Bone modeling controlled by a nickel-titanium shape memory alloy intramedullary nail

Smart Biomaterials in Biomedical Applications: Current Advances and Possible Future Directions

Smart biomaterials with the capacity to alter their properties in response to an outside stimulus or from within the environment around them have picked up significant attention in the biomedical community. This is primarily due to the interest in their biomedical applications that may be anticipated from them in a considerable number of dynamic structures and devices. Shape-memory materials are some of these materials that have been exclusively used for these applications. They exhibit unique structural reconfiguration features they adapt as per the provided environmental conditions and can be designed for their enhanced biocompatibility. Numerous research initiatives have focused on these smart biocompatible materials over the last few decades to enhance their biomedical applications. Shape-memory materials play a significant role in this regard to meet new surgical and medical devices' requirements for special features and utility cases. Because of the favorable design variety, different biomedical shape-memory materials can be developed by modifying their chemical and physical behaviors to accommodate the desired requirements. In this review, recent advances and characteristics of smart biomaterials for biomedical applications are described. The authors also discuss about their clinical translations in tissue engineering, drug delivery, and medical devices.

Biomechanical design optimization of proximal humerus locked plates: A review

BACKGROUND

Proximal humerus locked plates (PHLPs) are widely used for fracture surgery. Yet, non-union, malunion, infection, avascular necrosis, screw cut-out (i.e., perforation), fixation failure, and re-operation occur. Most biomechanical investigators compare a specific PHLP configuration to other implants like non-locked plates, nails, wires, and arthroplasties. However, it is unknown whether the PHLP configuration is biomechanically optimal according to some well-known biomechanical criteria. Therefore, this is the first review of the systematic optimization of plate and/or screw design variables for improved PHLP biomechanical performance.

METHODS

The PubMed website was searched for papers using the terms "proximal humerus" or "shoulder" plus "biomechanics/biomechanical" plus "locked/locking plates". PHLP papers were included if they were (a) optimization studies that systematically varied plate and screw variables to determine their influence on PHLP's biomechanical performance; (b) focused on plate and screw variables rather than augmentation techniques (i.e., extra implants, bone struts, or cement); (c) published after the year 2000 signaling the commercial availability of locked plate technology; and (d) written in English.

RESULTS

The 41 eligible papers involved experimental testing and/or finite element modeling. Plate variables investigated by these papers were geometry, material, and/or position, while screw variables studied were number, distribution, angle, size, and/or threads. Numerical outcomes given by these papers included stiffness, strength, fracture motion, bone and implant stress, and/or the number of loading cycles to failure. But, no paper fully optimized any plate or screw variable for a PHLP by simultaneously applying four well-established biomechanical criteria: (a) allow controlled fracture motion for early callus generation; (b) reduce bone and implant stress below the material's ultimate stress to prevent failure; (c) maintain sufficient bone-plate interface stress to reduce bone resorption (i.e., stress shielding); and (d) increase the number of loading cycles before failure for a clinically beneficial lifespan (i.e., fatigue life). Finally, this review made suggestions for future work, identified clinical implications, and assessed the quality of the papers reviewed.

CONCLUSIONS

Applying biomechanical optimization criteria can assist biomedical engineers in designing or evaluating PHLPs, so orthopaedic surgeons can have superior PHLP constructs for clinical use.

3D printing metal implants in orthopedic surgery: Methods, applications and future prospects

Background

Currently, metal implants are widely used in orthopedic surgeries, including fracture fixation, spinal fusion, joint replacement, and bone tumor defect repair. However, conventional implants are difficult to be customized according to the recipient's skeletal anatomy and defect characteristics, leading to difficulties in meeting the individual needs of patients. Additive manufacturing (AM) or three-dimensional (3D) printing technology, an advanced digital fabrication technique capable of producing components with complex and precise structures, offers opportunities for personalization.

Methods

We systematically reviewed the literature on 3D printing orthopedic metal implants over the past 10 years. Relevant animal, cellular, and clinical studies were searched in PubMed and Web of Science. In this paper, we introduce the 3D printing method and the characteristics of biometals and summarize the properties of 3D printing metal implants and their clinical applications in orthopedic surgery. On this basis, we discuss potential possibilities for further generalization and improvement.

Results

3D printing technology has facilitated the use of metal implants in different orthopedic procedures. By combining medical images from techniques such as CT and MRI, 3D printing technology allows the precise fabrication of complex metal implants based on the anatomy of the injured tissue. Such patient-specific implants not only reduce excessive mechanical strength and eliminate stress-shielding effects, but also improve biocompatibility and functionality, increase cell and nutrient permeability, and promote angiogenesis and bone growth. In addition, 3D printing technology has the advantages of low cost, fast manufacturing cycles, and high reproducibility, which can shorten patients' surgery and hospitalization time. Many clinical trials have been conducted using customized implants. However, the use of modeling software, the operation of printing equipment, the high demand for metal implant materials, and the lack of guidance from relevant laws and regulations have limited its further application.

Conclusions

There are advantages of 3D printing metal implants in orthopedic applications such as personalization, promotion of osseointegration, short production cycle, and high material utilization. With the continuous learning of modeling software by surgeons, the improvement of 3D printing technology, the development of metal materials that better meet clinical needs, and the improvement of laws and regulations, 3D printing metal implants can be applied to more orthopedic surgeries.

The translational potential of this paper

Precision, intelligence, and personalization are the future direction of orthopedics. It is reasonable to believe that 3D printing technology will be more deeply integrated with artificial intelligence, 4D printing, and big data to play a greater role in orthopedic metal implants and eventually become an important part of the digital economy. We aim to summarize the latest developments in 3D printing metal implants for engineers and surgeons to design implants that more closely mimic the morphology and function of native bone.

Environment-Induced Degradation of Shape Memory Alloys: Role of Alloying and Nature of Environment

Shape memory effects coupled with superelasticity are the distinctive characteristics of shape memory alloys (SMAs), a type of metal. When these alloys are subject to thermomechanical processing, they have the inherent ability to react to stimuli, such as heat. As a result, these alloys have established their usefulness in a variety of fields and have in recent years been chosen for use in stents, sensors, actuators, and several other forms of life-saving medical equipment. When it comes to the shape memory materials, nickel-titanium (Ni-Ti) alloys are in the forefront and have been chosen for use in a spectrum of demanding applications. As shape memory alloys (SMAs) are chosen for use in critical environments, such as blood streams (arteries and veins), orthodontic applications, orthopedic implants, and high temperature surroundings, such as actuators in aircraft engines, the phenomenon of environment-induced degradation is of both interest and concern. Hence, the environment-induced degradation behavior of the shape memory alloys (SMAs) needs to be studied to find viable ways to improve their resistance to an aggressive environment. The degradation that occurs upon exposure to an aggressive environment is often referred to as corrosion. Environment-induced degradation, or corrosion, being an unavoidable factor, certain techniques can be used for the purpose of enhancing the degradation resistance of shape memory alloys (SMAs). In this paper, we present and discuss the specific role of microstructure and contribution of environment to the degradation behavior of shape memory alloys (SMAs) while concurrently providing methods to resist both the development and growth of the degradation caused by the environment.

Biomechanical design optimization of distal femur locked plates: A review

Clinical findings, manufacturer instructions, and surgeon's preferences often dictate the implantation of distal femur locked plates (DFLPs), but healing problems and implant failures still persist. Also, most biomechanical researchers compare a particular DFLP configuration to implants like plates and nails. However, this begs the question: Is this specific DFLP configuration biomechanically optimal to encourage early callus formation, reduce bone and implant failure, and minimize bone "stress shielding"? Consequently, it is crucial to optimize, or characterize, the biomechanical performance (stiffness, strength, fracture micro-motion, bone stress, plate stress) of DFLPs influenced by plate variables (geometry, position, material) and screw variables (distribution, size, number, angle, material). Thus, this article reviews 20 years of biomechanical design optimization studies on DFLPs. As such, Google Scholar and PubMed websites were searched for articles in English published since 2000 using the terms "distal femur plates" or "supracondylar femur plates" plus "biomechanics/biomechanical" and "locked/locking," followed by searching article reference lists. Key numerical outcomes and common trends were identified, such as: (a) plate cross-sectional area moment of inertia can be enlarged to lower plate stress at the fracture; (b) plate material has a larger influence on plate stress than plate thickness, buttress screws, and inserts for empty plate holes; (c) screw distribution has a major influence on fracture micro-motion, etc. Recommendations for future work and clinical implications are then provided, such as: (a) simultaneously optimizing fracture micro-motion for early healing, reducing bone and implant stresses to prevent re-injury, lowering "stress shielding" to avoid bone resorption, and ensuring adequate fatigue life; (b) examining alternate non-metallic materials for plates and screws; (c) assessing the influence of condylar screw number, distribution, and angulation, etc. This information can benefit biomedical engineers in designing or evaluating DFLPs, as well as orthopedic surgeons in choosing the best DFLPs for their patients.

Bone tissue engineering for treating osteonecrosis of the femoral head

Osteonecrosis of the femoral head (ONFH) is a devastating and complicated disease with an unclear etiology. Femoral head-preserving surgeries have been devoted to delaying and hindering the collapse of the femoral head since their introduction in the last century. However, the isolated femoral head-preserving surgeries cannot prevent the natural progression of ONFH, and the combination of autogenous or allogeneic bone grafting often leads to many undesired complications. To tackle this dilemma, bone tissue engineering has been widely developed to compensate for the deficiencies of these surgeries. During the last decades, great progress has been made in ingenious bone tissue engineering for ONFH treatment. Herein, we comprehensively summarize the state-of-the-art progress made in bone tissue engineering for ONFH treatment. The definition, classification, etiology, diagnosis, and current treatments of ONFH are first described. Then, the recent progress in the development of various bone-repairing biomaterials, including bioceramics, natural polymers, synthetic polymers, and metals, for treating ONFH is presented. Thereafter, regenerative therapies for ONFH treatment are also discussed. Finally, we give some personal insights on the current challenges of these therapeutic strategies in the clinic and the future development of bone tissue engineering for ONFH treatment.

Implantation of heat treatment Ti6al4v alloys in femoral bone of Wistar rats

Two heat treatments were carried out at below (Ti6Al4V₈₀₀) and above (Ti6Al4V₁₀₅₀) the beta-phase transformation temperature (T_TRANSUS = 980 °C), to study the effect of microstructural changes on osseointegration. The alloys were implanted in the femurs of hind legs of Wistar rats for 15, 30, and 60 days. Histology of the femur sections obtained for the first 15 days showed inflammatory tissue surrounding the implants and tissue contraction, which prevented osseointegration in early stages. After 30 days, trabecular bone, reduction of inflammatory tissue around the implants, and osseointegration were observed in Ti6Al4V as received and Ti6Al4V₁₀₅₀ alloys, while osseointegration was detected for the three alloys after 60 days. These results were supported through morphometric studies based on the analysis of Bone Implant Contact (BIC), where there was a larger bone contact after 60 days for the Ti6Al4V₁₀₅₀ alloy; indicating that microstructural features of the Ti6Al4V alloys influence their osseointegration, with the lamellar microstructure (Ti6Al4V₁₀₅₀), being the most responsive. Graphical abstract.

Biodegradable shape memory alloys: Progress and prospects

Shape memory alloys (SMAs) have a wide range of potential novel medical applications due to their superelastic properties and ability to restore and retain a 'memorised' shape. However, most SMAs are permanent and do not degrade in the body when used in implantable devices. The use of non-degrading metals may lead to the requirement for secondary removal surgery and this in turn may introduce both short and long-term health risks, or additional waste disposal requirements. Biodegradable SMAs can effectively eliminate these issues by gradually degrading inside the human body while providing the necessary support for healing purposes, therefore significantly alleviating patient discomfort and improving healing efficiency. This paper reviews the current progress in biodegradable SMAs from the perspective of biodegradability, mechanical properties, and biocompatibility. By providing insights into the status of SMAs and biodegradation mechanisms, the prospects for Mg- and Fe-based biodegradable SMAs to advance biodegradable SMA-based medical devices are explored. Finally, the remaining challenges and potential solutions in the biodegradable SMAs area are discussed, providing suggestions and research frameworks for future studies on this topic.

On the road to smart biomaterials for bone research: definitions, concepts, advances, and outlook

The demand for biomaterials that promote the repair, replacement, or restoration of hard and soft tissues continues to grow as the population ages. Traditionally, smart biomaterials have been thought as those that respond to stimuli. However, the continuous evolution of the field warrants a fresh look at the concept of smartness of biomaterials. This review presents a redefinition of the term "Smart Biomaterial" and discusses recent advances in and applications of smart biomaterials for hard tissue restoration and regeneration. To clarify the use of the term "smart biomaterials", we propose four degrees of smartness according to the level of interaction of the biomaterials with the bio-environment and the biological/cellular responses they elicit, defining these materials as inert, active, responsive, and autonomous. Then, we present an up-to-date survey of applications of smart biomaterials for hard tissues, based on the materials' responses (external and internal stimuli) and their use as immune-modulatory biomaterials. Finally, we discuss the limitations and obstacles to the translation from basic research (bench) to clinical utilization that is required for the development of clinically relevant applications of these technologies.

Is the 0.2%-Strain-Offset Approach Appropriate for Calculating the Yield Stress of Cortical Bone?

The 0.2% strain offset approach is mostly used to calculate the yield stress and serves as an efficient method for cross-lab comparisons of measured material properties. However, it is difficult to accurately determine the yield of the bone. Especially when computational models require accurate material parameters, clarification of the yield point is needed. We tested 24 cortical specimens harvested from six bovine femora in three-point bending mode, and 11 bovine femoral cortical specimens in the tensile mode. The Young's modulus and yield stress for each specimen derived from the specimen-specific finite element (FE) optimization method was regarded as the most ideal constitutive parameter. Then, the strain offset optimization method was used to find the strain offset closest to the ideal yield stress for the 24 specimens. The results showed that the 0 strain offsets underestimated (- 25%) the yield stress in bending and tensile tests, while the 0.2% strain offsets overestimated the yield stress (+ 65%) in three-point bending tests. Instead, the yield stress determined by 0.007 and 0.05% strain offset for bending and tensile loading respectively, can effectively characterize the biomechanical responses of the bone, thereby helping to build an accurate FE model.

Biomechanical design using in-vitro finite element modeling of distal femur fracture plates made from semi-rigid materials versus traditional metals for post-operative toe-touch weight-bearing

This proof-of-concept study designs distal femur fracture plates from semi-rigid materials vs. traditional metals for toe-touch weight-bearing recommended to patients immediately after surgery. The two-fold goal was to (a) reduce stress shielding (SS) by increasing cortical bone stress thereby reducing the risk of bone absorption and plate loosening, and (b) reduce delayed healing (DH) via early callus formation by optimizing axial interfragmentary motion (AIM). Finite element analysis was used to design semi-rigid plates whose elastic moduli E ensured plates permitted AIM of 0.2 - 1 mm for early callus formation. A low hip joint force of 700 N (i.e. 100% x body weight) was applied, which corresponds to a typical 140 N toe-touch foot-to-ground force (i.e. 20% x body weight) recommended to patients after surgery. Analysis was done using 2 screw materials (steel or titanium) and types (locked or non-locked). Steel and titanium plates were also analyzed. Semi-rigid plates (vs. metal plates) had lower overall femur/plate construct stiffnesses of 508 - 1482 N/mm, higher cortical bone stresses under the plate by 2.02x - 3.27x thereby reducing SS, and lower E values of 414 - 2302 MPa to permit AIM of 0.2 - 1 mm thereby reducing DH.

Sensitivity and Uncertainty Analysis of One-Dimensional Tanaka and Liang-Rogers Shape Memory Alloy Constitutive Models

A shape memory alloy (SMA) can remember its original shape and recover from strain due to loading once it is exposed to heat (shape memory effect). SMAs also exhibit elastic response to applied stress above the characteristic temperature at which transformation to austenite is completed (pseudoelasticity or superelasticity). Shape memory effect and pseudoelasticity of SMAs have been addressed by several microscopic thermodynamic and macroscopic phenomenological models using different modeling approaches. The Tanaka and Liang-Rogers models are two of the most widely used macroscopic phenomenological constitutive models for describing SMA behavior. In this paper, we performed sensitivity and uncertainty analysis using Sobol and extended Fourier Amplitude Sensitivity Testing (eFAST) methods for the Tanaka and Liang-Rogers models at different operating temperatures and loading conditions. The stress-dependent and average sensitivity indices have been analyzed and are presented for determining the most influential parameters for these models. The results show that variability is primarily caused by a change in operating temperature and loading conditions. Both models appear to be influenced by the uncertainty in elastic modulus of the material significantly. The analyses presented in this paper aim to provide a better insight for designing applications using SMAs by increasing the understanding of these models’ sensitivity to the input parameters and the cause of output variability due to uncertainty in the same input parameters.

Comparison of Mechanical Stability of Elastic Titanium, Nickel-Titanium, and Stainless Steel Nails Used in the Fixation of Diaphyseal Long Bone Fractures

Elastic nails made of the nickel-titanium shape memory alloy (Nitinol) have been reported to control bone modeling in animal studies. However, the mechanical stability of the Nitinol nail in the fixation of long bone fractures remains unclear. This study compared mechanical stability among nails made of three materials, namely Nitinol, titanium, and stainless steel, in the fixation of long bone fractures. These three materials had identical shapes (arc length: π/2 and radius: 260 mm). A cylindrical sawbone with a 10-mm gap and fixed with two C-shaped elastic nails was used to examine the stability of the nails. A finite element (FE) model was developed based on the sawbone model. The end cap for elastic nails was not used in the sawbone test but was considered based on a constraint equation in FE simulation. The results of stability tests appeared to depend on the presence or absence of the end cap. In the sawbone test, the titanium nail yielded a higher ultimate force against the applied load than did the stainless steel and Nitinol nails before the gap completely closed; the difference in linear stiffness between the nails was nonsignificant. In FE simulation, the titanium nail produced smaller gap shortening than did stainless steel and Nitinol nails without the end cap; the difference in gap shortening between the nails was minor with the end cap. The titanium elastic nail should be a better choice in managing diaphyseal long bone fractures when the end cap is not used. For Nitinol and stainless steel nails, the end cap should be used to stop the nail from dropping out and to stabilize the fractured bone.

Nickel-Titanium Shape-Memory Sawtooth-Arm Embracing Clamp for Complex Femoral Revision Hip Arthroplasty

PURPOSES

To examine the clinical outcomes of patients treated with a nickel-titanium shape-memory sawtooth-arm embracing clamp (Ni-Ti SSEC) in complex femoral revision surgery.

METHODS

We retrospectively evaluated the outcomes for 21 complex femoral revision hip arthroplasties that we treated using an Ni-Ti SSEC. The Ni-Ti SSEC was used for various procedures, including the fixation of extremely long cortical windows (11 patients), femoral shaft osteotomy (4 patients), an extended trochanteric osteotomy (3 patients), and protection of a penetrated femoral cortex by a primary stem (3 patients). All patients received follow-up care for an average of 48.2 months.

RESULTS

The mean time of Ni-Ti SSEC insertion intraoperatively was 6 minutes. The mean Harris Hip Score improved from 21.2 points before revision surgery to 83.1 points at the most recent examination. No implant failures or malunions occurred. Dislocation and deep infection occurred in 1 case during the follow-up period.

CONCLUSIONS

Our results show that the embracing clamp is a simple and valid method for fixing osteotomies in treating complex femoral revision surgery.

Transcutaneous electromagnetic induction heating of an intramedullary nickel-titanium shape memory implant

PURPOSE

Inadequate mechanical stimuli are a major cause for nonunions following surgery for femoral and tibial shaft fractures. Adapting fixation rigidity during the course of fracture healing requires additional surgery. Nickel-titanium (NiTi) implants can change shape and rigidity by employing a temperature-dependent shape-memory effect. As a first step in the development of advanced intramedullary (IM) NiTi devices for fracture healing, this study aimed to test the feasibility and safety of transcutaneous electromagnetic induction heating of an IM NiTi implant in a rat model.

METHODS

In 51 rats, NiTi implants were introduced into the left distal femur. Forty-four animals were transferred to an induction coil, and the implant was electromagnetically heated to temperatures between 40° and 60 °C Blood samples were drawn before and four hours after the procedure. Interleukin (IL)-1, IL-4, IL-10, tumour necrosis factor alpha (TNF-α) and interferon gamma (IFN-γ) were measured. Animals were sacrificed at three weeks. Histological specimens from the hind leg and liver were retrieved and examined for inflammatory changes, necrosis or corrosion pits.

RESULTS

All animals successfully underwent the surgical procedure. Following transcutaneous induction heating, target temperature was confirmed in 37/44 rats. Postoperative controls showed no signs of undue limitations. Neither cytokine measurements nor histological specimens showed any significant differences between groups. There were no corrosion pits or necrosis.

CONCLUSION

We conclude that electromagnetic induction heating of IM NiTi implants is feasible and safe in a rat femur model. These findings reflect a further step in the development of novel concepts for IM fracture fixation that might lead to better fracture healing, less patient discomfort and less need for surgical interventions.

Effect of micro-arc oxidation surface modification on the properties of the NiTi shape memory alloy

In this paper, the effects of micro-arc oxidation (MAO) surface modification (alumina coatings) on the phase transformation behavior, shape memory characteristics, in vitro haemocopatibility and cytocompatibility of the biomedical NiTi alloy were investigated respectively by differential scanning calorimetry, bending test, hemolysis ratio test, dynamic blood clotting test, platelet adhesion test and cytotoxicity testing by human osteoblasts (Hobs). The results showed that there were no obvious changes of the phase transformation temperatures and shape memory characteristics of the NiTi alloy after the MAO surface modification and the coating could withstand the thermal shock and volume change caused by martensite-austenite phase transformation. Compared to the uncoated NiTi alloys, the MAO surface modification could effectively improve the haemocopatibility of the coated NiTi alloys by the reduced hemolysis ratio, the prolonged dynamic clotting time and the decreased number of platelet adhesion; and the rough and porous alumina coatings could obviously promote the adherence, spread and proliferation of the Hobs with the significant increase of proliferation number of Hobs adhered on the surface of the coated NiTi alloys (P < 0.05).

Shape Memory Alloy Expandable Pedicle Screw to Enhance Fixation in Osteoporotic Bone: Primary Design and Finite Element Simulation

The properties of shape memory alloys, specifically the equiatomic intermetallic NiTi, are unique and significant in that they offer simple and effective solutions for some of the biomechanical issues encountered in orthopedics. Pedicle screws, used as an anchoring point for the implantation of spinal instrumentations in the spinal fracture and deformity treatments, entail the major drawback of loosening and backing out in osteoporotic bone. The strength of the screw contact with the surrounding bone diminishes as the bone degrades due to osteoporosis. The SMArtTM pedicle screw design is developed to address the existing issue in degraded bone. It is based on the interaction of bi-stable shape memory-superelastic elements. The bi-stable assembly acts antagonistically and consists of an external superelastic tube that expands the design protrusions when body temperature is attained; also an internal shape memory wire, inserted into the tube, retracts the assembly while locally heated to above the body temperature. This innovative bi-stable solution augments the pull-out resistance while still allowing for screw removal. The antagonistic wire-tube assembly was evaluated and parametrically analyzed as for the interaction of the superelastic tube and shape memory wire using a finite element model developed in COMSOL Multiphysics®. The outcomes of the simulation suggest that shape memory NiTi inserts on the SMArtTM pedicle screw can achieve the desired antagonistic functionality of expansion and retraction. Consequently, a parametric analysis was conducted over the effect of different sizes of wires and tubes. The dimensions for the first sample of this innovative pedicle screw were determined based on the results of this analysis.

Biocompatible, smooth, plasma-treated nickel-titanium surface--an adequate platform for cell growth

High nickel content is believed to reduce the number of biomedical applications of nickel-titanium alloy due to the reported toxicity of nickel. The reduction in nickel release and minimized exposure of the cell to nickel can optimize the biocompatibility of the alloy and increase its use in the application where its shape memory effects and pseudoelasticity are particularly useful, e.g., spinal implants. Many treatments have been tried to improve the biocompatibility of Ni-Ti, and results suggest that a native, smooth surface could provide sufficient tolerance, biologically. We hypothesized that the native surface of nickel-titanium supports cell differentiation and insures good biocompatibility. Three types of surface modifications were investigated: thermal oxidation, alkali treatment, and plasma sputtering, and compared with smooth, ground surface. Thermal oxidation caused a drop in surface nickel content, while negligible chemistry changes were observed for plasma-modified samples when compared with control ground samples. In contrast, alkali treatment caused significant increase in surface nickel concentration and accelerated nickel release. Nickel release was also accelerated in thermally oxidized samples at 600 °C, while in other samples it remained at low level. Both thermal oxidation and alkali treatment increased the roughness of the surface, but mean roughness R(a) was significantly greater for the alkali-treated ones. Ground and plasma-modified samples had 'smooth' surfaces with R(a)=4 nm. Deformability tests showed that the adhesion of the surface layers on samples oxidized at 600 °C and alkali treatment samples was not sufficient; the layer delaminated upon deformation. It was observed that the cell cytoskeletons on the samples with a high nickel content or release were less developed, suggesting some negative effects of nickel on cell growth. These effects were observed primarily during initial cell contact with the surface. The most favorable cell responses were observed for ground and plasma-sputtered surfaces. These studies indicated that smooth, plasma-modified surfaces provide sufficient properties for cells to grow.

Nickel-titanium shape-memory sawtooth-arm embracing fixator for periprosthetic femoral fractures

PURPOSE

We reviewed data to determine outcomes for 21 consecutive Vancouver type B1 or type C periprosthetic fractures that we treated between 2001 and 2008 using a nickel-titanium shape-memory sawtooth-arm embracing fixator.

METHODS

The study participants were 12 men and 9 women (mean age, 70.8 years; range, 42-85 years). The average duration of follow-up monitoring was 39.7 months (range, 1-78 months). In five cases, cables and screws were used for further stabilisation. No bone grafting was performed for any of the patients.

RESULTS

Results were satisfactory, except for one patient who died one month after surgery from a cause unrelated to arthroplasty. Bone union was achieved in the remaining 20 cases within an average of 5.25 months. No implant failures or malunions occurred in any of the patients. The average Harris hip score at the final follow-up examination was 79.3 points.

CONCLUSIONS

Our results show that the embracing fixator is a valid alternative treatment for Vancouver type B1 or type C periprosthetic femoral fractures.

Biomedical Applications of Shape Memory Alloys

Shape memory alloys, and in particular NiTi alloys, are characterized by two unique behaviors, thermally or mechanically activated: the shape memory effect and pseudo-elastic effect. These behaviors, due to the peculiar crystallographic structure of the alloys, assure the recovery of the original shape even after large deformations and the maintenance of a constant applied force in correspondence of significant displacements. These properties, joined with good corrosion and bending resistance, biological and magnetic resonance compatibility, explain the large diffusion, in the last 20 years, of SMA in the production of biomedical devices, in particular for mini-invasive techniques. In this paper a detailed review of the main applications of NiTi alloys in dental, orthopedics, vascular, neurological, and surgical fields is presented. In particular for each device the main characteristics and the advantages of using SMA are discussed. Moreover, the paper underlines the opportunities and the room for new ideas able to enlarge the range of SMA applications. However, it is fundamental to remember that the complexity of the material and application requires a strict collaboration between clinicians, engineers, physicists and chemists for defining accurately the problem, finding the best solution in terms of device design and accordingly optimizing the NiTi alloy properties.

Surface treatment of NiTi for medical applications

This article gives an overview of methods applied for surface treatment of nickel-titanium shape memory alloys in medical applications. The different methods are classified into the three major groups: <I>removal</I>, <I>oxidation</I> and <I>coating</I>. The principle behind each group of methods is explained and the pros and cons of the different methods are discussed.

Fibronectin modulates osteoblast behavior on Nitinol

We have previously demonstrated that primary rat osteoclasts behave differently when cultured on austenite and martensite Nitinol. In this study, we coated the two phases of Nitinol with plasma fibronectin and studied if this modifies the proliferation and cell cycle of MC3T3-E1 osteoblasts. The influence of the crystalline structure of Nitinol on the remodeling and conformation of fibronectin was also studied. The results on austenite demonstrated that fibronectin was more strongly remodeled and the cells spread better compared with the martensite phase. Interestingly, the conformation of the protein showed no differences between austenite and martensite. In addition, fibronectin improved cell proliferation in both phases, but the effect of fibronectin coating was stronger on the austenite surface. In addition, in both Nitinol phases, the proportion of cells in the G(1) phase was observed to grow in the presence of fibronectin. This could indicate cell differentiation on Nitinol.

Biocompatibility of sol-gel-derived titania-silica coated intramedullary NiTi nails

We investigated bone response to sol-gel-derived titania-silica coated functional intramedullary NiTi nails that applied a continuous bending force. Nails 26 mm in length, either straight or with a radius of curvature of 28 or 15 mm, were implanted in the cooled martensite form from a proximal to distal direction into the medullary cavity of the right femur in 40 Sprague-Dawley rats. Body temperature restored the austenite form, causing the curved implants to generate a bending force on the bone. The femurs were examined after 24 weeks. Bone length measurements did not reveal any bowing or shortening of the bone in the experimental groups. The results from histomorphometry demonstrated that the stronger bending force, together with sol-gel surface treatment, resulted in more bone deposition around the implant and the formation of significantly less fibrous tissue. Straight intramedullary nails, even those with a titania-silica coating, were poorly attached when compared to the implants with a curved austenite structure.

Surface mechanical properties, corrosion resistance, and cytocompatibility of nitrogen plasma-implanted nickel-titanium alloys: a comparative study with commonly used medical grade materials

Stainless steel and titanium alloys are the most common metallic orthopedic materials. Recently, nickel-titanium (NiTi) shape memory alloys have attracted much attention due to their shape memory effect and super-elasticity. However, this alloy consists of equal amounts of nickel and titanium, and nickel is a well known sensitizer to cause allergy or other deleterious effects in living tissues. Nickel ion leaching is correspondingly worse if the surface corrosion resistance deteriorates. We have therefore modified the NiTi surface by nitrogen plasma immersion ion implantation (PIII). The surface chemistry and corrosion resistance of the implanted samples were studied and compared with those of the untreated NiTi alloys, stainless steel, and Ti-6Al-4V alloy serving as controls. Immersion tests were carried out to investigate the extent of nickel leaching under simulated human body conditions and cytocompatibility tests were conducted using enhanced green fluorescent protein mice osteoblasts. The X-ray photoelectron spectroscopy results reveal that a thin titanium nitride (TiN) layer with higher hardness is formed on the surface after nitrogen PIII. The corrosion resistance of the implanted sample is also superior to that of the untreated NiTi and stainless steel and comparable to that of titanium alloy. The release of nickel ions is significantly reduced compared with the untreated NiTi. The sample with surface TiN exhibits the highest amount of cell proliferation whereas stainless steel fares the worst. Compared with coatings, the plasma-implanted structure does not delaminate as easily and nitrogen PIII is a viable way to improve the properties of NiTi orthopedic implants.

Do K-wires made from shape memory alloys increase pull-out forces? A preliminary experimental cadaver study in bovine bone

After osteosynthesis of the proximal humerus by Kirschner wires (K-wire), loosening and secondary loss can occur. This study tested primary fixation of wires made from a shape memory alloy (SMA) Nitinol (NiTi), compared to conventional steel K-wires by pull-out tests. Blocks of cancellous bone were tested with three wire types: NiTi-K-wire with split apex geometry and conventional steel K-wires with and without threads. We found that NiTi-wires can be pulled out of bone more easily than steel wires (P=0.05), even though the former had rougher surfaces. The application of NiTi-wires through bone produced no better stability in comparison to normal steel K-wires, because of triggering the memory effect. Further studies are required to determine if NiTi wires of another appropriate design, surface and localization are superior to conventional wires in the context of this application.

Magnetic resonance imaging of phase transitions in nitinol

Magnetic resonance images are prone to artifacts caused by metallic objects. Apart from being a source of image degradation, such artifacts can also provide information about the magnetic properties of the foreign object. In this work, we aim to explore the potential of magnetic resonance imaging to detect and characterize changes in magnetic properties of nitinol undergoing temperature- or strain-induced phase changes. A spin echo and a gradient echo method were used to measure the magnetization changes related to the phase transformations. Results of both methods were in agreement and in accordance with the independent measurements using a vibrating sample magnetometer. Magnetic resonance imaging turned out to be a suitable method to visualize and quantify magnetization and phase changes in situ. It is not restricted to a single imaging strategy and does not require any modification of the test object. The results indicate the potential of magnetic resonance imaging to provide direct feedback of the thermomechanical state of the alloy.

The release of nickel from orthodontic NiTi wires is increased by dynamic mechanical loading but not constrained by surface nitridation

The influence of dynamic mechanical loading and of surface nitridation on the nickel release from superelastic nickel-titanium orthodontic wires was investigated under ultrapure conditions. Commercially available superelastic NiTi arch wires (size 0.018 x 0.025'') without surface modification (Neo Sentalloy) and with nitrogen ion implantation surface treatment (Neo Sentalloy Ionguard) were analyzed. Mechanical loading of wire segments with a force similar to the physiological situation was performed with a frequency of 5 Hz in ultrapure water and saline solution, respectively. The release of nickel was monitored by atomic absorption spectroscopy for up to 36 days. The mechanically loaded wires released significantly more nickel ( approximately 45 ng cm(-2) d(-1)) than did nonloaded wires (<1 ng cm(-2) d(-1)). There was no statistically significant effect of the testing solution (water or NaCl) or of the surface nitridation. The total amount of released nickel was small in all cases, but may nevertheless account for the occasional clinical observations of adverse reactions during application of NiTi-based orthodontic appliances. The surface nitridation did not constrain the release of nickel from NiTi under continuous mechanical stress.

Shape Memory Alloys for Biomedical Applications

NiTi shape memory alloy (SMA) products appeared to the medical markets in 1980’s, their global market being more than US$ 130 billion in 2002. In most medical applications material must be biocompatible. NiTi offers the bodytemperature activated shape memory effect (SME), superelasticity (SE) and the damping capacity, which all can be applied in medical use. The dental arch wires and stents are benefiting from SE. The NiTi vena cava filters obtain their umbrella shaped mesh when SMEactivated. Generally the NiTi tubes and guidewires are applied in the minimally invasive medical procedures and in the interventional radiology. There are numerous steerable, hingeless, kink resistant, highly flexible clinical instruments that may provide constant force. NiTi is used for the dental implants and the attachments of the partial dentures and for the orthopaedics. In the latter one the main applications are the clamps for connecting bone fractures or parts for e.g. the spinal bentcalibration bar. Miniaturization has enabled small SMAactuators that are applicable in active endoscopes with allround bending and in actuators for kidney or heart pumps. The main risks using NiTi are the insecure fatigue life and possible cytotoxicity.

In vitro bioactivity and osteoblast response of porous NiTi synthesized by SHS using nanocrystalline Ni-Ti reaction agent

Porous NiTi with an average porosity of 55 vol % and a general pore size of 100-600 microm was synthesized by self-propagating high temperature synthesis (SHS) with the addition of mechanically alloyed nanocrystalline Ni-Ti as the reaction agent. The SHS of porous NiTi using elemental powders was also performed for comparison. To enhance the bioactivity of the metal surface, porous NiTi synthesized by nanocrystalline Ni-Ti was subjected to chemical treatment to form a layer of TiO(2) coating. The porous NiTi with TiO(2) coating was subsequently immersed in a simulated body fluid (SBF) to investigate its apatite forming ability. The effects of the addition of nanocrystalline Ni-Ti as reaction agent and the application of apatite coating on osteoblastic behavior were studied in primary cultures of human osteoblast cells. Results showed that the main phases in porous NiTi synthesized by elemental powders were NiTi, Ti(2)Ni, and unreacted free Ni. By using nanocrystalline Ni-Ti as reaction agent, the secondary intermetallic phase of Ti(2)Ni was significantly reduced and the free Ni was eliminated. TiO(2) coating with anatase phase was formed on the surface of porous NiTi after the chemical treatment. A layer consisting of nanocrystalline carbonate-containing apatite was formed on the surface of TiO(2) coating after soaking in SBF. The preliminary cell culture studies showed that the porous NiTi synthesized with the addition of nanocrystalline Ni-Ti attracted marked attachment and proliferation of the osteoblast cells. This gives the evidence of the potential biomedical applications of the porous NiTi.

A novel treatment of grade III acromioclavicular joint dislocations with a C-hook implant

INTRODUCTION

This study evaluates the results of the new surgical treatment of complete acromioclavicular (ac) dislocations using coracoclavicular (cc) fixation with a shape memory metal C-hook implant.

MATERIALS AND METHODS

Fifteen patients were prospectively analyzed. They all had a Tossy III ac dislocation due to trauma. The ac ligament was reinserted using a surgical bone anchor, and the position of the joint was restored by fixing it with a C-hook. After 3 months the C-hook was removed. Functional status, symptom severity, X-rays and patient satisfaction were analyzed during clinical control visits. The follow-up time was 1 year.

RESULTS

At 12 weeks, full shoulder function had been achieved by 93% of the patients. The final control visit showed full recovery of active ROM in all patients. Two patients had mild pain during certain movements. X-rays showed the precise anatomical position of ac joint with no statistically significant differences compared to the healthy side. Patient contentment was excellent in 14 cases and satisfactory in one case. The average sick-leave was 58 days, including the removal operation. Minor osteolysis of the clavicle was noticed in two patients.

CONCLUSION

The new C-hook implant provides accurate anatomical reduction, conserves the articular surfaces and enables fast functional recovery with excellent patient contentment. Technically, the implant is easy to use. Based on this study, the C-hook presents a reliable novel treatment option in surgical ac repair.

Fabrication and characteristics of bioactive sodium titanate/titania graded film on NiTi shape memory alloy

A bioactive sodium titanate/titania graded film was formed in situ on NiTi shape memory alloy (SMA) by oxidizing in H(2)O(2) solution and subsequent NaOH treatment and characterized by scanning electron microscopy, Raman spectroscopy, X-ray diffraction, Fourier transform infrared spectroscopy, and X-ray photoelectron spectroscopy (XPS). The bioactivity of the film was investigated using a simulated body fluid (SBF) soaking test. A titania (TiO(2)) layer was first found on NiTi substrate after oxidized in H(2)O(2) solution, and then a porous sodium titanate (Na(2)TiO(3))/titania film with many Ti--OH groups and a trace of Ni(2)O(3) was formed by the reaction of partial TiO(2) phase with NaOH solution. After immersion in SBF for 12 h, apatite was observed to nucleate and grow on the film. With longer soaking time, more apatite appeared on its surface but our control experiments didn't reveal any apatite formation on the chemically polished NiTi SMA, which indicates the bioactivity of NiTi implants could be improved by the formation of the bioactive film. Moreover, XPS depth profiles of O, Ni, Ti, and Na show the bioactive film possesses a smooth graded interface structure to NiTi substrate, which is in favor of sufficient mechanical stability of apatite layer by subsequent deposition in SBF.

Morphological characterization and in vitro biocompatibility of a porous nickel–titanium alloy

Disks consisting of macroporous nickel-titanium alloy (NiTi, Nitinol, Actipore) are used as implants in clinical surgery, e.g. for fixation of spinal dysfunctions. The morphological properties were studied by scanning electron microscopy (SEM) and by synchrotron radiation-based microtomography (SRmuCT). The composition was studied by X-ray diffractometry (XRD), differential scanning calorimetry (DSC), and energy-dispersive X-ray spectroscopy (EDX). The mechanical properties were studied with temperature-dependent dynamical mechanical analysis (DMA). Studies on the biocompatibility were performed by co-incubation of porous NiTi samples with isolated peripheral blood leukocyte fractions (polymorphonuclear neutrophil granulocytes, PMN; peripheral blood mononuclear leukocytes, PBMC) in comparison with control cultures without NiTi samples. The cell adherence to the NiTi surface was analyzed by fluorescence microscopy and scanning electron microscopy. The activation of adherent leukocytes was analyzed by measurement of the released cytokines using enzyme-linked immunosorbent assay (ELISA). The cytokine response of PMN (analyzed by the release of IL-1ra and IL-8) was not significantly different between cell cultures with or without NiTi. There was a significant increase in the release of IL-1ra (p<0.001), IL-6 (p<0.05), and IL-8 (p<0.05) from PBMC in the presence of NiTi samples. In contrast, the release of TNF-alpha by PBMC was not significantly elevated in the presence of NiTi. IL-2 was released from PBMC only in the range of the lower detection limit in all cell cultures. The material, clearly macroporous with an interconnecting porosity, consists of NiTi (martensite; monoclinic, and austenite; cubic) with small impurities of NiTi2 and possibly NiC(x). The material is not superelastic upon manual compression and shows a good biocompatibility.

Carbon plasma immersion ion implantation of nickel–titanium shape memory alloys

Nickel-titanium (NiTi) shape memory alloys possess super-elasticity in addition to the well-known shape memory effect and are potentially suitable for orthopedic implants. However, a critical concern is the release of harmful Ni ions from the implants into the living tissues. We propose to enhance the corrosion resistance and other surface and biological properties of NiTi using carbon plasma immersion ion implantation and deposition (PIII&D). Our corrosion and simulated body fluid tests indicate that either an ion-mixed amorphous carbon coating fabricated by PIII&D or direct carbon PIII can drastically improve the corrosion resistance and block the out-diffusion of Ni from the materials. Our tribological tests show that the treated surfaces are mechanically more superior and cytotoxicity tests reveal that both sets of plasma-treated samples favor adhesion and proliferation of osteoblasts.

Investigation of nickel suppression and cytocompatibility of surface-treated nickel-titanium shape memory alloys by using plasma immersion ion implantation

Nickel-titanium (NiTi) shape memory alloys are increasingly being used in orthopedic applications. However, there is a concern that Ni is harmful to the human body. We have recently investigated the use of nitrogen, or oxygen plasma immersion ion implantation to mitigate this deleterious effect. Our results reveal that the near-surface Ni concentration in all the treated samples is significantly suppressed. In addition, our in vitro tests show that the plasma-treated surfaces are cytologically compatible allowing the attachment and proliferation of osteoblasts. Among the two types of samples, the best biological effects are found on the samples with nitrogen implantation.

Corrosion resistance, surface mechanical properties, and cytocompatibility of plasma immersion ion implantation-treated nickel-titanium shape memory alloys

Nickel-titanium shape memory alloys are promising materials in orthopedic applications because of their unique properties. However, for prolonged use in a human body, deterioration of the corrosion resistance of the materials becomes a critical issue because of the increasing possibility of deleterious ions released from the substrate to living tissues. We have investigated the use of nitrogen, acetylene, and oxygen plasma immersion ion implantation (PIII) to improve the corrosion resistance and mechanical properties of the materials. Our results reveal that the corrosion resistance and mechanical properties such as hardness and elastic modulus are significantly enhanced after surface treatment. The release of nickel is drastically reduced as compared with the untreated control. In addition, our in vitro tests show that the plasma-treated surfaces are well tolerated by osteoblasts. Among the three types of samples, the best biological effects are observed on the nitrogen PIII samples.

Smart intramedullary rod for correction of pediatric bone deformity: a preliminary study

We were interested in determining if a smart intramedullary rod made of nitinol shape-memory alloy is capable of correcting deformed immature long bones. Because of limitations in our study design the process was reversed in that we examined the smart rod's ability to create a deformity rather than to correct one. Smart rods of different lengths and diameters were heat-treated to resume a radius of curvature of 30 to 110 mm. The low and high temperature phases of the smart rods were set, respectively, at 0 degrees C to 4 degrees C and 36 degrees C to 38 degrees C. The preshaped smart intramedullary rods were implanted in the cooled martensite phase in the medullary canal of the tibia in eight rabbits, where they restored their austenite form, causing a continuous bending force. On a weekly basis anteroposterior and lateral radiographs of the surgically treated tibia and the contralateral tibia were obtained for comparison. Rabbits were euthanized 6 weeks after surgery and computed tomography scans of both tibias were used for image analysis. Smart rods with a larger radius of curvature showed only minimal signs of remodeling; however, rods with a radius of curvature of 50 and 70 mm generated enough force history to create bone remodeling and deformation. The amount of bone deformation was highly magnified when unicortical corticotomy on the tension side was done. Based on this preliminary study the technology of the smart intramedullary rod may provide a valuable alternative method to correct pediatric skeletal deformities.

Analytical technique for quantification of selected resorbable calcium phosphate bone void fillers with the use of polarized-light microscopy

Synthetic calcium phosphate bone void fillers promote varying rates of bone formation and material resorption depending on chemistry, porosity, pore structure, and implant site. The objective of this study was to quantify the resorption of a novel ultraporous beta-tricalcium phosphate cancellous bone void filler with simultaneous quantification of bone formation in a canine humerus model. Potential measurement error involved in conventional histomorphometry using Von Kossa stains inspired the development of a new technique. This technique utilizes bright-field and polarized-light microscopy in conjunction with image analysis software, allowing more accurate histomorphometry. This technique was validated with two separate controlled experiments. Scanning electron microscopy further supported the results. The findings suggest that the use of polarized-light microscopy combined with image analysis software can be an effective tool in simultaneously quantifying calcium phosphate resorption and bone formation.

Effect of porosity on the osteointegration and bone ingrowth of a weight-bearing nickel-titanium bone graft substitute

Porous nickel-titanium (NiTi) alloy is a promising new material for a bone graft substitute with good strength properties and an elastic modulus closer to that of bone than any other metallic material. The purpose of this study was to evaluate the effect of porosity on the osteointegration of NiTi implants in rat bone. The porosities (average void volume) and the mean pore size (MPS) were 66.1% and 259+/-30 microm (group 1, n=14), 59.2% and 272+/-17 microm (group 2, n=4) and 46.6% and 505+/-136 microm (group 3, n=15), respectively. The implants were implanted in the distal femoral metaphysis of the rats for 30 weeks. The proportional bone-implant contact was best in group 1 (51%) without a significant difference compared to group 3 (39%). Group 2 had lower contact values (29%) than group 1 (p=0.038). Fibrotic tissue within the porous implant was found more often in group 1 than in group 3 (p=0.021), in which 12 samples out of 15 showed no signs of fibrosis. In conclusion, porosity of 66.1% (MPS 259+/-30 microm) showed best bone contact (51%) of the porosities tested here. However, the porosity of 46.6% (MPS 505+/-136 microm) with bone contact of 39% was not significantly inferior in this respect and showed lower incidence of fibrosis within the porous implant.

Calcium phosphate coating of nickel-titanium shape-memory alloys. Coating procedure and adherence of leukocytes and platelets

Nickel-titanium shape-memory alloys (NiTi-SMA) were coated with calcium phosphate by dipping in oversaturated calcium phosphate solution. The layer thickness (typically 5-20 micrometer) can be varied by choice of the immersion time. The porous nature of the layer of microcrystals makes it mechanically stable enough to withstand both the shape-memory transition upon cooling and heating and also strong bending of the material (superelastic effect). This layer may improve the biocompatibility of NiTi-SMA, particulary for osteosynthetic devices by creating a more physiological surface and by restricting a potential nickel release. The adherence of human leukocytes (peripheral blood mononuclear cells and polymorphonuclear neutrophil granulocytes) and platelets to the calcium phosphate layer was analyzed in vitro. In comparison to non-coated NiTi-SMA, leukocytes and platelets showed a significantly increased adhesion to the coated NiTi-SMA.