Intramedullary Mg2Ag nails augment callus formation during fracture healing in mice

An overview of magnesium-based implants in orthopaedics and a prospect of its application in spine fusion

Due to matching biomechanical properties and significant biological activity, Mg-based implants present great potential in orthopedic applications. In recent years, the biocompatibility and therapeutic effect of magnesium-based implants have been widely investigated in trauma repair. In contrast, the R&D work of Mg-based implants in spinal fusion is still limited. This review firstly introduced the general background for Mg-based implants. Secondly, the mechanical properties and degradation behaviors of Mg and its traditional and novel alloys were reviewed. Then, different surface modification techniques of Mg-based implants were described. Thirdly, this review comprehensively summarized the biological pathways of Mg degradation to promote bone formation in neuro-musculoskeletal circuit, angiogenesis with H-type vessel formation, osteogenesis with osteoblasts activation and chondrocyte ossification as an integrated system. Fourthly, this review followed the translation process of Mg-based implants via updating the preclinical studies in fracture fixation, sports trauma repair and reconstruction, and bone distraction for large bone defect. Furthermore, the pilot clinical studies were involved to demonstrate the reliable clinical safety and satisfactory bioactive effects of Mg-based implants in bone formation. Finally, this review introduced the background of spine fusion surgeryand the challenges of biological matching cage development. At last, this review prospected the translation potential of a hybrid Mg-PEEK spine fusion cage design.

Application of Bioactive Materials for Osteogenic Function in Bone Tissue Engineering

Bone tissue defects present a major challenge in orthopedic surgery. Bone tissue engineering using multiple versatile bioactive materials is a potential strategy for bone-defect repair and regeneration. Due to their unique physicochemical and mechanical properties, biofunctional materials can enhance cellular adhesion, proliferation, and osteogenic differentiation, thereby supporting and stimulating the formation of new bone tissue. 3D bioprinting and physical stimuli-responsive strategies have been employed in various studies on bone regeneration for the fabrication of desired multifunctional biomaterials with integrated bone tissue repair and regeneration properties. In this review, biomaterials applied to bone tissue engineering, emerging 3D bioprinting techniques, and physical stimuli-responsive strategies for the rational manufacturing of novel biomaterials with bone therapeutic and regenerative functions are summarized. Furthermore, the impact of biomaterials on the osteogenic differentiation of stem cells and the potential pathways associated with biomaterial-induced osteogenesis are discussed.

Cytocompatibility, cell-material interaction, and osteogenic differentiation of MC3T3-E1 pre-osteoblasts in contact with engineered Mg/PLA composites

Bioabsorbable Mg wire-reinforced poly-lactic acid (PLA) matrix composites are potential candidate for load-bearing orthopedic implants offering tailorable mechanical and degradation properties by stacking sequence, volume fraction and surface modification of Mg wires. In this study, we investigated the cytocompatibility, cell-material interaction, and bone differentiation behavior of MC3T3-E1 pre-osteoblast cells for medical-grade PLA, Mg/PLA, and PEO-Mg/PLA (having PEO surface modification on Mg wires) composites. MTT and live/dead assay showed excellent biocompatibility of both composites while cell-material interaction analysis revealed that cells were able to adhere and proliferate on the surface of composites. Cells on the longitudinal surface of composites showed a high and uniform cell density while those on transversal surfaces initially avoided Mg regions but later migrated back after the formation of the passivation layer. Bone differentiation tests showed that cells in extracts of PLA and composites were able to initiate the differentiation process as osteogenesis-related gene expressions, alkaline phosphatase protein quantity, and calcium mineralization increased after 7 and 14 days of culture. Interestingly, the bone differentiation response of PEO-Mg/PLA composite was found to be similar to medical-grade PLA, proving its superiority over Mg/PLA composite.

Chronic kidney disease: a contraindication for using biodegradable magnesium or its alloys as potential orthopedic implants?

Magnesium (Mg) has gained widespread recognition as a potential revolutionary orthopedic biomaterial. However, whether the biodegradation of the Mg-based orthopedic implants would pose a risk to patients with chronic kidney disease (CKD) remains undetermined as the kidney is a key organ regulating mineral homeostasis. A rat CKD model was established by a 5/6 subtotal nephrectomy approach, followed by intramedullary implantation of three types of pins: stainless steel, high pure Mg with high corrosion resistance, and the Mg-Sr-Zn alloy with a fast degradation rate. The long-term biosafety of the biodegradable Mg or its alloys as orthopedic implants were systematically evaluated. During an experimental period of 12 weeks, the implantation did not result in a substantial rise of Mg ion concentration in serum or major organs such as hearts, livers, spleens, lungs, or kidneys. No pathological changes were observed in organs using various histological techniques. No significantly increased iNOS-positive cells or apoptotic cells in these organs were identified. The biodegradable Mg or its alloys as orthopedic implants did not pose an extra health risk to CKD rats at long-term follow-up, suggesting that these biodegradable orthopedic devices might be suitable for most target populations, including patients with CKD.

Challenges and Pitfalls of Research Designs Involving Magnesium-Based Biomaterials: An Overview

Magnesium-based biomaterials hold remarkable promise for various clinical applications, offering advantages such as reduced stress-shielding and enhanced bone strengthening and vascular remodeling compared to traditional materials. However, ensuring the quality of preclinical research is crucial for the development of these implants. To achieve implant success, an understanding of the cellular responses post-implantation, proper model selection, and good study design are crucial. There are several challenges to reaching a safe and effective translation of laboratory findings into clinical practice. The utilization of Mg-based biomedical devices eliminates the need for biomaterial removal surgery post-healing and mitigates adverse effects associated with permanent biomaterial implantation. However, the high corrosion rate of Mg-based implants poses challenges such as unexpected degradation, structural failure, hydrogen evolution, alkalization, and cytotoxicity. The biocompatibility and degradability of materials based on magnesium have been studied by many researchers in vitro; however, evaluations addressing the impact of the material in vivo still need to be improved. Several animal models, including rats, rabbits, dogs, and pigs, have been explored to assess the potential of magnesium-based materials. Moreover, strategies such as alloying and coating have been identified to enhance the degradation rate of magnesium-based materials in vivo to transform these challenges into opportunities. This review aims to explore the utilization of Mg implants across various biomedical applications within cellular (in vitro) and animal (in vivo) models.

Influence of implant base material on secondary bone healing: an in silico study

The implant material at the fracture site influences fracture healing not only from biological perspective but also from mechanical perspective. Biodegradable implants such as magnesium (Mg) based alloys have shown faster secondary bone healing properties as compared to bioinert implants such as titanium (Ti). The general reasoning behind this is the benefit of Mg from biocompatibility perspectives. We studied the effect of Ti and Mg as base materials for implants from mechanical perspectives, where we focused on the displacements at the fracture site of the tibia and their influence on the stimulus for bone healing. We found out that in comparison to Ti, Mg implants have minimal stress shielding problem, only which led to better mechanical stimulus at the fracture site.

The development of magnesium-based biomaterials in bone tissue engineering: A review

Bone regeneration is a vital clinical challenge in massive or complicated bone defects. Recently, bone tissue engineering has come to the fore to meet the demand for bone repair with various innovative materials. However, the reported materials usually cannot satisfy the requirements, such as ideal mechanical and osteogenic properties, as well as biocompatibility at the same time. Mg-based biomaterials have considerable potential in bone tissue engineering owing to their excellent mechanical strength and biosafety. Moreover, the biocompatibility and osteogenic activity of Mg-based biomaterials have been the research focuses in recent years. The main limitation faced in the applications of Mg-based biomaterials is rapid degradation, which can produce excessive Mg2+ and hydrogen, affecting the healing of the bone defect. In order to overcome the limitations, researchers have explored several ways to improve the properties of Mg-based biomaterials, including alloying, surface modification with coatings, and synthesizing other composite materials to control the degradation rate upon implantation. This article reviewed the osteogenic mechanism and requirement for appropriate degradation rate and focused on current progress in the biomedical use of Mg-based biomaterials to inspire more clinical applications of Mg in bone regeneration in the future.

Magnesium-based alloys with adapted interfaces for bone implants and tissue engineering

Magnesium and its alloys are one of the most used materials for bone implants and tissue engineering. They are characterized by numerous advantages such as biodegradability, high biocompatibility and mechanical properties with values close to the human bone. Unfortunately, the implant surface must be adequately tuned, or Mg-based alloys must be alloyed with other chemical elements due to their increased corrosion effect in physiological media. This article reviews the clinical challenges related to bone repair and regeneration, classifying bone defects and presenting some of the most used and modern therapies for bone injuries, such as Ilizarov or Masquelet techniques or stem cell treatments. The implant interface challenges are related to new bone formation and fracture healing, implant degradation and hydrogen release. A detailed analysis of mechanical properties during implant degradation is extensively described based on different literature studies that included in vitro and in vivo tests correlated with material properties' characterization. Mg-based trauma implants such as plates and screws, intramedullary nails, Herbert screws, spine cages, rings for joint treatment and regenerative scaffolds are presented, taking into consideration their manufacturing technology, the implant geometrical dimensions and shape, the type of in vivo or in vitro studies and fracture localization. Modern technologies that modify or adapt the Mg-based implant interfaces are described by presenting the main surface microstructural modifications, physical deposition and chemical conversion coatings. The last part of the article provides some recommendations from a translational perspective, identifies the challenges associated with Mg-based implants and presents some future opportunities. This review outlines the available literature on trauma and regenerative bone implants and describes the main techniques used to control the alloy corrosion rate and the cellular environment of the implant.

Silver-Containing Biomaterials for Biomedical Hard Tissue Implants

Bacterial infection caused by biomaterials is a very serious problem in the clinical treatment of implants. The emergence of antibiotic resistance has prompted other antibacterial agents to replace traditional antibiotics. Silver is rapidly developing as an antibacterial candidate material to inhibit bone infections due to its significant advantages such as high antibacterial timeliness, high antibacterial efficiency, and less susceptibility to bacterial resistance. However, silver has strong cytotoxicity, which can cause inflammatory reactions and oxidative stress, thereby destroying tissue regeneration, making the application of silver-containing biomaterials extremely challenging. In this paper, the application of silver in biomaterials is reviewed, focusing on the following three issues: 1) how to ensure the excellent antibacterial properties of silver, and not easy to cause bacterial resistance; 2) how to choose the appropriate method to combine silver with biomaterials; 3) how to make silver-containing biomaterials in hard tissue implants have further research. Following a brief introduction, the discussion focuses on the application of silver-containing biomaterials, with an emphasis on the effects of silver on the physicochemical properties, structural properties, and biological properties of biomaterials. Finally, the review concludes with the authors' perspectives on the challenges and future directions of silver in commercialization and in-depth research.

Polymer bilayer-Micro arc oxidation surface coating on pure magnesium for bone implantation

Background

Pure magnesium-based ortho-implants have a number of advantages. However, vital parameters like degradation rate and biocompatibility still call for significant improvement.

Methods

In this study, poly (1,3-trimethylene carbonate) (PTMC) and polydopamine (PDA) bilayer and micro arc oxidation composite coatings were prepared successively on magnesium surface by immersion method and microarc oxidation. Its corrosion resistance and biocompatibility were evaluated by in vitro corrosion tests, cellular compatibility experiments, and in vivo animal experiments.

Results

In vitro experiments demonstrated that the composite coating provides excellent corrosion protection and biocompatibility. Animal studies demonstrated that the composite coating slowed the degradation of the implant and was not toxic to animal viscera.

Conclusion

In conclusion, the inorganic-organic composite coating proposed in this study provided good corrosion resistance and enhanced biocompatibility for pure magnesium implants.

The translational potential of this article

The translational potential of this article is to develop an anti-corrosion composite coating on a pure magnesium surface and to verify the viability of its use in animal models. It is hoped to open up a new approach to the design of new degradable orthopedic magnesium-based implants.

Long-term in vivo degradation of Mg-Zn-Ca elastic stable intramedullary nails and their influence on the physis of juvenile sheep

The use of bioresorbable magnesium (Mg)-based elastic stable intramedullary nails (ESIN) is highly promising for the treatment of pediatric long-bone fractures. Being fully resorbable, a removal surgery is not required, preventing repeated physical and psychological stress for the child. Further, the osteoconductive properties of the material support fracture healing. Nowadays, ESIN are exclusively implanted in a non-transphyseal manner to prevent growth discrepancies, although transphyseal implantation would often be required to guarantee optimized fracture stabilization. Here, we investigated the influence of trans-epiphyseally implanted Mg-Zinc (Zn)-Calcium (Ca) ESIN on the proximal tibial physis of juvenile sheep over a period of three years, until skeletal maturity was reached. We used the two alloying systems ZX10 (Mg-1Zn-0.3Ca, in wt%) and ZX00 (Mg-0.3Zn-0.4Ca, in wt%) for this study. To elaborate potential growth disturbances such as leg-length differences and axis deviations we used a combination of in vivo clinical computed tomography (cCT) and ex vivo micro CT (μCT), and also performed histology studies on the extracted bones to obtain information on the related tissue. Because there is a lack of long-term data regarding the degradation performance of magnesium-based implants, we used cCT and μCT data to evaluate the implant volume, gas volume and degradation rate of both alloying systems over a period of 148 weeks. We show that transepiphyseal implantation of Mg-Zn-Ca ESIN has no negative influence on the longitudinal bone growth in juvenile sheep, and that there is no axis deviation observed in all cases. We also illustrate that 95 % of the ESIN degraded over nearly three years, converging the time point of full resorption. We thus conclude that both, ZX10 and ZX00, constitute promising implant materials for the ESIN technique.

Advances in Animal Models for Studying Bone Fracture Healing

Fracture is a common traumatic injury that is mostly caused by traffic accidents, falls, and falls from height. Fracture healing is a long-term and complex process, and the mode of repair and rate of healing are influenced by a variety of factors. The prevention, treatment, and rehabilitation of fractures are issues that urgently need to be addressed. The preparation of the right animal model can accurately simulate the occurrence of fractures, identify and observe normal and abnormal healing processes, study disease mechanisms, and optimize and develop specific treatment methods. We summarize the current status of fracture healing research, the characteristics of different animal models and the modeling methods for different fracture types, analyze their advantages and disadvantages, and provide a reference basis for basic experimental fracture modeling.

Magnesium-Containing Silicate Bioceramic Degradable Intramedullary Nail for Bone Fractures

Intramedullary nails (INs) have significant advantages in rigid fracture fixation. Due to the stress shielding effect and lack of biological activity, traditional metal INs often lead to delay union or nonunion fracture healing. Undegradable metals also need to be removed by a second surgery, which will impose a potential risk to the patient. Current degradable biomaterials with low strength cannot be used in INs. Manufacturing high-strength biodegradable INs (BINs) is still a challenge. Here, we reported a novel high strength bioactive magnesium-containing silicate (CSi-Mg) BIN. This BIN is manufactured by using casting, freeze drying, and sintering techniques and has extremely high bending strength and stable internal and external structures. The manufacturing parameters were systematically studied, such as the paste component, freeze-drying process, and sintering process. This manufacturing method can be applied to various sizes of BINs. The CSi-Mg BIN also has good bioactivity and biodegradation properties. This novel bioactive BIN is expected to replace the traditional metal INs and become a more effective way of treating fractures.

High-resolution ex vivo analysis of the degradation and osseointegration of Mg-xGd implant screws in 3D

Biodegradable magnesium (Mg) alloys can revolutionize osteosynthesis, because they have mechanical properties similar to those of the bone, and degrade over time, avoiding the need of removal surgery. However, they are not yet routinely applied because their degradation behavior is not fully understood.

In this study we have investigated and quantified the degradation and osseointegration behavior of two biodegradable Mg alloys based on gadolinium (Gd) at high resolution.

Mg-5Gd and Mg-10Gd screws were inserted in rat tibia for 4, 8 and 12 weeks. Afterward, the degradation rate and degradation homogeneity, as well as bone-to-implant interface, were studied with synchrotron radiation micro computed tomography and histology. Titanium (Ti) and polyether ether ketone (PEEK) were used as controls material to evaluate osseointegration.

Our results showed that Mg-5Gd degraded faster and less homogeneously than Mg-10Gd. Both alloys gradually form a stable degradation layer at the interface and were surrounded by new bone tissue. The results were correlated to in vitro data obtained from the same material and shape. The average bone-to-implant contact of the Mg-xGd implants was comparable to that of Ti and higher than for PEEK. The results suggest that both Mg-xGd alloys are suitable as materials for bone implants.

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High-resolution non-destructive synchrotron micro computed tomography of biodegradable Mg alloys ex vivo.

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Mg-xGd implants exhibit a high bone-to-implant contact, similar to titanium implants.

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Initially Mg-xGd implants are surrounded by a lesser bone volume fraction but reach similar levels as reference materials.

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Mg-xGd implants degrade at rates lower than 1 mm a⁻¹ in vivo, decreasing to less than 0.4 mm a⁻¹ after 12 weeks.

Potential bioactive coating system for high-performance absorbable magnesium bone implants

Magnesium alloys are considered the most suitable absorbable metals for bone fracture fixation implants. The main challenge in absorbable magnesium alloys is their high corrosion/degradation rate that needs to be controlled. Various coatings have been applied to magnesium alloys to slow down their corrosion rates to match their corrosion rate to the regeneration rate of the bone fracture. In this review, a bioactive coating is proposed to slow down the corrosion rate of magnesium alloys and accelerate the bone fracture healing process. The main aim of the bioactive coatings is to enhance the direct attachment of living tissues and thereby facilitate osteoconduction. Hydroxyapatite, collagen type I, recombinant human bone morphogenetic proteins 2, simvastatin, zoledronate, and strontium are six bioactive agents that show high potential for developing a bioactive coating system for high-performance absorbable magnesium bone implants. In addition to coating, the substrate itself can be made bioactive by alloying magnesium with calcium, zinc, copper, and manganese that were found to promote bone regeneration.

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Bioactive-coated magnesium implant could accelerate bone fracture healing time to match with magnesium degradation.

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Hydroxyapatite, collagen type I, recombinant human bone morphogenetic proteins 2, simvastatin, zoledronate, and strontium are high potential bioactive coating materials.

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The incorporation of Ca, Zn, Cu, Sr, and Mn in Mg base-metal could further enhance bone formation.

Implant degradation of low-alloyed Mg-Zn-Ca in osteoporotic, old and juvenile rats

Implant removal is unnecessary for biodegradable magnesium (Mg)-based implants and, therefore, the related risk for implant-induced fractures is limited. Aging, on the other hand, is associated with low bone-turnover and decreased bone mass and density, and thus increased fracture risk. Osteoporosis is accompanied by Mg deficiency, therefore, we hypothesized that Mg-based implants may support bone formation by Mg²⁺ ion release in an ovariectomy-induced osteoporotic rat model. Hence, we investigated osseointegration and implant degradation of a low-alloyed, degrading Mg-Zn-Ca implant (ZX00) in ovariectomy-induced osteoporotic (Osteo), old healthy (OH), and juvenile healthy (JH) groups of female Sprague Dawley rats via in vivo micro-computed tomography (µCT). For the Osteo rats, we demonstrate diminished trabecular bone already after 8 weeks upon ovariectomy and significantly enhanced implant volume loss, with correspondingly pronounced gas formation, compared to the OH and JH groups. Sclerotic rim development was observed in about half of the osteoporotic rats, suggesting a prevention from foreign-body and osteonecrosis development. Synchrotron radiation-based µCT confirmed lower bone volume fractions in the Osteo group compared to the OH and JH groups. Qualitative histological analysis additionally visualized the enhanced implant degradation in the Osteo group. To date, ZX00 provides an interesting implant material for young and older healthy patients, but it may not be of advantage in pharmacologically untreated osteoporotic conditions. STATEMENT OF SIGNIFICANCE: Magnesium-based implants are promising candidates for treatment of osteoporotic fractures because of their biodegradable, biomechanical, anti-bacterial and bone regenerative properties. Here we investigate magnesium‒zinc‒calcium implant materials in a rat model with ovariectomy-induced osteoporosis (Osteo group) and compare the related osseointegration and implant degradation with the results obtained for old healthy (OH) and juvenile healthy (JH) rats. The work applied an appropriate disease model for osteoporosis and focused in particular on long-term implant degradation for different bone conditions. Enhanced implant degradation and sclerotic rim formation was observed in osteoporotic rats, which illustrates that the setting of different bone models generates significantly modified clinical outcome. It further illustrated that these differences must be taken into account in future biodegradable implant development.

Mg-, Zn-, and Fe-Based Alloys With Antibacterial Properties as Orthopedic Implant Materials

Implant-associated infection (IAI) is one of the major challenges in orthopedic surgery. The development of implants with inherent antibacterial properties is an effective strategy to resolve this issue. In recent years, biodegradable alloy materials have received considerable attention because of their superior comprehensive performance in the field of orthopedic implants. Studies on biodegradable alloy orthopedic implants with antibacterial properties have gradually increased. This review summarizes the recent advances in biodegradable magnesium- (Mg-), iron- (Fe-), and zinc- (Zn-) based alloys with antibacterial properties as orthopedic implant materials. The antibacterial mechanisms of these alloy materials are also outlined, thus providing more basis and insights on the design and application of biodegradable alloys with antibacterial properties as orthopedic implants.

Influences of Extrusion and Silver Content on the Degradation of Mg-Ag Alloys In Vitro and In Vivo

Binary magnesium-silver (Mg-Ag) alloys were designed as antibacterial materials for biomedical implant applications. In the present study, we focused on the effects of extrusion (extrusion ratio (ER): 1, 7.1, and 72.2) and Ag content (Ag = 0, 3, and 6 wt.%) on the degradation of Mg-Ag alloys in vitro and in vivo via microstructure characterization and corrosion/degradation measurements. The results showed that the Ag promoted a galvanic reaction with the Mg matrix to accelerate degradation or formed a protective oxide mesh texture to inhibit degradation, especially in vivo. Ag might also be beneficial for product crystallization, biomineralization, and organic matter deposition. For pure Mg, extrusion produced a more refined grain and decreased the degradation rate. For the Mg-Ag alloys, a low extrusion ratio (7.1) accelerated the degradation caused by the increase in the proportion of the precipitate. This promoted the release of Mg2+ and Ag+, which led to more deposition of organic matter and calcium phosphate, but also more H2 bubbles, which led to disturbance of product deposition in some local positions or even inflammatory reactions. Extrusion at a higher ratio (72.2) dissolved the precipitates. This resulted in moderate degradation rates and less gas production, which promoted osteogenesis without an obvious inflammation reaction.

In vitro and in vivo assessment of the effect of biodegradable magnesium alloys on osteogenesis

Magnesium (Mg) and some of its alloys are considered promising biodegradable metallic biomaterials for bone implant applications. The osteogenesis effect of Mg alloys is widely reported; however, the underlying mechanisms are still not clear. In this study, pure Mg, Mg-3Zn, and Mg-2Zn-1Mn were prepared, and their degradation behavior, biocompatibility, and osteogenesis effect were systematically assessed both in vitro and in vivo. Primary rat bone marrow-derived mesenchymal stem cells (BMSCs) were used to evaluate the biocompatibility of the prepared Mg alloys, and a rat femur fracture model was used to assess the stimulating effect of these alloys on bone-tissue formation. Mg-2Zn-1Mn showed higher corrosion resistance and more stable degradation behavior than pure Mg and Mg-3Zn. Extracts of the three materials showed significant stimulating effects on osteogenic differentiation of BMSCs along with non-cytotoxicity. Implantation of Mg-2Zn-1Mn wires into the femur of rats demonstrated superior histocompatibility, stable degradation, and notable promotion of osteogenesis without systemic toxicity. Moreover, the results of both in vitro and in vivo assessments demonstrated that bone morphogenetic proteins and fibroblast growth factor receptors are involved in the stimulating effect of Mg alloys. STATEMENT OF SIGNIFICANCE: This work reports the degradation behavior, biocompatibility, and osteogenic effect of pure Mg and Mg-3Zn and Mg-2Zn-1Mn alloys in both in vitro and in vivo conditions. Mg-2Zn-1Mn showed higher corrosion resistance and more stable degradation behavior than pure Mg and Mg-3Zn. The extracts of the three materials showed a significant stimulating effect on osteogenic differentiation of rat bone marrow-derived mesenchymal stem cells (BMSCs) along with non-cytotoxicity. Mg-2Zn-1Mn wires implanted into the femur of rats showed good histocompatibility, stable degradation, and notable promotion of osteogenesis without systemic toxicity. The results of the present study suggest that bone morphogenetic proteins (BMPs) and fibroblast growth factor receptors (FGFRs) are involved in the stimulating effect of Mg alloys on osteogenesis.

Magnesium-Based Alloys Used in Orthopedic Surgery

Magnesium (Mg)-based alloys have become an important category of materials that is attracting more and more attention due to their high potential use as orthopedic temporary implants. These alloys are a viable alternative to nondegradable metals implants in orthopedics. In this paper, a detailed overview covering alloy development and manufacturing techniques is described. Further, important attributes for Mg-based alloys involved in orthopedic implants fabrication, physiological and toxicological effects of each alloying element, mechanical properties, osteogenesis, and angiogenesis of Mg are presented. A section detailing the main biocompatible Mg-based alloys, with examples of mechanical properties, degradation behavior, and cytotoxicity tests related to in vitro experiments, is also provided. Special attention is given to animal testing, and the clinical translation is also reviewed, focusing on the main clinical cases that were conducted under human use approval.

Dynamic in vivo monitoring of fracture healing process in response to magnesium implant with multimodal imaging: Pilot longitudinal study in a rat external fixation model

Rodent models are commonly used in pre-clinical research of magnesium (Mg) -based and other types of biomaterials for fracture treatment. Most studies selected unstable fixation methods, and there is a...

Biodegradable metals for bone defect repair: A systematic review and meta-analysis based on animal studies

Biodegradable metals are promising candidates for bone defect repair. With an evidence-based approach, this study investigated and analyzed the performance and degradation properties of biodegradable metals in animal models for bone defect repair to explore their potential clinical translation. Animal studies on bone defect repair with biodegradable metals in comparison with other traditional biomaterials were reviewed. Data was carefully collected after identification of population, intervention, comparison, outcome, and study design (PICOS), and following the inclusion criteria of biodegradable metals in animal studies. 30 publications on pure Mg, Mg alloys, pure Zn and Zn alloys were finally included after extraction from a collected database of 2543 publications. A qualitative systematic review and a quantitative meta-analysis were performed. Given the heterogeneity in animal model, anatomical site and critical size defect (CSD), biodegradable metals exhibited mixed effects on bone defect repair and degradation in animal studies in comparison with traditional non-degradable metals, biodegradable polymers, bioceramics, and autogenous bone grafts. The results indicated that there were limitations in the experimental design of the included studies, and quality of the evidence presented by the studies was very low. To enhance clinical translation of biodegradable metals, evidence-based research with data validity is needed. Future studies should adopt standardized experimental protocols in investigating the effects of biodegradable metals on bone defect repair with animal models.

Macrophage-derived oncostatin M/bone morphogenetic protein 6 in response to Mg-based materials influences pro-osteogenic activity of human umbilical cord perivascular cells

Macrophages are the central immune cell involved in the foreign body reaction to the implants. Furthermore, the magnesium-based materials could modulate macrophage functions, and subsequently influence bone formation via not clearly understood mechanisms. To analysis the roles of materials (magnesium and its gadolinium-based alloy; Mg and Mg-10Gd) on secretion of macrophages and their effects on pro-osteogenic activity, human mesenchymal stem cells (MSC) and macrophages were cocultured directly on the materials surface. Here, oncostatin M (OSM) - glycoprotein 130 (gp130) signaling complex as well as BMP6/SMAD were found to be involved in the Mg and Mg-10Gd multifactorial modulating osteogenic differentiation. Furthermore, materials upregulated the gene expression of bone morphogenetic protein 6 (BMP6) in macrophages, as well as its protein receptors and mothers against decapentaplegic homolog (SMAD) 1/4/5 in cocultured MSC. Besides, both materials could reduce the secretion of tumour necrosis factor alpha (TNFα) and interleukin 1 beta (IL1β) in macrophages and cocultures. These results collectively imply that Mg and Mg-10Gd could create a beneficial microenvironment for osteogenic differentiation and further support Mg-based biomaterial immunomodulatory properties by modulating the interactions of macrophages and MSC for bone regeneration. STATEMENT OF SIGNIFICANCE: Mg-activated macrophages could regulate the pro-osteogenic activity via OSM/gp130 and Smad-related signalling. The neutralisation assay was utilised to confirm the hypothesis of inductive osteoblastic differentiation of human MSC via OSM/gp130 signalling. Current study are essential to evidence that the coordinated communication between macrophages and MSC (OSM/gp130/BMP6/TNFα/IL1β), which could be utilised for improving magnesium-based bone biomaterials and therapeutic applications.

Clinical translation and challenges of biodegradable magnesium-based interference screws in ACL reconstruction

As one of the most promising fixators developed for anterior cruciate ligament (ACL) reconstruction, biodegradable magnesium (Mg)-based interference screws have gained increasing attention attributed to their appropriate modulus and favorable biological properties during degradation after surgical insertion. However, its fast degradation and insufficient mechanical strength have also been recognized as one of the major causes to limit their further application clinically. This review focused on the following four parts. Firstly, the advantages of Mg or its alloys over their counterparts as orthopaedic implants in the fixation of tendon grafts in ACL reconstruction were discussed. Subsequently, the underlying mechanisms behind the contributions of Mg ions to the tendon-bone healing were introduced. Thirdly, the technical challenges of Mg-based interference screws towards clinical trials were discussed, which was followed by the introduction of currently used modification methods for gaining improved corrosion resistance and mechanical properties. Finally, novel strategies including development of Mg/Titanium (Ti) hybrid fixators and Mg-based screws with innovative structure for achieving clinically customized therapies were proposed. Collectively, the advancements in the basic and translational research on the Mg-based interference screws may lay the foundation for exploring a new era in the treatment of the tendon-bone insertion (TBI) and related disorders.

Investigation of the impact of magnesium versus titanium implants on protein composition in osteoblast by label free quantification

Metallic implant biomaterials predominate in orthopaedic surgery. Compared to titanium-based permanent implants, magnesium-based ones offer new possibilities as they possess mechanical properties closer to the ones of bones and they are biodegradable. Furthermore, magnesium is more and more considered to be "bioactive" i.e., able to elicit a specific tissue response or to strengthen the intimate contact between the implant and the osseous tissue. Indeed, several studies demonstrated the overall beneficial effect of magnesium-based materials on bone tissue (in vivo and in vitro). Here, the direct effects of titanium and magnesium on osteoblasts were measured on proteomes levels in order to highlight metal-specific and relevant proteins. Out of 2100 identified proteins, only 10 and 81 differentially regulated proteins, compare to the control, were isolated for titanium and magnesium samples, respectively. Selected ones according to their relationship to bone tissue were further discussed. Most of them were involved in extracellular matrix maturation and remodelling (two having a negative effect on mineralisation). A fine-tuned balanced between osteoblast maturation, differentiation and viability was observed.

The effect of different coatings on bone response and degradation behavior of porous magnesium-strontium devices in segmental defect regeneration

Regeneration of long-bone segmental defects remains a challenge for orthopedic surgery. Current treatment options often require several revision procedures to maintain acceptable alignment and achieve osseous healing. A novel hollow tubular system utilizing magnesium-strontium (Mg-Sr) alloy with autogenous morselized bone filled inside to repair segmental defects was developed. To improve the corrosion and biocompatible properties, two coatings, Ca-P and Sr-P coatings, were prepared on surface of the implants. Feasibility of applying these coated implants was systematically evaluated in vitro and in vivo, and simultaneously to have a better understanding on the relationship of degradation and bone regeneration on the healing process. According to the in vitro corrosion study by electrochemical measurements, greater corrosion resistance was obtained for Ca-P coated sample, and attributed to the double-layer protective structure. The cytotoxicity and alkaline phosphatase (ALP) assays demonstrated enhanced bioactivity for Sr-P coated group because of the long-lasting release of beneficial Sr2+. At 12 weeks post-implantation with Mg-Sr alloy porous device, the segmental defects were effectively repaired with respect to both integrity and continuity. In addition, compared with the Ca-P coated implant, the Sr-P coated implant was more proficient at promoting bone formation and mineralization. In summary, the Sr-P coated implants have bioactive properties and exceptional durability, and promote bone healing that is close to the natural rate, implying their potential application for the regeneration of segmental defects.

Biodegradable magnesium-based biomaterials: An overview of challenges and opportunities

As promising biodegradable materials with nontoxic degradation products, magnesium (Mg) and its alloys have received more and more attention in the biomedical field very recently. Having excellent biocompatibility and unique mechanical properties, magnesium-based alloys currently cover a broad range of applications in the biomedical field. The use of Mg-based biomedical devices eliminates the need for biomaterial removal surgery after the healing process and reduces adverse effects induced by the implantation of permanent biomaterials. However, the high corrosion rate of Mg-based implants leads to unexpected degradation, structural failure, hydrogen evolution, alkalization, and cytotoxicity. To overcome these limitations, alloying Mg with suitable alloying elements and surface treatment come highly recommended. In this area, open questions remain on the behavior of Mg-based biomaterials in the human body and the effects of different factors that have resulted in these challenges. In addition to that, many techniques are yet to be verified to turn these challenges into opportunities. Accordingly, this article aims to review major challenges and opportunities for Mg-based biomaterials to minimize the challenges for the development of novel biomaterials made of Mg and its alloys.

Biodegradable intramedullary nail (BIN) with high-strength bioceramics for bone fracture

About 10 million fractures occur worldwide each year, of which more than 60% are long bone fractures. It is generally agreed that intramedullary nails have significant advantages in rigid fracture fixation. Metal intramedullary nails (INs) can provide strong support but a stress shielding effect can occur that results in nonunion healing in clinic. Nondegradable metals also need to be removed by a second operation. Could INs be biodegradable and used to overcome this issue? As current degradable biomaterials always suffer from low strength and cannot be used in Ins, herein, we report a novel device consisting of biodegradable IN (BIN) made for the first time with bioceramics. These BINs have an extremely high bending strength and stable internal and external structure. Experiments show that the BINs could not only fix and support the tibial fracture model, but also promote osteogenesis and affect the microenvironment of the bone marrow cavity. Therefore, they could be expected to replace traditional metal IN and become a more effective treatment option for tibial fractures.

Biodegradable Zn-Cu alloys show antibacterial activity against MRSA bone infection by inhibiting pathogen adhesion and biofilm formation

Bone and joint-related infections remain the primary and most critical complications of orthopedic surgery. We have innovatively prepared Zn-Cu alloys to achieve outstanding material and antibacterial properties. In this study, we systematically assessed the material properties and antibacterial activity of these Zn-Cu alloys. Our results showed that the Zn-2Cu alloy had the best mechanical properties, biocompatibility, and osteogenic properties. Findings of microbial cultures, CLSM, SEM, and TEM indicated that Zn-2Cu alloy can inhibit both coagulase-positive and coagulase-negative staphylococci, as well as antibiotic-resistant strains (MRSA and MRSE), by preventing the bacteria adhesion and the biofilm formation. Zn-2Cu alloy could broadly affect the expression of MRSA genes associated with adhesion, autolysis, biofilm formation, virulence, and drug resistance. A rat femur intramedullary nail infection-prevention model was established and the Zn-2Cu alloy-treated group showed significant antibacterial activity against MRSA and reduced the inflammatory toxic side-effects and infection-related bone loss. Collectively, our results indicate the potential utility of Zn-Cu alloy implants with 2 wt% Cu in treating orthopedic infections. Statement of significance: Osteomyelitis is a serious complication of orthopedic surgeries. Wide use of antibiotics contributes to the appearance of multi-drug resistant strains like methicillin-resistant staphylococcus aureus (MRSA). Alternatively, anti-osteomyelitis implants with broad-spectrum antibacterial properties can be favorable. Here, the antibacterial performance of biodegradable Zn-Cu alloys was evaluated with four different bacteria strains including antibiotic-resistant strains (MRSA and MRSE). Zn-Cu alloys exert excellent bacterial killing capability in all strains. In a rat femur infection model, the alloy showed significant antibacterial activity against MRSA and reduced inflammatory toxic side-effects as well as infection-related bone loss. The antibacterial property of Zn-2Cu alloy was associated with inhibition of gene expression related to wall synthesis, adhesion, colonization, biofilm formation, autolysis, and secretion of virulence factors in MRSA.

A lean magnesium-zinc-calcium alloy ZX00 used for bone fracture stabilization in a large growing-animal model

Over the last decade, demand has increased for developing new, alternative materials in pediatric trauma care to overcome the disadvantages associated with conventional implant materials. Magnesium (Mg)-based alloys seem to adequately fulfill the vision of a homogeneously resorbable, biocompatible, load-bearing and functionally supportive implant. The aim of the present study is to introduce the high-strength, lean alloy Mg‒0.45Zn‒0.45Ca, in wt% (ZX00), and for the first time investigate the clinical applicability of screw osteosynthesis using this alloy that contains no rare-earth elements. The alloy was applied in a growing sheep model with osteotomized bone (simulating a fracture) and compared to a non-osteotomy control group regarding degradation behavior and fracture healing. The alloy exhibits an ultimate tensile strength of 285.7 ± 3.1 MPa, an elongation at fracture of 18.2 ± 2.1%, and a reduced in vitro degradation rate compared to alloys containing higher amounts of Zn. In vivo, no significant difference between the osteotomized bone and the control group was found regarding the change in screw volume over implantation time. Therefore, it can be concluded that the fracture healing process, including its effects on the surrounding area, has no significant influence on degradation behavior. There was also no negative influence from hydrogen-gas formation on fracture healing. Despite the proximal and distal screws showing chronologically different gas release, the osteotomy showed complete consolidation. STATEMENT OF SIGNIFICANCE: Conventional implants involve several disadvantages in pediatric trauma care. Magnesium-based alloys seem to overcome these issues as discussed in the recent literature. This study evaluates the clinical applicability of high-strength lean Mg‒0.45Zn‒0.45Ca (ZX00) screws in a growing-sheep model. Two groups, one including a simulated fracture and one group without fracture, underwent implantation of the alloy and were compared to each other. No significant difference regarding screw volume was observed between the groups. There was no negative influence of hydrogen-gas formation on fracture healing and a complete fracture consolidation was found after 12 weeks for all animals investigated.

A lean bioabsorbable magnesium-zinc-calcium alloy ZX00 used for operative treatment of medial malleolus fractures: early clinical results of a prospective non-randomized first in man study

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.

Methods

A total of 20 patients with isolated, bimalleolar, or trimalleolar ankle fractures were recruited between July 2018 and October 2019. Fracture reduction was achieved through bioabsorbable Mg-based screws composed of pure Mg alloyed with zinc (Zn) and calcium (Ca) ( Mg-Zn0.45-Ca0.45, in wt.%; ZX00). Visual analogue scale (VAS) and the presence of complications (adverse events) during follow-up (12 weeks) were used to evaluate the clinical outcomes. The functional outcomes were analyzed through the range of motion (ROM) of the ankle joint and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Fracture reduction and gas formation were assessed using several plane radiographs.

Results

The follow-up was performed after at least 12 weeks. The mean difference in ROM of the talocrural joint between the treated and the non-treated sites decreased from 39° (SD 12°) after two weeks to 8° (SD 11°) after 12 weeks (p ≤ 0.05). After 12 weeks, the mean AOFAS score was 92.5 points (SD 4.1). Blood analysis revealed that Mg and Ca were within a physiologically normal range. All ankle fractures were reduced and stabilized sufficiently by two Mg screws. A complete consolidation of all fractures was achieved. No loosening or breakage of screws was observed.

Conclusion

This first prospective clinical investigation of fracture reduction and fixation using lean, bioabsorbable, REE-free ZX00 screws showed excellent clinical and functional outcomes.

Cite this article: Bone Joint Res 2020;9(8):477–483.

Understanding Protein Networks Using Vester's Sensitivity Model

Magnesium-based biomaterials belong to the third generation of biomaterials that are also bioactive. These smart materials combine bioactivity and biodegradability, and elicit specific cellular responses at the molecular level. In fact, osteoinductive properties have been observed in mesenchymal stem cells in the presence of Magnesium. The mechanistic understanding of the physiological effects however, remains a difficult task as Mg is involved in a multitude of biological reactions. The study of protein interactions may shed light on the molecular processes in Mg-stimulated cells, therefore, suitable data mining tools are required to analyze the large amount data generated via proteomics. Protein compositions over time between two conditions (human mesenchymal stem cells cultured with and without Mg degradation products) were analyzed using Vester's Sensitivity Model. Proteins whose dynamics significantly change from one setup to the other were classified into four categories: passive, active, critical, and buffering according to their regulatory activity. In this work, we demonstrated the use of Vester's Sensitivity Model as an appropriate data mining tool. Protein network analyses highlighted the primary role of Mg-based implant degradation on cell metabolism without deleterious effect on cell viability. Furthermore, key proteins involved in calcium-dependant cellular activities were emphasized leading to further studies.

The effects of severe plastic deformation on the mechanical and corrosion characteristics of a bioresorbable Mg-ZKQX6000 alloy

In this work, a bioresorbable Mg-ZKQX6000 (Mg-6Zn-0.6Zr-0.4Ag-0.2Ca (wt%)) alloy was severely plastically deformed via equal channel angular pressing (ECAP) according to three unique hybrid routes at low temperatures (200 °C to 125 °C). The roles of ECAP processing on microstructure, and ensuing mechanical properties and corrosion rates, are assessed. Microstructurally, ECAP induces a complex plethora of features, especially variations in grain sizes and precipitates' sizes, distributions, and morphologies for individual cases. Mechanically, ECAP generally refined grain size, resulting in ultra-high strength levels of about 400 MPa in ultimate tensile strength for several cases; however, deformation via ECAP of precipitates induced embrittlement and low elongation to failure levels. Corrosion testing, conducted in simulated bodily fluid at bodily pH levels to mimic conditions in the human body, revealed consistent corrosion rates across several techniques (mass loss, hydrogen evolution, and electrochemical impedance spectroscopy (EIS)), showing that severe plastic deformation deteriorates corrosion resistance for this material. In-situ corrosion monitoring explained that corrosion accelerated after ECAP due to the creation of heterogeneous, anodic shear zones, which exhibited dense regions of refined grains and fine precipitates. Suggestions for future design and thermomechanical processing of Mg alloys for bioresorbable orthopedic implants are provided.

Bio-inspired biomaterial Mg-Zn-Ca: a review of the main mechanical and biological properties of Mg-based alloys

The toxicity of alloying elements in magnesium alloys used for biomedical purposes is an interesting and innovative subject, due to the great technological advances that would result from their application in medical devices (MDs) in traumatology. Recently promising results have been published regarding the rates of degradation and mechanical integrity that can support Mg alloys; this has led to an interest in understanding the toxicological features of these emerging biomaterials. The growing interest of different segments of the MD market has increased the determination of different research groups to clarify the behavior of alloying elements in vivo. This review covers the influence of the alloying elements on the body, the toxicity of the elements in Mg-Zn-Ca, as well as the mechanical properties, degradation, processes of obtaining the alloy, medical approaches and future perspectives on the use of the Mg in the manufacture of MDs for various medical applications.

Biodegradable Magnesium-Based Implants in Orthopedics-A General Review and Perspectives

Biodegradable Mg-based metals may be promising orthopedic implants for treating challenging bone diseases, attributed to their desirable mechanical and osteopromotive properties. This Review summarizes the current status and future research trends for Mg-based orthopedic implants. First, the properties between Mg-based implants and traditional orthopedic implants are compared on the following aspects: in vitro and in vivo degradation mechanisms of Mg-based implants, peri-implant bone responses, the fate of the degradation products, and the cellular and molecular mechanisms underlying the beneficial effects of Mg ions on osteogenesis. Then, the preclinical studies conducted at the low weight bearing sites of animals are introduced. The innovative strategies (for example, via designing Mg-containing hybrid systems) are discussed to address the limitations of Mg-based metals prior to their clinical applications at weight-bearing sites. Finally, the available clinical studies are summarized and the challenges and perspectives of Mg-based orthopedic implants are discussed. Taken together, the progress made on the development of Mg-based implants in basic, translational, and clinical research has laid down a foundation for developing a new era in the treatment of challenging and prevalent bone diseases.

Inflammatory response to magnesium-based biodegradable implant materials

Biodegradability and mechanical properties of magnesium alloys are attractive for orthopaedic and cardiovascular applications. In order to study their cytotoxicity usually bone cells are used. However, after implantation, diverse and versatile cells are recruited and interact. Among the first ones coming into play are cells of the immune system, which are responsible for the inflammatory reaction. Macrophages play a central role in the inflammatory process due to the production of cytokines involved in the tissue healing but also in the possible failure of the implants. In order to evaluate the in vitro influence of the degradation products of magnesium-based alloys on cytokine release, the extracts of pure magnesium and two magnesium alloys (with gadolinium and silver as alloying elements) were examined in an inflammatory in vitro model. Human promonocytic cells (U937 cells) were differentiated into macrophages and further cultured with magnesium-based extracts for 1 and 3 days (simulating early and late inflammatory reaction phases), either at 37 °C or at 39 °C (mimicking normal and inflammatory conditions, respectively). All extracts exhibit very good cytocompatibility on differentiated macrophages. Results suggest that M1 and even more M2 profiles of macrophage were stimulated by the extracts of Mg. Furthermore, Mg-10Gd and Mg-2Ag extracts introduced a nuancing effect by rather inhibiting macrophage M1 profile. Magnesium-based biomaterials could thus induce a faster inflammation resolution while improving tissue repair. STATEMENT OF SIGNIFICANCE: Macrophage are the key-cells during inflammation and can influence the fate of tissue healing and implant performance. Magnesium-based implants are biodegradable and bioactive. Here we selected an in vitro system to model early and late inflammation and effect of pyrexia (37 °C versus 39 °C). We showed the beneficial and nuancing effects of magnesium (Mg) and the selected alloying elements (silver (Ag) and gadolinium (Gd)) on the macrophage polarisation. Mg extracts exacerbated simultaneously the macrophage M1 and M2 profiles while Mg-2Ag and Mg-10Gd rather inhibited the M1 differentiation. Furthermore, 39 °C exhibited protective effect by either decreasing cytokine production or promoting anti-inflammatory ones, with or without extracts. Mg-based biomaterials could thus induce a faster inflammation resolution while improving tissue repair.

Microstructure, mechanical properties, and degradation of Mg-Ag alloy after equal-channel angular pressing

Enhancing the strength of Mg-based biodegradable alloys without decreasing their corrosion resistance is a major engineering challenge. In addition, the growing demand for effective reduction of infections and inflammation after implant placement motivates the design of alloys with appropriate compositions or coatings. One promising alloying element is silver, whose antibacterial effect has long been known. Therefore, a Mg-4% Ag alloy was selected for this study. The alloy was investigated under three conditions: as-cast, after T4 treatment, and after T4 treatment with subsequent equal-channel angular pressing (ECAP) using a newly developed double-ECAP die, which offers an equivalent strain per pass of 1.6. The first pass through the double-ECAP die was conducted at 370 °C and the second at 330 °C using route B_C. The microstructure of the as-cast Mg-4% Ag consisted of large grains (several hundred microns) and a dendritic structure with micron-sized Mg₅₄Ag₁₇ precipitates. T4 heat treatment caused dissolution of the dendrites and formation of a solid solution without changing the grain size. Consequently, the ultimate compressive strength (UCS) was increased by approximately 30%, and the compressive strain at fracture reached approximately 23%. The compressive yield strength (CYS) remained nearly constant at approximately 30 MPa. Subsequent ECAP led to strong grain refinement (from 350 μm to 38 μm after one pass and 15 μm after two passes) and further increases in the CYS and UCS, to 45 and 300 MPa after the first pass and 62 and 325 MPa after the second pass, respectively. The as-cast alloy exhibited a very high degradation rate in a simulated body fluid at approximately 36 °C. The degradation rate of the alloy after T4 treatment was much lower. Subsequent ECAP had no significant effect on the degradation properties. Thus, it can be concluded that grain refinement has little effect on the degradation rate.

Crevice corrosion - A newly observed mechanism of degradation in biomedical magnesium

Crevice-induced corrosion is not desirable to occur in metallic magnesium (Mg) during many industrial applications. However, orthopedic implants made of Mg alloys have been demonstrated to degrade faster between the joining surface of bone plates and screws after implantation, suggesting the crevice corrosion may occur in the physiological environment. In this paper, a resin device is designed to parallel high purity magnesium (HP-Mg) plates with closely spaced slits. After a standard corrosion test in the phosphate-buffered saline (PBS) solution, the paralleled HP-Mg samples embedded in the custom-made resin device corrode faster than those without the resin device. The corrosion morphology of Mg with the resin device exhibits features of crevice corrosion with many deep holes and river-like texture. Moreover, implantation of the bone plate and screws in vivo demonstrates similar corrosion morphology as that of the in vitro test, suggesting the occurrence of crevice-enhanced corrosion in the bone-bone plate interface, as well as the contact area between the bone plate and the screws. STATEMENT OF SIGNIFICANCE: Understanding the corrosion behavior of Mg and Mg alloys after implantation is one of the main challenges for developing desirable biodegradable Mg alloys or effective methods to adjust the corrosion rate of Mg-based implants. In this paper, we attempted to understand the corrosion behaviors of HP-Mg at the joining surface between HP-Mg plates or HP-Mg screws and bone tissues after implantation. We designed an in vitro setup to mimic the crevice environment of the in vivo joining surface and found that the crevices existing on the HP-Mg would significantly accelerate the corrosion rate and change the corrosion morphology of HP-Mg plates. The in vivo implantation also showed similar corrosion morphology caused by crevice corrosion, which appeared at the joining surface between HP-Mg plates or HP-Mg screws and bone tissues. Then, we proposed a new corrosion mechanism of Mg-based alloys inside the crevice. The findings of this study can help us broaden our cognition on the corrosion behavior of Mg and Mg alloy-based orthopedic implants.

LOC103691336/miR-138-5p/BMPR2 axis modulates Mg-mediated osteogenic differentiation in rat femoral fracture model and rat primary bone marrow stromal cells

Intramedullary stabilization is frequently used to treat long bone fractures. Since implant removal can become technically very challenging with the potential to cause further tissue damage, biodegradable materials are emerging as alternative options. Magnesium (Mg)-based biodegradable implants have a controllable degradation rate and good tissue compatibility, which makes them attractive for musculoskeletal research. Herein, the degradation of Mg and steel implants, the pathological characteristics and osteoblast differentiation in mice femora were examined. To investigate the molecular mechanism, we analyzed the differentially expressed long noncoding RNAs (lncRNAs) and messenger RNAs (mRNAs) in Mg-implanted or stain-steel-implanted callus tissues. lncRNA LOC103691336 was upregulated in Mg-implanted tissues and most relevant to BMPR2, a kinase receptor of BMPs with an established role in osteogenesis. The knockdown of LOC103691336 attenuated Mg-mediated osteogenic differentiation. Furthermore, miR-138-5p, previously reported to inhibit osteogenic differentiation, could bind to LOC103691336 and BMPR2 in bone marrow stromal cells (BMSCs). LOC103691336 competed with BMPR2 for miR-138-5p binding in BMSCs to attenuate the inhibitory effect of miR-138-5p on BMPR2 expression. Finally, the effect of LOC103691336 knockdown on Mg-mediated osteogenic differentiation could be attenuated by miR-138-5p inhibition. In conclusion, we provided a novel mechanism of Mg implants mediating the osteogenesis differentiation and demonstrated that Mg implants may be promising for improving fracture healing.

Proteome analysis of human mesenchymal stem cells undergoing chondrogenesis when exposed to the products of various magnesium-based materials degradation

Treatment of physeal fractures (15%–30% of all paediatric fractures) remains a challenge as in approximately 10% of the cases, significant growth disturbance may occur. Bioresorbable Magnesium-based implants represent a strategy to minimize damage (i.e., load support until bone healing without second surgery). Nevertheless, the absence of harmful effects of magnesium-implants and their degradation products on the growth plate should be confirmed. Here, the proteome of human mesenchymal stem cells undergoing chondrogenesis was evaluated when exposed to the products of various Magnesium-based materials degradation. The results of this study indicate that the materials induced regulation of proteins associated with cell chondrogenesis and cartilage formation, which should be beneficial for cartilage regeneration.

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Degradation products from Mg-based materials generated changes in protein expression.

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Relevant proteins involved in cartilage formation were upregulated.

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Potential application of especially Pure-Mg and Mg-10Gd for cartilage regeneration.

Antibacterial properties and biocompatibility in vivo and vitro of composite coating of pure magnesium ultrasonic micro-arc oxidation phytic acid copper loaded

Bone infection and implant secondary removal remains a clinical challenge. We used ultrasonic micro-arc oxidation (UMAO) and conversion of phytic acid copper plating to prepare a pure magnesium polyhydric biofilm; we evaluated the surface microstructures, phase, element composition, and wettability of the film in vitro. The antibacterial activity of films with different Cu contents was confirmed by coating method, imaging examination, and microbiological cultures in vitro. The biocompatibility of biofilms was confirmed by cell proliferation, vitality, and morphology assays in vitro and histological evaluation in vivo. MC3T3-E1 cells were co-cultured with different films to assess cell viability on the films. The results showed that the mass fraction of Cu increased with increasing time of copper plating, and the surface of the Cu group was more dense and uniform. Additionally, copper coating significantly inhibited the growth of E. coli and Staphylococcus aurous. We also found that the adhesion, proliferation, and differentiation of the cells on the surface of copper plating were enhanced. Copper implantation of animals in vivo showed fine ability to promote bone growth. Antibacterial activity and biocompatibility of pure magnesium UMAO-phytic acid-Cu3min implant film are excellent, so the film has potential application value in the treatment of bone implantation.

Evaluation of the mechanisms and effects of Mg-Ag-Y alloy on the tumor growth and metastasis of the MG63 osteosarcoma cell line

Osteosarcoma is a malignant primary bone tumor, which often associates with pulmonary metastasis. The radical surgery of osteosarcoma often requires internal orthopedic implants. Therefore, implants with antitumor properties should be developed. Magnesium (Mg) and its alloys possess great potential as orthopedic materials, given their biodegradable properties, superior osteogenesis performance, and antitumor features. However, problems arise with their uncontrolled degradation rates and their unknown antitumor mechanisms. In our study, when compared with pure Mg, the rare element silver alloyed with yttrium (Ag-Y) could extremely enhance the corrosion resistance of these elements, giving the Ex-Mg-1Ag-1Y alloy better anticorrosion rates. Here, we implanted the Ex-Mg-1Ag-1Y alloy and pure Mg and Ti alloy in vivo around tumors in nude mice (BALB/c). Notably, the local tumor weight in Mg alloy and pure Mg groups were much smaller than that in Ti alloy group in 36 days after surgery (6.59 ± 0.70, 6.76 ± 0.62, and 8.54 ± 0.56 g), while the general scores of lung metastasis in Mg alloy and pure Mg groups were also lower than Ti alloy group (64.50 ± 7.64, 62.73 ± 7.84, and 87.60 ± 9.43). Therefore, the Mg and Ex-Mg-1Ag-1Y alloy, both demonstrated resisting effects against local tumor growth and pulmonary metastasis, which could be performed by changing the extracellular acidosis microenvironment, elevating the Mg concentration, suppressing C-X-C chemokine receptor type 4 (CXCR4) levels, and increasing prostacyclin (PGI₂ ) synthesis. Our work revealed that the Ex-Mg-1Ag-1Y alloy may be a promising orthopedic implant for treating osteosarcoma due to its better corrosion resistance and antitumor attributes. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B:2537-2548, 2019.

Corrosion and bone healing of Mg-Y-Zn-Zr-Ca alloy implants: Comparative in vivo study in a non-immobilized rat femoral fracture model

Biodegradable magnesium (Mg) alloys exhibit improved mechanical properties compared to degradable polymers while degrading in vivo circumventing the complications of permanent metals, obviating the need for surgical removal. This study investigated the safety and efficacy of Mg-Y-Zn-Zr-Ca (WZ42) alloy compared to non-degradable Ti6Al4V over a 14-week follow-up implanted as pins to fix a full osteotomy in rat femurs and as wires wrapped around the outside of the femurs as a cerclage. We used a fully load bearing model allowing implants to intentionally experience realistic loads without immobilization. To assess systemic toxicity, blood cell count and serum biochemical tests were performed. Livers and kidneys were harvested to observe any accumulation of alloying elements. Hard and soft tissues adjacent to the fracture site were also histologically examined. Degradation behavior and bone morphology were determined using micro-computed tomography scans. Corrosion occurred gradually, with degradation seen after two weeks of implantation with points of high stress observed near the fracture site ultimately resulting in WZ42 alloy pin fracture. At 14 weeks however, normal bone healing was observed in femurs fixed with the WZ42 alloy confirmed by the presence of osteoid, osteoblast activity, and new bone formation. Blood testing exhibited no significant changes arising from the WZ42 alloy compared to the two control groups. No recognizable differences in the morphology and more importantly, no accumulation of Mg, Zn, and Ca in the kidney and liver of rats were observed. These load bearing model results collectively taken, thus demonstrate the feasibility for use of the Mg-Y-Zn-Zr-Ca alloy for long bone fracture fixation applications.

Biocompatibility evaluation of antibacterial Ti-Ag alloys with nanotubular coatings

BACKGROUND

Implant-related infection is a major problem postsurgery. As an alternative to a localized antibiotic release system, we used Ag to fabricate Ti-Ag alloys with nanotubular coatings (TiAg-NTs). Ag has excellent antibacterial properties, but its biological toxicity is a concern. Therefore, we performed biological experiments both in vitro and in vivo to evaluate the biocompatibility of TiAg-NTs with different concentrations of Ag (1%, 2%, and 4%).

METHODS

For in vitro experiments, cytocompatibility, including cell attachment, viability, and proliferation, was tested, and genes and proteins related to osteogenic differentiation were also evaluated. For in vivo assays, the rat femoral condylar insertion model was used, and micro-computed tomography (micro-CT) and histological analysis were conducted to analyze bone formation around implants at 1, 2, and 4 weeks after surgery.

RESULTS

Both in vitro and in vivo results indicate that Ti2%Ag-NT showed comparable cytocompatibility with commercially pure Ti (cp-Ti), and it could achieve good osseointegration with the surrounding bone tissue.

CONCLUSION

We thus believe that Ti2%Ag-NT is a potential biomaterial for orthopedics.

Comparison of a resorbable magnesium implant in small and large growing-animal models

Fracture treatment in children needs new implant materials to overcome disadvantages associated with removal surgery. Magnesium-based implants constitute a biocompatible and bioresorbable alternative. In adults and especially in children, implant safety needs to be evaluated. In children the bone turnover rate is higher and implant material might influence growth capacity, and the long-term effect of accumulated particles or ions is more critical due to the host's prolonged post-surgery lifespan. In this study we aimed to investigate the degradation behavior of ZX00 (Mg-0.45Zn-0.45Ca; in wt.%) in a small and a large animal model to find out whether there is a difference between the two models (i) in degradation rate and (ii) in bone formation and in-growth. Our results 6, 12 and 24 weeks after ZX00 implantation showed no negative effects on bone formation and in-growth, and no adverse effects such as fibrotic or sclerotic encapsulation. The degradation rate did not significantly differ between the two growing-animal models, and both showed slow and homogeneous degradation performance. Our conclusion is that small animal models may be sufficient to investigate degradation rates and provide preliminary evidence on bone formation and in-growth of implant materials in a growing-animal model.

STATEMENT OF SIGNIFICANCE

The safety of implant material is of the utmost importance, especially in children, who have enhanced bone turnover, more growth capacity and longer postoperative lifespans. Magnesium (Mg)-based implants have long been of great interest in pediatric orthopedic and trauma surgery, due to their good biocompatibility, biodegradability and biomechanics. In the study documented in this manuscript we investigated Mg-Zn-Ca implant material without rare-earth elements, and compared its outcome in a small and a large growing-animal model. In both models we observed bone formation and in-growth which featured no adverse effects such as fibrotic or sclerotic encapsulation, and slow homogeneous degradation performance of the Mg-based implant material.

The effect of osteoblasts on the surface oxidation processes of biodegradable Mg and Mg-Ag alloys studied by synchrotron IR microspectroscopy

High-resolution analytical methods, including synchrotron infrared microspectroscopy combined with wavelength-dispersive X-ray emission spectroscopy were applied to study the structure and chemical composition of the oxidized layer of pure and Ag-alloyed Mg exposed to cell culture media without and with osteoblasts. Comparative analysis has been done on pure Mg immersed in two different cell culture media: Dulbecco's Modified Eagle's Medium (DMEM) and Roswell Park Memorial Institute medium (RPMI), whereas Mg-xAg binary alloys (x = 2, 4, 6, 8 wt%) were studied after immersion in DMEM. It is shown that the physicochemical formation of degradation products as well as the activity of the biological component is influenced by the addition of silver. It could be demonstrated that the presence of Ag in the Mg alloy enhances the chemical reaction between Mg and C to form amorphous and/or crystalline MgCO₃ on account of CaCO₃. As a consequence, the further available P and Ca react easily to form Mg-poor amorphous calcium phosphate phases. Osteoblasts actively adjusted these phases towards hydroxyapatite-like phases.

Resorbable implants in pediatric fracture treatment

Pediatric osteosynthesis has developed over the last 20 years, thereby reducing medical and economic burden, including long and expensive hospitalization. Currently, conventional and rigid alloying systems such as titanium are used for stabilization of bone fractures in children. In many cases, implants must be removed, as otherwise growth would be impeded. Biodegradable implant materials exhibit beneficial properties and would make a second removal surgery unnecessary. In the following article, we will give an overview of implant materials that are currently used in pediatric traumatology with a focus on Mg-based implants. Furthermore, we will discuss current scientific knowledge on resorbable implants, including results from pre-clinics and clinics.

In vitro and in vivo evaluation of novel biodegradable Mg-Ag-Y alloys for use as resorbable bone fixation implant

Magnesium (Mg) alloy is gaining more interest because of its degradability and osteogenic potential. Still, it has some deficiencies, such as its rapid degradation rate, insufficient mechanical property. This research aimed to design a novel biodegradable Mg-argentum (Ag)-yttrium (Y) alloy, and Y was added to improve degradable and mechanical property. Mg-Ag-Y alloys were characterized for mechanical features, practicabilities in vitro and in vivo. The mechanical features results shown that this novel component was similar to native bone tissue in elastic moduli, tensile, and compressive stress. Then mesenchymal stem cells (MSCs) were seeded in alloys to assess cell toxicity in vitro. The results showed that its aqueous extract was suitable for MSCs adhesion and proliferation. Then the alloy was evaluated for biomedical applications in nonfractured distal femora of Sprague Dawley rats for 6 weeks, compared with those of pure-Mg and stainless steel groups. All rats survived, and hematological and histological evaluation showed no abnormal physiology 6 weeks postimplantation, and measurements of serum Mg²⁺ concentration were within normal levels. X-ray scanning, microcomputed tomography, and histological examinations were performed to evaluate the degradability and osteogenic potential. The results indicated that the degradation rate of alloy was 0.91 mm per year, (range 0.77-1.22 mm), and pure-Mg 1.80 mm per year (1.43-2.26 mm). The new bone quantity was 3.18 mm³ (1.46-4.44 mm³ ) in Mg-Ag-Y alloys group, 1.39 mm³ (0.54-2.32 mm³ ) in pure-Mg group, and none in stainless steel group. These promising results suggest potential clinical application of Mg-Ag-Y alloys for use as resorbable bone fixation implant. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 2059-2069, 2018.

Gas formation and biological effects of biodegradable magnesium in a preclinical and clinical observation

Magnesium alloys are biodegradable metals receiving increasing attention, but the clinical applications of these materials are delayed by concerns over the rapid corrosion rate and gas formation. Unlike corrosion, which weakens mechanical properties, the gas formation issue has received little attention. Therefore, we evaluated the gas formation and biological effects for Mg implants through preclinical (immersed in Earle's balanced salt solution and in vivo) and clinical studies. The immersion test examined the gas volume and composition. The in vivo study also examined gas volume and histological analysis. The clinical study examined the gas volume and safety after Mg screw metatarsal fixation. Gas was mainly composed of H₂, CO and CO₂. Maximum volumes of gas formed after 5 days for in vivo and 7 days in clinical study. Within the clinical examination, two superficial wound complications healed with local wound care. Osteolytic lesions in the surrounding metaphysis of the Mg screw insertion developed in all cases and union occurred at 3 months. Mg implants released gas with variable volumes and composition (H₂, CO, and CO₂), with no long-term toxic effects on the surrounding tissue. The implants enabled bone healing, although complications of wound breakdown and osteolytic lesions developed.