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Kjellin P, Danielsson K, Håkansson J, Agrenius K, Andersson T, Stenlund P. Biomechanical and histomorphometric evaluation of skin integration on titanium and PEEK implants with different surface treatments. J Mater Sci Mater Med 2022; 33:68. [PMID: 36178551 PMCID: PMC9525375 DOI: 10.1007/s10856-022-06687-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/22/2022] [Indexed: 05/14/2023]
Abstract
Percutaneous implants are frequently affected by bacterial growth at the skin-implant interface. Integration between implant and surrounding skin is important to prevent bacteria from spreading to the underlying tissue. The standard method to evaluate skin-implant integration is by histomorphometry on samples which have been placed in tissue grown in vivo or ex vivo. In this study, a biomechanical method was developed and evaluated. The integration of implants into porcine skin was studied in an ex vivo model, where pig skin samples were cultivated in a nutrient solution. Cylindrical shaped implants, consisting of polyether ether ketone (PEEK) and titanium (Ti) with different surface treatments, were implanted in the skin tissue and the skin was grown in nutrient solution for 2 weeks. The implants were then extracted from the implantation site and the mechanical force during extraction was measured as a quantitative assessment of skin-implant integration. Implants from each group were also processed for histomorphometry and the degree of epidermal downgrowth (ED) and tissue to implant contact (TIC) was measured. A higher mean pullout force was observed for the PEEK implants compared to the Ti implants. Applying nanosized hydroxyapatite (HA) on Ti and PEEK increased the pullout force compared to uncoated controls, 24% for machined and 70% for blasted Ti, and 51% for machined PEEK. Treatment of Ti and PEEK with nanosized zirconium phosphate (ZrP) did not increase the pullout force. The histomorphometry analysis showed correlation between ED and pullout force, where the pullout force was inversely proportional to ED. For TIC, no significant differences were observed between the groups of same material (i.e. Ti, Ti+HA, Ti+ZrP, and PEEK, PEEK + HA, PEEK + ZrP), but it was significantly higher for PEEK compared to Ti. Scanning electron microscopy analysis was done on samples before and after the pullout tests, showing that the ZrP coating was unaffected by the 2 week ex vivo implantation and pullout procedure, no dissolution or detachment of the coating was observed. For the HA coating, a loss of coating was seen on approximately 5% of the total surface area of the implant. Graphical abstract.
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Affiliation(s)
- Per Kjellin
- Promimic AB, AstraZeneca BioventureHub, SE, 43183, Mölndal, Sweden.
| | - Karin Danielsson
- Promimic AB, AstraZeneca BioventureHub, SE, 43183, Mölndal, Sweden
| | - Joakim Håkansson
- Department of Methodology, Textile and Medical Technology, RISE Research Institutes of Sweden, SE, 50115, Borås, Sweden
- Department of Laboratory Medicine, Institute of Biomedicine, Gothenburg University, SE, 40530, Göteborg, Sweden
| | - Karin Agrenius
- Department of Methodology, Textile and Medical Technology, RISE Research Institutes of Sweden, SE, 50115, Borås, Sweden
| | - Therese Andersson
- Department of Methodology, Textile and Medical Technology, RISE Research Institutes of Sweden, SE, 50115, Borås, Sweden
| | - Patrik Stenlund
- Department of Methodology, Textile and Medical Technology, RISE Research Institutes of Sweden, SE, 50115, Borås, Sweden
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Johansson ML, Calon TGA, Omar O, Shah FA, Trobos M, Thomsen P, Stokroos RJ, Palmquist A. Multimodal Analysis of the Tissue Response to a Bone-Anchored Hearing Implant: Presentation of a Two-Year Case Report of a Patient With Recurrent Pain, Inflammation, and Infection, Including a Systematic Literature Review. Front Cell Infect Microbiol 2021; 11:640899. [PMID: 33859952 PMCID: PMC8042154 DOI: 10.3389/fcimb.2021.640899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/03/2021] [Indexed: 12/04/2022] Open
Abstract
Osseointegration is a well-established concept used in applications including the percutaneous Bone-Anchored Hearing System (BAHS) and auricular rehabilitation. To date, few retrieved implants have been described. A systematic review including cases where percutaneous bone-anchored implants inserted in the temporal bone were retrieved and analyzed was performed. We also present the case of a patient who received a BAHS for mixed hearing loss. After the initial surgery, several episodes of soft tissue inflammation accompanied by pain were observed, leading to elective abutment removal 14 months post-surgery. Two years post-implantation, the implant was removed due to pain and subjected to a multiscale and multimodal analysis: microbial DNA using molecular fingerprinting, gene expression using quantitative real-time polymerase chain reaction (qPCR), X-ray microcomputed tomography (micro-CT), histology, histomorphometry, backscattered scanning electron microscopy (BSE-SEM), Raman spectroscopy, and fluorescence in situ hybridization (FISH). Evidence of osseointegration was provided via micro-CT, histology, BSE-SEM, and Raman spectroscopy. Polymicrobial colonization in the periabutment area and on the implant, including that with Staphylococcus aureus and Staphylococcus epidermidis, was determined using a molecular analysis via a 16S-23S rDNA interspace [IS]-region-based profiling method (IS-Pro). The histology suggested bacterial colonization in the skin and in the peri-implant bone. FISH confirmed the localization of S. aureus and coagulase-negative staphylococci in the skin. Ten articles (54 implants, 47 patients) met the inclusion criteria for the literature search. The analyzed samples were either BAHS (35 implants) or bone-anchored aural epitheses (19 implants) in situ between 2 weeks and 8 years. The main reasons for elective removal were nonuse/changes in treatment, pain, or skin reactions. Most samples were evaluated using histology, demonstrating osseointegration, but with the absence of bone under the implants’ proximal flange. Taken together, the literature and this case report show clear evidence of osseointegration, despite prominent complications. Nevertheless, despite implant osseointegration, chronic pain related to the BAHS may be associated with a chronic bacterial infection and raised inflammatory response in the absence of macroscopic signs of infection. It is suggested that a multimodal analysis of peri-implant health provides possibilities for device improvements and to guide diagnostic and therapeutic strategies to alleviate the impact of complications.
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Affiliation(s)
- Martin L Johansson
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Research and Technology, Oticon Medical AB, Askim, Sweden
| | - Tim G A Calon
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Omar Omar
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Furqan A Shah
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margarita Trobos
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Thomsen
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robert J Stokroos
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, Netherlands.,Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anders Palmquist
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Caspers CJI, Nelissen RC, Verhamme LM, Meijer FJA, Mylanus EAM, Hol MKS. Clinical Presentation, Management, and Outcomes of Idiopathic Pain in Percutaneous Bone-anchored Hearing Implants. Otol Neurotol 2019; 40:1292-8. [PMID: 31725591 DOI: 10.1097/MAO.0000000000002382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To identify clinical features and investigate treatment outcomes of patients with idiopathic pain related to a percutaneous bone-anchored hearing implant (BAHI) and to propose management recommendations. STUDY DESIGN Retrospective chart analysis. SETTING Tertiary referral center. PATIENTS The clinical data of 14 patients who were treated for idiopathic pain around their percutaneous BAHI between May 2007 and February 2018 at our tertiary referral center were reviewed. MAIN OUTCOME MEASURES Pain after treatment and implant loss. RESULTS All 14 patients received treatment with oral antibiotics. Nine patients received oral antibiotic combination therapy for 4 weeks, whereafter pain resolved in 4. Out of the five other patients, receiving either antibiotic monotherapy or shortened antibiotic combination therapy, pain resolved in two. In case of persistent pain (57.1%) after initial treatment, other pain management therapies were attempted, however all with only limited effect. Six patients (42.8%) underwent elective removal of the implant. In two patients spontaneous implant loss occurred. In two of the four patients who underwent reimplantation, pain relapsed. In one of these, pain resolved after the removal of the new implant. In the other patient, pain persisted, despite abutment removal. With exception of this latter patient, all other 13 patients were pain free at the latest follow-up. Cone beam computed tomography did not offer additional information regarding diagnosis or treatment. CONCLUSION Idiopathic pain in BAHI is a rare but bothersome symptom which can result in implant removal. After oral antibiotic combination treatment, symptoms resolved in approximately 40% of patients. Therefore, we think conservative treatment with these antibiotics before implant removal surgery, is worth considering.
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Jang CH, Lee H, Kim M, Kim GH. Accelerated osteointegration of the titanium-implant coated with biocomponents, collagen/hydroxyapatite/bone morphogenetic protein-2, for bone-anchored hearing aid. J IND ENG CHEM 2018. [DOI: 10.1016/j.jiec.2018.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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van Hoof M, Wigren S, Duimel H, Savelkoul PHM, Flynn M, Stokroos RJ. Can the Hydroxyapatite-Coated Skin-Penetrating Abutment for Bone Conduction Hearing Implants Integrate with the Surrounding Skin? Front Surg 2015; 2:45. [PMID: 26442276 PMCID: PMC4568398 DOI: 10.3389/fsurg.2015.00045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/21/2015] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Percutaneous implants, such as bone conduction hearing implants, suffer from complications that include inflammation of the surrounding skin. A sealed skin-abutment interface can prevent the ingress of bacteria, which should reduce the occurrence of peri-abutment dermatitis. It was hypothesized that a hydroxyapatite (HA)-coated abutment in conjunction with soft tissue preservation surgery should enable integration with the adjacent skin. Previous research has confirmed that integration is never achieved with as-machined titanium abutments. Here, we investigate, in vivo, if skin integration is achievable in patients using a HA-coated abutment. MATERIALS AND METHODS One titanium abutment (control) and one HA-coated abutment (case) together with the surrounding skin were surgically retrieved from two patients who had a medical indication for this procedure. Histological sections of the skin were investigated using light microscopy. The abutment was qualitatively analyzed using scanning electron microscopy. RESULTS The titanium abutment only had a partial and thin layer of attached amorphous biological material. The HA-coated abutment was almost fully covered by a pronounced thick layer of organized skin, composed of different interconnected structural layers. CONCLUSION Proof-of-principle evidence that the HA-coated abutment can achieve integration with the surrounding skin was presented for the first time.
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Affiliation(s)
- Marc van Hoof
- Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center , Maastricht , Netherlands
| | - Stina Wigren
- Cochlear Bone Anchored Solutions AB , Mölnlycke , Sweden
| | - Hans Duimel
- Institute of Nanoscopy, Maastricht University Medical Center , Maastricht , Netherlands
| | - Paul H M Savelkoul
- Department of Medical Microbiology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center , Maastricht , Netherlands ; Department of Medical Microbiology and Infection Control, VU University Medical Center , Amsterdam , Netherlands
| | - Mark Flynn
- Cochlear Bone Anchored Solutions AB , Mölnlycke , Sweden
| | - Robert Jan Stokroos
- Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center , Maastricht , Netherlands
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Abstract
Bone-anchored hearing devices have evolved over recent years. This article provides an overview of the device history, indications, evolution of surgical technique, evidence for benefit and focuses on the challenges that are faced in the pediatric population.
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Affiliation(s)
- Jayesh Doshi
- Department of ENT, Salford Royal Hospital, Manchester, UK
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Siau D, Nik H, Hobson JC, Roper AJ, Rothera MP, Green KM. Bone-anchored hearing aids and chronic pain: a long-term complication and a cause for elective implant removal. J Laryngol Otol 2012; 126:445-9. [PMID: 22559796 DOI: 10.1017/S0022215112000394] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To report a case series of elective removal of bone-anchored hearing aid implants, and reasons for removal. DESIGN Retrospective review of a prospectively collected database. SETTING Two tertiary referral centres in the Manchester area: Manchester Royal Infirmary and Salford Royal University Hospital. PARTICIPANTS A series of 499 adults and children who had undergone a total of 602 implant insertions (1984-2008). MAIN OUTCOME MEASURES Implant removal rates, and reasons. RESULTS Twenty-seven of the 602 implants (4.5 per cent) required removal. Of these, 12 were due to pain (2.0 per cent), seven to persistent infection (1.2 per cent), three to failure of osseointegration (0.5 per cent), three to trauma (0.5 per cent) and two to other reasons (0.4 per cent). CONCLUSION Chronic implant site pain represents the main reason why implants are removed electively, and affects 2 per cent of all implants. This complication has important medico-legal implications and should be discussed when obtaining informed consent for implantation.
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