personalized titanium scaffold mimicking that of the osteocyte microenvironment is challenging due to its complex geometrical cues. The effect of scaffolds geometrical cues and implantation sites on osteogenesis is still not clear. In this study, personalized titanium scaffolds with homogeneous diamond-like structures mimicking that of the osteocyte microenvironment were precisely designed and fabricated by selected laser melting method. The effects of different geometric cues, including porosity, pore sizes and interconnection properties, on cellular behavior were investigated. Biomimetic mechanical properties of porous titanium alloy scaffold were predesigned and simulated by finite element analysis. In vitro experiment revealed that homogeneous diamond-like structures mimicking that of the osteocyte microenvironment triggered osteocyte adhesion and migration behavior. Typical implantation sites, including rabbit femur, beagle femur, and beagle skull, were used to study the implantation sites effects on bone regeneration. In vivo experimental results indicated that different implantation sites showed significant differences. This study helps to understand the scaffolds geometrical microenvironment and implantation sites effects on osteogenesis mechanism. And it is beneficial to the development of bone implants with better bone regeneration ability.

Biomimetic titanium implant coated with extracellular matrix enhances and accelerates osteogenesis

Aim: To evaluate the biological function of titanium implants coated with cell-derived mineralized extracellular matrix, which mimics a bony microenvironment. Materials & methods: A biomimetic titanium implant was fabricated primarily by modifying the titanium surface with TiO₂ nanotubes or sand-blasted, acid-etched topography, then was coated with mineralized extracellular matrix constructed by culturing bone marrow mesenchymal stromal cells. The osteogenic ability of biomimetic titanium surface in vitro and in vivo were evaluated. Results: In vitro and in vivo studies revealed that the biomimetic titanium implant enhanced and accelerated osteogenesis of bone marrow stromal cells by increasing cell proliferation and calcium deposition. Conclusion: By combining surface topography modification with biological coating, the results provided a valuable method to produce biomimetic titanium implants with excellent osteogenic ability.

Cell type specific adhesion to surfaces functionalised by amine plasma polymers

Our previously-obtained impressive results of highly increased C2C12 mouse myoblast adhesion to amine plasma polymers (PPs) motivated current detailed studies of cell resistance to trypsinization, cell proliferation, motility, and the rate of attachment carried out for fibroblasts (LF), keratinocytes (HaCaT), rat vascular smooth muscle cells (VSMC), and endothelial cells (HUVEC, HSVEC, and CPAE) on three different amine PPs. We demonstrated the striking difference in the resistance to trypsin treatment between endothelial and non-endothelial cells. The increased resistance observed for the non-endothelial cell types was accompanied by an increased rate of cellular attachment, even though spontaneous migration was comparable to the control, i.e., to the standard cultivation surface. As demonstrated on LF fibroblasts, the resistance to trypsin was similar in serum-supplemented and serum-free media, i.e., medium without cell adhesion-mediating proteins. The increased cell adhesion was also confirmed for LF cells by an independent technique, single-cell force spectroscopy. This method, as well as the cell attachment rate, proved the difference among the plasma polymers with different amounts of amine groups, but other investigated techniques could not reveal the differences in the cell behaviour on different amine PPs. Based on all the results, the increased resistance to trypsinization of C2C12, LF, HaCaT, and VSMC cells on amine PPs can be explained most probably by a non-specific cell adhesion such as electrostatic interaction between the cells and amine groups on the material surface, rather than by the receptor-mediated adhesion through serum-derived proteins adsorbed on the PPs.

Influence of the mechanical properties of biomaterials on degradability, cell behaviors and signaling pathways: current progress and challenges

The development of suitable biomaterials with the ability to improve repair and regeneration of human tissues is continuously in progress, and mechanical properties of biomaterials play a critical role in their success in the clinical setting. Both biomaterial degradability and signaling cascades of cell interactions with biomaterials are significantly influenced by the mechanical properties of biomaterials, determining the final repair effect of bio-implants. Actually, the mechanical properties of biomaterials play a critical role in designing and developing medical material products both in research and in practice. Currently, advances in mechanics have provided new possibilities for researchers to investigate and modulate both the substrates and cell behaviors with respect to material perfection in tissue engineering. Achieving convenient and accurate approaches for producing different types of biomaterials is now possible by applying computerized methods. In this review, we have systematically clarified the influence of several selected mechanical properties of biomaterials (including stress/strain, elasticity/stiffness and certain time-dependent mechanical properties) on biomaterial degradability, cell behaviors and signaling pathways. Furthermore, the mechanical design targets and approaches for optimizing the mechanical properties of biomaterials, as well as the challenges and prospects are elaborated. This review will certainly bring up new ideas and possibilities for the field of tissue engineering and regenerative biomaterials.

Zn-Incorporated TiO2 Nanotube Surface Improves Osteogenesis Ability Through Influencing Immunomodulatory Function of Macrophages

PURPOSE

Zinc (Zn), an essential trace element in the body, has stable chemical properties, excellent osteogenic ability and moderate immunomodulatory property. In the present study, a Zn-incorporated TiO2 nanotube (TNT) was fabricated on titanium (Ti) implant material. We aimed to evaluate the influence of nano-scale topography and Zn on behaviors of murine RAW 264.7 macrophages. Moreover, the effects of Zn-incorporated TNT surface-regulated macrophages on the behaviors and osteogenic differentiation of murine MC3T3-E1 osteoblasts were also investigated.

METHODS

TNT coatings were firstly fabricated on a pure Ti surface using anodic oxidation, and then nano-scale Zn particles were incorporated onto TNTs by the hydrothermal method. Surface topography, chemical composition, roughness, hydrophilicity, Zn release pattern and protein adsorption ability of the Zn-incorporated TiO2 nanotube surface were characterized by scanning electron microscopy (SEM), X-ray diffraction (XRD) and X-ray photoelectron spectroscopy (XPS), surface profiler, contact angle test, Zn release test and protein adsorption test. The cell behaviors and both pro-inflammatory (M1) and pro-regenerative (M2) marker gene and protein levels in macrophages cultured on Zn-incorporated TNTs surfaces with different TNT diameters were detected. The supernatants of macrophages were extracted and preserved as conditioned medium (CM). Furthermore, the behaviors and osteogenic properties of osteoblasts cultured in CM on various surfaces were evaluated.

RESULTS

The release profile of Zn on Zn-incorporated TNT surfaces revealed a controlled release pattern. Macrophages cultured on Zn-incorporated TNT surfaces displayed enhanced gene and protein expression of M2 markers, and M1 markers were moderately inhibited, compared with the LPS group (the inflammation model). When cultured in CM, osteoblasts cultured on Zn-incorporated TNTs showed strengthened cell proliferation, adhesion, osteogenesis-related gene expression, alkaline phosphatase activity and extracellular mineralization, compared with their TNT counterparts and the Ti group.

CONCLUSION

This study suggests that the application of Zn-incorporated TNT surfaces may establish an osteogenic microenvironment and accelerate bone formation. It provided a promising strategy of Ti surface modification for a better applicable prospect.

Controlled Delivery of Curcumin and Vitamin K2 from Hydroxyapatite-Coated Titanium Implant for Enhanced in Vitro Chemoprevention, Osteogenesis, and in Vivo Osseointegration

Successful repair of critical-sized tumor-resection defects, especially in load-bearing bones, still remains a major challenge in clinical orthopedics. Titanium (Ti) implants have been increasingly used in the past few decades because of titanium's suitable mechanical properties and biocompatibility; however, it shows insufficient integration with the surrounding bone. In this study, the plasma spray technique is utilized to form homogeneous hydroxyapatite (HA) coating on the surface of the Ti implant to enhance osseointegration at the tissue-implant interface. These coated implants are loaded with curcumin and vitamin K2 to introduce chemopreventive and osteogenesis ability via controlled release of these biomolecules. The synergistic effect of these two biomolecules showed enhanced in vitro osteoblast (hFOB) cell attachment and proliferation for 11 days. Moreover, these biomolecules showed lower in vitro osteosarcoma (MG-63) cell proliferation after 3, 7, and 11 days. An in vivo study was carried out to evaluate the bone bonded zone in a rat distal femur model at an early wound healing stage of 5 days. Modified Masson Goldner staining of the tissue-implant section showed improved contact between tissue and implant in dual drug-loaded HA-coated Ti implants compared to control implants. This work presents a successful fabrication of a mechanically competent functional Ti implant with the advantages of enhanced in vitro osteoblast proliferation, osteosarcoma inhibition, and in vivo osseointegration, indicating the potential for load-bearing bone-defect repair after tumor resection.

Treatments for enhancing the biocompatibility of titanium implants

Titanium surface treatment is a crucial process for achieving sufficient osseointegration of an implant into the bone. If the implant does not heal sufficiently, serious complications may occur, e.g. infection, inflammation, aseptic loosening of the implant, or the stress-shielding effect, as a result of which the implant may need to be reoperated. After a titanium graft has been implanted, several interactions are crucial in order to create a strong bone-implant connection. It is essential that cells adhere to the surface of the implant. Surface roughness has a significant influence on cell adhesion, and also on improving and accelerating osseointegration. Other highly important factors are biocompatibility and resistance to bacterial contamination. Bio-inertness of titanium is ensured by the protective film of titanium oxides that forms spontaneously on its surface. This film prevents the penetration of metal compounds, and it is well-adhesive for calcium and phosphate ions, which are necessary for the formation of the mineralized bone structure. Since the presence of the film alone is not sufficient for the biocompatibility of titanium, a suitable surface finish is required to create a firm bone-implant connection. In this review, we explain and compare the most widely-used methods for modulating the surface roughness of titanium implants in order to enhance cell adhesion on the surface of the implant, e.g. plasma spraying, sandblasting, acid etching, laser treatment, sol-gel etc., The methods are divided into three overlapping groups, according to the type of modification.

Porous Tantalum and Titanium in Orthopedics: A Review

Porous metal is metal with special porous structures, which can offer high biocompatibility and low Young's modulus to satisfy the need for orthopedic applications. Titanium and tantalum are the most widely used porous metals in orthopedics due to their excellent biomechanical properties and biocompatibility. Porous titanium and tantalum have been studied and applied for a long history until now. Here in this review, various manufacturing methods of titanium and tantalum porous metals are introduced. Application of these porous metals in different parts of the body are summarized, and strengths and weaknesses of these porous metal implants in clinical practice are discussed frankly for future improvement from the viewpoint of orthopedic surgeons. Then according to the requirements from clinics, progress in research for clinical use is illustrated in four aspects. Various creative designs of microporous and functionally gradient structure, surface modification, and functional compound systems of porous metal are exhibited as reference for future research. Finally, the directions of orthopedic porous metal development were proposed from the clinical view based on the rapid progress of additive manufacturing. Controllable design of both macroscopic anatomical bionic shape and microscopic functional bionic gradient porous metal, which could meet the rigorous mechanical demand of bone reconstruction, should be developed as the focus. The modification of a porous metal surface and construction of a functional porous metal compound system, empowering stronger cell proliferation and antimicrobial and antineoplastic property to the porous metal implant, also should be taken into consideration.

Partial Bone Formation in Additive Manufactured Porous Implants Reduces Predicted Stress and Danger of Fatigue Failure

New porous implant designs made possible by additive manufacturing allow for increased osseointegration, potentially improving implant performance and longevity for patients that require massive bone implants. The aim of this study was to evaluate how implantation and the strain distribution in the implant affect the pattern of bone ingrowth and how changes in tissue density within the pores alter the stresses in implants. The hypothesis was that porous metal implants are susceptible to fatigue failure, and that this reduces as osteointegration occurs. A phenomenological, finite element analysis (FEA) bone remodelling model was used to predict partial bone formation for two porous (pore sizes of 700 μm and 1500 μm), laser sintered Ti₆Al₄V implants in an ovine condylar defect model, and was compared and verified against in vivo, histology results. The FEA models predicted partial bone formation within the porous implants, but over-estimated the amount of bone-surface area compared to histology results. The stress and strain in the implant and adjacent tissues were assessed before, during bone remodelling, and at equilibrium. Results showed that partial bone formation improves the stress distribution locally by reducing stress concentrations for both pore sizes, by at least 20%. This improves the long-term fatigue resistance for the larger pore implant, as excessively high stress is reduced to safer levels (86% of fatigue strength) as bone forms. The stress distribution only changed slightly in regions without bone growth. As the extent of bone formation into extensively porous bone implants depends on the level of stress shielding, the design of the implant and stiffness have significant influence on bone integration and need to be considered carefully to ensure the safety of implants with substantial porous regions. To our knowledge this is the first time that the effect of bone formation on stress distribution within a porous implant has been described and characterised.

Electrically polarized TiO2 nanotubes on Ti implants to enhance early-stage osseointegration

Ti is characteristically bioinert and is supplemented with modifications in surface topography and chemistry to find use in biomedical applications. The aim of this study is to understand the effects of surface charge on TiO2 nanotubes (TNT) on Ti implants towards early stage osseointegration. We hypothesize that charge storage on TNT will improve bioactivity and enhance early-stage osseointegration in vivo. Commercially pure Ti surface was altered by growing TNT via anodic oxidation followed by the introduction of surface charge through electrothermal polarization to form bioelectret. Our results indicate a stored charge of 37.15 ± 14 mC/cm2 for TNT surfaces. The polarized TNT (TNT-Ps) samples did not show any charge leakage up to 18 months, and improved wettability with a measured contact angle less than 1°. No cellular toxicity through osteoblast proliferation and differentiation in vitro were shown by the TNT-Ps. Enhanced new bone formation at 5 weeks post-implantation for the TNT-Ps in contrast to TNTs was observed in vivo. Histomorphometric analyses show ∼40% increase in mineralized bone formation around the TNT-P implants than the TNTs at 5 weeks, which is indicative of accelerated bone remodeling cycle. These results show that stored surface charge on TiO2 nanotubes helped to accelerate bone healing due to early-stage osseointegration in vivo. STATEMENT OF SIGNIFICANCE: To improve surface bioactivity of metallic biomaterials, various approaches have been proposed and implemented. Among them, stored surface charge has been explored to enhance biological responses for hydroxyapatite ceramics where charged surfaces show favorable bone tissue ingrowth. However, surface charge effects have not yet been explored as a way to mitigate bio-inertness of titanium. This study intends to understand novel integration of bioactive titania-nanotubes and charge storage as surface modification for titanium implants. Our results show excellent biological response due to surface charge on titania-nanotubes offering possibilities of faster healing particularly for patients with compromised bone health.

Effects of Aloe Vera Gel Extract in Doped Hydroxyapatite-Coated Titanium Implants on in Vivo and in Vitro Biological Properties

Hydroxyapatite-coated titanium alloys have been a popular choice as bone implants for load-bearing applications for the compositional similarity of hydroxyapatite to natural bone. The limited osteoinductive properties exhibited by the hydroxyapatite (HA) coatings have led to the incorporation of growth factor or dopants for improved osseointegration. This study aims to investigate the effects of a naturally occurring aloe vera gel extract, acemannan, in doped hydroxyapatite coatings on the in vitro osteoblast cell viability and in vivo new bone formation in a rat distal femur model. Silver oxide and silica-doped hydroxyapatite coatings were developed by the induction plasma spray coating method on Ti alloys to introduce antibacterial properties along with induction of angiogenic properties, respectively. The doped coating was further consecutively dip coated with acemannan to analyze its effects on the in vivo early stage osseointegration and chitosan to control the burst release of the acemannan from the calcium phosphate matrix. The results show controlled release of acemannan from the chitosan coatings, with enhanced osteoblast cell viability by the incorporation of acemannan in vitro. Improved osseointegration with a seamless implant interface and improved new bone formation was noted by the acemannan and chitosan coating in vivo, 5 weeks after implantation. Our results demonstrate the efficacy of a combination of natural medicine and naturally occurring polymer in a doped hydroxyapatite-coated titanium implant on the bone tissue regeneration for load-bearing orthopedic applications.

Direct comparison of additively manufactured porous titanium and tantalum implants towards in vivo osseointegration

Material properties of implants such as volume porosity and nanoscale surface modification have been shown to enhance cell-material interactions in vitro and osseointegration in vivo. Porous tantalum (Ta) and titanium (Ti) coatings are widely used for non-cemented implants, which are fabricated using different processing routes. In recent years, some of those implants are being manufactured using additive manufacturing. However, limited knowledge is available on direct comparison of additively manufactured porous Ta and Ti structures towards early stage osseointegration. In this study, we have fabricated porous Ta and Ti6Al4V (Ti64) implants using laser engineered net shaping (LENS™) with similar volume fraction porosity to compare the influence of surface characteristics and material chemistry on in vivo response using a rat distal femur model for 5 and 12 weeks. We have also assessed whether surface modification on Ti64 can elicit similar in vivo response as porous Ta in a rat distal femur model for 5 and 12 weeks. The harvested implants were histologically analyzed for osteoid surface per bone surface. Field emission scanning electron microscopy (FESEM) was done to assess the bone-implant interface. The results presented here indicate comparable performance of porous Ta and surface modified porous Ti64 implants towards early stage osseointegration at 5 weeks post implantation through seamless bone-material interlocking. However, a continued and extended efficacy of porous Ta is found in terms of higher osteoid formation at 12 weeks post-surgery.

Stability and osteogenic potential evaluation of micro-patterned titania mesoporous-nanotube structures

Background: Although titanium dioxide nanotubes (TNTs) had great potential to promote osteogenesis, their weak bonding strength with titanium substrates greatly limited their clinical application. Purpose: The objective of this study was to maintain porosity and improve the stability of TNT coatings by preparing some micro-patterned mesoporous/nanotube (MP/TNT) structures via a photolithography-assisted anodization technology. Methods: The adhesion strength of different coatings was studied by ultrasonic cleaning machine and scratch tester. The early adhesion, spreading, proliferation and differentiation of MC3T3-E1 cells on different substrates were investigated in vitro by fluorescent staining, CCK8, alkaline phosphatase activity, mineralization and polymerase chain reaction assays, respectively. Results: Results of ultrasonic and scratch assays showed that the stability of TNTs (especially 125 nm) was significantly improved after being patterned with MP structures. In vitro cell assays further demonstrated that the insertion of MP structure into 125 nm TNT coating, which was denoted as MP125, could effectively improve the early adhesion, spreading and proliferation of surface MC3T3-E1 cells without damaging their osteogenic differentiation. Conclusion: We determined that the MP/TNT patterned samples (especially MP125) have excellent stability and osteogenesis properties, and may have better clinical application prospects.

Comparative effects of controlled release of sodium bicarbonate and doxorubicin on osteoblast and osteosarcoma cell viability

This study intends to analyze the effects of doxorubicin and sodium bicarbonate release with polycaprolactone (PCL) coating on calcium phosphate system which is a bone like material, on the cell viability and proliferation of osteosarcoma and osteoblast. Increased systematic pH concentrations locally by the release of sodium bicarbonate diminished acidosis and hence, alleviated malignancy. In our studies, we have shown that the same of dosage of doxorubicin inhibited both osteoblast and osteosarcoma cell attachment and viability whereas, sodium bicarbonate abated osteosarcoma cell proliferation. Sodium bicarbonate also inhibited osteoblast cell proliferation in the early time points, however, the cell viability increased after the initial burst release of the molecule. Polymer coating on calcium phosphate-based implants, as carriers of drug, can minimize chances of toxic effects of higher oral drug dosage in the body, and also help in delivering effective doses of drugs, locally to the target tissues, as compared to the oral drug delivery approach. A coating of PCL was thus incorporated to control the initial burst release of bicarbonate, which enhanced the osteoblast cell viability, but was capable of diminishing osteosarcoma cell proliferation. The novelty and clinical significance of this study lies in the understanding of unique delivery using encapsulated naturally occurring and more benign sodium bicarbonate, for usage after excision of the cancerous bone, without any adverse effects on normal bone cells.

Bone marrow stromal cells interaction with titanium; Effects of composition and surface modification

Inflammation and implant loosening are major concerns when using titanium implants for hard tissue engineering applications. Surface modification is one of the promising tools to enhance tissue-material integration in metallic implants. Here, we used anodization technique to modify the surface of commercially pure titanium (CP-Ti) and titanium alloy (Ti-6Al-4V) samples. Our results show that electrolyte composition, anodization time and voltage dictated the formation of well-organized nanotubes. Although electrolyte containing HF in water resulted in nanotube formation on Ti, the presence of NH4F and ethylene glycol was necessary for successful nanotube formation on Ti-6Al-4V. Upon examination of the interaction of bone marrow stromal cells (BMSCs) with the modified samples, we found that Ti-6Al-4V without nanotubes induced cell proliferation and cluster of differentiation 40 ligand (CD40L) expression which facilitates B-cell activation to promote early bone healing. However, the expression of glioma associated protein 2 (GLI2), which regulates CD40L, was reduced in Ti-6Al-4V and the presence of nanotubes further reduced its expression. The inflammatory cytokine interleukin-6 (IL-6) expression was reduced by nanotube presence on Ti. These results suggest that Ti-6Al-4V with nanotubes may be suitable implants because they have no effect on BMSC growth and inflammation.

Bone regeneration strategies: Engineered scaffolds, bioactive molecules and stem cells current stage and future perspectives

Bone fractures are the most common traumatic injuries in humans. The repair of bone fractures is a regenerative process that recapitulates many of the biological events of embryonic skeletal development. Most of the time it leads to successful healing and the recovery of the damaged bone. Unfortunately, about 5-10% of fractures will lead to delayed healing or non-union, more so in the case of co-morbidities such as diabetes. In this article, we review the different strategies to heal bone defects using synthetic bone graft substitutes, biologically active substances and stem cells. The majority of currently available reviews focus on strategies that are still at the early stages of development and use mostly in vitro experiments with cell lines or stem cells. Here, we focus on what is already implemented in the clinics, what is currently in clinical trials, and what has been tested in animal models. Treatment approaches can be classified in three major categories: i) synthetic bone graft substitutes (BGS) whose architecture and surface can be optimized; ii) BGS combined with bioactive molecules such as growth factors, peptides or small molecules targeting bone precursor cells, bone formation and metabolism; iii) cell-based strategies with progenitor cells combined or not with active molecules that can be injected or seeded on BGS for improved delivery. We review the major types of adult stromal cells (bone marrow, adipose and periosteum derived) that have been used and compare their properties. Finally, we discuss the remaining challenges that need to be addressed to significantly improve the healing of bone defects.

Calcium phosphate coated 3D printed porous titanium with nanoscale surface modification for orthopedic and dental applications

This study aims to improve the interfacial bonding between the osseous host tissue and the implant surface through the application of doped calcium phosphate (CaP) coating on 3D printed porous titanium. Porous titanium (Ti) cylinders with 25% volume porosity were fabricated using Laser Engineered Net Shaping (LENS™), a commercial 3D Printing technique. The surface of these 3D printed cylinders was modified by growing TiO2 nanotubes first, followed by a coating of with Sr2+ and Si4+ doped bioactive CaP ceramic in simulated body fluid (SBF). Doped CaP coated implants were hypothesized to show enhanced early stage bone tissue integration. Biological properties of these implants were investigated in vivo using a rat distal femur model after 4 and 10 weeks. CaP coated porous Ti implants have enhanced tissue ingrowth as was evident from the CT scan analysis, push out test results, and the histological analysis compared to porous implants with or without surface modification via titania nanotubes. Increased osteoid-like new bone formation and accelerated mineralization was revealed inside the CaP coated porous implants. It is envisioned that such an approach of adding a bioactive doped CaP layer on porous Ti surface can reduce healing time by enhancing early stage osseointegration in vivo.

3D printed β-TCP bone tissue engineering scaffolds: Effects of chemistry on in vivo biological properties in a rabbit tibia model

In this study the effects of 3D printed SiO2 and ZnO doped tricalcium phosphate (TCP) scaffolds with interconnected pores were evaluated on the in vivo bone formation and healing properties of a rabbit tibial defect model. Pure and doped TCP scaffolds were fabricated by a ceramic powder-based 3D printing technique and implanted into critical sized rabbit tibial defects for up to 4 months. In vivo bone regeneration was evaluated using chronological radiological examination, histological evaluations, SEM micrographs and fluorochrome labeling studies. Radiograph results showed that Si/Zn doped samples had slower degradation kinetics than the pure TCP samples. 3D printing of TCP scaffolds improved bone formation. The addition of dopants in the TCP scaffolds improved osteogenic capabilities when compared to the pure scaffolds. In summary, our findings indicate that addition of dopants to the TCP scaffolds enhanced bone formation and in turn leading to accelerated healing.

Effects of PCL, PEG and PLGA polymers on curcumin release from calcium phosphate matrix for in vitro and in vivo bone regeneration

Calcium phosphate materials are widely used as bone-like scaffolds or coating for metallic hip and knee implants due to their excellent biocompatibility, compositional similarity to natural bone and controllable bioresorbability. Local delivery of drugs or osteogenic factors from scaffolds and implants are required over a desired period of time for an effectual treatment of various musculoskeletal disorders. Curcumin, an antioxidant and anti-inflammatory molecule, enhances osteoblastc activity in addition to its anti-osteoclastic activity. However, due to its poor solubility and high intestinal liver metabolism, it showed limited oral efficacy in various preclinical and clinical studies. To enhance its bioavailability and to provide higher release, we have used poly (ε-caprolactone) (PCL), poly ethylene glycol (PEG) and poly lactide co glycolide (PLGA) as the polymeric system to enable continuous release of curcumin from the hydroxyapatite matrix for 22 days. Additionally, curcumin was incorporated in plasma sprayed hydroxyapatite coated Ti6Al4V substrate to study in vitro cell material interaction using human fetal osteoblast (hFOB) cells for load bearing implants. MTT cell viability assay and morphological characterization by FESEM showed highest cell viability with samples coated with curcumin-PCL-PEG. Finally, 3D printed interconnected macro porous β-TCP scaffolds were prepared and curcumin-PCL-PEG was loaded to assess the effects of curcumin on in vivo bone regeneration. The presence of curcumin in TCP results in enhanced bone formation after 6 weeks. Complete mineralized bone formation increased from 29.6 % to 44.9% in curcumin-coated scaffolds compared to pure TCP. Results show that local release of curcumin can be designed for both load bearing or non-load bearing implants with the aid of polymers, which can be considered an excellent candidate for wound healing and tissue regeneration applications in bone tissue engineering.

Surface modification of biomaterials and biomedical devices using additive manufacturing

The demand for synthetic biomaterials in medical devices, pharmaceutical products and, tissue replacement applications are growing steadily due to aging population worldwide. The use for patient matched devices is also increasing due to availability and integration of new technologies. Applications of additive manufacturing (AM) or 3D printing (3DP) in biomaterials have also increased significantly over the past decade towards traditional as well as innovative next generation Class I, II and III devices. In this review, we have focused our attention towards the use of AM in surface modified biomaterials to enhance their in vitro and in vivo performances. Specifically, we have discussed the use of AM to deliberately modify the surfaces of different classes of biomaterials with spatial specificity in a single manufacturing process as well as commented on the future outlook towards surface modification using AM.

STATEMENT OF SIGNIFICANCE

It is widely understood that the success of implanted medical devices depends largely on favorable material-tissue interactions. Additive manufacturing has gained traction as a viable and unique approach to engineered biomaterials, for both bulk and surface properties that improve implant outcomes. This review explores how additive manufacturing techniques have been and can be used to augment the surfaces of biomedical devices for direct clinical applications.

Repositioning Titanium: An In Vitro Evaluation of Laser-Generated Microporous, Microrough Titanium Templates As a Potential Bridging Interface for Enhanced Osseointegration and Durability of Implants

Although titanium alloys remain the preferred biomaterials for the manufacture of biomedical implants today, such devices can fail within 15 years of implantation due to inadequate osseointegration. Furthermore, wear debris toxicity due to alloy metal ion release has been found to cause side-effects including neurotoxicity and chronic inflammation. Titanium, with its known biocompatibility, corrosion resistance, and high elastic modulus, could if harnessed in the form of a superficial scaffold or bridging device, resolve such issues. A novel three-dimensional culture approach was used to investigate the potential osteoinductive and osseointegrative capabilities of a laser-generated microporous, microrough medical grade IV titanium template on human skeletal stem cells (SSCs). Human SSCs seeded on a rough 90-µm pore surface of ethylene oxide-sterilized templates were observed to be strongly adherent, and to display early osteogenic differentiation, despite their inverted culture in basal conditions over 21 days. Limited cellular migration across the template surface highlighted the importance of high surface wettability in maximizing cell adhesion, spreading and cell-biomaterial interaction, while restricted cell ingrowth within the conical-shaped pores underlined the crucial role of pore geometry and size in determining the extent of osseointegration of an implant device. The overall findings indicate that titanium only devices, with appropriate optimizations to porosity and surface wettability, could yet play a major role in improving the long-term efficacy, durability, and safety of future implant technology.

Effects of MgO and SiO2 on Plasma-Sprayed Hydroxyapatite Coating: An in Vivo Study in Rat Distal Femoral Defects

Plasma-sprayed hydroxyapatite (HA)-coated titanium implants have been widely used in orthopedic applications due to their inheritance of an excellent mechanical property from titanium and great osteoconductivity from HA. However, the lack of osteoinductivity limits their further applications. In this study, 1 wt % MgO and 0.5 wt % SiO₂ were mixed with HA for making plasma-sprayed coatings on titanium implants. Plasma-sprayed HA- and MgO/SiO₂-HA-coated titanium implants showed adhesive bond strengths of 25.73 ± 1.92 and 23.44 ± 2.89 MPa, respectively. The presence of MgO and SiO₂ significantly increased the osteogenesis, osseointegration, and bone mineralization of HA-coated titanium implants by the evaluation of their histomorphology after 6, 10, and 14 weeks of implantation in rat distal femoral defects. Implant pushout tests also showed a shear modulus of 149.83 ± 3.69 MPa for MgO/SiO₂-HA-coated implants after 14 weeks of implantation, compared to 52.68 ± 10.41 MPa for uncoated implants and 83.92 ± 3.68 MPa for pure HA-coated implants; These are differences in the shear modulus of 96% and 56.4%, respectively. This study assesses for the first time the quality of the bone-implant interface of induction plasma-sprayed MgO and SiO₂ binary-doped HA coatings on load-bearing implants compared to bare titanium and pure HA coatings in a quantitative manner. Relating the osseointegration and interface shear modulus to the quality of implant fixation is critical to the advancement and implementation of HA-coated orthopedic implants.

Understanding long-term silver release from surface modified porous titanium implants

Prevention of orthopedic device related infection (ODRI) using antibiotics has met with limited amount of success and is still a big concern during post-surgery. As an alternative, use of silver as an antibiotic treatment to prevent surgical infections is being used due to the well-established antimicrobial properties of silver. However, in most cases silver is used in particulate form with wound dressings or with short-term devices such as catheters but not with load-bearing implants. We hypothesize that strongly adherent silver to load-bearing implants can offer longer term solution to infection in vivo. Keeping that in mind, the focus of this study was to understand the long term release study of silver ions for a period of minimum 6months from silver coated surface modified porous titanium implants. Implants were fabricated using a LENS™ system, a powder based additive manufacturing technique, with at least 25% volume porosity, with and without TiO2 nanotubes in phosphate buffer saline (pH 7.4) to see if the total release of silver ions is within the toxic limit for human cells. Considering the fact that infection sites may reduce the local pH, silver release was also studied in acetate buffer (pH 5.0) for a period of 4weeks. Along with that, the osseointegrative properties as well as cytotoxicity of porous titanium implants were assessed in vivo for a period of 12weeks using a rat distal femur model. In vivo results indicate that porous titanium implants with silver coating show comparable, if not better, biocompatibility and bonding at the bone-implant interface negating any concerns related to toxicity related to silver to normal cells. The current research is based on our recently patented technology, however focused on understanding longer-term silver release to mitigate infection related problems in load-bearing implants that can even arise several months after the surgery.

STATEMENT OF SIGNIFICANCE

Prevention of orthopedic device related infection using antibiotics has met with limited success and is still a big concern during post-surgery. Use of silver as an antibiotic treatment to prevent surgical infections is being explored due to the well-established antimicrobial properties of silver. However, in most cases silver is used in particulate form with wound dressings or with short-term devices such as catheters but not with load-bearing implants. We hypothesize that strongly adherent silver to load-bearing implants can offer longer-term solution towards infection in vivo. Keeping that in mind, the focus of this study was to understand the long-term release of silver ions, for a period of minimum 6months, from silver coated surface modified porous titanium implants.