Osteogenic protein-1 delivered by hydroxyapatite-coated implants improves bone ingrowth in extracortical bone bridging

There Are over 60 Ways to Produce Biocompatible Calcium Orthophosphate (CaPO4) Deposits on Various Substrates

A The present overview describes various production techniques for biocompatible calcium orthophosphate (abbreviated as CaPO4) deposits (coatings, films and layers) on the surfaces of various types of substrates to impart the biocompatible properties for artificial bone grafts. Since, after being implanted, the grafts always interact with the surrounding biological tissues at the interfaces, their surface properties are considered critical to clinical success. Due to the limited number of materials that can be tolerated in vivo, a new specialty of surface engineering has been developed to desirably modify any unacceptable material surface characteristics while maintaining the useful bulk performance. In 1975, the development of this approach led to the emergence of a special class of artificial bone grafts, in which various mechanically stable (and thus suitable for load-bearing applications) implantable biomaterials and artificial devices were coated with CaPO4. Since then, more than 7500 papers have been published on this subject and more than 500 new publications are added annually. In this review, a comprehensive analysis of the available literature has been performed with the main goal of finding as many deposition techniques as possible and more than 60 methods (double that if all known modifications are counted) for producing CaPO4 deposits on various substrates have been systematically described. Thus, besides the introduction, general knowledge and terminology, this review consists of two unequal parts. The first (bigger) part is a comprehensive summary of the known CaPO4 deposition techniques both currently used and discontinued/underdeveloped ones with brief descriptions of their major physical and chemical principles coupled with the key process parameters (when possible) to inform readers of their existence and remind them of the unused ones. The second (smaller) part includes fleeting essays on the most important properties and current biomedical applications of the CaPO4 deposits with an indication of possible future developments.

Random and aligned electrostatically spun PLLA nanofibrous membranes enhance bone repair in mouse femur midshaft defects

Long-segment bone defects are a common clinical challenge and abstract biomaterials are a promising therapy. Poly-L-lactic acid (PLLA) nanofibrous membranes prepared by electrostatic spinning have a good bone repair potential. However, there are random and aligned surface morphologies of electrostatic spun PLLA nanofibrous membranes, which can affect the migration, proliferation, and differentiation ability of cells. The role of surface morphology in the repair of long bone defects in vivo is currently unknown. In this study, random and aligned electrostatically spun PLLA nanofibrous membranes were prepared, characterised, and implanted into a femur midshaft defect mouse model. The ability of electrostatically spun PLLA nanofibrous membranes to enhance bone repair was tested using X-ray photography, high-resolution micro-computed tomography (micro-CT), and pathological section specimens. The results showed that both random and aligned electrostatically spun PLLA nanofibrous membranes enhanced bone regeneration at bone defects, but the aligned ones exhibited superior results. These results provide a theoretical basis for engineering the surface morphology of bone repair materials.

Comparison of in vivo failure of precipitation-coated hydroxyapatite temporary anchorage devices with that of uncoated temporary anchorage devices over 18 months

INTRODUCTION

The objective was to compare the stability of hydroxyapatite-coated (HA) temporary anchorage devices (TADs) with uncoated TADs.

METHODS

Maxillary arches of 92 patients with Class II Division 1 malocclusion requiring premolar extractions were randomly distributed to receive both types of Ti-6Al-4V alloy TADs by a single operator. TADs were replicas of each other except for the HA precipitation surface coating of the threaded part. TADs were placed between the roots of the first molar and the second premolar and were immediately loaded by a 300 g of force nickel-titanium spring for retraction of the anterior segment. The main outcome was the loosening of the TAD.

RESULTS

TADs of each type were placed in 92 patients. The patients were recalled monthly for 18 months; 10 TADs failed in the HA-coated group (11%), whereas 12 TADs (13%) failed in the uncoated group, with a statistically insignificant difference between the survivability of the TADs in the 2 groups (P = 0.67, log-rank). The Kaplan-Meier curve showed better survivability of the HA-coated TADs between the second and fifth months. The TADs placed on the left side (19.6%) failed significantly more than on the right side (4.3%) (P = 0.002) when placed by a right-handed operator in right-handed patients.

CONCLUSION

The premise that the HA-coated TADs will have a lower failure rate seems incorrect.

Surface coating of orthopedic implant to enhance the osseointegration and reduction of bacterial colonization: a review

The use of orthopedic implants in surgical technology has fostered restoration of physiological functions. Along with successful treatment, orthopedic implants suffer from various complications and fail to offer functions correspondent to native physiology. The major problems include aseptic and septic loosening due to bone nonunion and implant site infection due to bacterial colonization. Crucial advances in material selection in the design and development of coating matrixes an opportunity for the prevention of implant failure. However, many coating materials are limited in in-vitro testing and few of them thrive in clinical tests. The rate of implant failure has surged with the increasing rates of revision surgery creating physical and sensitive discomfort as well as economic burdens. To overcome critical pathogenic activities several systematic coating techniques have been developed offering excellent results that combat infection and enhance bone integration. This review article includes some more common implant coating matrixes with excellent in vitro and in vivo results focusing on infection rates, causes, complications, coating materials, host immune responses and significant research gaps. This study provides a comprehensive overview of potential coating technology, with functional combination coatings which are focused on ultimate clinical practice with substantial improvement on in-vivo tests. This includes the development of rapidly growing hydrogel coating techniques with the potential to generate several accurate and precise coating procedures.

Osteointegration of hydroxyapatite-coated collars in cemented massive endoprostheses following revision surgery

Aims

Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery.

Methods

Retrospective review of osseointegration frequency, pattern, and timing to a specific HA-coated collar on massive endoprostheses used in revision surgery at our tertiary referral centre between 2010 to 2017 was undertaken. Osseointegration was radiologically classified on cases with a minimum follow-up of six months.

Results

In all, 39 patients underwent radiological review at mean 43.5 months; 22/39 (56.4%) showed no osseointegration to the collar. Revision endoprostheses for aseptic loosening were less likely to show osseointegration compared with other indications for revision. Oncological cases with previous or current infection were more likely to show osseointegration to ≥ 1 collar side than those without evidence of prior infection.

Conclusion

This seven-year review identified osseointegration of HA-coated collars after revision surgery is less likely (43.6%, 17/39) than after primary surgery. Young patients who undergo revision surgery following initial oncological indication may benefit the most from this collar design. Use in revision oncological cases with a history of infection may be beneficial. HA-coated collars showed limited benefit for patients undergoing revision for failed arthroplasty with history of infection.

Cite this article: Bone Jt Open 2021;2(6):371–379.

Assessment of Extra-Cortical Bone Bridge Interface in Cemented Mega Endoprosthesis for Limb Salvage Surgery

Introduction:

Mega endoprosthesis replacement for resection of primary malignant bone tumour requires immediate and long-term stability, particularly in the young and active patient. Extracortical bone bridge interface (EBBI) is a technique whereby autograft is wrapped around the interface junction of bone and porous-coated implant to induce and enhance bone formation for biological incorporation. This procedure increases the mean torsional stiffness and the mean maximum torque, which eventually improves the implant's long-term survival.

Material and methods:

The extracortical bone bridge interface's radiological parameter was evaluated at the prosthesis bone junction two years after surgery utilising a picture archiving and communication system (PACS). The radiograph's anteroposterior and lateral view was analysed for both thickness and length in all four cortices. The analysis was done in SPSS Version 24 using One-Way ANOVA and independent T-Test. Results were presented as mean and standard deviation and considered significant when the p-value was < 0.05.

Results:

The mean average thickness was 2.2293mm (SD 1.829), and the mean average length was 31.95% (SD 24.55). We observed that the thickness and length of EBBI were superior in the young patient or patients with giant cell tumour that did not receive chemotherapy, compared to patients treated for osteosarcoma. The distal femur also had better EBBI compared to the proximal tibia. However, the final multivariable statistical analysis showed no significant difference in all variables. EBBI thickness was significantly and positively correlated with EBBI Length (p<0.001). We conclude that, for each 1mm increase in EBBI thickness, the length will increase by 0.06% on average. About 17.2% of patients out of the 29 showed no radiological evidence of EBBI.

Conclusion:

From our study, there were no factors that significantly contributed to the formation and incorporation of EBBI

Bioinspired surface modification of orthopedic implants for bone tissue engineering

Biomedical implants have been widely used in various orthopedic treatments, including total hip arthroplasty, joint arthrodesis, fracture fixation, non-union, dental repair, etc. The modern research and development of orthopedic implants have gradually shifted from traditional mechanical support to a bioactive graft in order to endow them with better osteoinduction and osteoconduction. Inspired by structural and mechanical properties of natural bone, this review provides a panorama of current biological surface modifications for facilitating the interaction between medical implants and bone tissue and gives a future outlook for fabricating the next-generation multifunctional and smart implants by systematically biomimicking the physiological processes involved in formation and functioning of bones.

Abundant heterotopic bone formation following use of rhBMP-2 in the treatment of acetabular bone defects during revision hip arthroplasty

Revision hip arthroplasty in the setting of periacetabular bone loss presents a significant challenge, as options for restoring bone loss are limited. Recombinant human bone morphogenetic protein-2 may offer a solution by promoting bone growth to restore bone stock before implant reimplantation. Here we present a case of a patient with a periprosthetic acetabulum fracture, resulting in pelvic discontinuity as the result of significant periacetabular bone loss. Using a staged approach, periacetabular bone stock was nearly entirely reconstituted using recombinant BMPs and allograft, which resulted in stable fixation, but with abundant heterotopic bone formation. Recombinant BMP-2 offers a useful tool for restoring bone stock in complex hip arthroplasty revision cases with periacetabular bone loss; however, caution must be used as overabundant bone growth as heterotopic ossification may result.

Recent coating developments for combination devices in orthopedic and dental applications: A literature review

Orthopedic and dental implants have been used successfully for decades to replace or repair missing or damaged bones, joints, and teeth, thereby restoring patient function subsequent to disease or injury. However, although device success rates are generally high, patient outcomes are sometimes compromised due to device-related problems such as insufficient integration, local tissue inflammation, and infection. Many different types of surface coatings have been developed to address these shortcomings, including those that incorporate therapeutic agents to provide localized delivery to the surgical site. While these coatings hold enormous potential for improving device function, the list of requirements that an ideal combination coating must fulfill is extensive, and no single coating system today simultaneously addresses all of the criteria. Some of the primary challenges related to current coatings are non-optimal release kinetics, which most often are too rapid, the potential for inducing antibiotic resistance in target organisms, high susceptibility to mechanical abrasion and delamination, toxicity, difficult and expensive regulatory approval pathways, and high manufacturing costs. This review provides a survey of the most recent developments in the field, i.e., those published in the last 2-3years, with a particular focus on technologies that have potential for overcoming the most significant challenges facing therapeutically-loaded coatings. It is concluded that the ideal coating remains an unrealized target, but that advances in the field and emerging technologies are bringing it closer to reality. The significant amount of research currently being conducted in the field provides a level of optimism that many functional combination coatings will ultimately transition into clinical practice, significantly improving patient outcomes.

The treatment of atrophic, recalcitrant long-bone nonunion in the upper extremity with human recombinant bone morphogenetic protein-7 (rhBMP-7) and plate fixation: A retrospective review

INTRODUCTION

Recombinant Human Bone Morphogenetic Protein-7 (rhBMP-7) has been shown to promote fracture healing in both clinical studies and basic science models, however, there is little information from large-scale studies of its use for human nonunion. The purpose of this study was to determine the safety and efficacy of rhBMP-7 in the treatment of atrophic human long-bone nonunions in the upper extremity.

PATIENTS AND METHODS

This was a single center, retrospective, longitudinal cohort study of patients treated with compression plating and the application of rhBMP-7 in isolation to a long-bone nonunion. Patients over sixteen years of age with an atrophic, aseptic nonunion of a humerus, radius, ulna or clavicle were eligible for inclusion.

RESULTS

We identified seventy eligible patients who were treated with rhBMP-7 for a long-bone nonunion between July 1997 and April 2012. The mean age of the patients at the time of treatment with rhBMP-7 was 50.7 years (range, 20-92 years). Five patients were lost to follow-up prior to definitive clinical or radiographic union. During the one-year post-operative period fifty-six patients had achieved union and two patients developed a stable fibrous union after the index procedure. Two patients had early implant failure and five patients had persistent nonunion. Thus, the union rate following initial surgery was 89% (58/65) and four of the five nonunion patients went on to heal following revision open reduction and internal fixation.

CONCLUSION

We found that the application of rhBMP-7 for upper extremity nonunion was an effective method (89% union rate) of treating this challenging pathology. Additionally, if not initially successful, further reconstruction was not compromised by rhBMP-7 use.

New Ti-Alloys and Surface Modifications to Improve the Mechanical Properties and the Biological Response to Orthopedic and Dental Implants: A Review

Titanium implants are widely used in the orthopedic and dentistry fields for many decades, for joint arthroplasties, spinal and maxillofacial reconstructions, and dental prostheses. However, despite the quite satisfactory survival rates failures still exist. New Ti-alloys and surface treatments have been developed, in an attempt to overcome those failures. This review provides information about new Ti-alloys that provide better mechanical properties to the implants, such as superelasticity, mechanical strength, and corrosion resistance. Furthermore, in vitro and in vivo studies, which investigate the biocompatibility and cytotoxicity of these new biomaterials, are introduced. In addition, data regarding the bioactivity of new surface treatments and surface topographies on Ti-implants is provided. The aim of this paper is to discuss the current trends, advantages, and disadvantages of new titanium-based biomaterials, fabricated to enhance the quality of life of many patients around the world.

Calcium orthophosphate deposits: Preparation, properties and biomedical applications

Since various interactions among cells, surrounding tissues and implanted biomaterials always occur at their interfaces, the surface properties of potential implants appear to be of paramount importance for the clinical success. In view of the fact that a limited amount of materials appear to be tolerated by living organisms, a special discipline called surface engineering was developed to initiate the desirable changes to the exterior properties of various materials but still maintaining their useful bulk performances. In 1975, this approach resulted in the introduction of a special class of artificial bone grafts, composed of various mechanically stable (consequently, suitable for load bearing applications) implantable biomaterials and/or bio-devices covered by calcium orthophosphates (CaPO4) to both improve biocompatibility and provide an adequate bonding to the adjacent bones. Over 5000 publications on this topic were published since then. Therefore, a thorough analysis of the available literature has been performed and about 50 (this number is doubled, if all possible modifications are counted) deposition techniques of CaPO4 have been revealed, systematized and described. These CaPO4 deposits (coatings, films and layers) used to improve the surface properties of various types of artificial implants are the topic of this review.

Hydroxyapatite-coated collars reduce radiolucent line progression in cemented distal femoral bone tumor implants

BACKGROUND

Aseptic loosening of massive bone tumor implants is a major cause of prosthesis failure. Evidence suggests that an osteointegrated hydroxyapatite (HA)-coated collar would reduce the incidence of aseptic loosening around the cemented intramedullary stem in distal femoral bone tumor prostheses. Because these implants often are used in young patients with a tumor, such treatment might extend the longevity of tumor implants. Questions/purposes We asked whether (1) HA-coated collars were more likely to osteointegrate; (2) HA collars were associated with fewer progressive radiolucent lines around the stem-cement interface; and (3) HA-coated collars were associated with less bone loss at the bone-shoulder implant junction?

METHODS

Twenty-two patients were pair-matched to one of two groups--either (1) implants with a HA-coated ingrowth collar (HA Collar Group); or (2) implants without an ingrowth collar (Noncollar Group). Age, sex, and length of followup were similar in both groups. HA-coated collars were developed and used at our institution from 1992 to address the high failure rate attributable to aseptic loosening in patients with massive bone tumor implants. Before this, smooth titanium shafts were used routinely adjacent to bone at the transection site. The minimum followup was 2 years (mean, 7 years; range, 2-12 years). Radiographs obtained throughout the followup period were analyzed and osteointegration at the shaft of the implant quantified. Radiolucent line progression around the cemented stem was semi-quantitatively assessed and cortical bone loss at the bone-shoulder implant junction was measured during the followup period.

RESULTS

Comparison of the most recent radiographs showed nine of 11 patients had osteointegrated HA collars, whereas only one patient in the Noncollar Group had osteointegration (p > 0.001). The radiolucent line score quantified around the cemented stem was lower in the HA Collar Group when compared with the Noncollar Group (p = 0.001). Results showed an increase in cortical bone loss at the bone-shoulder implant junction in the Noncollar Group when compared with the HA Collar Group (p < 0.001).

CONCLUSIONS

Osteointegration at the implant collar resulted in fewer radiolucent lines adjacent to the intramedullary cemented stem and decreased cortical bone loss immediately adjacent to the transection site. These results suggest that the HA collar may help reduce the risk of aseptic loosening in patients with this type of implant, but longer followup and a larger prospective comparison series are necessary to prove this more definitively.

Bi-functionalization of a calcium phosphate-coated titanium surface with slow-release simvastatin and metronidazole to provide antibacterial activities and pro-osteodifferentiation capabilities

Coating the surface of titanium implants or other bone graft substitute materials with calcium phosphate (Ca-P) crystals is an effective way to enhance the osteoconduction of the implants. Ca-P coating alone cannot confer pro-osteodifferentiation and antibacterial capabilities on implants; however, it can serve as a carrier for biological agents which could improve the performance of implants and bone substitutes. Here, we constructed a novel, bi-functional Ca-P coating with combined pro-osteodifferentiation and antibacterial capabilities. Different concentrations of metronidazole (MNZ) and simvastatin (SIM) were integrated into biomimetic Ca-P coatings on the surface of titanium disks. The biological effects of this bi-functional biomimetic coating on human bone marrow mesenchymal stem cells (hBMMSCs), human adipose derived stromal cells (hASCs), and Porphyromonas gingivalis were assessed in vitro. We observed that Ca-P coatings loaded with both SIM and MNZ display favorable release kinetics without affecting cell proliferation or attachment. In the inhibition zone test, we found that the bi-functional coating showed lasting antibacterial effects when incubated with Porphyromonas gingivalis for 2 and 4 days. Moreover, the osteodifferentiation of hBMMSCs and hASCs were increased when cultured on this bi-functional coating for 7 and 14 days. Both drugs were loaded onto the Ca-P coating at specific concentrations (10⁻⁵ M SIM; 10⁻² M MNZ) to achieve optimal release kinetics. Considering the safety, stability and low cost of SIM and MNZ, this novel bi-functional Ca-P coating technique represents a promising method to improve the performance of metal implants or other bone substitute materials, and can theoretically be easily translated to clinical applications.

Long-term survival of cemented distal femoral endoprostheses with a hydroxyapatite-coated collar: a histological study and a radiographic follow-up

BACKGROUND

The objective of this study was to examine the degree of osteointegration into a hydroxyapatite-coated collar and relate this finding to aseptic loosening in patients with a distal femoral replacement used to treat primary bone cancer. Our hypothesis was that the implant collar would increase osteointegration and reduce the rate of aseptic implant loosening.

METHODS

Sixty-one patients treated with a primary cemented distal femoral prosthesis between 1992 and 2001 were included in this study. The mean duration of follow-up was 8.5 years (range, two to eighteen years). Extracortical bone growth into the grooved hydroxyapatite-coated collar was quantified radiographically. Histological sections through four hydroxyapatite-coated collars and four implants with no collar, retrieved following amputation due to local recurrence or at autopsy at a mean of 3.5 years (range, 1.4 to 6.1 years) after implantation, were evaluated as well.

RESULTS

Five (8%) of the implants were revised because of aseptic loosening, 3% of the implants fractured, and 3% were revised because of infection. Six limbs (10%) required amputation because of local tumor recurrence. On radiographs, osteointegration into the collar was seen to have occurred in 70% of the patients and did not correlate with sex, age, diagnosis, or length of time postoperatively. Histological analysis showed mature lamellar bone within the grooves of the hydroxyapatite-coated collar, and bone was observed in direct contact with the hydroxyapatite coating. Extracortical bone failed to make direct contact with the surface of the implants manufactured without a collar.

CONCLUSIONS

The use of cemented distal femoral massive bone tumor prostheses with a hydroxyapatite-coated collar located at the shoulder of the implant was followed by a low (8%) rate of revision due to aseptic loosening. The use of hydroxyapatite grooved collars may lead to osteointegration of the implant shoulder (collar) and may reduce the rate of aseptic loosening.

The future of biologic coatings for orthopaedic implants

Implants are widely used for orthopaedic applications such as fixing fractures, repairing non-unions, obtaining a joint arthrodesis, total joint arthroplasty, spinal reconstruction, and soft tissue anchorage. Previously, orthopaedic implants were designed simply as mechanical devices; the biological aspects of the implant were a byproduct of stable internal/external fixation of the device to the surrounding bone or soft tissue. More recently, biologic coatings have been incorporated into orthopaedic implants in order to modulate the surrounding biological environment. This opinion article reviews current and potential future use of biologic coatings for orthopaedic implants to facilitate osseointegration and mitigate possible adverse tissue responses including the foreign body reaction and implant infection. While many of these coatings are still in the preclinical testing stage, bioengineers, material scientists and surgeons continue to explore surface coatings as a means of improving clinical outcome of patients undergoing orthopaedic surgery.

Protein Nano-Object Integrator (ProNOI) for generating atomic style objects for molecular modeling

Background

With the progress of nanotechnology, one frequently has to model biological macromolecules simultaneously with nano-objects. However, the atomic structures of the nano objects are typically not available or they are solid state entities. Because of that, the researchers have to investigate such nano systems by generating models of the nano objects in a manner that the existing software be able to carry the simulations. In addition, it should allow generating composite objects with complex shape by combining basic geometrical figures and embedding biological macromolecules within the system.

Results

Here we report the Protein Nano-Object Integrator (ProNOI) which allows for generating atomic-style geometrical objects with user desired shape and dimensions. Unlimited number of objects can be created and combined with biological macromolecules in Protein Data Bank (PDB) format file. Once the objects are generated, the users can use sliders to manipulate their shape, dimension and absolute position. In addition, the software offers the option to charge the objects with either specified surface or volumetric charge density and to model them with user-desired dielectric constants. According to the user preference, the biological macromolecule atoms can be assigned charges and radii according to four different force fields: Amber, Charmm, OPLS and PARSE. The biological macromolecules and the atomic-style objects are exported as a position, charge and radius (PQR) file, or if a default dielectric constant distribution is not selected, it is exported as a position, charge, radius and epsilon (PQRE) file. As illustration of the capabilities of the ProNOI, we created a composite object in a shape of a robot, aptly named the Clemson Robot, whose parts are charged with various volumetric charge densities and holds the barnase-barstar protein complex in its hand.

Conclusions

The Protein Nano-Object Integrator (ProNOI) is a convenient tool for generating atomic-style nano shapes in conjunction with biological macromolecule(s). Charges and radii on the macromolecule atoms and the atoms in the shapes are assigned according to the user’s preferences allowing various scenarios of modeling. The default output file is in PQR (PQRE) format which is readable by almost any software available in biophysical field. It can be downloaded from: http://compbio.clemson.edu/downloadDir/ProNO_integrator.tar.gz