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Huang H, Liu X, Wang J, Suo M, Zhang J, Sun T, Wang H, Liu C, Li Z. Strategies to improve the performance of polyetheretherketone (PEEK) as orthopedic implants: from surface modification to addition of bioactive materials. J Mater Chem B 2024; 12:4533-4552. [PMID: 38477504 DOI: 10.1039/d3tb02740f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Polyetheretherketone (PEEK), as a high-performance polymer, is widely used for bone defect repair due to its homogeneous modulus of elasticity of human bone, good biocompatibility, excellent chemical stability and projectability. However, the highly hydrophobic surface of PEEK is biologically inert, which makes it difficult for cells and proteins to attach, and is accompanied by the development of infections that ultimately lead to failure of PEEK implants. In order to further enhance the potential of PEEK as an orthopedic implant, researchers have explored modification methods such as surface modification by physical and chemical means and the addition of bioactive substances to PEEK-based materials to enhance the mechanical properties, osteogenic activity and antimicrobial properties of PEEK. However, these current modification methods still have obvious shortcomings in terms of cost, maneuverability, stability and cytotoxicity, which still need to be explored by researchers. This paper reviews some of the modification methods that have been used to improve the performance of PEEK over the last three years in anticipation of the need for researchers to design PEEK orthopedic implants that better meet clinical needs.
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Affiliation(s)
- Huagui Huang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, People's Republic of China
- Division of Energy Materials (DNL22), Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China.
| | - Xin Liu
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, People's Republic of China
| | - Jinzuo Wang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, People's Republic of China
| | - Moran Suo
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, People's Republic of China
| | - Jing Zhang
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, People's Republic of China
| | - Tianze Sun
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, People's Republic of China
| | - Honghua Wang
- Division of Energy Materials (DNL22), Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China.
| | - Chengde Liu
- Department of Polymer Science & Materials, Dalian University of Technology, Dalian, People's Republic of China.
| | - Zhonghai Li
- Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, People's Republic of China.
- Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, People's Republic of China
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Yu YM, Lu YP, Zhang T, Zheng YF, Liu YS, Xia DD. Biomaterials science and surface engineering strategies for dental peri-implantitis management. Mil Med Res 2024; 11:29. [PMID: 38741175 DOI: 10.1186/s40779-024-00532-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/29/2024] [Indexed: 05/16/2024] Open
Abstract
Peri-implantitis is a bacterial infection that causes soft tissue inflammatory lesions and alveolar bone resorption, ultimately resulting in implant failure. Dental implants for clinical use barely have antibacterial properties, and bacterial colonization and biofilm formation on the dental implants are major causes of peri-implantitis. Treatment strategies such as mechanical debridement and antibiotic therapy have been used to remove dental plaque. However, it is particularly important to prevent the occurrence of peri-implantitis rather than treatment. Therefore, the current research spot has focused on improving the antibacterial properties of dental implants, such as the construction of specific micro-nano surface texture, the introduction of diverse functional coatings, or the application of materials with intrinsic antibacterial properties. The aforementioned antibacterial surfaces can be incorporated with bioactive molecules, metallic nanoparticles, or other functional components to further enhance the osteogenic properties and accelerate the healing process. In this review, we summarize the recent developments in biomaterial science and the modification strategies applied to dental implants to inhibit biofilm formation and facilitate bone-implant integration. Furthermore, we summarized the obstacles existing in the process of laboratory research to reach the clinic products, and propose corresponding directions for future developments and research perspectives, so that to provide insights into the rational design and construction of dental implants with the aim to balance antibacterial efficacy, biological safety, and osteogenic property.
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Affiliation(s)
- Ya-Meng Yu
- Department of Dental Materials, Peking University School and Hospital of Stomatology, Beijing, 100081, China
- National Center for Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing Key Laboratory of Digital Stomatology & NHC Key Laboratory of Digital Stomatology & NMPA Key Laboratory for Dental Materials, Beijing, 100081, China
| | - Yu-Pu Lu
- Department of Dental Materials, Peking University School and Hospital of Stomatology, Beijing, 100081, China
- National Center for Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing Key Laboratory of Digital Stomatology & NHC Key Laboratory of Digital Stomatology & NMPA Key Laboratory for Dental Materials, Beijing, 100081, China
| | - Ting Zhang
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
| | - Yu-Feng Zheng
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China.
| | - Yun-Song Liu
- National Center for Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing Key Laboratory of Digital Stomatology & NHC Key Laboratory of Digital Stomatology & NMPA Key Laboratory for Dental Materials, Beijing, 100081, China.
- Department of Prosthodontics, Peking University School and Hospital of Stomatology, Beijing, 100081, China.
| | - Dan-Dan Xia
- Department of Dental Materials, Peking University School and Hospital of Stomatology, Beijing, 100081, China.
- National Center for Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing Key Laboratory of Digital Stomatology & NHC Key Laboratory of Digital Stomatology & NMPA Key Laboratory for Dental Materials, Beijing, 100081, China.
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Sharma P, Singh J, Singh B. Evaluation of physiochemical and biomedical properties of psyllium-poly(vinyl phosphonic acid-co-acrylamide)-cl-N,N-methylene bis acrylamide based hydrogels. Int J Biol Macromol 2024; 260:129546. [PMID: 38246461 DOI: 10.1016/j.ijbiomac.2024.129546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 01/07/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
Present investigation deals with the synthesis of psyllium based copolymeric hydrogels and evaluation of their physiochemical and biomedical properties. These copolymers have been prepared by grafting of poly(vinyl phosphonic acid) (poly (VPA)) and poly(acrylamide) (poly(AAm)) onto psyllium in the presence of crosslinker N,N-methylene bis acrylamide (NNMBA). These copolymers [psyllium-poly(VPA-co-AAm)-cl-NNMBA] were characterized by field emission-scanning electron micrographs (FE-SEM), electron dispersion X-ray analysis (EDAX), Atomic force microscopy (AFM), Fourier transform infrared spectroscopy (FTIR), 13C-nuclear magnetic resonance (NMR), X-ray diffraction (XRD), and thermogravimetric analysis (TGA)- differential thermal analysis (DTG). FESEM, AFM and XRD demonstrated heterogeneous morphology with a rough surface and an amorphous nature. Diffusion of ornidazole occurred with a non-Fickian diffusion mechanism, and the release profile data was fitted in the Korsemeyer-Peppas kinetic model. Biochemical analysis of hydrogel properties confirmed the blood-compatible nature during blood-polymer interactions and revealed haemolysis value 3.95 ± 0.05 %. The hydrogels exhibited mucoadhesive character during biomembrane-polymer interactions and demonstrated detachment force = 99.0 ± 0.016 mN. During 2,2-diphenyl-1-picrylhydrazyl reagent (DPPH) assay, free radical scavenging was observed 37.83 ± 3.64 % which illustrated antioxidant properties of hydrogels. Physiological and biomedical properties revealed that these hydrogels could be explored for drug delivery uses.
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Affiliation(s)
- Prerna Sharma
- Department of Chemistry, Himachal Pradesh University, Shimla 171005, India
| | - Jasvir Singh
- Department of Chemistry, Himachal Pradesh University, Shimla 171005, India
| | - Baljit Singh
- Department of Chemistry, Himachal Pradesh University, Shimla 171005, India.
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Goh M, Min K, Kim YH, Tae G. Chemically heparinized PEEK via a green method to immobilize bone morphogenetic protein-2 (BMP-2) for enhanced osteogenic activity. RSC Adv 2024; 14:1866-1874. [PMID: 38192324 PMCID: PMC10772708 DOI: 10.1039/d3ra07660a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/25/2023] [Indexed: 01/10/2024] Open
Abstract
Osseointegration remains one of the major challenges in the success of bone-related implants. Recently, polyetheretherketone (PEEK) has emerged as an alternative material in orthopedic and dental applications due to its bone-mimicking mechanical properties. However, its bioinertness resulting in poor osseointegration has limited its potential application. So, the surface modification of PEEK with bone morphogenetic protein-2 (BMP-2) can be a potential approach for improving osseointegration. In this study, we proposed the chemical modification of heparin onto PEEK through an environmentally benign method to exploit the BMP-2 binding affinity of heparin. The heparin was successfully functionalized on the PEEK surface via a combination of ozone and UV treatment without using organic solvents or chemicals. Furthermore, BMP-2 was efficiently immobilized on PEEK and exhibited a sustained release of BMP-2 compared to the pristine PEEK with enhancement of bioactivity in terms of proliferation as well as osteogenic differentiation of MG-63. The significant synergistic effect of BMP-2 and heparin grafting on osteogenic differentiation of MG-63 was observed. Overall, we demonstrated a relatively safe method where no harsh chemical reagent or organic solvent was involved in the process of heparin grafting onto PEEK. The BMP-2 loaded, heparin-grafted PEEK could serve as a potential platform for osseointegration improvement of PEEK-based bone implants.
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Affiliation(s)
- MeeiChyn Goh
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology (GIST) Gwangju 61005 Republic of Korea
| | - Kiyoon Min
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology (GIST) Gwangju 61005 Republic of Korea
| | - Young Ha Kim
- Korea Institute of Science and Technology Hwarang-ro 14-gil 5, Seongbuk-gu Seoul 02792 Republic of Korea
| | - Giyoong Tae
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology (GIST) Gwangju 61005 Republic of Korea
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Chen Y, Chen Y, Han T, Xie Z, Yang Y, Chen S, Wang C. Enhanced osteogenic and antibacterial properties of polyetheretherketone by ultraviolet-initiated grafting polymerization of a gelatin methacryloyl/epsilon-poly-L-lysine/laponite hydrogel coating. J Biomed Mater Res A 2023; 111:1808-1821. [PMID: 37548424 DOI: 10.1002/jbm.a.37589] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/30/2023] [Accepted: 06/27/2023] [Indexed: 08/08/2023]
Abstract
Polyetheretherketone (PEEK) is a promising material for use in orthopedic implants, but its bio-inert character and lack of antibacterial activity limit its applications in bone repair. In the present study, considering the advantages of PEEK in self-initiated graft polymerization and of hydrogels in bone tissue engineering, we constructed a hydrogel coating (GPL) consisting of Gelatin methacryloyl (GelMA), methacrylamide-modified ε-poly-l-lysine (ε-PLMA) and Laponite on PEEK through UV-initiated crosslinking. The coating improved the hydrophilicity of PEEK, and the coating degraded slowly so that approximately 80% was retained after incubation in PBS for 8 weeks. In vitro studies revealed that as compared to culturing on PEEK, culturing on PEEK-GPL led to enhanced viability and adhesion of cultured human umbilical cord Wharton's jelly-derived mesenchymal stem cells (hWJ-MSCs). Due to the synergistic effect of the micron-scale three-dimensional surface and Laponite, PEEK-GPL exhibited a significantly improved induction of osteogenic differentiation of hWJ-MSCs compared to PEEK, as demonstrated by increased alkaline phosphatase activity, matrix mineralization, and expression of osteogenesis-related genes. Furthermore, PEEK-GPL showed antibacterial activity upon contact with Staphylococcus aureus and Escherichia coli, and this activity would be maintained before complete degradation of the hydrogel because the ε-PLMA was cross-linked covalently into the coating. Thus, PEEK-GPL achieved both osteogenesis and infection prevention in a single simple step, providing a feasible approach for the extensive use of PEEK in bone implants.
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Affiliation(s)
- Yuhong Chen
- Department of Prosthodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Oral Diseases, Nanjing, China
| | - Yiyi Chen
- Department of Prosthodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Oral Diseases, Nanjing, China
| | - Tianlei Han
- Department of Prosthodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Oral Diseases, Nanjing, China
| | - Zhe Xie
- Department of Prosthodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Oral Diseases, Nanjing, China
| | - Yuchen Yang
- Department of Prosthodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Oral Diseases, Nanjing, China
| | - Siyuan Chen
- Department of Prosthodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Oral Diseases, Nanjing, China
| | - Chen Wang
- Department of Prosthodontics, Affiliated Hospital of Stomatology, Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Oral Diseases, Nanjing, China
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Pu F, Yu Y, Zhang Z, Wu W, Shao Z, Li C, Feng J, Xue L, Chen F. Research and Application of Medical Polyetheretherketone as Bone Repair Material. Macromol Biosci 2023; 23:e2300032. [PMID: 37088909 DOI: 10.1002/mabi.202300032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/01/2023] [Indexed: 04/25/2023]
Abstract
Polyetheretherketone (PEEK) can potentially be used for bone repair because its elastic modulus is similar to that of human natural bone and good biocompatibility and chemical stability. However, its hydrophobicity and biological inertness limit its application in the biomedical field. Inspired by the composition, structure, and function of bone tissue, many strategies are proposed to change the structure and functionality of the PEEK surface. In this review, the applications of PEEK in bone repair and the optimization strategy for PEEK's biological activity are reviewed, which provides a direction for the development of multifunctional bone repair materials in the future.
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Affiliation(s)
- Feifei Pu
- Department of Orthopedics, Traditional Chinese and Western Medicine Hospital of Wuhan (Wuhan No.1 Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yihan Yu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Zhicai Zhang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Wei Wu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Zengwu Shao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Chao Li
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Jing Feng
- Department of Orthopedics, Traditional Chinese and Western Medicine Hospital of Wuhan (Wuhan No.1 Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Longjian Xue
- School of Power and Mechanical Engineering, Wuhan University, Wuhan, Hubei, 430072, China
| | - Fengxia Chen
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, 430071, China
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Wei Z, Zhang Z, Zhu W, Weng X. Polyetheretherketone development in bone tissue engineering and orthopedic surgery. Front Bioeng Biotechnol 2023; 11:1207277. [PMID: 37456732 PMCID: PMC10345210 DOI: 10.3389/fbioe.2023.1207277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023] Open
Abstract
Polyetheretherketone (PEEK) has been widely used in the medical field as an implant material, especially in bone tissue engineering and orthopedic surgery, in recent years. This material exhibits superior stability at high temperatures and is biosecured without harmful reactions. However, the chemical and biological inertness of PEEK still limits its applications. Recently, many approaches have been applied to improve its performance, including the modulation of physical morphology, chemical composition and antimicrobial agents, which advanced the osteointegration as well as antibacterial properties of PEEK materials. Based on the evolution of PEEK biomedical devices, many studies on the use of PEEK implants in spine surgery, joint surgery and trauma repair have been performed in the past few years, in most of which PEEK implants show better outcomes than traditional metal implants. This paper summarizes recent studies on the modification and application of biomedical PEEK materials, which provides further research directions for PEEK implants.
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Affiliation(s)
- Zhanqi Wei
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Ze Zhang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Wei Zhu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Al-Shalawi FD, Mohamed Ariff AH, Jung DW, Mohd Ariffin MKA, Seng Kim CL, Brabazon D, Al-Osaimi MO. Biomaterials as Implants in the Orthopedic Field for Regenerative Medicine: Metal versus Synthetic Polymers. Polymers (Basel) 2023; 15:2601. [PMID: 37376247 DOI: 10.3390/polym15122601] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Patients suffering bone fractures in different parts of the body require implants that will enable similar function to that of the natural bone that they are replacing. Joint diseases (rheumatoid arthritis and osteoarthritis) also require surgical intervention with implants such as hip and knee joint replacement. Biomaterial implants are utilized to fix fractures or replace parts of the body. For the majority of these implant cases, either metal or polymer biomaterials are chosen in order to have a similar functional capacity to the original bone material. The biomaterials that are employed most often for implants of bone fracture are metals such as stainless steel and titanium, and polymers such as polyethene and polyetheretherketone (PEEK). This review compared metallic and synthetic polymer implant biomaterials that can be employed to secure load-bearing bone fractures due to their ability to withstand the mechanical stresses and strains of the body, with a focus on their classification, properties, and application.
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Affiliation(s)
- Faisal Dakhelallah Al-Shalawi
- Department of Mechanical and Manufacturing Engineering, Faculty of Engineering, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Azmah Hanim Mohamed Ariff
- Department of Mechanical and Manufacturing Engineering, Faculty of Engineering, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
- Research Center Advanced Engineering Materials and Composites (AEMC), Faculty of Engineering, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Dong-Won Jung
- Faculty of Applied Energy System, Major of Mechanical Engineering, Jeju National University, 102 Jejudaehak-ro, Jeju-si 63243, Republic of Korea
| | - Mohd Khairol Anuar Mohd Ariffin
- Department of Mechanical and Manufacturing Engineering, Faculty of Engineering, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Collin Looi Seng Kim
- Department of Orthopaedic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Dermot Brabazon
- Advanced Manufacturing Research Centre, and Advanced Processing Technology Research Centre, School of Mechanical and Manufacturing Engineering, Dublin City University, Glasnevin, D09 V209 Dublin 9, Ireland
| | - Maha Obaid Al-Osaimi
- Department of Microbiology, Faculty of Agriculture, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
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Surface Treatments of PEEK for Osseointegration to Bone. Biomolecules 2023; 13:biom13030464. [PMID: 36979399 PMCID: PMC10046336 DOI: 10.3390/biom13030464] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Polymers, in general, and Poly (Ether-Ether-Ketone) (PEEK) have emerged as potential alternatives to conventional osseous implant biomaterials. Due to its distinct advantages over metallic implants, PEEK has been gaining increasing attention as a prime candidate for orthopaedic and dental implants. However, PEEK has a highly hydrophobic and bioinert surface that attenuates the differentiation and proliferation of osteoblasts and leads to implant failure. Several improvements have been made to the osseointegration potential of PEEK, which can be classified into three main categories: (1) surface functionalization with bioactive agents by physical or chemical means; (2) incorporation of bioactive materials either as surface coatings or as composites; and (3) construction of three-dimensionally porous structures on its surfaces. The physical treatments, such as plasma treatments of various elements, accelerated neutron beams, or conventional techniques like sandblasting and laser or ultraviolet radiation, change the micro-geometry of the implant surface. The chemical treatments change the surface composition of PEEK and should be titrated at the time of exposure. The implant surface can be incorporated with a bioactive material that should be selected following the desired use, loading condition, and antimicrobial load around the implant. For optimal results, a combination of the methods above is utilized to compensate for the limitations of individual methods. This review summarizes these methods and their combinations for optimizing the surface of PEEK for utilization as an implanted biomaterial.
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Zhang B, Leng J, Ouyang Z, Yang Z, Zhang Q, Li Q, Li D, Zhao H. Superhydrophilic and topography-regulatable surface grafting on PEEK to improve cellular affinity. BIOMATERIALS ADVANCES 2023; 146:213310. [PMID: 36716597 DOI: 10.1016/j.bioadv.2023.213310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/29/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
Polyetheretherketone (PEEK) has been widely used in the preparation of orthopedic implants due to its biological inertness and similar mechanical modulus to natural bone. However, the affinity between biological tissue (bone and soft tissue) and PEEK surface is weak, leading to low osseointegration and an increased risk of inflammation. The situation could be improved by modifying PEEK surface. Surfaces with good hydrophilicity and proper microtopography would promote cellular adhesion and proliferation. This work presented a two-step surface modification method to achieve the effect. Polyacrylic acid (PAA) chains were grafted on PEEK surface by UV irradiation. Then, ethylenediamine (EDA) was added to introduce amino groups and promote the cross-linking of PAA chains. Furthermore, a mathematical model was built to describe and regulate the surface topography growth process semi-quantitatively. The model fits experimental data quite well (adjusted R2 = 0.779). Results showed that the modified PEEK surface obtained superhydrophilicity. It significantly improved the adhesion and proliferation of BMSCs and MFBs by activating the FAK pathway and Rho family GTPase. The cellular affinity performed better when the surface topography was in network structure with holes in about 25 μm depth and 20-50 μm diameter. Good hydrophilicity seems necessary for the FAK pathway activation, but simply improving surface hydrophilicity might not be enough for cellular affinity improvement. Surface topography at micron scale should be a more important cue. This simple surface modification method could be contributed to further study of cell-microtopography interaction and have potential applications in clinical PEEK orthopedic implants.
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Affiliation(s)
- Bowen Zhang
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, Shaanxi, China; National Medical Products Administration (NMPA), Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi'an Jiaotong University, 710054 Xi'an, Shaanxi, China
| | - Junqing Leng
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, Shaanxi, China; National Medical Products Administration (NMPA), Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi'an Jiaotong University, 710054 Xi'an, Shaanxi, China
| | - Zhicong Ouyang
- Academy of Orthopedics·Guangdong Province, Orthopedic Hospital of Guangdong Province, Department of Spine Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, 510665 Guangzhou, China
| | - Zijian Yang
- Academy of Orthopedics·Guangdong Province, Orthopedic Hospital of Guangdong Province, Department of Spine Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, 510665 Guangzhou, China
| | - Qing Zhang
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, Shaanxi, China; Center for Medical Device Evaluation, National Medical Products Administration (NMPA), 100081 Beijing, China
| | - Qingchu Li
- Academy of Orthopedics·Guangdong Province, Orthopedic Hospital of Guangdong Province, Department of Spine Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, 510665 Guangzhou, China
| | - Dichen Li
- State Key Laboratory for Manufacturing System Engineering, School of Mechanical Engineering, Xi'an Jiaotong University, 710054 Xi'an, Shaanxi, China; National Medical Products Administration (NMPA), Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, Xi'an Jiaotong University, 710054 Xi'an, Shaanxi, China.
| | - Huiyu Zhao
- Academy of Orthopedics·Guangdong Province, Orthopedic Hospital of Guangdong Province, Department of Spine Surgery, Center for Orthopaedic Surgery, The Third Affiliated Hospital of Southern Medical University, 510665 Guangzhou, China.
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Poly (Ether-Ether-Ketone) for Biomedical Applications: From Enhancing Bioactivity to Reinforced-Bioactive Composites-An Overview. Polymers (Basel) 2023; 15:polym15020373. [PMID: 36679253 PMCID: PMC9861117 DOI: 10.3390/polym15020373] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/21/2022] [Accepted: 12/24/2022] [Indexed: 01/13/2023] Open
Abstract
The global orthopedic market is forecasted to reach US$79.5 billion by the end of this decade. Factors driving the increase in this market are population aging, sports injury, road traffic accidents, and overweight, which justify a growing demand for orthopedic implants. Therefore, it is of utmost importance to develop bone implants with superior mechanical and biological properties to face the demand and improve patients' quality of life. Today, metallic implants still hold a dominant position in the global orthopedic implant market, mainly due to their superior mechanical resistance. However, their performance might be jeopardized due to the possible release of metallic debris, leading to cytotoxic effects and inflammatory responses in the body. Poly (ether-ether-ketone) (PEEK) is a biocompatible, high-performance polymer and one of the most prominent candidates to be used in manufacturing bone implants due to its similarity to the mechanical properties of bone. Unfortunately, the bioinert nature of PEEK culminates in its diminished osseointegration. Notwithstanding, PEEK's bioactivity can be improved through surface modification techniques and by the development of bioactive composites. This paper overviews the advantages of using PEEK for manufacturing implants and addresses the most common strategies to improve the bioactivity of PEEK in order to promote enhanced biomechanical performance.
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12
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Ma T, Zhang J, Sun S, Meng W, Zhang Y, Wu J. Current treatment methods to improve the bioactivity and bonding strength of PEEK for dental application: A systematic review. Eur Polym J 2023. [DOI: 10.1016/j.eurpolymj.2022.111757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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13
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Pidhatika B, Widyaya VT, Nalam PC, Swasono YA, Ardhani R. Surface Modifications of High-Performance Polymer Polyetheretherketone (PEEK) to Improve Its Biological Performance in Dentistry. Polymers (Basel) 2022; 14:polym14245526. [PMID: 36559893 PMCID: PMC9787615 DOI: 10.3390/polym14245526] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022] Open
Abstract
This comprehensive review focuses on polyetheretherketone (PEEK), a synthetic thermoplastic polymer, for applications in dentistry. As a high-performance polymer, PEEK is intrinsically robust yet biocompatible, making it an ideal substitute for titanium-the current gold standard in dentistry. PEEK, however, is also inert due to its low surface energy and brings challenges when employed in dentistry. Inert PEEK often falls short of achieving a few critical requirements of clinical dental materials, such as adhesiveness, osseoconductivity, antibacterial properties, and resistance to tribocorrosion. This study aims to review these properties and explore the various surface modification strategies that enhance the performance of PEEK. Literatures searches were conducted on Google Scholar, Research Gate, and PubMed databases using PEEK, polyetheretherketone, osseointegration of PEEK, PEEK in dentistry, tribology of PEEK, surface modifications, dental applications, bonding strength, surface topography, adhesive in dentistry, and dental implant as keywords. Literature on the topics of surface modification to increase adhesiveness, tribology, and osseointegration of PEEK were included in the review. The unavailability of full texts was considered when excluding literature. Surface modifications via chemical strategies (such as sulfonation, plasma treatment, UV treatment, surface coating, surface polymerization, etc.) and/or physical approaches (such as sandblasting, laser treatment, accelerated neutral atom beam, layer-by-layer assembly, particle leaching, etc.) discussed in the literature are summarized and compared. Further, approaches such as the incorporation of bioactive materials, e.g., osteogenic agents, antibacterial agents, etc., to enhance the abovementioned desired properties are explored. This review presents surface modification as a critical and essential approach to enhance the biological performance of PEEK in dentistry by retaining its mechanical robustness.
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Affiliation(s)
- Bidhari Pidhatika
- Research Center for Polymer Technology, National Research and Innovation Agency, Republic of Indonesia PRTPL BRIN Indonesia, Serpong, Tangerang Selatan 15314, Indonesia
- Collaborative Research Center for Biomedical Scaffolds, National Research and Innovation Agency of the Republic Indonesia and Universitas Gadjah Mada, Jalan Denta No. 1, Sekip Utara, Yogyakarta 55281, Indonesia
| | - Vania Tanda Widyaya
- Research Center for Polymer Technology, National Research and Innovation Agency, Republic of Indonesia PRTPL BRIN Indonesia, Serpong, Tangerang Selatan 15314, Indonesia
| | - Prathima C. Nalam
- Department of Materials Design and Innovation, University at Buffalo, Buffalo, NY 14260-1900, USA
| | - Yogi Angga Swasono
- Research Center for Polymer Technology, National Research and Innovation Agency, Republic of Indonesia PRTPL BRIN Indonesia, Serpong, Tangerang Selatan 15314, Indonesia
| | - Retno Ardhani
- Department of Dental Biomedical Science, Faculty of Dentistry, Universitas Gadjah Mada, Jalan Denta No. 1, Sekip Utara, Yogyakarta 55281, Indonesia
- Correspondence:
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14
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PEEK and Hyaluronan-Based 3D Printed Structures: Promising Combination to Improve Bone Regeneration. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27248749. [PMID: 36557882 PMCID: PMC9787780 DOI: 10.3390/molecules27248749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/30/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
Hybrid bone substitute made up of a 3D printed polyetheretherketone (PEEK) scaffold coated with methacrylated hyaluronic acid (MeHA)-hydroxyapatite (HAp) hydrogel is the objective of the present work. Development and characterization of the scaffold and of the MeHA-HAp after its infiltration and UV photocrosslinking have been followed by analyses of its biological properties using human mesenchymal stem cells (MSCs). Interconnected porous PEEK matrices were produced by fused deposition modeling (FDM) characterized by a reticular pattern with 0°/90° raster orientation and square pores. In parallel, a MeHA-HAp slurry has been synthesized and infiltrated in the PEEK scaffolds. The mechanical properties of the coated and pure PEEK scaffold have been evaluated, showing that the inclusion of MeHA-HAp into the lattice geometry did not significantly change the strength of the PEEK structure with Young's modulus of 1034.9 ± 126.1 MPa and 1020.0 ± 63.7 MPa for PEEK and PEEK-MeHA-HAp scaffolds, respectively. Human MSCs were seeded on bare and coated scaffolds and cultured for up to 28 days to determine the adhesion, proliferation, migration and osteogenic differentiation. In vitro results showed that the MeHA-HAp coating promotes MSCs adhesion and proliferation and contributes to osteogenic differentiation and extracellular matrix mineralization. This study provides an efficient solution for the development of a scaffold combining the great mechanical performances of PEEK with the bioactive properties of MeHA and HAp, having high potential for translational clinical applications.
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15
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Qiu P, Feng L, Fu Q, Dai T, Liu M, Wang P, Lan Y. Dual-Functional Polyetheretherketone Surface with an Enhanced Osteogenic Capability and an Antibacterial Adhesion Property In Vitro by Chitosan Modification. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2022; 38:14712-14724. [PMID: 36420594 DOI: 10.1021/acs.langmuir.2c02267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
A chitosan layer was covalently bonded to a polyetheretherketone (PEEK) surface using a simple facile self-assembly method to address inadequate biological activity and infection around the implant. The surface characterization, layer degradation, biological activity, and antibacterial adhesion properties of chitosan-modified PEEK (PEEK-CS) were studied. Through chitosan grafting, the surface morphology changed, the surface roughness increased, and the contact angle decreased significantly. PEEK-CS boosted cell adhesion, proliferation, increased alkaline phosphate activity, extracellular matrix mineralization, and expression of osteogenic genes. PEEK-CS demonstrated less adhesion to Porphyromonas gingivalis as well as less bacterial adhesion to P. gingivalis and Streptococcus mutans. According to our findings, chitosan modification significantly improved the osteogenic ability and antibacterial adhesion of PEEK in vitro.
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Affiliation(s)
- Peng Qiu
- Department of Prosthodontics, The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou646000, China
- Luzhou Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Luzhou646000, China
| | - Le Feng
- Department of Prosthodontics, The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou646000, China
- Luzhou Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Luzhou646000, China
| | - Qilin Fu
- Department of Prosthodontics, The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou646000, China
- Luzhou Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Luzhou646000, China
| | - Tao Dai
- Department of Prosthodontics, The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou646000, China
- Luzhou Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Luzhou646000, China
| | - Min Liu
- Department of Prosthodontics, The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou646000, China
- Luzhou Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Luzhou646000, China
| | - Pin Wang
- Department of Prosthodontics, The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou646000, China
- Luzhou Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Luzhou646000, China
| | - Yuyan Lan
- Department of Prosthodontics, The Affiliated Stomatological Hospital of Southwest Medical University, Luzhou646000, China
- Luzhou Key Laboratory of Oral & Maxillofacial Reconstruction and Regeneration, Luzhou646000, China
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16
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Zheng Z, Liu P, Zhang X, Jingguo xin, Yongjie wang, Zou X, Mei X, Zhang S, Zhang S. Strategies to improve bioactive and antibacterial properties of polyetheretherketone (PEEK) for use as orthopedic implants. Mater Today Bio 2022; 16:100402. [PMID: 36105676 PMCID: PMC9466655 DOI: 10.1016/j.mtbio.2022.100402] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 12/26/2022] Open
Abstract
Polyetheretherketone (PEEK) has gradually become the mainstream material for preparing orthopedic implants due to its similar elastic modulus to human bone, high strength, excellent wear resistance, radiolucency, and biocompatibility. Since the 1990s, PEEK has increasingly been used in orthopedics. Yet, the widespread application of PEEK is limited by its bio-inertness, hydrophobicity, and susceptibility to microbial infections. Further enhancing the osteogenic properties of PEEK-based implants remains a difficult task. This article reviews some modification methods of PEEK in the last five years, including surface modification of PEEK or incorporating materials into the PEEK matrix. For surface modification, PEEK can be modified by chemical treatment, physical treatment, or surface coating with bioactive substances. For PEEK composite material, adding bioactive filler into PEEK through the melting blending method or 3D printing technology can increase the biological activity of PEEK. In addition, some modification methods such as sulfonation treatment of PEEK or grafting antibacterial substances on PEEK can enhance the antibacterial performance of PEEK. These strategies aim to improve the bioactive and antibacterial properties of the modified PEEK. The researchers believe that these modifications could provide valuable guidance on the future design of PEEK orthopedic implants.
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17
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Gao X, Wang H, Luan S, Zhou G. Low-Temperature Printed Hierarchically Porous Induced-Biomineralization Polyaryletherketone Scaffold for Bone Tissue Engineering. Adv Healthc Mater 2022; 11:e2200977. [PMID: 35816736 DOI: 10.1002/adhm.202200977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/08/2022] [Indexed: 01/27/2023]
Abstract
Polyetheretherketone (PEEK) as a popular orthopaedic implant is usually fabricated into a hierarchically porous structure for improving osteogenic activity. However, the applications are limited due to the excessively high processing temperature and uncontrollably tedious modification routes. Here, an amorphous polyaryletherketone with carboxyl groups (PAEK-COOH) is synthesized and fabricated to the hierarchically controllable porous scaffolds via a low-temperature 3D-printing process. The prepared PAEK-COOH scaffolds present controllable porous structures ranging from nano- to micro-scale, and their mechanical strengths are comparable to that of trabecular bone. More importantly, the in vitro experiments show that the nanoporous surface is conducive to promoting cellular adhesion, and carboxyl groups can induce hydroxyapatite mineralization via electrostatic interaction. The in vivo experiments demonstrate that the PAEK-COOH scaffolds offer much better osseointegration without additional active ingredients, compared to that of PEEK. Therefore, this work will not only develop a promising candidate for bone tissue engineering, but provide a viable method to design PAEK biomaterials.
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Affiliation(s)
- Xinshuai Gao
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China.,University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Honghua Wang
- Division of Energy Materials (DNL22), Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, 116023, P. R. China
| | - Shifang Luan
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China.,University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Guangyuan Zhou
- Division of Energy Materials (DNL22), Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, 116023, P. R. China
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18
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The Single-Step Fabrication of a Poly (Sodium Vinylsulfonate)-Grafted Polyetheretherketone Surface to Ameliorate Its Osteogenic Activity. COATINGS 2022. [DOI: 10.3390/coatings12060868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Polyetheretherketone (PEEK) is considered a potential material for replacing traditional biomedical metals used in orthopedic implants because of its similar elastic modulus to human bone. However, the poor osteogenic activity of PEEK itself hinders its clinical application. In this study, a PEEK surface was grafted with poly (sodium vinylsulfonate) through a single-step ultraviolet-initiated graft polymerization method to ameliorate its osteogenic activity. X-ray photoelectron spectroscopy and water contact angle measurements confirmed that different amounts of poly (sodium vinylsulfonate) were grafted onto the PEEK surface upon varying the ultraviolet irradiation time. Atomic force microscopy revealed that the surface topography and roughness of PEEK before and after surface grafting did not change significantly. The in vitro results showed that grafting with poly (sodium vinylsulfonate) rendered the PEEK surface with improved MC3T3-E1 osteoblast compatibility and osteogenic activity. Moreover, a PEEK surface with a higher grafting amount of poly (sodium vinylsulfonate) was observed to be more beneficial to the proliferation and osteogenic differentiation of MC3T3-E1 osteoblasts. Collectively, by employing this simple and one-step method, the osteogenic activity of PEEK can be enhanced, paving the way for the clinical application of PEEK in orthopedic implants.
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19
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Buck E, Lee S, Gao Q, Tran SD, Tamimi F, Stone LS, Cerruti M. The Role of Surface Chemistry in the Osseointegration of PEEK Implants. ACS Biomater Sci Eng 2022; 8:1506-1521. [PMID: 35290033 DOI: 10.1021/acsbiomaterials.1c01434] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Poly(etheretherketone) (PEEK) implants suffer from poor osseointegration because of chronic inflammation. In this study, we hypothesized that adding NH2 and COOH groups to the surface of PEEK could modulate macrophage responses by altering protein adsorption and improve its osseointegration. NH2 and COOH-functionalized PEEK surfaces induced pro- and anti-inflammatory macrophage responses, respectively, and differences in protein adsorption patterns on these surfaces were related to the varied inflammatory responses. The macrophage responses to NH2 surfaces significantly reduced the osteogenic differentiation of mesenchymal stem cells (MSCs). MSCs cultured on NH2 surfaces differentiated less than those on COOH surfaces even though NH2 surfaces promoted the most mineralization in simulated body fluid solutions. After 14 days in rat tibia unicortical defects, the bone around NH2 surfaces had thinner trabeculae and higher specific bone surface than the bone around unmodified implants; surprisingly, the NH2 implants significantly increased bone-binding over the unmodified implants, while COOH implants only showed a trend for increasing bone-binding. Taken together, these results suggest that both mineral-binding and immune responses play a role in osseointegration, and PEEK implant integration may be improved with mixtures of these two functional groups to harness the ability to reduce inflammation and bind bone strongly.
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Affiliation(s)
- Emily Buck
- Mining and Materials Engineering, McGill University, 3610 University Street, Montreal, Quebec H3A 0C5, Canada
| | - Seunghwan Lee
- Faculty of Dentistry, McGill University, 2001 McGill College Avenue #500, Montreal, Quebec H3A 1G1, Canada.,Alan Edwards Center for Research on Pain, McGill University, 740 Dr. Penfield Avenue, Montreal, Quebec H3A 0G1, Canada
| | - Qiman Gao
- Faculty of Dentistry, McGill University, 2001 McGill College Avenue #500, Montreal, Quebec H3A 1G1, Canada
| | - Simon D Tran
- Faculty of Dentistry, McGill University, 2001 McGill College Avenue #500, Montreal, Quebec H3A 1G1, Canada
| | - Faleh Tamimi
- Faculty of Dentistry, McGill University, 2001 McGill College Avenue #500, Montreal, Quebec H3A 1G1, Canada
| | - Laura S Stone
- Faculty of Dentistry, McGill University, 2001 McGill College Avenue #500, Montreal, Quebec H3A 1G1, Canada.,Alan Edwards Center for Research on Pain, McGill University, 740 Dr. Penfield Avenue, Montreal, Quebec H3A 0G1, Canada
| | - Marta Cerruti
- Mining and Materials Engineering, McGill University, 3610 University Street, Montreal, Quebec H3A 0C5, Canada
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20
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Qin S, Lu Z, Gan K, Qiao C, Li B, Chen T, Gao Y, Jiang L, Liu H. Construction of a
BMP
‐2 gene delivery system for polyetheretherketone bone implant material and its effect on bone formation in vitro. J Biomed Mater Res B Appl Biomater 2022; 110:2075-2088. [PMID: 35398972 DOI: 10.1002/jbm.b.35062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/15/2022] [Accepted: 03/19/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Shuang Qin
- Department of Oral Comprehensive Therapy, Hospital of Stomatology Jilin University Changchun China
| | - Zhengkuan Lu
- Department of Oral Comprehensive Therapy, Hospital of Stomatology Jilin University Changchun China
| | - Kang Gan
- Department of Stomatology The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Chunyan Qiao
- Department of Oral Pathology, Hospital of Stomatology Jilin University Changchun China
| | - Baosheng Li
- Department of Dental Implantology, Hospital of Stomatology Jilin University Changchun China
| | - Tianjie Chen
- Department of Oral Comprehensive Therapy, Hospital of Stomatology Jilin University Changchun China
| | - Yunbo Gao
- Department of Oral Comprehensive Therapy, Hospital of Stomatology Jilin University Changchun China
| | - Lingling Jiang
- Department of Oral Comprehensive Therapy, Hospital of Stomatology Jilin University Changchun China
| | - Hong Liu
- Department of Oral Comprehensive Therapy, Hospital of Stomatology Jilin University Changchun China
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21
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Chen J, Cao G, Li L, Cai Q, Dunne N, Li X. Modification of polyether ether ketone for the repairing of bone defects. Biomed Mater 2022; 17. [PMID: 35395651 DOI: 10.1088/1748-605x/ac65cd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/08/2022] [Indexed: 11/12/2022]
Abstract
Bone damage as a consequence of disease or trauma is a common global occurrence. For bone damage treatment - bone implant materials are necessary across three classifications of surgical intervention (i.e. fixation, repair, and replacement). Many types of bone implant materials have been developed to meet the requirements of bone repair. Among them, polyether ether ketone (PEEK) has been considered as one of the next generation of bone implant materials, owing to its advantages related to good biocompatibility, chemical stability, X-ray permeability, elastic modulus comparable to natural bone, as well as the ease of processing and modification. However, as PEEK is a naturally bioinert material, some modification is needed to improve its integration with adjacent bones after implantation. Therefore, it has become a very hot topic of biomaterials research and various strategies for the modification of PEEK including blending, 3D printing, coating, chemical modification and the introduction of bioactive and/or antibacterial substances have been proposed. In this systematic review, the recent advances in modification of PEEK and its application prospect as bone implants are summarized, and the remaining challenges are also discussed.
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Affiliation(s)
- Junfeng Chen
- Beihang University, 37 Xueyuan Rd, Haidian District, Beijing, Beijing, 100083, CHINA
| | - Guangxiu Cao
- Beihang University, 37 Xueyuan Rd, Haidian District, Beijing, Beijing, 100083, CHINA
| | - Linhao Li
- Beihang University, 37 Xueyuan Rd, Haidian District, Beijing, 100083, CHINA
| | - Qiang Cai
- Tsinghua University Department of Materials Science and Engineering, 30 shuangqing Rd, Haidian District, Beijing, Beijing, 100084, CHINA
| | - Nicholas Dunne
- School of Mechanical and Manufacturing Engineering, Dublin City University, Dublin 9, Dublin, D09, IRELAND
| | - Xiaoming Li
- Biological Science and Medical Engineering, Beihang University, 37 Xueyuan Rd, Haidian District, Beijing, Beijing, 100083, CHINA
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Zheng Y, Gao A, Bai J, Liao Q, Wu Y, Zhang W, Guan M, Tong L, Geng D, Zhao X, Chu PK, Wang H. A programmed surface on polyetheretherketone for sequentially dictating osteoimmunomodulation and bone regeneration to achieve ameliorative osseointegration under osteoporotic conditions. Bioact Mater 2022; 14:364-376. [PMID: 35386814 PMCID: PMC8964985 DOI: 10.1016/j.bioactmat.2022.01.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023] Open
Abstract
Polyetheretherketone (PEEK) is a desirable alternative to conventional biomedical metals for orthopedic implants due to the excellent mechanical properties. However, the inherent bioinertness of PEEK contributes to inferior osseointegration of PEEK implants, especially under pathological conditions of osteoporosis. Herein, a programmed surface is designed and fabricated on PEEK to dictate osteoimmunomodulation and bone regeneration sequentially. A degradable hybrid coating consisting of poly(lactide-co-glycolide) and alendronate (ALN) loaded nano-hydroxyapatite is deposited on PEEK and then interleukin-4 (IL-4) is grafted onto the outer surface of the hybrid coating with the aid of N2 plasma immersion ion implantation and subsequent immersion in IL-4 solution. Dominant release of IL-4 together with ALN and Ca2+ during the first few days synergistically mitigates the early acute inflammatory reactions and creates an osteoimmunomodulatory microenvironment that facilitates bone regeneration. Afterwards, slow and sustained delivery of ALN and Ca2+ in the following weeks boosts osteogenesis and suppresses osteoclastogenesis simultaneously, consequently ameliorating bone-implant osseointegration even under osteoporotic conditions. By taking into account the different phases in bone repair, this strategy of constructing advanced bone implants with sequential functions provides customizable and clinically viable therapy to osteoporotic patients. A programmed surface is designed and fabricated on PEEK to dictate osteoimmunomodulation and bone regeneration sequentially. A degradable coating consisting ALN loaded nano-HA is deposited on PEEK, with IL-4 being grafted onto the outmost surface. Dominant release of IL-4 together with ALN and Ca2+ synergistically mitigates the early acute inflammatory reactions. Slow and sustained delivery of ALN and Ca2+ boosts osteogenesis and suppresses osteoclastogenesis simultaneously. Sequential regulation of peri-implant biological responses is achieved to match the dynamic process of bone regeneration.
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Affiliation(s)
- Yanyan Zheng
- Center for Human Tissues and Organs Degeneration, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
- School of Basic Medical Sciences and Forensic Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Ang Gao
- Center for Human Tissues and Organs Degeneration, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Jiaxiang Bai
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Qing Liao
- Center for Human Tissues and Organs Degeneration, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Yuzheng Wu
- Department of Physics, Department of Materials Science and Engineering, Department of Biomedical Engineering, City University of Hong Kong, Tat Chee Avenue, Kowloon, Hong Kong, China
| | - Wei Zhang
- Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Min Guan
- Center for Human Tissues and Organs Degeneration, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Liping Tong
- Center for Human Tissues and Organs Degeneration, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
- Corresponding author
| | - Dechun Geng
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
- Corresponding author
| | - Xin Zhao
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Paul K. Chu
- Department of Physics, Department of Materials Science and Engineering, Department of Biomedical Engineering, City University of Hong Kong, Tat Chee Avenue, Kowloon, Hong Kong, China
| | - Huaiyu Wang
- Center for Human Tissues and Organs Degeneration, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
- Corresponding author
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23
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Biofunctional phosphorylated magnetic scaffold for bone tissue engineering. Colloids Surf B Biointerfaces 2021; 211:112284. [PMID: 34952284 DOI: 10.1016/j.colsurfb.2021.112284] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/23/2021] [Accepted: 12/10/2021] [Indexed: 12/21/2022]
Abstract
The development of highly bioactive engineered scaffolds is required to promote bone regeneration and the success of bone tissue engineering treatment approaches. This study attempts to fabricate a biofunctional magnetic scaffold based on new phosphorylated polycaprolactone combined with gelatin (MNPs-PCL-P/gelatin). Phosphorylated polymer and magnetic nanoparticles (MNPs) were synthesized and characterized by NMR, FT-IR, TEM, and DLS instruments. The synthetic polymer, MNPs, and biopolymer were mixed then freeze-dried to prepare a porous scaffold. Physiochemical assessments showed that a scaffold with well-developed porous morphology, and stable structure was obtained. MNPs-PCL-P/gelatin scaffold had no toxicity on human dental pulp stem cells (hDPSCs). The use of phosphorous-containing polymer resulted in improvement of the scaffold's osteoconductivity to support proper cell attachment and promote cell proliferation. Phosphate group by mimicking function of bone phosphate groups stimulate bone mineralization that reflected by alizarin red S staining assay. The presence of MNPs resulted in higher ALP activity and increased expression level of RUNX2, BMP2 osteogenic biomarkers. Also, phosphorylation enhanced osteoinductivity of scaffold and upregulate RUNX2, BMP2, COL1A1, and OCN genes in phosphors-containing scaffold test groups. It seems that biocompatible MNPs-PCL-P/gelatin scaffold possesses the potential of applications in bone tissue engineering.
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24
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Len’shina NA, Shurygina MP, Chesnokov SA. Photoreduction Reaction of Carbonyl-Containing Compounds in the Synthesis and Modification of Polymers. POLYMER SCIENCE SERIES B 2021. [DOI: 10.1134/s1560090421060130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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25
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The surface modification of long carbon fiber reinforced polyether ether ketone with bioactive composite hydrogel for effective osteogenicity. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 130:112451. [PMID: 34702530 DOI: 10.1016/j.msec.2021.112451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/30/2021] [Accepted: 09/19/2021] [Indexed: 11/20/2022]
Abstract
Long carbon fiber reinforced polyether ether ketone (LCFRPEEK) is fabricated using a three-dimensional (3D) needle-punched method in our previous work, which is considered as a potential orthopedic implant due to its high mechanical strength and isotropic properties, as well as having an elastic modulus similar to human cortical bone. However, the LCFRPEEK has inferior integration with bone tissue, limiting its clinical application. Thus, a facile surface modification method, using gelatin methacrylate/polyacrylamide composite hydrogel coating (GelMA/PAAM) loading with dexamethasone (Dex) on our newly-developed LCFRPEEK composite via concentrated sulfuric acid sulfonating and ultraviolet (UV) irradiation grafting methods, has been developed to tackle the problem. The results demonstrate that the GelMA/PAAM/Dex coating modified sulfonated LCFRPEEK (SCP/GP/Dex) has a hydrophilicity surface, a long-term Dex release capability and forms more bone-like apatite nodules in SBF. The SCP/GP/Dex also displays enhanced cytocompatibility and osteogenic differentiation in terms of rat bone marrow mesenchymal stem cells (rBMSCs) responses in vitro assay. The in vivo rat cranial defect assay confirms that SCP/GP/Dex boosts bone regeneration/osseointegration, which significantly improves osteogenic fixation between the implant and bone tissue. Therefore, the newly-developed LCFRPEEK modified via GelMA/PAAM/Dex bioactive coating exhibits improved biocompatibility and osteogenic integration capability, which has the basis for an orthopedic implant for clinical application.
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Sun A, Lin X, Xue Z, Huang J, Bai X, Huang L, Lin X, Weng S, Chen M. Facile surface functional polyetheretherketone with antibacterial and immunoregulatory activities for enhanced regeneration toward bacterium-infected bone destruction. Drug Deliv 2021; 28:1649-1663. [PMID: 34338560 PMCID: PMC8330770 DOI: 10.1080/10717544.2021.1960924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Existing biologically inert or unmodified implants to treat infectious bone defects or osteomyelitis still cannot effectively solve bacterial infection and osseointegration. In this work, a simple co-deposition strategy was developed to modify porous polyetheretherketone (PEEK) with improved antibacterial activity and controllable immunoregulatory ability. After PEEK was treated by H2SO4 to obtain porous PEEK (SPEEK), the self-polymerization of dopamine was operated on SPEEK in the solution of dopamine and gentamicin sulfate (GS) to prepare polydopamine (pDA) and GS layer-modified SPEEK (labeled as SPEEK–pDA–GS). The morphology, surface property, and molecular structure of SPEEK–pDA–GS were investigated. Besides the antibacterial property of SPEEK–pDA–GS ascribed to the successful immobilization of GS, SPEEK–pDA–GS exhibited promoted osseointegration through the results of mineralization, alkaline phosphatase (ALP) levels and osteogenic gene expression. Furthermore, the evaluation of the cell proliferation suggested that SPEEK–pDA–GS possessed the biocompatibility and the immunoregulatory ability that induced macrophages to anti-inflammatory M2 phenotype. Using rat as model, in vivo results containing X-ray, μ-CT, immunohistochemistry, and pathological analysis showed the excellent healing effect of SPEEK–pDA–GS on bone defect with infection with biological safety. This work illustrates a new insight into the simple and effective modification of PEEK and other implants with antibacterial, immunoregulatory, and osseointegration abilities for clinical requirement.
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Affiliation(s)
- An'an Sun
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xi Lin
- Department of Emergency Surgery, Center for Trauma Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhiqiang Xue
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jiyue Huang
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xinxin Bai
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Lingling Huang
- Department of Stomatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xinhua Lin
- Department of Pharmaceutical Analysis, School of Pharmacy, Higher Educational Key Laboratory for Nano Biomedical Technology of Fujian Province, Fujian Medical University, Fuzhou, China
| | - Shaohuang Weng
- Department of Pharmaceutical Analysis, School of Pharmacy, Higher Educational Key Laboratory for Nano Biomedical Technology of Fujian Province, Fujian Medical University, Fuzhou, China
| | - Min Chen
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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He M, Huang Y, Xu H, Feng G, Liu L, Li Y, Sun D, Zhang L. Modification of polyetheretherketone implants: From enhancing bone integration to enabling multi-modal therapeutics. Acta Biomater 2021; 129:18-32. [PMID: 34020056 DOI: 10.1016/j.actbio.2021.05.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 02/08/2023]
Abstract
Polyetheretherketone (PEEK) is a popular thermoplastic material widely used in engineering applications due to its favorable mechanical properties and stability at high temperatures. With the first implantable grade PEEK being commercialized in 1990s, the use of PEEK has since grown exponentially in the biomedical field and has rapidly transformed a large section of the medical devices landscape. Nowadays, PEEK is a standard biomaterial used across a wide range of implant applications, however, its bioinertness remains a limitation for bone repair applications. The increasing demand for enhanced treatment efficacy/improved patient quality of life, calls for next-generation implants that can offer fast bone integration as well as other desirable therapeutic functions. As such, modification of PEEK implants has progressively shifted from offering desirable mechanical properties, enhancing bioactivity/fast osteointegration, to more recently, tackling post-surgery bacterial infection/biofilm formation, modulation of inflammation and management of bone cancers. Such progress is also accompanied by the evolution of the PEEK manufacturing technologies, to meet the ever increasing demand for more patient specific devices. However, no review has comprehensively covered the recently engaged application areas to date. This paper provides an up-to-date review on the development of PEEK-based biomedical devices in the past 10 years, with particularly focus on modifying PEEK for multi-modal therapeutics. The aim is to provide the peers with a timely update, which may guide and inspire the research and development of next generation PEEK-based healthcare products. STATEMENT OF SIGNIFICANCE: Significant progress has been made in PEEK processing and modification techniques in the past decades, which greatly contributed to its wide applications in the biomedical field. Despite the high volume of published literature on PEEK implant related research, there is a lack of review on its emerging applications in multi-modal therapeutics, which involve bone regeneration, anti-bacteria/anti-inflammation, and cancer inhibition, etc. This timely review covers the state-of-the-art in these exciting areas and provides the important guidance for next generation PEEK based biomedical device research and development.
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Liu X, Guan N, Shen H, Zhang Z, Chen B, Li Y, Hua S. Investigating the effect of water‐mixing nitrogen atmospheric pressure plasma jet on polyether‐ether‐ketone and time stability under different conditions. J Appl Polym Sci 2021. [DOI: 10.1002/app.50586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Xin Liu
- Key Laboratory for Precision and Non‐traditional Machining Technology of the Ministry of Education Dalian University of Technology Dalian China
- Collaborative Innovation Center of Major Machine Manufacturing in Liaoning Dalian University of Technology Dalian China
| | - Naiqiao Guan
- Key Laboratory for Precision and Non‐traditional Machining Technology of the Ministry of Education Dalian University of Technology Dalian China
| | - Haiyang Shen
- Key Laboratory for Precision and Non‐traditional Machining Technology of the Ministry of Education Dalian University of Technology Dalian China
| | - Zhongtao Zhang
- Key Laboratory for Precision and Non‐traditional Machining Technology of the Ministry of Education Dalian University of Technology Dalian China
| | - Boxi Chen
- Key Laboratory for Precision and Non‐traditional Machining Technology of the Ministry of Education Dalian University of Technology Dalian China
| | - Yuheng Li
- Key Laboratory for Precision and Non‐traditional Machining Technology of the Ministry of Education Dalian University of Technology Dalian China
| | - Shungang Hua
- Key Laboratory for Precision and Non‐traditional Machining Technology of the Ministry of Education Dalian University of Technology Dalian China
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Jiang X, Yao Y, Tang W, Han D, Zhang L, Zhao K, Wang S, Meng Y. Both Phosphonic Acid- and Fluorine-Containing Poly(aryl ether)-hydroxyapatite Biocomposites: Toward Enhanced Biocompatibility and Bonelike Elastic Modulus. ACS APPLIED BIO MATERIALS 2020; 3:9019-9030. [PMID: 35019579 DOI: 10.1021/acsabm.0c01254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Metal-based implants possess excellent mechanical strength, corrosion resistance, and biocompatibility and can deliver favorable performances in clinic treatments. However, modulus mismatching is considered a common defect for metal-based materials, while polymer-based materials with a bonelike elastic modulus have been regarded as one of the most promising candidates for bone replacement implants. In this work, a phosphonic acid- and fluorine-containing poly(aryl ether) (PAE) resin is designed and synthesized, which is determined to be an amorphous polymer with excellent thermostability. The elastic modulus of composites is improved to 15.7 GPa by reinforcing with 60 wt % hydroxyapatite (HA), which demonstrates admirable protein adsorption and hydrophilicity. After 14 days of immersion in simulated body fluid, a layer of HA deposition can be observed, indicating favorable bioactivity in advance, and the preliminary in vitro cell experiments also suggest that PAE-HA composites possess favorable cell responses on adhesion, proliferation, and differentiation, which reveal the feasibility of synthesized polymers to be employed as bone replacement materials, while the adjustability in molecular chains also leaves room for further investigations.
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Affiliation(s)
- Xunyuan Jiang
- The Key Laboratory of Low-carbon Chemistry & Energy Conservation of Guangdong Province, State Key Laboratory of Optoelectronic Materials Technologies, Sun Yat-sen University, Guangzhou 510275, P. R. China
| | - Yitong Yao
- Hospital of Stomotology, Guanghua School of Stomatology, Guangdong Research Center for Dental and Cranial Rehabilitation and Material Engineering, Sun Yat-sen University, Guangzhou 510080, P. R. China
| | - Weiming Tang
- The Key Laboratory of Low-carbon Chemistry & Energy Conservation of Guangdong Province, State Key Laboratory of Optoelectronic Materials Technologies, Sun Yat-sen University, Guangzhou 510275, P. R. China
| | - Dongmei Han
- The Key Laboratory of Low-carbon Chemistry & Energy Conservation of Guangdong Province, State Key Laboratory of Optoelectronic Materials Technologies, Sun Yat-sen University, Guangzhou 510275, P. R. China
| | - Li Zhang
- Analytical & Testing Center, Sichuan University, Chengdu, Sichuan 610064, P. R. China
| | - Ke Zhao
- Hospital of Stomotology, Guanghua School of Stomatology, Guangdong Research Center for Dental and Cranial Rehabilitation and Material Engineering, Sun Yat-sen University, Guangzhou 510080, P. R. China
| | - Shuanjin Wang
- The Key Laboratory of Low-carbon Chemistry & Energy Conservation of Guangdong Province, State Key Laboratory of Optoelectronic Materials Technologies, Sun Yat-sen University, Guangzhou 510275, P. R. China
| | - Yuezhong Meng
- The Key Laboratory of Low-carbon Chemistry & Energy Conservation of Guangdong Province, State Key Laboratory of Optoelectronic Materials Technologies, Sun Yat-sen University, Guangzhou 510275, P. R. China
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Abstract
Some treatment options available to repair bone defects are the use of autogenous and allogeneic bone grafts. The drawback of the first one is the donor site’s limitation and the need for a second operation on the same patient. In the allograft method, the problems are associated with transmitted diseases and high susceptibility to rejection. As an alternative to biological grafts, polymers can be used in bone repair. Some polymers used in the orthopedic field are poly(methyl methacrylate), poly(ether-ether-ketone), and ultra-high molecular weight polyethylene (UHMWPE). UHMWPE has drawn much attention since it combines low friction coefficient and high wear and impact resistance. However, UHMWPE is a bioinert material, which means that it does not interact with the bone tissue. UHMWPE composites and nanocomposites with hydroxyapatite (HA) are widely studied in the literature to mitigate these issues. HA is the main component of the inorganic phase in the natural bone, and the addition of this bioactive filler to the polymeric matrix aims to mimic bone composition. This brief review discusses some polymers used in orthopedic applications, focusing on the UHMWPE/HA composites as a potential bone substitute.
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Ma Z, Zhao X, Zhao J, Zhao Z, Wang Q, Zhang C. Biologically Modified Polyether Ether Ketone as Dental Implant Material. Front Bioeng Biotechnol 2020; 8:620537. [PMID: 33392178 PMCID: PMC7775513 DOI: 10.3389/fbioe.2020.620537] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Polyether ether ketone (PEEK) is a non-toxic polymer with elastic modulus close to human bone. Compared with metal implants, PEEK has advantages such as evasion of stress shielding effect, easy processing, and similar color as teeth, among others. Therefore, it is an excellent substitute material for titanium dental orthopedic implants. However, PEEK's biological inertia limits its use as an implant. To change PEEK's biological inertia and increase its binding ability with bone tissue as an implant, researchers have explored a number of modification methods to enhance PEEK's biological activities such as cellular compatibility, osteogenic activity, and antibacterial activity. This review summarizes current biological activity modification methods for PEEK, including surface modification and blending modification, and analyzes the advantages and disadvantages of each modification method. We believe that modified PEEK will be a promising dental and orthopedic implant material.
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Affiliation(s)
- Zhangyu Ma
- Department of Stomatology, The First Hospital of Jilin University, Changchun, China
| | - Xingyu Zhao
- Department of Bone and Joint Surgery, The First Hospital of Jilin University, Changchun, China
| | - Jing Zhao
- Department of Stomatology, China-Japan Friendship Hospital, Beijing, China
| | - Zhilong Zhao
- Department of Stomatology, The First Hospital of Jilin University, Changchun, China
| | - Qihui Wang
- Department of Stomatology, The First Hospital of Jilin University, Changchun, China
| | - Congxiao Zhang
- Department of Stomatology, The First Hospital of Jilin University, Changchun, China
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32
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Ma Z, Li L, Shi X, Wang Z, Guo M, Wang Y, Jiao Z, Zhang C, Zhang P. Enhanced osteogenic activities of polyetheretherketone surface modified by poly(sodium p‐styrene sulfonate) via ultraviolet‐induced polymerization. J Appl Polym Sci 2020. [DOI: 10.1002/app.49157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Zhangyu Ma
- Department of StomatologyThe First Hospital of Jilin University Changchun China
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
| | - Linlong Li
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
- University of Chinese Academy of Sciences Beijing China
| | - Xincui Shi
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
| | - Zongliang Wang
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
| | - Min Guo
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
| | - Yu Wang
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
| | - Zixue Jiao
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
| | - Congxiao Zhang
- Department of StomatologyThe First Hospital of Jilin University Changchun China
| | - Peibiao Zhang
- Key Laboratory of Polymer EcomaterialsChangchun Institute of Applied Chemistry, Chinese Academy of Sciences Changchun China
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33
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Photoinduced self-initiated graft polymerization of methacrylate monomers on poly(ether ether ketone) substrates and surface parameters for controlling cell adhesion. Polym J 2020. [DOI: 10.1038/s41428-020-0318-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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34
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Tretto PHW, Dos Santos MBF, Spazzin AO, Pereira GKR, Bacchi A. Assessment of stress/strain in dental implants and abutments of alternative materials compared to conventional titanium alloy-3D non-linear finite element analysis. Comput Methods Biomech Biomed Engin 2020; 23:372-383. [PMID: 32116034 DOI: 10.1080/10255842.2020.1731481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The aim of this study was to assess the stress/strain in dental implant/abutments with alternative materials, in implants with different microgeometry, through finite element analysis (FEA). Three-dimensional models were created to simulate the clinical situation of replacement of a maxillary central incisor with implants, in a type III bone, with a provisional single crown, loaded with 100 N in a perpendicular direction. The FEA parameters studied were: implant materials-titanium, porous titanium, titanium-zirconia, zirconia, reinforced fiberglass composite (RFC), and polyetheretherketone (PEEK); and abutment materials-titanium, zirconia, RFC, and PEEK; implant macrogeometry-tapered of trapezoidal threads (TTT) and cylindrical of triangular threads (CTT) (ø4.3 mm × 11 mm). Microstrain, von Mises, shear, and maximum and minimum principal stresses in the structures and in peri-implant bone were compared. There was increased stress and strain in peri-implant bone tissue caused by implants of materials with lower elastic modulus (mainly for PEEK and RFC). They also presented higher concentration of stresses in the implant itself (especially RFC). Zirconia implants led to lower stress and strains in peri-implant bone tissue. Less rigid abutments (RFC and PEEK) associated with titanium implants led to higher stress in the implant and in peri-implant bone tissue. The TTT macrogeometry showed a higher stress concentration in the implant and peri-implant bone tissue. The stress/strain in peri-implant bone tissue and implant structures were affected by the material used, where reduced values were caused by stiffer materials. Lower stress/strain values were obtained with cylindrical implants of triangular treads.
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Affiliation(s)
| | | | - Aloisio Oro Spazzin
- Graduate Program in Dentistry, Meridional Faculty-IMED, Passo Fundo, RS, Brazil
| | - Gabriel Kalil Rocha Pereira
- Graduate Program in Oral Science (Prosthodontics Units), Federal University of Santa Maria - UFSM, Santa Maria, RS, Brazil
| | - Atais Bacchi
- Graduate Program in Dentistry, Meridional Faculty-IMED, Passo Fundo, RS, Brazil
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Flejszar M, Chmielarz P. Surface Modifications of Poly(Ether Ether Ketone) via Polymerization Methods-Current Status and Future Prospects. MATERIALS (BASEL, SWITZERLAND) 2020; 13:E999. [PMID: 32102217 PMCID: PMC7078635 DOI: 10.3390/ma13040999] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/14/2020] [Accepted: 02/20/2020] [Indexed: 12/24/2022]
Abstract
Surface modification of poly(ether ether ketone) (PEEK) aimed at applying it as a bone implant material aroused the unflagging interest of the research community. In view of the development of implantology and the growing demand for new biomaterials, increasing biocompatibility and improving osseointegration are becoming the primary goals of PEEK surface modifications. The main aim of this review is to summarize the use of polymerization methods and various monomers applied for surface modification of PEEK to increase its bioactivity, which is a critical factor for successful applications of biomedical materials. In addition, the future directions of PEEK surface modifications are suggested, pointing to low-ppm surface-initiated atom transfer radical polymerization (SI-ATRP) as a method with unexplored capacity for flat surface modifications.
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Affiliation(s)
| | - Paweł Chmielarz
- Department of Physical Chemistry, Faculty of Chemistry, Rzeszow University of Technology, Al. Powstańców Warszawy 6, 35-959 Rzeszów, Poland;
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Yakufu M, Wang Z, Wang Y, Jiao Z, Guo M, Liu J, Zhang P. Covalently functionalized poly(etheretherketone) implants with osteogenic growth peptide (OGP) to improve osteogenesis activity. RSC Adv 2020; 10:9777-9785. [PMID: 35498607 PMCID: PMC9050223 DOI: 10.1039/d0ra00103a] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/15/2020] [Indexed: 11/21/2022] Open
Abstract
Polyetheretherketone (PEEK), as the most promising implant material for orthopedics and dental applications, has bone-like stiffness, excellent fatigue resistance, X-ray transparency, and near absence of immune toxicity. However, due to biological inertness, its bone conduction and bone ingrowth performance is limited. The surface modification of PEEK is an option to overcome these shortcomings and retain most of its favorable properties, especially when excellent osseointegration is desired. In this study, a simple reaction procedure was employed to bind the osteogenic growth peptide (OGP) on the surface of PEEK materials by covalent chemical grafting to construct a bioactive interface. The PEEK surface was activated by N,N′-disuccinimidyl carbonate (DSC) after hydroxylation, and then OGP was covalently grafted with amino groups. The functionalized surface of PEEK samples were characterized by X-ray photoelectron spectroscopy (XPS), Fourier-transform infrared spectroscopy (FT-IR), water contact angle measurement and biological evaluation in vitro. OGP-functionalized PEEK surface significantly promoted the attachment, proliferation, alkaline phosphatase (ALP) activity and mineralization of pre-osteoblast cells (MC3T3-E1). The in vivo rat tibia implantation model is adopted and micro-CT analyses demonstrated that the OGP coating significantly promoted new bone formation around the samples. The in vitro and in vivo results reveal that the modification by covalent chemical functionalization with OGP on PEEK surface can augment new bone formation surrounding implants compared to bare PEEK and PEEK implant modified by covalently attached OGP is promising in orthopedic and dental applications. Polyetheretherketone (PEEK), as the most promising implant material for orthopedics and dental applications, has bone-like stiffness, excellent fatigue resistance, X-ray transparency, and near absence of immune toxicity.![]()
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Affiliation(s)
- Maihemuti Yakufu
- Department of Orthopaedics
- The First Hospital of Jilin University
- Changchun
- China
- Key Laboratory of Polymer Ecomaterials
| | - Zongliang Wang
- Key Laboratory of Polymer Ecomaterials
- Changchun Institute of Applied Chemistry
- Chinese Academy of Sciences
- Changchun 130022
- China
| | - Yu Wang
- Key Laboratory of Polymer Ecomaterials
- Changchun Institute of Applied Chemistry
- Chinese Academy of Sciences
- Changchun 130022
- China
| | - Zixue Jiao
- Key Laboratory of Polymer Ecomaterials
- Changchun Institute of Applied Chemistry
- Chinese Academy of Sciences
- Changchun 130022
- China
| | - Min Guo
- Key Laboratory of Polymer Ecomaterials
- Changchun Institute of Applied Chemistry
- Chinese Academy of Sciences
- Changchun 130022
- China
| | - Jianguo Liu
- Department of Orthopaedics
- The First Hospital of Jilin University
- Changchun
- China
| | - Peibiao Zhang
- Key Laboratory of Polymer Ecomaterials
- Changchun Institute of Applied Chemistry
- Chinese Academy of Sciences
- Changchun 130022
- China
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37
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Knaus J, Schaffarczyk D, Cölfen H. On the Future Design of Bio-Inspired Polyetheretherketone Dental Implants. Macromol Biosci 2019; 20:e1900239. [PMID: 31802617 DOI: 10.1002/mabi.201900239] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 10/10/2019] [Indexed: 11/09/2022]
Abstract
Polyetheretherketone (PEEK) is a promising implant material because of its excellent mechanical characteristics. Although this polymer is a standard material in spinal applications, PEEK is not in use in the manufacturing of dental implants, where titanium is still the most-used material. This may be caused by its relative bio-inertness. By the use of various surface modification techniques, efforts have been made to enhance its osseointegrative characteristics to enable the polymer to be used in dentistry. In this feature paper, the state-of-the-art for dental implants is given and different surface modification techniques of PEEK are discussed. The focus will lie on a covalently attached surface layer mimicking natural bone. The usage of such covalently anchored biomimetic composite materials combines many advantageous properties: A biocompatible organic matrix and a mineral component provide the cells with a surrounding close to natural bone. Bone-related cells may not recognize the implant as a foreign body and therefore, may heal and integrate faster and more firmly. Because neither metal-based nor ceramics are ideal material candidates for a dental implant, the combination of PEEK and a covalently anchored mineralized biopolymer layer may be the start of the desired evolution in dental surgery.
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Affiliation(s)
- Jennifer Knaus
- Department of Chemistry, Physical Chemistry, University of Konstanz, Universitätsstraße 10, 78457, Konstanz, Germany.,stimOS GmbH, Byk-Gulden-Straße 2, 78467, Konstanz, Germany
| | | | - Helmut Cölfen
- Department of Chemistry, Physical Chemistry, University of Konstanz, Universitätsstraße 10, 78457, Konstanz, Germany
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38
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Buck E, Li H, Cerruti M. Surface Modification Strategies to Improve the Osseointegration of Poly(etheretherketone) and Its Composites. Macromol Biosci 2019; 20:e1900271. [DOI: 10.1002/mabi.201900271] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/18/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Emily Buck
- Department of Mining and Materials EngineeringMcGill University 3610 University Street Montreal QC H3A 0C5 Canada
| | - Hao Li
- Department of Mining and Materials EngineeringMcGill University 3610 University Street Montreal QC H3A 0C5 Canada
| | - Marta Cerruti
- Department of Mining and Materials EngineeringMcGill University 3610 University Street Montreal QC H3A 0C5 Canada
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39
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Plasma treatment of polyether-ether-ketone: A means of obtaining desirable biomedical characteristics. Eur Polym J 2019. [DOI: 10.1016/j.eurpolymj.2019.06.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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40
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Xu X, Li Y, Wang L, Li Y, Pan J, Fu X, Luo Z, Sui Y, Zhang S, Wang L, Ni Y, Zhang L, Wei S. Triple-functional polyetheretherketone surface with enhanced bacteriostasis and anti-inflammatory and osseointegrative properties for implant application. Biomaterials 2019; 212:98-114. [PMID: 31112825 DOI: 10.1016/j.biomaterials.2019.05.014] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 12/14/2022]
Abstract
Polyetheretherketone (PEEK) is considered a potential orthopedic/dental material because of its excellent mechanical and chemical properties (e.g., similar elastic modulus to that of human bone). However, the poor bacteriostasis and anti-inflammatory and osseointegrative properties of bioinert PEEK impede its clinical application. We previously developed a facile and versatile surface modification method using dexamethasone plus minocycline-loaded liposomes (Dex/Mino liposomes) bonded by a mussel-inspired polydopamine coating, which effectively modulated cell inflammatory response and discouraged bacterial colonization in vitro. Herein, we report the application of this multifunctional surface modification method to improve bioinert PEEK, aimed at further studying the in vitro osteogenesis and in vivo properties of Dex/Mino liposome-modified PEEK to prevent bacterial contamination, attenuate the inflammatory response, and enhance ossification for physiologic osseointegration. Our study established that the Dex/Mino liposome-modified PEEK surface presented favorable stability and cytocompatibility. Compared with bare PEEK, improved osteogenic differentiation of human mesenchymal stem cells under both osteoinductive and osteoconductive conditions was found on the functionalized surface due to the liposomal Dex releasing. In vivo bacteriostasis assay confirmed that Mino released from the functionalized surface provided an effective antibacterial effect. Moreover, the subcutaneous foreign body reaction and beagle femur implantation models corroborated the enhanced anti-inflammatory and osteointegrative properties of the functionalized PEEK. Our findings indicate that the developed Dex/Mino liposome-modified PEEK with enhanced antibacterial, anti-inflammatory, and osseointegrative capacity has great potential as an orthopedic/dental implant material for clinical application.
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Affiliation(s)
- Xiao Xu
- Department of Oral and Maxillofacial Surgery/Central Laboratory, Peking University School and Hospital of Stomatology, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing 100081, PR China
| | - Yongliang Li
- Second Dental Center, School and Hospital of Stomatology, Peking University, Beijing 100081, PR China
| | - Lixin Wang
- Department of Stomatology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, PR China
| | - Yan Li
- Laboratory of Biomaterials and Regenerative Medicine, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, PR China
| | - Jijia Pan
- Laboratory of Biomaterials and Regenerative Medicine, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, PR China
| | - Xiaoming Fu
- Department of Oral and Maxillofacial Surgery/Central Laboratory, Peking University School and Hospital of Stomatology, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing 100081, PR China
| | - Zuyuan Luo
- Laboratory of Biomaterials and Regenerative Medicine, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, PR China
| | - Yi Sui
- Department of Oral and Maxillofacial Surgery/Central Laboratory, Peking University School and Hospital of Stomatology, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing 100081, PR China
| | - Siqi Zhang
- Laboratory of Biomaterials and Regenerative Medicine, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, PR China
| | - Liang Wang
- Department of Oral and Maxillofacial Surgery/Central Laboratory, Peking University School and Hospital of Stomatology, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing 100081, PR China
| | - Yaofeng Ni
- Department of Stomatology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, PR China
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery/Central Laboratory, Peking University School and Hospital of Stomatology, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing 100081, PR China.
| | - Shicheng Wei
- Department of Oral and Maxillofacial Surgery/Central Laboratory, Peking University School and Hospital of Stomatology, National Engineering Laboratory for Digital and Material Technology of Stomatology, Beijing Key Laboratory of Digital Stomatology, Beijing 100081, PR China; Laboratory of Biomaterials and Regenerative Medicine, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, PR China.
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Liu L, Zheng Y, Zhang Q, Yu L, Hu Z, Liu Y. Surface phosphonation treatment shows dose-dependent enhancement of the bioactivity of polyetheretherketone. RSC Adv 2019; 9:30076-30086. [PMID: 35530193 PMCID: PMC9072086 DOI: 10.1039/c9ra05229a] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 04/30/2020] [Accepted: 09/16/2019] [Indexed: 11/21/2022] Open
Abstract
Polyetheretherketone (PEEK) is a promising alternative for biomedical metallic implants in orthopedic and dental applications because its elastic modulus is similar to that of bone.
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Affiliation(s)
- Lvhua Liu
- School of Basic Medical Sciences
- North Sichuan Medical College
- Nanchong
- China
| | - Yanyan Zheng
- School of Basic Medical Sciences
- North Sichuan Medical College
- Nanchong
- China
| | - Qianyu Zhang
- Department of Stomatology
- North Sichuan Medical College and Affiliated Hospital of North Sichuan Medical College
- Nanchong
- China
| | - Lin Yu
- Department of Pharmacology
- North Sichuan Medical College
- Nanchong
- China
| | - Ziliang Hu
- Department of Preventive Medicine
- North Sichuan Medical College
- Nanchong
- China
| | - Ying Liu
- Department of Stomatology
- North Sichuan Medical College and Affiliated Hospital of North Sichuan Medical College
- Nanchong
- China
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