Phase stability and biological property evaluation of plasma sprayed hydroxyapatite coatings for orthopedic and dental applications

Surface treatment of PET multifilament textile for biomedical applications: roughness modification and fibroblast viability assessment

OBJECTIVES

The aim of this study was to investigate the potential of tuning the topography of textile surfaces for biomedical applications towards modified cell-substrate interactions.

METHODS

For that purpose, a supercritical Nitrogen N2 jet was used to spray glass particles on multi-filament polyethylene terephthalate (PET) yarns and on woven fabrics. The influence of the jet projection parameters such as the jet pressure (P) and the standoff distance (SoD) on the roughness was investigated.

RESULTS

The impact of the particles created local filament ruptures on the treated surfaces towards hairiness increase. The results show that the treatment increases the roughness by up to 17 % at P 300 bars and SoD 300 mm while the strength of the material is slightly decreased. The biological study brings out that proliferation can be slightly limited on a more hairy surface, and is increased when the surface is more flat. After 10 days of fibroblast culture, the cells covered the entire surface of the fabrics and had mainly grown unidirectionally, forming cell clusters oriented along the longitudinal axis of the textile yarns. Clusters were generated at yarn crossings.

CONCLUSIONS

This approach revealed that the particle projection technology can help tuning the cell proliferation on a textile surface.

Natural medicine delivery from 3D printed bone substitutes

Unmet medical needs in treating critical-size bone defects have led to the development of numerous innovative bone tissue engineering implants. Although additive manufacturing allows flexible patient-specific treatments by modifying topological properties with various materials, the development of ideal bone implants that aid new tissue regeneration and reduce post-implantation bone disorders has been limited. Natural biomolecules are gaining the attention of the health industry due to their excellent safety profiles, providing equivalent or superior performances when compared to more expensive growth factors and synthetic drugs. Supplementing additive manufacturing with natural biomolecules enables the design of novel multifunctional bone implants that provide controlled biochemical delivery for bone tissue engineering applications. Controlled release of naturally derived biomolecules from a three-dimensional (3D) printed implant may improve implant-host tissue integration, new bone formation, bone healing, and blood vessel growth. The present review introduces us to the current progress and limitations of 3D printed bone implants with drug delivery capabilities, followed by an in-depth discussion on cutting-edge technologies for incorporating natural medicinal compounds embedded within the 3D printed scaffolds or on implant surfaces, highlighting their applications in several pre- and post-implantation bone-related disorders.

Hydroxyapatite coated titanium with curcumin and epigallocatechin gallate for orthopedic and dental applications

Titanium and its alloy are clinically used as an implant material for load-bearing applications to treat bone defects. However, the lack of biological interaction between bone tissue and implant and the risk of infection are still critical challenges in clinical orthopedics. In the current work, we have developed a novel approach by first 1) modifying the implant surface using hydroxyapatite (HA) coating to enhance bioactivity and 2) integrating curcumin and epigallocatechin gallate (EGCG) in the coating that would induce chemopreventive and osteogenic potential and impart antibacterial properties to the implant. The study shows that curcumin and EGCG exhibit controlled and sustained release profiles in acidic and physiological environments. Curcumin and EGCG also show in vitro cytotoxicity toward osteosarcoma cells after 11 days, and the dual system shows a ~94 % reduction in bacterial growth, indicating their in vitro chemopreventive potential and antibacterial efficacy. The release of both curcumin and EGCG was found to be compatible with osteoblast cells and further promotes their growth. It shows a 3-fold enhancement in cellular viability in the dual drug-loaded implant compared to the untreated samples. These findings suggest that multifunctional HA-coated Ti6Al4V implants integrated with curcumin and EGCG could be a promising strategy for osteosarcoma inhibition and osteoblast cell growth while preventing infection.

In situ titanium phosphate formation on a titanium implant as ultrahigh bonding with nano-hydroxyapatite coating for rapid osseointegration

Titanium (Ti) has been widely used as a dental implant material due to its excellent mechanical property and good biocompatibility. However, its poor biological activity severely limits its ability to bond with bony tissues. To ameliorate this situation, a preparation method of ultra-high bonding nano-hydroxyapatite (n-HA) coating on the Ti surface is urgently needed. Here, Ti phosphate/n-HA (TiP-Ca) composite coatings with ultra-high bonding were prepared by a two-step hydrothermal treatment. The TiP coating was first formed in situ on the pure Ti substrate and then n-HA crystals further grew on the TiP surface. The formation mechanism of composite coating and reasons for increased bonding strength were systematically investigated. The results show that the TiP-Ca coating remains stable and exhibits an ultra-high bonding strength with the Ti implant (up to 783.30 ± 207.46 N). An effective solution was designed to address the problems of easy peel off. Cell experiments showed that TiP-Ca could promote the adhesion of MC3T3-E1 and expression of OCN, Runx2, and ALP. In vivo evaluation further confirmed that the TiP-Ca composite coating significantly enhanced osseointegration. The designed coating shows great potential in clinical application of implants.

Improving Biocompatibility for Next Generation of Metallic Implants

The increasing need for joint replacement surgeries, musculoskeletal repairs, and orthodontics worldwide prompts emerging technologies to evolve with healthcare's changing landscape. Metallic orthopaedic materials have a shared application history with the aerospace industry, making them only partly efficient in the biomedical domain. However, suitability of metallic materials in bone tissue replacements and regenerative therapies remains unchallenged due to their superior mechanical properties, eventhough they are not perfectly biocompatible. Therefore, exploring ways to improve biocompatibility is the most critical step toward designing the next generation of metallic biomaterials. This review discusses methods of improving biocompatibility of metals used in biomedical devices using surface modification, bulk modification, and incorporation of biologics. Our investigation spans multiple length scales, from bulk metals to the effect of microporosities, surface nanoarchitecture, and biomolecules such as DNA incorporation for enhanced biological response in metallic materials. We examine recent technologies such as 3D printing in alloy design and storing surface charge on nanoarchitecture surfaces, metal-on-metal, and ceramic-on-metal coatings to present a coherent and comprehensive understanding of the subject. Finally, we consider the advantages and challenges of metallic biomaterials and identify future directions.

Hydrothermal Synthesis of Fluorapatite Coatings over Titanium Implants for Enhanced Osseointegration-An In Vivo Study in the Rabbit

This work aims at the development and characterization of fluorapatite coatings, innovatively prepared by the hydrothermal method, aiming for enhanced osseointegration of titanium implants. Fluoride-containing coatings were prepared and characterized by scanning and transmission electron microscopy, Fourier-transform infrared spectroscopy-attenuated total reflectance, and X-ray photoelectron spectroscopy. The biological response was characterized by microtomographic evaluation and histomorphometric analysis upon orthotopic implantation in a translational rabbit experimental model. Physic-chemical analysis revealed the inclusion of fluoride in the apatite lattice with fluorapatite formation, associated with the presence of citrate species. The in vivo biological assessment of coated implants revealed an enhanced bone formation process-with increased bone-to-implant contact and bone volume. The attained enhancement of the osteogenic process may be attributable to the conjoined modulatory activity of selected fluoride and citrate levels within the produced coatings. In this regard, the production of fluorapatite coatings with citrate, through the hydrothermal method, entails a promising approach for enhanced osseointegration in implant dentistry and orthopedic applications.

Ginger and Garlic Extracts Enhance Osteogenesis in 3D Printed Calcium Phosphate Bone Scaffolds with Bimodal Pore Distribution

Natural medicines have long been used to treat physiological ailments where both ginger (gingerol) and garlic (allicin) are key players in immune system promotion, reduction in blood pressure, and lowering inflammation response. With their efficacy in bone healing, these compounds have great value as medicinal additives in bone scaffolds for localized treatment to support tissue formation, along with providing their natural therapeutic benefits. Utilization of 3D-printed (3DP) bone tissue engineering scaffolds as drug delivery vehicles for ginger and garlic extracts enables patient specificity in bone defect applications with enhanced osseointegration. Our objective is to understand their combined efficacy on osteogenesis when released from 3DP calcium phosphate bone scaffolds designed with a bimodal pore distribution. With a porous core and dense exterior, the resulting scaffolds have good mechanical integrity with 10 ± 1 MPa compressive strengths. Results show that ginger + garlic extracts released from bone scaffolds enhance their osteogenic potential through on site drug delivery. Both compounds exhibit exponential drug release profiles which fit Weibull distribution equations. The release of ginger extract also increases osteoblast proliferation by 59%. Both compounds show decreased osteoclast resorption activity, with a greater than 20% reduction in pit area on sample surfaces. Ginger + garlic extract induces a twofold increase in early osteoid tissue formation in vivo at week 4, in addition to a 30% increase in total bone area and a 90% increase in osteocytes with respect to control 3DP tricalcium phosphate scaffolds. Late-stage bone healing at week 10 reveals healthy angiogenic tissue, a twofold higher bone mineralization, and significant enhancement of type I collagen formation in the presence of ginger and garlic extracts. Naturally sourced ginger and garlic extracts provide osteogenic promotion and improved bone tissue in-growth in a patient-specific 3DP scaffold biomedical device for low load-bearing bone tissue engineering and dental applications.

Bioactive Surface Modifications through Thermally Sprayed Hydroxyapatite Composite Coatings: A Review over Selective Reinforcements

Hydroxyapatite (HA) has been an excellent replacement for the natural bone in orthopedic applications, owing to its close resemblance; however, it is brittle and has low strength. Surface modification techniques...

Synthesis of fish scale derived hydroxyapatite silica propyl bis aminoethoxy ethane cuprous complex (HASPBAEECC) as a novel hybrid nano-catalyst for highly efficient synthesis of new benzimidazole-1,2,3-triazole hybrid analogues as antifungal agents

The preparation, characterization and application of hydroxyapatite silica propyl bis aminoethoxy ethane cuprous complex (HASPBAEECC) as a novel hybrid nano-catalyst for synthesis of new benzimidazole-1,2,3-triazole hybrid analogues as promising antifungal agents have been described. HASPBAEECC is fully characterized by different microscopic, spectroscopic and physical techniques, including scanning electron microscopy (SEM), transmission, X-ray diffraction (XRD), energy-dispersive X-ray spectroscopy (EDS), thermogravimetric analysis (TGA) and FT-IR. The 'Click̕ Huisgen cycloaddition reaction of N-propargyl benzimidazole with diverse azidoalkyls in a THF-water media at ambient temperature provides the products in good-to-excellent yields using HASPBAEECC. HASPBAEECC is proved to be a stable, low cost, reusable and environmentally benign nanohybrid catalyst. The target compounds were screened against some pathogenic fungal comprising Candida albicans, Candida krusei, Candida parapsilosis, Aspergillus fumigatus and Aspergillus flavus in which it was determined that compounds 11f and 11 h have displayed promising antifungal activity similar to fluconazole as a reference drug. HASPBAEECC is a novel hybrid nano-catalyst for highly efficient synthesis of new benzimidazole-1,2,3- triazole hybrid analogues as antifungal agents.

Modification of the surface nanotopography of implant devices: A translational perspective

There is an increasing need for the development of superior, safe, and more sophisticated implants, especially as our society historically has been moving towards an increasingly aging population. Currently, most research is being focused on the next generation of advanced medical implants, that are not only biocompatible but have modified surfaces that direct specific immunomodulation at cellular level. While there is a plethora of information on cell-surface interaction and how surfaces can be nanofabricated at research level, less is known about how the academic knowledge has been translated into clinical trials and commercial technologies. In this review, we provide a clinical translational perspective on the use of controlled physical surface modification of medical implants, presenting an analysis of data acquired from clinical trials and commercial products. We also evaluate the state-of-the-art of nanofabrication techniques that are being applied for implant surface modification at a clinical level. Finally, we identify some current challenges in the field, including the need of more advanced nanopatterning techniques, the comparatively small number of clinical trials and comment on future avenues to be explored for a successful clinical translation.

La3+ and F- dual-doped multifunctional hydroxyapatite nanoparticles: Synthesis and characterization

Hydroxyapatite (HA) co-doped with La³⁺ and F^- ions were synthesized by the precipitation method and sintered at 1,100°C for 1 hr. Samples were characterized by the standard experimental methods including the density, X-Ray Diffraction (XRD), Fourier Transform Infrared Spectroscopy (FTIR), and Scanning Electron Microscopy (SEM) to investigate their microstructure, phase formation, and bonding characteristics in detail. Moreover, the materials produced were identified using the microhardness tests. It was observed that in the most of materials, the hydroxyapatite was found to be the main phase with a minor amount of β-tricalcium phosphate (β-TCP). Furthermore, the presence of fluoride and small amount of β-TCP was verified with all the characteristic FTIR bands of hydroxyapatite for the majority of samples studied. The result in SEM evaluation is that the produced HA powders have less deformed, uniformly distributed, and regularly shaped particles. Here, the material density has changed towards a less dense state with the increasing rate of La doping, but statistically significant difference was not obtained (p, .1942 > .05) with increase of the F doping. A significant difference was obtained the microhardness values between La³⁺ and F^- ions co-doped HA materials and pure HA (p [.0053] < .05). Accordingly, this study confirmed that since the La³⁺ and F^- ions can potentially increase the efficacy of HA. According to the spectral, mechanical, and microstructure analysis result, this material can be as a good candidate product for use as an occluding material for dental application.

Behavior of rat bone marrow stem cells on titanium surfaces modified by laser-beam and deposition of calcium phosphate

OBJECTIVES

The aim of this study was to evaluate the behavior of rat bone marrow stem cells seeded on a Ti-15Mo alloy surface modified by laser-beam irradiation followed by calcium phosphate deposition.

MATERIALS AND METHODS

A total of four groups were evaluated: polished commercially pure titanium (cpTi): Ti-P; laser irradiation + calcium phosphate deposition on cpTi: Ti-LCP; polished Ti-15Mo alloy: Ti15Mo-P; and laser irradiation + calcium phosphate deposition on Ti-15Mo alloy: Ti15Mo-LCP. Before and after laser irradiation and calcium phosphate deposition on the surfaces, physicochemical and morphological analyses were performed: Scanning Electron Microscopy (SEM) and Energy Dispersive Spectroscopy (EDX). The wettability of the samples was evaluated by contact angle measurement. In addition, the behavior of osteoblast-like cells to these surfaces was evaluated for cell morphology, adhesion, proliferation and viability, evaluation of alkaline phosphatase formation and gene expression of osteogenesis markers.

RESULTS

Surfaces wet-abrade with grit paper (P) showed oriented groves, while the laser irradiation and calcium phosphate deposition (LCP) produced porosity on both cpTi and Ti15Mo alloy groups with deposits of hydroxyapatite (HA) crystals (SEM). EDX showed no contamination after surface modification in both metal samples. A complete wetting was observed for both LCP groups, whereas P surfaces exhibited high degree of hydrophobicity. There was a statistical difference in the intragroup comparison of proliferation and viability (p < 0.05). The ALP activity showed higher values in the Ti15Mo alloy at 10 days of culture. The gene expression of bone related molecules did not present significant differences at 7 and 14 days among different metals and surface treatments.

CONCLUSION

Ti15-Mo seems to be an alternative alloy to cpTi for dental implants. Surface treatment by laser irradiation followed by phosphate deposition seems to positively interact with bone cells.

CLINICAL RELEVANCE

Ti-15Mo alloy surface modified by laser-beam irradiation followed by calcium phosphate deposition may improve and accelerate the osseointegration process of dental implants.

The synergistic promotion of osseointegration by nanostructure design and silicon substitution of hydroxyapatite coatings in a diabetic model

Accumulating evidence indicates much higher failure rates for biomedical titanium implants in diabetic patients. This phenomenon is attributed to impaired osteoblastic function, suppressed angiogenesis capacity, and abnormal osteoclast activation in diabetic patients. Our previous study demonstrated that titanium implants coated with highly crystalline nanostructured hydroxyapatite (nHA) promoted the osteogenic differentiation of bone marrow stromal cells (BMSCs) and bone-implant osseointegration under healthy conditions. Furthermore, recent studies showed that silicon-substituted biomaterials exhibited excellent osteogenesis and angiogenesis performance while repressing osteoclastogenesis. Hence, we proposed that a combination of nanostructural modification and Si substitution might produce synergetic effects to mitigate the impaired osseointegration of bone implants under diabetes mellitus (DM) conditions. To confirm this hypothesis, titanium implants coated with highly crystalline Si-substituted nHA (Si-nHA) were successfully fabricated via atmospheric plasma spraying combined with hydrothermal treatment. An in vitro study demonstrated that compared to the original HA coating, the nHA coating improved osteogenic and angiogenic differentiation and altered the OPG/RANKL ratio of DM-BMSCs. In addition, the Si-nHA coating further enhanced cell proliferation, improved osteogenic and angiogenic differentiation, and repressed osteoclastogenesis in DM-BMSCs. An in vivo study confirmed that the titanium implants coated with nHA or Si-nHA effectively promoted bone formation and bone-implant osseointegration in a diabetic rabbit model, with the Si-nHA coating exhibiting the best stimulatory effect. Collectively, the results suggest that the nanostructured topography and Si substitution act synergistically to ameliorate the poor bone regeneration and osseointegration associated with DM. Thus, the results provide a promising coating method for dental and orthopedic applications under diabetic conditions.

ZnO Nanosheet-Coated TiZrPdSiNb Alloy as a Piezoelectric Hybrid Material for Self-Stimulating Orthopedic Implants

A Ti-based alloy (Ti₄₅Zr₁₅Pd₃₀Si₅Nb₅) with already proven excellent mechanical and biocompatibility features has been coated with piezoelectric zinc oxide (ZnO) to induce the electrical self-stimulation of cells. ZnO was grown onto the pristine alloy in two different morphologies: a flat dense film and an array of nanosheets. The effect of the combined material on osteoblasts (electrically stimulable cells) was analyzed in terms of proliferation, cell adhesion, expression of differentiation markers and induction of calcium transients. Although both ZnO structures were biocompatible and did not induce inflammatory response, only the array of ZnO nanosheets was able to induce calcium transients, which improved the proliferation of Saos-2 cells and enhanced the expression of some early differentiation expression genes. The usual motion of the cells imposes strain to the ZnO nanosheets, which, in turn, create local electric fields owing to their piezoelectric character. These electric fields cause the opening of calcium voltage gates and boost cell proliferation and early differentiation. Thus, the modification of the Ti₄₅Zr₁₅Pd₃₀Si₅Nb₅ surface with an array of ZnO nanosheets endows the alloy with smart characteristics, making it capable of electric self-stimulation.

The shape-effect of calcium phosphate nanoparticle based films on their osteogenic properties

Calcium phosphates (CaPs) in the form of hydroxyapatite (HA) have been extensively studied in the context of bone regeneration due to their chemical similarity to natural bone mineral. While HA is known to promote osteogenic differentiation, the structural properties of the ceramic have been shown to affect the extent of this effect; several studies have suggested that nanostructured HA can improve the bioactivity. However, the role shape plays in the osteogenic potential is more elusive. Here we studied the effect of HA nanoparticle shape on the ability to induce osteogenesis in human mesenchymal stromal cells (hMSCs) by developing nanoparticle films using needle-, rice- and spherical-shaped HA. We showed that the HA films made from all three shapes of nanoparticles induced increased levels of osteogenic markers (i.e. runt-related transcription factor 2 (RUNX2), bone morphogenetic protein 2 (BMP2), alkaline phosphatase (ALP), osteopontin (OPN), osteocalcin (OCN) on protein and gene level in comparison to hMSCs cultured on cover glass slides. Furthermore, their expression levels and profiles differed significantly as a function of nanoparticle shape. We also showed that nanoparticle films were more efficient in inducing osteogenic gene expression in hMSCs compared to adding nanoparticles to hMSCs in culture media. Finally, we demonstrated that hMSC morphology upon adhesion to the HA nanoparticle films is dependent on nanoparticle shape, with hMSCs exhibiting a more spread morphology on needle-shaped nanoparticle films compared to hMSCs seeded on rice- and spherical-shaped nanoparticle films. Our data suggests that HA nanoparticle films are efficient in inducing hMSC osteogenesis in basic cell culture conditions and that nanoparticle shape plays a vital role in cell adhesion and morphology and extent of induction of osteogenic differentiation.

Electrodeposited Hydroxyapatite-Based Biocoatings: Recent Progress and Future Challenges

Hydroxyapatite has become an important coating material for bioimplants, following the introduction of synthetic HAp in the 1950s. The HAp coatings require controlled surface roughness/porosity, adequate corrosion resistance and need to show favorable tribological behavior. The deposition rate must be sufficiently fast and the coating technique needs to be applied at different scales on substrates having a diverse structure, composition, size, and shape. A detailed overview of dry and wet coating methods is given. The benefits of electrodeposition include controlled thickness and morphology, ability to coat a wide range of component size/shape and ease of industrial processing. Pulsed current and potential techniques have provided denser and more uniform coatings on different metallic materials/implants. The mechanism of HAp electrodeposition is considered and the effect of operational variables on deposit properties is highlighted. The most recent progress in the field is critically reviewed. Developments in mineral substituted and included particle, composite HAp coatings, including those reinforced by metallic, ceramic and polymeric particles; carbon nanotubes, modified graphenes, chitosan, and heparin, are considered in detail. Technical challenges which deserve further research are identified and a forward look in the field of the electrodeposited HAp coatings is taken.

Current Challenges and Innovative Developments in Hydroxyapatite-Based Coatings on Metallic Materials for Bone Implantation: A Review

Biomaterials are in use for the replacement and reconstruction of several tissues and organs as treatment and enhancement. Metallic, organic, and composites are some of the common materials currently in practice. Metallic materials contribute a big share of their mechanical strength and resistance to corrosion properties, while organic polymeric materials stand high due to their biocompatibility, biodegradability, and natural availability. To enhance the biocompatibility of these metals and alloys, coatings are frequently applied. Organic polymeric materials and ceramics are extensively utilized for this purpose due to their outstanding characteristics of biocompatibility and biodegradability. Hydroxyapatite (HAp) is the material from the ceramic class which is an ultimate candidate for coating on these metals for biomedical applications. HAp possesses similar chemical and structural characteristics to normal human bone. Due to the bioactivity and biocompatibility of HAp, it is used for bone implants for regenerating bone tissues. This review covers an extensive study of the development of HAp coatings specifically for the orthopaedic applications that include different coating techniques and the process parameters of these coating techniques. Additionally, the future direction and challenges have been also discussed briefly in this review, including the coating of HAp in combination with other calcium magnesium phosphates that occur naturally in human bone.

Micro/nanostructured calcium phytate coating on titanium fabricated by chemical conversion deposition for biomedical application

A bioactive micro/nanostructured calcium phytate coating was successfully prepared on titanium surfaces by chemical conversion deposition, mainly through hydrothermal treatment of a mixed solution of phytic acid and saturated calcium hydroxide solution. Ultraviolet radiation was carried out to improve the adhesion of the coating to the titanium substrate. Pure titanium with a sandblasted/acid-etched surface was used as the control group. The topography and chemical composition of the modified surfaces were characterized by scanning electron microscopy (SEM), atomic force microscopy (AFM), X-ray photoelectron spectroscopy (XPS), energy-dispersive X-ray spectroscopy (EDX), and static water contact angle measurement. A pull-off test was performed to measure the coating-to-substrate adhesion strength. Bovine serum albumin was used as a model to study the protein adsorption effect. Cells were cultured on titanium surfaces for 7 days in osteogenic differentiation medium, then the osteoblast compatibility in vitro were explored by alkaline phosphatase and alizarin red staining. After 1, 2, 4 and 8 wks of immediate implantation of titanium implants into the mandibles of New Zealand white rabbits, biological effects in vivo were researched by microcomputed tomography analysis and histological evaluation. The results indicated that the roughness and hydrophilicity of the modified surfaces with micro/nanostructure remarkably increased compared to those of the control group. The pull-off test showed the average adhesion strength at the coating-substrate interface to be higher than 13.56 ± 1.71 MPa. In addition, approximately 4.41 mg/L calcium ion was released from the calcium phytate micro/nano coatings to the local environment after 48 h of immersion. More importantly, the micro/nanostructure titanium substrates significantly promoted cellular differentiation in vitro and in vivo. After 8 wks, the bone implant contact ratio (BIC, %) of the modified implants was higher than that of the control group, at 94.09 ± 0.55% and 86.18 ± 1.99% (p < 0.05). Overall, this study provided new insights into the factors promoting early osseointegration of titanium alloys, which had great potential not only for dental implants but also for various other biomaterial applications.

Enhanced cellular osteogenic differentiation on CoFe2O4/P(VDF-TrFE) nanocomposite coatings under static magnetic field

Cellular responses can be regulated and manipulated through combining stimuli-responsive biomaterial with external stimulus. In this present, the magneto-responsive CoFe₂O₄/P(VDF-TrFE) nanocomposite coatings were designed to understand cell behaviors of preosteoblasts, as well as get insight into the underlying mechanism of osteogenic differentiation under static magnetic field (SMF). CoFe₂O₄/P(VDF-TrFE) nanocomposite coatings with differential magnetic property (low, medium and high magnetization) were prepared by incorporation of different mass fraction of CoFe₂O₄ nanoparticles (6%, 13 %, 20 %) into P(VDF-TrFE) matrix. Cell experiments indicated that all nanocomposite coatings with the assistance of SMF could promote the cell attachment, proliferation and osteogenic differentiation of MC3T3-E1 cells. Among different nanocomposite coatings, low magnetization coating (6%) showed a higher ALP activity and gene expression of Runx2, Col-I, OCN. Molecular biology assays demonstrated that the combination of nanocomposite coatings and SMF could significantly up-regulate the expression level of α2β1 integrin and p-ERK. Whereas, the addition of inhibitor U0126 down-regulated sharply the expression level of p-ERK, which indicated that cellular osteogenic differentiation of MC3T3-E1 cells was governed through α2β1 integrin-mediated MEK/ERK signaling pathways during CoFe₂O₄/P(VDF-TrFE) nanocomposite coatings were combined with SMF. This work provided a promising strategy to enhance cellular osteogenic differentiation through a remote-control manner, which exhibited great potential in the application of bone tissue repair and regeneration.

Enhanced osteogenesis properties of titanium implant materials by highly uniform mesoporous thin films of hydroxyapatite and titania intermediate layer

Titanium (Ti) has been widely used for medical and dental applications; however, bare Ti cannot be properly connected to a living bone, and hence some modifications are needed for this purpose. The present study describes the synthesis of mesoporous hydroxyapatite thin films (MHF) on titanium implant materials for speeding up and shortening the processes of osteointegration. The uniform MHF was coated on a Ti substrate following the insertion of intermediate titania (TiO₂) film via the sol-gel dip-coating method. The intermediate titania layer improved the bonding strength between the MHF and Ti substrate. MHFs were synthesized using a precursor solution containing phosphoric acid, calcium nitrate tetrahydrate, and a nonionic surfactant (C₁₂E₁₀) as the phosphate source, calcium source, and structure-directing agent, respectively. The effect of calcination temperature on phase composition, morphology, microstructure, roughness, and wettability of the MHFs was investigated using XRD, FE-SEM, COM, AFM, and contact angle measurement. The XRD results revealed the crystalline hydroxyapatite phase, which was improved with an increase in the calcination temperature. Moreover, the FE-SEM images showed the crack-free MHFs, uniform thickness of the layer, and mesoporous surface morphology. In addition, it was found that the roughness and wettability of the samples change upon the alteration of calcination temperature. The biological studies demonstrated that MHFs support the adhesion and proliferation of the mesenchymal stem cells (MSCs) and guid them toward osteogenic differentiation. Therefore, the MHFs prepared in this study may be useful in a wide range of applications, particularly in bone regeneration medicine.

The morphological effect of nanostructured hydroxyapatite coatings on the osteoinduction and osteogenic capacity of porous titanium

Weak osteogenic activity affects the long-term fixation and lifespan of titanium (Ti) implants. Surface modification along with a built-in porous structure is a highly considerable approach to improve the osteoinduction and osseointegration capacity of Ti. Herein, the osteoinduction and osteogenic activities of electrochemically deposited (ED) nanoplate-like, nanorod-like and nanoneedle-like hydroxyapatite (HA) coatings (named EDHA-P, EDHA-R, and EDHA-N, respectively) were evaluated in vitro and in vivo by comparison with those of acid/alkali (AA) treatment. The results revealed that the apatite forming ability of all nanostructured EDHA coatings was excellent, and only 12 h of soaking in SBF was needed to induce a complete layer of apatite. More serum proteins adsorbed on EDHA-P than others. In cellular experiments, different from those on EDHA-R and EDHA-N, the cells on EDHA-P presented a polygonal shape with lamellipodia extension, and thus exhibited a relatively larger spreading area. Furthermore, EDHA-P was more favorable for the enhancement of the proliferation and ALP activity of BMSCs, and the up-regulation of OPN gene expression. Based on the good biological performance in vitro, EDHA-P was selected to further evaluate its osteoinduction and osteogenic activities in vivo by comparison with AA treatment. Interestingly, a greater ability of ectopic osteoinduction was observed in the EDHA-P group compared to that in the AA group. At the osseous site, EDHA-P promoted more bone on/ingrowth, and had a higher area percentage of newly formed bone in the bone-implant interface and inner pores of the implants than in the AA group. Thus, a nanoplate-like HA coating has good potential in improving the osteoinductivity and osteogenic activity of porous Ti implants in clinical applications.

Natural Antibiotic Oregano in Hydroxyapatite-Coated Titanium Reduces Osteoclastic Bone Resorption for Orthopedic and Dental Applications

Traditional infection prevention and treatment methods include synthetic antibiotics, which can cause severe adverse side effects. Carvacrol and thymol are biologically active monoterpenoid extractants from oregano leaves with antibiotic capabilities; however, little is known regarding their effects on bone tissue engineering. The objective of this work is to understand their effects on osteogenesis, specifically with osteoblast and osteoclast cells, from surface-modified Ti6Al4V with plasma sprayed hydroxyapatite (HA) coatings. This system is an alternative to cemented implants to aid in bone healing. Results reveal that full carvacrol release from the HA matrix is successful in aqueous environments and modulation of release kinetics can also be made using polycaprolactone (PCL) and polyethylene glycol (PEG) polymers. From HA-pressed disc samples in physiological pH, full carvacrol release is achieved in 10 days using PCL/PEG, about 95% release in 50 days using no polymer, and 60% in 50 days when using a PCL coating. Without polymer, full carvacrol release is achieved after 3 days from HA coatings in both physiological pH and acidic pH, mimicking the post-surgery environment. The release is assessed as a diffusion-based mechanism in phosphate-buffered saline but degradation-based mechanism in acetate buffer solution. Carvacrol and thymol show bacterial inhibition of Staphylococcus epidermidis and no cytotoxic effects on osteoblast proliferation in vitro. Carvacrol and thymol also induce a significant 7% reduction in osteoclast tartrate-resistant acid phosphatase (TRAP) activity, caused by poorly attached cellular morphologies, leading to an approximately 65% reduction in osteoclast resorption pit formation. Our goal is to demonstrate a natural medicinal system that can support bone healing while providing infection prevention and reducing costly revision surgeries for orthopedic and dental applications.

Surface Modification Techniques of Titanium and its Alloys to Functionally Optimize Their Biomedical Properties: Thematic Review

Depending on the requirements of specific applications, implanted materials including metals, ceramics, and polymers have been used in various disciplines of medicine. Titanium and its alloys as implant materials play a critical role in the orthopedic and dental procedures. However, they still require the utilization of surface modification technologies to not only achieve the robust osteointegration but also to increase the antibacterial properties, which can avoid the implant-related infections. This article aims to provide a summary of the latest advances in surface modification techniques, of titanium and its alloys, specifically in biomedical applications. These surface techniques include plasma spray, physical vapor deposition, sol-gel, micro-arc oxidation, etc. Moreover, the microstructure evolution is comprehensively discussed, which is followed by enhanced mechanical properties, osseointegration, antibacterial properties, and clinical outcomes. Future researches should focus on the combination of multiple methods or improving the structure and composition of the composite coating to further enhance the coating performance.

Effects of vitamin C on osteoblast proliferation and osteosarcoma inhibition using plasma coated hydroxyapatite on titanium implants

Plasma-sprayed hydroxyapatite (HAp) coated titanium (Ti) implants are being extensively used in orthopedic surgeries and post-tumor resection to repair load-bearing segmental bone defects. In this study, vitamin C, an abundantly available natural biomolecule, is loaded onto plasma-sprayed HAp-coated commercially pure titanium (cpTi) surface to evaluate its chemopreventive and osteogenic properties, suggesting its clinical significance as an alternative or adjunct therapy in the treatment for osteosarcoma bone resection. Controlled release of vitamin C from HAp coated cpTi implant is assessed by in vitro drug release study, where Korsmeyer-Peppas model was applied to understand the release kinetics. After 21 days, the implants loaded with 400 and 800 μg of vitamin C showed a cumulative release of 62.7 and 74.1% in acidic microenvironment, whereas, 50.9% and 53.1% of total vitamin C release were observed by the implants loaded with 400 and 800 μg of vitamin C in physiological pH, respectively. To observe the effects of in vitro vitamin C release on osteosarcoma and osteoblast cellular activity, MG-63 (human osteosarcoma) and hFOB (human fetal osteoblast) cells were cultured on the surface of the implant and MTT cell viability assay and FESEM were carried out at 3 and 7 days of culture. Presence of high dosages 25 mM vitamin C shows a statistically significant (p≤0.05) decrease in osteosarcoma cell viability after 3 days, while both 5 mM and 25mM vitamin C reduced cellular viability by 2.5 folds (p≤0.05) compared to the control after 7 days. Interestingly, the presence of vitamin C showed no obvious signs of cytotoxicity towards osteoblast cell-line at day 3 and day 7, as confirmed by the MTT assay. Additionally, the FESEM images depict layers of hFOB cellular morphology on the surface of the implants, suggesting excellent cytocompatibility towards the osteoblast cells. These results suggest that vitamin C loaded HAp coated cpTi implant with improved osteogenic and chemopreventive properties can be considered as a promising reconstructive option to repair the post-tumor resection defects in osteosarcoma.

Novel Extrusion-Microdrilling Approach to Fabricate Calcium Phosphate-Based Bioceramic Scaffolds Enabling Fast Bone Regeneration

This study proposes a novel approach, termed extrusion-microdrilling, to fabricate three-dimensional (3D) interconnected bioceramic scaffolds with channel-like macropores for bone regeneration. The extrusion-microdrilling method is characterized by ease of use, high efficiency, structural flexibility, and precision. The 3D interconnected β-tricalcium phosphate bioceramic (EM-TCP) scaffolds prepared by this method showed channel-like square macropores (∼650 μm) by extrusion and channel-like round macropores (∼570 μm) by microdrilling as well as copious micropores. By incorporating a strontium-containing phosphate-based glass (SrPG), the obtained calcium phosphate-based bioceramic (EM-TCP/SrPG) scaffolds had noticeably higher compressive strength, lower porosity, and smaller macropore size, tremendously enhanced in vitro proliferation and osteogenic differentiation of mouse bone marrow stromal cells, and suppressed in vitro osteoclastic activities of RAW264.7 cells, as compared with the EM-TCP scaffolds. In vivo assessment results indicated that at postoperative week 6, new vessels and a large percentage of new bone tissues (24-25%) were formed throughout the interconnected macropores of EM-TCP and EM-TCP/SrPG, which were implanted in the femoral defects of rabbits; the bone formation of the EM-TCP group was comparable to that of the EM-TCP/SrPG group. At 12 weeks postimplantation, the bone formation percentage of EM-TCP was slightly reduced, while that of EM-TCP/SrPG with a slower degradation rate was pronouncedly increased. This work provides a new strategy to fabricate interconnected bioceramic scaffolds allowing for fast bone regeneration, and the EM-TCP/SrPG scaffolds are promising for efficiently repairing bone defects.

Assessing the Bioactivity of Gentamicin-Preloaded Hydroxyapatite/Chitosan Composite Coating on Titanium Substrate

The electrophoretic deposition process (EPD) was utilized to produce bioactive hydroxyapatite/chitosan (HAP/CS) and hydroxyapatite/chitosan/gentamicin (HAP/CS/Gent) coatings on titanium. The bioactivity of newly synthesized composite coatings was investigated in the simulated body fluid (SBF) and examined by X-ray diffraction, Fourier transform infrared spectroscopy, and field emission scanning electron microscopy. The obtained results revealed carbonate-substituted hydroxyapatite after immersion in SBF, emphasizing the similarity of the biomimetically grown HAP with the naturally occurring apatite in the bone. The formation of biomimetic HAP was confirmed by electrochemical impedance spectroscopy and polarization measurements, through the decrease in corrosion current density and coating capacitance values after 28-day immersion in SBF. The osseointegration ability was further validated by measuring the alkaline phosphatase activity (ALP) indicating the favorable osseopromotive properties of deposited coatings (significant increase in ALP levels for both HAP/CS (3.206 U mL-1) and HAP/CS/Gent (4.039 U mL-1) coatings, compared to the control (0.900 U mL-1)). Drug-release kinetics was investigated in deionized water at 37 °C by high-performance liquid chromatography coupled with mass spectrometry. Release profiles revealed the beneficial "burst-release effect" (∼21% of gentamicin released in the first 48 h) as a potentially promising solution against the biofilm formation in the initial period. When tested against human and mice fibroblast cells (MRC-5 and L929), both composite coatings showed a noncytotoxic effect (viability >85%), providing a promising basis for further medical application trials.

Recent advances in the design of cardiovascular materials for biomedical applications

Biomaterials dominate the field of cardiovascular therapeutics, a multitude of which have been used to repair and replace injured heart tissue. This field has evolved beyond the simple selection of compatible materials and now focuses on the rational design of controlled structures that integrate with the cardiovascular system. However, the compatibility of these materials with the blood presents a major limitation to their clinical application. In this context, surface modification strategies can enhance blood compatibility and several recent advances in this area have emerged. This review summarizes the recent applications of biomaterials in cardiovascular therapies, the improvements in their biocompatibility and the surface modification technologies that have the potential to improve clinical outcomes.

Controlled Delivery of Curcumin and Vitamin K2 from Hydroxyapatite-Coated Titanium Implant for Enhanced in Vitro Chemoprevention, Osteogenesis, and in Vivo Osseointegration

Successful repair of critical-sized tumor-resection defects, especially in load-bearing bones, still remains a major challenge in clinical orthopedics. Titanium (Ti) implants have been increasingly used in the past few decades because of titanium's suitable mechanical properties and biocompatibility; however, it shows insufficient integration with the surrounding bone. In this study, the plasma spray technique is utilized to form homogeneous hydroxyapatite (HA) coating on the surface of the Ti implant to enhance osseointegration at the tissue-implant interface. These coated implants are loaded with curcumin and vitamin K2 to introduce chemopreventive and osteogenesis ability via controlled release of these biomolecules. The synergistic effect of these two biomolecules showed enhanced in vitro osteoblast (hFOB) cell attachment and proliferation for 11 days. Moreover, these biomolecules showed lower in vitro osteosarcoma (MG-63) cell proliferation after 3, 7, and 11 days. An in vivo study was carried out to evaluate the bone bonded zone in a rat distal femur model at an early wound healing stage of 5 days. Modified Masson Goldner staining of the tissue-implant section showed improved contact between tissue and implant in dual drug-loaded HA-coated Ti implants compared to control implants. This work presents a successful fabrication of a mechanically competent functional Ti implant with the advantages of enhanced in vitro osteoblast proliferation, osteosarcoma inhibition, and in vivo osseointegration, indicating the potential for load-bearing bone-defect repair after tumor resection.

In-vitro comparison of hydroxyapatite coatings obtained by cold spray and conventional thermal spray technologies

Hydroxyapatite (HA) coatings onto Ti6Al4V alloy substrates were obtained by several thermal spray technologies: atmospheric plasma spray (APS) and high velocity oxy fuel (HVOF), together with the cold spray (CS) technique. A characterization study has been performed by means of surface and microstructure analyses, as well as biological performance. In-vitro tests were performed with primary human osteoblasts at 1, 7 and 14 days of cell culture on substrates. Cell viability was tested by MTS and LIVE/DEAD assays, cell differentiation by alkaline phosphatase (ALP) quantification, and cell morphology was analyzed by scanning electron microscopy. The HA coatings showed an increase of HA crystallinity from 62,4% to 89%, but also an increase of hydrophilicity from ∼32° to 0°, with the decrease of the operating temperature of the thermal spray techniques (APS > HVOF > CS). Additionally, APS HA coatings showed more surface micro-features than HVOF and CS HA coatings; cells onto APS HA coatings showed faster attachment by acquiring osteoblastic morphology in comparison with the rounded cell morphology observed onto CS HA coatings at 1 day of cell culture. HVOF HA coatings also showed proper cell adherence but did not show extended filopodia as cells onto APS HA coatings. However, at 14 days of cell culture, higher cell proliferation and differentiation was detected on HA coatings with higher crystallinity (HVOF and CS techniques). Cell attachment is suggested to be favoured by surface micro-features but also moderate surface wettability whereas cell proliferation and differentiation is suggested to be highly influenced by HA crystallinity and crystal size.

Tantalum-incorporated hydroxyapatite coating on titanium implants: its mechanical and in vitro osteogenic properties

OBJECTIVE

The fabrication of bioactive coatings on metallic implants to enhance osseointegration has become a topic of general interest in orthopedics and dentistry. Hydroxyapatite (HA) coating has been shown to induce bone formation and promote bone-implant integration. Unfortunately, poor mechanical performance has hindered this from becoming a favorable coating material. The majority of present studies have focused in incorporating different elements into HA coatings to improve mechanical properties. In recent years, tantalum (Ta) has received increasing attention due to its excellent biocompatibility and corrosion resistance. The aim of on the present study was to investigate the fabrication and biological performance of Ta-incorporated HA coatings.

METHODS

Ta-incorporated HA coatings were fabricated using the plasma spray technique on a titanium substrate, and the surface characteristics and mechanical properties were examined. In addition, the effects of Ta-incorporated HA coatings on the biological behavior of mesenchymal stem cells (BMSCs) were investigated.

RESULTS

Ta-incorporated HA coatings with microporous structure had higher roughness and wettability. In addition, the bonding strength of Ta/HA coatings with the substrate was substantially superior to HA coatings. Furthermore, Ta-incorporated HA coatings not only facilitated initial cell adhesion and faster proliferation, but also promoted the osteogenic differentiation of BMSCs.

CONCLUSION

These results indicate that the incorporation of Ta could improve mechanical performance and increase the osteogenic activity of HA coatings. The Ta-incorporated HA coating fabricated by plasma spraying is expected to be a promising bio-coating material for metallic implants.

In Vitro Characterizations of Si4+ and Zn2+ Doped Plasma Sprayed Hydroxyapatite Coatings Using Osteoblast and Osteoclast Coculture

Osteoporosis is one of the most commonly identified bone disorders, which leads to an enhanced risk of bone fracture, especially for the older population. Hydroxyapatite (HA) coated titanium (Ti) alloys have been used widespread for load bearing applications like hip or knee replacements owing to their compositional similarity to natural bone; however, incorporation of osteoinductivity is still a challenge. The objective of this study is to evaluate the effects of SiO₂ and ZnO as dopants in HA coated Ti alloys on cellular osteoporotic conditions mimicked by an in vitro osteoblast and osteoclast coculture model. HA, Si-HA, and Zn-HA coatings showed adhesive bond strengths of 25.7 ± 1.9 MPa, 23.8 ± 2.3 MPa, and 22.9 ± 3.5 MPa, respectively. To study the effects of doped HA coatings on the simulated osteoporotic cellular condition, human mesenchymal stem cells (hMSCs) and monocytes (THP-1) were seeded simultaneously in a ratio of 1:4, respectively. Gene expressions studies were carried out with marker genes showing that the presence of the dopants in the HA coating enhanced osteoblast proliferation along with diminishing cell growth of osteoclasts. This study demonstrates the promising effects of SiO₂ and ZnO in plasma sprayed HA coatings on alleviating osteoporosis cellular conditions, which can potentially be used for load-bearing implants in aging patients whose bone resorption is more dominant than bone formation.

A Facile Flow-Casting Production of Bioactive Glass Coatings on Porous Titanium for Bone Tissue Engineering

Additive manufacturing enabled the fabrication of porous titanium (PT) with customized porosity and mechanical properties. However, functionalization of PT surfaces with bioactive coatings is being challenged due to sophisticated geometry and highly porous structure. In this study, a facile flow-casting technique was developed to produce homogeneous 45S5 bioactive glass (BG) coatings on the entire surface of PT. The coating weight as a function of BG concentration in a BG-PVA slurry was investigated to achieve controllable coating yield without blocking macropore structure. The annealing-treated BG coating not only exhibited compact adhesion confirmed by qualitative sonication treatment, but also enhanced the mechanical properties of PT scaffolds. Moreover, in-vitro assessments of BG-coated PT cultured with MC3T3-E1 cells was carried out having in mind their potential as bioactive bone implants. The experimental results in this study offer a simple and versatile approach for the bio-functionalization of PT and other porous biomedical devices.

Effects of PCL, PEG and PLGA polymers on curcumin release from calcium phosphate matrix for in vitro and in vivo bone regeneration

Calcium phosphate materials are widely used as bone-like scaffolds or coating for metallic hip and knee implants due to their excellent biocompatibility, compositional similarity to natural bone and controllable bioresorbability. Local delivery of drugs or osteogenic factors from scaffolds and implants are required over a desired period of time for an effectual treatment of various musculoskeletal disorders. Curcumin, an antioxidant and anti-inflammatory molecule, enhances osteoblastc activity in addition to its anti-osteoclastic activity. However, due to its poor solubility and high intestinal liver metabolism, it showed limited oral efficacy in various preclinical and clinical studies. To enhance its bioavailability and to provide higher release, we have used poly (ε-caprolactone) (PCL), poly ethylene glycol (PEG) and poly lactide co glycolide (PLGA) as the polymeric system to enable continuous release of curcumin from the hydroxyapatite matrix for 22 days. Additionally, curcumin was incorporated in plasma sprayed hydroxyapatite coated Ti6Al4V substrate to study in vitro cell material interaction using human fetal osteoblast (hFOB) cells for load bearing implants. MTT cell viability assay and morphological characterization by FESEM showed highest cell viability with samples coated with curcumin-PCL-PEG. Finally, 3D printed interconnected macro porous β-TCP scaffolds were prepared and curcumin-PCL-PEG was loaded to assess the effects of curcumin on in vivo bone regeneration. The presence of curcumin in TCP results in enhanced bone formation after 6 weeks. Complete mineralized bone formation increased from 29.6 % to 44.9% in curcumin-coated scaffolds compared to pure TCP. Results show that local release of curcumin can be designed for both load bearing or non-load bearing implants with the aid of polymers, which can be considered an excellent candidate for wound healing and tissue regeneration applications in bone tissue engineering.

Incorporation of Nanoalumina Improves Mechanical Properties and Osteogenesis of Hydroxyapatite Bioceramics

A handful of work focused on improving the intrinsic low mechanical properties of hydroxyapatite (HA) by various reinforcing agents. However, the big challenge regarding improving mechanical properties is maintaining bioactivity. To address this issue, we report fabrication of apatite-based composites by incorporation of alumina nanoparticles (n-Al₂O₃). Although numerous studies have used micron or submicron alumina for reinforcing hydroxyapatite, only few reports are available about the use of n-Al₂O₃. In this study, spark plasma sintering (SPS) method was utilized to develop HA-nAl₂O₃ dense bodies. Compared to the conventional sintering, decomposition of HA and formation of calcium aluminates phases are restricted using SPS. Moreover, n-Al₂O₃ acts as a bioactive agent while its conventional form is an inert bioceramics. The addition of n-Al₂O₃ resulted in 40% improvement in hardness along with a 110% increase in fracture toughness, while attaining nearly full dense bodies. The in vitro characterization of nanocomposite demonstrated improved bone-specific cell function markers as evidenced by cell attachment and proliferation, alkaline phosphatase activity, calcium and collagen detection and nitric oxide production. Specifically, gene expression analysis demonstrated that introduction of n-Al₂O₃ in HA matrix resulted in accelerated osteogenic differentiation of osteoblast and mesenchymal stem cells, as expression of Runx-2 and OSP showed 2.5 and 19.6 fold increase after 2 weeks (p < 0.05). Moreover, protein adsorption analysis showed enhanced adsorption of plasma proteins to HA-nAl₂O₃ sample compared to HA. These findings suggest that HA-nAl₂O₃ could be a prospective candidate for orthopedic applications due to its improved mechanical and osteogenic properties.

Surface modification of biomaterials and biomedical devices using additive manufacturing

The demand for synthetic biomaterials in medical devices, pharmaceutical products and, tissue replacement applications are growing steadily due to aging population worldwide. The use for patient matched devices is also increasing due to availability and integration of new technologies. Applications of additive manufacturing (AM) or 3D printing (3DP) in biomaterials have also increased significantly over the past decade towards traditional as well as innovative next generation Class I, II and III devices. In this review, we have focused our attention towards the use of AM in surface modified biomaterials to enhance their in vitro and in vivo performances. Specifically, we have discussed the use of AM to deliberately modify the surfaces of different classes of biomaterials with spatial specificity in a single manufacturing process as well as commented on the future outlook towards surface modification using AM.

STATEMENT OF SIGNIFICANCE

It is widely understood that the success of implanted medical devices depends largely on favorable material-tissue interactions. Additive manufacturing has gained traction as a viable and unique approach to engineered biomaterials, for both bulk and surface properties that improve implant outcomes. This review explores how additive manufacturing techniques have been and can be used to augment the surfaces of biomedical devices for direct clinical applications.