The combined effect of zinc and calcium on the biodegradation of ultrahigh-purity magnesium implants

Biodegradable ultrahigh-purity magnesium and its alloy ZX00 promote osteogenesis in the medullary cavity and glycogenolysis in the liver

Magnesium (Mg)-based implants have become an attractive alternative to conventional permanent implants in the orthopedic field. While biocompatibility, degradation kinetics, and osseointegration of Mg-based implants have been mostly investigated, the impact of degradation products on bone remodeling and potential systemic effects remains unclear. The aim of this study was to evaluate the early and mid-term local and systemic tissue responses of degrading ultrahigh-purity ZX00 (Mg-Zn-Ca alloy) and ultrahigh-purity Mg (XHP-Mg) pins in a juvenile healthy rat model. The potential differences between implant types (degradable vs. permanent), implantation, and age-related changes were investigated using titanium (Ti), sham-operated, and control groups (non-intervention), respectively. Degradation products of ZX00 and XHP-Mg pins promote osteogenesis in the medullary cavity by upregulating the expression levels of Bmp2 and Opg within 14 days post-surgery. The higher degradation rate of XHP-Mg resulted in the accumulation of degradation products starting from day 3 and upregulation of different genes, particularly Ccl2 and Cepbp. Besides good osseointegration and new bone tissue formation, we found a more parallel hydroxyapatite/collagen orientation along Mg-based pins in the perimeter region compared to Ti pins. In the liver, reduced glycogen levels in Mg-based pins indicated that degradation products promote glycogenolysis, while only the ZX00 group showed a higher serum glucagon level on day 14. Results suggest that degrading ZX00 and XHP-Mg pins stimulate osteogenesis mainly via Bmp2 and Opg and promote glycogenolysis in the liver, while the higher degradation rate of XHP-Mg pins resulted in upregulation of different genes and metabolites. STATEMENT OF SIGNIFICANCE: Bioresorbable magnesium (Mg)-based implants are promising alternative candidates for orthopedic interventions. Until now, a few in vivo studies explored how Mg-based implants promote osteogenesis in the medullary cavity and modulate systemic tissue responses. Herein, results demonstrate i) the degradation rate of the Mg-based implants has a crucial effect on osteogenesis via regulating Bmp2 and Opg expression in the medullary cavity, ii) a parallel HAp/collagen matrix pattern in ZX00 and XHP-Mg groups compared to the Ti group, iii) both Mg pins promote glycogenolysis in the liver. Our findings highlight the dual role of Mg-based implants in bone remodeling and systemic metabolic modulation. Nevertheless, this is the first study to report the interaction between Mg-based implants and liver metabolism.

Stronger and coarser-grained biodegradable zinc alloys

Zinc is emerging as a key material for next-generation biodegradable implants1-5. However, its inherent softness limits its use in load-bearing orthopaedic implants. Although reducing the grain size of zinc can make it stronger, it also destabilizes its mechanical properties and thus makes it less durable at body temperature6. Here we show that extruded Zn alloys of dilute compositions can achieve ultrahigh strength and excellent durability when their micron-scale grain size is increased while maintaining a basal texture. In this inverse Hall-Petch effect, the dominant deformation mode changes from inter-granular grain boundary sliding and dynamic recrystallization at the original grain size to intra-granular pyramidal slip and unusual twinning at the increased grain size. The role of the anomalous twins, termed 'accommodation twins' in this work, is to accommodate the altered grain shape in the plane lying perpendicular to the external loading direction, in contrast to the well-known 'mechanical twins' whose role is to deliver plasticity along the external loading direction7,8. The strength level achieved in these dilute zinc alloys is nearly double those of biodegradable implants made of magnesium alloys-making them the strongest and most stable biodegradable alloys available, to our knowledge, for fabricating bone fixation implants.

Physical exercise impacts bone remodeling around bio-resorbable magnesium implants

Physical exercise has been shown to induce positive reactions in bone healing but next to nothing is known about how it affects the nanostructure, in particular around implants. In this study, we established this link by using small-angle X-ray scattering tensor tomography (SASTT) to investigate nanostructural parameters in 3D such as mineral particle orientation and thickness. As a model system, rat femoral bone with a bio-resorbable implant (ultra-high purity magnesium) was used. One-half of the rats underwent treadmill exercise while the other half were moving freely in a cage. At two- and six-weeks post-surgery, rats were sacrificed, and samples were taken. Our results point to an earlier start and stronger remodeling when physical exercise is applied and to a stronger reorientation of the mineralized collagen fibers around the implant. This study reveals the nanostructural response of bone with bio-resorbable implants to physical exercise. Understanding this response is very important for designing post-surgery treatments. STATEMENT OF SIGNIFICANCE: Physical exercise is known to have beneficial effects on the human body and is often incorporated into the recovery process following orthopedic surgeries. While the response of bone to physical exercise is well-documented, the structural response of bone to early exercise after implant placement, particularly its impact on the nanostructure, has not been extensively studied. In this study, we identify the effects of physical exercise on the bone nanostructure and the remodeling process around a bioresorbable implant. These findings could help develop tailored physical exercise strategies for post-surgery recovery in patients.

Monitoring osseointegration and degradation of Mg-alloy implants through plasma biomarkers of inflammation and bone regeneration

Magnesium-degradable implants have excellent mechanical and osteogenic properties for temporary orthopedic use but are underutilized due to insufficient methods to monitor implant osseointegration and tissue healing. This study evaluated the use of circulatory biomarkers to monitor the bilateral implantation of a Mg-alloy in rats' femurs. A total of 16 biomarkers were measured from plasma samples collected at multiple timepoints up to 90 days post-implantation. Mg-alloy, Ti-alloy, and Sham (noncritical bone defect) groups were followed with computed tomography, histological, and SEM-EDX analysis. The Sham group showed higher DKK1, OPG, VEGF, and KIM-1 levels than implanted groups. The Mg-alloy group had delayed bone regeneration due to gas release but demonstrated active regeneration up to 180 days and superior osseointegration. Elevated IL-10 and reduced FGF23 at day 28 correlated with accelerated implant degradation. These results underline the complex interactions between biomaterials and biological systems in orthopedic applications and show the value of circulating markers to follow-up implantation.

Achieving biomimetic porosity and strength of bone in magnesium scaffolds through binder jet additive manufacturing

Magnesium (Mg) alloys are a promising candidate for synthetic bone tissue substitutes. In bone tissue engineering, achieving a balance between pore characteristics that facilitate biological functions and the essential stiffness required for load-bearing functions is extremely challenging. This study employs binder jet additive manufacturing to fabricate an interconnected porous structure in Mg alloys that mimics the microporosity and mechanical properties of human cortical bone types. Using scanning electron microscopy, micro-computed tomography, and mercury intrusion porosimetry, we found that the binder jet printed and sintered (BJPS) MgZnZr alloys possess an interconnected porous structure, featuring an overall porosity of 13.3 %, a median pore size of 12.7 μm, and pore interconnectivity exceeding 95 %. The BJPS MgZnZr alloy demonstrated a tensile strength of ~130 MPa, a yield strength of ~100 MPa, an elastic modulus of ~21.5 GPa, and an ultimate compressive strength of ~349 MPa. These values align with the ranges observed in human bone types and outperform those of porous Mg alloys produced using the other conventional and additive manufacturing methods. Moreover, the BJPS MgZnZr alloy showed level 0 cytotoxicity with a greater MC3T3-E1 cell viability, attachment, and proliferation when compared to a cast MgZnZr counterpart, since the highly interconnected 3D porous structure provides cells with an additional dimension for infiltration. Finally, we provide evidence for the concept of using binder jet additive manufacturing for fabricating Mg implants tailored for applications in hard tissue engineering, including craniomaxillofacial procedures, bone fixation, and substitutes for bone grafts. The results of this study provide a solid foundation for future advancements in digital manufacturing of Mg alloys for biomedical applications.

In Vivo Study of Organ and Tissue Stability According to the Types of Bioresorbable Bone Screws

Biodegradable material, such as magnesium alloy or polylactic acid (PLA), is a promising candidate for orthopedic surgery. The alloying of metals and the addition of rare earths to increase mechanical strength are still questionable in terms of biosafety as absorbent materials. Therefore, the purpose of this study is to understand the effect of substances due to the degradation of various biodegradable substances on organs in the body or surrounding tissues. A total of eighty male Sprague-Dawley rats were selected for this study, and the animals were divided into four groups. Each of the three experimental groups was implanted with magnesium alloy, polymer, and titanium implants; the control group only drilled into the cortical bone. Serum assay, micro-CT, hematoxylin and eosin staining, immunoblotting, and real-time PCR were evaluated. There was no significant difference between the two groups of magnesium alloy and polymer in serum assay, but micro-CT analysis confirmed that magnesium alloy degrades faster than polymer, and histological examination showed a strong inflammatory response in the early stages, which was similarly observed in immunoblotting and real-time PCR. Our findings show that there was no toxicity due to the degradation of the biodegradable material, and the difference in each inflammatory response is thought to be determined by the rate of degradation in the body.

Quantitative Imaging of Magnesium Biodegradation by 3D X‐Ray Ptychography and Electron Microscopy

Magnesium‐based alloys are excellent materials for temporary medical implants, but understanding and controlling their corrosion performance is crucial. Most nanoscale corrosion studies focus on the surface, providing only 2D information. In contrast, macro‐ and microscale X‐ray tomography offers representative volume information, which is, however, comparatively low in resolution and rather qualitative. Here a new mesoscale approach overcomes these drawbacks and bridges the scale gap by combining 3D measurements using ptychographic X‐ray computed tomography (PXCT) with electron microscopy. This combination allows to observe the corrosion progress non‐destructively in 3D and provides high‐resolution chemical information on the corrosion products. A medical Mg–Zn–Ca alloy is used and compared the same sample in the pristine and corroded states. With PXCT an isotropic resolution of 85 and 123 nm is achieved for the pristine and corroded states respectively, which enables to distinguish nanoscale Mg2Ca precipitates from the matrix. The corroded state in best approximation to the in situ conditions is imaged and reveals the complexity of corrosion products. The results illustrate that the corrosion‐layer is dense and defect‐free, and the corrosion of the material is grain‐orientation sensitive. The developed workflow can advance research on bioactive materials and corrosion‐sensitive functional materials.

Assessment of tissue response in vivo: PET-CT imaging of titanium and biodegradable magnesium implants

To study in vivo the bioactivity of biodegradable magnesium implants and other possible biomaterials, we are proposing a previously unexplored application of PET-CT imaging, using available tracers to follow soft tissue and bone remodelling and immune response in the presence of orthopaedic implants. Female Wistar rats received either implants (Ti6Al7Nb titanium or WE43 magnesium) or corresponding transcortical sham defects into the diaphyseal area of the femurs. Inflammatory response was followed with [18F]FDG and osteogenesis with [18F]NaF, over the period of 1.5 months after surgery. An additional pilot study with [68Ga]NODAGA-RGD tracer specific to αvβ3 integrin expression was performed to follow the angiogenesis for one month. [18F]FDG tracer uptake peaked on day 3 before declining in all groups, with Mg and Ti groups exhibiting overall higher uptake compared to sham. This suggests increased cellular activity and tissue response in the presence of Mg during the initial weeks, with Ti showing a subsequent increase in tracer uptake on day 45, indicating a foreign body reaction. [18F]NaF uptake demonstrated the superior osteogenic potential of Mg compared to Ti, with peak uptake on day 7 for all groups. [68Ga]NODAGA-RGD pilot study revealed differences in tracer uptake trends between groups, particularly the prolonged expression of αvβ3 integrin in the presence of implants. Based on the observed differences in the uptake trends of radiotracers depending on implant material, we suggest that PET-CT is a suitable modality for long-term in vivo assessment of orthopaedic biomaterial biocompatibility and underlying tissue reactions. STATEMENT OF SIGNIFICANCE: The study explores the novel use of positron emission tomography for the assessment of the influence that biomaterials have on the surrounding tissues. Previous related studies have mostly focused on material-related effects such as implant-associated infections or to follow the osseointegration in prosthetics, but the use of PET to evaluate the materials has not been reported before. The approach tests the feasibility of using repeated PET-CT imaging to follow the tissue response over time, potentially improving the methodology for adopting new biomaterials for clinical use.

Chronic kidney disease: a contraindication for using biodegradable magnesium or its alloys as potential orthopedic implants?

Magnesium (Mg) has gained widespread recognition as a potential revolutionary orthopedic biomaterial. However, whether the biodegradation of the Mg-based orthopedic implants would pose a risk to patients with chronic kidney disease (CKD) remains undetermined as the kidney is a key organ regulating mineral homeostasis. A rat CKD model was established by a 5/6 subtotal nephrectomy approach, followed by intramedullary implantation of three types of pins: stainless steel, high pure Mg with high corrosion resistance, and the Mg-Sr-Zn alloy with a fast degradation rate. The long-term biosafety of the biodegradable Mg or its alloys as orthopedic implants were systematically evaluated. During an experimental period of 12 weeks, the implantation did not result in a substantial rise of Mg ion concentration in serum or major organs such as hearts, livers, spleens, lungs, or kidneys. No pathological changes were observed in organs using various histological techniques. No significantly increased iNOS-positive cells or apoptotic cells in these organs were identified. The biodegradable Mg or its alloys as orthopedic implants did not pose an extra health risk to CKD rats at long-term follow-up, suggesting that these biodegradable orthopedic devices might be suitable for most target populations, including patients with CKD.

Mg alloys with antitumor and anticorrosion properties for orthopedic oncology: A review from mechanisms to application strategies

As a primary malignant bone cancer, osteosarcoma (OS) poses a great threat to human health and is still a huge challenge for clinicians. At present, surgical resection is the main treatment strategy for OS. However, surgical intervention will result in a large bone defect, and some tumor cells remaining around the excised bone tissue often lead to the recurrence and metastasis of OS. Biomedical Mg-based materials have been widely employed as orthopedic implants in bone defect reconstruction, and, especially, they can eradicate the residual OS cells due to the antitumor activities of their degradation products. Nevertheless, the fast corrosion rate of Mg alloys has greatly limited their application scope in the biomedical field, and the improvement of the corrosion resistance will impair the antitumor effects, which mainly arise from their rapid corrosion. Hence, it is vital to balance the corrosion resistance and the antitumor activities of Mg alloys. The presented review systematically discussed the potential antitumor mechanisms of three corrosion products of Mg alloys. Moreover, several strategies to simultaneously enhance the anticorrosion properties and antitumor effects of Mg alloys were also proposed.

Mg-Zn-Ca Alloy (ZX00) Screws Are Resorbed at a Mean of 2.5 Years After Medial Malleolar Fracture Fixation: Follow-up of a First-in-humans Application and Insights From a Sheep Model

BACKGROUND

In the ongoing development of bioresorbable implants, there has been a particular focus on magnesium (Mg)-based alloys. Several Mg alloys have shown promising properties, including a lean, bioresorbable magnesium-zinc-calcium (Mg-Zn-Ca) alloy designated as ZX00. To our knowledge, this is the first clinically tested Mg-based alloy free from rare-earth elements or other elements. Its use in medial malleolar fractures has allowed for bone healing without requiring surgical removal. It is thus of interest to assess the resorption behavior of this novel bioresorbable implant.

QUESTIONS/PURPOSES

(1) What is the behavior of implanted Mg-alloy (ZX00) screws in terms of resorption (implant volume, implant surface, and gas volume) and bone response (histologic evaluation) in a sheep model after 13 months and 25 months? (2) What are the radiographic changes and clinical outcomes, including patient-reported outcome measures, at a mean of 2.5 years after Mg-alloy (ZX00) screw fixation in patients with medial malleolar fractures?

METHODS

A sheep model was used to assess 18 Mg-alloy (ZX00) different-length screws (29 mm, 24 mm, and 16 mm) implanted in the tibiae and compared with six titanium-alloy screws. Micro-CT was performed at 13 and 25 months to quantify the implant volume, implant surface, and gas volume at the implant sites, as well as histology at both timepoints. Between July 2018 and October 2019, we treated 20 patients with ZX00 screws for medial malleolar fractures in a first-in-humans study. We considered isolated, bimalleolar, or trimalleolar fractures potentially eligible. Thus, 20 patients were eligible for follow-up. However, 5% (one patient) of patients were excluded from the analysis because of an unplanned surgery for a pre-existing osteochondral lesion of the talus performed 17 months after ZX00 implantation. Additionally, another 5% (one patient) of patients were lost before reaching the minimum study follow-up period. Our required minimum follow-up period was 18 months to ensure sufficient time to observe the outcomes of interest. At this timepoint, 10% (two patients) of patients were either missing or lost to follow-up. The follow-up time was a mean of 2.5 ± 0.6 years and a median of 2.4 years (range 18 to 43 months).

RESULTS

In this sheep model, after 13 months, the 29-mm screws (initial volume: 198 ± 1 mm 3 ) degraded by 41% (116 ± 6 mm 3 , mean difference 82 [95% CI 71 to 92]; p < 0.001), and after 25 months by 65% (69 ± 7 mm 3 , mean difference 130 [95% CI 117 to 142]; p < 0.001). After 13 months, the 24-mm screws (initial volume: 174 ± 0.2 mm 3 ) degraded by 51% (86 ± 21 mm 3 , mean difference 88 [95% CI 52 to 123]; p = 0.004), and after 25 months by 72% (49 ± 25 mm 3 , mean difference 125 [95% CI 83 to 167]; p = 0.003). After 13 months, the 16-mm screws (initial volume: 112 ± 5 mm 3 ) degraded by 57% (49 ± 8 mm 3 , mean difference 63 [95% CI 50 to 76]; p < 0.001), and after 25 months by 61% (45 ± 10 mm 3 , mean difference 67 [95% CI 52 to 82]; p < 0.001). Histologic evaluation qualitatively showed ongoing resorption with new bone formation closely connected to the resorbing screw without an inflammatory reaction. In patients treated with Mg-alloy screws after a mean of 2.5 years, the implants were radiographically not visible in 17 of 18 patients and the bone had homogenous texture in 15 of 18 patients. No clinical or patient-reported complications were observed.

CONCLUSION

In this sheep model, Mg-alloy (ZX00) screws showed a resorption to one-third of the original volume after 25 months, without eliciting adverse immunologic reactions, supporting biocompatibility during this period. Mg-alloy (ZX00) implants were not detectable on radiographs after a mean of 2.5 years, suggesting full resorption, but further studies are needed to assess environmental changes regarding bone quality at the implantation site after implant resorption.

CLINICAL RELEVANCE

The study demonstrated successful healing of medial malleolar fractures using bioresorbable Mg-alloy screws without clinical complications or revision surgery, resulting in pain-free ankle function after 2.5 years. Future prospective studies with larger samples and extended follow-up periods are necessary to comprehensively assess the long-term effectiveness and safety of ZX00 screws, including an exploration of limitations when there is altered bone integrity, such as in those with osteoporosis. Additional use of advanced imaging techniques, such as high-resolution CT, can enhance evaluation accuracy.

In vitro and in vivo degradation behavior of Mg-0.45Zn-0.45Ca (ZX00) screws for orthopedic applications

Magnesium (Mg) alloys have become a potential material for orthopedic implants due to their unnecessary implant removal, biocompatibility, and mechanical integrity until fracture healing. This study examined the in vitro and in vivo degradation of an Mg fixation screw composed of Mg-0.45Zn-0.45Ca (ZX00, in wt.%). With ZX00 human-sized implants, in vitro immersion tests up to 28 days under physiological conditions, along with electrochemical measurements were performed for the first time. In addition, ZX00 screws were implanted in the diaphysis of sheep for 6, 12, and 24 weeks to assess the degradation and biocompatibility of the screws in vivo. Using scanning electron microscopy (SEM) coupled with energy dispersive X-ray spectroscopy (EDX), micro-computed tomography (μCT), X-ray photoelectron spectroscopy (XPS), and histology, the surface and cross-sectional morphologies of the corrosion layers formed, as well as the bone-corrosion-layer-implant interfaces, were analyzed. Our findings from in vivo testing demonstrated that ZX00 alloy promotes bone healing and the formation of new bone in direct contact with the corrosion products. In addition, the same elemental composition of corrosion products was observed for in vitro and in vivo experiments; however, their elemental distribution and thicknesses differ depending on the implant location. Our findings suggest that the corrosion resistance was microstructure-dependent. The head zone was the least corrosion-resistant, indicating that the production procedure could impact the corrosion performance of the implant. In spite of this, the formation of new bone and no adverse effects on the surrounding tissues demonstrated that the ZX00 is a suitable Mg-based alloy for temporary bone implants.

Recent advances in 3D printing of biodegradable metals for orthopaedic applications

The use of biodegradable polymers for treating bone-related diseases has become a focal point in the field of biomedicine. Recent advancements in material technology have expanded the range of materials suitable for orthopaedic implants. Three-dimensional (3D) printing technology has become prevalent in healthcare, and while organ printing is still in its early stages and faces ethical and technical hurdles, 3D printing is capable of creating 3D structures that are supportive and controllable. The technique has shown promise in fields such as tissue engineering and regenerative medicine, and new innovations in cell and bio-printing and printing materials have expanded its possibilities. In clinical settings, 3D printing of biodegradable metals is mainly used in orthopedics and stomatology. 3D-printed patient-specific osteotomy instruments, orthopedic implants, and dental implants have been approved by the US FDA for clinical use. Metals are often used to provide support for hard tissue and prevent complications. Currently, 70-80% of clinically used implants are made from niobium, tantalum, nitinol, titanium alloys, cobalt-chromium alloys, and stainless steels. However, there has been increasing interest in biodegradable metals such as magnesium, calcium, zinc, and iron, with numerous recent findings. The advantages of 3D printing, such as low manufacturing costs, complex geometry capabilities, and short fabrication periods, have led to widespread adoption in academia and industry. 3D printing of metals with controllable structures represents a cutting-edge technology for developing metallic implants for biomedical applications. This review explores existing biomaterials used in 3D printing-based orthopedics as well as biodegradable metals and their applications in developing metallic medical implants and devices. The challenges and future directions of this technology are also discussed.