Tailored Surface Treatment of 3D Printed Porous Ti6Al4V by Microarc Oxidation for Enhanced Osseointegration via Optimized Bone In-Growth Patterns and Interlocked Bone/Implant Interface

Coatless modification of 3D-printed Ti6Al4V implants through tailored Cu ion implantation combined with UV photofunctionalization to enhance cell attachment, osteogenesis and angiogenesis

The three-dimensional-printed Ti6Al4V implant (3DTi) has been widely accepted for the reconstruction of massive bone defects in orthopedics owing to several advantages, such as its tailored shape design, avoiding bone graft and superior bone-implant interlock. However, the osteoinduction activity of 3DTi is inadequate when applied clinically even though it exhibits osteoconduction. This study developes a comprehensive coatless strategy for the surface improvement of 3DTi through copper (Cu) ion implantation and ultraviolet (UV) photofunctionalization to enhance osteoinductivity. The newly constructed functional 3DTi (UV/Ti-Cu) achieved stable and controllable Cu doping, sustained Cu2+ releasing, and increased surface hydrophilicity. By performing cellular experiments, we determined that the safe dose range of Cu ion implantation was less than 5×1016 ions/cm2. The implanted Cu2+ enhanced the ALP activity and the apatite formation ability of bone marrow stromal cells (BMSCs) while slightly decreasing proliferation ability. When combined with UV photofunctionalization, cell adhesion and proliferation were significantly promoted and bone mineralization was further increased. Meanwhile, UV/Ti-Cu was conducive to the migration and angiogenesis of human umbilical vein endothelial cells (HUVECs) in vitro, theoretically facilitating vascular coupling osteogenesis. In conclusion, UV/Ti-Cu is a novel attempt to apply two coatless techniques for the surface modification of 3DTi. In addition, it is considered a potential bone substrate for repairing bone defects.

3D-Printed custom-made hemipelvic endoprosthetic reconstruction following periacetabular tumor resection: utilizing a novel classification system

BACKGROUND

Customized 3D-printed pelvic implants with a porous structure have revolutionized periacetabular pelvic defect reconstruction after tumor resection, offering improved osteointegration, long-term stability, and anatomical fit. However, the lack of an established classification system hampers implementation and progress.

METHODS

We formulated a novel classification system based on pelvic defect morphology and 3D-printed hemipelvis endoprostheses. It integrates surgical approach, osteotomy guide plate and prosthesis design, postoperative rehabilitation plans, and perioperative processes.

RESULTS

Retrospectively analyzing 60 patients (31 males, 29 females), we classified them into Type A (15 patients: Aa = 6, Ab = 9), Type B (27 patients: Ba = 15, Bb = 12), Type C (17 patients). All underwent customized osteotomy guide plate-assisted tumor resection and 3D-printed hemipelvic endoprosthesis reconstruction. Follow-up duration was median 36.5 ± 15.0 months (range, 6 to 74 months). The mean operating time was 430.0 ± 106.7 min, intraoperative blood loss 2018.3 ± 1305.6 ml, transfusion volume 2510.0 ± 1778.1 ml. Complications occurred in 13 patients (21.7%), including poor wound healing (10.0%), deep prosthesis infection (6.7%), hip dislocation (3.3%), screw fracture (1.7%), and interface loosening (1.7%). VAS score improved from 5.5 ± 1.4 to 1.7 ± 1.3, MSTS-93 score from 14.8 ± 2.5 to 23.0 ± 5.6. Implant osseointegration success rate was 98.5% (128/130), with one Type Ba patient experiencing distal prosthesis loosening.

CONCLUSION

The West China classification may supplement the Enneking and Dunham classification, enhancing interdisciplinary communication and surgical outcomes. However, further validation and wider adoption are required to confirm clinical effectiveness.

Complete Removal of Residual Particles and Realization of Mechanical Properties to Improve Osseointegration in Additively Manufactured Ti6Al4 V Scaffolds through Flowing Acid Etching

Massive unmelted Ti6Al4 V (Ti64) particles presented across all surfaces of additively manufactured Ti64 scaffolds significantly impacted the designed surface topography, mechanical properties, and permeability, reducing the osseointegration of the scaffolds. In this study, the proposed flowing acid etching (FAE) method presented high efficiency in eliminating Ti64 particles and enhancing the surface modification capacity across all surfaces of Ti64 scaffolds. The Ti64 particles across all surfaces of the scaffolds were completely removed effectively and evenly. The surface topography of the scaffolds closely resembled the design after the 75 s FAE treatment. The actual elastic modulus of the treated scaffolds (3.206 ± 0.040 GPa) was closer to the designed value (3.110 GPa), and a micrometer-scale structure was constructed on the inner and outer surfaces of the scaffolds after the 90 s FAE treatment. However, the yield strength of scaffolds was reduced to 89.743 ± 0.893 MPa from 118.251 ± 0.982 MPa after the 90 s FAE treatment. The FAE method also showed higher efficiency in decreasing the roughness and enhancing the hydrophilicity and surface energy of all of the surfaces. The FAE treatment improved the permeability of scaffolds efficiently, and the permeability of scaffolds increased to 11.93 ± 0.21 × 10-10 mm2 from 8.57 ± 0.021 × 10-10 mm2 after the 90 s FAE treatment. The treated Ti64 scaffolds after the 90 s FAE treatment exhibited optimized osseointegration effects in vitro and in vivo. In conclusion, the FAE method was an efficient way to eliminate unmelted Ti64 particles and obtain ideal surface topography, mechanical properties, and permeability to promote osseointegration in additively manufactured Ti64 scaffolds.

Transition-state defect structure: A new strategy for TiO2-based porous materials to enhance photodegradation of pollutants

The aim of this paper is to investigate the derived structure and properties of Zeolitic Imidazolate Framework-8 (ZIF-8), and the effect of residual structural on the catalytic properties after loading with Titanium Dioxide (TiO2). For this purpose, we ingeniously prepare C-ZIF-8@TiO2 with a transition-state defect structure and apply it for efficiently degrading organic dye wastewater represented by Rhodamine B (Rh-B). Thanks to the transition-state defect structure loaded with TiO2 and ZIF-8 self-derived Carbon (C) and Zinc Oxide (ZnO), the catalytic performance of C-ZIF-8@TiO2 is superior to that of TiO2 and normal TiO2/ZIF-8 composites, and it is effective in degrading a variety of antibiotics and dyes. The related characterization also shows good photovoltaic properties and long-term durability for C-ZIF-8@TiO2. The mechanism on free radical action is elucidated and the possible degradation pathway for Rh-B is speculated. Therefore, C-ZIF-8@TiO2 provides a new strategy for the degradation of organic pollutants in water bodies.

Comparative analysis of the physical, chemical, and microbiological properties of Ti-6Al-4V disks produced by different methods and subjected to surface treatments

STATEMENT OF PROBLEM

To improve the osseointegration of dental implants and reduce microbiological growth, different micro- and nanoscale surface topographies can be used.

PURPOSE

The purpose of this in vitro study was to evaluate the influence of Ti-6Al-4V with 4 surfaces, machined (DU), machined+hydroxyapatite (DUHAp), machined+acid-alkali treatment (DUAA), and additive manufacturing (DMA), on the physical, chemical, and microbiological properties.

MATERIAL AND METHODS

The topography of Ti-6Al-4V disks with the 4 surfaces was evaluated by scanning electron microscopy (SEM), the chemical composition by energy dispersive X-ray spectroscopy (EDS), and the crystalline structure by X-ray diffraction (XRD). Physical and chemical properties were analyzed by using wettability and surface free energy, roughness, and microbial adhesion against Staphylococcus aureus by colony forming units (CFU). One-way ANOVA analysis of variance and the Tukey multiple comparisons test were applied to evaluate the data, except CFU, which was submitted to the Kruskal-Wallis nonparametric test (α=.05).

RESULTS

DU photomicrographs showed a topography characteristic of a polished machined surface, DUHAp and DUAA exhibited patterns corresponding to the surface modifications performed, and in DMA the presence of partially fused spherical particles was observed. The EDS identified chemical elements inherent in the Ti-6Al-4V, and the DUHAp and DUAA disks also had the ions from the treatments applied. XRD patterns revealed similarities between DU and DMA, as well as characteristic peaks of hydroxyapatite (HA) in the DUHAp disk and the DUAA. Compared with DU and DMA the DUHAp and DUAA groups showed hydrophilic behavior with smaller contact angles and higher surface free energy (P<.05). DMA showed a higher mean value of roughness, different from the others (P<.05), and a higher CFU for S. aureus (P=.006).

CONCLUSIONS

DUHAp and DUAA showed similar behaviors regarding wettability, surface free energy, and bacterial adhesion. Among the untreated groups, DMA exhibited higher roughness, bacterial adhesion, and lower wettability and surface free energy.

Simvastatin/hydrogel-loaded 3D-printed titanium alloy scaffolds suppress osteosarcoma via TF/NOX2-associated ferroptosis while repairing bone defects

Postoperative anatomical reconstruction and prevention of local recurrence after tumor resection are two vital clinical challenges in osteosarcoma treatment. A three-dimensional (3D)-printed porous Ti6Al4V scaffold (3DTi) is an ideal material for reconstructing critical bone defects with numerous advantages over traditional implants, including a lower elasticity modulus, stronger bone-implant interlock, and larger drug-loading space. Simvastatin is a multitarget drug with anti-tumor and osteogenic potential; however, its efficiency is unsatisfactory when delivered systematically. Here, simvastatin was loaded into a 3DTi using a thermosensitive poly (lactic-co-glycolic) acid (PLGA)-polyethylene glycol (PEG)-PLGA hydrogel as a carrier to exert anti-osteosarcoma and osteogenic effects. Newly constructed simvastatin/hydrogel-loaded 3DTi (Sim-3DTi) was comprehensively appraised, and its newfound anti-osteosarcoma mechanism was explained. Specifically, in a bone defect model of rabbit condyles, Sim-3DTi exhibited enhanced osteogenesis, bone in-growth, and osseointegration compared with 3DTi alone, with greater bone morphogenetic protein 2 expression. In our nude mice model, simvastatin loading reduced tumor volume by 59%-77 % without organic damage, implying good anti-osteosarcoma activity and biosafety. Furthermore, Sim-3DTi induced ferroptosis by upregulating transferrin and nicotinamide adenine dinucleotide phosphate oxidase 2 levels in osteosarcoma both in vivo and in vitro. Sim-3DTi is a promising osteogenic bone substitute for osteosarcoma-related bone defects, with a ferroptosis-mediated anti-osteosarcoma effect.

Advancements in incorporating metal ions onto the surface of biomedical titanium and its alloys via micro-arc oxidation: a research review

The incorporation of biologically active metallic elements into nano/micron-scale coatings through micro-arc oxidation (MAO) shows significant potential in enhancing the biological characteristics and functionality of titanium-based materials. By introducing diverse metal ions onto titanium implant surfaces, not only can their antibacterial, anti-inflammatory and corrosion resistance properties be heightened, but it also promotes vascular growth and facilitates the formation of new bone tissue. This review provides a thorough examination of recent advancements in this field, covering the characteristics of commonly used metal ions and their associated preparation parameters. It also highlights the diverse applications of specific metal ions in enhancing osteogenesis, angiogenesis, antibacterial efficacy, anti-inflammatory and corrosion resistance properties of titanium implants. Furthermore, the review discusses challenges faced and future prospects in this promising area of research. In conclusion, the synergistic approach of micro-arc oxidation and metal ion doping demonstrates substantial promise in advancing the effectiveness of biomedical titanium and its alloys, promising improved outcomes in medical implant applications.

Black phosphorus-incorporated novel Ti-12Mo-10Zr implant for multimodal treatment of osteosarcoma

The repair and reconstruction of large bone defects after bone tumor resection is still a great clinical challenge. At present, orthopedic implant reconstruction is the mainstream treatment for repairing bone defects. However, according to clinical feedback, local tumor recurrence and nonunion of bone graft are common reasons leading to the failure of bone defect repair and reconstruction after bone tumor resection, which seriously threaten the physical and mental health of patients. On this basis, here the self-developed low modulus Ti-12Mo-10Zr alloy (TMZ) was chosen as substrate material. To improve its biological activity and osteointegration, calcium, oxygen, and phosphorus co-doped microporous coating was prepared on TMZ alloy by microarc oxidation (MAO). Then, black phosphorus (BP) nanosheets were incorporated onto MAO treated TMZ alloy to obtain multifunctional composites. The obtained BP-MAO-TMZ implant exhibited excellent photothermal effects and effective ablation of osteosarcoma cancer cells under the irradiation of 808 nm near infrared laser, while no photothermal or therapeutic effects were observed for TMZ alloy. Meanwhile, the structure/component bionic coating obtained after MAO treatment as well as the P-driven in situ biomineralization performance after incorporation of BP nanosheets endowed BP-MAO-TMZ implant with synergistic promoting effect on MC3T3-E1 osteoblasts' activity, proliferation and differentiation ability. This study is expected to provide effective clinical solutions for problems of difficult bone regeneration and tumor recurrence after tumor resection in patients with bone tumors and to solve a series of medical problems such as poor prognosis and poor postoperative quality of patients life with malignant bone tumors.

Material extrusion additive manufacturing of poly(lactic acid)/Ti6Al4V@calcium phosphate core-shell nanocomposite scaffolds for bone tissue applications

The use of porous scaffolds with appropriate mechanical and biological features for the host tissue is one of the challenges in repairing critical-size bone defects. With today's three-dimensional (3D) printing technology, scaffolds can be customized and personalized, thereby eliminating the problems associated with conventional methods. In this work, after preparing Ti6Al4V/Calcium phosphate (Ti64@CaP) core-shell nanocomposite via a solution-based process, by taking advantage of fused deposition modeling (FDM), porous poly(lactic acid) (PLA)-Ti64@CaP nanocomposite scaffolds were fabricated. Scanning electron microscope (SEM) showed that nanostructured calcium phosphate was distributed uniformly on the surface of Ti64 particles. Also, X-ray diffraction (XRD) indicated that calcium phosphate forms an octacalcium phosphate (OCP) phase. As a result of incorporating 6 wt% Ti64@CaP into the PLA, the compressive modulus and ultimate compressive strength values increased from 1.4 GPa and 29.5 MPa to 2.0 GPa and 53.5 MPa, respectively. Furthermore, the differential scanning calorimetry results revealed an increase in the glass transition temperature of PLA, rising from 57.0 to 62.4 °C, due to the addition of 6 wt% Ti64@CaP. However, it is worth noting that there was a moderate decrease in the crystallization and melting temperatures of the nanocomposite filament, which dropped from 97.0 to 89.5 °C and 167 to 162.9 °C, respectively. The scaffolds were seeded with human adipose tissue-derived mesenchymal stem cells (hADSCs) to investigate their biocompatibility and cell proliferation. Calcium deposition, ALP activity, and bone-related proteins and genes were also used to evaluate the bone differentiation potential of hADSCs. The obtained results showed that introducing Ti64@CaP considerably improved in vitro biocompatibility, facilitating the attachment, differentiation, and proliferation of hADSCs. Considering the findings of this study, the 3D-printed nanocomposite scaffold could be considered a promising candidate for bone tissue engineering applications.

Pelvic-girdle reconstruction with three-dimensional-printed endoprostheses after limb-salvage surgery for pelvic sarcomas: current landscape

Resection of pelvic bone tumors and the subsequent reconstruction of the pelvic girdle pose challenges due to complex anatomy, load-bearing demands, and significant defects. 3D-printed implants have revolutionized pelvic girdle reconstruction by offering customized solutions, porous surface structures for precise resection with custom guides, and improved integration. Many tertiary medical centers have adopted 3Dprinted hemipelvic endoprostheses, leading to enhanced outcomes. However, most studies are limited to single centers, with a small number of cases and short follow-up periods. Additionally, the design of these implants often relies heavily on individual experience, resulting in a lack of uniformity and significant variation. To provide a comprehensive assessment of this technology, we conducted an analysis of existing literature, encompassing tumor resection classification, various types of prosthesis design, reconstruction concepts, and post-reconstruction functional outcomes.

Micro-arc oxidation (MAO) and its potential for improving the performance of titanium implants in biomedical applications

Titanium (Ti) and its alloys have good biocompatibility, mechanical properties and corrosion resistance, making them attractive for biomedical applications. However, their biological inertness and lack of antimicrobial properties may compromise the success of implants. In this review, the potential of micro-arc oxidation (MAO) technology to create bioactive coatings on Ti implants is discussed. The review covers the following aspects: 1) different factors, such as electrolyte, voltage and current, affect the properties of MAO coatings; 2) MAO coatings affect biocompatibility, including cytocompatibility, hemocompatibility, angiogenic activity, corrosion resistance, osteogenic activity and osseointegration; 3) antibacterial properties can be achieved by adding copper (Cu), silver (Ag), zinc (Zn) and other elements to achieve antimicrobial properties; and 4) MAO can be combined with other physical and chemical techniques to enhance the performance of MAO coatings. It is concluded that MAO coatings offer new opportunities for improving the use of Ti and its alloys in biomedical applications, and some suggestions for future research are provided.

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.

An overview of 3D printed metal implants in orthopedic applications: Present and future perspectives

With the ability to produce components with complex and precise structures, additive manufacturing or 3D printing techniques are now widely applied in both industry and consumer markets. The emergence of tissue engineering has facilitated the application of 3D printing in the field of biomedical implants. 3D printed implants with proper structural design can not only eliminate the stress shielding effect but also improve in vivo biocompatibility and functionality. By combining medical images derived from technologies such as X-ray scanning, CT, MRI, or ultrasonic scanning, 3D printing can be used to create patient-specific implants with almost the same anatomical structures as the injured tissues. Numerous clinical trials have already been conducted with customized implants. However, the limited availability of raw materials for printing and a lack of guidance from related regulations or laws may impede the development of 3D printing in medical implants. This review provides information on the current state of 3D printing techniques in orthopedic implant applications. The current challenges and future perspectives are also included.

The Concept of Scaffold-Guided Bone Regeneration for the Treatment of Long Bone Defects: Current Clinical Application and Future Perspective

The treatment of bone defects remains a challenging clinical problem with high reintervention rates, morbidity, and resulting significant healthcare costs. Surgical techniques are constantly evolving, but outcomes can be influenced by several parameters, including the patient's age, comorbidities, systemic disorders, the anatomical location of the defect, and the surgeon's preference and experience. The most used therapeutic modalities for the regeneration of long bone defects include distraction osteogenesis (bone transport), free vascularized fibular grafts, the Masquelet technique, allograft, and (arthroplasty with) mega-prostheses. Over the past 25 years, three-dimensional (3D) printing, a breakthrough layer-by-layer manufacturing technology that produces final parts directly from 3D model data, has taken off and transformed the treatment of bone defects by enabling personalized therapies with highly porous 3D-printed implants tailored to the patient. Therefore, to reduce the morbidities and complications associated with current treatment regimens, efforts have been made in translational research toward 3D-printed scaffolds to facilitate bone regeneration. Three-dimensional printed scaffolds should not only provide osteoconductive surfaces for cell attachment and subsequent bone formation but also provide physical support and containment of bone graft material during the regeneration process, enhancing bone ingrowth, while simultaneously, orthopaedic implants supply mechanical strength with rigid, stable external and/or internal fixation. In this perspective review, we focus on elaborating on the history of bone defect treatment methods and assessing current treatment approaches as well as recent developments, including existing evidence on the advantages and disadvantages of 3D-printed scaffolds for bone defect regeneration. Furthermore, it is evident that the regulatory framework and organization and financing of evidence-based clinical trials remains very complex, and new challenges for non-biodegradable and biodegradable 3D-printed scaffolds for bone regeneration are emerging that have not yet been sufficiently addressed, such as guideline development for specific surgical indications, clinically feasible design concepts for needed multicentre international preclinical and clinical trials, the current medico-legal status, and reimbursement. These challenges underscore the need for intensive exchange and open and honest debate among leaders in the field. This goal can be addressed in a well-planned and focused stakeholder workshop on the topic of patient-specific 3D-printed scaffolds for long bone defect regeneration, as proposed in this perspective review.

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.

Sequential osseointegration of a novel implant system based on 3D printing in comparison with conventional titanium implants

OBJECTIVES

To evaluate the sequential osseointegration of a novel titanium implant system based on a 3D printing technology in comparison with conventional titanium implants.

MATERIAL AND METHODS

Two novel titanium implants based on 3D printing were tested in the mandible of eight Beagle dogs. As a control, two different commercially available titanium implants were used. The implants were staged to accommodate healing periods of 2 and 6 weeks. The primary outcome variable was bone-to-implant contact (BIC) in non-decalcified tissue sections and micro-CT analysis.

RESULTS

Histomorphometrically, the proportions of tissues adjacent to the implant surfaces were similar for all implants, whereas the BIC percentage of new mineralized bone was greater for the control implants after both 2 and 6 weeks (p < .05). Micro-CT analysis revealed increasing osseous volume and BIC from 2 to 6 weeks. In contrast to the histomorphometry, the BIC evaluation with the micro-CT data revealed a significantly higher BIC for the two test implants compared with controls (p < .001). The analysis of the total implant surface area disclosed a value that was approximately double as high for the test compared to the control implants.

CONCLUSIONS

The novel titanium implant system based on 3D printing yielded values for osseointegration that were adequate and satisfactory. The higher percentage of new mineralized bone in the control implants is explained by the fact of a completely different three-dimensional surface area.

Porous surface with fusion peptides embedded in strontium titanate nanotubes elevates osteogenic and antibacterial activity of additively manufactured titanium alloy

It is still a big challenge in orthopedics to treat infected bone defects properly using medical metals. The use of three-dimensional (3D) scaffold materials that simultaneously mimic the skeletal hierarchy and induce sustainable osteogenic and antibacterial functions are a promising solution with an increasing appeal. In this study, we first designed a bifunctional fusion peptide (HHC36-RGD, HR) by linking antimicrobial peptide (HHC36) and arginine-glycine-aspartate (RGD) peptide via 6-aminohexanoic acid. Then the 3D scaffold was fabricated by additive manufacturing, and the strontium titanate nanotube structure (3D-STN) was constructed on its surface. Finally, the HR was anchored to the 3D-STN with the aid of polydopamine (PDA, P), forming the 3D-STN-P-HR scaffold. The results showed that the scaffold exhibited an ordered 3D porous structure, and that the surface was covered by a dense HHC36-RGD layer. Expectedly, the adsorption of PDA effectively slowed down the release of HR. Moreover, the functionalized scaffold had a significant inhibitory effect on Staphylococcus aureus and Escherichia coli, and its antibacterial rate could reach more than 95%. The results of in vitro cell culture experiments demonstrated that the 3D-STN-P-HR scaffold possessed excellent cytocompatibility and could promote the transcription of osteogenic differentiation-related genes and the expression of related proteins. In conclusion, the functionally modified 3D porous titanium alloy scaffold (3D-STN-P-HR) has a balanced antibacterial and osteogenic function, which bodes well for future potential in the customized functional reconstruction of complex-shaped infected bone defects.

Study of the Effect of Anodic Oxidation on the Corrosion Properties of the Ti6Al4V Implant Produced from SLM

Additive technologies allowed for the development of medicine and implantology, enabling the production of personalized and highly porous implants. Although implants of this type are used clinically, they are usually only heat treated. Surface modification using electrochemical methods can significantly improve the biocompatibility of biomaterials used for implants, including printed ones. The study examined the effect of anodizing oxidation on the biocompatibility of a porous implant made of Ti6Al4V by the SLM method. The study used a proprietary spinal implant intended for the treatment of discopathy in the c4–c5 section. As part of the work, the manufactured implant was assessed in terms of compliance with the requirements for implants (structure testing—metallography) and the accuracy of the pores produced (pore size and porosity). The samples were subjected to surface modification using anodic oxidation. The research was carried out for 6 weeks in in vitro conditions. Surface topographies and corrosion properties (corrosion potential, ion release) were compared for unmodified and anodically oxidized samples. The tests showed no effect of anodic oxidation on the surface topography and improved corrosion properties. Anodic oxidation stabilized the corrosion potential and limited the release of ions to the environment.

Micron/Submicron Scaled Hierarchical Ti Phosphate/Ti Oxide Hybrid Coating on 3D Printed Scaffolds for Improved Osteointegration

Three-dimensional (3D) printed implants have attracted substantial attention in the field of personalized medicine, but negative impacts on mechanical properties or initial osteointegration have limited their application. To address these problems, we prepared hierarchical Ti phosphate/Ti oxide (TiP-Ti) hybrid coatings on 3D printed Ti scaffolds. The surface morphology, chemical composition, and bonding strength of the scaffolds were characterized by scanning electron microscopy (SEM), atomic force microscopy (AFM), contact angle measurement, X-ray diffraction (XRD), and scratch test. In vitro performance was analyzed by colonization and proliferation of rat bone marrow mesenchymal stem cells (BMSCs). In vivo osteointegration of the scaffolds in rat femurs was assessed by micro-CT and histological analyses. The results demonstrated improved cell colonization and proliferation as well as excellent osteointegration obtained by incorporation of our scaffolds with the novel TiP-Ti coating. In conclusion, micron/submicron scaled Ti phosphate/Ti oxide hybrid coatings on 3D printed scaffolds have promising potential in future biomedical applications.

A pH-neutral bioactive glass coated 3D-printed porous Ti6Al4V scaffold with enhanced osseointegration

Osseointegration is vital for the success of non-degradable implants like those made of titanium alloys. In order to promote osseointegration, implants are made porous, providing space for bone ingrowth. Despite extensive optimization of the pore geometry and porosity, bone ingrowth into implants is still marginal; further modification to promote bone ingrowth as well as osseointegration becomes paramount. In this study, a pH neutral bioactive glass with the composition of 10.8% P₂O₅-54.2% SiO₂-35% CaO (mol%; hereinafter referred to as PSC) was successfully coated on 3D-printed porous Ti6Al4V scaffolds using an in situ sol-gel method. This PSC coating is strongly bonded to the substrate and quickly induces the formation of hydroxyapatite on the scaffold surface upon contact with body fluid. In vitro, the PSC-coated Ti6Al4V scaffolds showed superior biocompatibility, cell proliferation promotion, cell adhesion, osteogenic differentiation and mineralization compared to their bare counterparts, implying better osseointegration. In vivo experiments confirmed this expectation; after being implanted, the coated scaffolds had more bone ingrowth and osseointegration, and consequently, higher push-out strength was achieved, proving the validity of the proposed concept in this study. In conclusion, PSC coating on 3D-printed porous Ti6Al4V scaffolds can improve osteogenesis, bone ingrowth, and osseointegration. Together with the versatility of this in situ sol-gel coating method, titanium alloy implants with better biological performances may be developed for immediate clinical applications.

Surface Modification of Additively Fabricated Titanium-Based Implants by Means of Bioactive Micro-Arc Oxidation Coatings for Bone Replacement

In this work, the micro-arc oxidation method is used to fabricate surface-modified complex-structured titanium implant coatings to improve biocompatibility. Depending on the utilized electrolyte solution and micro-arc oxidation process parameters, three different types of coatings (one of them-oxide, another two-calcium phosphates) were obtained, differing in their coating thickness, crystallite phase composition and, thus, with a significantly different biocompatibility. An analytical approach based on X-ray computed tomography utilizing software-aided coating recognition is employed in this work to reveal their structural uniformity. Electrochemical studies prove that the coatings exhibit varying levels of corrosion protection. In vitro and in vivo experiments of the three different micro-arc oxidation coatings prove high biocompatibility towards adult stem cells (investigation of cell adhesion, proliferation and osteogenic differentiation), as well as in vivo biocompatibility (including histological analysis). These results demonstrate superior biological properties compared to unmodified titanium surfaces. The ratio of calcium and phosphorus in coatings, as well as their phase composition, have a great influence on the biological response of the coatings.

The combination of a 3D-Printed porous Ti-6Al-4V alloy scaffold and stem cell sheet technology for the construction of biomimetic engineered bone at an ectopic site

Cell sheet technology has been widely used in bone tissue engineering and regenerative medicine. However, controlling the shape and volume of large pieces of engineered bone tissue remains impossible without additional suitable scaffolds. Three-dimensional (3D) printed titanium (Ti) alloy scaffolds are mostly used as implant materials for repairing bone defects, but the unsatisfactory bioactivities of traditional Ti-based scaffolds severely limit their clinical applications. Herein, we hypothesize that the combination of bone marrow mesenchymal stem cell (BMSC) sheet technology and 3D porous Ti–6Al–4V (PT) alloy scaffolds could be used to fabricate biomimetic engineered bone. First, various concentrations of BMSCs were directly cocultured with PT scaffolds to obtain complexes of osteoblastic cell sheets and scaffolds. Then, as an experimental control, an osteoblastic BMSC sheet was prepared by continuous culturing under osteogenic conditions for 2 weeks without passaging and used to wrap the scaffolds. The BMSC sheet was composed of several layers of extracellular matrix (ECM) and a mass of BMSCs. The BMSCs exhibited excellent adherent, proliferative and osteogenic potential when cocultured with PT scaffolds, which may be attributed to the ability of the 3D microstructure of scaffolds to facilitate the biological behaviors of cells, as confirmed by the in vitro results. Moreover, the presence of BMSCs and ECM increased the angiogenic potential of PT scaffolds by the secretion of VEGF. Micro-CT and histological analysis confirmed the in vivo formation of biomimetic engineered bone when the complex of cocultured BMSCs and PT scaffolds and the scaffolds wrapped by prepared BMSC sheets were implanted subcutaneously into nude mice. Therefore, the combination of BMSC sheet technology and 3D-printed PT scaffolds could be used to construct customized biomimetic engineered bone, offering a novel and promising strategy for the precise repair of bone defects.

A review on in vitro/in vivo response of additively manufactured Ti-6Al-4V alloy

Bone replacement using porous and solid metallic implants, such as Ti-alloy implants, is regarded as one of the most practical therapeutic approaches in biomedical engineering. The bone is a complex tissue with various mechanical properties based on the site of action. Patient-specific Ti-6Al-4V constructs may address the key needs in bone treatment for having customized implants that mimic the complex structure of the natural tissue and diminish the risk of implant failure. This review focuses on the most promising methods of fabricating such patient-specific Ti-6Al-4V implants using additive manufacturing (AM) with a specific emphasis on the popular subcategory, which is powder bed fusion (PBF). Characteristics of the ideal implant to promote optimized tissue-implant interactions, as well as physical, mechanical/chemical treatments and modifications will be discussed. Accordingly, such investigations will be classified into 3B-based approaches (Biofunctionality, Bioactivity, and Biostability), which mainly govern native body response and ultimately the success in implantation.

Functional engineering strategies of 3D printed implants for hard tissue replacement

Three-dimensional printing technology with the rapid development of printing materials are widely recognized as a promising way to fabricate bioartificial bone tissues. In consideration of the disadvantages of bone substitutes, including poor mechanical properties, lack of vascularization and insufficient osteointegration, functional modification strategies can provide multiple functions and desired characteristics of printing materials, enhance their physicochemical and biological properties in bone tissue engineering. Thus, this review focuses on the advances of functional engineering strategies for 3D printed biomaterials in hard tissue replacement. It is structured as introducing 3D printing technologies, properties of printing materials (metals, ceramics and polymers) and typical functional engineering strategies utilized in the application of bone, cartilage and joint regeneration.

Osseointegration of 3D-printed titanium implants with surface and structure modifications

BACKGROUND

The purpose of this study was to establish a mechanical and histological basis for the development of biocompatible maxillofacial reconstruction implants by combining 3D-printed porous titanium structures and surface treatment. Improved osseointegration of 3D-printed titanium implants for reconstruction of maxillofacial segmental bone defect could be advantageous in not only quick osseointegration into the bone tissue but also in stabilizing the reconstruction.

METHODS

Various macro-mesh titanium scaffolds were fabricated by 3D-printing. Human mesenchymal stem cells were used for cell attachment and proliferation assays. Osteogenic differentiation was confirmed by quantitative polymerase chain reaction analysis. The osseointegration rate was measured using micro computed tomography imaging and histological analysis.

RESULTS

In three dimensional-printed scaffold, globular microparticle shape was observed regardless of structure or surface modification. Cell attachment and proliferation rates increased according to the internal mesh structure and surface modification. However, osteogenic differentiation in vitro and osseointegration in vivo revealed that non-mesh structure/non-surface modified scaffolds showed the most appropriate treatment effect.

CONCLUSION

3D-printed solid structure is the most suitable option for maxillofacial reconstruction. Various mesh structures reduced osteogenesis of the mesenchymal stem cells and osseointegration compared with that by the solid structure. Surface modification by microarc oxidation induced cell proliferation and increased the expression of some osteogenic genes partially; however, most of the markers revealed that the non-anodized solid scaffold was the most suitable for maxillofacial reconstruction.

The application of biomaterials in osteogenesis: A bibliometric and visualized analysis

Osteogenesis serves an important role in bone tissue repairing. Novel biomaterials are widely prevalent as materials for orthopedic implants due to their biocompatibility and osteogenetic ability. The purpose of this study was to comprehensively analyze hotspots and future trend of biomaterials research in osteogenesis based on bibliometric and visualized analysis. A total of 1,523 papers about biomaterials research in osteogenesis between 2000 and 2021 were included in this study. During the above 20 years, China’s leading position in the global biomaterials research in osteogenesis was obvious, and it was also the country that most frequently participates in international cooperation. Chinese Academy of Sciences was the most productive institution and the leader of research cooperation. Acta Biomaterialia and Biomaterials have published the largest number of articles in the field of biomaterials research in osteogenesis. Meanwhile, Acta Biomaterialia and Biomaterials were also the two journals with the highest total citation frequency. Wu CT, Chang J, Kaplan DL, and Xiao Y all made important contributions in the field of biomaterials research in osteogenesis. At present, there are five research hotspots in the field of biomaterials research in osteogenesis: 1) the immunomodulatory role of biomaterial-related inflammatory; 2) mechanisms of osteogenesis in biomaterials; 3) 3D printing and clinical application of biomaterials; 4) bone tissue engineering for biomaterial osteogenesis; and 5) regenerative medicine for biomaterial osteogenesis. The results of this study showed that mechanisms of osteogenesis in biomaterials, bone tissue engineering for biomaterial osteogenesis, and regenerative medicine for biomaterial osteogenesis will remain research hotspots in the future. International cooperation was also expected to expand and deepen the field of biomaterials research in osteogenesis.

Additively manufactured metallic biomaterials

Metal additive manufacturing (AM) has led to an evolution in the design and fabrication of hard tissue substitutes, enabling personalized implants to address each patient's specific needs. In addition, internal pore architectures integrated within additively manufactured scaffolds, have provided an opportunity to further develop and engineer functional implants for better tissue integration, and long-term durability. In this review, the latest advances in different aspects of the design and manufacturing of additively manufactured metallic biomaterials are highlighted. After introducing metal AM processes, biocompatible metals adapted for integration with AM machines are presented. Then, we elaborate on the tools and approaches undertaken for the design of porous scaffold with engineered internal architecture including, topology optimization techniques, as well as unit cell patterns based on lattice networks, and triply periodic minimal surface. Here, the new possibilities brought by the functionally gradient porous structures to meet the conflicting scaffold design requirements are thoroughly discussed. Subsequently, the design constraints and physical characteristics of the additively manufactured constructs are reviewed in terms of input parameters such as design features and AM processing parameters. We assess the proposed applications of additively manufactured implants for regeneration of different tissue types and the efforts made towards their clinical translation. Finally, we conclude the review with the emerging directions and perspectives for further development of AM in the medical industry.

Fighting Antibiotic-Resistant Bacterial Infections by Surface Biofunctionalization of 3D-Printed Porous Titanium Implants with Reduced Graphene Oxide and Silver Nanoparticles

Nanoparticles (NPs) have high multifunctional potential to simultaneously enhance implant osseointegration and prevent infections caused by antibiotic-resistant bacteria. Here, we present the first report on using plasma electrolytic oxidation (PEO) to incorporate different combinations of reduced graphene oxide (rGO) and silver (Ag) NPs on additively manufactured geometrically ordered volume-porous titanium implants. The rGO nanosheets were mainly embedded parallel with the PEO surfaces. However, the formation of ‘nano-knife’ structures (particles embedded perpendicularly to the implant surfaces) was also found around the pores of the PEO layers. Enhanced in vitro antibacterial activity against methicillin-resistant Staphylococcus aureus was observed for the rGO+Ag-containing surfaces compared to the PEO surfaces prepared only with AgNPs. This was caused by a significant improvement in the generation of reactive oxygen species, higher levels of Ag+ release, and the presence of rGO ‘nano-knife’ structures. In addition, the implants developed in this study stimulated the metabolic activity and osteogenic differentiation of MC3T3-E1 preosteoblast cells compared to the PEO surfaces without nanoparticles. Therefore, the PEO titanium surfaces incorporating controlled levels of rGO+Ag nanoparticles have high clinical potential as multifunctional surfaces for 3D-printed orthopaedic implants.

3D-printed vertebral body for anterior spinal reconstruction in patients with thoracolumbar spinal tumors

OBJECTIVE

A 3D-printed vertebral prosthesis can be used to reconstruct a bone defect more precisely because of its tailored shape, with its innermost porous structure inducing bone ingrowth. The aim of this study was to evaluate the clinical outcomes of using a 3D-printed artificial vertebral body for spinal reconstruction after en bloc resection of thoracolumbar tumors.

METHODS

This was a retrospective analysis of 23 consecutive patients who underwent surgical treatment for thoracolumbar tumors at our hospital. En bloc resection was performed in all cases, based on the Weinstein-Boriani-Biagini surgical staging system, and anterior reconstruction was performed using a 3D-printed artificial vertebral body. Prosthesis subsidence, fusion status, and instrumentation-related complications were evaluated. Stability of the anterior reconstruction method was evaluated by CT, and CT Hounsfield unit (HU) values were measured to evaluate fusion status.

RESULTS

The median follow-up was 37 (range 24-58) months. A customized 3D-printed artificial vertebral body was used in 10 patients, with an off-the-shelf 3D-printed artificial vertebral body used in the other 13 patients. The artificial vertebral body was implanted anteriorly in 5 patients and posteriorly in 18 patients. The overall fusion rate was 87.0%. The average prosthesis subsidence at the final follow-up was 1.60 ± 1.79 mm. Instrument failure occurred in 2 patients, both of whom had substantial subsidence (8.47 and 3.69 mm, respectively). At 3 months, 6 months, and 1 year postoperatively, the mean CT HU values within the artificial vertebral body were 1930 ± 294, 1997 ± 336, and 1994 ± 257, respectively, with each of these values being significantly higher than the immediate postoperative value of 1744 ± 321 (p < 0.05).

CONCLUSIONS

The use of a 3D-printed artificial vertebral body for anterior reconstruction after en bloc resection of the thoracolumbar spinal tumor may be a feasible and reliable option. The low incidence of prosthesis subsidence of 3D-printed endoprostheses can provide good stability instantly. Measurement of HU values with CT is a valuable method to evaluate the osseointegration at the bone-metal interface of a 3D-printed vertebral prosthesis.

Construction of a Hierarchical Micro-/Submicro-/Nanostructured 3D-Printed Ti6Al4V Surface Feature to Promote Osteogenesis: Involvement of Sema7A through the ITGB1/FAK/ERK Signaling Pathway

Constructing hierarchical hybrid structures is considered a facile method to improve the osseointegration of implants. Herein, a hierarchical micro-/submicro-/nanostructured surface feature of Ti6Al4V implants (3DAT group) was successfully constructed by combining the inherently formed three-dimensional (3D)-printed microscale topography, acid-etched sub-micropits, and anodized nanotubes. Compared with the classical SLA surface, the microscale topography and sub-micropits increased the three-dimensional space for the cell growth and mechanical stability of implants, while the modification of nanotubes dramatically improved the surface hydrophilicity, protein adsorption, and biomineralization. Most importantly, the 3DAT surface feature possessed excellent osteogenic performance in vitro and in vivo, with the involvement of semaphorin 7A (Sema7A) as revealed by RNA-seq through the ITGB1/FAK/ERK signaling pathway. The present study suggested that the hierarchically structured surface design strategy could accelerate the osseointegration rate of 3D-printed Ti6Al4V implants, promising personalized reconstruction of bone defects.

3D printing applications in spine surgery: an evidence-based assessment toward personalized patient care

PURPOSE

Spine surgery entails a wide spectrum of complicated pathologies. Over the years, numerous assistive tools have been introduced to the modern neurosurgeon's armamentarium including neuronavigation and visualization technologies. In this review, we aimed to summarize the available data on 3D printing applications in spine surgery as well as an assessment of the future implications of 3D printing.

METHODS

We performed a comprehensive review of the literature on 3D printing applications in spine surgery.

RESULTS

Over the past decade, 3D printing and additive manufacturing applications, which allow for increased precision and customizability, have gained significant traction, particularly spine surgery. 3D printing applications in spine surgery were initially limited to preoperative visualization, as 3D printing had been primarily used to produce preoperative models of patient-specific deformities or spinal tumors. More recently, 3D printing has been used intraoperatively in the form of 3D customizable implants and personalized screw guides.

CONCLUSIONS

Despite promising preliminary results, the applications of 3D printing are so recent that the available data regarding these new technologies in spine surgery remains scarce, especially data related to long-term outcomes.

[Research progress of in-situ three dimensional bio-printing technology for repairing bone and cartilage injuries]

OBJECTIVE

To review the research progress of in-situ three dimensional (3D) bio-printing technology in the repair of bone and cartilage injuries.

METHODS

Literature on the application of in-situ 3D bio-printing technology to repair bone and cartilage injuries at home and abroad in recent years was reviewed, analyzed, and summarized.

RESULTS

As a new tissue engineering technology, in-situ 3D bio-printing technology is mainly applied to repair bone, cartilage, and skin tissue injuries. By combining biomaterials, bioactive substances, and cells, tissue is printed directly at the site of injury or defect. At present, the research on the technology mainly focuses on printing mode, bio-ink, and printing technology; the application research in the field of bone and cartilage mainly focuses on pre-vascularization, adjusting the composition of bio-ink, improving scaffold structure, printing technology, loading drugs, cells, and bioactive factors, so as to promote tissue injury repair.

CONCLUSION

Multiple animal experiments have confirmed that in-situ 3D bio-printing technology can construct bone and cartilage tissue grafts in a real-time, rapid, and minimally invasive manner. In the future, it is necessary to continue to develop bio-inks suitable for specific tissue grafts, as well as combine with robotics, fusion imaging, and computer-aided medicine to improve printing efficiency.

Nanoscale Modification of Titanium Implants Improves Behaviors of Bone Mesenchymal Stem Cells and Osteogenesis In Vivo

The surficial micro/nanotopography and physiochemical properties of titanium implants are essential for osteogenesis. However, these surface characters' influence on stem cell behaviors and osteogenesis is still not fully understood. In this study, titanium implants with different surface roughness, nanostructure, and wettability were fabricated by further nanoscale modification of sandblasted and acid-etched titanium (SLA: sandblasted and acid-etched) by H₂O₂ treatment (hSLAs: H₂O₂ treated SLA). The rat bone mesenchymal stem cells (rBMSCs: rat bone mesenchymal stem cells) are cultured on SLA and hSLA surfaces, and the cell behaviors of attachment, spreading, proliferation, and osteogenic differentiation are further analyzed. Measurements of surface characteristics show hSLA surface is equipped with nanoscale pores on microcavities and appeared to be hydrophilic. In vitro cell studies demonstrated that the hSLA titanium significantly enhances cell response to attachment, spreading, and proliferation. The hSLAs with proper degree of H₂O₂ etching (h1SLA: treating SLA with H₂O₂ for 1 hour) harvest the best improvement of differentiation of rBMSCs. Finally, the osteogenesis in beagle dogs was tested, and the h1SLA implants perform much better bone formation than SLA implants. These results indicate that the nanoscale modification of SLA titanium surface endowing nanostructures, roughness, and wettability could significantly improve the behaviors of bone mesenchymal stem cells and osteogenesis on the scaffold surface. These nanoscale modified SLA titanium scaffolds, fabricated in our study with enhanced cell affinity and osteogenesis, had great potential for implant dentistry.

Advanced Surface Modification for 3D-Printed Titanium Alloy Implant Interface Functionalization

With the development of three-dimensional (3D) printed technology, 3D printed alloy implants, especially titanium alloy, play a critical role in biomedical fields such as orthopedics and dentistry. However, untreated titanium alloy implants always possess a bioinert surface that prevents the interface osseointegration, which is necessary to perform surface modification to enhance its biological functions. In this article, we discuss the principles and processes of chemical, physical, and biological surface modification technologies on 3D printed titanium alloy implants in detail. Furthermore, the challenges on antibacterial, osteogenesis, and mechanical properties of 3D-printed titanium alloy implants by surface modification are summarized. Future research studies, including the combination of multiple modification technologies or the coordination of the structure and composition of the composite coating are also present. This review provides leading-edge functionalization strategies of the 3D printed titanium alloy implants.

3D-printed porous Ti6Al4V scaffolds for long bone repair in animal models: a systematic review

BACKGROUND

Titanium and its alloys have been widely employed for bone tissue repair and implant manufacturing. The rapid development of three-dimensional (3D) printing technology has allowed fabrication of porous titanium scaffolds with controllable microstructures, which is considered to be an effective method for promoting rapid bone formation and decreasing bone absorption. The purpose of this systematic review was to evaluate the osteogenic potential of 3D-printed porous Ti6Al4V (Ti64) scaffold for repairing long bone defects in animal models and to investigate the influential factors that might affect its osteogenic capacity.

METHODS

Electronic literature search was conducted in the following databases: PubMed, Web of Science, and Embase up to September 2021. The SYRCLE's tool and the modified CAMARADES list were used to assess the risk of bias and methodological quality, respectively. Due to heterogeneity of the selected studies in relation to protocol and outcomes evaluated, a meta-analysis could not be performed.

RESULTS

The initial search revealed 5858 studies. Only 46 animal studies were found to be eligible based on the inclusion criteria. Rabbit was the most commonly utilized animal model. A pore size of around 500-600 µm and porosity of 60-70% were found to be the most ideal parameters for designing the Ti64 scaffold, where both dodecahedron and diamond pores optimally promoted osteogenesis. Histological analysis of the scaffold in a rabbit model revealed that the maximum bone area fraction reached 59.3 ± 8.1% at weeks 8-10. Based on micro-CT assessment, the maximum bone volume fraction was found to be 34.0 ± 6.0% at weeks 12.

CONCLUSIONS

Ti64 scaffold might act as a promising medium for providing sufficient mechanical support and a stable environment for new bone formation in long bone defects. Trail registration The study protocol was registered in the PROSPERO database under the number CRD42020194100.

Facile and Versatile Surface Functional Polyetheretherketone with Enhanced Bacteriostasis and Osseointegrative Capability for Implant Application

Implant-associated infections and inadequate osseointegration are two challenges of implant materials in orthopedics. In this study, a lithium-ion-loaded (Li+)/mussel-inspired antimicrobial peptide (AMP) designed to improve the osseointegration and inhibit bacterial infections effectively is prepared on a polyetheretherketone (PEEK) biomaterial surface through the combination of hydrothermal treatment and mussel-inspired chemistry. The results illustrate that the multifunctional PEEK material demonstrated a great inhibitory effect on Escherichia coli and Staphylococcus aureus, which was attributed to irreversible bacterial membrane damage. In addition, the multifunctional PEEK can simultaneously upregulate the expression of osteogenesis-associated genes/proteins via the Wnt/β-catenin signaling pathway. Furthermore, an in vivo assay of an infection model revealed that the multifunctional PEEK implants killed bacteria with an efficiency of 95.03%. More importantly, the multifunctional PEEK implants accelerated the implant-bone interface osseointegration compared with pure PEEK implants in the noninfection model. Overall, this work provides a promising strategy for improving orthopedic implant materials with ideal osseointegration and infection prevention simultaneously, which may have broad application clinical prospects.

Surface Treatment and Bioinspired Coating for 3D-Printed Implants

Three-dimensional (3D) printing technology has developed rapidly and demonstrates great potential in biomedical applications. Although 3D printing techniques have good control over the macrostructure of metallic implants, the surface properties have superior control over the tissue response. By focusing on the types of surface treatments, the osseointegration activity of the bone-implant interface is enhanced. Therefore, this review paper aims to discuss the surface functionalities of metallic implants regarding their physical structure, chemical composition, and biological reaction through surface treatment and bioactive coating. The perspective on the current challenges and future directions for development of surface treatment on 3D-printed implants is also presented.

3D Printed Multifunctional Ti6Al4V-Based Hybrid Scaffold for the Management of Osteosarcoma

Osteosarcoma is a challenging bone disease which is commonly associated with critically sized bone defects and cancer recurrence. Here, we designed and developed a multifunctional, hierarchical structured bone scaffold which can meet the demanding requirements for osteosarcoma management. The 3D printed Ti₆Al₄V scaffold with hydrothermally induced TiO₂/TiP coating can offer a unique photothermal conversion property for in vitro bone cancer ablation. The scaffold is also infused with drug-laden gelatin/hydroxyapatite nanocomposite, which provides the ideal porous structure for cell adhesion/bone ingrowth and promotes bone regeneration. The scaffold has been thoroughly characterized by SEM/EDX, TEM, XPS, XRD, TGA, and UV-vis, and its in vitro bone cancer ablation efficiency has been validated using MG-63 cells. The hybrid scaffold showed excellent biocompatibility, and its osteointegration function has been demonstrated using an animal model.

Biomimetic Cell-Substrate of Chitosan-Cross-linked Polyaniline Patterning on TiO2 Nanotubes Enables hBM-MSCs to Differentiate the Osteoblast Cell Type

Titanium-based substrates are widely used in orthopedic treatments and hard tissue engineering. However, many of these titanium (Ti) substrates fail to interact properly between the cell-to-implant interface, which can lead to loosening and dislocation from the implant site. As a result, scaffold implant-associated complications and the need for multiple surgeries lead to an increased clinical burden. To address these challenges, we engineered osteoconductive and osteoinductive biosubstrates of chitosan (CS)-cross-linked polyaniline (PANI) nanonets coated on titanium nanotubes (TiO₂NTs) in an attempt to mimic bone tissue's major extracellular matrix. Inspired by the architectural and tunable mechanical properties of such tissue, the TiO₂NTs-PANI@CS-based biofilm conferred strong anticorrosion, the ability to nucleate hydroxyapatite nanoparticles, and excellent biocompatibility with human bone marrow-derived mesenchymal stem cells (hBM-MSCs). An in vitro study showed that the substrate-supported cell activities induced greater cell proliferation and differentiation compared to cell-TiO₂NTs alone. Notably, the bone-related genes (collagen-I, OPN, OCN, and RUNX 2) were highly expressed within TiO₂NTs-PANI@CS over a period of 14 days, indicating greater bone cell differentiation. These findings demonstrate that the in vitro functionality of the cells on the osteoinductive-like platform of TiO₂NTs-PANI@CS improves the efficiency for osteoblastic cell regeneration and that the substrate potentially has utility in bone tissue engineering applications.

Influence of porous tantalum scaffold pore size on osteogenesis and osteointegration: A comprehensive study based on 3D-printing technology

The emerging role of porous tantalum (Ta) scaffold for bone tissue engineering is noticed due to its outstanding biological properties. However, it is controversial which pore size and porosity are more conducive for bone defect repair. In the present work, porous tantalum scaffolds with pore sizes of 100-200, 200-400, 400-600 and 600-800 μm and corresponding porosities of 25%, 55%, 75%, and 85% were constructed, using computer aided design and 3D printing technologies, then comprehensively studied by in vitro and in vivo studies. We found that Ta scaffold with pore size of 400-600 μm showed stronger ability in facilitating cell adhesion, proliferation, and osteogenic differentiation in vitro. In vivo tests identified that porous tantalum scaffolds with pore size of 400-600 μm showed better performance of bone ingrowth and integration. In mechanism, computational fluid dynamics analysis proved porous tantalum scaffolds with pore size of 400-600 μm hold appropriate permeability and surface area, which facilitated cell adhesion and proliferation. Our results strongly indicate that pore size and porosity are essential for further applications of porous tantalum scaffolds, and porous tantalum scaffolds with pore size 400-600 μm are conducive to osteogenesis and osseointegration. These findings provide new evidence for further application of porous tantalum scaffolds for bone defect repair.

Properties improvement of titanium alloys scaffolds in bone tissue engineering: a literature review

Owing to their excellent biocompatibility and corrosion-resistant properties, titanium (Ti) (and its alloy) are essential artificial substitute biomaterials for orthopedics. However, flaws, such as weak osteogenic induction ability and higher Young's modulus, have been observed during clinical application. As a result, short- and long-term postoperative follow-up has found that several complications have occurred. For decades, scientists have exerted efforts to compensate for these deficiencies. Different modification methods have been investigated, including changing alloy contents, surface structure transformation, three-dimensional (3D) structure transformation, coating, and surface functionalization technologies. The cell-surface interaction effect and imitation of the natural 3D bone structure are the two main mechanisms of these improved methods. In recent years, significant progress has been made in materials science research methods, including thorough research of titanium alloys of different compositions, precise surface pattern control technology, controllable 3D structure construction technology, improvement of coating technologies, and novel concepts of surface functionalization. These improvements facilitate the possibility for further research in the field of bone tissue engineering. Although the underlying mechanism is still not fully understood, these studies still have some implications for clinical practice. Therefore, for the direction of further research, it is beneficial to summarize these studies according to the basal method used. This literature review aimed to classify these technologies, thereby providing beginners with a preliminary understanding of the field.

Surface treatment of 3D printed porous Ti6Al4V implants by ultraviolet photofunctionalization for improved osseointegration

Three-dimensional (3D)-printed porous Ti6Al4V implants play an important role in the reconstruction of bone defects. However, its osseointegration capacity needs to be further improved, and related methods are inadequate, especially lacking customized surface treatment technology. Consequently, we aimed to design an omnidirectional radiator based on ultraviolet (UV) photofunctionalization for the surface treatment of 3D-printed porous Ti6Al4V implants, and studied its osseointegration promotion effects in vitro and in vivo, while elucidating related mechanisms. Following UV treatment, the porous Ti6Al4V scaffolds exhibited significantly improved hydrophilicity, cytocompatibility, and alkaline phosphatase activity, while preserving their original mechanical properties. The increased osteointegration strength was further proven using a rabbit condyle defect model in vivo, in which UV treatment exhibited a high efficiency in the osteointegration enhancement of porous Ti6Al4V scaffolds by increasing bone ingrowth (BI), the bone-implant contact ratio (BICR), and the mineralized/osteoid bone ratio. The advantages of UV treatment for 3D-printed porous Ti6Al4V implants using the omnidirectional radiator in the study were as follows: 1) it can significantly improve the osseointegration capacity of porous titanium implants despite the blocking out of UV rays by the porous structure; 2) it can evenly treat the surface of porous implants while preserving their original topography or other morphological features; and 3) it is an easy-to-operate low-cost process, making it worthy of wide clinical application.

•

An omnidirectional radiator based on ultraviolet photofunctionalization was invented..

•

The omnidirectional radiator can evenly treat the surface of the porous implants..

•

The present method can enhance osteoinetegration of porous Ti6Al4V implants in a convenient way with a low cost.

Chimeric Peptides Quickly Modify the Surface of Personalized 3D Printing Titanium Implants to Promote Osseointegration

Titanium (Ti) and titanium alloys have been widely used in the field of biomedicine. However, the unmatched biomechanics and poor bioactivities of conventional Ti implants usually lead to insufficient osseointegration. To tackle these challenges, it is critical to develop a novel Ti implant that meets the bioadaptive requirements for load-bearing critical bone defects. Notably, three-dimensional (3D)-printed Ti implants mimic the microstructure and mechanical properties of natural bones. Additionally, eco-friendly techniques based on inorganic-binding peptides have been applied to modify Ti surfaces. Herein, in our study, Ti surfaces were modified to reinforce osseointegration using chimeric peptides constructed by connecting W9, RP1P, and minTBP-1 directly or via (GP)4, respectively. PR1P is derived from the extracellular VEGF-binding domain of prominin-1, which increases the expression of VEGF and promotes the binding of VEGF to endothelial cells, thereby accelerating angiogenesis. W9 induces osteoblast differentiation in bone marrow mesenchymal stem cells and human mesenchymal stem cells to promote bone formation. Overall, chimeric peptides promote osseointegration by promoting angiogenesis and osteogenesis. Additionally, chimeric peptides with P3&4 were more effective than those with P1&2 in improving osseointegration, which might be ascribed to the capacity of P3&4 to provide a greater range for chimeric peptides to express their activity. This work successfully used chimeric peptides to modify 3D-Ti implant surfaces to improve osseointegration on the implant-bone surface.

Biomedical Applications of Metal 3D Printing

Additive manufacturing's attributes include print customization, low per-unit cost for small- to mid-batch production, seamless interfacing with mainstream medical 3D imaging techniques, and feasibility to create free-form objects in materials that are biocompatible and biodegradable. Consequently, additive manufacturing is apposite for a wide range of biomedical applications including custom biocompatible implants that mimic the mechanical response of bone, biodegradable scaffolds with engineered degradation rate, medical surgical tools, and biomedical instrumentation. This review surveys the materials, 3D printing methods and technologies, and biomedical applications of metal 3D printing, providing a historical perspective while focusing on the state of the art. It then identifies a number of exciting directions of future growth: (a) the improvement of mainstream additive manufacturing methods and associated feedstock; (b) the exploration of mature, less utilized metal 3D printing techniques; (c) the optimization of additively manufactured load-bearing structures via artificial intelligence; and (d) the creation of monolithic, multimaterial, finely featured, multifunctional implants.

Silver-Releasing Micro-/Nanoporous Coating on Additively Manufactured Macroporous Ti-Ta-Nb-Zr Scaffolds with High Osseointegration and Antibacterial Properties

The two major problems of titanium alloy surface of bone/dental implants were the lack of native tissue integration and associated infection. To solve these problems, the development of self-defending implants with intrinsic osteogenic properties has been highlighted, in which titanium alloy surfaces of bone/dental implants are endowed with antibacterial property by silver (Ag) incorporated in biomaterials. In this study, we biofunctionalized the surface of selective laser melting (SLM) manufactured volume-porous Ti-Ta-Nb-Zr scaffolds by using plasma electrolytic oxidation (PEO) as a way to eliminate the peri-operative bacterial load and promote osseointegration. In the experiment, the PEO process operated with three different concentration (1, 1, and 2 g/L) of a AgNO3 solution. As a result, a titanium oxide coating embedded with calcium and phosphorous and Ag was formed by one-step PEO treatment, and a presence of HAp was detected by X-ray diffraction (XRD) and XPS. In addition, Ag ions were found to be released from the scaffolds for at least 28 days, resulting in an effective prevention of bacterial adhesion and a decrease of the number of planktonic bacteria, with no sign of cytotoxicity shown simultaneously. Highly porosity micropores were formed on the surface of scaffolds after oxidation, and the mechanical properties did not show any signs of change. Besides, a strong calcium deposition and osteoconductive effect were found on the surface of PEO-treated Ag scaffolds. To sum up, this study reveals the potential of PEO coatings to biofunctionalize SLM Ti-Ta-Nb-Zr scaffolds with antibacterial agents. The biomaterials developed here, therefore, exploit the biofunctionalized behavior of Ag to offer strong antibacterial behavior and osteogenic promotion without cytotoxicity of Ag against mammalian cells.

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

Practical strategy to construct anti-osteosarcoma bone substitutes by loading cisplatin into 3D-printed titanium alloy implants using a thermosensitive hydrogel

Surgical resection and perioperative adjuvant chemotherapy-based therapies have improved the prognosis of patients with osteosarcoma; however, intraoperative bone defects, local tumour recurrence, and chemotherapy-induced adverse effects still affect the quality of life of patients. Emerging 3D-printed titanium alloy (Ti₆Al₄V) implants have advantages over traditional implants in bone repair, including lower elastic modulus, lower stiffness, better bone conduction, more bone in-growth, stronger mechanical interlocking, and lager drug-loading capacity by their inherent porous structure. Here, cisplatin, a clinical first-line anti-osteosarcoma drug, was loaded into Ti₆Al₄V implants, within a PLGA-PEG-PLGA thermo-sensitive hydrogel, to construct bone substitutes with both anti-osteosarcoma and bone-repair functions. The optimal concentrations of cisplatin (0.8 and 1.6 mg/mL) were first determined in vitro. Thereafter, the anti-tumour effect and biosafety of the cisplatin/hydrogel-loaded implants, as well as their bone-repair potential were evaluated in vivo in tumour-bearing mouse, and bone defect rabbit models, respectively. The loading of cisplatin reduced tumour volume by more than two-thirds (from 641.1 to 201.4 mm³) with negligible organ damage, achieving better anti-tumour effects while avoiding the adverse effects of systemic cisplatin delivery. Although bone repair was hindered by cisplatin loading at 4 weeks, no difference was observed at 8 weeks in the context of implants with versus without cisplatin, indicating acceptable long-term stability of all implants (with 8.48%–10.04% bone in-growth and 16.94%–20.53% osseointegration). Overall, cisplatin/hydrogel-loaded 3D-printed Ti₆Al₄V implants are safe and effective for treating osteosarcoma-caused bone defects, and should be considered for clinical use.

•

Vehiculated within PLGA-PEG-PLGA hydrogel, cisplatin can be conveniently loaded into 3D-printed Ti₆Al₄V implants.

•

The cisplatin/hydrogel-loaded implants are safe and show a good anti-tumour potential both in vitro and in vivo.

•

This strategy has better anti-osteosarcoma effects and fewer side effects than the conventional cisplatin delivery method.

•

Cisplatin loading does not decrease the bone repair effect of 3D-printed Ti₆Al₄V implants 8 weeks after surgery.

•

As the components of the implants are non-toxic, this strategy has great potential for clinical translation.