Development of a new biodegradable operative clip made of a magnesium alloy: Evaluation of its safety and tolerability for canine cholecystectomy

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

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

Study on Mechanical Properties and Degradation Behavior of Magnesium Alloy Vascular Clip

The Mg alloy vascular clip has biodegradability and good biocompatibility, which can improve the convenience and safety of clinical application. However, the Mg alloy vascular clip also has some disadvantages, such as an unreasonable structure design and a degradation rate which is too fast. In this study, the process of clamping blood vessels with a biodegradable Mg alloy (Mg-Zn-Nd-Zr and Mg-Zn-Nd) general V-type vascular clip was simulated by finite element simulation software (Abaqus). A new type of vascular clip, the P-type vascular clip, was analyzed and investigated through simulation. The differences between Mg alloy vascular clips of V-type and P-type were analyzed by finite element simulation. In addition, the effects of Zr element on the mechanical properties and corrosion resistance of P-type vascular clips were also investigated to improve the mechanical stability. The results show that during the V-type vascular clip closure of Mg-Zn-Nd-Zr alloy, this clip has some problems, such as uneven distribution of blood vessel stress, crevices in blood vessels and stress concentration. The improved P-type vascular clip has uniform closure, and there is no gap in the blood vessel, which can effectively avoid stress concentration. The improved P-type vascular clip is well closed and can effectively avoid stress concentration. The corrosion resistance of the Mg-Zn-Nd-Zr alloy P-type clip was better than that of the Mg-Zn-Nd alloy P-type clip (degradation rate of 2.02 mm/y and 2.61 mm/y on the 7th day, respectively). Mg-Zn-Nd-Zr alloy The P-type vascular clip remained closed even on the 7th day, which could meet the requirements of clinical application.

Bioabsorbable zinc alloys for use in urological surgery

PURPOSE

Non-absorbable clips are widely used in urologic surgery and they may come in contact with an open urinary tract intraoperatively. As a result, stray clips in the urinary tract and associated intractable infections have been reported. We developed a bioabsorbable metal and evaluated whether it would dissolve if it strayed into the urinary tract.

METHODS

We prepared four types of alloys mainly comprising zinc (Zn) with small amounts of magnesium (Mg) and strontium (Sr), and the biological effects, degradability, strength, and ductility were investigated. Each alloy was implanted in the bladder of five rats for 4, 8, and 12 weeks. The alloys were removed and evaluated for degradability, stone adhesion, and tissue changes. The Zn-Mg-Sr alloy had degradability and no stone adhesion in the rat experiments, and it was implanted in the bladders of five pigs for 24 weeks. The Mg and Zn levels in the blood were measured, and staple changes were confirmed by cystoscopy.

RESULTS

Zn-Mg-Sr alloys showed the best degradability of 6.51% at 12 weeks. In pig experiments, the degradation rate was 3.72% at 24 weeks. None of the pigs had changes in the Zn or Mg concentrations in the blood. Overall, the bladder incision was healed and the gross pathology showed wound healing.

CONCLUSIONS

The Zn-Mg-Sr alloys were safely used in animal experiments. Furthermore, the alloys are easy to process and can be formed into various shapes, such as staples, making them useful in robotic surgery.

Zinc-nutrient element based alloys for absorbable wound closure devices fabrication: Current status, challenges, and future prospects

The need for the development of load-bearing, absorbable wound closure devices is driving the research for novel materials that possess both good biodegradability and superior mechanical characteristics. Biodegradable metals (BMs), namely: magnesium (Mg), zinc (Zn) and iron (Fe), which are currently being investigated for absorbable vascular stent and orthopaedic implant applications, are slowly gaining research interest for the fabrication of wound closure devices. The current review presents an overview of the traditional and novel BM-based intracutaneous and transcutaneous wound closure devices, and identifies Zn as a promising substitute for the traditional materials used in the fabrication of absorbable load-bearing sutures, internal staples, and subcuticular staples. In order to further strengthen Zn to be used in highly stressed situations, nutrient elements (NEs), including calcium (Ca), Mg, Fe, and copper (Cu), are identified as promising alloying elements for the strengthening of Zn-based wound closure device material that simultaneously provide potential therapeutic benefit to the wound healing process during implant biodegradation process. The influence of NEs on the fundamental characteristics of biodegradable Zn are reviewed and critically assessed with regard to the mechanical properties and biodegradability requirements of different wound closure devices. The opportunities and challenges in the development of Zn-based wound closure device materials are presented to inspire future research on this rapidly growing field.

Corrosion and biocompatibility behaviours of microarc oxidation/phytic acid coated magnesium alloy clips for use in cholecystectomy in a rabbit model

With the popularisation of laparoscopic cholecystectomy, ligation clips have been commonly used for ligating the cystic duct and cystic artery. However, non-degradable clips remain in the body long-term, which significantly increases the risk of the clip becoming detached. Thus, magnesium alloys have attracted tremendous attention owing to their biodegradability and good biocompatibility. However, the poor corrosion resistance hinders the clinical application of magnesium alloys with microarc oxidation/phytic acid (MAO/PA) composite coatings as protective coatings. Here, these alloys were used to hinder the rapid material degradation in aqueous solution. Electrochemical tests were conducted to evaluate the in vivo degradation behaviour in simulated body fluid (SBF) for Mg-Zn-Y-Nd alloys, and scanning electron microscopy (SEM) was used to observe the micromorphology of in vivo clip degradation. Cell toxicity, cell adhesion, and flow cytometry were performed in vitro to detect cytocompatibility. Biochemical detection of serum magnesium, serum creatinine (CREA), blood urea nitrogen (BUN), alanine transaminase (ALT), and alanine aminotransferase (AST), and haematoxylin-eosin (HE) staining of the heart, liver, and kidney tissues in vivo was conducted to determine the biocompatibility properties after surgery. Electrochemical measurements and SEM images revealed that the MAO/PA-coated magnesium alloy delayed corrosion in SBF. The apoptosis rate increased slightly with increased extract concentration. Nevertheless, MAO/PA-coated magnesium alloys still exhibited good cytocompatibility. No obvious abnormality was observed in the blood biochemical test or HE staining. Thus, MAO/PA-coated magnesium alloys exhibit better corrosion than bare magnesium. In addition, Mg-Zn-Y-Nd and MAO/PA-coated magnesium alloys exhibited no cytotoxicity, good adhesion, and biosafety.

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

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

In vivo evaluation of bending strengths and degradation rates of different magnesium pin designs for oral stapler

Magnesium alloys have been potential biodegradable implants in the areas of bone, cardiovascular system, gastrointestinal tract, and so on. The purpose of this study is to evaluate Mg-2Zn alloy degradation as a potential suture material. The study included Sprague-Dawley (SD) rats in vivo. In 24 male SD rats, tests in the leg muscle were conducted using traditional surgical incision and insertion of magnesium alloys of different designs into the tissue. The material degradation topography, elemental composition, and strength of the pins were analyzed. This paper explores magnesium pins with different cross-sectional shapes and diameters to establish a suitable pin diameter and shape for use as an oral stapler, which must have a good balance of degradation rate and strength. The results showed there were good bending strengths over different degradation periods in groups with diameters of 0.8 mm and 0.5 mm, and no significantly different bending strength between the groups of triangle and round cross-section shapes with same diameter of 0.3 mm, although the degradation rate still needs to be improved.

Clip as Nidus for Choledocholithiasis after Cholecystectomy-Literature Review

Background and Objectives

Foreign material in the biliary tree may serve as a nidus for stone formation and would usually present as choledocholithiasis with jaundice or cholangitis. Overall it is a rare occurrence, but there are many anecdotal reports of ingested matter or surgical material such as suture or clips causing biliary stones. Especially interesting are the cases in which there is migration of a metallic clip used in laparoscopic cholecystectomy. Cholecystectomy is such a common operation that although the phenomenon is rare, it is important because it is preventable, and as such a review of the topic seems worthwhile.

Methods

The available literature was searched using the EMBASE and Ovid databases and reviewed. The various devices and sutures used to occlude the cystic duct in laparoscopic cholecystectomy are discussed with reference to their safety.

Results and Conclusion

We found that the harmonic scalpel is a reasonable alternative with minimal complications but is however limited by cost. Electrosurgical vessel-sealing, ultrasonic shears, absorbable sutures such as endoloops (PDS), and polymer clips as well absorbable magnesium-calcium-zinc alloy clip are discussed.

Mg-Zn-Ca Alloys for Hemostasis Clips for Vessel Ligation: In Vitro and In Vivo Studies of Their Degradation and Response

To control the degradation rate of magnesium (Mg) alloys, chitosan (CHI) and L-glutamic acid (LGA) were used as coatings on Mg-Zn-Ca alloys via dip coating. In this study, either two or seven CHI/LGA layers were applied as a coating on Mg-2.8Zn-0.8Ca alloy (ZX31) and Mg-2.8Zn-0.8Ca hemostasis clips (ZX31 clips). The morphologies, compositions, and surface roughness of the specimens were characterized via scanning electron microscopy, Fourier transform infrared spectroscopy, and surface measurement devices. The degradation rates and behavior of the specimens were evaluated by immersing them in simulated body fluids and by applying these ZX31 clips on rabbits’ uterine tubes for five weeks. The specimen with seven layers (ZX31(CHI/LGA)₇) exhibited improved corrosion behavior when compared with ZX31 or ZX31(CHI/LGA)₂, with a reduced degradation rate of the Mg alloy in a simulated body environment. In vivo experiments showed that ZX31 clips exhibited good biocompatibilities in each group but could not maintain the clamping function for five weeks. The weight loss of ZX31(CHI/LGA)₇ was significantly lower than that of the other groups. Consequently, it was verified that CHI can be used as a protective layer on a magnesium alloy surface via in vitro and in vivo experiments.

In vitro and in vivo studies on the degradation and biosafety of Mg-Zn-Ca-Y alloy hemostatic clip with the carotid artery of SD rat model

An Mg-Zn-Ca-Y alloy operative clip was developed to overcome the drawbacks of the Ti clips such as ion dissolution inflammation, interference imaging diagnosis, and the potential harm that permanent retention brings to the patient. The structure optimization design of the hemostatic clip was carried out by the finite element numerical simulation method to realize the matching between the structure design and the material properties. Hot extrusion and wire cutting process was used to prepare the Mg-Zn-Ca-Y alloy operative clip. Corrosion degradation behavior of Mg-Zn-Ca-Y alloy in vitro was investigated using electrochemical noise (EN) and immersion test in Simulated body fluid (SBF). The carotid artery of SD rats was clipped using the Mg-Zn-Ca-Y operative clip to evaluate occlusion safety and the complete corrosion degradation behavior and biocompatibility of Mg-Zn-Ca-Y alloy clip in vivo were investigated using micro-computed tomography, histological analysis, and blood biochemical indicators. It was found that the newly designed Mg-Zn-Ca-Y clip can successfully ligate the carotid artery, and no blood leakage occurred after surgery. After eight months, the Mg-Zn-Ca-Y clip degraded utterly. Histological analysis and various blood biochemical parameters in SD rat serum samples collected at different time periods showed no tissue inflammation around the clips.

Development of bioabsorbable zinc-magnesium alloy wire and validation of its application to urinary tract surgeries

PURPOSE

Metallic medical devices are typically constructed from non-bioabsorbable metals that remains in the body and causes considerable complications. Particularly in the urinary tract, calculus, intractable infection, and misdiagnosis as calculus are often caused by non-bioabsorbable metals. Here, we developed a zinc-magnesium alloy as a new bioabsorbable metal and sought to evaluate the bioabsorbable behavior of zinc and zinc-magnesium alloy in a rat bladder implantation model.

METHODS

We prepared zinc-magnesium alloy wires with various proportions of magnesium and investigated the strength, shape retention, formability, and absorbability of these novel materials. Then, we implanted zinc and zinc-magnesium alloy rings formed by the wires into rat bladder. Rats were euthanized at the end of the observation period, and the rings were removed for volume evaluation. Extracted bladder tissues were subjected to histological analysis.

RESULTS

The strength of the zinc wire was enhanced by more than fourfold upon the addition of magnesium, without loss of ductility. Linear reduction of ring volume in urine was observed based on the concentration of magnesium within the ring. Nearly all rings were covered with a thin layer of calculus. Histological findings of the transected urinary bladder tissues did not differ among groups.

CONCLUSIONS

Zinc-magnesium alloy is a promising candidate for use as a bioabsorbable medical device in the urinary tract.

Biodegradable Surgical Staple Composed of Magnesium Alloy

Currently, surgical staples are composed of non-biodegradable titanium (Ti) that can cause allergic reactions and interfere with imaging. This paper proposes a novel biodegradable magnesium (Mg) alloy staple and discusses analyses conducted to evaluate its safety and feasibility. Specifically, finite element analysis revealed that the proposed staple has a suitable stress distribution while stapling and maintaining closure. Further, an immersion test using artificial intestinal juice produced satisfactory biodegradable behavior, mechanical durability, and biocompatibility in vitro. Hydrogen resulting from rapid corrosion of Mg was observed in small quantities only in the first week of immersion, and most staples maintained their shapes until at least the fourth week. Further, the tensile force was maintained for more than a week and was reduced to approximately one-half by the fourth week. In addition, the Mg concentration of the intestinal artificial juice was at a low cytotoxic level. In porcine intestinal anastomoses, the Mg alloy staples caused neither technical failure nor such complications as anastomotic leakage, hematoma, or adhesion. No necrosis or serious inflammation reaction was histopathologically recognized. Thus, the proposed Mg alloy staple offers a promising alternative to Ti alloy staples.

Novel biodegradable magnesium alloy clips compared with titanium clips for hepatectomy in a rat model

Background

The use of surgical metal clips is crucial for ligating vessels in various operations. The currently available metal clips have several drawbacks; they are permanent and interfere with imaging techniques such as computed tomography (CT) or magnetic resonance (MR) imaging and carry the potential risk of endo-clip migration. We recently developed a novel magnesium (Mg) alloy for biodegradable clips that reduces artifacts on CT imaging. This study aimed to examine the tolerance, biodegradability, and biocompatibility of the Mg alloy clips compared with those of standard titanium (Ti) clips in hepatectomy.

Methods

Thirty Wistar rats were divided into two groups based on the clip used (groups A and B). The vascular pedicle, including hepatic artery, portal vein, bile duct, and hepatic vein of the left lateral lobe, was ligated with the Ti clip in group A or the Mg alloy clip in group B, and then the left lateral lobe was removed. The rats were sacrificed at 1, 4, 12, 24, and 36 weeks after surgery. Clinical and histological evaluations were performed. Absorption rate was calculated by measuring the clip volume.

Results

Although the Mg alloy clips showed biodegradability over time, there were no significant differences in the serum concentration of Mg between the two groups. The remaining volume ratio of Mg alloy clips was 95.5, 94.3, 80.0, 36.2, and 16.7% at 1, 4, 12, 24, and 36 weeks, respectively. No side effects occurred. Most of the microscopic changes were similar in both groups.

Conclusions

The new biodegradable Mg alloy clips are safe and feasible in vessel ligation for hepatectomy in a rat model and reduce artifacts in CT imaging compared with the standard Ti clips.

In vitro and in vivo biocompatibility of Mg-Zn-Ca alloy operative clip

At present, titanium (Ti) and its alloys are most commonly use in hemostasis clip clinical applications. However, the Ti Clip cannot be absorbed in human body and produce artifacts on computed tomography (CT), and induce clinically relevant hypersensitivity in patients. In order to overcome the drawbacks of the non-degradable Ti clips, an Mg–Zn–Ca alloy operative clip was fabricated by combining hot extrusion and blanking processing. In vitro and in vivo biocompatibility of Mg–Zn–Ca alloy operative clip were evaluated by L-929 Cells and SD rat model respectively. It was found that Mg–Zn–Ca alloy exhibited non-cytotoxic to L929 cells. In vivo implantation showed that the newly designed Mg–Zn–Ca clip can successfully ligated carotid artery and no blood leakage occurred post-surgery. During the period of the clip degradation, a small amount of H₂ gas formation and no tissue inflammation around the clips were observed. The degradation rate of the clip near the heart ligated the arteries faster than that of clip far away the heart due do the effect of arterial blood. Histological analysis and various blood biochemical parameters in rat serum samples collected at different times after clip implantation showed no tissue inflammation around the clips.

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Mg–3Zn-0.2Ca alloy operative clip by combining hot extrusion and blanking processing.

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Mg–3Zn-0.2Ca alloy exhibited no cell toxicity to L929 cells in in vitro cell test.

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The newly designed Mg–Zn–Ca clip can successfully ligated carotid artery.

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Histological analysis and blood biochemistry parameters showed no tissue inflammation around the clips.