Mechanical properties and in vitro biological response to porous titanium alloys prepared for use in intervertebral implants

Design and performance analysis of 3D-printed stiffness gradient femoral scaffold

Studies on 3D-printed porous bone scaffolds mostly focus on materials or structural parameters, while the repair of large femoral defects needs to select appropriate structural parameters according to the needs of different parts. In this paper, a kind of stiffness gradient scaffold design idea is proposed. Different structures are selected according to the different functions of different parts of the scaffold. At the same time, an integrated fixation device is designed to fix the scaffold. Finite element method was used to analyze the stress and strain of homogeneous scaffolds and the stiffness gradient scaffolds, and the relative displacement and stress between stiffness gradient scaffolds and bone in the case of integrated fixation and steel plate fixation. The results showed that the stress distribution of the stiffness gradient scaffolds was more uniform, and the strain of host bone tissue was changed greatly, which was beneficial to the growth of bone tissue. The integrated fixation method is more stable, less stress and evenly distributed. Therefore, the integrated fixation device combined with the design of stiffness gradient can repair the large femoral bone defect well.

Impact of surface roughness and bulk porosity on spinal interbody implants

Spinal fusion surgeries are performed to treat a multitude of cervical and lumbar diseases that lead to pain and disability. Spinal interbody fusion involves inserting a cage between the spinal vertebrae, and is often utilized for indirect neurologic decompression, correction of spinal alignment, anterior column stability, and increased fusion rate. The long-term success of interbody fusion relies on complete osseointegration between the implant surface and vertebral end plates. Titanium (Ti)-based alloys and polyetheretherketone (PEEK) interbody cages represent the most commonly utilized materials and provide sufficient mechanics and biocompatibility to assist in fusion. However, modification to the surface and bulk characteristics of these materials has been shown to maximize osseointegration and long-term stability. Specifically, the introduction of intrinsic porosity and surface roughness has been shown to affect spinal interbody mechanics, vascularization, osteoblast attachment, and ingrowth potential. This narrative review synthesizes the mechanical, in vitro, in vivo, and clinical effects on fusion efficacy associated with introduction of porosity in Ti (neat and alloy) and PEEK intervertebral implants.

Biomechanical analysis of customized cage conforming to the endplate morphology in anterior cervical discectomy fusion: A finite element analysis

In anterior cervical discectomy and fusion (ACDF), an interbody fusion device is an essential implant. An unsuitable interbody fusion device can cause postoperative complications, including subsidence and nonunion. We designed a customized intervertebral fusion device to reduce postoperative complications and validated it by finite element analysis. Herein, we built a non-homogeneous model of the C3-7 cervical spine. Three implant models (customized cage, commercial cage, and bone graft cage) were constructed and placed in the C45 cervical segment after ACDF surgery. The simulated range of motion (ROM), stress at the cage-bone interface, and stress on the cage and implants were compared under different conditions. The commercial cage showed maximum stress peaks at 40.3 MPa and 43.2 MPa in the inferior endplate of C4 and superior endplate of C5 under rotational conditions, higher compared to 29.7 MPa and 26.4 MPa, respectively, in the customized cage. The ROM was not significantly different between the three cages placed after ACDF. The stresses on the commercial cage were higher compared to the other two cages under all conditions. The bone graft in the customized cage was subject to higher stress than the commercial cage under all conditions, particularly lateral bending, wherein the maximum stress was 5.5 MPa. These results showed that a customized cage that better conformed to the vertebral anatomy was promising for reducing the risk of stress shielding and the occurrence of subsidence.

Use of Porous Titanium Trabecular as a Bone Defect Regenerator: In Vivo Study

The application of porous materials is increasingly being used in orthopaedic surgery due to its good results. Bone growth within the pores results in excellent mechanical fixation with the bone, as well as good bone regeneration. The pores, in addition to being colonised by bone, produce a decrease in the modulus of elasticity that favours the transfer of loads to the bone. This research shows the results of an experimental study where we have created critical osteoperiosteal defects of 10 mm on rabbit’s radius diaphysis. In one group of 10 rabbits (experimental group) we have implanted a bioactive porous titanium cylinder, and in another group we have allowed spontaneous regeneration (control group). Mechanical tests were performed to assess the material. Image diagnostic techniques (X-ray, scanner and 3D scan: there are no references on the literature with the use of CT-scan in bone defects) and histological and histomorphometric studies post-op and after 3, 6 and 12 months after the surgery were performed. All the control cases went through a pseudoarthrosis. In 9 of the 10 cases of the experimental group complete regeneration was observed, with a normal cortical-marrow structure established at 6 months, similar to normal bone. Titanium trabecular reached a bone percentage of bone inside the implant of 49.3% on its surface 3 months post-op, 75.6% at 6 months and 81.3% at 12 months. This porous titanium biomaterial has appropriate characteristics to allow bone ingrowth, and it can be proposed as a bone graft substitute to regenerate bone defects, as a scaffold, or as a coating to achieve implant osteointegration.

On-Growth and In-Growth Osseointegration Enhancement in PM Porous Ti-Scaffolds by Two Different Bioactivation Strategies: Alkali Thermochemical Treatment and RGD Peptide Coating

A lack of primary stability and osteointegration in metallic implants may result in implant loosening and failure. Adding porosity to metallic implants reduces the stress shielding effect and improves implant performance, allowing the surrounding bone tissue to grow into the scaffold. However, a bioactive surface is needed to stimulate implant osteointegration and improve mechanical stability. In this study, porous titanium implants were produced via powder sintering to create different porous diameters and open interconnectivity. Two strategies were used to generate a bioactive surface on the metallic foams: (1) an inorganic alkali thermochemical treatment, (2) grafting a cell adhesive tripeptide (RGD). RGD peptides exhibit an affinity for integrins expressed by osteoblasts, and have been reported to improve osteoblast adhesion, whereas the thermochemical treatment is known to improve titanium implant osseointegration upon implantation. Bioactivated scaffolds and control samples were implanted into the tibiae of rabbits to analyze the effect of these two strategies in vivo regarding bone tissue regeneration through interconnected porosity. Histomorphometric evaluation was performed at 4 and 12 weeks after implantation. Bone-to-implant contact (BIC) and bone in-growth and on-growth were evaluated in different regions of interest (ROIs) inside and outside the implant. The results of this study show that after a long-term postoperative period, the RGD-coated samples presented higher quantification values of quantified newly formed bone tissue in the implant's outer area. However, the total analyzed bone in-growth was observed to be slightly greater in the scaffolds treated with alkali thermochemical treatment. These results suggest that both strategies contribute to enhancing porous metallic implant stability and osteointegration, and a combination of both strategies might be worth pursuing.

A case report on a IV-degree thermal crush injury of right upper arm：The application of functional prosthesis implantation technology

Severe IV-degree thermal crush injury of limbs involved the subcutaneous fascia, muscle and bone, which may lead to amputation and has a great impact on the patient's quality of life. We can repair wounds with pedicle flaps or even free flaps, However, there are still huge challenges in bone defect of extremities and functional reconstruction. In recent years, with the development of functional prostheses, we have reconstructed limb functions in many patients helping them to complete their daily lives. We report a case where the right upper arm was injured by thermal crush, leading severe burns to the skin, fascia, muscle and bone. We applied a pedicled latissimus dorsi flap and a free anterolateral thigh flap to repair the wound, and realized the function of limb salvage and movement of the right upper arm by implanting 3D printed scapula, upper arm and elbow joint prostheses. This case illustrates that IV-degree burns involving bones have new technologies to repair and achieve mobility now.

Investigation of the influence of TiO2distribution on HA/TiO2composite wetting ability using the dispersant SDBS, high-temperature annealing, and ultrasonication

The use of composites such as hydroxyapatite (HA)/TiO₂in bioapplications has attracted increasing attention in recent years. Herein, for the enhancement wetting ability and biocompatibility, the HA/TiO₂composite was subjected to different treatments to improve nanoparticle (NP) distribution and surface energy with an aim of mitigating nanotoxicity concerns. The treatments included ultrasonication, high-temperature annealing, and addition of a dispersant and surfactant, sodium dodecylbenzenesulfonate (SDBS). Contact angle measurement tests revealed the effect of SDBS addition on the distribution of TiO₂NPs on the HA surface: a decrease in the contact angle and, thus, an increase in the wetting ability of the HA/TiO₂composite were observed. The combination of annealing and SDBS addition treatments allowed for guest TiO₂particles to be uniformly distributed on the surface of the host HA particles, showing a rapid conversion from a hydrophobic to superhydrophilic property.In vitroinvestigation suggested that the cell viabilities of annealed HA/TiO₂, SDBS-added HA/TiO₂, and SDBS-added and annealed HA/TiO₂reached 89.7%, 94.7%, and 95.8%, respectively, while those of HA and untreated HA/TiO₂were 80.3% and 86.9%, respectively. The modified composites exhibited lower cytotoxicities than the unmodified systems (HA and HA/TiO₂). Furthermore, the cell adhesion behavior of the composites was confirmed through actin-4',6-Diamidino-2-phenylindole (DAPI) staining, which showed negligible changes in the cytoskeleton architecture of the cells. This study confirmed that a modified HA/TiO₂composite has potential for bioapplications.

Mineralization of Titanium Surfaces: Biomimetic Implants

The surface modification by the formation of apatitic compounds, such as hydroxyapatite, improves biological fixation implants at an early stage after implantation. The structure, which is identical to mineral content of human bone, has the potential to be osteoinductive and/or osteoconductive materials. These calcium phosphates provoke the action of the cell signals that interact with the surface after implantation in order to quickly regenerate bone in contact with dental implants with mineral coating. A new generation of calcium phosphate coatings applied on the titanium surfaces of dental implants using laser, plasma-sprayed, laser-ablation, or electrochemical deposition processes produces that response. However, these modifications produce failures and bad responses in long-term behavior. Calcium phosphates films result in heterogeneous degradation due to the lack of crystallinity of the phosphates with a fast dissolution; conversely, the film presents cracks, which produce fractures in the coating. New thermochemical treatments have been developed to obtain biomimetic surfaces with calcium phosphate compounds that overcome the aforementioned problems. Among them, the chemical modification using biomineralization treatments has been extended to other materials, including composites, bioceramics, biopolymers, peptides, organic molecules, and other metallic materials, showing the potential for growing a calcium phosphate layer under biomimetic conditions.

Exploring Macroporosity of Additively Manufactured Titanium Metamaterials for Bone Regeneration with Quality by Design: A Systematic Literature Review

Additive manufacturing facilitates the design of porous metal implants with detailed internal architecture. A rationally designed porous structure can provide to biocompatible titanium alloys biomimetic mechanical and biological properties for bone regeneration. However, increased porosity results in decreased material strength. The porosity and pore sizes that are ideal for porous implants are still controversial in the literature, complicating the justification of a design decision. Recently, metallic porous biomaterials have been proposed for load-bearing applications beyond surface coatings. This recent science lacks standards, but the Quality by Design (QbD) system can assist the design process in a systematic way. This study used the QbD system to explore the Quality Target Product Profile and Ideal Quality Attributes of additively manufactured titanium porous scaffolds for bone regeneration with a biomimetic approach. For this purpose, a total of 807 experimental results extracted from 50 different studies were benchmarked against proposed target values based on bone properties, governmental regulations, and scientific research relevant to bone implants. The scaffold properties such as unit cell geometry, pore size, porosity, compressive strength, and fatigue strength were studied. The results of this study may help future research to effectively direct the design process under the QbD system.

Porous fusion cage design via integrated global-local topology optimization and biomechanical analysis of performance

Porous fusion cage is considered as a satisfactory substitute for solid fusion cage in transforaminal lumbar interbody fusion (TLIF) surgery due to its interconnectivity for bone ingrowth and appropriate stiffness reducing the risk of cage subsidence and stress shielding. This study presents an integrated global-local topology optimization approach to obtain porous titanium (Ti) fusion cage with desired biomechanical properties. Local topology optimizations are first conducted to obtain unit cells, and the numerical homogenization method is used to quantified the mechanical properties of unit cells. The preferred porous structure is then fabricated using selective laser melting, and its mechanical property is further verified via compression tests and numerical simulation. Afterward, global topology optimization is used for the global layout. The porous fusion cage obtained by the Boolean intersection between global structural layout and the porous structure decreases the solid volume of the cage by 9% for packing more bone grafts while achieving the same stiffness to conventional porous fusion cage. To eliminate stress concentration in the thin-wall structure, framework structures are constructed on the porous fusion cage. Although the alleviation of cage subsidence and stress shielding is decelerated, peak stress on the cage is significantly decreased, and more even stress distribution is demonstrated in the reinforced porous fusion cage. It promises long-term integrity and functions of the fusion cage. Overall, the reinforced porous fusion cage achieves a favorable mechanical performance and is a promising candidate for fusion surgery. The proposed optimization approach is promising for fusion cage design and can be extended to other orthopedic implant designs.

In Vitro Bone Cell Behavior on Porous Titanium Samples: Influence of Porosity by Loose Sintering and Space Holder Techniques

A great variety of powder metallurgy techniques can produce biomimetic porous titanium structures with similar mechanical properties to host bone tissue. In this work, loose sintering and space holder techniques, two frequently used metallurgical techniques, are compared to evaluate the influences of porosity (content, size, morphology and wall roughness), mechanical properties (stiffness and yield strength) and in-vitro cellular responses (adhesion and proliferation of myoblasts and osteoblasts). These comparisons are made to achieve the best balance between biomechanical and bifunctional behavior of a partial porous implant for cortical bone replacement. Cell adhesion (filopodia presence) and spreading were promoted on both porous surfaces and fully dense substrates (non-porous control surfaces). Porous scaffold samples designed using 50 vol.% NaCl space holder technique had an improved bioactive response over those obtained with the loose sintering technique due to higher roughness and scaffold pore diameter. However, the presence of large and heterogeneous pores compromises the mechanical reliability of the implant. Considering both scenarios, the substrates obtained with 40 vol.% NH4HCO3 and pore size ranges between 100 and 200 μm provide a balanced optimization of size and strength to promote in-vitro osseointegration.

Improved Bioactivity of 3D Printed Porous Titanium Alloy Scaffold with Chitosan/Magnesium-Calcium Silicate Composite for Orthopaedic Applications

Recently, cases of bone defects have been increasing incrementally. Thus, repair or replacement of bone defects is gradually becoming a huge problem for orthopaedic surgeons. Three-dimensional (3D) scaffolds have since emerged as a potential candidate for bone replacement, of which titanium (Ti) alloys are one of the most promising candidates among the metal alloys due to their low cytotoxicity and mechanical properties. However, bioactivity remains a problem for metal alloys, which can be enhanced using simple immersion techniques to coat bioactive compounds onto the surface of Ti⁻6Al⁻4V scaffolds. In our study, we fabricated magnesium-calcium silicate (Mg⁻CS) and chitosan (CH) compounds onto Ti⁻6Al⁻4V scaffolds. Characterization of these surface-modified scaffolds involved an assessment of physicochemical properties as well as mechanical testing. Adhesion, proliferation, and growth of human Wharton's Jelly mesenchymal stem cells (WJMSCs) were assessed in vitro. In addition, the cell attachment morphology was examined using scanning electron microscopy to assess adhesion qualities. Osteogenic and mineralization assays were conducted to assess osteogenic expression. In conclusion, the Mg⁻CS/CH coated Ti⁻6Al⁻4V scaffolds were able to exhibit and retain pore sizes and their original morphologies and architectures, which significantly affected subsequent hard tissue regeneration. In addition, the surface was shown to be hydrophilic after modification and showed mechanical strength comparable to natural bone. Not only were our modified scaffolds able to match the mechanical properties of natural bone, it was also found that such modifications enhanced cellular behavior such as adhesion, proliferation, and differentiation, which led to enhanced osteogenesis and mineralization downstream. In vivo results indicated that Mg⁻CS/CH coated Ti⁻6Al⁻4V enhances the bone regeneration and ingrowth at the critical size bone defects of rabbits. These results indicated that the proposed Mg⁻CS/CH coated Ti⁻6Al⁻4V scaffolds exhibited a favorable, inducive micro-environment that could serve as a promising modification for future bone tissue engineering scaffolds.

In vitro and in vivo evaluations of mechanical properties, biocompatibility and osteogenic ability of sintered porous titanium alloy implant

A new sintering technique using Ti6Al4V powder suspension was performed to prepare porous Ti6Al4V alloys. The porous alloys could be fabricated with different porosities and pore sizes by controlling the quantity and size of spacer particles added to the Ti6Al4V powder. The characteristics and biological properties of the porous Ti6Al4V with two different porosities were evaluated by mechanical tests, cell tests and implantation. Dense Ti6Al4V was used as the control. Compared with the control group, the porous Ti6Al4V showed good biocompatibility and osteogenic ability, which makes this type of porous alloy a good prospective material for biomedical application. And compared with 50% porosity, the alloy with 75% porosity had the optimal mechanical properties, and suitable pore size and porosity, which allowed more bone ingrowth.

Enhanced bone healing in porous Ti implanted rabbit combining bioactive modification and mechanical stimulation

To improve the bone healing efficiency of porous titanium implants, desired biological properties of implants are mandatory, involving bioactivity, osteoconductivity, osteoinductivity and a stable environment. In this study, bare porous titanium (abbr. pTi) with the porosity of 70% was fabricated by vacuum diffusion bonding of titanium meshes. Hydroxyapatite-coated pTi (abbr. Hap-pTi) was obtained by successively subjecting pTi to alkali heat treatment, pre-calcification and simulated body fluid. Both pTi and Hap-pTi were respectively implanted into the tibia defect model (ϕ10 mm × 6 mm) in New Zealand white rabbits, then subjected to non-invasively axial compressive loads at high-magnitude low-frequency (HMLF), which were denoted as F-pTi and F-Hap-pTi, respectively. Bone repairing efficiencies were analyzed by postoperative X-ray examination, optical observation and HE staining after 14 and 30 days of implantation. ALP and OCN contents in serum were also examined at 30 days. Results showed that the sham group and sham group with mechanical stimulation (abbr. F-sham) preferably caused bone fractures. Qualitatively, Hap-pTi reduced the risk of bone fractures and enhanced bone healing slightly more effectively compared to bared pTi. However, both Hap-pTi combined with mechanical stimulation and F-pTi in the case of bioactive modification could result in a higher bone healing efficiency (F-Hap-pTi). The molecular signaling investigation of ALP and OCN contents in serum further revealed a probable synergistic effect of Hap coating coupling with HMLF compression on improving bone repairing efficiency. It provides a candidate of clinically applicable therapy for osseous defects.

Laser beam melting 3D printing of Ti6Al4V based porous structured dental implants: fabrication, biocompatibility analysis and photoelastic study

Fabricating Ti alloy based dental implants with defined porous scaffold structure is a promising strategy for improving the osteoinduction of implants. In this study, we use Laser Beam Melting (LBM) 3D printing technique to fabricate porous Ti6Al4V dental implant prototypes with three controlled pore sizes (200, 350 and 500 μm). The mechanical stress distribution in the surrounding bone tissue is characterized by photoelastography and associated finite element simulation. For in-vitro studies, experiments on implants’ biocompatibility and osteogenic capability are conducted to evaluate the cellular response correlated to the porous structure. As the preliminary results, porous structured implants show a lower stress-shielding to the surrounding bone at the implant neck and a more densed distribution at the bottom site compared to the reference implant. From the cell proliferation tests and the immunofluorescence images, 350 and 500 μm pore sized implants demonstrate a better biocompatibility in terms of cell growth, migration and adhesion. Osteogenic genes expression of the 350 μm group is significantly increased alone with the ALP activity test. All these suggest that a pore size of 350 μm provides an optimal provides an optimal potential for improving the mechanical shielding to the surrounding bones and osteoinduction of the implant itself.

Additively Manufactured Scaffolds for Bone Tissue Engineering and the Prediction of their Mechanical Behavior: A Review

Additive manufacturing (AM), nowadays commonly known as 3D printing, is a revolutionary materials processing technology, particularly suitable for the production of low-volume parts with high shape complexities and often with multiple functions. As such, it holds great promise for the fabrication of patient-specific implants. In recent years, remarkable progress has been made in implementing AM in the bio-fabrication field. This paper presents an overview on the state-of-the-art AM technology for bone tissue engineering (BTE) scaffolds, with a particular focus on the AM scaffolds made of metallic biomaterials. It starts with a brief description of architecture design strategies to meet the biological and mechanical property requirements of scaffolds. Then, it summarizes the working principles, advantages and limitations of each of AM methods suitable for creating porous structures and manufacturing scaffolds from powdered materials. It elaborates on the finite-element (FE) analysis applied to predict the mechanical behavior of AM scaffolds, as well as the effect of the architectural design of porous structure on its mechanical properties. The review ends up with the authors’ view on the current challenges and further research directions.

Titanium wire implants with nanotube arrays: A study model for localized cancer treatment

Adverse complications associated with systemic administration of anti-cancer drugs are a major problem in cancer therapy in current clinical practice. To increase effectiveness and reduce side effects, localized drug delivery to tumour sites requiring therapy is essential. Direct delivery of potent anti-cancer drugs locally to the cancer site based on nanotechnology has been recognised as a promising alternative approach. Previously, we reported the design and fabrication of nano-engineered 3D titanium wire based implants with titania (TiO2) nanotube arrays (Ti-TNTs) for applications such as bone integration by using in-vitro culture systems. The aim of present study is to demonstrate the feasibility of using such Ti-TNTs loaded with anti-cancer agent for localized cancer therapy using pre-clinical cancer models and to test local drug delivery efficiency and anti-tumour efficacy within the tumour environment. TNF-related apoptosis-inducing ligand (TRAIL) which has proven anti-cancer properties was selected as the model drug for therapeutic delivery by Ti-TNTs. Our in-vitro 2D and 3D cell culture studies demonstrated a significant decrease in breast cancer cell viability upon incubation with TRAIL loaded Ti-TNT implants (TRAIL-TNTs). Subcutaneous tumour xenografts were established to test TRAIL-TNTs implant performance in the tumour environment by monitoring the changes in tumour burden over a selected time course. TRAIL-TNTs showed a significant regression in tumour burden within the first three days of implant insertion at the tumour site. Based on current experimental findings these Ti-TNTs wire implants have shown promising capacity to load and deliver anti-cancer agents maintaining their efficacy for cancer treatment.

Porous titanium and Ti-35Nb alloy: effects on gene expression of osteoblastic cells derived from human alveolar bone

Tests on titanium alloys that possess low elastic modulus, corrosion resistance and minimal potential toxicity are ongoing. This study aimed to evaluate the behavior of human osteoblastic cells cultured on dense and porous Titanium (Ti) samples comparing to dense and porous Ti-35 Niobium (Ti-35Nb) samples, using gene expression analysis. Scanning electronic microscopy confirmed surface porosity and pore interconnectivity and X-ray diffraction showed titanium beta-phase stabilization in Ti-35Nb alloy. There were no differences in expression of transforming growth factor-β, integrin-β1, alkaline phosphatase, osteopontin, macrophage colony stimulating factor, prostaglandin E synthase, and apolipoprotein E regarding the type of alloy, porosity and experimental period. The experimental period was a significant factor for the markers: bone sialoprotein II and interleukin 6, with expression increasing over time. Porosity diminished Runt-related transcription factor-2 (Runx-2) expression. Cells adhering to the Ti-35Nb alloy showed statistically similar expression to those adhering to commercially pure Ti grade II, for all the markers tested. In conclusion, the molecular mechanisms of interaction between human osteoblasts and the Ti-35Nb alloy follow the principal routes of osseointegration of commercially pure Ti grade II. Porosity impaired the route of transcription factor Runx-2.