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Huo M, He S, Zhang Y, Liu Q, Liu M, Zhou G, Zhou P, Lu J. Mechano-driven intervertebral bone bridging via oriented mechanical stimulus in a twist metamaterial cage: An in silico study. Comput Biol Med 2024; 171:108149. [PMID: 38401455 DOI: 10.1016/j.compbiomed.2024.108149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 01/11/2024] [Accepted: 02/12/2024] [Indexed: 02/26/2024]
Abstract
Stiffer cages provide sufficient mechanical support but fail to promote bone ingrowth due to stress shielding. It remains challenging for fusion cage to satisfy both bone bridging and mechanical stability. Here we designed a fusion cage based on twist metamaterial for improved bone ingrowth, and proved its superiority to the conventional diagonal-based cage in silico. The fusion process was numerically reproduced via an injury-induced osteogenesis model and the mechano-driven bone remodeling algorithm, and the outcomes fusion effects were evaluated by the morphological features of the newly-formed bone and the biomechanical behaviors of the bone-cage composite. The twist-based cages exhibited oriented bone formation in the depth direction, in comparison to the diagonal-based cages. The axial stiffness of the bone-cage composites with twist-based cages was notably higher than that with diagonal-based cages; meanwhile, the ranges of motion of the twist-based fusion segment were lower. It was concluded that the twist metamaterial cages led to oriented bone ingrowth, superior mechanical stability of the bone-cage composite, and less detrimental impacts on the adjacent bones. More generally, metamaterials with a tunable displacement mode of struts might provide more design freedom in implant designs to offer customized mechanical stimulus for osseointegration.
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Affiliation(s)
- Mengke Huo
- State Key Laboratory of Digital Medical Engineering, School of Biological Science & Medical Engineering, Southeast University, Nanjing, China; Department of Mechanical Engineering, City University of Hong Kong, Hong Kong, China; CityU-Shenzhen Futian Research Institute, Shenzhen, China
| | - Siyuan He
- State Key Laboratory of Digital Medical Engineering, School of Biological Science & Medical Engineering, Southeast University, Nanjing, China.
| | - Yun Zhang
- State Key Laboratory of Digital Medical Engineering, School of Biological Science & Medical Engineering, Southeast University, Nanjing, China; Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Qing Liu
- State Key Laboratory of Digital Medical Engineering, School of Biological Science & Medical Engineering, Southeast University, Nanjing, China
| | - Mengxing Liu
- Shenzhen Mindray Bio-Medical Electronics Co., Ltd, Shenzhen, China; Wuhan Mindray Scientific Co., Ltd, Wuhan, China
| | - Guangquan Zhou
- State Key Laboratory of Digital Medical Engineering, School of Biological Science & Medical Engineering, Southeast University, Nanjing, China
| | - Ping Zhou
- State Key Laboratory of Digital Medical Engineering, School of Biological Science & Medical Engineering, Southeast University, Nanjing, China
| | - Jian Lu
- Department of Mechanical Engineering, City University of Hong Kong, Hong Kong, China; CityU-Shenzhen Futian Research Institute, Shenzhen, China; Centre for Advanced Structural Materials, City University of Hong Kong Shenzhen Research Institute, Greater Bay Joint Division, Shenyang National Laboratory for Materials Science, Shenzhen, China
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2
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Gupta R, Judkins L, Friday CS, Ulsh JB, Kovach SJ, Mehta S, Tomonto C, Manogharan G, Hast MW. Functionally graded 3D printed plates for rib fracture fixation. Clin Biomech (Bristol, Avon) 2024; 111:106151. [PMID: 37989063 PMCID: PMC10842059 DOI: 10.1016/j.clinbiomech.2023.106151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Design freedom offered by additive manufacturing allows for the implementation of functional gradients - where mechanical stiffness is decreased along the length of the implant. It is unclear if such changes will influence failure mechanisms in the context of rib fracture repair. We hypothesized that our novel functionally graded rib implants would be less stiff than controls and decrease occurrence of secondary fracture at implant ends. METHODS Five novel additively manufactured rib implants were tested along with a clinically used Control implant. Fracture reconstructions were modeled with custom synthetic rib bones with a transverse B1 fracture. Ribs were compressed in a cyclic two-point bend test for 360,000 cycles followed by a ramp to failure test. Differences in cyclic stiffness, 3D interfragmentary motions, ramp-to-failure stiffness, maximum load, and work to failure were determined. FINDINGS The Control group had lower construct stiffness (0.76 ± 0.28 N/mm), compared to all novel implant designs (means: 1.35-1.61 N/mm, p < 0.05) and rotated significantly more about the bending axis (2.7° ± 1.3°) than the additively manufactured groups (means between 1.2° - 1.6°, p < 0.05). All constructs failed via bone fracture at the most posterior screw hole. Experimental implants were stiffer than Controls, and there were few significant differences between functional gradient groups. INTERPRETATION Additively manufactured, functionally graded designs have the potential to change the form and function of trauma implants. Here, the impact of functional gradients was limited because implants had small cross-sectional areas.
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Affiliation(s)
- Richa Gupta
- McKay Orthopaedic Research Lab, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren Judkins
- Department of Mechanical Engineering, Pennsylvania State University, University Park, PA, USA
| | - Chet S Friday
- McKay Orthopaedic Research Lab, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph B Ulsh
- McKay Orthopaedic Research Lab, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen J Kovach
- McKay Orthopaedic Research Lab, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Samir Mehta
- McKay Orthopaedic Research Lab, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Guha Manogharan
- Department of Mechanical Engineering, Pennsylvania State University, University Park, PA, USA
| | - Michael W Hast
- McKay Orthopaedic Research Lab, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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Guadalupi M, Crovace AM, Monopoli Forleo D, Staffieri F, Lacitignola L. Pressure-Sensitive Walkway System for Evaluation of Lameness in Dogs Affected by Unilateral Cranial Cruciate Ligament Rupture Treated with Porous Tibial Tuberosity Advancement. Vet Sci 2023; 10:696. [PMID: 38133247 PMCID: PMC10747910 DOI: 10.3390/vetsci10120696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
The aim of this study was to objectively evaluate lameness in dogs affected by a unilateral cranial cruciate ligament rupture (CrCLR) treated with porous tibial tuberosity advancement before surgery and at three different timepoints after surgery, using the GAITRite® system (version 4.9Wr), a pressure-sensitive walkway system that is able to calculate several spatiotemporal gait parameters simultaneously for each limb. The dogs walked on the pressure-sensitive walkway before (T0) and 30 (T1), 90 (T2), and 120 (T3) days after surgery. Pressure measurements (gait lameness score and total pressure index %) were collected for S (treated with porous TTA) and C (healthy contralateral limb) at T0, T1, T2, and T3 and statistically evaluated. An ANOVA test was performed to compare the data, and a value of p < 0.05 was considered significant. Twenty dogs (n = 20) of various common breeds and ages with CrCLR were enrolled in the study. The results showed that there was a statistically significant difference in the GAIT4Dog® lameness score (GLS) and TPI% between S and C for each timepoint. Statistically significant differences in the GLS and TPI% between S at T0 and S at T2 and between S at T0 and S at T3 (p < 0.001) were found. The results showed that there was a statistically significant difference in the GAIT4Dog® lameness score (GLS) and TPI% between S and C for each timepoint. Statistically significant differences in the GLS and TPI% between S at T0 and S at T2 and between S at T0 and S at T3 were found. The GLS and TPI% increased statistically significantly from 90 days after surgery compared to the preoperative measurements. Moreover, comparing the GLS and TPI% between the treated limb and the control limb showed that a statistically significant difference remained at each timepoint.
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Affiliation(s)
- Marta Guadalupi
- Dottorato di Ricerca in “Trapianti di Tessuti ed Organi e Terapie Cellulari”, Università degli Studi di Bari Aldo Moro, 70100 Bari, Italy;
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Jonica, Università degli Studi di Bari Aldo Moro, 70100 Bari, Italy;
| | | | - Donato Monopoli Forleo
- Departamento de Ingeniería Mecánica, Instituto Tecnológico de Canarias (ITC), Añepa, esq. Tigotán s/n, 35118 Las Palmas de Gran Canaria, Spain;
| | - Francesco Staffieri
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Jonica, Università degli Studi di Bari Aldo Moro, 70100 Bari, Italy;
| | - Luca Lacitignola
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Jonica, Università degli Studi di Bari Aldo Moro, 70100 Bari, Italy;
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Wu H, Chen X, Kong L, Liu P. Mechanical and Biological Properties of Titanium and Its Alloys for Oral Implant with Preparation Techniques: A Review. MATERIALS (BASEL, SWITZERLAND) 2023; 16:6860. [PMID: 37959457 PMCID: PMC10649385 DOI: 10.3390/ma16216860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
Dental implants have revolutionised restorative dentistry, offering patients a natural-looking and durable solution to replace missing or severely damaged teeth. Titanium and its alloys have emerged as the gold standard among the various materials available due to their exceptional properties. One of the critical advantages of titanium and its alloys is their remarkable biocompatibility which ensures minimal adverse reactions within the human body. Furthermore, they exhibit outstanding corrosion resistance ensuring the longevity of the implant. Their mechanical properties, including hardness, tensile strength, yield strength, and fatigue strength, align perfectly with the demanding requirements of dental implants, guaranteeing the restoration's functionality and durability. This narrative review aims to provide a comprehensive understanding of the manufacturing techniques employed for titanium and its alloy dental implants while shedding light on their intrinsic properties. It also presents crucial proof-of-concept examples, offering tangible evidence of these materials' effectiveness in clinical applications. However, despite their numerous advantages, certain limitations still exist necessitating ongoing research and development efforts. This review will briefly touch upon these restrictions and explore the evolving trends likely to shape the future of titanium and its alloy dental implants.
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Affiliation(s)
| | | | | | - Ping Liu
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, China; (H.W.); (X.C.); (L.K.)
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Pu F, Yu Y, Zhang Z, Wu W, Shao Z, Li C, Feng J, Xue L, Chen F. Research and Application of Medical Polyetheretherketone as Bone Repair Material. Macromol Biosci 2023; 23:e2300032. [PMID: 37088909 DOI: 10.1002/mabi.202300032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/01/2023] [Indexed: 04/25/2023]
Abstract
Polyetheretherketone (PEEK) can potentially be used for bone repair because its elastic modulus is similar to that of human natural bone and good biocompatibility and chemical stability. However, its hydrophobicity and biological inertness limit its application in the biomedical field. Inspired by the composition, structure, and function of bone tissue, many strategies are proposed to change the structure and functionality of the PEEK surface. In this review, the applications of PEEK in bone repair and the optimization strategy for PEEK's biological activity are reviewed, which provides a direction for the development of multifunctional bone repair materials in the future.
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Affiliation(s)
- Feifei Pu
- Department of Orthopedics, Traditional Chinese and Western Medicine Hospital of Wuhan (Wuhan No.1 Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yihan Yu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Zhicai Zhang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Wei Wu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Zengwu Shao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Chao Li
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Jing Feng
- Department of Orthopedics, Traditional Chinese and Western Medicine Hospital of Wuhan (Wuhan No.1 Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Longjian Xue
- School of Power and Mechanical Engineering, Wuhan University, Wuhan, Hubei, 430072, China
| | - Fengxia Chen
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, 430071, China
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Patel NA, O’Bryant S, Rogers CD, Boyett CK, Chakravarti S, Gendreau J, Brown NJ, Pennington ZA, Hatcher NB, Kuo C, Diaz-Aguilar LD, Pham MH. Three-Dimensional-Printed Titanium Versus Polyetheretherketone Cages for Lumbar Interbody Fusion: A Systematic Review of Comparative In Vitro, Animal, and Human Studies. Neurospine 2023; 20:451-463. [PMID: 37401063 PMCID: PMC10323354 DOI: 10.14245/ns.2346244.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/04/2023] [Accepted: 04/19/2023] [Indexed: 07/05/2023] Open
Abstract
Interbody fusion is a workhorse technique in lumbar spine surgery that facilities indirect decompression, sagittal plane realignment, and successful bony fusion. The 2 most commonly employed cage materials are titanium (Ti) alloy and polyetheretherketone (PEEK). While Ti alloy implants have superior osteoinductive properties they more poorly match the biomechanical properties of cancellous bones. Newly developed 3-dimensional (3D)-printed porous titanium (3D-pTi) address this disadvantage and are proposed as a new standard for lumbar interbody fusion (LIF) devices. In the present study, the literature directly comparing 3D-pTi and PEEK interbody devices is systematically reviewed with a focus on fusion outcomes and subsidence rates reported in the in vitro, animal, and human literature. A systematic review directly comparing outcomes of PEEK and 3D-pTi interbody spinal cages was performed. PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Mean Newcastle-Ottawa Scale score for cohort studies was 6.4. A total of 7 eligible studies were included, comprising a combination of clinical series, ovine animal data, and in vitro biomechanical studies. There was a total population of 299 human and 59 ovine subjects, with 134 human (44.8%) and 38 (64.4%) ovine models implanted with 3D-pTi cages. Of the 7 studies, 6 reported overall outcomes in favor of 3D-pTi compared to PEEK, including subsidence and osseointegration, while 1 study reported neutral outcomes for device related revision and reoperation rate. Though limited data are available, the current literature supports 3D-pTi interbodies as offering superior fusion outcomes relative to PEEK interbodies for LIF without increasing subsidence or reoperation risk. Histologic evidence suggests 3D-Ti to have superior osteoinductive properties that may underlie these superior outcomes, but additional clinical investigation is merited.
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Affiliation(s)
- Neal A. Patel
- School of Medicine, Mercer University, Columbus, GA, USA
| | | | | | | | - Sachiv Chakravarti
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | - Nolan J. Brown
- Department of Neurosurgery, University of California Irvine, Orange, CA, USA
| | | | | | - Cathleen Kuo
- Department of Neurosurgery, University of Buffalo, Buffalo, NY, USA
| | | | - Martin H. Pham
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
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7
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Avery D, Morandini L, Celt N, Bergey L, Simmons J, Martin RK, Donahue HJ, Olivares-Navarrete R. Immune cell response to orthopedic and craniofacial biomaterials depends on biomaterial composition. Acta Biomater 2023; 161:285-297. [PMID: 36905954 PMCID: PMC10269274 DOI: 10.1016/j.actbio.2023.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/20/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
Materials for craniofacial and orthopedic implants are commonly selected based on mechanical properties and corrosion resistance. The biocompatibility of these materials is typically assessed in vitro using cell lines, but little is known about the response of immune cells to these materials. This study aimed to evaluate the inflammatory and immune cell response to four common orthopedic materials [pure titanium (Ti), titanium alloy (TiAlV), 316L stainless steel (SS), polyetheretherketone (PEEK)]. Following implantation into mice, we found high recruitment of neutrophils, pro-inflammatory macrophages, and CD4+ T cells in response to PEEK and SS implants. Neutrophils produced higher levels of neutrophil elastase, myeloperoxidase, and neutrophil extracellular traps in vitro in response to PEEK and SS than neutrophils on Ti or TiAlV. Macrophages co-cultured on PEEK, SS, or TiAlV increased polarization of T cells towards Th1/Th17 subsets and decreased Th2/Treg polarization compared to Ti substrates. Although SS and PEEK are considered biocompatible materials, both induce a more robust inflammatory response than Ti or Ti alloy characterized by high infiltration of neutrophils and T cells, which may cause fibrous encapsulation of these materials. STATEMENT OF SIGNIFICANCE: Materials for craniofacial and orthopedic implants are commonly selected based on their mechanical properties and corrosion resistance. This study aimed to evaluate the immune cell response to four common orthopedic and craniofacial biomaterials: pure titanium, titanium-aluminum-vanadium alloy, 316L stainless steel, and PEEK. Our results demonstrate that while the biomaterials tested have been shown to be biocompatible and clinically successful, the inflammatory response is largely driven by chemical composition of the biomaterials.
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Affiliation(s)
- Derek Avery
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Lais Morandini
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Natalie Celt
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Leah Bergey
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Jamelle Simmons
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Rebecca K Martin
- Department of Microbiology and Immunology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Henry J Donahue
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA, United States
| | - Rene Olivares-Navarrete
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA, United States.
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8
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Levy HA, Karamian BA, Yalla GR, Canseco JA, Vaccaro AR, Kepler CK. Impact of surface roughness and bulk porosity on spinal interbody implants. J Biomed Mater Res B Appl Biomater 2023; 111:478-489. [PMID: 36075112 DOI: 10.1002/jbm.b.35161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 07/19/2022] [Accepted: 08/25/2022] [Indexed: 12/15/2022]
Abstract
Spinal fusion surgeries are performed to treat a multitude of cervical and lumbar diseases that lead to pain and disability. Spinal interbody fusion involves inserting a cage between the spinal vertebrae, and is often utilized for indirect neurologic decompression, correction of spinal alignment, anterior column stability, and increased fusion rate. The long-term success of interbody fusion relies on complete osseointegration between the implant surface and vertebral end plates. Titanium (Ti)-based alloys and polyetheretherketone (PEEK) interbody cages represent the most commonly utilized materials and provide sufficient mechanics and biocompatibility to assist in fusion. However, modification to the surface and bulk characteristics of these materials has been shown to maximize osseointegration and long-term stability. Specifically, the introduction of intrinsic porosity and surface roughness has been shown to affect spinal interbody mechanics, vascularization, osteoblast attachment, and ingrowth potential. This narrative review synthesizes the mechanical, in vitro, in vivo, and clinical effects on fusion efficacy associated with introduction of porosity in Ti (neat and alloy) and PEEK intervertebral implants.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, USA
| | - Goutham R Yalla
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Pidhatika B, Widyaya VT, Nalam PC, Swasono YA, Ardhani R. Surface Modifications of High-Performance Polymer Polyetheretherketone (PEEK) to Improve Its Biological Performance in Dentistry. Polymers (Basel) 2022; 14:polym14245526. [PMID: 36559893 PMCID: PMC9787615 DOI: 10.3390/polym14245526] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022] Open
Abstract
This comprehensive review focuses on polyetheretherketone (PEEK), a synthetic thermoplastic polymer, for applications in dentistry. As a high-performance polymer, PEEK is intrinsically robust yet biocompatible, making it an ideal substitute for titanium-the current gold standard in dentistry. PEEK, however, is also inert due to its low surface energy and brings challenges when employed in dentistry. Inert PEEK often falls short of achieving a few critical requirements of clinical dental materials, such as adhesiveness, osseoconductivity, antibacterial properties, and resistance to tribocorrosion. This study aims to review these properties and explore the various surface modification strategies that enhance the performance of PEEK. Literatures searches were conducted on Google Scholar, Research Gate, and PubMed databases using PEEK, polyetheretherketone, osseointegration of PEEK, PEEK in dentistry, tribology of PEEK, surface modifications, dental applications, bonding strength, surface topography, adhesive in dentistry, and dental implant as keywords. Literature on the topics of surface modification to increase adhesiveness, tribology, and osseointegration of PEEK were included in the review. The unavailability of full texts was considered when excluding literature. Surface modifications via chemical strategies (such as sulfonation, plasma treatment, UV treatment, surface coating, surface polymerization, etc.) and/or physical approaches (such as sandblasting, laser treatment, accelerated neutral atom beam, layer-by-layer assembly, particle leaching, etc.) discussed in the literature are summarized and compared. Further, approaches such as the incorporation of bioactive materials, e.g., osteogenic agents, antibacterial agents, etc., to enhance the abovementioned desired properties are explored. This review presents surface modification as a critical and essential approach to enhance the biological performance of PEEK in dentistry by retaining its mechanical robustness.
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Affiliation(s)
- Bidhari Pidhatika
- Research Center for Polymer Technology, National Research and Innovation Agency, Republic of Indonesia PRTPL BRIN Indonesia, Serpong, Tangerang Selatan 15314, Indonesia
- Collaborative Research Center for Biomedical Scaffolds, National Research and Innovation Agency of the Republic Indonesia and Universitas Gadjah Mada, Jalan Denta No. 1, Sekip Utara, Yogyakarta 55281, Indonesia
| | - Vania Tanda Widyaya
- Research Center for Polymer Technology, National Research and Innovation Agency, Republic of Indonesia PRTPL BRIN Indonesia, Serpong, Tangerang Selatan 15314, Indonesia
| | - Prathima C. Nalam
- Department of Materials Design and Innovation, University at Buffalo, Buffalo, NY 14260-1900, USA
| | - Yogi Angga Swasono
- Research Center for Polymer Technology, National Research and Innovation Agency, Republic of Indonesia PRTPL BRIN Indonesia, Serpong, Tangerang Selatan 15314, Indonesia
| | - Retno Ardhani
- Department of Dental Biomedical Science, Faculty of Dentistry, Universitas Gadjah Mada, Jalan Denta No. 1, Sekip Utara, Yogyakarta 55281, Indonesia
- Correspondence:
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10
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Weng Y, Di M, Wu T, Ma X, Yang Q, Lu WW. Endplate volumetric bone mineral density biomechanically matched interbody cage. Front Bioeng Biotechnol 2022; 10:1075574. [PMID: 36561040 PMCID: PMC9763577 DOI: 10.3389/fbioe.2022.1075574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Disc degenerative problems affect the aging population, globally, and interbody fusion is a crucial surgical treatment. The interbody cage is the critical implant in interbody fusion surgery; however, its subsidence risk becomes a remarkable clinical complication. Cage subsidence is caused due to a mismatch of material properties between the bone and implant, specifically, the higher elastic modulus of the cage relative to that of the spinal segments, inducing subsidence. Our recent observation has demonstrated that endplate volumetric bone mineral density (EP-vBMD) measured through the greatest cortex-occupied 1.25-mm height region of interest, using automatic phantomless quantitative computed tomography scanning, could be an independent cage subsidence predictor and a tool for cage selection instruction. Porous design on the metallic cage is a trend in interbody fusion devices as it provides a solution to the subsidence problem. Moreover, the superior osseointegration effect of the metallic cage, like the titanium alloy cage, is retained. Patient-specific customization of porous metallic cages based on the greatest subsidence-related EP-vBMD may be a good modification for the cage design as it can achieve biomechanical matching with the contacting bone tissue. We proposed a novel perspective on porous metallic cages by customizing the elastic modulus of porous metallic cages by modifying its porosity according to endplate elastic modulus calculated from EP-vBMD. A three-grade porosity customization strategy was introduced, and direct porosity-modulus customization was also available depending on the patient's or doctor's discretion.
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Affiliation(s)
- Yuanzhi Weng
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Mingyuan Di
- Graduate School, Tianjin Medical University, Tianjin, China,Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China
| | - Tianchi Wu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xinlong Ma
- Tianjin Hospital, Tianjin University, Tianjin, China
| | - Qiang Yang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, Tianjin, China,*Correspondence: Qiang Yang, ; Weijia William Lu,
| | - Weijia William Lu
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China,Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China,Research Center for Human Tissue and Organs Degeneration, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen, China,*Correspondence: Qiang Yang, ; Weijia William Lu,
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Naghavi SA, Tamaddon M, Marghoub A, Wang K, Babamiri BB, Hazeli K, Xu W, Lu X, Sun C, Wang L, Moazen M, Wang L, Li D, Liu C. Mechanical Characterisation and Numerical Modelling of TPMS-Based Gyroid and Diamond Ti6Al4V Scaffolds for Bone Implants: An Integrated Approach for Translational Consideration. Bioengineering (Basel) 2022; 9:504. [PMID: 36290472 PMCID: PMC9598079 DOI: 10.3390/bioengineering9100504] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 07/25/2023] Open
Abstract
Additive manufacturing has been used to develop a variety of scaffold designs for clinical and industrial applications. Mechanical properties (i.e., compression, tension, bending, and torsion response) of these scaffolds are significantly important for load-bearing orthopaedic implants. In this study, we designed and additively manufactured porous metallic biomaterials based on two different types of triply periodic minimal surface structures (i.e., gyroid and diamond) that mimic the mechanical properties of bone, such as porosity, stiffness, and strength. Physical and mechanical properties, including compressive, tensile, bending, and torsional stiffness and strength of the developed scaffolds, were then characterised experimentally and numerically using finite element method. Sheet thickness was constant at 300 μm, and the unit cell size was varied to generate different pore sizes and porosities. Gyroid scaffolds had a pore size in the range of 600-1200 μm and a porosity in the range of 54-72%, respectively. Corresponding values for the diamond were 900-1500 μm and 56-70%. Both structure types were validated experimentally, and a wide range of mechanical properties (including stiffness and yield strength) were predicted using the finite element method. The stiffness and strength of both structures are comparable to that of cortical bone, hence reducing the risks of scaffold failure. The results demonstrate that the developed scaffolds mimic the physical and mechanical properties of cortical bone and can be suitable for bone replacement and orthopaedic implants. However, an optimal design should be chosen based on specific performance requirements.
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Affiliation(s)
- Seyed Ataollah Naghavi
- Institute of Orthopaedic & Musculoskeletal, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Stanmore, London HA7 4LP, UK
| | - Maryam Tamaddon
- Institute of Orthopaedic & Musculoskeletal, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Stanmore, London HA7 4LP, UK
| | - Arsalan Marghoub
- Department of Mechanical Engineering, University College London, London WC1E 7JE, UK
| | - Katherine Wang
- Department of Mechanical Engineering, University College London, London WC1E 7JE, UK
| | - Behzad Bahrami Babamiri
- Aerospace and Mechanical Engineering Department, The University of Arizona, Tucson, AZ 85721, USA
| | - Kavan Hazeli
- Aerospace and Mechanical Engineering Department, The University of Arizona, Tucson, AZ 85721, USA
| | - Wei Xu
- Institute of Orthopaedic & Musculoskeletal, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Stanmore, London HA7 4LP, UK
- National Engineering Research Center for Advanced Rolling and Intelligent Manufacturing, Institute of Engineering Technology, University of Science and Technology Beijing, Beijing 100083, China
| | - Xin Lu
- National Engineering Research Center for Advanced Rolling and Intelligent Manufacturing, Institute of Engineering Technology, University of Science and Technology Beijing, Beijing 100083, China
| | - Changning Sun
- Institute of Orthopaedic & Musculoskeletal, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Stanmore, London HA7 4LP, UK
- State Key Laboratory for Manufacturing Systems Engineering, School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an 710049, China
- National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710054, China
| | - Liqing Wang
- State Key Laboratory of Metal Matrix Composites, School of Materials Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Mehran Moazen
- Department of Mechanical Engineering, University College London, London WC1E 7JE, UK
| | - Ling Wang
- State Key Laboratory for Manufacturing Systems Engineering, School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an 710049, China
- National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710054, China
| | - Dichen Li
- State Key Laboratory for Manufacturing Systems Engineering, School of Mechanical Engineering, Xi’an Jiaotong University, Xi’an 710049, China
- National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi’an Jiaotong University, Xi’an 710054, China
| | - Chaozong Liu
- Institute of Orthopaedic & Musculoskeletal, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, Stanmore, London HA7 4LP, UK
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Corrosion Resistance of 3D Printed Ti6Al4V Gyroid Lattices with Varying Porosity. MATERIALS 2022; 15:ma15144805. [PMID: 35888273 PMCID: PMC9316743 DOI: 10.3390/ma15144805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 02/04/2023]
Abstract
Corrosion of medical implants is a possible failure mode via induced local inflammatory effects, systemic deposition and corrosion related mechanical failure. Cyclic potentiodynamic polarisation (CPP) testing was utilized to evaluate the effect of increased porosity (60% and 80%) and decreased wall thickness in gyroid lattice structures on the electrochemical behaviour of LPBF Ti6Al4V structures. The use of CPP allowed for the landmarks of breakdown potential, resting potential and vertex potential to be analysed, as well as facilitating the construction of Tafel plots and qualitative Goldberg analysis. The results indicated that 60% gyroid samples were most susceptible to the onset of pitting corrosion when compared to 80% gyroid and solid samples. This was shown through decreased breakdown and vertex potentials and were found to correlate to increased lattice surface area to void volume ratio. Tafel plots indicated that despite the earlier onset of pitting corrosion, both gyroid test groups displayed lower rates of corrosion per year, indicating a lower severity of corrosion. This study highlighted inherent tradeoffs between lattice optimisation and corrosion behaviour with a potential parabolic link between void volume, surface area and corrosion being identified. This potential link is supported by 60% gyroid samples having the lowest breakdown potentials, but investigation into other porosity ranges is suggested to support the hypothesis. All 3D printed materials studied here showed breakdown potentials higher than ASTM F2129's suggestion of 800 mV for evaluation within the physiological environment, indicating that under static conditions pitting and crevice corrosion should not initiate within the body.
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Fogel G, Martin N, Lynch K, Pelletier MH, Wills D, Wang T, Walsh WR, Williams GM, Malik J, Peng Y, Jekir M. Subsidence and fusion performance of a 3D-printed porous interbody cage with stress-optimized body lattice and microporous endplates - a comprehensive mechanical and biological analysis. Spine J 2022; 22:1028-1037. [PMID: 35017054 DOI: 10.1016/j.spinee.2022.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 12/22/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND CONTEXT Cage subsidence remains a serious complication after spinal fusion surgery. Novel porous designs in the cage body or endplate offer attractive options to improve subsidence and osseointegration performance. PURPOSE To elucidate the relative contribution of a porous design in each of the two major domains (body and endplates) to cage stiffness and subsidence performance, using standardized mechanical testing methods, and to analyze the fusion progression via an established ovine interbody fusion model to support the mechanical testing findings. STUDY DESIGN/SETTING A comparative preclinical study using standardized mechanical testing and established animal model. METHODS To isolate the subsidence performance contributed by each porous cage design feature, namely the stress-optimized body lattice (vs. a solid body) and microporous endplates (vs. smooth endplates), four groups of cages (two-by-two combination of these two features) were tested in: (1) static axial compression of the cage (per ASTM F2077) and (2) static subsidence (per ASTM F2267). To evaluate the progression of fusion, titanium cages were created with a microporous endplate and internal lattice architecture analogous to commercial implants used in subsidence testing and implanted in an endplate-sparing, ovine intervertebral body fusion model. RESULTS The cage stiffness was reduced by 16.7% by the porous body lattice, and by 16.6% by the microporous endplates. The porous titanium cage with both porous features showed the lowest stiffness with a value of 40.4±0.3 kN/mm (Mean±SEM) and a block stiffness of 1976.8±27.4 N/mm for subsidence. The body lattice showed no significant impact on the block stiffness (1.4% reduction), while the microporous endplates decreased the block stiffness significantly by 24.9% (p<.0001). All segments implanted with porous titanium cages were deemed rigidly fused by manual palpation, except one at 12 weeks, consistent with robotic ROM testing and radiographic and histologic observations. A reduction in ROM was noted from 12 to 26 weeks (4.1±1.6° to 2.2±1.4° in lateral bending, p<.05; 2.1±0.6° to 1.5±0.3° in axial rotation, p<.05); and 3.3±1.6° to 1.9±1.2° in flexion extension, p=.07). Bone in the available void improved with time in the central aperture (54±35% to 83±13%, p<.05) and porous cage structure (19±26% to 37±21%, p=.15). CONCLUSIONS Body lattice and microporous endplates features can effectively reduce the cage stiffness, therefore reducing the risk of stress shielding and promoting early fusion. While body lattice showed no impact on block stiffness and the microporous endplates reduced the block stiffness, a titanium cage with microporous endplates and internal lattice supported bone ingrowth and segmental mechanical stability as early as 12 weeks in ovine interbody fusion. CLINICAL SIGNIFICANCE Porous titanium cage architecture can offer an attractive solution to increase the available space for bone ingrowth and bridging to support successful spinal fusion while mitigating risks of increased subsidence.
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Affiliation(s)
- Guy Fogel
- Spine Pain Begone Clinic, 2833 Babcock Rd Suite 306, San Antonio, TX 78229, USA
| | | | - Kelli Lynch
- NuVasive, 7475 Lusk Blvd., San Diego, CA 92129, USA
| | - Matthew H Pelletier
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | - Daniel Wills
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | - Tian Wang
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | - William R Walsh
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, UNSW Sydney, Level 1, Clinical Sciences Building, Gate 6, Avoca St, Randwick, Sydney, NSW 2031, Australia
| | | | - Jeremy Malik
- NuVasive, 7475 Lusk Blvd., San Diego, CA 92129, USA
| | - Yun Peng
- NuVasive, 7475 Lusk Blvd., San Diego, CA 92129, USA.
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Laratta JL, Vivace BJ, López-Peña M, Guzón FM, Gonzalez-Cantalpeidra A, Jorge-Mora A, Villar-Liste RM, Pino-Lopez L, Lukyanchuk A, Taghizadeh EA, Pino-Minguez J. 3D-printed titanium cages without bone graft outperform PEEK cages with autograft in an animal model. Spine J 2022; 22:1016-1027. [PMID: 34906741 DOI: 10.1016/j.spinee.2021.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Modernization of 3D printing has allowed for the production of porous titanium interbody cages (3D-pTi) which purportedly optimize implant characteristics and increase osseointegration; however, this remains largely unstudied in vivo. PURPOSE To compare osseointegration of three-dimensional (3D) titanium cages without bone graft and Polyether-ether-ketone (PEEK) interbody cages with autologous iliac crest bone graft (AICBG). STUDY DESIGN Animal study utilizing an ovine in vivo model of lumbar fusion. METHODS Interbody cages of PEEK or 3D-pTi supplied by Spineart SA (Geneva, Switzerland) were implanted in seven living sheep at L2-L3 and L4-L5, leaving the intervening disc space untreated. Both implant materials were used in each sheep and randomized to the aforementioned disc spaces. Computed tomography (CT) was obtained at 4 weeks and 8 weeks. MicroCT and histological sections were obtained to evaluate osseointegration. RESULTS MicroCT demonstrated osseous in-growth of native cancellous bone in the trabecular architecture of the 3D-pTi interbody cages and no interaction between the PEEK cages with the surrounding native bone. Qualitative histology revealed robust osseointegration in 3D-pTi implants and negligible osseointegration with localized fibrosis in PEEK implants. Evidence of intramembranous and endochondral ossification was apparent with the 3D-pTi cages. Quantitative histometric bone implant contact demonstrated significantly more contact in the 3D-pTi implants versus PEEK (p<.001); region of interest calculations also demonstrated significantly greater osseous and cartilaginous interdigitation at the implant-native bone interface with the 3D-pTi cages (p=.008 and p=.015, respectively). CONCLUSIONS 3D-pTi interbody cages without bone graft outperform PEEK interbody cages with AICBG in terms of osseointegration at 4 and 8 weeks postoperatively in an ovine lumbar fusion model. CLINICAL SIGNIFICANCE 3D-pTi interbody cages demonstrated early and robust osseointegration without any bone graft or additive osteoinductive agents. This may yield early stability in anterior lumbar arthrodesis and potentially bolster the rate of successful fusion. This could be of particular advantage in patients with spinal neoplasms needing post-ablative arthrodesis, where local autograft use would be ill advised.
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Affiliation(s)
- Joseph L Laratta
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Bradley J Vivace
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
| | - Mónica López-Peña
- University of Santiago de Compostela, School of Veterinary Medicine, Santiago de Compostela, Galicia, Spain
| | - Fernando Muñoz Guzón
- University of Santiago de Compostela, School of Veterinary Medicine, Santiago de Compostela, Galicia, Spain
| | | | - Alberto Jorge-Mora
- Santiago de Compostela University Hospital, Department of Orthopaedic Surgery, Santiago de Compostela, Galicia, Spain
| | - Rosa Maria Villar-Liste
- Fundación IDIS. Santiago de Compostela University Hospital, Santiago de Compostela, Galicia, Spain
| | - Laura Pino-Lopez
- Fundación IDIS. Santiago de Compostela University Hospital, Santiago de Compostela, Galicia, Spain
| | | | | | - Jesús Pino-Minguez
- Santiago de Compostela University Hospital, Department of Orthopaedic Surgery, Santiago de Compostela, Galicia, Spain
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Wu MH, Lee MH, Wu C, Tsai PI, Hsu WB, Huang SI, Lin TH, Yang KY, Chen CY, Chen SH, Lee CY, Huang TJ, Tsau FH, Li YY. In Vitro and In Vivo Comparison of Bone Growth Characteristics in Additive-Manufactured Porous Titanium, Nonporous Titanium, and Porous Tantalum Interbody Cages. MATERIALS 2022; 15:ma15103670. [PMID: 35629694 PMCID: PMC9147460 DOI: 10.3390/ma15103670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/04/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023]
Abstract
Autogenous bone grafts are the gold standard for interbody fusion implant materials; however, they have several disadvantages. Tantalum (Ta) and titanium (Ti) are ideal materials for interbody cages because of their biocompatibility, particularly when they are incorporated into a three-dimensional (3D) porous structure. We conducted an in vitro investigation of the cell attachment and osteogenic markers of self-fabricated uniform porous Ti (20%, 40%, 60%, and 80%), nonporous Ti, and porous Ta cages (n = 6) in each group. Cell attachment, osteogenic markers, and alkaline phosphatase (ALP) were measured. An in vivo study was performed using a pig-posterior-instrumented anterior interbody fusion model to compare the porous Ti (60%), nonporous Ti, and porous Ta interbody cages in 12 pigs. Implant migration and subsidence, determined using plain radiographs, were recorded before surgery, immediately after surgery, and at 1, 3, and 6 months after surgery. Harvested implants were assessed for bone ingrowth and attachment. Relative to the 20% and 40% porous Ti cages, the 60% and 80% cages achieved superior cellular migration into cage pores. Among the cages, osteogenic marker and ALP activity levels were the highest in the 60% porous Ti cage, osteocalcin expression was the highest in the nonporous Ti cage, and the 60% porous Ti cage exhibited the lowest subsidence. In conclusion, the designed porous Ti cage is biocompatible and suitable for lumbar interbody fusion surgery and exhibits faster fusion with less subsidence compared with porous Ta and nonporous Ti cages.
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Affiliation(s)
- Meng-Huang Wu
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan; (M.-H.W.); (C.-Y.C.); (C.-Y.L.); (T.-J.H.)
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 110301, Taiwan
- TMU Biodesign Center, Taipei Medical University, Taipei 110301, Taiwan
| | - Ming-Hsueh Lee
- Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan;
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi 613016, Taiwan
| | - Christopher Wu
- College of Medicine, Taipei Medical University, Taipei 110301, Taiwan;
| | - Pei-I Tsai
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Chutung, Hsinchu County 310401, Taiwan; (P.-I.T.); (S.-I.H.); (K.-Y.Y.)
| | - Wei-Bin Hsu
- Sports Medicine Center, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan;
| | - Shin-I Huang
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Chutung, Hsinchu County 310401, Taiwan; (P.-I.T.); (S.-I.H.); (K.-Y.Y.)
| | - Tzu-Hung Lin
- Material and Chemical Research Laboratories, Industrial Technology Research Institute, Chutung, Hsinchu County 310401, Taiwan;
| | - Kuo-Yi Yang
- Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Chutung, Hsinchu County 310401, Taiwan; (P.-I.T.); (S.-I.H.); (K.-Y.Y.)
| | - Chih-Yu Chen
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan; (M.-H.W.); (C.-Y.C.); (C.-Y.L.); (T.-J.H.)
- TMU Biodesign Center, Taipei Medical University, Taipei 110301, Taiwan
- Department of Orthopedics, Shuang-Ho Hospital, Taipei Medical University, Taipei 235041, Taiwan
| | - Shih-Hao Chen
- Department of Orthopedic Surgery, Buddhist Tzu-Chi General Hospital, Taichung Branch, Taichung 427213, Taiwan;
- Department of Orthopedic Surgery, Tzu-Chi University, Hualien 970374, Taiwan
| | - Ching-Yu Lee
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan; (M.-H.W.); (C.-Y.C.); (C.-Y.L.); (T.-J.H.)
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 110301, Taiwan
| | - Tsung-Jen Huang
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan; (M.-H.W.); (C.-Y.C.); (C.-Y.L.); (T.-J.H.)
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 110301, Taiwan
| | - Fang-Hei Tsau
- Laser and Additive Manufacturing Technology Center, Southern Region Campus, Industrial Technology Research Institute, Tainan 734045, Taiwan;
| | - Yen-Yao Li
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi 613016, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333323, Taiwan
- Correspondence: ; Tel.: +88653621000 (ext. 2855)
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Zheng Z, Hu L, Ge Y, Qi J, Sun Q, Li Z, Lin L, Tang B. Surface Modification of Poly(ether ether ketone) by Simple Chemical Grafting of Strontium Chondroitin Sulfate to Improve its Anti-Inflammation, Angiogenesis, Osteogenic Properties. Adv Healthc Mater 2022; 11:e2200398. [PMID: 35481900 DOI: 10.1002/adhm.202200398] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/31/2022] [Indexed: 12/19/2022]
Abstract
Besides inducing osteogenic differentiation, the surface modification of poly(ether ether ketone) (PEEK) is highly expected to improve its angiogenic activity and reduce the inflammatory response in the surrounding tissue. Herein, strontium chondroitin sulfate is first attempted to be introduced into the surface of sulfonated PEEK (SPEEK-CS@Sr) based on the Schiff base reaction between PEEK and ethylenediamine (EDA) and the amidation reaction between EDA and chondroitin sulfate (CS). The surface characteristics of SPEEK-CS@Sr implant are systematically investigated, and its biological properties in vitro and in vivo are also evaluated. The results show that the surface of SPEEK-CS@Sr implant exhibits a 3D microporous structure and good hydrophilicity, and can steadily release Sr ions. Importantly, the SPEEK-CS@Sr not only displays excellent biocompatibility, but also can remarkably promote cell adhesion and spread, improve osteogenic activity and angiogenic activity, and reduce the inflammatory response compared to the original PEEK. Therefore, this study presents the surface modification of PEEK material by simple chemical grafting of strontium chondroitin sulfate to improve its angiogenesis, anti-inflammation, and osteogenic properties, and the as-fabricated SPEEK-CS@Sr has the potential to serve as a promising orthopedic implant in bone tissue engineering.
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Affiliation(s)
- Zhe Zheng
- Department of Biomedical Engineering Southern University of Science and Technology Shenzhen Guangdong P. R. China
| | - Liqiu Hu
- Department of Biomedical Engineering Southern University of Science and Technology Shenzhen Guangdong P. R. China
| | - Yongmei Ge
- Department of Biomedical Engineering Southern University of Science and Technology Shenzhen Guangdong P. R. China
- Harbin Institute of Technology Harbin Heilongjiang P. R. China
| | - Jianchao Qi
- Department of Biomedical Engineering Southern University of Science and Technology Shenzhen Guangdong P. R. China
- Department of Joint and Orthopedics Zhujiang Hospital Southern Medical University Guangzhou Guangdong P. R. China
- Department of Emergency surgery Shengli Clinical Medical College of Fujian Medical University Fujian Provincial Hospital Fuzhou P. R. China
| | - Qili Sun
- Department of Biomedical Engineering Southern University of Science and Technology Shenzhen Guangdong P. R. China
| | - Zhenjian Li
- Department of Biomedical Engineering Southern University of Science and Technology Shenzhen Guangdong P. R. China
| | - Lijun Lin
- Department of Joint and Orthopedics Zhujiang Hospital Southern Medical University Guangzhou Guangdong P. R. China
| | - Bin Tang
- Department of Biomedical Engineering Southern University of Science and Technology Shenzhen Guangdong P. R. China
- Guangdong Provincial Key Laboratory of Cell Microenvironment and Disease Research Shenzhen Guangdong P. R. China
- Shenzhen Key Laboratory of Cell Microenvironment Shenzhen Guangdong P. R. China
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Radiological and Clinical Outcomes after Anterior Cervical Discectomy and Fusion (ACDF) with an Innovative 3D Printed Cellular Titanium Cage Filled with Vertebral Bone Marrow. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6339910. [PMID: 35528156 PMCID: PMC9071886 DOI: 10.1155/2022/6339910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022]
Abstract
Objectives To assess the clinical and radiological outcomes after ACDF with 3D printed cellular titanium cages filled with bone marrow and to compare the clinical and radiological results with the current scientific literature. Methods ACDF was performed monosegmentally under standardized conditions. X-rays were analyzed to determine the range of motion, fusion rates, and subsidence preoperatively and 3 and 12 months postoperatively. Clinical outcome measurements included neck disability index (NDI), visual analogue scale (VAS) for brachialgia and cervicalgia, and patient satisfaction. Results 18 patients were included in the study. The mean RoM decreased from 7.7° ± 2.6 preoperatively to 1.7° ± 1.1° after 3 months and 1.8° ± 1.2° 12 months after surgery. The fusion rates were at 94.4% after 3 and 12 months. The mean subsidence was 0.9 mm ± 0.5 mm 3 months postoperatively and 1.1 mm ± 0.5 mm 12 months after surgery. The mean NDI improved significantly from preoperatively to 12 months postoperatively (34.6 ± 6.2 and 3.4 ± 4.1, respectively). The VAS-neck also showed a large improvement from 5.8 ± 2.2 before and 1.3 ± 1.4 12 months after surgery, as did the VAS-arm (6.4 ± 1.5 and 0.9 ± 1.6, respectively). Patient satisfaction was high throughout the follow-up period. Conclusion ACDF with a 3D printed titanium cage resulted in fast fusion without pathological subsidence. In comparison to other cage materials such as PEEK, the 3D printed titanium cage was noninferior in regard to its fusion rate and clinical results.
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18
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Static and Fatigue Load Bearing Investigation on Porous Structure Titanium Additively Manufactured Anterior Cervical Cages. BIOMED RESEARCH INTERNATIONAL 2022; 2022:6534749. [PMID: 35355825 PMCID: PMC8959973 DOI: 10.1155/2022/6534749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/21/2022] [Indexed: 11/24/2022]
Abstract
This study investigates the static and fatigue behavior of porous and conventional anterior cervical cages. Porous structure titanium anterior cervical cages were manufactured using direct selective laser sintering technique. Four different types of cervical cages were designed and manufactured, among which three designs consist of porous structure (type 1, type 2, and type 3) and manufactured using metal 3D printing. Remaining one design (type 4) was manufactured using conventional machining and did not consist any porous structure. All types of manufactured cages were tested in compression under static and fatigue loading conditions as per ASTM F2077 standard. Static and fatigue subsidence testing was performed using ASTM F2267 standard. Static compression testing results of type 1 and type 4 cages reported higher yield load when compared to the type 2 and type 3 cages. Static subsidence testing results reported almost 11% less subsidence rate for additively manufactured cages than the conventional cages. Fatigue subsidence testing results showed that type 2 and type 3 cages can withstood approximately 21% higher number of cycles before subsidence as compare to the type 1 and type 4 cages. During fatigue testing, all the cages design survived 5 million cycles at the 3000 N loading. For 6000 N and 8000 N, loading rate type 2 and type 3 cages showed lower fatigue life when compared to other cages design. Since fatigue life of type 2 and type 3 cage designs were reported lower than other cages design, it is concluded that the performance of the additively manufactured porous cages can be significantly varied based upon the cage design features.
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19
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Loenen ACY, Peters MJM, Bevers RTJ, Schaffrath C, van Haver E, Cuijpers VMJI, Rademakers T, van Rietbergen B, Willems PC, Arts JJ. Early bone ingrowth and segmental stability of a trussed titanium cage versus a polyether ether ketone cage in an ovine lumbar interbody fusion model. Spine J 2022; 22:174-182. [PMID: 34274502 DOI: 10.1016/j.spinee.2021.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar interbody fusion is an effective treatment for unstable spinal segments. However, the time needed to establish a solid bony interbody fusion between the two vertebrae may be longer than twelve months after surgery. During this time window, the instrumented spinal segment is assumed to be at increased risk for instability related complications such as cage migration or subsidence. It is hypothesized that the design of new interbody cages that enable direct osseointegration of the cage at the vertebral endplates, without requiring full bony fusion between the two vertebral endplates, might shorten the time window that the instrumented spinal segment is susceptible to failure. PURPOSE To quantify the bone ingrowth and resulting segmental stability during consolidation of lumbar interbody fusion using two different cage types. STUDY DESIGN Preclinical ovine model. METHODS Seven skeletally mature sheep underwent bi-segmental lumbar interbody fusion surgery with one conventional polyether ether ketone (PEEK) cage, and one newly developed trussed titanium (TT) cage. After a postoperative time period of 13 weeks, non-destructive range of motion testing, and histologic analysis was performed. Additionally, sample specific finite element (FE) analysis was performed to predict the stability of the interbody fusion region alone. RESULTS Physiological movement of complete spinal motion segments did not reveal significant differences between the segments operated with PEEK and TT cages. The onset of creeping substitution within the cage seemed to be sooner for PEEK cages, which led to significantly higher bone volume over total volume (BV/TV) compared with the TT cages. TT cages showed significantly more direct bone to implant contact (BIC). Although the mean stability of the interbody fusion region alone was not statistically different between the PEEK and TT cages, the variation within the cage types illustrated an all-or-nothing response for the PEEK cages while a more gradual increase in stability was found for the TT cages. CONCLUSIONS Spinal segments operated with conventional PEEK cages were not different from those operated with newly developed TT cages in terms of segmental stability but did show a different mechanism of bone ingrowth and attachment. Based on the differences in development of bony fusion, we hypothesize that TT cages might facilitate increased early segmental stability by direct osseointegration of the cage at the vertebral endplates without requiring complete bony bridging through the cage. CLINICAL SIGNIFICANCE Interbody cage type affects the consolidation process of spinal interbody fusion. Whether different consolidation processes of spinal interbody fusion result in clinically significant differences requires further investigation.
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Affiliation(s)
- Arjan C Y Loenen
- Department of Orthopedic Surgery, Laboratory for Experimental Orthopedics, CAPHRI, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Biomedical Engineering, Orthopedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Marloes J M Peters
- Department of Orthopedic Surgery, Laboratory for Experimental Orthopedics, CAPHRI, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Raymond T J Bevers
- Department of Orthopedic Surgery, Laboratory for Experimental Orthopedics, CAPHRI, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Vincent M J I Cuijpers
- Department of Biomaterials, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Timo Rademakers
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht, the Netherlands
| | - Bert van Rietbergen
- Department of Orthopedic Surgery, Laboratory for Experimental Orthopedics, CAPHRI, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Biomedical Engineering, Orthopedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Paul C Willems
- Department of Orthopedic Surgery, Laboratory for Experimental Orthopedics, CAPHRI, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jacobus J Arts
- Department of Orthopedic Surgery, Laboratory for Experimental Orthopedics, CAPHRI, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Biomedical Engineering, Orthopedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands.
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20
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Lee JS, Son DW, Lee SH, Ki SS, Lee SW, Song GS, Woo JB, Kim YH. The Effect of Hounsfield Unit Value with Conventional Computed Tomography and Intraoperative Distraction on Postoperative Intervertebral Height Reduction in Patients Following Stand-Alone Anterior Cervical Discectomy and Fusion. J Korean Neurosurg Soc 2021; 65:96-106. [PMID: 34963207 PMCID: PMC8752891 DOI: 10.3340/jkns.2021.0131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/04/2021] [Indexed: 11/27/2022] Open
Abstract
Objective The most common complication of anterior cervical discectomy and fusion (ACDF) is cage subsidence and maintenance of disc height affects postoperative clinical outcomes. We considered cage subsidence as an inappropriate indicator for evaluating preservation of disc height. Thus, this study aimed to consider patients with complications such as reduced total disc height compared to that before surgery and evaluate the relevance of several factors before ACDF.
Methods We retrospectively reviewed the medical records of 40 patients who underwent stand-alone single-level ACDF using a polyetheretherketone (PEEK) cage at our institution between January 2012 and December 2018. Our study population comprised 19 male and 21 female patients aged 24–70 years. The minimum follow-up period was 1 year. Twenty-seven patients had preoperative bone mineral density (BMD) data on dual-energy X-ray absorptiometry. Clinical parameters included sex, age, body mass index, smoking history, and prior medical history. Radiologic parameters included the C2-7 cobb angle, segmental angle, sagittal vertical axis, disc height, and total intervertebral height (TIH) at the preoperative and postoperative periods. Cage decrement was defined as the reduction in TIH at the 6-month follow-up compared to preoperative TIH. To evaluate the bone quality, Hounsfield unit (HU) value was calculated in the axial and sagittal images of conventional computed tomography.
Results Lumbar BMD values and cervical HU values were significantly correlated (r=0.733, p<0.001). We divided the patients into two groups based on cage decrement, and 47.5% of the total patients were regarded as cage decrement. There were statistically significant differences in the parameters of measuring the HU value of the vertebra and intraoperative distraction between the two groups. Using these identified factors, we performed a receiver operating characteristic (ROC) curve analysis. Based on the ROC curve, the cut-off point was 530 at the HU value of the upper cortical and cancellous vertebrae (p=0.014; area under the curve [AUC], 0.727; sensitivity, 94.7%; specificity, 42.9%) and 22.41 at intraoperative distraction (p=0.017; AUC, 0.722; sensitivity, 85.7%; specificity, 57.9%). Using this value, we converted these parameters into a bifurcated variable and assessed the multinomial regression analysis to evaluate the risk factors for cage decrement in ACDF. Intraoperative distraction and HU value of the upper vertebral body were independent factors of postoperative subsidence.
Conclusion Insufficient intraoperative distraction and low HU value showed a strong relationship with postoperative intervertebral height reduction following single stand-alone PEEK cage ACDF.
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Affiliation(s)
- Jun Seok Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Dong Wuk Son
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Su Hun Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Sung Soon Ki
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Joon Bum Woo
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
| | - Young Ha Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, School of Medicine, Pusan National University, Yangsan, Korea
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21
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Corso KA, Kothari P, Corrado K, Michielli A, Ruppenkamp J, Bowden D. Early revision events among patients with a three dimensional (3D) printed cellular titanium or PEEK (polyetheretherketone) spinal cage for single-level lumbar spinal fusion. Expert Rev Med Devices 2021; 19:195-201. [PMID: 34937486 DOI: 10.1080/17434440.2022.2020637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Three-dimensional (3D) printed spinal cages are a new design of intervertebral body fusion devices. Clinical data on these devices are limited. The objective of this study was to describe six-month events for a new and older cage design. METHODS A retrospective, descriptive cohort study of patients that received a 3D-printed-titanium or PEEK (polyetheretherketone) cage with single-level lumbar fusion was performed using a United States hospital-based database. Outcomes evaluated were device-related revision and non-device related reoperation events 6 months after lumbar fusion. The 3D-printed-titanium and PEEK groups were propensity-score matched. Both unmatched and matched groups were descriptively analyzed. There were 93 and 2,082 patients with a 3D-printed-titanium and PEEK cage that met study criteria. The sample size was 93 patients per group after matching. RESULTS There were no occurrences of revisions in the 3D-printed-titanium and eleven occurrences in the PEEK group before matching; PEEK had no occurrences of revision after matching. Ten total reoperation events were identified. DISCUSSION Our findings suggest occurrence of 6-month revision or reoperation is similar or lower for both cages than reported in published literature. The low occurrence of early events for 3D-printed-titianium cages is promising. Further, real-world studies on 3D-printed cages are warranted.
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Affiliation(s)
- Katherine A Corso
- Johnson & Johnson, Medical Devices, Medical Device Epidemiology and Real World Data Sciences, New Brunswick, NJ, USA
| | | | | | | | - Jill Ruppenkamp
- Johnson & Johnson, Medical Devices, Medical Device Epidemiology and Real World Data Sciences, New Brunswick, NJ, USA
| | - Dawn Bowden
- Johnson & Johnson, Medical Devices, Health Economics and Market Access, Raynham, MA, USA
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22
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Toop N, Gifford C, Motiei-Langroudi R, Farzadi A, Boulter D, Forghani R, Farhadi HF. Can activated titanium interbody cages accelerate or enhance spinal fusion? a review of the literature and a design for clinical trials. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2021; 33:1. [PMID: 34921610 PMCID: PMC8684547 DOI: 10.1007/s10856-021-06628-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/16/2021] [Indexed: 06/14/2023]
Abstract
While spinal interbody cage options have proliferated in the past decade, relatively little work has been done to explore the comparative potential of biomaterial technologies in promoting stable fusion. Innovations such as micro-etching and nano-architectural designs have shown purported benefits in in vitro studies, but lack clinical data describing their optimal implementation. Here, we critically assess the pre-clinical data supportive of various commercially available interbody cage biomaterial, topographical, and structural designs. We describe in detail the osteointegrative and osteoconductive benefits conferred by these modifications with a focus on polyetheretherketone (PEEK) and titanium (Ti) interbody implants. Further, we describe the rationale and design for two randomized controlled trials, which aim to address the paucity of clinical data available by comparing interbody fusion outcomes between either PEEK or activated Ti lumbar interbody cages. Utilizing dual-energy computed tomography (DECT), these studies will evaluate the relative implant-bone integration and fusion rates achieved by either micro-etched Ti or standard PEEK interbody devices. Taken together, greater understanding of the relative osseointegration profile at the implant-bone interface of cages with distinct topographies will be crucial in guiding the rational design of further studies and innovations.
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Affiliation(s)
- Nathaniel Toop
- Departments of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Connor Gifford
- Departments of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Arghavan Farzadi
- Departments of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel Boulter
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Reza Forghani
- Department of Radiology, McGill University, Montreal, QC, Canada
| | - H Francis Farhadi
- Department of Neurosurgery, College of Medicine, University of Kentucky, Lexington, KY, USA.
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23
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Liu B, Wang H, Zhang N, Zhang M, Cheng CK. Femoral Stems With Porous Lattice Structures: A Review. Front Bioeng Biotechnol 2021; 9:772539. [PMID: 34869289 PMCID: PMC8637819 DOI: 10.3389/fbioe.2021.772539] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/29/2021] [Indexed: 01/16/2023] Open
Abstract
Cementless femoral stems are prone to stress shielding of the femoral bone, which is caused by a mismatch in stiffness between the femoral stem and femur. This can cause bone resorption and resultant loosening of the implant. It is possible to reduce the stress shielding by using a femoral stem with porous structures and lower stiffness. A porous structure also provides a secondary function of allowing bone ingrowth, thus improving the long-term stability of the prosthesis. Furthermore, due to the advent of additive manufacturing (AM) technology, it is possible to fabricate femoral stems with internal porous lattices. Several review articles have discussed porous structures, mainly focusing on the geometric design, mechanical properties and influence on bone ingrowth. However, the safety and effectiveness of porous femoral stems depend not only on the characteristic of porous structure but also on the macro design of the femoral stem; for example, the distribution of the porous structure, the stem geometric shape, the material, and the manufacturing process. This review focuses on porous femoral stems, including the porous structure, macro geometric design of the stem, performance evaluation, research methods used for designing and evaluating the femoral stems, materials and manufacturing techniques. In addition, this review will evaluate whether porous femoral stems can reduce stress shielding and increase bone ingrowth, in addition to analyzing their shortcomings and related risks and providing ideas for potential design improvements.
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Affiliation(s)
- Bolun Liu
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Huizhi Wang
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ningze Zhang
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Min Zhang
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Cheng-Kung Cheng
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China.,School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
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24
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Finite Element Analysis on Initial Crack Site of Porous Structure Fabricated by Electron Beam Additive Manufacturing. MATERIALS 2021; 14:ma14237467. [PMID: 34885622 PMCID: PMC8659206 DOI: 10.3390/ma14237467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 12/04/2022]
Abstract
Ti6Al4V specimens with porous structures can be fabricated by additive manufacturing to obtain the desired Young’s modulus. Their mechanical strength and deformation behavior can be evaluated using finite element analysis (FEA), with various models and simulation methodologies described in the existing literature. Most studies focused on the evaluation accuracy of the mechanical strength and deformation behavior using complex models. This study presents a simple elastic model for brittle specimens followed by an electron beam additive manufacturing (EBAM) process to predict the initial crack site and threshold of applied stress related to the failure of cubic unit lattice structures. Six cubic lattice specimens with different porosities were fabricated by EBAM, and compression tests were performed and compared to the FEA results. In this study, two different types of deformation behavior were observed in the specimens with low and high porosities. The adopted elastic model and the threshold of applied stress calculated via FEA showed good capabilities for predicting the initial crack sites of these specimens. The methodology presented in this study should provide a simple yet accurate method to predict the fracture initiation of porous structure parts.
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25
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McGregor M, Patel S, McLachlin S, Vlasea M. Data related to architectural bone parameters and the relationship to Ti lattice design for powder bed fusion additive manufacturing. Data Brief 2021; 39:107633. [PMID: 34917699 PMCID: PMC8646123 DOI: 10.1016/j.dib.2021.107633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022] Open
Abstract
The data included in this article provides additional supporting information on our publication (McGregor et al. [1]) on the review of the natural lattice architecture in human bone and its implication towards titanium (Ti) lattice design for laser powder bed fusion and electron beam powder bed fusion. For this work, X-ray computed tomography was deployed to understand and visualize a Ti-6Al-4V lattice structure manufactured by laser powder bed fusion. This manuscript includes details about the manufacturing of the lattice structure using laser powder bed fusion and computed tomography methods used for analyzing the lattice structure. Additionally, a comprehensive literature review was conducted to understand how lattice parameters are controlled in additively manufactured Ti and Ti-alloy parts aimed at replacing or augmenting human bone. From this literature review, lattice design information was collected and is summarized in tabular form in this manuscript.
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Affiliation(s)
- Martine McGregor
- University of Waterloo, Department of Mechanical and Mechatronics Engineering, Waterloo, ON N2L 3G1, Canada
| | - Sagar Patel
- University of Waterloo, Department of Mechanical and Mechatronics Engineering, Waterloo, ON N2L 3G1, Canada
| | - Stewart McLachlin
- University of Waterloo, Department of Mechanical and Mechatronics Engineering, Waterloo, ON N2L 3G1, Canada
| | - Mihaela Vlasea
- University of Waterloo, Department of Mechanical and Mechatronics Engineering, Waterloo, ON N2L 3G1, Canada
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26
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Meena VK, Kalra P, Sinha RK. Finite element study on the influence of pore size and structure on stress shielding effect of additive manufactured spinal cage. Comput Methods Biomech Biomed Engin 2021; 25:566-577. [PMID: 34551629 DOI: 10.1080/10255842.2021.1970142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The stress shielding effect occurs when the orthopedic implant reduces the load delivered to the bone, causing inefficient stress transfer to the host bone. The usage of porous additive manufactured (AM) cages reduces the stress shielding effect and promotes bone ingrowth also. The purpose of this work is to study the stress and deformation on porous hybrid spinal cages under different loading conditions using Finite Element Analysis (FEA). The spinal cages consisting of three porous structures with pore sizes ranging from 0.4 to 0.6 mm were investigated for stress shielding and fatigue strength. The results showed a significant reduction in stress shielding for the studied designs and conclude that the pore size has a greater significant effect on stress shielding than the porous structure in spinal cages.
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Affiliation(s)
- Vijay Kumar Meena
- Biomedical Instrumentation, Central Scientific Instruments Organisation, Chandigarh, India.,Department of Production Engineering, Punjab Engineering College, Chandigarh, India
| | - Parveen Kalra
- Department of Production Engineering, Punjab Engineering College, Chandigarh, India
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27
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Abudouaini H, Wu T, Liu H, Wang B, Chen H, Huang C, Hong Y, Meng Y. Partial uncinatectomy combined with anterior cervical discectomy and fusion for the treatment of one-level cervical radiculopathy: analysis of clinical efficacy and sagittal alignment. BMC Musculoskelet Disord 2021; 22:777. [PMID: 34511102 PMCID: PMC8436428 DOI: 10.1186/s12891-021-04680-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Biomechanical studies have demonstrated that uncovertebral joint contributes to segment mobility and stability to a certain extent. Simultaneously, osteophytes arising from the uncinate process are a common cause of cervical spondylotic radiculopathy (CSR). For such patients, partial uncinatectomy (UT) may be required. However, the clinical efficacy and sagittal alignment of partial UT during anterior cervical discectomy and fusion (ACDF) have not been fully elucidated. METHODS A total of 87 patients who had undergone single level ACDF using a zero-profile device from July 2014 to December 2018 were included. Based on whether the foraminal part of the uncovertebral joint was resected or preserved, the patients were divided into the ACDF with UT group (n = 37) and the ACDF without UT group (n = 50). Perioperative data, radiographic parameters, clinical outcomes, and complications were compared between the two groups. RESULTS The mean follow-up was 16.86 ± 5.63 and 18.36 ± 7.51 months in the ACDF with UT group and ACDF without UT group, respectively (p > 0.05). The average preoperative VAS arm score was 5.89 ± 1.00 in the ACDF with UT group and 5.18 ± 1.21 in the ACDF without UT group (p = 0.038). However, the average VAS arm score was 4.22 ± 0.64, 4.06 ± 1.13 and 1.68 ± 0.71, 1.60 ± 0.70 at 1 week post operation and at final follow up, respectively, (p > 0.05). We also found that the C2-7 SVA and St-SVA at the last follow-up and their change (last follow-up value - preoperative value) in the ACDF with UT group were significantly higher than ACDF without UT group (p < 0.05). No marked differences in the other cervical sagittal parameters, fusion rate or complications, including dysphagia, ASD, and subsidence, were observed. CONCLUSIONS Our result indicates that ACDF using a zero-p implant with or without partial UT both provide satisfactory clinical efficacy and acceptable safety. However, additional partial UT may has a negative effect on cervical sagittal alignment.
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Affiliation(s)
- Haimiti Abudouaini
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Rd, Chengdu, China
| | - Tingkui Wu
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Rd, Chengdu, China
| | - Hao Liu
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Rd, Chengdu, China.
| | - Beiyu Wang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Rd, Chengdu, China
| | - Hua Chen
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Rd, Chengdu, China
| | - Chengyi Huang
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Rd, Chengdu, China
| | - Ying Hong
- Department of Anesthesia and Operation Center, West China school of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Meng
- Department of Orthopedic Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang Rd, Chengdu, China
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Meena VK, Kumar P, Kalra P, Sinha RK. Additive manufacturing for metallic spinal implants: A systematic review. ANNALS OF 3D PRINTED MEDICINE 2021. [DOI: 10.1016/j.stlm.2021.100021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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29
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Yamaguchi S, Le PTM, Shintani SA, Takadama H, Ito M, Ferraris S, Spriano S. Iodine-Loaded Calcium Titanate for Bone Repair with Sustainable Antibacterial Activity Prepared by Solution and Heat Treatment. NANOMATERIALS 2021; 11:nano11092199. [PMID: 34578515 PMCID: PMC8472594 DOI: 10.3390/nano11092199] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022]
Abstract
In the orthopedic and dental fields, simultaneously conferring titanium (Ti) and its alloy implants with antibacterial and bone-bonding capabilities is an outstanding challenge. In the present study, we developed a novel combined solution and heat treatment that controllably incorporates 0.7% to 10.5% of iodine into Ti and its alloys by ion exchange with calcium ions in a bioactive calcium titanate. The treated metals formed iodine-containing calcium-deficient calcium titanate with abundant Ti-OH groups on their surfaces. High-resolution XPS analysis revealed that the incorporated iodine ions were mainly positively charged. The surface treatment also induced a shift in the isoelectric point toward a higher pH, which indicated a prevalence of basic surface functionalities. The Ti loaded with 8.6% iodine slowly released 5.6 ppm of iodine over 90 days and exhibited strong antibacterial activity (reduction rate >99%) against methicillin-resistant Staphylococcus aureus (MRSA), S. aureus, Escherichia coli, and S. epidermidis. A long-term stability test of the antibacterial activity on MRSA showed that the treated Ti maintained a >99% reduction until 3 months, and then it gradually decreased after 6 months (to a 97.3% reduction). There was no cytotoxicity in MC3T3-E1 or L929 cells, whereas apatite formed on the treated metal in a simulated body fluid within 3 days. It is expected that the iodine-carrying Ti and its alloys will be particularly useful for orthopedic and dental implants since they reliably bond to bone and prevent infection owing to their apatite formation, cytocompatibility, and sustainable antibacterial activity.
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Affiliation(s)
- Seiji Yamaguchi
- Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, 1200 Matsumoto, Kasugai 487-8501, Aichi, Japan; (P.T.M.L.); (S.A.S.); (H.T.); (M.I.)
- Correspondence: ; Tel.: +81-568-51-6420; Fax: +81-568-51-5370
| | - Phuc Thi Minh Le
- Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, 1200 Matsumoto, Kasugai 487-8501, Aichi, Japan; (P.T.M.L.); (S.A.S.); (H.T.); (M.I.)
| | - Seine A. Shintani
- Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, 1200 Matsumoto, Kasugai 487-8501, Aichi, Japan; (P.T.M.L.); (S.A.S.); (H.T.); (M.I.)
| | - Hiroaki Takadama
- Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, 1200 Matsumoto, Kasugai 487-8501, Aichi, Japan; (P.T.M.L.); (S.A.S.); (H.T.); (M.I.)
| | - Morihiro Ito
- Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, 1200 Matsumoto, Kasugai 487-8501, Aichi, Japan; (P.T.M.L.); (S.A.S.); (H.T.); (M.I.)
| | - Sara Ferraris
- Politecnico di Torino, Corso Duca degli Abruzzi 24, Corso Duca degli Abruzzi 24, 10129 Torino, Italy; (S.F.); (S.S.)
| | - Silvia Spriano
- Politecnico di Torino, Corso Duca degli Abruzzi 24, Corso Duca degli Abruzzi 24, 10129 Torino, Italy; (S.F.); (S.S.)
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Evaluation of cage subsidence in standalone lateral lumbar interbody fusion: novel 3D-printed titanium versus polyetheretherketone (PEEK) cage. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2377-2384. [PMID: 34215921 DOI: 10.1007/s00586-021-06912-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/03/2021] [Accepted: 06/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aims to compare the early subsidence rate (6-12 months) of standalone novel 3D-printed titanium (Ti) versus polyetheretherketone (PEEK) interbody cages after lateral lumbar interbody fusion (LLIF). METHOD A retrospective study of 113 patients (186 levels) who underwent LLIF surgery with Ti or PEEK cages was conducted. Early subsidence was measured in each treated level using the Marchi et al. classification in radiographs or CT scans acquired at 6-12 months follow-up. Multivariate logistic regression analyses with generalized mixed models, setting subsidence as the outcome variable and including cage type (Ti vs PEEK) as well as significant and trending variables (p < 0.10) in univariate analyses, were conducted. RESULTS In total, 51 female and 62 male patients were analyzed. The median [IQR] age at surgery was 60.0 [51.0-70.0] years. Of the 186 levels, 119 levels were treated using PEEK and 67 levels with Ti cages. The overall subsidence rate for Grades I-III was significantly less in the Ti versus the PEEK group (p = 0.003). For high-grade subsidence (Grade II or III), Ti cages also demonstrated a subsidence rate (3.0%) that was significantly less compared to PEEK cages (18.5%) (p = 0.002). Multivariate analysis showed that patients treated with Ti cages were less likely to develop severe subsidence compared to those treated with PEEK (OR = 0.05, 95% CI = 0.01, 0.30) (p = 0.001). CONCLUSION Our study demonstrated that 3D-printed novel Ti cages had a significantly lower early subsidence rate compared to PEEK cages in standalone LLIF patients.
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Ragni E, Perucca Orfei C, Bidossi A, De Vecchi E, Francaviglia N, Romano A, Maestretti G, Tartara F, de Girolamo L. Superior Osteo-Inductive and Osteo-Conductive Properties of Trabecular Titanium vs. PEEK Scaffolds on Human Mesenchymal Stem Cells: A Proof of Concept for the Use of Fusion Cages. Int J Mol Sci 2021; 22:ijms22052379. [PMID: 33673509 PMCID: PMC7956826 DOI: 10.3390/ijms22052379] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 12/20/2022] Open
Abstract
Fusion cages composed of titanium and its alloys are emerging as valuable alternative to standard polyetheretherketone (PEEK) ones routinely used in cervical and lumbar spine surgery. Aim of this study was to evaluate osteo-inductive and osteo-conductive ability of an innovative trabecular titanium (T-Ti) scaffold on human mesenchymal stem cells (hMSCs), in both absence and presence of biochemical osteogenic stimuli. Same abilities were assessed on PEEK and standard 2D plastic surface, the latter meant as gold-standard for in vitro differentiation studies. hMSCs adhered and colonized both T-Ti and PEEK scaffolds. In absence of osteogenic factors, T-Ti triggered osteogenic induction of MSCs, as demonstrated by alkaline phosphatase activity and calcium deposition increments, while PEEK and standard 2D did not. Addition of osteogenic stimuli reinforced osteogenic differentiation of hMSCs cultured on T-Ti in a significantly higher manner with respect to standard 2D plastic culture surfaces, whereas PEEK almost completely abolished the process. T-Ti driven differentiation towards osteoblasts was confirmed by gene and marker expression analyses, even in absence of osteogenic stimuli. These results clearly indicate superior in vitro osteo-inductive and osteo-conductive capacity of T-Ti compared to PEEK, and make ground for further studies supporting the use of T-Ti cages to improve bone fusion.
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Affiliation(s)
- Enrico Ragni
- Laboratorio di Biotecnologie Applicate all’Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Via R. Galeazzi 4, I-20161 Milano, Italy; (E.R.); (C.P.O.)
| | - Carlotta Perucca Orfei
- Laboratorio di Biotecnologie Applicate all’Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Via R. Galeazzi 4, I-20161 Milano, Italy; (E.R.); (C.P.O.)
| | - Alessandro Bidossi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Via R. Galeazzi 4, I-20161 Milano, Italy; (A.B.); (E.D.V.)
| | - Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Istituto Ortopedico Galeazzi, Via R. Galeazzi 4, I-20161 Milano, Italy; (A.B.); (E.D.V.)
| | - Natale Francaviglia
- Neurochirurgia Funzionale, Istituto Ortopedico Villa Salus, Contrada Spalla, I-96010 Melilli, Italy;
| | - Alberto Romano
- Unità Operativa di Neurochirurgia, Humanitas Istituto Clinico Catanese, Contrada Cubba Marletta 11, I-95045 Misterbianco, Italy;
| | | | | | - Laura de Girolamo
- Laboratorio di Biotecnologie Applicate all’Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Via R. Galeazzi 4, I-20161 Milano, Italy; (E.R.); (C.P.O.)
- Correspondence: ; Tel.: +39-02-66214059
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Spece H, Basgul C, Andrews CE, MacDonald DW, Taheri ML, Kurtz SM. A systematic review of preclinical in vivo testing of 3D printed porous Ti6Al4V for orthopedic applications, part I: Animal models and bone ingrowth outcome measures. J Biomed Mater Res B Appl Biomater 2021; 109:1436-1454. [PMID: 33484102 DOI: 10.1002/jbm.b.34803] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 11/20/2020] [Accepted: 01/09/2021] [Indexed: 01/20/2023]
Abstract
For Ti6Al4V orthopedic and spinal implants, osseointegration is often achieved using complex porous geometries created via additive manufacturing (AM). While AM porous titanium (pTi) has shown clinical success, concerns regarding metallic implants have spurred interest in alternative AM biomaterials for osseointegration. Insights regarding the evaluation of these new materials may be supported by better understanding the role of preclinical testing for AM pTi. We therefore asked: (a) What animal models have been most commonly used to evaluate AM porous Ti6Al4V for orthopedic bone ingrowth; (b) What were the primary reported quantitative outcome measures for these models; and (c) What were the bone ingrowth outcomes associated with the most frequently used models? We performed a systematic literature search and identified 58 articles meeting our inclusion criteria. We found that AM pTi was evaluated most often using rabbit and sheep femoral condyle defect (FCD) models. Additional ingrowth models including transcortical and segmental defects, spinal fusions, and calvarial defects were also used with various animals based on the study goals. Quantitative outcome measures determined via histomorphometry including ''bone ingrowth'' (range: 3.92-53.4% for rabbit/sheep FCD) and bone-implant contact (range: 9.9-59.7% for rabbit/sheep FCD) were the most common. Studies also used 3D imaging to report outcomes such as bone volume fraction (BV/TV, range: 4.4-61.1% for rabbit/sheep FCD), and push-out testing for outcomes such as maximum removal force (range: 46.6-3092 N for rabbit/sheep FCD). Though there were many commonalities among the study methods, we also found significant heterogeneity in the outcome terms and definitions. The considerable diversity in testing and reporting may no longer be necessary considering the reported success of AM pTi across all model types and the ample literature supporting the rabbit and sheep as suitable small and large animal models, respectively. Ultimately, more standardized animal models and reporting of bone ingrowth for porous AM materials will be useful for future studies.
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Affiliation(s)
- Hannah Spece
- Implant Research Core, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Cemile Basgul
- Implant Research Core, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Daniel W MacDonald
- Implant Research Core, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Steven M Kurtz
- Implant Research Core, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA.,Exponent, Inc., Philadelphia, Pennsylvania, USA
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van den Brink W, Lamerigts N. Complete Osseointegration of a Retrieved 3-D Printed Porous Titanium Cervical Cage. Front Surg 2020; 7:526020. [PMID: 33330602 PMCID: PMC7732662 DOI: 10.3389/fsurg.2020.526020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 09/09/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction: Porous 3D-printed titanium has only recently been introduced for spinal applications. Evidence around its use is currently limited to animal studies and only few human case series. This study describes the histological findings of a retrieved EIT cervical cage, explanted 2 years after insertion. Materials and Methods: The patient underwent a double level C4/C5 & C5/C6 anterior cervical decompression using EIT cervical cages without an anterior plate. Two years later the C6/7 level degenerated and began to cause myelopathic symptoms. In order to address the kyphotic imbalance of the cervical spine and fix the C6/7 level, the surgeon decided to remove the C5/6 cervical cage and bridge the fusion from C4 to C7 inclusive. The retrieved cage was histologically evaluated for bone ingrowth and signs of inflammation. Results: MRI demonstrated spinal canal stenosis at C6/C7. Plain radiographs confirmed well-integrated cervical cages at 2 years postoperative. The peroperative surgical need to use a chisel to remove the implant at C5/C6 reconfirmed the solid fusion of the segment. Macroscopically white tissue, indicative of bone, was present at both superior and inferior surfaces of the explanted specimen. Histological evaluation revealed complete osseointegration of the 5 mm high EIT Cellular Titanium® cervical cage, displaying mature lamellar bone in combination with bone marrow throughout the cage. Furthermore, a pattern of trabecular bone apposition (without fibrous tissue interface) and physiological remodeling activity was observed directly on the cellular titanium scaffold. Conclusion: This histological retrieval study of a radiologically fused cervical EIT cage clearly demonstrates complete osseointegration within a 2-year time frame. The scaffold exhibits a bone in growth pattern and maturation of bone tissue similar of what has been demonstrated in animal studies evaluating similar porous titanium implants. The complete osseointegration throughout the cage indicates physiological loading conditions even in the central part of the cage. This pattern suggests the absence, or at least the minimization, of stress-shielding in this type of porous titanium cage.
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Fan B, Guo Z, Li X, Li S, Gao P, Xiao X, Wu J, Shen C, Jiao Y, Hou W. Electroactive barium titanate coated titanium scaffold improves osteogenesis and osseointegration with low-intensity pulsed ultrasound for large segmental bone defects. Bioact Mater 2020; 5:1087-1101. [PMID: 32695938 PMCID: PMC7363989 DOI: 10.1016/j.bioactmat.2020.07.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/03/2020] [Accepted: 07/03/2020] [Indexed: 12/17/2022] Open
Abstract
For large segmental bone defects, porous titanium scaffolds have some advantages, however, they lack electrical activity which hinders their further use. In this study, a barium titanate (BaTiO3) piezoelectric ceramic was used to modify the surface of a porous Ti6Al4V scaffold (pTi), which was characterized by scanning electron microscopy, energy dispersive spectroscopy, X-ray photoelectron spectroscopy, and roughness and water contact angle analyses. Low intensity pulsed ultrasound (LIPUS) was applied in vitro and in vivo study. The activity of bone marrow mesenchymal stem cells, including adhesion, proliferation, and gene expression, was significantly superior in the BaTiO3/pTi, pTi + LIPUS, and BaTiO3/pTi + LIPUS groups than in the pTi group. The activity was also higher in the BaTiO3/pTi + LIPUS group than in the BaTiO3/pTi and pTi + LIPUS groups. Additionally, micro-computed tomography, the mineral apposition rate, histomorphology, and the peak pull-out load showed that these scaffold conditions significantly enhanced osteogenesis and osseointegration 6 and 12 weeks after implantation in large segmental bone defects in the radius of rabbits compared with those resulting from the pTi condition. Consequently, the improved osteogenesis and osseointegration make the BaTiO3/pTi + LIPUS a promising method to promote bone regeneration in large segmental bone defects for clinical application.
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Affiliation(s)
- Bo Fan
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
- Orthopedic Centre-Spine Surgery, The 940 Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, China
| | - Zheng Guo
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Xiaokang Li
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Songkai Li
- Orthopedic Centre-Spine Surgery, The 940 Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, 730050, China
| | - Peng Gao
- Department of Joint Surgery and Sports Medicine, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, 410016, PR China
| | - Xin Xiao
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Jie Wu
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Chao Shen
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Yilai Jiao
- Shenyang National Laboratory for Materials Science, Institute of Metal Research, Chinese Academy of Sciences, Shenyang, 110016, China
| | - Wentao Hou
- Shenyang National Laboratory for Materials Science, Institute of Metal Research, Chinese Academy of Sciences, Shenyang, 110016, China
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Liu W, Li X, Jiao Y, Wu C, Guo S, Xiao X, Wei X, Wu J, Gao P, Wang N, Lu Y, Tang Z, Zhao Q, Zhang J, Tang Y, Shi L, Guo Z. Biological Effects of a Three-Dimensionally Printed Ti6Al4V Scaffold Coated with Piezoelectric BaTiO 3 Nanoparticles on Bone Formation. ACS APPLIED MATERIALS & INTERFACES 2020; 12:51885-51903. [PMID: 33166458 DOI: 10.1021/acsami.0c10957] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Bone defect repair at load-bearing sites is a challenging clinical problem for orthopedists. Defect reconstruction with implants is the most common treatment; however, it requires the implant to have good mechanical properties and the capacity to promote bone formation. In recent years, the piezoelectric effect, in which electrical activity can be generated due to mechanical deformation, of native bone, which promotes bone formation, has been increasingly valued. Therefore, implants with piezoelectric effects have also attracted great attention from orthopedists. In this study, we developed a bioactive composite scaffold consisting of BaTiO3, a piezoelectric ceramic material, coated on porous Ti6Al4V. This composite scaffold showed not only appropriate mechanical properties, sufficient bone and blood vessel ingrowth space, and a suitable material surface topography but also a reconstructed electromagnetic microenvironment. The osteoconductive and osteoinductive properties of the scaffold were reflected by the proliferation, migration, and osteogenic differentiation of mesenchymal stem cells. The ability of the scaffold to support vascularization was reflected by the proliferation and migration of human umbilical vein endothelial cells and their secretion of VEGF and PDGF-BB. A well-established sheep spinal fusion model was used to evaluate bony fusion in vivo. Sheep underwent implantation with different scaffolds, and X-ray, micro-computed tomography, van Gieson staining, and elemental energy-dispersive spectroscopy were used to analyze bone formation. Isolated cervical angiography and visualization analysis were used to assess angiogenesis at 4 and 8 months after transplantation. The results of cellular and animal studies showed that the piezoelectric effect could significantly reinforce osteogenesis and angiogenesis. Furthermore, we also discuss the molecular mechanism by which the piezoelectric effect promotes osteogenic differentiation and vascularization. In summary, Ti6Al4V scaffold coated with BaTiO3 is a promising composite biomaterial for repairing bone defects, especially at load-bearing sites, that may have great clinical translation potential.
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Affiliation(s)
- Wenwen Liu
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Xiaokang Li
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Yilai Jiao
- Shenyang National Laboratory for Materials Science, Institute of Metal Research Chinese Academy of Sciences, Shenyang 110016, China
| | - Cong Wu
- Department of Materials Science and Engineering, Xi'an University of Technology, Xi'an 710048, China
| | - Shuo Guo
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Xin Xiao
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Xinghui Wei
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Jie Wu
- Department of Orthopaedics, the 8th Medical Center of Chinese PLA General Hospital, Beijing, 100091, China
| | - Peng Gao
- Department of Joint Surgery and Sports Medicine, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, 410016, China
| | - Ning Wang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Yajie Lu
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Zhen Tang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Quanming Zhao
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Jinsong Zhang
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Yufei Tang
- Department of Materials Science and Engineering, Xi'an University of Technology, Xi'an 710048, China
| | - Lei Shi
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Zheng Guo
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, China
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The Use of Simulated Body Fluid (SBF) for Assessing Materials Bioactivity in the Context of Tissue Engineering: Review and Challenges. Biomimetics (Basel) 2020; 5:biomimetics5040057. [PMID: 33138246 PMCID: PMC7709622 DOI: 10.3390/biomimetics5040057] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 01/16/2023] Open
Abstract
Some special implantable materials are defined as “bioactive” if they can bond to living bone, forming a tight and chemically-stable interface. This property, which is inherent to some glass compositions, or can be induced by applying appropriate surface treatments on otherwise bio-inert metals, can be evaluated in vitro by immersion studies in simulated body fluid (SBF), mimicking the composition of human plasma. As a result, apatite coating may form on the material surface, and the presence of this bone-like “biomimetic skin” is considered predictive of bone-bonding ability in vivo. This review article summarizes the story and evolution of in vitro bioactivity testing methods using SBF, highlighting the influence of testing parameters (e.g., formulation and circulation of the solution) and material-related parameters (e.g., composition, geometry, texture). Suggestions for future methodological refinements are also provided at the end of the paper.
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Park JW, Kang HG, Kang HG. New 3-dimensional implant application as an alternative to allograft in limb salvage surgery: a technical note on 10 cases. Acta Orthop 2020; 91:617-619. [PMID: 32619154 PMCID: PMC8023955 DOI: 10.1080/17453674.2020.1788698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Jong Woong Park
- Orthopaedic Oncology Clinic, National Cancer Center, Korea,E-mail: @ncc.re.kr
| | - Hyun Guy Kang
- Orthopaedic Oncology Clinic, National Cancer Center, Korea
| | - Hyun Guy Kang
- Orthopaedic Oncology Clinic, National Cancer Center, Korea
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An animal model of early-stage femoral head osteonecrosis induced by cryo-insult in small tailed Han sheep. J Orthop Translat 2020; 26:84-91. [PMID: 33437627 PMCID: PMC7773976 DOI: 10.1016/j.jot.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/16/2020] [Accepted: 06/26/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose This study investigated the ability of liquid nitrogen cryo-insults to induce early-stage osteonecrosis of the femoral head (ONFH) in small tail Han sheep. Methods 16 animals were subjected to unilateral cryo-insult using cryogen equipment with a cryo-insult probe, followed 1, 3, and 6 months later by X-ray, CT scanning, micro-CT scanning, and histological evaluation. Results X-ray evaluation of operative femoral heads (Op-FHs) at each time point showed low density areas under the cartilage surface that paralleled sclerosis belts, and CT scans showed sclerosis and cyst areas in Op-FHs. Micro-CT analysis showed that the ratio of bone to total volume and mean trabecular thickness of regions of interest (ROIs) were lower in Op-FHs than in normal femoral heads (No-FHs) at each time point (n = 4, p < 0.05). Histological evaluation at 1 month showed that necrotic changes were dominant as evidenced by moderate empty lacunae, decreases in the number of hematopoietic cells, and moderate increases in the number of fibroblasts. At 3 and 6 months, fractured trabeculae, fibroblasts, and new blood capillaries were increased, indicating an absorption and repair process. Bone volume fraction of ROIs of Op-FHs was lower than in No-FHs at each time point (n = 4, p < 0.05) in histological evaluation. At 6 months, the maximum load of No-FHs was higher than Op-FHs (n = 4, p < 0.05). Conclusion These findings indicate that early-stage ONFH can be induced in small tail Han sheep using cryogenic equipment. The translational potential of this article This animal model may be helpful in developing new treatment modalities for human ONFH.
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Park PJ, Lehman RA. Optimizing the Spinal Interbody Implant: Current Advances in Material Modification and Surface Treatment Technologies. Curr Rev Musculoskelet Med 2020; 13:688-695. [PMID: 32816234 DOI: 10.1007/s12178-020-09673-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Interbody implants allow for fusion of the anterior column of the spine between vertebral body endplates. As rates of spinal fusion surgery have increased over the past several years, significant research has been devoted to optimizing both the mechanical and biologic properties of the interbody implant in order to promote bony fusion. The first interbody implants used decades ago were fashioned from cortical autograft. Currently, titanium alloy and polyetheretherketone (PEEK) are the most widely used and studied materials for this purpose. This review focuses on recent innovations in material modification and surface treatment techniques for both titanium and PEEK implants to maximize fusion rates in spinal surgery. RECENT FINDINGS Titanium has an elastic modulus much higher than native bone and however has better osseointegrative properties than PEEK. PEEK, however, has an elastic modulus closer to that of bone without any of the advantageous biologic properties that titanium has. Increasing porosity and surface roughness of titanium implants have been shown to improve the mechanical properties of titanium implants, while the biologic properties of PEEK have been enhanced using surface coating technology, either with titanium or with hydroxyapatite (HA). Techniques such as increasing porosity, surface roughening, and surface coating are just some of the recent innovations aimed at optimizing both mechanical and biologic properties of interbody implants to promote spinal fusion. The future of interbody implant design will rely on continued improvements of PEEK and titanium implants as well as exploring new implant materials altogether.
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Affiliation(s)
- Paul J Park
- The Spine Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, 5141 Broadway, 3 Field West-022, New York, NY, 10034, USA.
| | - Ronald A Lehman
- The Spine Hospital, NewYork-Presbyterian/Columbia University Irving Medical Center, 5141 Broadway, 3 Field West-022, New York, NY, 10034, USA
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Zheng Y, Han Q, Wang J, Li D, Song Z, Yu J. Promotion of Osseointegration between Implant and Bone Interface by Titanium Alloy Porous Scaffolds Prepared by 3D Printing. ACS Biomater Sci Eng 2020; 6:5181-5190. [PMID: 33455268 DOI: 10.1021/acsbiomaterials.0c00662] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Titanium alloy prostheses have been widely used for the treatment of orthopedic diseases, in which the interconnected porosity and appropriate pore size are crucial for the osseointegration capacity. Three-dimensional (3D) printing technology provides an efficient method to construct prosthesis scaffolds with controllable internal and surface structure, but printing high-porosity (>60%) scaffolds with pore diameters below 300 μm as implants structures has not yet been studied. In this work, four types of titanium alloy scaffolds with interconnected porosity more than 70% were successfully prepared by selective laser melting (SLM). The actual mean pore sizes of cylindrical scaffolds are 542, 366, 202, and 134 μm. Through the in vitro characterization of the scaffolds, in vivo experiments, and mechanical experiments, it is concluded that as the scaffold pore diameter decreases, the titanium alloy scaffold with diameter of 202 μm has the strongest osseointegration ability and is also the most stable one with the surrounding bone. These findings provide a reference for the clinical pore-size design of porous scaffolds with optimal bone growth stability on the surface of the titanium alloy implant.
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Affiliation(s)
- Yuhao Zheng
- Department of Sports Medicine, First Hospital of Jilin University, Changchun 130021, P. R. China.,State Key Laboratory of Inorganic Synthesis and Preparative Chemistry, College of Chemistry, Jilin University, Changchun 130012, P. R. China.,International Center of Future Science, Jilin University, Changchun 130012, P. R. China
| | - Qing Han
- Department of Joint Surgery, Orthopedic Medical Center, Second Hospital of Jilin University, Changchun 130000, P. R. China
| | - Jincheng Wang
- Department of Joint Surgery, Orthopedic Medical Center, Second Hospital of Jilin University, Changchun 130000, P. R. China
| | - Dongdong Li
- Key Laboratory of Automobile Materials of MOE, Department of Materials Science and Engineering, Jilin University, Changchun 130012, P. R. China
| | - Zhiming Song
- Department of Sports Medicine, First Hospital of Jilin University, Changchun 130021, P. R. China
| | - Jihong Yu
- State Key Laboratory of Inorganic Synthesis and Preparative Chemistry, College of Chemistry, Jilin University, Changchun 130012, P. R. China.,International Center of Future Science, Jilin University, Changchun 130012, P. R. China
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Park JW, Kang HG, Kim JH, Kim HS. New 3-dimensional implant application as an alternative to allograft in limb salvage surgery: a technical note on 10 cases. Acta Orthop 2020; 91:489-496. [PMID: 32396448 PMCID: PMC8023892 DOI: 10.1080/17453674.2020.1755543] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Jong Woong Park
- Orthopaedic Oncology Clinic, National Cancer Center, Goyang; ,Division of Convergence Technology, National Cancer Center, Goyang;;
| | - Hyun Guy Kang
- Orthopaedic Oncology Clinic, National Cancer Center, Goyang; ,Division of Convergence Technology, National Cancer Center, Goyang;; ,Correspondence: (HGK)
| | - June Hyuk Kim
- Orthopaedic Oncology Clinic, National Cancer Center, Goyang;
| | - Han-Soo Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
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Noh SH, Park JY, Kuh SU, Chin DK, Kim KS, Cho YE, Kim KH. Association of complete uncinate process removal on 2-year assessment of radiologic outcomes: subsidence and sagittal balance in patients receiving one-level anterior cervical discectomy and fusion. BMC Musculoskelet Disord 2020; 21:439. [PMID: 32631290 PMCID: PMC7339441 DOI: 10.1186/s12891-020-03443-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 06/22/2020] [Indexed: 12/12/2022] Open
Abstract
Background Many patients with cervical radiculopathy experience stenosis of the neural foramens due to cumulative osteophyte or uncovertebral joint hypertrophy. For cervical foraminal stenosis, complete uncinate process resection (UPR) is often conducted concurrently with anterior discectomy and fusion (ACDF). The aim of this study was to assess the clinical and radiological outcomes of ACDF with complete UPR versus ACDF without UPR. Methods In total, 105 patients who performed one-level ACDF with a cage-and-plate construct between 2011 and 2015 were retrospectively reviewed. Among them, 37 patients had ACDF with complete UPR, and 68 patients had ACDF without UPR. Radiologic outcomes of disc height, C2–C7 lordosis, T1 slope, C2–C7 sagittal vertical axis (SVA), center of the sella turcica–C7 SVA (St-SVA), spino-cranial angle (SCA), and fusion rate were evaluated on plain X-ray at pre-operation, immediately post-operation, and at 2-year follow-up. For statistically matched pairs analysis, ACDF with UPR group (24 patients) and ACDF without UPR (24 patients) were compared. Results All of the clinical parameters improved at the 2-year follow up (P < 0.0001). Improvement in visual analogue scale (VAS) scores for arm pain was significantly improved in the ACDF with complete UPR group immediately post-operation. All cervical sagittal parameters, including cervical lordosis, segmental angle, disc height, C2-C7 SVA, St-SVA, T1 slope, and SCA, except for preoperative St-SVA, SCA, and disc height of 2 years follow-up, were similar between the ACDF with complete UPR and ACDF without UPR groups. Differences in disc height, C2-C7 SVA, and SCA at 2-year follow up after preoperative examination, however, were statistically significant (p < 0.05). Subsidence occurred in 9 patients (ACDF with complete UPR: 8 cases [33%] versus ACDF without UPR: 1 cases [4%]; p < 0.05). Conclusions Cervical sagittal alignment after ACDF with complete UPR is not significantly different from that achieved with ACDF without UPR. However, subsidence appears to occur more often after ACDF with complete UPR than after ACDF without UPR, although with little to no clinical impact. More precise and careful selection of patients is needed when deciding on additional complete UPR.
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Affiliation(s)
- Sung Hyun Noh
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, South Korea.,Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeong Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Uk Kuh
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Kyu Chin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Keun Su Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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Arts M, Torensma B, Wolfs J. Porous titanium cervical interbody fusion device in the treatment of degenerative cervical radiculopathy; 1-year results of a prospective controlled trial. Spine J 2020; 20:1065-1072. [PMID: 32205276 DOI: 10.1016/j.spinee.2020.03.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy with an interbody cage (ACDF) to obtain fusion is a common procedure in cervical spine surgery. Presently, polyetheretherketone (PEEK) with (auto) graft is frequently used for interbody fusion although alternative implant technology like 3-D printing titanium has been introduced recently. PURPOSE Reporting the clinical and quantitative radiological outcome of a prospective cohort of 3-D printed porous titanium implants. STUDY DESIGN/SETTING Prospective study of patients with single level ACDF using 3-D printed porous titanium cervical implants. These data were compared with 48 patients from the PEEK with autograft group of the previously performed CAncellous Structured Ceramic Arthrodesis DEvice trial. PATIENT SAMPLE Fourty-nine patients were included. OUTCOME MEASURES Neck disability index (NDI), visual analog scale (VAS), self-reported perceived recovery, and fusion status. METHODS The clinical outcomes and fusion rates were documented at 3, 6, and 12 months. Dynamic X-rays were analyzed to determine range of motion (ROM) of the operated level. Fusion was defined as rotation ≤4° and ≤1.25 mm translation on flexion-extension films. RESULTS The mean NDI improved from 41.2 preoperatively to 19.4 at 12 months postoperatively. Both VAS arm and VAS neck improved significantly after surgery and 77.1% of the patients reported complete or nearly complete recovery at 12 months. The mean ROM of the affected disc level decreased from 8.7° (range 2.6-21.4) before surgery to 1.6° (0.0-4.6°) after 12 months. The fusion rate at 3, 6, and 12 months was 84%, 89%, and 91% respectively, compared with 67%, 72%, and 90%, in the PEEK group. CONCLUSIONS 3-D printed porous titanium cervical implants resulted in significant clinical improvement after surgery. The fusion rate of porous titanium compared with PEEK with autograft at 12 months was similar, although porous titanium resulted in faster consolidation. In addition, one level anterior cervical fusion can be successfully achieved without additional plating.
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Affiliation(s)
- Mark Arts
- Deptartment of Neurosurgery, Haaglanden Medical Center, PO Box 432, 2501 CK, The Hague, The Netherlands.
| | - Bart Torensma
- Deptartment of Neurosurgery, Haaglanden Medical Center, PO Box 432, 2501 CK, The Hague, The Netherlands
| | - Jasper Wolfs
- Deptartment of Neurosurgery, Haaglanden Medical Center, PO Box 432, 2501 CK, The Hague, The Netherlands
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Wang Q, Zhou P, Liu S, Attarilar S, Ma RLW, Zhong Y, Wang L. Multi-Scale Surface Treatments of Titanium Implants for Rapid Osseointegration: A Review. NANOMATERIALS (BASEL, SWITZERLAND) 2020; 10:E1244. [PMID: 32604854 PMCID: PMC7353126 DOI: 10.3390/nano10061244] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/30/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023]
Abstract
The propose of this review was to summarize the advances in multi-scale surface technology of titanium implants to accelerate the osseointegration process. The several multi-scaled methods used for improving wettability, roughness, and bioactivity of implant surfaces are reviewed. In addition, macro-scale methods (e.g., 3D printing (3DP) and laser surface texturing (LST)), micro-scale (e.g., grit-blasting, acid-etching, and Sand-blasted, Large-grit, and Acid-etching (SLA)) and nano-scale methods (e.g., plasma-spraying and anodization) are also discussed, and these surfaces are known to have favorable properties in clinical applications. Functionalized coatings with organic and non-organic loadings suggest good prospects for the future of modern biotechnology. Nevertheless, because of high cost and low clinical validation, these partial coatings have not been commercially available so far. A large number of in vitro and in vivo investigations are necessary in order to obtain in-depth exploration about the efficiency of functional implant surfaces. The prospective titanium implants should possess the optimum chemistry, bionic characteristics, and standardized modern topographies to achieve rapid osseointegration.
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Affiliation(s)
- Qingge Wang
- School of Metallurgical Engineering, Xi’an University of Architecture and Technology, No.13 Yanta Road, Xi’an 710055, China;
| | - Peng Zhou
- School of Aeronautical Materials Engineering, Xi’an Aeronautical Polytechnic Institute, Xi’an 710089, China;
| | - Shifeng Liu
- School of Metallurgical Engineering, Xi’an University of Architecture and Technology, No.13 Yanta Road, Xi’an 710055, China;
| | - Shokouh Attarilar
- State Key Laboratory of Metal Matrix Composites, School of Material Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China;
| | - Robin Lok-Wang Ma
- Department of Mechanical and Aerospace Engineering, The Hong Kong University of Science and Technology, Hong Kong 999077, China; (R.L.-W.M.); (Y.Z.)
| | - Yinsheng Zhong
- Department of Mechanical and Aerospace Engineering, The Hong Kong University of Science and Technology, Hong Kong 999077, China; (R.L.-W.M.); (Y.Z.)
| | - Liqiang Wang
- State Key Laboratory of Metal Matrix Composites, School of Material Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China;
- National Engineering Research Center for Nanotechnology (NERCN), 28 East JiangChuan Road, Shanghai 200241, China
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Additively Manufactured Continuous Cell-Size Gradient Porous Scaffolds: Pore Characteristics, Mechanical Properties and Biological Responses In Vitro. MATERIALS 2020; 13:ma13112589. [PMID: 32517161 PMCID: PMC7321598 DOI: 10.3390/ma13112589] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/30/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022]
Abstract
Porous scaffolds with graded open porosity combining a morphology similar to that of bone with mechanical and biological properties are becoming an attractive candidate for bone grafts. In this work, scaffolds with a continuous cell-size gradient were studied from the aspects of pore properties, mechanical properties and bio-functional properties. Using a mathematical method named triply periodic minimal surfaces (TPMS), uniform and graded scaffolds with Gyroid and Diamond units were manufactured by selective laser melting (SLM) with Ti-6Al-4V, followed by micro-computer tomography (CT) reconstruction, mechanical testing and in vitro evaluation. It was found that gradient scaffolds were preferably replicated by SLM with continuous graded changes in surface area and pore size, but their pore size should be designed to be ≥ 450 μm to ensure good interconnectivity. Both the Gyroid and Diamond structures have superior strength compared to cancellous bones, and their elastic modulus is comparable to the bones. In comparison, Gyroid exhibits better performances than Diamond in terms of the elastic modulus, ultimate strength and ductility. In vitro cell culture experiments show that the gradients provide an ideal growth environment for osteoblast growth in which cells survive well and distribute uniformly due to biocompatibility of the Ti-6Al-4V material, interconnectivity and suitable pore size.
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Effects of Surface Topography and Chemistry on Polyether-Ether-Ketone (PEEK) and Titanium Osseointegration. Spine (Phila Pa 1976) 2020; 45:E417-E424. [PMID: 31703050 DOI: 10.1097/brs.0000000000003303] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An in vivo study examining the functional osseointegration of smooth, rough, and porous surface topographies presenting polyether-ether-ketone (PEEK) or titanium surface chemistry. OBJECTIVE To investigate the effects of surface topography and surface chemistry on implant osseointegration. SUMMARY OF BACKGROUND DATA Interbody fusion devices have been used for decades to facilitate fusion across the disc space, yet debate continues over their optimal surface topography and chemistry. Though both factors influence osseointegration, the relative effects of each are not fully understood. METHODS Smooth, rough, and porous implants presenting either a PEEK or titanium surface chemistry were implanted into the proximal tibial metaphyses of 36 skeletally mature male Sprague Dawley rats. At 8 weeks, animals were euthanized and bone-implant interfaces were subjected to micro-computed tomography analysis (n = 12), histology (n = 4), and biomechanical pullout testing (n = 8) to assess functional osseointegration and implant fixation. RESULTS Micro-computed tomography analysis demonstrated that bone ingrowth was 38.9 ± 2.8% for porous PEEK and 30.7 ± 3.3% for porous titanium (P = 0.07). No differences in fixation strength were detected between porous PEEK and porous titanium despite titanium surfaces exhibiting an overall increase in bone-implant contact compared with PEEK (P < 0.01). Porous surfaces exhibited increased fixation strength compared with smooth and rough surfaces regardless of surface chemistry (P < 0.05). Across all groups both surface topography and chemistry had a significant overall effect on fixation strength (P < 0.05), but topography accounted for 65.3% of the total variance (ω = 0.65), whereas surface chemistry accounted for 5.9% (ω = 0.06). CONCLUSIONS The effect of surface topography (specifically porosity) dominated the effect of surface chemistry in this study and could lead to further improvements in orthopedic device design. The poor osseointegration of existing smooth PEEK implants may be linked more to their smooth surface topography rather than their material composition. LEVEL OF EVIDENCE N/A.
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Effect of Gradient Energy Density on the Microstructure and Mechanical Properties of Ti6Al4V Fabricated by Selective Electron Beam Additive Manufacture. MATERIALS 2020; 13:ma13071509. [PMID: 32224887 PMCID: PMC7177318 DOI: 10.3390/ma13071509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/16/2022]
Abstract
Selective Electron Beam Additive Manufacturing (SEBAM) is a promising powder bed fusion additive manufacturing technique for titanium alloys that select particular area melting in different energy density for producing complexly shaped biomedical devices. For most commercial Ti6Al4V porous medical devices, the gradient energy density is usually applied to manufacture in one component during the SEBAM process which selects different energy density built on particular zones. This paper presents gradient energy density base characterization study on an SEBAM built rectangular specimen with a size of 3 mm × 20 mm × 60 mm. The specimen was divided into three zones were built in gradient energy density from 16 to 26.5 J/mm3. The microstructure and mechanical properties were investigated by means of scanning electron microscopy, X-ray diffraction, transmission electron microscopy and mechanical test. The α' martensitic and lack of fusion were observed in the low energy density (LED) built zone. However, no α' phase and no irregular pores were observed both in overlap energy density (OED) and high energy density (HED) built zones located at the middle and bottom of the specimen respectively. This implies the top location and lower energy density have positive effects on the cooling rate but negative effects on densification. The subsequence mechanical properties result also supports this point. Moreover, the intermetallic Ti3Al found in the bottom may be due to the heat transfer from the following melting layer. Furthermore, the microstructure evolution in gradient energy built zones is discussed based on the findings of the microstructure and thermal history correlation analysis.
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Integration of a Three-Dimensional-Printed Titanium Implant in Human Tissues: Case Study. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10020553] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A titanium alloy implant of appropriate pore size can potentially enhance osseointegration and soft tissue integration. However, the human clinical application of such implants has not been reported. Here, we present a case of limb salvage surgery for a bone tumor using customized three-dimensional (3D)-printed Ti6Al4V radius and ulna implants. The patient presented with local recurrence at the proximal junction of the ulna and underwent a re-wide excision. Single forearm bone surgery was performed using another 3D-printed implant after resection of the recurrent tumor with an ulnar implant. Host osseointegration and soft tissue integration of the retrieved implant were quantified through histological evaluation. The total tissue integration rates of the implant at the proximal and distal bone junctions were 45.96% and 15.03%, respectively. The mesh structure enhanced bone integration by up to 10.81% in the proximal and by up to 8.91% in the distal bone junction. Furthermore, the soft tissue adhesion rates of the implant shaft were 59.50% and 50.26% in the axial and longitudinal cuts, respectively. No area was left unoccupied throughout the shaft of the implant. Overall, these results indicate that the 3D-printed Ti6Al4V titanium alloy implant with a rough surface has considerable tissue integration ability.
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Zhang W, Sun C, Zhu J, Zhang W, Leng H, Song C. 3D printed porous titanium cages filled with simvastatin hydrogel promotes bone ingrowth and spinal fusion in rhesus macaques. Biomater Sci 2020; 8:4147-4156. [PMID: 32496502 DOI: 10.1039/d0bm00361a] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Sustainable release of simvastatin from poloxamer 407 hydrogel in 3D-printed porous Ti6Al4V for spinal fusion in rhesus macaques.
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Affiliation(s)
- Wen Zhang
- Department of Spine Surgery
- Shandong Provincial Hospital Affiliated to Shandong First Medical University
- Shandong Provincial Hospital Affiliated to Shandong University
- Jinan
- China
| | - Chuiguo Sun
- Department of Orthopaedics
- Peking University Third Hospital
- Beijing
- China
| | - Junxiong Zhu
- Department of Orthopaedics
- Peking University Third Hospital
- Beijing
- China
- Beijing Key Laboratory of Spinal Diseases
| | - Weifang Zhang
- Department of Nuclear Medicine
- Peking University Third Hospital
- Beijing
- China
| | - Huijie Leng
- Department of Orthopaedics
- Peking University Third Hospital
- Beijing
- China
- Beijing Key Laboratory of Spinal Diseases
| | - Chunli Song
- Department of Orthopaedics
- Peking University Third Hospital
- Beijing
- China
- Beijing Key Laboratory of Spinal Diseases
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50
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Chang CW, Chung YH, Chang CJ, Chen YN, Li CT, Chang CH, Peng YT. Computational comparison of bone cement and poly aryl-ether-ether-ketone spacer in single-segment posterior lumbar interbody fusion: a pilot study. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 43:10.1007/s13246-019-00832-8. [PMID: 31834586 DOI: 10.1007/s13246-019-00832-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
Posterior lumbar interbody fusion (PLIF) with a spacer and posterior instrument (PI) via minimally invasive surgery (MIS) restores intervertebral height in degenerated disks. To align with MIS, the spacer has to be shaped with a slim geometry. However, the thin spacer increases the subsidence and migration after PLIF. This study aimed to propose a new lumbar fusion approach using bone cement to achieve a larger supporting area than that achieved by the currently used poly aryl-ether-ether-ketone (PEEK) spacer and assess the feasibility of this approach using a sawbone model. Furthermore, the mechanical responses, including the range of motion (ROM) and bone stress with the bone cement spacer were compared to those noted with the PEEK spacer by finite element (FE) simulation. An FE lumbar L3-L4 model with PEEK and bone cement spacers and PI was developed. Four fixing conditions were considered: intact lumbar L3-L4 segment, lumbar L3-L4 segment with PI, PEEK spacer plus PI, and bone cement spacer plus PI. Four kinds of 10-NM moments (flexion, extension, lateral bending, and rotation) and two different bone qualities (normal and osteoporotic) were considered. The bone cement spacer yielded smaller ROMs in extension and rotation than the PEEK spacer, while the ROMs of the bone cement spacer in flexion and lateral bending were slightly greater than with the PEEK spacer. Compared with the PEEK spacer, peak contact pressure on the superior surface of L4 with the bone cement spacer in rotation decreased by 74% (from 8.68 to 2.25 MPa) and 69.1% (from 9.1 to 2.82 MPa), respectively, in the normal and osteoporotic bone. Use of bone cement as a spacer with PI is a potential approach to decrease the bone stress in lumbar fusion and warrants further research.
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Affiliation(s)
- Chih-Wei Chang
- Department of BioMedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Hsuan Chung
- Department of Orthopedics, Show Chwan Memorial Hospital, Changhua City, Taiwan
| | - Chia-Jung Chang
- Department of BioMedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Nien Chen
- Department of Physical Therapy, Asia University, 500, Lioufeng Rd, Wufeng, Taichung, 41354, Taiwan.
| | - Chun-Ting Li
- Institute of Geriatric Welfare Technology & Science, Mackay Medical College, No. 46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, 25245, Taiwan.
| | - Chih-Han Chang
- Department of BioMedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Yao-Te Peng
- Department of BioMedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Metal Industries Research & Development Centre, Kaohsiung City, Taiwan
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