Construction and performance evaluation of a sustained release implant material polyetheretherketone with antibacterial properties

Strategies to improve the performance of polyetheretherketone (PEEK) as orthopedic implants: from surface modification to addition of bioactive materials

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.

Methods to improve antibacterial properties of PEEK: A review

As a thermoplastic and bioinert polymer, polyether ether ketone (PEEK) serves as spine implants, femoral stems, cranial implants, and joint arthroplasty implants due to its mechanical properties resembling the cortical bone, chemical stability, and radiolucency. Although there are standards and antibiotic treatments for infection control during and after surgery, the infection risk is lowered but can not be eliminated. The antibacterial properties of PEEK implants should be improved to provide better infection control. This review includes the strategies for enhancing the antibacterial properties of PEEK in four categories: immobilization of functional materials and functional groups, forming nanocomposites, changing surface topography, and coating with antibacterial material. The measuring methods of antibacterial properties of the current studies of PEEK are explained in detail under quantitative, qualitative, andin vivomethods. The mechanisms of bacterial inhibition by reactive oxygen species generation, contact killing, trap killing, and limited bacterial adhesion on hydrophobic surfaces are explained with corresponding antibacterial compounds or techniques. The prospective analysis of the current studies is done, and dual systems combining osteogenic and antibacterial agents immobilized on the surface of PEEK are found the promising solution for a better implant design.

Novel CAD-CAM fabrication of a custom-made ball attachment retentive housing: an in-vitro study

PURPOSE

This study aims to evaluate the digitally designed ball attachment housing in its initial retentive force and after 2 years of simulated clinical use and to compare it with the regular nylon ball attachment housing.

MATERIALS AND METHODS

Twenty implants with their corresponding ball abutments (diameter 4.5 × 4.0 mm) were inserted in resin blocks. They were divided into two groups. In Group I, ten ball abutments each received their corresponding conventional attachment with nylon rings. In Group II, ten ball abutments received the novel CAD-CAM polyetheretherketone ball attachment housing. A universal testing machine was used to measure the retention force. The achieved maximum values of retention force were recorded at the beginning of the study (initial retention) and after 2 years of artificial ageing (2000 cycles of insertion and removal). Results were statistically analyzed using an independent sample T test.

RESULTS

The PEEK attachment housing showed high retention forces (25.12 ± 0.99 N) compared to the conventional attachment with a nylon ring (15.76 ± 0.93 N) in the initial dislodgement test. There was a statistically significant difference in mean retention at the initial retention test and after 2 years of stimulated usage between the two studied groups, p = 0.000.

CONCLUSIONS

Within the limitations of this study, the novel CAD-CAM-PEEK attachment showed high retention characteristics compared to the conventional attachment with nylon rings, initially and after simulated long-term use.

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

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

Bioactive Polyetheretherketone with Gelatin Hydrogel Leads to Sustained Release of Bone Morphogenetic Protein-2 and Promotes Osteogenic Differentiation

Polyetheretherketone (PEEK) is one of the most promising implant materials for hard tissues due to its similar elastic modulus; however, usage of PEEK is still limited owing to its biological inertness and low osteoconductivity. The objective of the study was to provide PEEK with the ability to sustain the release of growth factors and the osteogenic differentiation of stem cells. The PEEK surface was sandblasted and modified with polydopamine (PDA). Moreover, successful sandblasting and PDA modification of the PEEK surface was confirmed through physicochemical characterization. The gelatin hydrogel was then chemically bound to the PEEK by adding a solution of glutaraldehyde and gelatin to the surface of the PDA-modified PEEK. The binding and degradation of the gelatin hydrogel with PEEK (GPEEK) were confirmed, and the GPEEK mineralization was observed in simulated body fluid. Sustained release of bone morphogenetic protein (BMP)-2 was observed in GPEEK. When cultured on GPEEK with BMP-2, human mesenchymal stem cells (hMSCs) exhibited osteogenic differentiation. We conclude that PEEK with a gelatin hydrogel incorporating BMP-2 is a promising substrate for bone tissue engineering.

Research progress and future prospects of antimicrobial modified polyetheretherketone (PEEK) for the treatment of bone infections

Infection of the bone is a difficult problem in orthopedic diseases. The key and basis of the treatment of bone infection is the effective control of local infection, as well as the elimination of infection focus and dead cavities. The most commonly used approach utilized for the prevention and management of bone infection is the application of antibiotic bone cement. However, the incorporation of antibiotics into the cement matrix has been found to considerably compromise the mechanical characteristics of bone cement. Moreover, some investigations have indicated that the antibiotic release rate of antibiotic bone cement is relatively low. Polyetheretherketone (PEEK) and its composites have been considered to perfectly address the challenges above, according to its favorable biomechanical characteristics and diverse surface functionalizations. This article provides a comprehensive overview of the recent advancements in the antimicrobial modification of PEEK composites in the field of antibacterial therapy of bone infection. Furthermore, the potential application of PEEK-modified materials in clinical treatment was discussed and predicted.

Recent advances on nanomaterials for antibacterial treatment of oral diseases

An imbalance of bacteria in oral environment can lead to a variety of oral diseases, such as periodontal disease, dental caries, and peri-implant inflammation. In the long term, in view of the increasing bacterial resistance, finding suitable alternatives to traditional antibacterial methods is an important research today. With the development of nanotechnology, antibacterial agents based on nanomaterials have attracted much attention in dental field due to their low cost, stable structures, excellent antibacterial properties and broad antibacterial spectrum. Multifunctional nanomaterials can break through the limitations of single therapy and have the functions of remineralization and osteogenesis on the basis of antibacterial, which has made significant progress in the long-term prevention and treatment of oral diseases. In this review, we have summarized the applications of metal and their oxides, organic and composite nanomaterials in oral field in recent five years. These nanomaterials can not only inactivate oral bacteria, but also achieve more efficient treatment and prevention of oral diseases by improving the properties of the materials themselves, enhancing the precision of targeted delivery of drugs and imparting richer functions. Finally, future challenges and untapped potential are elaborated to demonstrate the future prospects of antibacterial nanomaterials in oral field.

Surface Treatments of PEEK for Osseointegration to Bone

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.

Regulation of Staphylococcus aureus Virulence and Application of Nanotherapeutics to Eradicate S. aureus Infection

Staphylococcus aureus is a versatile pathogen known to cause hospital- and community-acquired, foodborne, and zoonotic infections. The clinical infections by S. aureus cause an increase in morbidity and mortality rates and treatment costs, aggravated by the emergence of drug-resistant strains. As a multi-faceted pathogen, it is imperative to consolidate the knowledge on its pathogenesis, including the mechanisms of virulence regulation, development of antimicrobial resistance, and biofilm formation, to make it amenable to different treatment strategies. Nanomaterials provide a suitable platform to address this challenge, with the potential to control intracellular parasitism and multidrug resistance where conventional therapies show limited efficacy. In a nutshell, the first part of this review focuses on the impact of S. aureus on human health and the role of virulence factors and biofilms during pathogenesis. The second part discusses the large diversity of nanoparticles and their applications in controlling S. aureus infections, including combination with antibiotics and phytochemicals and the incorporation of antimicrobial coatings for biomaterials. Finally, the limitations and prospects using nanomaterials are highlighted, aiming to foster the development of novel nanotechnology-driven therapies against multidrug-resistant S. aureus.

Multifunctionalized carbon-fiber-reinforced polyetheretherketone implant for rapid osseointegration under infected environment

Carbon fiber reinforced polyetheretherketone (CFRPEEK) possesses a similar elastic modulus to that of human cortical bone and is considered as a promising candidate to replace metallic implants. However, the bioinertness and deficiency of antibacterial activities impede its application in orthopedic and dentistry. In this work, titanium plasma immersion ion implantation (Ti-PIII) is applied to modify CFRPEEK, achieving unique multi-hierarchical nanostructures and active sites on the surface. Then, hybrid polydopamine (PDA)@ZnO-EDN1 nanoparticles (NPs) are introduced to construct versatile surfaces with improved osteogenic and angiogenic properties and excellent antibacterial properties. Our study established that the modified CFRPEEK presented favorable stability and cytocompatibility. Compared with bare CFRPEEK, improved osteogenic differentiation of rat mesenchymal stem cells (BMSCs) and vascularization of human umbilical vein endothelial cells (HUVECs) are found on the functionalized surface due to the zinc ions and EDN1 releasing. In vitro bacteriostasis assay confirms that hybrid PDA@ZnO NPs on the functionalized surface provided an effective antibacterial effect. Moreover, the rat infected model corroborates the enhanced antibiosis and osteointegration of the functionalized CFRPEEK. Our findings indicate that the multilevel nanostructured PDA@ZnO-EDN1 coated CFRPEEK with enhanced antibacterial, angiogenic, and osteogenic capacity has great potential as an orthopedic/dental implant material for clinical application.

Decorated Polyetheretherketone Implants with Antibacterial and Antioxidative Effects through Layer-by-Layer Nanoarchitectonics Facilitate Diabetic Bone Integration with Infection

Patients suffering diabetic bone defects still need some new and effective strategies to achieve enhanced prognostic effects. Although medical implants are the common treatment of bone defects, the excessive oxidative stress and high risk of bacterial infection in diabetes mellitus lead to a higher risk of implant failure. To improve the healing ability of diabetic bone defects, herein, polyetheretherketone (PEEK) was modified through a developed layer-by-layer (LBL) construction strategy to obtain multifunctional PEEK (SP@(TA-GS/PF)*3) by the assembly of tannic acid (TA), gentamicin sulfate (GS) and Pluronic F127 (PF127) on the basis of prepared porous PEEK through sulfonation (SPEEK). The prepared SP@(TA-GS/PF)*3 exhibited sustained antimicrobial activity and enhanced the differentiation of osteoblast (MC3T3-E1) for needed osteogenesis. Moreover, SP@(TA-GS/PF)*3 scavenged excessive oxidative stress to promote the growth of H₂O₂ damaged HUVEC with enhanced secretion of VEGF for neovascularization. In addition, the remarkable in vivo outcomes of angiogenesis and osseointegration were revealed by the subcutaneous implant model and bone tissue implant model in diabetic rats, respectively. The in vitro and in vivo results demonstrated that modified PEEK with multifunction can be an attractive tool for enhancing bone integration under diabetic conditions, underpinning the clinical application potential of modified implants for diabetic osseointegration.

Treatment methods toward improving the anti-infection ability of poly(etheretherketone) implants for medical applications

Due to its favorable chemical stability, biocompatibility, and mechanical properties, Poly(etheretherketone) (PEEK) is a promising material for repairing bone and dental hard tissue defects. However, there are critical disadvantages: PEEK is biologically and chemically inert, which influences osseointegration of implants and bonding strength of prostheses, and its mechanical properties still cannot meet the requirements for some medical applications. Furthermore, bacterial infections and inflammatory reactions often accompany bone defects caused by trauma or inflammation or teeth loss caused by periodontitis. Previous studies mainly focused on enhancing PEEK's bioactivity and mechanical performance, but PEEK also lacks effective anti-infection ability. Thus, it is necessary to improve its anti-infection ability, and this is considered in this paper from two aspects. The first is to inhibit the attachment and growth of bacteria on the material, and the second is to endow the material with immunoregulatory ability, which means mobilizing the host immune system to protect tissue from inflammation. In this review, we analyze and discuss the existing treatment methods to improve the antibacterial and immunomodulatory abilities of PEEK addressing their limitations, relevant future challenges, and required research efforts.

Application of biomolecules modification strategies on PEEK and its composites for osteogenesis and antibacterial properties

As orthopedic and dental implants, polyetheretherketone (PEEK) is expected to be a common substitute material of titanium (Ti) and its alloys due to its good biocompatibility, chemical stability, and elastic modulus close to that of bone tissue. It could avoid metal allergy and bone resorption caused by the stress shielding effect of Ti implants, widely studied in the medical field. However, the lack of biological activity is not conducive to the clinical application of PEEK implants. Therefore, the surface modification of PEEK has increasingly become one of the research hotspots. Researchers have explored various biomolecules modification methods to effectively enhance the osteogenic and antibacterial activities of PEEK and its composites. Therefore, this review mainly summarizes the recent research of PEEK modified by biomolecules and discusses the further research directions to promote the clinical transformation of PEEK implants.

Approaches to Biofunctionalize Polyetheretherketone for Antibacterial: A Review

Due to excellent mechanical properties and similar elastic modulus compared with human cortical bone, polyetheretherketone (PEEK) has become one of the most promising orthopedic implant materials. However, implant-associated infections (IAIs) remain a challenging issue since PEEK is bio-inert. In order to fabricate an antibacterial bio-functional surface, modifications of PEEK had been widely investigated. This review summarizes the modification strategies to biofunctionalize PEEK for antibacterial. We will begin with reviewing different approaches, such as surface-coating modifications and controlled release of antimicrobials. Furthermore, blending modifications and 3D printing technology were discussed. Finally, we compare the effects among different approaches. We aimed to provide an in-depth understanding of the antibacterial modification and optimize the design of the PEEK orthopedic implant.