Implant osseointegration and the role of microroughness and nanostructures: lessons for spine implants

In vitro and in vivo evaluation of the osseointegration capacity of a polycarbonate-urethane zirconium-oxide composite material for application in a focal knee resurfacing implant

Currently available focal knee resurfacing implants (FKRIs) are fully or partially composed of metals, which show a large disparity in elastic modulus relative to bone and cartilage tissue. Although titanium is known for its excellent osseointegration, the application in FKRIs can lead to potential stress-shielding and metal implants can cause degeneration of the opposing articulating cartilage due to the high resulting contact stresses. Furthermore, metal implants do not allow for follow-up using magnetic resonance imaging (MRI).To overcome the drawbacks of using metal based FKRIs, a biomimetic and MRI compatible bi-layered non-resorbable thermoplastic polycarbonate-urethane (PCU)-based FKRI was developed. The objective of this preclinical study was to evaluate the mechanical properties, biocompatibility and osteoconduction of a novel Bionate® 75D - zirconium oxide (B75D-ZrO2) composite material in vitro and the osseointegration of a B75D-ZrO2 composite stem PCU implant in a caprine animal model. The tensile strength and elastic modulus of the B75D-ZrO2 composite were characterized through in vitro mechanical tests under ambient and physiological conditions. In vitro biocompatibility and osteoconductivity were evaluated by exposing human mesenchymal stem cells to the B75D-ZrO2 composite and culturing the cells under osteogenic conditions. Cell activity and mineralization were assessed and compared to Bionate® 75D (B75D) and titanium disks. The in vivo osseointegration of implants containing a B75D-ZrO2 stem was compared to implants with a B75D stem and titanium stem in a caprine large animal model. After a follow-up of 6 months, bone histomorphometry was performed to assess the bone-to-implant contact area (BIC). Mechanical testing showed that the B75D-ZrO2 composite material possesses an elastic modulus in the range of the elastic modulus reported for trabecular bone. The B75D-ZrO2 composite material facilitated cell mediated mineralization to a comparable extent as titanium. A significantly higher bone-to-implant contact (BIC) score was observed in the B75D-ZrO2 implants compared to the B75D implants. The BIC of B75D-ZrO2 implants was not significantly different compared to titanium implants. A biocompatible B75D-ZrO2 composite approximating the elastic modulus of trabecular bone was developed by compounding B75D with zirconium oxide. In vivo evaluation showed an significant increase of osseointegration for B75D-ZrO2 composite stem implants compared to B75D polymer stem PCU implants. The osseointegration of B75D-ZrO2 composite stem PCU implants was not significantly different in comparison to analogous titanium stem metal implants.

Reduced osseointegration in disuse and denervation rat models results from impaired cellular responses to multiscale microstructured titanium surfaces

Immobilization-induced skeletal unloading results in muscle atrophy and rapid bone loss, thereby increasing the risk of falling and the need for implant therapy in patients with extended bed rest or neuromuscular injuries. Skeletal unloading causes bone loss by altering bone growth and resorption, suggesting that implant performance might be affected. To test this, we focused on early events in implant osseointegration. We used the rat sciatic neurectomy-induced disuse model under two different settings. In Study 1, 16 Sprague Dawley rats (SD) were separated into control, sham operated+cast immobilization, and sciatic neurectomy+casting groups; titanium implants with multiscale microtextured topography and hydrophilic chemistry (modSLA) were inserted in the distal femoral metaphysis. Neurectomy surgeries and casting were performed at the same surgical setting as implant placement; rats were euthanized 4 weeks post-implantation. In Study 2, we established the unloaded condition before implantation. A total of 12 SD rats were divided into control and sciatic+femoral neurectomy groups. A total of 24 days after sciatic and femoral neurectomy surgery, rats received implants. Study 2 rats were euthanized at 4 weeks post-implantation. MicroCT and histomorphometry showed that trabecular bone and osseointegration were reduced when disuse was established before implantation. Osteoblasts isolated from Study 1 sciatic neurectomy tibial bones exhibited impaired differentiation on modSLA culture disks, revealing a possible mechanism responsible for the decreased osseointegration observed in the Study 2 rats. This study addressed the importance of considering the mechanical unloading and muscle function history before implant insertion and suggests that implant performance was reduced due to poor cellular ability to regenerate.

Biomechanical Effects of Different Prosthesis Types and Fixation Ranges in Multisegmental Total En Bloc Spondylectomy: A Finite Element Study

OBJECTIVE

Multi-segmental total en bloc spondylectomy (TES) gradually became more commonly used by clinicians. However, the choice of surgical strategy is unclear. This study aims to investigate the biomechanical performance of different prosthesis types and fixation ranges in multisegmental TES.

METHODS

In this study, a validated finite element model of T12-L2 post-spondylectomy operations were carried out. The prostheses of these models used either 3D-printed artificial vertebrae or titanium mesh cages. The fixed range was two or three segment levels. Range of motion, stress distribution of the endplate and internal fixation system, intervertebral disc pressure, and facet joint surface force of four postoperative models and intact model in flexion and extension, as well as lateral bending and rotation were analyzed and compared.

RESULTS

The type of prosthesis used in the anterior column reconstruction mainly affected the stress of the adjacent endplate and the prosthesis itself. The posterior fixation range had a greater influence on the overall range of motion (ROM), the ROM of the adjacent segment, the stress of the screw-rod system, and adjacent facet joint surface force. For the model of the same prosthesis, the increase of fixed length resulted in an obvious reduction of ROM. The maximal decrease was 70.23% during extension, and the minimal decrease was 30.19% during rotation.

CONCLUSION

In three-segment TES, the surgical strategy of using 3D-printed artificial prosthesis for anterior column support and pedicle screws for posterior fixation at both two upper and lower levels respectively can reduce the stress on internal fixation system, endplates, and adjacent intervertebral discs, resulting in a reduced risk of internal fixation failure, and ASD development.

Tailoring zirconia surface topography via femtosecond laser-induced nanoscale features: effects on osteoblast cells and antibacterial properties

The performance and long-term durability of dental implants hinge on the quality of bone integration and their resistance to bacteria. This research aims to introduce a surface modification strategy for zirconia implants utilizing femtosecond laser ablation techniques, exploring their impact on osteoblast cell behavior and bacterial performance, as well as the integral factors influencing the soft tissue quality surrounding dental implants. Ultrafast lasers were employed to craft nanoscale groove geometries on zirconia surfaces, with thorough analyses conducted using x-ray diffraction, scanning electron microscopy, atomic force microscopy, and water contact angle measurements. The study evaluated the response of human fetal osteoblastic cell lines to textured zirconia ceramics by assessing alkaline phosphatase activity, collagen I, and interleukin 1βsecretion over a 7 day period. Additionally, the antibacterial behavior of the textured surfaces was investigated usingFusobacterium nucleatum, a common culprit in infections associated with dental implants. Ciprofloxacin (CIP), a widely used antibacterial antibiotic, was loaded onto zirconia ceramic surfaces. The results of this study unveiled a substantial reduction in bacterial adhesion on textured zirconia surfaces. The fine biocompatibility of these surfaces was confirmed through the MTT assay and observations of cell morphology. Moreover, the human fetal osteoblastic cell line exhibited extensive spreading and secreted elevated levels of collagen I and interleukin 1βin the modified samples. Drug release evaluations demonstrated sustained CIP release through a diffusion mechanism, showcasing excellent antibacterial activity against pathogenic bacteria, includingStreptococcus mutans, Pseudomonas aeruginosa, andEscherichia coli.

The Addition of Hydroxyapatite Nanoparticles on Implant Surfaces Modified by Zirconia Blasting and Acid Etching to Enhance Peri-Implant Bone Healing

This study investigated the impact of adding hydroxyapatite nanoparticles to implant surfaces treated with zirconia blasting and acid etching (ZiHa), focusing on structural changes and bone healing parameters in low-density bone sites. The topographical characterization of titanium discs with a ZiHa surface and a commercially modified zirconia-blasted and acid-etched surface (Zi) was performed using scanning electron microscopy, profilometry, and surface-free energy. For the in vivo assessment, 22 female rats were ovariectomized and kept for 90 days, after which one implant from each group was randomly placed in each tibial metaphysis of the animals. Histological and immunohistochemical analyses were performed at 14 and 28 days postoperatively (decalcified lab processing), reverse torque testing was performed at 28 days, and histometry from calcified lab processing was performed at 60 days The group ZiHa promoted changes in surface morphology, forming evenly distributed pores. For bone healing, ZiHa showed a greater reverse torque, newly formed bone area, and bone/implant contact values compared to group Zi (p < 0.05; t-test). Qualitative histological and immunohistochemical analyses showed higher features of bone maturation for ZiHa on days 14 and 28. This preclinical study demonstrated that adding hydroxyapatite to zirconia-blasted and acid-etched surfaces enhanced peri-implant bone healing in ovariectomized rats. These findings support the potential for improving osseointegration of dental implants, especially in patients with compromised bone metabolism.

Effects of nanomodified titanium surfaces considering bacterial colonization and viability of osteoblasts and fibroblasts

This study investigates nanostructured titanium surfaces (Ti2 spikes) that promote the viability of osteoblasts and fibroblasts and prevent bacterial colonisation. Helium ion irradiation was adopted to produce nanometric-sized cones on titanium. Human osteoblasts (hFOB) and human gingiva fibroblasts (hGF) were used for analysis. A viability and a cytotoxicity assay were conducted to evaluate the lactate dehydrogenase (LDH) activity and assess cell damage in Ti2 spikes compared to titanium discs with a sandblasted and acid-etched (Ti2 SLA) surface. The antibacterial activity was investigated against Escherichia coli, Streptococcus mutans, Fusobacterium nucleatum, and Porphyromonas gingivalis. In the course of the cultivation, both hGF and hFOB demonstrated significantly reduced viability on the Ti2 spikes surface. hGF cells exhibited a slight but significant increase in LDH release. In contrast, hFOB showed reduced cytotoxicity on this surface. On the Ti2 spikes surface, hGF cells exhibited a significant reduction in gene expression of VCL, Src-1, and ITGα5. However, the integrin subunits ITGα1 and ITGα3 showed upregulation on the Ti2 spikes surface. The Ti2 spikes surface significantly increased the expression of almost all osteogenic markers. The results of conventional culturing demonstrated a statistically significant decrease in the number of viable cells for S. mutans, F. nucleaum, and greater quantities of P. gingivalis on Ti2 spikes surface compared to control. However, no such reduction was detected for E. coli. The long-term success of implants relies on establishing and maintaining hard and soft peri-implant tissues. Ti2 spikes represent a novel and promising approach to enhance osseointegration and optimize biocompatibility.

Enhancing the Biological Performance of Titanium Alloy through In Situ Modulation of the Surface Nanostructure: Near-Infrared-Responsive Antibacterial Function and Osteoinductivity

The poor clinical performance of titanium and its alloy implants is mainly attributed to their lack of antibacterial ability and poor osseointegration. The key and challenge lie in how to enhance their osteoinductivity while imparting antibacterial capability. In this study, a titanium oxide metasurface with light-responsive behavior was constructed on the surface of titanium alloy using an alkaline-acid bidirectional hydrothermal method. The effects of the acid type, acid concentration, hydrothermal time, hydrothermal temperature, and subsequent heat treatments on the optical behavior of the metasurface were systematically investigated with a focus on exploring the influence of the metasurface and photodynamic reaction on the osteogenic activity of osteoblasts. Results show that the type of acid and heat treatment significantly affect the light absorption of the titanium alloy surface, with HCl and post-heat-treatment favoring redshift in the light absorption. Under 808 nm near-infrared (NIR) irradiation for 10 min, in vitro antibacterial experiments demonstrate that the antibacterial rate of the metasurface titanium alloy against Staphylococcus aureus and Escherichia coli were 96.87% and 99.27%, respectively. In vitro cell experiments demonstrate that the nanostructure facilitates cell adhesion, proliferation, differentiation, and expression of osteogenic-related genes. Surprisingly, the nanostructure promoted the expression of relevant osteogenic genes of MC3T3-E1 under 808 nm NIR irradiation. This study provides a method for the surface modification of titanium alloy implants.

Wnt16 Increases Bone-to-Implant Contact in an Osteopenic Rat Model by Increasing Proliferation and Regulating the Differentiation of Bone Marrow Stromal Cells

Osseointegration is a complex biological cascade that regulates bone regeneration after implant placement. Implants possessing complex multiscale surface topographies augment this regenerative process through the regulation of bone marrow stromal cells (MSCs) that are in contact with the implant surface. One pathway regulating osteoblastic differentiation is Wnt signaling, and upregulation of non-canonical Wnts increases differentiation of MSCs on these titanium substrates. Wnt16 is a non-canonical Wnt shown to regulate bone morphology in mouse models. This study evaluated the role of Wnt16 during surface-mediated osteoblastic differentiation of MSCs in vitro and osseointegration in vivo. MSCs were cultured on Ti substrates with different surface properties and non-canonical Wnt expression was determined. Subsequently, MSCs were cultured on Ti substrates +/-Wnt16 (100 ng/mL) and anti-Wnt16 antibodies (2 μg/mL). Wnt16 expression was increased in cells grown on microrough surfaces that were processed to be hydrophilic and have nanoscale roughness. However, treatment MSCs on these surfaces with exogenous rhWnt16b increased total DNA content and osteoprotegerin production, but reduced osteoblastic differentiation and production of local factors necessary for osteogenesis. Addition of anti-Wnt16 antibodies blocked the inhibitor effects of Wnt16. The response to Wnt16 was likely independent of other osteogenic pathways like Wnt11-Wnt5a signaling and semaphorin 3a signaling. We used an established rat model of cortical and trabecular femoral bone impairment following botox injections (2 injections of 8 units/leg each, starting and maintenance doses) to assess Wnt16 effects on whole bone morphology and implant osseointegration. Wnt16 injections did not alter whole bone morphology significantly (BV/TV, cortical thickness, restoration of trabecular bone) but were effective at increasing cortical bone-to-implant contact during impaired osseointegration in the botox model. The mechanical quality of the increased bone was not sufficient to rescue the deleterious effects of botox. Clinically, these results are important to understand the interaction of cortical and trabecular bone during implant integration. They suggest a role for Wnt16 in modulating bone remodeling by reducing osteoclastic activity. Targeted strategies to temporally regulate Wnt16 after implant placement could be used to improve osseointegration by increasing the net pool of osteoprogenitor cells.

Atomic Layer Deposition of Zirconia on Titanium Implants Improves Osseointegration in Rabbit Bones

Purpose

Atomic layer deposition (ALD) is a method that can deposit zirconia uniformly on an atomic basis. The effect of deposited zirconia on titanium implants using ALD was evaluated in vivo.

Methods

Machined titanium implants (MTIs) were used as the Control. MTIs treated by sandblasting with large grit and acid etching (SA) and MTIs deposited with zirconia using ALD are referred to as Groups S and Z, respectively. Twelve implants were prepared for each group. Six rabbits were used as experimental animals. To evaluate the osteogenesis and osteocyte aspects around the implants, radiological and histological analyses were performed. The bone-to-implant contact (BIC) ratio was measured and statistically analyzed to evaluate the osseointegration capabilities.

Results

In the micro-CT analysis, more radiopaque bone tissues were observed around the implants in Groups S and Z. Histological observation found that Groups S and Z had more and denser mature bone tissues around the implants in the cortical bone area. Many new and mature bone tissues were also observed in the medullary cavity area. For the BIC ratio, Groups S and Z were significantly higher than the Control in the cortical bone area (P < 0.017), but there was no significant difference between Groups S and Z.

Conclusion

MTIs deposited with zirconia using ALD (Group Z) radiologically and histologically showed more mature bone formation and activated osteocytes compared with MTIs (Control). Group Z also had a significantly higher BIC ratio than the Control. Within the limitations of this study, depositing zirconia on the surface of MTIs using ALD can improve osseointegration in vivo.

Ion-incorporated titanium implants for staged regulation of antibacterial activity and immunoregulation-mediated osteogenesis

Antibacterial properties and osteogenic activity are considered as two crucial factors for the initial healing and long-term survivability of orthopedic implants. For decades, various drug-loaded implants to enhance biological activities have been investigated extensively. More importantly, to control the drug release timing is equally significant due to the sequential biological processes after implantation. Hence, developing a staged regulation system on the titanium surface is practically significant. Here, we prepared TiO2 nanotubes (TiO2 NTs) on the titanium surface by anodization, followed by the incorporation of zinc (Zn) and strontium (Sr) sequentially through a hydrothermal process. Surface characterization confirmed the successful fabrication of Zn and Sr-incorporated TiO2 NTs (Zn-Sr/TiO2) on the titanium surface. The ion release results exhibited the differential release characteristic of Zn and Sr, which meant the early-stage release of Zn and the long-term release of Sr. It was exactly in accord with  the biological process after implantation, laying the basis of staged regulation after implantation. Zn-Sr/TiO2 showed favorable anti-early infection properties both in vitro and in vivo. Its inhibition effect on bacterial biofilm formation was attributed to the resistance against bacteria's initial adhesion and the killing effect on planktonic bacteria. Additionally, the release of Sr could alleviate infection-induced damage via immunoregulation. The biocompatibility and osteogenic activity mediated by M2 macrophage activation were confirmed with in vitro and in vivo studies. Therefore, it exhibited great potential in staged regulation for antibacterial activity in the early stage and the M2 activation-mediated osteogenic activity in the late stage. The staged regulation process was based on the differential release of Zn and Sr to achieve the early antibacterial effect and the long-term immune-induced osteogenic activity, to prevent implant-related infection and achieve better osseointegration. These two kinds of ions played their roles synergistically and complement mutually. This work is expected to provide an innovative idea for realizing sequential regulation after implantation.

Porous 3D Printed Titanium Cages in Anterior Cervical Discectomy and Fusion are Associated With Less Subsidence, Improved Maintenance of Segmental Lordotic Correction, and Similar Clinical Outcomes as Allograft

STUDY-DESIGN

Retrospective chart review.

OBJECTIVES

Investigate radiographic and clinical outcomes of 3D printed titanium cages (3DTC) vs allograft in patients undergoing Anterior cervical discectomy and fusion (ACDF).

METHODS

Consecutive series of patients undergoing ACDF with 3DTC were compared to patients using corticocancellous allograft. Cage subsidence, fusion status, sagittal alignment, and patient-reported-outcomes. Radiographic evaluation was performed on the closing intraoperative x-ray and compared to films at 6-weeks, 6-months, and 1-year. Cage subsidence was calculated based on the amount of settling into superior and inferior endplates compared to the intraoperative x-ray. Fusion was assessed based on < 1 mm of flexion/extension motion. Sagittal alignment parameters and patient-reported-outcomes were measured.

RESULTS

Seventy six-patients/(120 levels) in 3DTC group and 77-patients/(115 levels) in allograft group were evaluated. No significant differences were noted in patient demographics, level fused or the number of levels fused between the groups. The most common level fused was C5-6. 3DTC had a significantly lower subsidence rate at all-time points as compared to allograft (P < .001). 3DTC maintained segmental lordosis better than allograft at all-time points including 1-year postop (P < .001). No significant differences were noted in fusion rate for 3DTC vs allograft at 6-months (P > .05). There were no significant differences in patient-reported-outcomes.

CONCLUSION

3D printed titanium cages had similar patient-reported outcomes and fusion rates as allograft, but less subsidence at all-time points. 3D printed titanium cages better maintained the segmental lordosis at the operative level at all-time points. Although longer term evaluation is needed, based on these results, 3DTC appear to be viable graft options for ACDF that better maintain disc space height and improve segmental lordotic interbody correction.

Evaluation of the Effects of Whey Protein and Moringa Oleifera Leaves Extract Mixture on Osseointegration in Rabbits

Background

Osteogenic, antioxidant and anti-inflammatory effects of Whey protein and M. oleifera gel prompted us to evaluate their role alone or in combination on osseointegration in rabbits.

Methods

In this study, 24 titanium implants were inserted in the femurs of six rabbits. One implant was placed without treatment, and another one was coated with a mixture of whey protein and M. oleifera gel for each side. The animals were divided into two groups of 2- and 6-week intervals and evaluated using histopathological and immunohistochemical techniques.

Results

Histological evaluation revealed a significant difference between the experimental and the control groups after two weeks in osteoblast and osteocyte counts. The experimental group had mature bone development after six weeks of implantation, while the control group had a woven bone. Immunohistochemical results showed that the experimental group, compared to the control group, exhibited early positive expression of osteoblast cells at two weeks after the experiment. Based on histopathological observations, the experimental group showed a tiny area of collagenous fiber in 6th week after the implantation.

Conclusion

A mixture of whey protein and M. oleifera could accelerate osseointegration and healing processes.

Implants coating strategies for antibacterial treatment in fracture and defect models: A systematic review of animal studies

Objective

Fracture-related infection (FRI) remains a major concern in orthopaedic trauma. Functionalizing implants with antibacterial coatings are a promising strategy in mitigating FRI. Numerous implant coatings have been reported but the preventive and therapeutic effects vary. This systematic review aimed to provide a comprehensive overview of current implant coating strategies to prevent and treat FRI in animal fracture and bone defect models.

Methods

A literature search was performed in three databases: PubMed, Web of Science and Embase, with predetermined keywords and criteria up to 28 February 2023. Preclinical studies on implant coatings in animal fracture or defect models that assessed antibacterial and bone healing effects were included.

Results

A total of 14 studies were included in this systematic review, seven of which used fracture models and seven used defect models. Passive coatings with bacteria adhesion resistance were investigated in two studies. Active coatings with bactericidal effects were investigated in 12 studies, four of which used metal ions including Ag+ and Cu2+; five studies used antibiotics including chlorhexidine, tigecycline, vancomycin, and gentamicin sulfate; and the other three studies used natural antibacterial materials including chitosan, antimicrobial peptides, and lysostaphin. Overall, these implant coatings exhibited promising efficacy in antibacterial effects and bone formation.

Conclusion

Antibacterial coating strategies reduced bacterial infections in animal models and favored bone healing in vivo. Future studies of implant coatings should focus on optimal biocompatibility, antibacterial effects against multi-drug resistant bacteria and polymicrobial infections, and osseointegration and osteogenesis promotion especially in osteoporotic bone by constructing multi-functional coatings for FRI therapy.

The translational potential of this paper

The clinical treatment of FRI is complex and challenging. This review summarizes novel orthopaedic implant coating strategies applied to FRI in preclinical studies, and offers a perspective on the future development of orthopaedic implant coatings, which can potentially contribute to alternative strategies in clinical practice.

Ultrathin TiO2 Coatings via Atomic Layer Deposition Strongly Improve Cellular Interactions on Planar and Nanotubular Biomedical Ti Substrates

This work aims to investigate the chemical and/or structural modification of Ti and Ti-6Al-4V (TiAlV) alloy surfaces to possess even more favorable properties toward cell growth. These modifications were achieved by (i) growing TiO2 nanotube layers on these substrates by anodization, (ii) surface coating by ultrathin TiO2 atomic layer deposition (ALD), or (iii) by the combination of both. In particular, an ultrathin TiO2 coating, achieved by 1 cycle of TiO2 ALD, was intended to shade the impurities of F- and V-based species in tested materials while preserving the original structure and morphology. The cell growth on TiO2-coated and uncoated TiO2 nanotube layers, Ti foils, and TiAlV alloy foils were compared after incubation for up to 72 h. For evaluation of the biocompatibility of tested materials, cell lines of different tissue origin, including predominantly MG-63 osteoblastic cells, were used. For all tested nanomaterials, adding an ultrathin TiO2 coating improved the growth of MG-63 cells and other cell lines compared with the non-TiO2-coated counterparts. Here, the presented approach of ultrathin TiO2 coating could be used potentially for improving implants, especially in terms of shading problematic F- and V-based species in TiO2 nanotube layers.

Nanoshell Formation at the Electrically Charged Gas-Water Interface of Collapsing Microbubbles: Insights from Atomic Force Microscopy Imaging

AFM imaging has revealed intriguing features when bulk nanobubbles were deposited on a positively charged substrate. Numerous spherical objects, each less than 20 nm in diameter, were observed on the substrate. These objects were adorned with noticeable, tiny protrusions, each measuring a few nanometers. These findings suggest the presence of solid shells contributing to the stability of the gas bodies. Furthermore, electrically charged microbubbles appear to play a critical role in the formation of these solid shells. The collapse of microbubbles in an electrolyte aqueous solution containing iron ions leads to a condensing ionic cloud, creating conditions necessary for solid nucleation at the interface. At the end of the collapsing process, concurrent multinucleation may result in the deposition of solid material on the interface, forming solid shells with specific structures on the surfaces. This study illuminates the phenomenon of electrically charged gas-water interfaces during microbubble collapse and highlights the generation of stabilized nanoshells in aqueous solutions without the need for chemical stabilizers.

Electrophoretically deposited titanium and its alloys in biomedical engineering: Recent progress and remaining challenges

Over the past decade, titanium implants have gained popularity as the number of performed implantation operations has significantly increased. There are a number of methods for modifying the surface of biomaterials, which are aimed at extending the life of titanium implants. The developments in this field in recent years have required a comprehensive discussion of all the properties of electrophoretically deposited coatings on titanium and its alloys, taking into account their bioactivity. The development that took place in this field in recent years required a comprehensive discussion of all the properties of coatings electrophoretically deposited on titanium and its alloys, with particular emphasis on their bioactivity. Herein, we attempt to assess the influence of the electrophoretic deposition (EPD) process parameters on these coatings' biological and mechanical properties. Particular attention has been addressed to the in-vitro and in-vivo studies conducted hitherto. We have seen an increased interest in using titanium alloys without the addition of toxic compounds and gaps in the EPD field such as the uncommon endeavors to develop a "Design of experiments" approach as well as the lack of assessment of the surface free energy and detailed topography of electrophoretically deposited coatings. The exact correlation of coating properties with EPD process parameters still seems explicitly not understood, necessitating more future investigations. Ipso facto, the exact mechanism of particle agglomeration and Hamaker's law need to be fathomable.

Clinical and radiological results of TLIF surgery with titanium-coated PEEK or uncoated PEEK cages: a prospective single-centre randomised study

BACKGROUND

A comparison of fusion rates and clinical outcomes of instrumented transforaminal interbody fusion (TLIF) between polyetheretherketone (PEEK) and titanium-coated PEEK (Ti-PEEK) cages is not well documented.

METHODS

A single-centre, prospective, randomised study included patients who underwent one-level TLIF between L3-S1 segments. Patients were randomised into one of two groups: TLIF surgery with the PEEK cage and TLIF surgery with the Ti-PEEK cage. Clinical results were measured. All patients were assessed by repeated X-rays and 3D CT scans. Cage integration was assessed using a modified Bridwell classification. The impact of obesity and smoking on fusion quality was also analysed. Patients in both groups were followed up for 2 years.

RESULTS

Altogether 87 patients were included in the study: of these 87 patients, 81 (93.1%) completed the 2-year follow-up. A significant improvement in clinical outcome was found in the two measurements scales in both groups (RM: p = 0.257, VAS: p = 0.229). There was an increase in CobbS and CobbL angle in both groups (p = 0.172 for CobbS and p = 0.403for CobbL). Bony fusion was achieved in 37 of 40 (92.5%) patients in the TiPEEK group and 35 of 41 (85.4%) in the PEEK group (p = 0.157). Cage subsided in 2 of 40 patients (5%) in the TiPEEK group and 11 of 41 (26.8%) in the PEEK group (p = 0.007). Body mass index > 30 and smoking were not predictive factors of bony fusion achievement.

CONCLUSION

There is no significant advantage of TiPEEK cages over PEEK cages in clinical outcome and fusion rate 2 years after surgery.

A strategy for enhancing bioactivity and osseointegration with antibacterial effect by incorporating magnesium in polylactic acid based biodegradable orthopedic implant

Biodegradable orthopedic implants are essential for restoring the physiological structure and function of bone tissue while ensuring complete degradation after recovery. Polylactic acid (PLA), a biodegradable polymer, is considered a promising material due to its considerable mechanical properties and biocompatibility. However, further improvements are necessary to enhance the mechanical strength and bioactivity of PLA for reliable load-bearing orthopedic applications. In this study, a multifunctional PLA-based composite was fabricated by incorporating tricalcium phosphate (TCP) microspheres and magnesium (Mg) particles homogenously at a volume fraction of 40 %. This approach aims to enhance mechanical strength, accelerate pore generation, and improve biological and antibacterial performance. Mg content was incorporated into the composite at varying values of 1, 3, and 5 vol% (referred to as PLA/TCP-1 Mg, PLA/TCP-3 Mg, and PLA/TCP-5 Mg, respectively). The compressive strength and stiffness were significantly enhanced in all composites, reaching 87.7, 85.9, and 84.1 MPa, and 2.7, 3.0, and 3.1 GPa, respectively. The degradation test indicated faster elimination of the reinforcers as the Mg content increased, resulting in accelerated pore generation to induce enhanced osseointegration. Because PLA/TCP-3 Mg and PLA/TCP-5 Mg exhibited cracks in the PLA matrix due to rapid corrosion of Mg forming corrosion byproducts, to optimize the Mg particle content, PLA/TCP-1 Mg was selected for further evaluation. As determined by in vitro biological and antibacterial testing, PLA/TCP-1 Mg showed enhanced bioactivity with pre-osteoblast cells and exhibited antibacterial properties by suppressing bacterial colonization. Overall, the multifunctional PLA/TCP-Mg composite showed improved mechanobiological performance, making it a promising material for biodegradable orthopedic implants.

Internal surface modification of additively manufactured macroporous TiAl6V4 biomimetic implants via a calciothermic reaction-based process and osteogenic in vivo responses

Three-dimensional macroporous titanium-aluminum-vanadium (TiAl6V4) implants produced by additive manufacturing (AM) can be grit blasted (GB) to yield microtextured exterior surfaces, with additional micro/nano-scale surface features provided by subsequent acid etching (AE). However, the line-of-sight nature of GB causes the topography of exterior GB + AE-modified surfaces to differ from internal GB-inaccessible surfaces. Previous in vitro studies using dense TiAl6V4 substrates indicated that a nonline-of-sight, calciothermic-reaction (CaR)-based process provided homogeneous osteogenic nanotextures on GB + AE surfaces, suggesting it could be used to achieve a homogeneous nanotopography on external and internal surfaces of macroporous AM constructs. Macroporous TiAl6V4 (3D) constructs were produced by direct laser melting and modified by GB + AE, with the CaR process then applied to 50% of constructs (3DCaR). The CaR process yielded nanoporous/nanorough internal surfaces throughout the macroporous constructs. Skeletally mature, male Sprague-Dawley rats were implanted with these constructs using a cranial on-lay model. Prior to implantation, a Cu++-free click hydrogel was applied to half of the constructs (3D + H, 3DCaR + H) to act as a challenge to osseointegration. Osseointegration was compared between the four implant groups (3D, 3DCaR, 3D + H, 3DCaR + H) at 4w. 3D + H implants exhibited lower bone volume (BV) and percent bone ingrowth (%BI) than the 3D implants. In contrast, osseointegrated 3DCaR + H implants had similar BV and %BI as the 3DCaR implants. Implant pull-off forces correlated with these results. In vitro analyses indicated that human bone marrow stromal cells (MSCs) exhibited enhanced production of osteoblast differentiation markers and factors associated with osteogenesis when grown on CaR-modified 3D substrates relative to control (TCPS) substrates. This work confirms that the CaR process provides osteogenic nanotextures on internal surfaces of macroporous 3D implants, and suggests that CaR-modified surfaces can promote osseointegration in cases where osteogenesis is impaired.

Stability, biomechanics and biocompatibility analysis following different preparation strategies of hierarchical zeolite coatings on titanium alloy surfaces

Traditional titanium alloy implant surfaces are inherently smooth and often lack effective osteoinductive properties. To overcome these limitations, coating technologies are frequently employed to enhance the efficiency of bone integration at the implant-host bone interface. Hierarchical zeolites, characterized by their chemical stability, can be applied to 3D-printed porous titanium alloy (pTi) surfaces as coating. The resulting novel implants with a "microporous-mesoporous-macroporous" spatial gradient structure can influence the behavior of adjacent cells; thereby, promoting the integration of bone at the implant interface. Consequently, a thorough exploration of various preparation methods is warranted for hierarchical zeolite coatings with respect to biocompatibility, coating stability, and osteogenesis. In this study, we employed three methods: in situ crystal growth, secondary growth, and layer-by-layer assembly, to construct hierarchical zeolite coatings on pTi, resulting in the development of a gradient structure. The findings of this investigation unequivocally demonstrated that the LBL-coating method consistently produced coatings characterized by superior uniformity, heightened surface roughness, and increased hydrophilicity, as well as increased biomechanical properties. These advantages considerably amplified cell adhesion, spreading, osteogenic differentiation, and mineralization of MC3T3-E1 cells, presenting superior biological functionality when compared to alternative coating methods. The outcomes of this research provide a solid theoretical basis for the clinical translation of hierarchical zeolite coatings in surface modifications for orthopedic implants.

Synergistic effect of hierarchical topographic structure on 3D-printed Titanium scaffold for enhanced coupling of osteogenesis and angiogenesis

The significance of the osteogenesis-angiogenesis relationship in the healing process of bone defects has been increasingly emphasized in recent academic research. Surface topography plays a crucial role in guiding cellular behaviors. Metal-organic framework (MOF) is an innovative biomaterial with nanoscale structural and topological features, enabling the modulation of scaffold physicochemical properties. This study involved the loading of varying quantities of UiO-66 nanocrystals onto alkali-heat treated 3D-printed titanium scaffolds, resulting in the formation of hierarchical micro/nano topography named UiO-66/AHTs. The physicochemical properties of these scaffolds were subsequently characterized. Furthermore, the impact of these scaffolds on the osteogenic potential of BMSCs, the angiogenic potential of HUVECs, and their intercellular communication were investigated. The findings of this study indicated that 1/2UiO-66/AHT outperformed other groups in terms of osteogenic and angiogenic induction, as well as in promoting intercellular crosstalk by enhancing paracrine effects. These results suggest a promising biomimetic hierarchical topography design that facilitates the coupling of osteogenesis and angiogenesis.

Fabrication of a micro/nanocomposite structure on the surface of high oxygen concentration titanium to promote bone formation

This study investigated the properties of the micro/nano composite structure on the surface of high oxygen concentration titanium (HOC-Ti) after anodic oxidation modification (HOC-NT) and evaluated its biocompatibility as a dental implant material in vitro and in vivo. HOC-Ti was produced by titanium powders and rutile powders using the powder metallurgy method. Its surface was modified by anodic oxidation. After detecting the electrochemical characteristics, the surface properties of HOC-NT were investigated. MC3T3 and MLO-Y4 cells were employed to evaluate the biocompatibility of HOC-NT and cocultured to study the effects of the changes in osteocytes induced by HOC-NT on osteoblasts. While, its possible mechanism was investigated. In addition, osseointegration around the HOC-NT implant was investigated through in vivo experiments. The results showed that a unique micronano composite structure on the HOC-Ti surface with excellent hydrophilicity and suitable surface roughness was created after anodic oxidation promoted by its electrochemical characteristics. The YAP protein may play an important role in regulating bone remodeling by β-catenin and Rankl/OPG Signaling Pathways. An in vivo study also revealed an accelerated formation rate of new bone and more stable osseointegration around the HOC-NT implant. In view of all experimental results, it could be concluded that the unique morphology of HOC-NT has enhanced physicochemical and biological properties. The promotion of bone formation around implants indicated the feasibility of HOC-NT for applications in oral implants.

Enhanced osteogenic and antibacterial properties of polyetheretherketone by ultraviolet-initiated grafting polymerization of a gelatin methacryloyl/epsilon-poly-L-lysine/laponite hydrogel coating

Polyetheretherketone (PEEK) is a promising material for use in orthopedic implants, but its bio-inert character and lack of antibacterial activity limit its applications in bone repair. In the present study, considering the advantages of PEEK in self-initiated graft polymerization and of hydrogels in bone tissue engineering, we constructed a hydrogel coating (GPL) consisting of Gelatin methacryloyl (GelMA), methacrylamide-modified ε-poly-l-lysine (ε-PLMA) and Laponite on PEEK through UV-initiated crosslinking. The coating improved the hydrophilicity of PEEK, and the coating degraded slowly so that approximately 80% was retained after incubation in PBS for 8 weeks. In vitro studies revealed that as compared to culturing on PEEK, culturing on PEEK-GPL led to enhanced viability and adhesion of cultured human umbilical cord Wharton's jelly-derived mesenchymal stem cells (hWJ-MSCs). Due to the synergistic effect of the micron-scale three-dimensional surface and Laponite, PEEK-GPL exhibited a significantly improved induction of osteogenic differentiation of hWJ-MSCs compared to PEEK, as demonstrated by increased alkaline phosphatase activity, matrix mineralization, and expression of osteogenesis-related genes. Furthermore, PEEK-GPL showed antibacterial activity upon contact with Staphylococcus aureus and Escherichia coli, and this activity would be maintained before complete degradation of the hydrogel because the ε-PLMA was cross-linked covalently into the coating. Thus, PEEK-GPL achieved both osteogenesis and infection prevention in a single simple step, providing a feasible approach for the extensive use of PEEK in bone implants.

Effect of sulfonation time on physicochemical, osteogenic, antibacterial properties and biocompatibility of carbon fiber reinforced polyether ether ketone

The carbon fiber reinforced polyetheretherketone (CFR-PEEK) has been increasingly used in orthopedics dentistry due to its excellent biocompatibility and mechanical properties. However, the biological inertness and poor antibacterial activity limit its clinical applications. This paper focused on the performances of CFR-PEEK with porous morphology that were exposed to different sulfonation periods (1, 3, 5, and 10 min, corresponding to CP-S1, CP-S3, CP-S5, and CP-S10, respectively). Residual sulfuric acid was removed by acetone rinsing, NaOH immersion, and hydrothermal treatment before in vitro and in vivo studies. The results showed some significant difference in the physicochemical properties, including energy dispersive X-ray spectroscopy (EDS) map of sulfur atoms, X-ray photoelectron spectroscopy (XPS) of valences of sulfur ions, Fourier transformation infrared spectroscopy (FTIR), hydrophilicity, hardness, and elastic modulus among CP-S3, CP-S5, and CP-S10. However, CP-S5 and CP-S10 were more effective in promoting the proliferation, adhesion, and osteogenic differentiation of seeded bone mesenchymal stem cells (BMSCs) and growth inhibition of S. aureus and P. gingivalis compared with other groups. Furthermore, the CP-S5 and CP-S10 samples achieved better cranial bone repair than the non-sulfonation group in a rat model. Therefore, it can be inferred that both 5 and 10 min are viable sulfonation durations for 30% CFR-PEEK. These findings provide a theoretical basis for developing CFR-PEEK for clinical applications.

Research and Application of Medical Polyetheretherketone as Bone Repair Material

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.

The current status of stimuli-responsive nanotechnologies on orthopedic titanium implant surfaces

With the continuous innovation and breakthrough of nanomedical technology, stimuli-responsive nanotechnology has been gradually applied to the surface modification of titanium implants to achieve brilliant antibacterial activity and promoted osteogenesis. Regarding to the different physiological and pathological microenvironment around implants before and after surgery, these surface nanomodifications are designed to respond to different stimuli and environmental changes in a timely, efficient, and specific way/manner. Here, we focus on the materials related to stimuli-responsive nanotechnology on titanium implant surface modification, including metals and their compounds, polymer materials and other materials. In addition, the mechanism of different response types is introduced according to different activation stimuli, including magnetic, electrical, photic, radio frequency and ultrasonic stimuli, pH and enzymatic stimuli (the internal stimuli). Meanwhile, the associated functions, potential applications and developing prospect were discussion.

Antibacterial PLA/Mg composite with enhanced mechanical and biological performance for biodegradable orthopedic implants

Biodegradability, bone-healing rate, and prevention of bacterial infection are critical factors for orthopedic implants. Polylactic acid (PLA) is a good candidate biodegradable material; however, it has insufficient mechanical strength and bioactivity for orthopedic implants. Magnesium (Mg), has good bioactivity, biodegradability, and sufficient mechanical properties, similar to that of bone. Moreover, Mg has an inherent antibacterial property via a photothermal effect, which generates localized heat, thus preventing bacterial infection. Therefore, Mg is a good candidate material for PLA composites, to improve their mechanical and biological performance and add an antibacterial property. Herein, we fabricated an antibacterial PLA/Mg composite for enhanced mechanical and biological performance with an antibacterial property for application as biodegradable orthopedic implants. The composite was fabricated with 15 and 30 vol% of Mg homogeneously dispersed in PLA without the generation of a defect using a high-shear mixer. The composites exhibited an enhanced compressive strength of 107.3 and 93.2 MPa, and stiffness of 2.3 and 2.5 GPa, respectively, compared with those of pure PLA which were 68.8 MPa and 1.6 GPa, respectively. Moreover, the PLA/Mg composite at 15 vol% Mg exhibited significant improvement of biological performance in terms of enhanced initial cell attachment and cell proliferation, whereas the composite at 30 vol% Mg showed deteriorated cell proliferation and differentiation because of the rapid degradation of the Mg particles. In turn, the PLA/Mg composites exerted an antibacterial effect based on the inherent antibacterial property of Mg as well as the photothermal effect induced by near-infrared (NIR) treatment, which can minimize infection after implantation surgery. Therefore, antibacterial PLA/Mg composites with enhanced mechanical and biological performance may be a candidate material with great potential for biodegradable orthopedic implants.

Bone marrow stromal cells generate an osteoinductive microenvironment when cultured on titanium-aluminum-vanadium substrates with biomimetic multiscale surface roughness

Osseointegration of titanium-based implants possessing complex macroscale/microscale/mesoscale/nanoscale (multiscale) topographies support a direct and functional connection with native bone tissue by promoting recruitment, attachment and osteoblastic differentiation of bone marrow stromal cells (MSCs). Recent studies show that the MSCs on these surfaces produce factors, including bone morphogenetic protein 2 (BMP2) that can cause MSCs not on the surface to undergo osteoblast differentiation, suggesting they may produce an osteogenic environmentin vivo. This study examined if soluble factors produced by MSCs in contact with titanium-aluminum-vanadium (Ti6Al4V) implants possessing a complex multiscale biomimetic topography are able to induce osteogenesis ectopically. Ti6Al4V disks were grit-blasted and acid-etched to create surfaces possessing macroscale and microscale roughness (MM), micro/meso/nanoscale topography (MN), and macro/micro/meso/nanoscale topography (MMN^TM). Polyether-ether-ketone (PEEK) disks were also fabricated by machining to medical-grade specifications. Surface properties were assessed by scanning electron microscopy, contact angle, optical profilometry, and x-ray photoelectron spectroscopy. MSCs were cultured in growth media (GM). Proteins and local factors in their conditioned media (CM) were measured on days 4, 8, 10 and 14: osteocalcin, osteopontin, osteoprotegerin, BMP2, BMP4, and cytokines interleukins 6, 4 and 10 (IL6, IL4, and IL10). CM was collected from D14 MSCs on MMN^TMand tissue culture polystyrene (TCPS) and lyophilized. Gel capsules containing active demineralized bone matrix (DBM), heat-inactivated DBM (iDBM), and iDBM + MMN-GM were implanted bilaterally in the gastrocnemius of athymic nude mice (N= 8 capsules/group). Controls included iDBM + GM; iDBM + TCPS-CM from D5 to D10 MSCs; iDBM + MMN-CM from D5 to D10; and iDBM + rhBMP2 (R&D Systems) at a concentration similar to D5-D10 production of MSCs on MMN^TMsurfaces. Legs were harvested at 35D. Bone formation was assessed by micro computed tomography and histomorphometry (hematoxylin and eosin staining) with the histology scored according to ASTM 2529-13. DNA was greatest on PEEK at all time points; DNA was lowest on MN at early time points, but increased with time. Cells on PEEK exhibited small changes in differentiation with reduced production of BMP2. Osteoblast differentiation was greatest on the MN and MMN^TM, reflecting increased production of BMP2 and BMP4. Pro-regenerative cytokines IL4 and IL10 were increased on Ti-based surfaces; IL6 was reduced compared to PEEK. None of the media from TCPS cultures was osteoinductive. However, MMN-CM exhibited increased bone formation compared to iDBM and iDBM + rhBMP2. Furthermore, exogenous rhBMP2 alone, at the concentration found in MMN-CM collected from D5 to D10 cultures, failed to induce new bone, indicating that other factors in the CM play a critical role in that osteoinductive microenvironment. MSCs cultured on MMN^TMTi6Al4V surfaces differentiate and produce an increase in local factors, including BMP2, and the CM from these cultures can induce ectopic bone formation compared to control groups, indicating that the increased bone formation arises from the local response by MSCs to a biomimetic, multiscale surface topography.

Ceramic Materials for Biomedical Applications: An Overview on Properties and Fabrication Processes

A growing interest in creating advanced biomaterials with specific physical and chemical properties is currently being observed. These high-standard materials must be capable to integrate into biological environments such as the oral cavity or other anatomical regions in the human body. Given these requirements, ceramic biomaterials offer a feasible solution in terms of mechanical strength, biological functionality, and biocompatibility. In this review, the fundamental physical, chemical, and mechanical properties of the main ceramic biomaterials and ceramic nanocomposites are drawn, along with some primary related applications in biomedical fields, such as orthopedics, dentistry, and regenerative medicine. Furthermore, an in-depth focus on bone-tissue engineering and biomimetic ceramic scaffold design and fabrication is presented.

Outcome of Ti/PEEK Versus PEEK Cages in Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

This study aims to present the clinical and radiographical outcomes of the titanium-polyetheretherketone (Ti/PEEK) composite cage compared to those of the standard PEEK cage in patients receiving minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

METHODS

Patients receiving 1 level MI-TLIF between October 2015 and October 2017 were included with a minimum of 2-year follow-up. The patients were segregated into 2 groups; Ti/PEEK group and PEEK group. Each patient was propensity-matched using preoperative age, sex, and body mass index. Early fusion rate was evaluated by computed tomography at postoperative 6 months. Clinical outcomes were assessed using the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores.

RESULTS

After matching, there were 27 patients included in each group. The demographics, diagnosis, and surgical details were not significantly different between the 2 groups. The 6-month rate was 88.9% in Ti/PEEK group. The fusion rate and cage subsidence rate had no difference between the 2 groups. The complication rate in the Ti/PEEK group was comparable to that in the PEEK group. There was no difference in VAS and ODI scores during a 2-year follow-up period.

CONCLUSIONS

The use of Ti/PEEK composite cage was as safe and effective as the use of PEEK cage in MI-TLIF. The 6-month fusion rate was 88.9%. Our finding revealed comparable clinical results for surgeons using Ti/PEEK composite cages in MI-TLIF compared to those using the PEEK cage.

Osseointegration of Titanium Implants in a Botox-Induced Muscle Paralysis Rat Model Is Sensitive to Surface Topography and Semaphorin 3A Treatment

Reduced skeletal loading associated with many conditions, such as neuromuscular injuries, can lead to bone fragility and may threaten the success of implant therapy. Our group has developed a botulinum toxin A (botox) injection model to imitate disease-reduced skeletal loading and reported that botox dramatically impaired the bone formation and osseointegration of titanium implants. Semaphorin 3A (sema3A) is an osteoprotective factor that increases bone formation and inhibits bone resorption, indicating its potential therapeutic role in improving osseointegration in vivo. We first evaluated the sema3A effect on whole bone morphology following botox injections by delivering sema3A via injection. We then evaluated the sema3A effect on the osseointegration of titanium implants with two different surface topographies by delivering sema3A to cortical bone defect sites prepared for implant insertion and above the implants after insertion using a copper-free click hydrogel that polymerizes rapidly in situ. Implants had hydrophobic smooth surfaces (PT) or multiscale biomimetic micro/nano topography (SLAnano). Sema3A rescued the botox-impaired bone formation. Furthermore, biomimetic Ti implants improved the bone-to-implant contact (BIC) and mechanical properties of the integrated bone in the botox-treated rats, which sema3A enhanced. This study demonstrated the value of biomimetic approaches combining multiscale topography and biologics in improving the clinical outcomes of implant therapy.

Impact of bone-implant gap size on the interfacial osseointegration: an in vivo study

BACKGROUND

The bone-implant gap resulted from morphological mismatch between cervical bony endplates and implant footprint may have adverse impact on bone-implant interfacial osseointegration of cervical disc arthroplasty (CDA). The purpose of the study was to evaluate the impact of bone-implant gap size on the interfacial osseointegration in a rabbit animal model.

METHODS

A series of round-plate implants with different teeth depth (0.5 mm, 1.0 mm, 1.5 mm and 2.0 mm) was specifically designed. A total of 48 New Zealand white rabbits were randomly categorized into four groups by the implants they received (0.5 mm: group A, 1.0 mm: group B, 1.5 mm: group C, 2.0 mm: group D). At 4^th and 12^th week after surgery, animals were sacrificed. Micro-CT, acid fuchsin and methylene blue staining and hematoxylin and eosin (HE) staining were conducted.

RESULTS

At 4^th week and 12^th week after surgery, both micro-CT and HE staining showed more new bone formation and larger bone coverage in group A and group B than that in group C and group D. At 12^th week, the bone biometric parameters were significantly superior in group C when compared with group D (p < 0.05). At 12^th week, hard tissue slicing demonstrated larger portion of direct contact of new bone to the HA coating in group A and group B.

CONCLUSIONS

Bone-implant gap size larger than 1.0 mm negatively affected bone-implant osseointegration between compact bone and HA coated implant surface.

A Review of 3D Polymeric Scaffolds for Bone Tissue Engineering: Principles, Fabrication Techniques, Immunomodulatory Roles, and Challenges

Over the last few years, biopolymers have attracted great interest in tissue engineering and regenerative medicine due to the great diversity of their chemical, mechanical, and physical properties for the fabrication of 3D scaffolds. This review is devoted to recent advances in synthetic and natural polymeric 3D scaffolds for bone tissue engineering (BTE) and regenerative therapies. The review comprehensively discusses the implications of biological macromolecules, structure, and composition of polymeric scaffolds used in BTE. Various approaches to fabricating 3D BTE scaffolds are discussed, including solvent casting and particle leaching, freeze-drying, thermally induced phase separation, gas foaming, electrospinning, and sol-gel techniques. Rapid prototyping technologies such as stereolithography, fused deposition modeling, selective laser sintering, and 3D bioprinting are also covered. The immunomodulatory roles of polymeric scaffolds utilized for BTE applications are discussed. In addition, the features and challenges of 3D polymer scaffolds fabricated using advanced additive manufacturing technologies (rapid prototyping) are addressed and compared to conventional subtractive manufacturing techniques. Finally, the challenges of applying scaffold-based BTE treatments in practice are discussed in-depth.

Impact of surface roughness and bulk porosity on spinal interbody implants

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.

Influence of porosity on osteogenesis, bone growth and osteointegration in trabecular tantalum scaffolds fabricated by additive manufacturing

Porous tantalum implants are a class of materials commonly used in clinical practice to repair bone defects. However, the cumbersome and problematic preparation procedure have limited their widespread application. Additive manufacturing has revolutionized the design and process of orthopedic implants, but the pore architecture feature of porous tantalum scaffolds prepared from additive materials for optimal osseointegration are unclear, particularly the influence of porosity. We prepared trabecular bone-mimicking tantalum scaffolds with three different porosities (60%, 70% and 80%) using the laser powder bed fusing technique to examine and compare the effects of adhesion, proliferation and osteogenic differentiation capacity of rat mesenchymal stem cells on the scaffolds in vitro. The in vivo bone ingrowth and osseointegration effects of each scaffold were analyzed in a rat femoral bone defect model. Three porous tantalum scaffolds were successfully prepared and characterized. In vitro studies showed that scaffolds with 70% and 80% porosity had a better ability to osteogenic proliferation and differentiation than scaffolds with 60% porosity. In vivo studies further confirmed that tantalum scaffolds with the 70% and 80% porosity had a better ability for bone ingrowh than the scaffold with 60% porosity. As for osseointegration, more bone was bound to the material in the scaffold with 70% porosity, suggesting that the 3D printed trabecular tantalum scaffold with 70% porosity could be the optimal choice for subsequent implant design, which we will further confirm in a large animal preclinical model for better clinical use.

Fabrication and Characterization of Piezoelectric Polymer Composites and Cytocompatibility with Mesenchymal Stem Cells

Piezoelectric materials are promising for biomedical applications because they can provide mechanical or electrical stimulations via converse or direct piezoelectric effects. The stimulations have been proven to be beneficial for cell proliferation and tissue regeneration. Recent reports showed that doping different contents of reduced graphene oxide (rGO) or polyaniline (PANi) into biodegradable polyhydroxybutyrate (PHB) enhanced their piezoelectric response, showing potential for biomedical applications. In this study, we aim to determine the correlation between physiochemical properties and the in vitro cell response to the PHB-based composite scaffolds with rGO or PANi. Specifically, we characterized the surface morphology, wetting behavior, electrochemical impedance, and piezoelectric properties of the composites and controls. The addition of rGO and PANi resulted in decreased fiber diameters and hydrophobicity of PHB. The increased surface energy of PHB after doping nanofillers led to a reduced water contact angle (WCA) from 101.84 ± 2.18° (for PHB) to 88.43 ± 0.83° after the addition of 3 wt % PANi, whereas doping 1 wt % rGO decreased the WCA value to 92.56 ± 2.43°. Meanwhile, doping 0.2 wt % rGO into PHB improved the piezoelectric properties compared to the PHB control and other composites. Adding up to 1 wt % rGO or 3 wt % PANi nanofillers in PHB did not affect the adhesion densities of bone marrow-derived mesenchymal stem cells (BMSCs) on the scaffolds. The aspect ratios of attached BMSCs on the composite scaffolds increased compared to the PHB control. The study indicated that the PHB-based composites are promising for potential applications such as regenerative medicine, tissue stimulation, and bio-sensing, which should be further studied.

Bone regeneration strategies based on organelle homeostasis of mesenchymal stem cells

The organelle modulation has emerged as a crucial contributor to the organismal homeostasis. The mesenchymal stem cells (MSCs), with their putative functions in maintaining the regeneration ability of adult tissues, have been identified as a major driver to underlie skeletal health. Bone is a structural and endocrine organ, in which the organelle regulation on mesenchymal stem cells (MSCs) function has most been discovered recently. Furthermore, potential treatments to control bone regeneration are developing using organelle-targeted techniques based on manipulating MSCs osteogenesis. In this review, we summarize the most current understanding of organelle regulation on MSCs in bone homeostasis, and to outline mechanistic insights as well as organelle-targeted approaches for accelerated bone regeneration.

Influence of the roughness of dental implants obtained by additive manufacturing on osteoblastic adhesion and proliferation: A systematic review

Objective

Critically analyzed the existing literature to answer the question "What is the influence of roughness of surfaces for dental implants obtained by additive manufacturing compared to machined on osteoblastic cell adhesion and proliferation?"

Design

This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was registered in the Open Science Framework. The personalized search strategy was applied to Embase, Pub Med, Scopus, and Science Direct databases and Google Scholar and ProQuest grey literature. The selection process was carried out in two stages independently by two reviewers according to the eligibility criteria. The risk of bias was analyzed using a checklist of important parameters to be considered.

Results

When applying the search strategy on databases 223 articles were found, after removing the duplicates, 171 were analyzed by title and abstract of which 25 were selected for full reading, of these, 6 met the eligibility criteria. 2 studies were included from the reference list totaling 8 articles included in this systematic review and none were included from the Grey Literature. 7 had a low risk of bias and 1 moderate.

Conclusions

1) Roughness is a property that must be analyzed and correlated with the chemical composition, intrinsic to the alloy and resulting from the surface treatment; morphology of topographic peaks and valleys; printing technique and its parameters; 2) Need for more studies on the biomolecular level to elucidate the mechanism by which the roughness and the morphology of topographical peaks and valleys descriptive of roughness influence osteoblastic adhesion and proliferation.

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

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

Behavior of Calcium Phosphate-Chitosan-Collagen Composite Coating on AISI 304 for Orthopedic Applications

Calcium phosphate/chitosan/collagen composite coating on AISI 304 stainless steel was investigated. Coatings were realized by galvanic coupling that occurs without an external power supply because it begins with the coupling between two metals with different standard electrochemical potentials. The process consists of the co-deposition of the three components with the calcium phosphate crystals incorporated into the polymeric composite of chitosan and collagen. Physical-chemical characterizations of the samples were executed to evaluate morphology and chemical composition. Morphological analyses have shown that the surface of the stainless steel is covered by the deposit, which has a very rough surface. XRD, Raman, and FTIR characterizations highlighted the presence of both calcium phosphate compounds and polymers. The coatings undergo a profound variation after aging in simulated body fluid, both in terms of composition and structure. The tests, carried out in simulated body fluid to scrutinize the corrosion resistance, have shown the protective behavior of the coating. In particular, the corrosion potential moved toward higher values with respect to uncoated steel, while the corrosion current density decreased. This good behavior was further confirmed by the very low quantification of the metal ions (practically absent) released in simulated body fluid during aging. Cytotoxicity tests using a pre-osteoblasts MC3T3-E1 cell line were also performed that attest the biocompatibility of the coating.

Cellular responses to nanoscale substrate topography of TiO2 nanotube arrays: cell morphology and adhesion

Nanotopographical features can be beneficial in augmenting cell functions and increasing osteogenic potential. However, the relationships between surface topographies and biological responses are difficult to establish due to the difficulty in controlling the surface topographical features at a low-nanometre scale. Herein, we report the fabrication of well-defined controllable titanium dioxide (TiO₂) nanotube arrays with a wide range of pore sizes, 30-175 nm in diameter, and use of the electrochemical anodization method to assess the effect of surface nanotopographies on cell morphology and adhesion. The results show that TiO₂ nanotube arrays with pore sizes of 30 and 80 nm allowed for cell spreading of bone marrow-derived mesenchymal stem cells with increased cell area coverage. Additionally, cell adhesion was significantly enhanced by controlled nanotopographies of TiO₂ nanotube arrays with 80 nm pore size. Our results demonstrate that surface modification at the nano-scale level with size tunability under controlled chemical/physical properties and culture conditions can greatly impact cell responses. These findings point to a new direction of material design for bone-tissue engineering in orthopaedic applications.

Femtosecond laser treatment promotes the surface bioactivity and bone ingrowth of Ti6Al4V bone scaffolds

In this study, a femtosecond laser with a wavelength of 800 nm was used to modify the surface of a titanium alloy bone scaffold created via selective laser melting (SLM). The outcomes demonstrated that the surface morphology of the bone scaffold after femtosecond laser treatment was micro-nano morphology. The hydrophobic structure of the scaffold was changed into a super-hydrophilic structure, improving the surface roughness, which was highly helpful for osteoblast adhesion and differentiation. The femtosecond laser surface treatment in vitro samples produced a thick layer of hydroxyapatite (HAP) with improved surface bioactivity. The effectiveness of osseointegration and interstitial growth of the specimens treated with the femtosecond laser surface were found to be better when bone scaffolds were implanted into the epiphysis of the tibia of rabbits. As a result, femtosecond laser therapy dramatically enhanced the surface activity of bone scaffolds and their capacity to integrate with the surrounding bone tissues, serving as a trustworthy benchmark for future biological scaffold research.

The Effect of Microcosm Biofilm Decontamination on Surface Topography, Chemistry, and Biocompatibility Dynamics of Implant Titanium Surfaces

Since the inception of dental implants, a steadily increasing prevalence of peri-implantitis has been documented. Irrespective of the treatment protocol applied for the management of peri-implantitis, this biofilm-associated pathology, continues to be a clinical challenge yielding unpredictable and variable levels of resolution, and in some cases resulting in implant loss. This paper investigated the effect of microcosm biofilm in vitro decontamination on surface topography, wettability, chemistry, and biocompatibility, following decontamination protocols applied to previously infected implant titanium (Ti) surfaces, both micro-rough -Sandblasted, Large-grit, Acid-etched (SLA)-and smooth surfaces -Machined (M). Microcosm biofilms were grown on SLA and M Ti discs. These were treated with TiBrushes (TiB), combination of TiB and photodynamic therapy (PDT), combination of TiB and 0.2%CHX/1%NaClO, plus or minus Ultraviolet-C (UV-C) radiation. Surface topography was evaluated by Scanning Electron Microscopy (SEM) and Laser Surface Profilometry. Surface function was analysed through wettability analysis. Surface chemistry evaluation of the discs was performed under SEM/Energy-dispersive X-ray spectroscopy (EDX) and X-ray photoelectron spectroscopy (XPS). Biocompatibility was tested with the cytocompatibility assay using human osteoblast-like osteosarcoma cell line (MG-63) cells. Elemental analysis of the discs disclosed chemical surface alterations resulting from the different treatment modalities. Titanium, carbon, oxygen, sodium, aluminium, silver, were identified by EDX as the main components of all the discs. Based on the data drawn from this study, we have shown that following the decontamination of Ti surfaces the biomaterial surface chemistry and topography was altered. The type of treatment and Ti surface had a significant effect on cytocompatibility (p = 0.0001). Although, no treatment modality hindered the titanium surface biocompatibility, parameters such as the use of chemical agents and micro-rough surfaces had a higher cytotoxic effect in MG-63 cells. The use of smooth surfaces, and photofunctionalisation of the TiO₂ layer had a beneficial effect on cytocompatibility following decontamination.

Regulation of Macrophage Polarization Through Periodic Photo-Thermal Treatment to Facilitate Osteogenesis

The richened reactive oxygen species (ROS) and their derived excessive inflammation at bone injured sites hinder osteogenesis of endosseous Ti-based implants. Herein, anti-oxidized polydopamine (PDA) is deposited on hydrothermal growth formed hydroxyapatite (HA) nanorods on Ti to form a core-shell structural nanorod-like array with HA as a core and PDA as an amorphous shell (PDA@HA), showing not only ROS scavenging ability but also near-infrared (NIR) light derived photo-thermal effects. PDA@HA suppresses inflammation based on its ROS scavenging ability to a certain extent, while periodic photo-thermal treatment (PTT) at a mild temperature (41 ± 1 °C) further accelerates the transition of the macrophages (MΦs) adhered to PDA@HA from the pro-inflammatory (M1) phenotype to the anti-inflammatory (M2) phenotype in vitro and in vivo. Transcriptomic analysis reveals that the activation of the PI3K-Akt1 signaling pathway is responsible for the periodic PTT induced acceleration of the M1-to-M2 transition of MΦs. Acting on mesenchymal stem cells (MSCs) with paracrine cytokines of M2 macrophages, PDA@HA with mild PTT greatly promote the osteogenetic functions of MSCs and thus osteogenesis. This work paves a way of employing mildly periodic PTT to induce a favorable immunomodulatory microenvironment for osteogenesis and provides insights into its underlying immunomodulation mechanism.

Randomized clinical trial to evaluate the efficacy and safety of two types of sandblasted with large-grit and acid-etched surface implants with different surface roughness

Objectives

This study aims to evaluate the efficacy and safety of two types of sandblasted with large-grit and acid-etched (SLA) surface implants with different surface roughness.

Patients and Methods This study was conducted based on a clinical record review of 55 patients (mean age, 53.00 years). A total of 80 SLA surface implants was placed. Among the 80 implants, 38 implants placed in 29 subjects had surface roughness (Ra) of 3.09 µm (test group, TG), while the other 42 implants placed in 31 subjects had a surface roughness (Ra) of 2.50 µm (control group, CG). A comparison was made of implant primary/secondary stability; success and survival rates; marginal bone loss; and soft tissue assessment including probing pocket depth (PPD), plaque index (PI), gingival index (GI), and bleeding on probing (BOP) between the groups at 1 year after implant placement.

Results

Among the implants that were initially registered, 1 from the TG and 4 from the CG dropped out, leaving 37 implants in the TG and 38 implants in the CG to be traced and analyzed. Although 1 TG case showed unstable primary stability, all cases showed stable secondary stability. Success and survival rates at 1 year after implant placement were 100% in both groups. Marginal bone loss was 0.07 mm and 0.00 mm for the TG and CG, respectively, but the difference was not significant. Among the several parameters for evaluation of soft tissue, the TG showed lower PI at 1 year after implant placement (TG=0.00, CG=0.29; P=0.0004), while the remaining categories showed no significant difference between the groups.

Conclusion

This study shows that the two types of SLA implants with different surface roughness have no difference in efficacy or safety. Therefore, both of the implants can be used safely and with promising outcomes.

Tailoring of TiAl6V4 Surface Nanostructure for Enhanced In Vitro Osteoblast Response via Gas/Solid (Non-Line-of-Sight) Oxidation/Reduction Reactions

An aging global population is accelerating the need for better, longer-lasting orthopaedic and dental implants. Additive manufacturing can provide patient-specific, titanium-alloy-based implants with tailored, three-dimensional, bone-like architecture. Studies using two-dimensional substrates have demonstrated that osteoblastic differentiation of bone marrow stromal cells (MSCs) is enhanced on surfaces possessing hierarchical macro/micro/nano-scale roughness that mimics the topography of osteoclast resorption pits on the bone surface. Conventional machined implants with these surfaces exhibit successful osseointegration, but the complex architectures produced by 3D printing make consistent nanoscale surface texturing difficult to achieve, and current line-of-sight methods used to roughen titanium alloy surfaces cannot reach all internal surfaces. Here, we demonstrate a new, non-line-of-sight, gas/solid-reaction-based process capable of generating well-controlled nanotopographies on all open (gas-exposed) surfaces of titanium alloy implants. Dense 3D-printed titanium-aluminum-vanadium (TiAl6V4) substrates were used to evaluate the evolution of surface nanostructure for development of this process. Substrates were either polished to be smooth (for easier evaluation of surface nanostructure evolution) or grit-blasted and acid-etched to present a microrough biomimetic topography. An ultrathin (90 ± 16 nm) conformal, titania-based surface layer was first formed by thermal oxidation (600 °C, 6 h, air). A calciothermic reduction (CaR) reaction (700 °C, 1 h) was then used to convert the surface titania (TiO₂) into thin layers of calcia (CaO, 77 ± 16 nm) and titanium (Ti, 51 ± 20 nm). Selective dissolution of the CaO layer (3 M acetic acid, 40 min) then yielded a thin nanoporous/nanorough Ti-based surface layer. The changes in surface nanostructure/chemistry after each step were confirmed by scanning and transmission electron microscopies with energy-dispersive X-ray analysis, X-ray diffraction, selected area electron diffraction, atomic force microscopy, and mass change analyses. In vitro studies indicated that human MSCs on CaR-modified microrough surfaces exhibited increased protein expression associated with osteoblast differentiation and promoted osteogenesis compared to unmodified microrough surfaces (increases of 387% in osteopontin, 210% in osteocalcin, 282% in bone morphogenic protein 2, 150% in bone morphogenic protein 4, 265% in osteoprotegerin, and 191% in vascular endothelial growth factor). This work suggests that this CaR-based technique can provide biomimetic topography on all biologically facing surfaces of complex, porous, additively manufactured TiAl6V4 implants.

Titanium nanotopography induces osteocyte lacunar-canalicular networks to strengthen osseointegration

Osteocyte network architecture is closely associated with bone turnover. The cellular mechanosensing system regulates osteocyte dendrite formation by enhancing focal adhesion. Therefore, titanium surface nanotopography might affect osteocyte network architecture and improve the peri-implant bone tissue quality, leading to strengthened osseointegration of bone-anchored implants. We aimed to investigate the effects of titanium nanosurfaces on the development of osteocyte lacunar-canalicular networks and osseointegration of dental implants. Alkaline etching created titanium nanosurfaces with anisotropically patterned dense nanospikes, superhydrophilicity, and hydroxyl groups. MLO-Y4 mouse osteocyte-like cells cultured on titanium nanosurfaces developed neuron-like dendrites with increased focal adhesion assembly and gap junctions. Maturation was promoted in osteocytes cultured on titanium nanosurfaces compared to cells cultured on machined or acid-etched micro-roughened titanium surfaces. Osteocytes cultured in type I three-dimensional collagen gels for seven days on nano-roughened titanium surfaces displayed well-developed interconnectivity with highly developed dendrites and gap junctions compared to the poor interconnectivity observed on the other titanium surfaces. Even if superhydrophilicity and hydroxyl groups were maintained, the loss of anisotropy-patterned nanospikes reduced expression of gap junction in osteocytes cultured on alkaline-etched titanium nanosurfaces. Four weeks after placing the titanium nanosurface implants in the upper jawbone of wild-type rats, osteocytes with numerous dendrites were found directly attached to the implant surface, forming well-developed lacunar-canalicular networks around the nano-roughened titanium implants. The osseointegration strength of the nano-roughened titanium implants was significantly higher than that of the micro-roughened titanium implants. These data indicate that titanium nanosurfaces promote osteocyte lacunar-canalicular network development via nanotopographical cues and strengthen osseointegration. STATEMENT OF SIGNIFICANCE: The clinical stability of bone-anchoring implant devices is influenced by the bone quality. The osteocyte network potentially affects bone quality and is established by the three-dimensional (3D) connection of neuron-like dendrites of well-matured osteocytes within the bone matrix. No biomaterials are known to regulate formation of the osteocyte network. The present study provides the first demonstration that titanium nanosurfaces with nanospikes created by alkali-etching treatment enhance the 3D formation of osteocyte networks by promoting osteocyte dendrite formation and maturation by nanotopographic cues, leading to strengthened osseointegration of titanium implants. Osteocytes attached to the titanium nanosurfaces via numerous cellular projections. The success of osteocyte regulation by nanotechnology paves the way for development of epoch-making technologies to control bone quality.

Medical Adhesives and Their Role in Laparoscopic Surgery—A Review of Literature

Laparoscopic surgery is undergoing rapid development. Replacing the traditional method of joining cut tissues with sutures or staples could greatly simplify and speed up laparoscopic procedures. This alternative could undoubtedly be adhesives. For decades, scientists have been working on a material to bond tissues together to create the best possible conditions for tissue regeneration. The results of research on tissue adhesives achieved over the past years show comparable treatment effects to traditional methods. Tissue adhesives are a good alternative to surgical sutures in wound closure. This article is a review of the most important groups of tissue adhesives including their properties and possible applications. Recent reports on the development of biological adhesives are also discussed.