Porous Tantalum and Titanium in Orthopedics: A Review

Choice of Spinal Interbody Fusion Cage Material and Design Influences Subsidence and Osseointegration Performance

OBJECTIVE

The objective of the study was to quantify the effect of cage material (titanium-alloy vs. polyetheretherketone or PEEK) and design (porous vs. solid) on subsidence and osseointegration.

METHODS

Three lateral cages (solid PEEK, solid titanium, and 3-dimension-printed porous titanium cages) were evaluated for cage stiffness, subsidence compression stiffness, and dynamic subsidence displacement under simulated postoperative spine loading. Dowel-shaped implants made of grit-blasted solid titanium alloy (solid titanium) and porous titanium were fabricated using commercially available processes. Samples were processed for mechanical push-out testing and polymethylmethacrylate histology following an established ovine bone implantation model.

RESULTS

The solid titanium cage exhibited the greatest stiffness (57.1 ± 0.6 kN/mm), followed by the porous titanium cage (40.4 ± 0.3 kN/mm) and the solid PEEK cage (37.1 ± 1.2 kN/mm). In the clinically relevant dynamic subsidence, the porous titanium cage showed the least amount of subsidence displacement (0.195 ± 0.012 mm), significantly less than that of the solid PEEK cage (0.328 ± 0.020 mm) and the solid titanium cage (0.538 ± 0.027 mm). Bony on-growth was noted histologically on all implant materials; however, only the porous titanium supported bony ingrowth with marked quantities of bone formed within the interconnected pores through 12 weeks. Functional differences in osseointegration were noted between groups during push-out testing. The porous titanium showed the highest maximum shear stress at 12 weeks and was the only group that demonstrated significant improvement (4-12 weeks).

CONCLUSIONS

The choice of material and design is critical to cage mechanical and biological performances. A porous titanium cage can reduce subsidence risk and generate biological stability through bone on-growth and ingrowth.

[Osteoimmunomodulatory effects of inorganic biomaterials in the process of bone repair]

OBJECTIVE

To review the osteoimmunomodulatory effects and related mechanisms of inorganic biomaterials in the process of bone repair.

METHODS

A wide range of relevant domestic and foreign literature was reviewed, the characteristics of various inorganic biomaterials in the process of bone repair were summarized, and the osteoimmunomodulatory mechanism in the process of bone repair was discussed.

RESULTS

Immune cells play a very important role in the dynamic balance of bone tissue. Inorganic biomaterials can directly regulate the immune cells in the body by changing their surface roughness, surface wettability, and other physical and chemical properties, constructing a suitable immune microenvironment, and then realizing dynamic regulation of bone repair.

CONCLUSION

Inorganic biomaterials are a class of biomaterials that are widely used in bone repair. Fully understanding the role of inorganic biomaterials in immunomodulation during bone repair will help to design novel bone immunomodulatory scaffolds for bone repair.

Addressing the Needs of the Rapidly Aging Society through the Development of Multifunctional Bioactive Coatings for Orthopedic Applications

The unprecedented aging of the world's population will boost the need for orthopedic implants and expose their current limitations to a greater extent due to the medical complexity of elderly patients and longer indwelling times of the implanted materials. Biocompatible metals with multifunctional bioactive coatings promise to provide the means for the controlled and tailorable release of different medications for patient-specific treatment while prolonging the material's lifespan and thus improving the surgical outcome. The objective of this work is to provide a review of several groups of biocompatible materials that might be utilized as constituents for the development of multifunctional bioactive coatings on metal materials with a focus on antimicrobial, pain-relieving, and anticoagulant properties. Moreover, the review presents a summary of medications used in clinical settings, the disadvantages of the commercially available products, and insight into the latest development strategies. For a more successful translation of such research into clinical practice, extensive knowledge of the chemical interactions between the components and a detailed understanding of the properties and mechanisms of biological matter are required. Moreover, the cost-efficiency of the surface treatment should be considered in the development process.

Genistein loaded into microporous surface of nano tantalum/PEEK composite with antibacterial effect regulating cellular response in vitro, and promoting osseointegration in vivo

Poly(ether-ether-ketone) (PEEK) with good biocompatibility exhibits high mechanical strengths but bioinert. In addition, tantalum (Ta) possesses outstanding osteogenesis but high density and elastic modulus, and cost. In this study, by blending Ta nanoparticles with PEEK, Ta/PEEK composite (TP) was prepared, which was then treated by concentrated sulfuric acid to form a microporous surface containing Ta particles on TP (TPS). Moreover, genistein (GS) with antibacterial property was loaded into the microporous surface of TPS (TPSG). Compared with TP, the surface properties (e.g., surface roughness and hydrophilicity) of TPS was obviously improved because of the microporous surface including Ta nanoparticles. Moreover, TPS showed low antibacterial properties because of presence of sulfonic group while TPSG exhibited excellent antibacterial properties due to GS loaded into the microporous surface. Furthermore, compared with TP, TPS obviously promoted attachment and proliferation of MG63 cells, while TPSG with GS remarkably inducing osteogenic differentiation of the cells compared with TPS in vitro. Moreover, in comparison with TP, TPS with optimized surface properties promoted new bone regeneration and osseointegration, while TPSG loading GS further enhanced bone regeneration as well as osseointegration in vivo. In summary, the GS loaded into microporous surface including Ta nanoparticles of TPSG exhibited antibacterial and osteogenic activity, which would have great potential for bone tissue repair.

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

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

Enhanced spreading, migration and osteodifferentiation of HBMSCs on macroporous CS-Ta - A biocompatible macroporous coating for hard tissue repair

Macroporous tantalum (Ta) coating was produced on titanium alloy implant for bone repair by cold spray (CS) technology, which is a promising technology for oxygen sensitive materials. The surface characteristics as well as in vitro cytocompatibility were systematically evaluated. The results showed that a rough and macroporous CS-Ta coating was formed on the Ti6Al4V (TC4) alloy surfaces. The surface roughness showed a significant enhancement from 17.06 μm (CS-Ta-S), 27.48 μm (CS-Ta-M) to 39.21 μm (CS-Ta-L) with the increase of the average pore diameter of CS-Ta coatings from 138.25 μm, 198.25 μm to 355.56 μm. In vitro results showed that macroporous CS-Ta structure with tantalum pentoxide (Ta₂O₅) was more favorable to induce human bone marrow derived mesenchymal stem cells (HBMSCs) spreading, migration and osteodifferentiation than TC4. Compared with the micro-scaled structure outside the macropores, the surface micro-nano structure inside the macropores was more favorable to promote osteodifferentiation with enhanced alkaline phosphatase (ALP) activity and extracellular matrix (ECM) mineralization. In particular, CS-Ta-L with the largest pore size showed significantly enhanced integrin-α5 expression, cell migration, ALP activity, ECM mineralization as well as osteogenic-related genes including ALP, osteopontin (OPN) and osteocalcin (OCN) expression. Our results indicated that macroporous Ta coatings by CS, especially CS-Ta-L, may be promising for hard tissue repairs.

The Use of Metaphyseal Cones and Sleeves in Revision Total Knee Arthroplasty

The burden of revision total knee arthroplasty (rTKA) is expected to increase with the rise in the number of TKA procedures being performed yearly. Management of bone loss during rTKA is challenging and necessitates appropriate surgical planning. Metaphyseal cones and sleeves have emerged as an increasing popular option for addressing metaphyseal femoral and tibial bone loss when performing rTKA. Understanding what cones and sleeves are commercially available and when to use them are critical parts of preoperative evaluation and planning. The purpose of this comprehensive review was to present different design philosophies, types of manufacturing, clinical outcomes, and the versatility and interchangeability of varying cones and sleeves with different TKA revision systems.

Immobilization of bioactive vascular endothelial growth factor onto Ca-deficient hydroxyapatite-coated Mg by covalent bonding using polydopamine

BACKGROUND

Bone tissue engineering (BTE) is considered a promising technology for repairing bone defects. Mg2+ promotes osteogenesis, which makes Mg-based scaffolds popular for research on orthopedic implant materials. Angiogenesis plays an important role in the process of bone tissue repair and regeneration, and it is one of the important problems in BTE urgently needs to be solved.

METHODS

Mg was firstly coated with Ca-deficient hydroxyapatite (CDHA) via hydrothermal treatment, and polydopamine (DOPA) was then used as the connecting medium to immobilize vascular endothelial growth factor (VEGF) on the CDHA coating. The physicochemical properties of the coatings were characterized by SEM, EDS, XPS, FTIR and immersion experiment in SBF. The ahesion, proliferation, and angiogenesis potential of the coatings were determined in vitro.

RESULTS

The composite coating significantly improved the corrosion resistance of Mg and prohibited excessively high local alkalinity. VEGF could be firmly immobilized on Mg via polydopamine. The CCK-8, live/dead staining and adhesion test results showed that the VEGF-DOPA-CDHA coating exhibited excellent biocompatibility and could significantly improve the adhesion and proliferation of MC3T3-E1 cells on Mg. Microtubule formation, immunofluorescence and Quantitative Real-Time PCR (qRT-PCR) experiments showed that VEGF immobilized on Mg still possessed bioactivity in promoting the differentiation of rat mesenchymal stem cells into endothelial cells.

CONCLUSION

In this study, we enabled the angiogenic biological activity of Mg by immobilizing VEGF on Mg. Mg was successfully coated with a functional VEGF-DOPA-CDHA composite coating. The CDHA coating significantly increased the corrosion resistance of Mg and prohibited the negative effect of excessively high local alkalinity on the biological activity of VEGF. As an intermediate layer, the DOPA coating protects Mg, and DOPA provides a binding site for VEGF so that VEGF can be firmly immobilized on Mg and give Mg angiogenic bioactivity during the initial period of implantation.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

The treatment of large bone defect is still one of the orthopedic trauma diseases that are difficult to be completely treated in clinic. The development of tissue engineering technology provides a new option for the treatment of large bone defects. The regeneration of blood vessels is of great significance for the repair of bone defects. In this study, VEGF was connected on the surface of degradable magnesium by covalent bonding. Vascular biofunctionalized magnesium scaffolds are expected to regenerate bone tissue with blood transport and be used in the clinical treatment of large bone defects.

Porous tantalum structure integrated on Ti6Al4V base by Laser Powder Bed Fusion for enhanced bony-ingrowth implants: In vitro and in vivo validation

Despite the widespread application of Ti6Al4V and tantalum (Ta) in orthopedics, bioinertia and high cost limit their further applicability, respectively, and tremendous efforts have been made on the Ti6Al4V-Ta alloy and Ta coating to address these drawbacks. However, the scaffolds obtained are unsatisfactory. In this study, novel high-interface-strength Ti6Al4V-based porous Ta scaffolds were successfully manufactured using Laser Powder Bed Fusion for the first time, in which porous Ta was directly manufactured on a solid Ti6Al4V substrate. Mechanical testing revealed that the novel scaffolds were biomechanically compatible, and the interfacial bonding strength was as high as 447.5 MPa. In vitro biocompatibility assay, using rat bone marrow mesenchymal stem cells (r-BMSCs), indicated that the novel scaffolds were biocompatible. Alkaline phosphatase and mineralized nodule determination demonstrated that the scaffolds favored the osteogenic differentiation of r-BMSCs. Moreover, scaffolds were implanted into rabbits with femur bone defects, and imaging and histological evaluation identified considerable new bone formation and bone ingrowth, suggesting that the scaffolds were well integrated with the host bone. Overall, these results demonstrated good mechanical compatibility, biocompatibility, and osteointegration performance of the novel Ti6Al4V-based porous Ta scaffold, which possesses great potential for orthopedic clinical applications.

3D-Printed Architected Materials Inspired by Cubic Bravais Lattices

Learning from Nature and leveraging 3D printing, mechanical testing, and numerical modeling, this study aims to provide a deeper understanding of the structure-property relationship of crystal-lattice-inspired materials, starting from the study of single unit cells inspired by the cubic Bravais crystal lattices. In particular, here we study the simple cubic (SC), body-centered cubic (BCC), and face-centered cubic (FCC) lattices. Mechanical testing of 3D-printed structures is used to investigate the influence of different printing parameters. Numerical models, validated based on experimental testing carried out on single unit cells and embedding manufacturing-induced defects, are used to derive the scaling laws for each studied topology, thus providing guidelines for materials selection and design, and the basis for future homogenization and optimization studies. We observe no clear effect of the layer thickness on the mechanical properties of both bulk material and lattice structures. Instead, the printing direction effect, negligible in solid samples, becomes relevant in lattice structures, yielding different stiffnesses of struts and nodes. This phenomenon is accounted for in the proposed simulation framework. The numerical models of large arrays, used to define the scaling laws, suggest that the chosen topologies have a mainly stretching-dominated behavior-a hallmark of structurally efficient structures-where the modulus scales linearly with the relative density. By looking ahead, mimicking the characteristic microscale structure of crystalline materials will allow replicating the typical behavior of crystals at a larger scale, combining the hardening traits of metallurgy with the characteristic behavior of polymers and the advantage of lightweight architected structures, leading to novel materials with multiple functions.

Recent Advances in Research on Antibacterial Metals and Alloys as Implant Materials

Implants are widely used in orthopedic surgery and are gaining attention of late. However, their use is restricted by implant-associated infections (IAI), which represent one of the most serious and dangerous complications of implant surgeries. Various strategies have been developed to prevent and treat IAI, among which the closest to clinical translation is designing metal materials with antibacterial functions by alloying methods based on existing materials, including titanium, cobalt, tantalum, and biodegradable metals. This review first discusses the complex interaction between bacteria, host cells, and materials in IAI and the mechanisms underlying the antibacterial effects of biomedical metals and alloys. Then, their applications for the prevention and treatment of IAI are highlighted. Finally, new insights into their clinical translation are provided. This review also provides suggestions for further development of antibacterial metals and alloys.

Polyoxometalates as Effective Nano-inhibitors of Amyloid Aggregation of Pro-inflammatory S100A9 Protein Involved in Neurodegenerative Diseases

Pro-inflammatory and amyloidogenic S100A9 protein is central to the amyloid-neuroinflammatory cascade in neurodegenerative diseases. Polyoxometalates (POMs) constitute a diverse group of nanomaterials, which showed potency in amyloid inhibition. Here, we have demonstrated that two selected nanosized niobium POMs, Nb₁₀ and TiNb₉, can act as potent inhibitors of S100A9 amyloid assembly. Kinetics analysis based on ThT fluorescence experiments showed that addition of either Nb₁₀ or TiNb₉ reduces the S100A9 amyloid formation rate and amyloid quantity. Atomic force microscopy imaging demonstrated the complete absence of long S100A9 amyloid fibrils at increasing concentrations of either POM and the presence of only round-shaped and slightly elongated aggregates. Molecular dynamics simulation revealed that both Nb₁₀ and TiNb₉ bind to native S100A9 homo-dimer by forming ionic interactions with the positively charged Lys residue-rich patches on the protein surface. The acrylamide quenching of intrinsic fluorescence showed that POM binding does not perturb the Trp 88 environment. The far and near UV circular dichroism revealed no large-scale perturbation of S100A9 secondary and tertiary structures upon POM binding. These indicate that POM binding involves only local conformational changes in the binding sites. By using intrinsic and 8-anilino-1-naphthalene sulfonate fluorescence titration experiments, we found that POMs bind to S100A9 with a K_d of ca. 2.5 μM. We suggest that the region, including Lys 50 to Lys 54 and characterized by high amyloid propensity, could be the key sequences involved in S1009 amyloid self-assembly. The inhibition and complete hindering of S100A9 amyloid pathways may be used in the therapeutic applications targeting the amyloid-neuroinflammatory cascade in neurodegenerative diseases.

Refractory Metal Coated Alumina Foams as Support Material for Stem Cell and Fibroblasts Cultivation

Ceramics are widely used as implant materials; however, they are brittle and may emit particles when used in these applications. To overcome this disadvantage, alumina foams, which represent a 3D cellular structure comparable to that of human trabecular bone structures, were sputter coated with platinum, tantalum or titanium and modified with fibronectin or collagen type I, components of the extracellular matrix (ECM). To proof the cell material interaction, the unmodified and modified materials were cultured with (a) mesenchymal stem cells being a perfect indicator for biocompatibility and releasing important cytokines of the stem cell niche and (b) with fibroblasts characterized as mediators of inflammation and therefore an important cellular component of the foreign body reaction and inflammation after implantation. To optimize and compare the influence of metal surfaces on cellular behavior, planar glass substrates have been used. Identified biocompatible metal surface of platinum, titanium and tantalum were sputtered on ceramic foams modified with the above-mentioned ECM components to investigate cellular behavior in a 3D environment. The cellular alumina support was characterized with respect to its cellular/porous structure and niche accessibility and coating thickness of the refractory metals; the average cell size was 2.3 mm, the average size of the cell windows was 1.8 mm, and the total foam porosity was 91.4%. The Pt, Ti and Ta coatings were completely dense covering the entire alumina foam surface. The metals titanium and tantalum were colonized very well by the stem cells without a coating of ECM components, whereas the fibroblasts preferred components of the ECM on the alumina foam surface.

Recent Trends in the Development of Bone Regenerative Biomaterials

The goal of a biomaterial is to support the bone tissue regeneration process at the defect site and eventually degrade in situ and get replaced with the newly generated bone tissue. Biomaterials that enhance bone regeneration have a wealth of potential clinical applications from the treatment of non-union fractures to spinal fusion. The use of bone regenerative biomaterials from bioceramics and polymeric components to support bone cell and tissue growth is a longstanding area of interest. Recently, various forms of bone repair materials such as hydrogel, nanofiber scaffolds, and 3D printing composite scaffolds are emerging. Current challenges include the engineering of biomaterials that can match both the mechanical and biological context of bone tissue matrix and support the vascularization of large tissue constructs. Biomaterials with new levels of biofunctionality that attempt to recreate nanoscale topographical, biofactor, and gene delivery cues from the extracellular environment are emerging as interesting candidate bone regenerative biomaterials. This review has been sculptured around a case-by-case basis of current research that is being undertaken in the field of bone regeneration engineering. We will highlight the current progress in the development of physicochemical properties and applications of bone defect repair materials and their perspectives in bone regeneration.

Cementless Fixation in Primary Total Knee Arthroplasty: Historical Perspective to Contemporary Application

Cemented total knee arthroplasty (TKA) has been considered the benchmark, with excellent clinical outcomes and low rates of aseptic loosening at the long-term follow-up. However, alterations of the bone/cement interface leading to aseptic loosening, particularly in younger and obese patients, along with increased life expectancy have led to a renewed interest in noncemented TKA fixation. Certain early noncemented designs exhibited higher rates of subsidence and component failure. Improvements in designs, materials, and surgical technique offer promise for improved results with contemporary noncemented TKA applications. In an increasing cost-conscious healthcare environment, implant cost is important to consider because press-fit prostheses are generally more expensive. However, this cost may be offset by shorter surgical times, cement costs, and the potential for osseous integration. Technological advances have improved the manufacturing of porous metals, with reported excellent midterm survivorship. Future prospective, randomized trials, and registry data are needed to delineate differences between cemented and noncemented fixation, survivorship, and patient-reported outcomes, especially in young, functionally active, and/or obese populations.

Design and Compressive Fatigue Properties of Irregular Porous Scaffolds for Orthopedics Fabricated Using Selective Laser Melting

An irregular porous structure plays a major role in bone tissue engineering, and it is more suitable for bone tissue growth than a regular porous structure. The response surface method was used to establish a relationship between the average pore size and the design parameters. The technology of selective laser melting was utilized to fabricate the porous Ti-6Al-4V scaffolds with an irregularity of (0.4) and porosities of (70, 80, and 90%) designed using the Voronoi-tessellation method. Compression tests of porous scaffolds showed an elastic modulus range of 0.84-1.97 GPa and an ultimate strength ranging within 21.0-99.1 MPa. The elastic modulus was mainly influenced by the porosity and heat-treatment process. Furthermore, the fatigue test results suggested that the number of cycles (9 × 10⁴ to 1.8 × 10⁶) was greatly influenced by the porosity and heat-treatment process. The heat treatment of annealing greatly improved the fatigue performance of porous scaffolds. The irregular porous scaffolds with lower porosity and after full annealing exhibited the best fatigue behavior.

Implantable PEKK/tantalum microparticles composite with improved surface performances for regulating cell behaviors, promoting bone formation and osseointegration

Polyetherketoneketone (PEKK) exhibits admirable biocompatibility and mechanical performances but bioinert while tantalum (Ta) possesses excellent osteogenesis and osseointegration but high elastic modulus and density, and processing is too difficult and expensive. In the present study, combining of the advantages of both PEKK and Ta, implantable composites of PEKK/Ta were fabricated by blending PEKK with Ta microparticles of 20 v% (PT20) and 40 v% (PT40) content. In comparison with PT20 and PEKK, the surface hydrophilicity, surface energy, roughness and proteins adsorption as well as mechanical performances of PT40 significantly increased because of the higher Ta particles content in PEKK. Furthermore, PT40 exhibited the mechanical performances (e.g., compressive strength and modulus of elasticity) close to the cortical bone of human. Compared with PT20 and PEKK, PT40 with higher Ta content remarkably enhanced the responses (including adhesion, proliferation and osteogenic differentiation) of MC3T3-E1 cells in vitro. Moreover, PT40 markedly improved bone formation as well as osseointegration in vivo. In short, incorporation of Ta microparticles into PEKK created implantable composites with improved surface performances, which played key roles in stimulating cell responses/bone formation as well as promoting osseointegration. PT40 might have great potential for bear-loading bone substitute.

Porous Scaffold Design for Additive Manufacturing in Orthopedics: A Review

With the increasing application of orthopedic scaffolds, a dramatically increasing number of requirements for scaffolds are precise. The porous structure has been a fundamental design in the bone tissue engineering or orthopedic clinics because of its low Young's modulus, high compressive strength, and abundant cell accommodation space. The porous structure manufactured by additive manufacturing (AM) technology has controllable pore size, pore shape, and porosity. The single unit can be designed and arrayed with AM, which brings controllable pore characteristics and mechanical properties. This paper presents the current status of porous designs in AM technology. The porous structures are stated from the cellular structure and the whole structure. In the aspect of the cellular structure, non-parametric design and parametric design are discussed here according to whether the algorithm generates the structure or not. The non-parametric design comprises the diamond, the body-centered cubic, and the polyhedral structure, etc. The Voronoi, the Triply Periodic Minimal Surface, and other parametric designs are mainly discussed in parametric design. In the discussion of cellular structures, we emphasize the design, and the resulting biomechanical and biological effects caused by designs. In the aspect of the whole structure, the recent experimental researches are reviewed on uniform design, layered gradient design, and layered gradient design based on topological optimization, etc. These parts are summarized because of the development of technology and the demand for mechanics or bone growth. Finally, the challenges faced by the porous designs and prospects of porous structure in orthopedics are proposed in this paper.

Design biodegradable Zn alloys: Second phases and their significant influences on alloy properties

Alloying combined with plastic deformation processing is widely used to improve mechanical properties of pure Zn. As-cast Zn and its alloys are brittle. Beside plastic deformation processing, no effective method has yet been found to eliminate the brittleness and even endow room temperature super-ductility. Second phase, induced by alloying, not only largely determines the ability of plastic deformation, but also influences strength, corrosion rate and cytotoxicity. Controlling second phase is important for designing biodegradable Zn alloys. In this review, knowledge related to second phases in biodegradable Zn alloys has been analyzed and summarized, including characteristics of binary phase diagrams, volume fraction of second phase in function of atomic percentage of an alloying element, and so on. Controversies about second phases in Zn-Li, Zn-Cu and Zn-Fe systems have been settled down, which benefits future studies. The effects of alloying elements and second phases on microstructure, strength, ductility, corrosion rate and cytotoxicity have been neatly summarized. Mg, Mn, Li, Cu and Ag are recommended as the major alloying elements, owing to their prominent beneficial effects on at least one of the above properties. In future, synergistic effects of these elements should be more thoroughly investigated. For other nutritional elements, such as Fe and Ca, refining second phase is a matter of vital concern.