Simultaneous Delivery of Multiple Antibacterial Agents from Additively Manufactured Porous Biomaterials to Fully Eradicate Planktonic and Adherent Staphylococcus aureus

Study on the Antibacterial Activity and Bone Inductivity of Nanosilver/PLGA-Coated TI-CU Implants

Background

Implants are widely used in the field of orthopedics and dental sciences. Titanium (TI) and its alloys have become the most widely used implant materials, but implant-associated infection remains a common and serious complication after implant surgery. In addition, titanium exhibits biological inertness, which prevents implants and bone tissue from binding strongly and may cause implants to loosen and fall out. Therefore, preventing implant infection and improving their bone induction ability are important goals.

Purpose

To study the antibacterial activity and bone induction ability of titanium-copper alloy implants coated with nanosilver/poly (lactic-co-glycolic acid) (NSPTICU) and provide a new approach for inhibiting implant-associated infection and promoting bone integration.

Methods

We first examined the in vitro osteogenic ability of NSPTICU implants by studying the proliferation and differentiation of MC3T3-E1 cells. Furthermore, the ability of NSPTICU implants to induce osteogenic activity in SD rats was studied by micro-computed tomography (micro-CT), hematoxylin-eosin (HE) staining, masson staining, immunohistochemistry and van gieson (VG) staining. The antibacterial activity of NSPTICU in vitro was studied with gram-positive Staphylococcus aureus (Sa) and gram-negative Escherichia coli (E. coli) bacteria. Sa was used as the test bacterium, and the antibacterial ability of NSPTICU implanted in rats was studied by gross view specimen collection, bacterial colony counting, HE staining and Giemsa staining.

Results

Alizarin red staining, alkaline phosphatase (ALP) staining, quantitative real-time polymerase chain reaction (qRT-PCR) and western blot analysis showed that NSPTICU promoted the osteogenic differentiation of MC3T3-E1 cells. The in vitro antimicrobial results showed that the NSPTICU implants exhibited better antibacterial properties. Animal experiments showed that NSPTICU can inhibit inflammation and promote the repair of bone defects.

Conclusion

NSPTICU has excellent antibacterial and bone induction ability, and has broad application prospects in the treatment of bone defects related to orthopedics and dental sciences.

Forty-Six Years of Technological Innovation in Musculoskeletal Medicine: An Analysis of a Patent Database (1973 to 2018)

BACKGROUND

Technological innovation in orthopaedics is key to advancing patient care. As emerging technologies near maturity, clinicians must be able to objectively assess where and when these technologies can be implemented. Patent databases are an underappreciated resource for quantifying innovation, especially within orthopaedic surgery. This study used a patent database to assess patent activity and relative growth of technologies in musculoskeletal medicine and orthopaedics over a period of 46 years.

METHODS

A total of 121,471 patent records were indexed from Lens.org , a patent database. These patents were grouped into subspecialty clusters and technology clusters using patent codes. Five-year (2014 to 2018), 10-year (2009 to 2018), and 30-year (1989 to 2018) compound annual growth rates were calculated and compared for each cluster.

RESULTS

Annual patent activity increased from one patent in 1973 to 4,866 patents in 2018. Of the eight subspecialty clusters, the largest number of patents were related to 'Inflammation' (n = 63,128; 40.57%). The 'Elbow', 'Shoulder', and 'Knee' clusters experienced increased annual patent activity since 2000. Of the 12 technological clusters, the largest number of patents were related to 'Drugs' (n = 55,324; 39.75%). The 'Custom/patient-specific instrumentation, 'Computer Modeling', 'Robotics', and 'Navigation' clusters saw growth in the average annual patent activity since 2000.

DISCUSSION

Innovation, as measured by patent activity in musculoskeletal medicine and orthopaedics, has seen notable growth since 1973. The 'Robotics' cluster seems poised to experience exponential growth in industry investment and technological developments over the next 5 to 10 years. The 'Diagnostics', 'Computer Modeling', 'Navigation', and 'Design and Manufacturing' clusters demonstrate potential for exponential growth in industry investment and technological developments within the next 10 to 20 years.

Prospects of Using Chitosan-Based Biopolymers in the Treatment of Peripheral Nerve Injuries

Peripheral nerve injuries are common neurological disorders, and the available treatment options, such as conservative management and surgical repair, often yield limited results. However, there is growing interest in the potential of using chitosan-based biopolymers as a novel therapeutic approach to treating these injuries. Chitosan-based biopolymers possess unique characteristics, including biocompatibility, biodegradability, and the ability to stimulate cell proliferation, making them highly suitable for repairing nerve defects and promoting nerve regeneration and functional recovery. Furthermore, these biopolymers can be utilized in drug delivery systems to control the release of therapeutic agents and facilitate the growth of nerve cells. This comprehensive review focuses on the latest advancements in utilizing chitosan-based biopolymers for peripheral nerve regeneration. By harnessing the potential of chitosan-based biopolymers, we can pave the way for innovative treatment strategies that significantly improve the outcomes of peripheral nerve injury repair, offering renewed hope and better prospects for patients in need.

Research progress of 3D printed poly (ether ether ketone) in the reconstruction of craniomaxillofacial bone defects

The clinical challenge of bone defects in the craniomaxillofacial region, which can lead to significant physiological dysfunction and psychological distress, persists due to the complex and unique anatomy of craniomaxillofacial bones. These critical-sized defects require the use of bone grafts or substitutes for effective reconstruction. However, current biomaterials and methods have specific limitations in meeting the clinical demands for structural reinforcement, mechanical support, exceptional biological performance, and aesthetically pleasing reconstruction of the facial structure. These drawbacks have led to a growing need for novel materials and technologies. The growing development of 3D printing can offer significant advantages to address these issues, as demonstrated by the fabrication of patient-specific bioactive constructs with controlled structural design for complex bone defects in medical applications using this technology. Poly (ether ether ketone) (PEEK), among a number of materials used, is gaining recognition as a feasible substitute for a customized structure that closely resembles natural bone. It has proven to be an excellent, conformable, and 3D-printable material with the potential to replace traditional autografts and titanium implants. However, its biological inertness poses certain limitations. Therefore, this review summarizes the distinctive features of craniomaxillofacial bones and current methods for bone reconstruction, and then focuses on the increasingly applied 3D printed PEEK constructs in this field and an update on the advanced modifications for improved mechanical properties, biological performance, and antibacterial capacity. Exploring the potential of 3D printed PEEK is expected to lead to more cost-effective, biocompatible, and personalized treatment of craniomaxillofacial bone defects in clinical applications.

Porous surface with fusion peptides embedded in strontium titanate nanotubes elevates osteogenic and antibacterial activity of additively manufactured titanium alloy

It is still a big challenge in orthopedics to treat infected bone defects properly using medical metals. The use of three-dimensional (3D) scaffold materials that simultaneously mimic the skeletal hierarchy and induce sustainable osteogenic and antibacterial functions are a promising solution with an increasing appeal. In this study, we first designed a bifunctional fusion peptide (HHC36-RGD, HR) by linking antimicrobial peptide (HHC36) and arginine-glycine-aspartate (RGD) peptide via 6-aminohexanoic acid. Then the 3D scaffold was fabricated by additive manufacturing, and the strontium titanate nanotube structure (3D-STN) was constructed on its surface. Finally, the HR was anchored to the 3D-STN with the aid of polydopamine (PDA, P), forming the 3D-STN-P-HR scaffold. The results showed that the scaffold exhibited an ordered 3D porous structure, and that the surface was covered by a dense HHC36-RGD layer. Expectedly, the adsorption of PDA effectively slowed down the release of HR. Moreover, the functionalized scaffold had a significant inhibitory effect on Staphylococcus aureus and Escherichia coli, and its antibacterial rate could reach more than 95%. The results of in vitro cell culture experiments demonstrated that the 3D-STN-P-HR scaffold possessed excellent cytocompatibility and could promote the transcription of osteogenic differentiation-related genes and the expression of related proteins. In conclusion, the functionally modified 3D porous titanium alloy scaffold (3D-STN-P-HR) has a balanced antibacterial and osteogenic function, which bodes well for future potential in the customized functional reconstruction of complex-shaped infected bone defects.

A review on in vitro/in vivo response of additively manufactured Ti-6Al-4V alloy

Bone replacement using porous and solid metallic implants, such as Ti-alloy implants, is regarded as one of the most practical therapeutic approaches in biomedical engineering. The bone is a complex tissue with various mechanical properties based on the site of action. Patient-specific Ti-6Al-4V constructs may address the key needs in bone treatment for having customized implants that mimic the complex structure of the natural tissue and diminish the risk of implant failure. This review focuses on the most promising methods of fabricating such patient-specific Ti-6Al-4V implants using additive manufacturing (AM) with a specific emphasis on the popular subcategory, which is powder bed fusion (PBF). Characteristics of the ideal implant to promote optimized tissue-implant interactions, as well as physical, mechanical/chemical treatments and modifications will be discussed. Accordingly, such investigations will be classified into 3B-based approaches (Biofunctionality, Bioactivity, and Biostability), which mainly govern native body response and ultimately the success in implantation.

Preventing Antibiotic-Resistant Infections: Additively Manufactured Porous Ti6Al4V Biofunctionalized with Ag and Fe Nanoparticles

Implant-associated infections are highly challenging to treat, particularly with the emergence of multidrug-resistant microbials. Effective preventive action is desired to be at the implant site. Surface biofunctionalization of implants through Ag-doping has demonstrated potent antibacterial results. However, it may adversely affect bone regeneration at high doses. Benefiting from the potential synergistic effects, combining Ag with other antibacterial agents can substantially decrease the required Ag concentration. To date, no study has been performed on immobilizing both Ag and Fe nanoparticles (NPs) on the surface of additively manufactured porous titanium. We additively manufactured porous titanium and biofunctionalized its surface with plasma electrolytic oxidation using a Ca/P-based electrolyte containing Fe NPs, Ag NPs, and the combinations. The specimen's surface morphology featured porous TiO2 bearing Ag and Fe NPs. During immersion, Ag and Fe ions were released for up to 28 days. Antibacterial assays against methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa showed that the specimens containing Ag NPs and Ag/Fe NPs exhibit bactericidal activity. The Ag and Fe NPs worked synergistically, even when Ag was reduced by up to three times. The biofunctionalized scaffold reduced Ag and Fe NPs, improving preosteoblasts proliferation and Ca-sensing receptor activation. In conclusion, surface biofunctionalization of porous titanium with Ag and Fe NPs is a promising strategy to prevent implant-associated infections and allow bone regeneration and, therefore, should be developed for clinical application.

One-step coordination of metal-phenolic networks as antibacterial coatings with sustainable and controllable copper release for urinary catheter applications

Catheter-associated urinary tract infections (CAUTIs) draw great concern due to increased demand for urinary catheters in hospitalization. Encrustation caused by urinary pathogens, especially Proteus mirabilis, results in blocking of the catheter lumen and further infections. In this study, a facile and low-cost surface modification strategy of urinary catheters was developed using one-step coordination of tannic acid (TA) and copper ions. The copper content of the coating could be manipulated by the number of TA-Cu (TC) layers, and the coating released copper in a pH-responsive manner. The coating exhibited high antibacterial efficiency (killed >99% of planktonic bacteria, and reduced biofilm coverage to <1% after 24 h) due to the synergistic antimicrobial effect of TA and copper ions. In vivo study with a rabbit model indicated that with two TC layers, the coated catheter could effectively inhibit bacterial growth in urine and colonization on the surface, and reduce encrustation formation. In addition, the TC-coated catheter exhibited better tissue compatibility compared to the unmodified catheter, probably due to the antibacterial performance of the coating. Such a straightforward coating strategy with good in vitro and in vivo antibacterial properties and biocompatibility holds great promise for combating CAUTIs in clinical practice.

Antibacterial Activity Studies of 3D-Printing Polyetheretherketone Substrates with Surface Growth of 2D TiO2/ZnO Rodlike Arrays

Heterogeneous metal implants have been applied in clinical treatments of skeletal wounds, but their low antibacterial properties and the possibility of a release of metal ions may have harmful influences on the human body. Therefore, a polymer implant with low cost, high safety, an elastic modulus similar to that of human bone, and a good antibacterial property must be produced for orthopedic treatments. In this study, the surface of a 3D-printed polyetheretherketone (PEEK) disk was grown with ZnO/TiO2 rodlike arrays using a chemical bath deposition. X-ray diffraction patterns and transmission electron microscopy images showed that TiO2/ZnO rodlike arrays were deposited onto the PEEK substrate. With the direct absorption of antibiotic agents onto the surface of TiO2/ZnO/PEEK samples, their antibacterial performances greater than the values of minimum inhibitory concentration required to inhibit the growth of 90% of Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus) remained for around 10 days. The concentration of Zn2+ ions in a buffer solution is reduced with the coating of a TiO2 layer on a ZnO rodlike array. The sample with absorption from a mixture containing ampicillin and vancomycin salts with a weight ratio of 1:1 had the best inhibitory effect on the growth of E. coli and S. aureus.

Advanced Surface Modification for 3D-Printed Titanium Alloy Implant Interface Functionalization

With the development of three-dimensional (3D) printed technology, 3D printed alloy implants, especially titanium alloy, play a critical role in biomedical fields such as orthopedics and dentistry. However, untreated titanium alloy implants always possess a bioinert surface that prevents the interface osseointegration, which is necessary to perform surface modification to enhance its biological functions. In this article, we discuss the principles and processes of chemical, physical, and biological surface modification technologies on 3D printed titanium alloy implants in detail. Furthermore, the challenges on antibacterial, osteogenesis, and mechanical properties of 3D-printed titanium alloy implants by surface modification are summarized. Future research studies, including the combination of multiple modification technologies or the coordination of the structure and composition of the composite coating are also present. This review provides leading-edge functionalization strategies of the 3D printed titanium alloy implants.

Programmed Death of Injured Pseudomonas aeruginosa on Mechano-Bactericidal Surfaces

Mechano-bactericidal surfaces deliver lethal effects to contacting bacteria. Until now, cell death has been attributed to the mechanical stress imparted to the bacterial cell envelope by the surface nanostructures; however, the process of bacterial death encountering nanostructured surfaces has not been fully illuminated. Here, we perform an in-depth investigation of the mechano-bactericidal action of black silicon (bSi) surfaces toward Gram-negative bacteria Pseudomonas aeruginosa. We discover that the mechanical injury is not sufficient to kill the bacteria immediately due to the survival of the inner plasma membrane. Instead, such sublethal mechanical injury leads to apoptosis-like death (ALD) in affected bacteria. In addition, when the mechanical stress is removed, the self-accumulated reactive oxygen species (ROS) incur poststress ALD in damaged cells in a nonstressed environment, revealing that the mechano-bactericidal actions have sustained physiological effects on the bacterium. This work creates a new facet and can introduce many new regulation tools to this field.

Eco-friendly bacteria-killing by nanorods through mechano-puncture with top selectivity

Nanorods can induce mechano-puncture of Staphylococcus aureus (S. aureus) that often impairs osseointegration of orthopedic implants, while the critical nanorod top sharpness able to puncture S. aureus and the predominant contributor between top sharpness and length to mechano-puncture activity remains elusive. Herein, we fabricated three kinds of Al₂O₃-wrapped nanorods patterned arrays with different lengths and top sharpness. The top-sharp nanorods have lengths of 469 and 884 nm and the shorter show a length identical to the top-flat nanorods. Driven by the equivalent adhesive force of S. aureus, the top-flat nanorods deform cell envelops, showing a bacteriostatic rate of 29% owing to proliferation-inhibited manner. The top-sharp nanorods puncture S. aureus, showing a bactericidal rate of 96% for the longer, and 98% for the shorter that simultaneously exhibits fair osseointegration in bacteria-infected rat tibias, identifying top sharpness as a predominate contributor to mechano-puncture activity. Based on finite-element simulation, such top-flat nanorod derives the maximum stress (S_max) of 5.65 MPa on cell wall, lower than its ultimate-tensile-strength (13 MPa); while such top-sharp and shorter nanorod derives S_max of 20.15 MPa to puncture cell envelop. Moreover, a critical top conical angle of 138° is identified for nanorods able to puncture S. aureus.

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Top sharpness depended mechano-puncture of nanorods against S. aureus is clarified.

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Top-flat nanorods deform bacterial cell envelop to inhibit their proliferation.

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Top-sharp nanorods (conical angle of 50°) puncture bacteria to intensely kill them.

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138° is confirmed as critical top conical angle for nanorods to puncture S. aureus.

Bacterial adhesion to biomaterials: What regulates this attachment? A review

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Bacterial adhesion to the surface of dental materials play a significant role in infections.

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The factors that govern microbial attachment involves different types of physical-chemical interactions and biological processes.

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Studying bacterial adhesion makes it possible to understand the mechanisms involved in attachment and helps in the search for technologies that promote antibacterial surfaces.

Bacterial attachment to biomaterials is of great interest to the medical and dental field due to its impact on dental implants, dental prostheses, and others, leading to the need to introduce methods for biofilm control and mitigation of infections. Biofilm adhesion is a multifactorial process and involves characteristics relevant to the bacterial cell as well as biological, chemical, and physical properties relative to the surface of biomaterials. Bacteria encountered different environmental conditions during their growth and developed interspecies communication strategies, as well as various mechanisms to detect the environment and facilitate survival, such as chemical sensors or physical detection mechanisms. However, the factors that govern microbial attachment to surfaces are not yet fully understood. In order to understand how bacteria interact with surfaces, as well as to characterize the physical-chemical properties of bacteria adhesins, and to determine their interrelation with the adhesion to the substrate, in recent years new techniques of atomic force microscopy (AFM) have been developed and helped by providing quantitative results. Thus, the purpose of this review is to gather current studies about the factors that regulate microbial adhesion to surfaces in order to offer a guide to studies to obtain technologies that provide an antimicrobial surface.

Toward Bactericidal Enhancement of Additively Manufactured Titanium Implants

Implant-associated infections (IAIs) are among the most intractable and costly complications in implant surgery. They can lead to surgery failure, a high economic burden, and a decrease in patient quality of life. This manuscript is devoted to introducing current antimicrobial strategies for additively manufactured (AM) titanium (Ti) implants and fostering a better understanding in order to pave the way for potential modern high-throughput technologies. Most bactericidal strategies rely on implant structure design and surface modification. By means of rational structural design, the performance of AM Ti implants can be improved by maintaining a favorable balance between the mechanical, osteogenic, and antibacterial properties. This subject becomes even more important when working with complex geometries; therefore, it is necessary to select appropriate surface modification techniques, including both topological and chemical modification. Antibacterial active metal and antibiotic coatings are among the most commonly used chemical modifications in AM Ti implants. These surface modifications can successfully inhibit bacterial adhesion and biofilm formation, and bacterial apoptosis, leading to improved antibacterial properties. As a result of certain issues such as drug resistance and cytotoxicity, the development of novel and alternative antimicrobial strategies is urgently required. In this regard, the present review paper provides insights into the enhancement of bactericidal properties in AM Ti implants.

Toward Designing of Anti-infective Hydrogels for Orthopedic Implants: From Lab to Clinic

An alarming increase in implant failure incidence due to microbial colonization on the administered orthopedic implants has become a horrifying threat to replacement surgeries and related health concerns. In essence, microbial adhesion and its subsequent biofilm formation, antibiotic resistance, and the host immune system's deficiency are the main culprits. An advanced class of biomaterials termed anti-infective hydrogel implant coatings are evolving to subdue these complications. On this account, this review provides an insight into the significance of anti-infective hydrogels for preventing orthopedic implant associated infections to improve the bone healing process. We briefly discuss the clinical course of implant failure, with a prime focus on orthopedic implants. We identify the different anti-infective coating strategies and hence several anti-infective agents which could be incorporated in the hydrogel matrix. The fundamental design criteria to be considered while fabricating anti-infective hydrogels for orthopedic implants will be discussed. We highlight the different hydrogel coatings based on the origin of the polymers involved in light of their antimicrobial efficacy. We summarize the relevant patents reported in the prevention of implant infections, including orthopedics. Finally, the challenges concerning the clinical translation of the aforesaid hydrogels are described, and considerable solutions for improved clinical practice and better future prospects are proposed.

The effects of plasma electrolytically oxidized layers containing Sr and Ca on the osteogenic behavior of selective laser melted Ti6Al4V porous implants

Surface biofunctionalization is frequently applied to enhance the functionality and longevity of orthopedic implants. Here, we investigated the osteogenic effects of additively manufactured porous Ti6Al4V implants whose surfaces were biofunctionalized using plasma electrolytic oxidation (PEO) in Ca/P-based electrolytes with or without strontium. Various levels of Sr and Ca were incorporated in the oxide layers by using different current densities and oxidation times. Increasing the current density and oxidation time resulted in thicker titanium oxide layers and enhanced the release of Ca²⁺ and Sr²⁺. Biofunctionalization with strontium resulted in enhanced pore density, a thinner TiO₂ layer, four-fold reduced release of Ca²⁺, and mainly anatase phases as compared to implants biofunctionalized in electrolytes containing solely Ca/P species under otherwise similar conditions. Different current densities and oxidation times significantly increased the osteogenic differentiation of MC3T3-E1 cells on implants biofunctionalized with strontium, when the PEO treatment was performed with a current density of 20 A/dm² for 5 and 10 min as well as for a current density of 40 A/dm² for 5 min. Therefore, addition of Sr in the PEO electrolyte and control of the PEO processing parameters represent a promising way to optimize the surface morphology and osteogenic activity of future porous AM implants.

Self-defending additively manufactured bone implants bearing silver and copper nanoparticles

Effective preventive measures against implant-associated infection (IAI) are desperately needed. Therefore, the development of self-defending implants with intrinsic antibacterial properties has gained significant momentum. Biomaterials biofunctionalized with silver (Ag) have resulted in effective antibacterial biomaterials, yet regularly induce cytotoxicity. In this study, the use of both Ag and copper (Cu) nanoparticles (NPs) on TiO2 surfaces was investigated to generate antibacterial and osteoconductive biomaterials. Hence, additively manufactured Ti-6Al-4V volume-porous implants were biofunctionalized with plasma electrolytic oxidation (PEO) through the incorporation of varying ratios of Ag and/or Cu NPs in the TiO2 layer covering the implant surface. For all experimental groups, the surface morphology, chemical composition, ion release profile, generation of reactive ion species, antibacterial activity against methicillin-resistant Staphylococcus aureus (MRSA) in vitro and ex vivo, as well as the response of pre-osteoblastic MC3T3-E1 cells in metabolic activity and differentiation assays were determined. PEO biofunctionalization resulted in rough and highly porous surfaces that released Ag and Cu ions for 28 days and generated hydroxyl as well as methyl radicals. A strong synergistic bactericidal behavior between Ag and Cu ions was detected, which allowed to decrease the concentration of Ag ions by 10-fold, while maintaining the same level of antibacterial activity. Antibacterial agar diffusion and quantitative assays indicated strong antibacterial activity in vitro for the implants containing Ag and Ag/Cu, while no antibacterial activity was observed for implants bearing only Cu NPs. Moreover, the biofunctionalized implants with ratios of up to 75% Ag and 25% Cu NP totally eradicated all bacteria in an ex vivo model using murine femora. Meanwhile, the biofunctionalized implants did not show any signs of cytotoxicity, while implants bearing only Cu NPs improved the metabolic activity after 7 and 11 days. The biomaterials developed here, therefore, exploit the synergistic behavior of Ag and Cu to simultaneously offer strong antibacterial behavior while fully mitigating the cytotoxicity of Ag against mammalian cells.

A multifunctional electrowritten bi-layered scaffold for guided bone regeneration

The guided bone regeneration (GBR) concept has been extensively utilized to treat maxillofacial bone defects in clinical practice. However, the repair efficacy of currently available GBR membranes is often compromised by their limited bone regeneration potential and deficient antibacterial activity. In this study, inspired by the bi-layered structure design of the commonly used Bio-Gide^Ⓡmembrane, we designed and fabricated a new kind of multifunctional bi-layered "GBR scaffold" combining solution electrospinning writing (SEW) and solution electrospinning (SES) techniques using a single SEW printer. Copper-loaded mesoporous silica nanoparticles (Cu@MSNs) were incorporated into the poly(lactic-co-glycolic acid)/gelatin (PLGA/Gel, denoted as PG) fiber matrix to construct a composite PG-Cu@MSNs fibrous scaffold. The obtained GBR scaffold consisted of a loose and porous SEW layer to support and facilitate bone ingrowth, and a dense and compact SES layer to resist non-osteoblast interference. The resulting enhanced mechanical properties, coordinated degradation profile, and facile preparation procedure imparted the composite scaffold with good clinical feasibility. In vitro biological experiments indicate that the PG-Cu@MSNs composite scaffold exhibited favorable osteogenic and antibacterial properties. Furthermore, an in vivo rat periodontal defect model further confirmed the promising bone regeneration efficacy of the PG-Cu@MSNs scaffold. In conclusion, the developed electrowritten Cu@MSNs-incorporated bi-layered scaffold with hierarchical architecture and concurrent osteogenic and antibacterial functions may hold great potential for application in GBR.

[Research progress on antibacterial properties of porous medical implant materials]

OBJECTIVE

The antibacterial properties of porous medical implant materials were reviewed to provide guidance for further improvement of new medical implant materials.

METHODS

The literature related to the antibacterial properties of porous medical implant materials in recent years was consulted, and the classification, characteristics and applications, and antibacterial methods of porous medical implant materials were reviewed.

RESULTS

Porous medical implant materials can be classified according to surface pore size, preparation process, degree of degradation in vivo, and material source. It is widely used in the medical field due to its good biocompatibility and biomechanical properties. Nevertheless, the antibacterial properties of porous medical implant materials themselves are not obvious, and their antibacterial properties need to be improved through structural modification, overall modification, and coating modification.

CONCLUSION

At present, coating modification as the mainstream modification method for improving the antibacterial properties of porous medical materials is still a research hotspot. The introduction of new antibacterial substances provides a new perspective for the development of new coated porous medical implant materials, so that the porous medical implant materials have a more reliable antibacterial effect while taking into account biocompatibility.

A multifunctional silk coating on additively manufactured porous titanium to prevent implant-associated infection and stimulate bone regeneration

Despite tremendous progress in the design and manufacturing of metallic implants, they do not outlive the patient. To illustrate, more than half of hip replacements will fail, mainly due to implant infection and loosening. Surface engineering approaches and, in particular, coatings can facilitate implant bio-functionality via the recruitment of more host cells for new bone formation and inhibition of bacterial colonization. Here, we used electrophoretic deposition to apply a silk fibroin solution consisting of tricalcium phosphate (TCP) and vancomycin as a coating on the surface of additively-manufactured porous titanium. Furthermore, the surface properties of the coatings developed and the release kinetics of the vancomycin were studied to evaluate the applied coating. The in vitro antibacterial behavior of the multifunctional coating, as well as the cell viability and osteogenic differentiation of the MC3T3-E1 cell line were extensively studied. The biomaterials developed exhibited an antibacterial behavior with a reduction of up to four orders of magnitude in both planktonic and adherent bacteria for 6 h and 1 d. A live-dead assay, the Alamar Blue activity, the DNA content, and cytoskeleton staining demonstrated a significant increase in the cell density of the coated groups versus the as-manufactured ones. The significantly enhanced calcium deposition and the increase in mineralization for the groups with TCP after 21 and 28 d, respectively, demonstrate upregulation of the MC3T3 cells' osteogenic differentiation. Our results collectively show that the multifunctional coating studied here can be potentially used to develop a new generation of orthopedic implants.

Toward Antibacterial Coatings for Personalized Implants

The complex reconstructive surgeries for which patient-specific orthopedic, maxillofacial, or dental implants are used often necessitate wounds that are open for a considerable amount of time. Unsurprisingly, this allows bacteria to establish implant-associated infection, despite the scrupulous sterilization efforts made during surgery. Here, we developed a prophylactic bactericidal coating via electrophoretic deposition technology for two 3D-printed porous titanium implant designs. The surface characteristics, antibiotic release behavior, antibacterial properties, and impact on osteoblast cell proliferation of the optimized coatings were investigated. The results unequivocally confirmed the biofunctionality of the implants in vitro. This study reveals a new avenue for future antibacterial patient-specific implants.

A multifaceted biomimetic interface to improve the longevity of orthopedic implants

The rise of additive manufacturing has provided a paradigm shift in the fabrication of precise, patient-specific implants that replicate the physical properties of native bone. However, eliciting an optimal biological response from such materials for rapid bone integration remains a challenge. Here we propose for the first time a one-step ion-assisted plasma polymerization process to create bio-functional 3D printed titanium (Ti) implants that offer rapid bone integration. Using selective laser melting, porous Ti implants with enhanced bone-mimicking mechanical properties were fabricated. The implants were functionalized uniformly with a highly reactive, radical-rich polymeric coating generated using a unique combination of plasma polymerization and plasma immersion ion implantation. We demonstrated the performance of such activated Ti implants with a focus on the coating's homogeneity, stability, and biological functionality. It was shown that the optimized coating was highly robust and possessed superb physico-chemical stability in a corrosive physiological solution. The plasma activated coating was cytocompatible and non-immunogenic; and through its high reactivity, it allowed for easy, one-step covalent immobilization of functional biomolecules in the absence of solvents or chemicals. The activated Ti implants bio-functionalized with bone morphogenetic protein 2 (BMP-2) showed a reduced protein desorption and a more sustained osteoblast response both in vitro and in vivo compared to implants modified through conventional physisorption of BMP-2. The versatile new approach presented here will enable the development of bio-functionalized additively manufactured implants that are patient-specific and offer improved integration with host tissue. STATEMENT OF SIGNIFICANCE: Additive manufacturing has revolutionized the fabrication of patient-specific orthopedic implants. Although such 3D printed implants can show desirable mechanical and mass transport properties, they often require surface bio-functionalities to enable control over the biological response. Surface covalent immobilization of bioactive molecules is a viable approach to achieve this. Here we report the development of additively manufactured titanium implants that precisely replicate the physical properties of native bone and are bio-functionalized in a simple, reagent-free step. Our results show that covalent attachment of bone-related growth factors through ion-assisted plasma polymerized interlayers circumvents their desorption in physiological solution and significantly improves the bone induction by the implants both in vitro and in vivo.

Bactericidal coating to prevent early and delayed implant-related infections

The occurrence of an implant-associated infection (IAI) with the formation of a persisting bacterial biofilm remains a major risk following orthopedic biomaterial implantation. Yet, progress in the fabrication of tunable and durable implant coatings with sufficient bactericidal activity to prevent IAI has been limited. Here, an electrospun composite coating was optimized for the combinatorial and sustained delivery of antibiotics. Antibiotics-laden poly(ε-caprolactone) (PCL) and poly`1q`(lactic-co glycolic acid) (PLGA) nanofibers were electrospun onto lattice structured titanium (Ti) implants. In order to achieve tunable and independent delivery of vancomycin (Van) and rifampicin (Rif), we investigated the influence of the specific drug-polymer interaction and the nanofiber coating composition on the drug release profile and durability of the polymer-Ti interface. We found that a bi-layered nanofiber structure, produced by electrospinning of an inner layer of [PCL/Van] and an outer layer of [PLGA/Rif], yielded the optimal combinatorial drug release profile. This resulted in markedly enhanced bactericidal activity against planktonic and adherent Staphylococcus aureus for 6 weeks as compared to single drug delivery. Moreover, after 6 weeks, synergistic bacterial killing was observed as a result of sustained Van and Rif release. The application of a nanofiber-filled lattice structure successfully prevented the delamination of the multi-layer coating after press-fit cadaveric bone implantation. This new lattice design, in conjunction with the multi-layer nanofiber structure, can be applied to develop tunable and durable coatings for various metallic implantable devices. This is particularly appealing to tune the release of multiple antimicrobial agents over a period of weeks to prevent early and delayed onset IAI.

Current Status of Vancomycin Analytical Methods

BACKGROUND

The glycopeptide antibiotics are a class of antimicrobial drugs that are an important alternative for cases of bacterial infections resistant to penicillins, besides being able to be used to treat infections in people allergic to pencilin. They have great activity against Gram-positive microorganisms, including methicillin-resistant Staphylococcus aureus (MRSA), by inhibiting the cell wall synthesis.

OBJECTIVE

There are many analytical methods in the literature for determination of antimicrobial glycopeptide vancomycin in different matrixes that are very effective; however, all of them use toxic solvents, contributing to the generation of waste, causing damage to the environment and to the operator, as well as increased costs of analysis.

RESULTS

The most prevailing method found was high performance liquid chromatography (HPLC), followed by microbiological assays and, in less quantity, spectrometric methods. The chromatographic methods use organic solvents that are toxic, such as acetonitrile and methanol, and buffer solutions, that can damage the equipment and the column. In the microbiological assays the disc diffusion methods are still in the majority. The spectrophotometric methods were based in the UV-Vis region using buffer solutions as a diluent.

CONCLUSIONS

All these methods can become greener, following green analytical chemistry principles, which could bring benefits both to the environment and the operator, and reduce costs.

HIGHLIGHTS

In this paper, a literature review regarding analytical methods for determination of vancomycin was carried out with a suggestion of greener alternatives.

Functionality-packed additively manufactured porous titanium implants

The holy grail of orthopedic implant design is to ward off both aseptic and septic loosening for long enough that the implant outlives the patient. Questing this holy grail is feasible only if orthopedic biomaterials possess a long list of functionalities that enable them to discharge the onerous task of permanently replacing the native bone tissue. Here, we present a rationally designed and additive manufacturing (AM) topologically ordered porous metallic biomaterial that is made from Ti-6Al-4V using selective laser melting and packs most (if not all) of the required functionalities into a single implant. In addition to presenting a fully interconnected porous structure and form-freedom that enables realization of patient-specific implants, the biomaterials developed here were biofunctionalized using plasma electrolytic oxidation to locally release both osteogenic (i.e. strontium) and antibacterial (i.e. silver ions) agents. The same single-step biofunctionalization process also incorporated hydroxyapatite into the surface of the implants. Our measurements verified the continued release of both types of active agents up to 28 days. Assessment of the antibacterial activity in vitro and in an ex vivo murine model demonstrated extraordinarily high levels of bactericidal effects against a highly virulent and multidrug-resistant Staphylococcus aureus strain (i.e. USA300) with total eradication of both planktonic and adherent bacteria. This strong antibacterial behavior was combined with a significantly enhanced osteogenic behavior, as evidenced by significantly higher levels of alkaline phosphatase (ALP) activity compared with non-biofunctionalized implants. Finally, we discovered synergistic antibacterial behavior between strontium and silver ions, meaning that 4-32 folds lower concentrations of silver ions were required to achieve growth inhibition and total killing of bacteria. The functionality-packed biomaterial presented here demonstrates a unique combination of functionalities that make it an advanced prototype of future orthopedic biomaterials where implants will outlive patients.

Immunomodulation of surface biofunctionalized 3D printed porous titanium implants

Additive manufacturing (AM) techniques have provided many opportunities for the rational design of porous metallic biomaterials with complex and precisely controlled topologies that give rise to unprecedented combinations of mechanical, physical, and biological properties. These favorable properties can be enhanced by surface biofunctionalization to enable full tissue regeneration and minimize the risk of implant-associated infections (IAIs). There is, however, an increasing need to investigate the immune responses triggered by surface biofunctionalized AM porous metals. Here, we studied the immunomodulatory effects of AM porous titanium (Ti-6Al-4V) printed using selective laser melting, and of two additional groups consisting of AM implants surface biofunctionalized using plasma electrolytic oxidation (PEO) with/without silver nanoparticles. The responses of human primary macrophages and human mesenchymal stromal cells (hMSCs) were studied in terms of cell viability, cell morphology and biomarkers of macrophage polarization. Non-treated AM porous titanium triggered a strong pro-inflammatory response in macrophages, albeit combined with signs of anti-inflammatory effects. The PEO treatment of AM porous titanium implants showed a higher potential to induce polarization towards a pro-repair macrophage phenotype. We detected no cytotoxicity against hMSCs in any of the groups. However, the incorporation of silver nanoparticles resulted in strong cytotoxicity against attached macrophages. The results of this study indicate the potential immunomodulatory effects of the AM porous titanium enhanced with PEO treatment, and point towards caution and further research when using silver nanoparticles for preventing IAIs.

Bone Regeneration in Critical-Sized Bone Defects Treated with Additively Manufactured Porous Metallic Biomaterials: The Effects of Inelastic Mechanical Properties

Additively manufactured (AM) porous metallic biomaterials, in general, and AM porous titanium, in particular, have recently emerged as promising candidates for bone substitution. The porous design of such materials allows for mimicking the elastic mechanical properties of native bone tissue and showed to be effective in improving bone regeneration. It is, however, not clear what role the other mechanical properties of the bulk material such as ductility play in the performance of such biomaterials. In this study, we compared the bone tissue regeneration performance of AM porous biomaterials made from the commonly used titanium alloy Ti6Al4V-ELI with that of commercially pure titanium (CP-Ti). CP-Ti was selected because of its high ductility as compared to Ti6Al4V-ELI. Critical-sized (6 mm diameter) femoral defects in rats were treated with implants made from both Ti6Al4V-ELI and CP-Ti. Bone regeneration was assessed up to 11 weeks using micro-CT scanning. The regenerated bone volume was assessed ex vivo followed by histology and biomechanical testing to assess osseointegration of the implants. The bony defects treated with AM CP-Ti implants generally showed higher volumes of regenerated bone as compared to those treated with AM Ti6Al4V-ELI. The torsional strength of the two titanium groups were similar however, and both considerably lower than those measured for intact bony tissue. These findings show the importance of material type and ductility of the bulk material in the ability for bone tissue regeneration of AM porous biomaterials.

Biofunctionalization of selective laser melted porous titanium using silver and zinc nanoparticles to prevent infections by antibiotic-resistant bacteria

Antibiotic-resistant bacteria are frequently involved in implant-associated infections (IAIs), making the treatment of these infections even more challenging. Therefore, multifunctional implant surfaces that simultaneously possess antibacterial activity and induce osseointegration are highly desired in order to prevent IAIs. The incorporation of multiple inorganic antibacterial agents onto the implant surface may aid in generating synergistic antibacterial behavior against a wide microbial spectrum while reducing the occurrence of bacterial resistance. In this study, porous titanium implants synthesized by selective laser melting (SLM) were biofunctionalized with plasma electrolytic oxidation (PEO) using electrolytes based on Ca/P species as well as silver and zinc nanoparticles in ratios from 0 to 100% that were tightly embedded into the growing titanium oxide layer. After the surface bio-functionalization process, silver and zinc ions were released from the implant surfaces for at least 28 days resulting in antibacterial leaching activity against methicillin-resistant Staphylococcus aureus (MRSA). Furthermore, the biofunctionalized implants generated reactive oxygen species, thereby contributing to antibacterial contact-killing. While implant surfaces containing up to 75% silver and 25% zinc nanoparticles fully eradicated both adherent and planktonic bacteria in vitro as well as in an ex vivo experiment performed using murine femora, solely zinc-bearing surfaces did not. The minimum inhibitory and bactericidal concentrations determined for different combinations of both types of ions confirmed the presence of a strong synergistic antibacterial behavior, which could be exploited to reduce the amount of required silver ions by two orders of magnitude (i.e., 120 folds). At the same time, the zinc bearing surfaces enhanced the metabolic activity of pre-osteoblasts after 3, 7, and 11 days. Altogether, implant biofunctionalization by PEO with silver and zinc nanoparticles is a fruitful strategy for the synthesis of multifunctional surfaces on orthopedic implants and the prevention of IAIs caused by antibiotic-resistant bacteria. STATEMENT OF SIGNIFICANCE: Implant-associated infections are becoming increasingly challenging to treat due to growing antibiotic resistance against antibiotics. Here, we propose an alternative approach where silver and zinc nanoparticles are simultaneously used for the biofunctionalization of rationally designed additively manufactured porous titanium. This combination of porous design and tailored surface treatment allows us to reduce the amount of required silver nanoparticles by two orders of magnitude, fully eradicate antibiotic-resistant bacteria, and enhance the osteogenic behavior of pre-osteoblasts. We demonstrate that the resulting implants display antibacterial activity in vitro and ex vivo against methicillin-resistant Staphylococcus aureus.

Multifunctional Properties of Quercitrin-Coated Porous Ti-6Al-4V Implants for Orthopaedic Applications Assessed In Vitro

(1) One strategy to improve the outcome of orthopedic implants is to use porous implants with the addition of a coating with an antibacterial biomolecule. In this study, we aimed to produce and test the biocompatibility, the osteopromotive (both under normal conditions and under a bacterial challenge with lipopolysaccharide (LPS)) and antibacterial activities of a porous Ti-6Al-4V implant coated with the flavonoid quercitrin in vitro. (2) Porous Ti-6Al-4V implants were produced by 3D printing and further functionalized with quercitrin by wet chemistry. Implants were characterized in terms of porosity and mechanical testing, and the coating with quercitrin by fluorescence staining. Implant biocompatibility and bioactivity was tested using MC3T3-E1 preosteoblasts by analyzing cytotoxicity, cell adhesion, osteocalcin production, and alkaline phosphatase (ALP) activity under control and under bacterial challenging conditions using lipopolysaccharide (LPS). Finally, the antibacterial properties of the implants were studied using Staphylococcus epidermidis by measuring bacterial viability and adhesion. (3) Porous implants showed pore size of about 500 µm and a porosity of 52%. The coating was homogeneous over all the 3D surface and did not alter the mechanical properties of the Young modulus. Quercitrin-coated implants showed higher biocompatibility, cell adhesion, and osteocalcin production compared with control implants. Moreover, higher ALP activity was observed for the quercitrin group under both normal and bacterial challenging conditions. Finally, S. epidermidis live/dead ratio and adhesion after 4 h of incubation was lower on quercitrin implants compared with the control. (4) Quercitrin-functionalized porous Ti-6Al-4V implants present a great potential as an orthopedic porous implant that decreases bacterial adhesion and viability while promoting bone cell growth and differentiation.

Electrodeposited Assembly of Additive-Free Silk Fibroin Coating from Pre-Assembled Nanospheres for Drug Delivery

Electrophoretically deposited (EPD) polymer-based coatings have been extensively reported as reservoirs in medical devices for delivery of therapeutic agents, but control over drug release remains a challenge. Here, a simple but uncommon assembly strategy for EPD polymer coatings was proposed to improve drug release without introducing any additives except the EPD matrix polymer precursor. The added value of the proposed strategy was demonstrated by developing a novel EPD silk fibroin (SF) coating assembled from pre-assembled SF nanospheres for an application model, that is, preventing infections around percutaneous orthopedic implants via local delivery of antibiotics. The EPD mechanism of this nanosphere coating involved oxidation of water near the substrate to neutralize SF nanospheres, resulting in irreversible deposition. The deposition process and mass could be easily controlled using the applied EPD parameters. In comparison with the EPD SF coating assembled in a conventional way (directly obtained from SF molecule solutions), this novel coating had a similar adhesion strength but exhibited a more hydrophobic nanotopography to induce better fibroblastic response. Moreover, the use of nanospheres as building blocks enabled 1.38 and 21 times enhancement on the antibiotic release amount and time (of 95% maximum dug release), respectively, while retaining drug effectiveness and showing undetectable cytotoxicity. This unexpected release kinetics was found attributable to the electrostatic and hydrophobic interactions between the drug and nanospheres and a negligible initial dissolution effect on the nanosphere coating. These results illustrate the promising potential of the pre-assembled strategy on EPD polymer coatings for superior control over drug delivery.

Meta-biomaterials

Meta-biomaterials are designer biomaterials with unusual and even unprecedented properties that primarily originate from their geometrical designs at different (usually smaller) length scales.

Micrococcal-Nuclease-Triggered On-Demand Release of Vancomycin from Intramedullary Implant Coating Eradicates Staphylococcus aureus Infection in Mouse Femoral Canals

Preventing orthopedic implant-associated bacterial infections remains a critical challenge. Current practices of physically blending high-dose antibiotics with bone cements is known for cytotoxicity while covalently tethering antibiotics to implant surfaces is ineffective in eradicating bacteria from the periprosthetic tissue environment due to the short-range bactericidal actions, which are limited to the implant surface. Here, we covalently functionalize poly(ethylene glycol) dimethacrylate hydrogel coatings with vancomycin via an oligonucleotide linker sensitive to Staphylococcus aureus (S. aureus) micrococcal nuclease (MN) (PEGDMA-Oligo-Vanco). This design enables the timely release of vancomycin in the presence of S. aureus to kill the bacteria both on the implant surface and within the periprosthetic tissue environment. Ti6Al4V intramedullary (IM) pins surface-tethered with dopamine methacrylamide (DopaMA) and uniformly coated with PEGDMA-Oligo-Vanco effectively prevented periprosthetic infections in mouse femoral canals inoculated with bioluminescent S. aureus. Longitudinal bioluminescence monitoring, μCT quantification of femoral bone changes, end point quantification of implant surface bacteria, and histological detection of S. aureus in the periprosthetic tissue environment confirmed rapid and sustained bacterial clearance by the PEGDMA-Oligo-Vanco coating. The observed eradication of bacteria was in stark contrast with the significant bacterial colonization on implants and osteomyelitis development found in the absence of the MN-sensitive bactericidal coating. The effective vancomycin tethering dose presented in this on-demand release strategy was >200 times lower than the typical prophylactic antibiotic contents used in bone cements and may be applied to medical implants and bone/dental cements to prevent periprosthetic infections in high-risk clinical scenarios. This study also supports the timely bactericidal action by MN-triggered release of antibiotics as an effective prophylactic method to bypass the notoriously harder to treat periprosthetic biofilms and osteomyelitis.

Porous Tantalum and Titanium in Orthopedics: A Review

Porous metal is metal with special porous structures, which can offer high biocompatibility and low Young's modulus to satisfy the need for orthopedic applications. Titanium and tantalum are the most widely used porous metals in orthopedics due to their excellent biomechanical properties and biocompatibility. Porous titanium and tantalum have been studied and applied for a long history until now. Here in this review, various manufacturing methods of titanium and tantalum porous metals are introduced. Application of these porous metals in different parts of the body are summarized, and strengths and weaknesses of these porous metal implants in clinical practice are discussed frankly for future improvement from the viewpoint of orthopedic surgeons. Then according to the requirements from clinics, progress in research for clinical use is illustrated in four aspects. Various creative designs of microporous and functionally gradient structure, surface modification, and functional compound systems of porous metal are exhibited as reference for future research. Finally, the directions of orthopedic porous metal development were proposed from the clinical view based on the rapid progress of additive manufacturing. Controllable design of both macroscopic anatomical bionic shape and microscopic functional bionic gradient porous metal, which could meet the rigorous mechanical demand of bone reconstruction, should be developed as the focus. The modification of a porous metal surface and construction of a functional porous metal compound system, empowering stronger cell proliferation and antimicrobial and antineoplastic property to the porous metal implant, also should be taken into consideration.

Towards osteogenic and bactericidal nanopatterns?

Recent discoveries have shown that nanopatterns with feature sizes ≤100 nm could direct stem cell fate or kill bacteria. These effects could be used to develop orthopedic implants with improved osseointegration and decreased chance of implant-associated infections. The quest for osteogenic and bactericidal nanopatterns is ongoing but no controlled nanopatterns with dual osteogenic and bactericidal functionalities have been found yet. In this study, electron beam induced deposition (EBID) was used for accurate and reproducible decoration of silicon surfaces with four different types of nanopatterns. The features used in the first two nanopatterns (OST1 and OST2) were derived from osteogenic nanopatterns known to induce osteogenic differentiation of stem cells in the absence of osteogenic supplements. Two modifications of these nanopatterns were also included (OST2-SQ, OST2-H90) to study the effects of controlled disorder and lower nanopillar heights. An E. coli K-12 strain was used for probing the response of bacteria to the nanopatterns. Three nanopatterns (OST2, OST2-SQ, and OST2-H90) exhibited clear bactericidal behavior as evidenced by severely damaged cells and disrupted formation of extracellular polymeric substance. These findings indicate that controlled nanopatterns with features derived from osteogenic ones can have bactericidal activity and that EBID represents an enabling nanotechnology to achieve (multi)functional nanopatterns for bone implants.

Engineering a multifunctional 3D-printed PLA-collagen-minocycline-nanoHydroxyapatite scaffold with combined antimicrobial and osteogenic effects for bone regeneration

3D-printing and additive manufacturing can be powerful techniques to design customized structures and produce synthetic bone grafts with multifunctional effects suitable for bone repair. In our work we aimed the development of novel multifunctionalized 3D printed poly(lactic acid) (PLA) scaffolds with bioinspired surface coatings able to reduce bacterial biofilm formation while favoring human bone marrow-derived mesenchymal stem cells (hMSCs) activity. For that purpose, 3D printing was used to prepare PLA scaffolds that were further multifunctionalized with collagen (Col), minocycline (MH) and bioinspired citrate- hydroxyapatite nanoparticles (cHA). PLA-Col-MH-cHA scaffolds provide a closer structural support approximation to native bone architecture with uniform macroporous, adequate wettability and an excellent compressive strength. The addition of MH resulted in an adequate antibiotic release profile that by being compatible with local drug delivery therapy was translated into antibacterial activities against Staphylococcus aureus, a main pathogen associated to bone-related infections. Subsequently, the hMSCs response to these scaffolds revealed that the incorporation of cHA significantly stimulated the adhesion, proliferation and osteogenesis-related gene expression (RUNX2, OCN and OPN) of hMSCs. Furthermore, the association of a bioinspired material (cHA) with the antibiotic MH resulted in a combined effect of an enhanced osteogenic activity. These findings, together with the antibiofilm activity depicted strengthen the appropriateness of this 3D-printed PLA-Col-MH-cHA scaffold for future use in bone repair. By targeting bone repair while mitigating the typical infections associated to bone implants, our 3D scaffolds deliver an integrated strategy with the combined effects further envisaging an increase in the success rate of bone-implanted devices.

Nanosilver/poly (dl-lactic-co-glycolic acid) on titanium implant surfaces for the enhancement of antibacterial properties and osteoinductivity

Background

Despite titanium (Ti) implants have been commonly used in the medical device field due to their superior biocompatibility, implant-associated bacterial infection remains a major clinical complication. Nanosilver, an effective antibacterial agent against a wide spectrum of bacterial strains, with a low-resistance potential, has attracted much interest too. Incorporation of nanosilver on Ti implants may be a promising approach to prevent biofilm formation.

Purpose

The objective of the study was to investigate the antibacterial effects and osteoinductive properties of nanosilver/poly (dl-lactic-co-glycolic acid)-coated titanium (NSPTi).

Methods

Gram-positive methicillin-resistant Staphylococcus aureus (MRSA) and the Gram-negative opportunistic pathogen Pseudomonas aeruginosa (PAO-1) were used to evaluate the antibacterial activity of NSPTi implants through the analysis of bacterial colonization in vitro and in vivo. Furthermore, we examined the osteoinductive potential of NSPTi implants by investigating the proliferation and differentiation of MC3T3-E1 preosteoblast cells. In vivo, the osteoinductive properties of NSPTi implants were assessed by radiographic evaluation, H&E staining, and Masson’s trichrome staining.

Results

In vitro, bacterial adhesion to the 2% NSPTi was significantly inhibited and <1% of adhered bacteria survived after 24 hours. In vitro, the average colony-forming units (CFU)/g ratios in the 2% NSPTi with 10³ CFU MRSA and PAO-1 were 1.50±0.68 and 1.75±0.6, respectively. In the uncoated Ti groups, the ratios were 1.03±0.82×10³ and 0.94±0.49×10³, respectively. These results demonstrated that NSPTi implants had prominent antibacterial properties. Proliferation of MC3T3-E1 cells on the 2% NSPTi sample was 1.51, 1.78, and 2.22 times that on the uncoated Ti control after 3, 5, and 7 days’ incubation, respectively. Furthermore, NSPTi implants promoted the maturation and differentiation of MC3T3-E1 cells. In vivo, NSPTi accelerated the formation of new bone while suppressing bacterial survival.

Conclusion

NSPTi implants have simultaneous antibacterial and osteoinductive activities and therefore have the potential in clinical applications.

Mechanical performance of additively manufactured meta-biomaterials

Additive manufacturing (AM) (=3D printing) and rational design techniques have enabled development of meta-biomaterials with unprecedented combinations of mechanical, mass transport, and biological properties. Such meta-biomaterials are usually topologically ordered and are designed by repeating a number of regular unit cells in different directions to create a lattice structure. Establishing accurate topology-property relationships is of critical importance for these materials. In this paper, we specifically focus on AM metallic meta-biomaterials aimed for application as bone substitutes and orthopaedic implants and review the currently available evidence regarding their mechanical performance under quasi-static and cyclic loading conditions. The topology-property relationships are reviewed for regular beam-based lattice structures, sheet-based lattice structures including those based on triply periodic minimal surface, and graded designs. The predictive models used for establishing the topology-property relationships including analytical and computational models are covered as well. Moreover, we present an overview of the effects of the AM processes, material type, tissue regeneration, biodegradation, surface bio-functionalization, post-manufacturing (heat) treatments, and loading profiles on the quasi-static mechanical properties and fatigue behavior of AM meta-biomaterials. AM meta-biomaterials exhibiting unusual mechanical properties such as negative Poisson's ratios (auxetic meta-biomaterials), shape memory behavior, and superelasitcity as well as the potential applications of such unusual behaviors (e.g. deployable implants) are presented too. The paper concludes with some suggestions for future research. STATEMENT OF SIGNIFICANCE: Additive manufacturing enables fabrication of meta-biomaterials with rare combinations of topological, mechanical, and mass transport properties. Given that the micro-scale topological design determines the macro-scale properties of meta-biomaterials, establishing topology-property relationships is the central research question when rationally designing meta-biomaterials. The interest in understanding the relationship between the topological design and material type on the one hand and the mechanical properties and fatigue behavior of meta-biomaterials on the other hand is currently booming. This paper presents and critically evaluates the most important trends and findings in this area with a special focus on the metallic biomaterials used for skeletal applications to enable researchers better understand the current state-of-the-art and to guide the design of future research projects.

Bactericidal effects of nanopatterns: A systematic review

We systematically reviewed the currently available evidence on how the design parameters of surface nanopatterns (e.g. height, diameter, and interspacing) relate to their bactericidal behavior. The systematic search of the literature resulted in 46 studies that satisfied the inclusion criteria of examining the bactericidal behavior of nanopatterns with known design parameters in absence of antibacterial agents. Twelve of the included studies also assessed the cytocompatibility of the nanopatterns. Natural and synthetic nanopatterns with a wide range of design parameters were reported in the included studies to exhibit bactericidal behavior. However, most design parameters were in the following ranges: heights of 100-1000 nm, diameters of 10-300 nm, and interspacings of  <500 nm. The most commonly used type of nanopatterns were nanopillars, which could kill bacteria in the following range of design parameters: heights of 100-900 nm, diameters of 20-207 nm, and interspacings of 9-380 nm. The vast majority of the cytocompatibility studies (11 out of 12) showed no adverse effects of bactericidal nanopatterns with the only exception being nanopatterns with extremely high aspect ratios. The paper concludes with a discussion on the evidence available in the literature regarding the killing mechanisms of nanopatterns and the effects of other parameters including surface affinity of bacteria, cell size, and extracellular polymeric substance (EPS) on the killing efficiency. STATEMENT OF SIGNIFICANCE: The use of nanopatterns to kill bacteria without the need for antibiotics represents a rapidly growing area of research. However, the optimum design parameters to maximize the bactericidal behavior of such physical features need to be fully identified. The present manuscript provides a systematic review of the bactericidal nanopatterned surfaces. Identifying the effective range of dimensions in terms of height, diameter, and interspacings, as well as covering their impact on mammalian cells, has enabled a comprehensive discussion including the bactericidal mechanisms and the factors controlling the bactericidal efficiency. Overall, this review helps the readers have a better understanding of the state-of-the-art in the design of bactericidal nanopatterns, serving as a design guideline and contributing to the design of future experimental studies.

Strategically prolonged release of multiple antibacterial components from a thin film coating for synergistic effects against Staphylococcus aureus infections

Biomaterial-associated infections (BAIs) remain a major challenge in clinical surgery because they can potentially cause serious disabilities in patients.

Additively manufactured porous metallic biomaterials

Additively manufactured (AM, =3D printed) porous metallic biomaterials with topologically ordered unit cells have created a lot of excitement and are currently receiving a lot of attention given their great potential for improving bone tissue regeneration and preventing implant-associated infections.

Antimicrobial Titanium Surface via Click-Immobilization of Peptide and Its in Vitro/Vivo Activity

The use of antimicrobial peptides (AMPs)-functionalized titanium implants is an efficient method for preventing bacterial infection. However, the attachment of AMPs to the surface of titanium implants remains a challenge. In this study, a "clickable" titanium surface was developed by using a silane coupling agent with an alkynyl group. The antimicrobial titanium implant was then constructed through the reaction between the "clickable" surface and azido-AMPs (PEG-HHC36:N₃-PEG₁₂-KRWWKWWRR) via click chemistry of Cu(I)-catalyzed azide-alkyne cycloaddition (CuAAC). Such an antimicrobial titanium implant, with an AMP density of 897.4 ± 67.3 ng/cm² (2.5 ± 0.2 molecules per nm²) on the surface, exhibited good and stable antimicrobial activity, inhibited 90.2% of Staphylococcus aureus and 88.1% of Escherichia coli after 2.5 h of incubation, and even inhibited 69.5% of Staphylococcus aureus after 4 days of degradation. The CCK-8 assay indicated that the antimicrobial titanium implant exhibited negligible cytotoxicity to mouse bone mesenchymal stem cells. In vivo assay illustrated that this implant could kill 78.8% of Staphylococcus aureus after 7 days. This method has great potential for the preparation of antimicrobial titanium implants and the prevention of infections in the clinic.

Data on a rat infection model to assess porous titanium implant coatings

A model is needed to study the effectiveness of different anti-bacterial coatings on complex metal implants in a bone environment. This article shares data on the design of porous titanium implants for intramedullary implantation in the proximal rat tibia. The implant length, diameter and porosity were optimized after testing on cadaveric specimens. This article shares data on which parameters are critical to establish a chronic implant infection in Sprague Dawley rats when using the new implant design. To this end, different strains of Staphylococcus aureus and inoculation doses were investigated.

Antibacterial and immunogenic behavior of silver coatings on additively manufactured porous titanium

Implant-associated infections (IAI) are often recurrent, expensive to treat, and associated with high rates of morbidity, if not mortality. We biofunctionalized the surface of additively manufactured volume-porous titanium implants using electrophoretic deposition (EPD) as a way to eliminate the peri-operative bacterial load and prevent IAI. Chitosan-based (Ch) coatings were incorporated with different concentrations of silver (Ag) nanoparticles or vancomycin. A full-scale in vitro and in vivo study was then performed to evaluate the antibacterial, immunogenic, and osteogenic activity of the developed implants. In vitro, Ch + vancomycin or Ch + Ag coatings completely eliminated, or reduced the number of planktonic and adherent Staphylococcus aureus by up to 4 orders of magnitude, respectively. In an in vivo tibia intramedullary implant model, Ch + Ag coatings caused no adverse immune or bone response under aseptic conditions. Following Staphylococcus aureus inoculation, Ch + vancomycin coatings reduced the implant infection rate as compared to chitosan-only coatings. Ch + Ag implants did not demonstrate antibacterial effects in vivo and even aggravated infection-mediated bone remodeling including increased osteoclast formation and inflammation-induced new bone formation. As an explanation for the poor antibacterial activity of Ch + Ag implants, it was found that antibacterial Ag concentrations were cytotoxic for neutrophils, and that non-toxic Ag concentrations diminished their phagocytic activity. This study shows the potential of EPD coating to biofunctionalize porous titanium implants with different antibacterial agents. Using this method, Ag-based coatings seem inferior to antibiotic coatings, as their adverse effects on the normal immune response could cancel the direct antibacterial effects of Ag nanoparticles. STATEMENT OF SIGNIFICANCE: Implant-associated infections (IAI) are a clinical, societal, and economical burden. Surface biofunctionalization approaches can render complex metal implants with strong local antibacterial action. The antibacterial effects of inorganic materials such as silver nanoparticles (Ag NPs) are often highlighted under very confined conditions in vitro. As a novelty, this study also reports the antibacterial, immunogenic, and osteogenic activity of Ag NP-coated additively-manufactured titanium in vivo. Importantly, it was found that the developed coatings could impair the normal function of neutrophils, the most important phagocytic cells protecting us from IAI. Not surprisingly, the Ag NP-based coatings were outperformed by an antibiotic-based coating. This emphasizes the importance of also targeting implant immune-modulatory functions in future coating strategies against IAI.

In-silico quest for bactericidal but non-cytotoxic nanopatterns

Nanopillar arrays that are bactericidal but not cytotoxic against the host cells could be used in implantable medical devices to prevent implant-associated infections. It is, however, unclear what heights, widths, interspacing, and shape should be used for the nanopillars to achieve the desired antibacterial effects while not hampering the integration of the device in the body. Here, we present an in-silico approach based on finite element modeling of the interactions between Staphylococcus aureus and nanopatterns on the one hand and osteoblasts and nanopatterns on the other hand to find the best design parameters. We found that while the height of the nanopillars seems to have little impact on the bactericidal behavior, shorter widths and larger interspacings substantially increase the bactericidal effects. The same combination of parameters could, however, also cause cytotoxicity. Our results suggest that a specific combination of height (120 nm), width (50 nm), and interspacing (300 nm) offers the bactericidal effects without cytotoxicity.

Direct covalent attachment of silver nanoparticles on radical-rich plasma polymer films for antibacterial applications

Prevention and treatment of biomaterial-associated infections (BAI) are imperative requirements for the effective and long-lasting function of orthopedic implants. Surface-functionalization of these materials with antibacterial agents, such as antibiotics, nanoparticles and peptides, is a promising approach to combat BAI. The well-known silver nanoparticles (AgNPs) in particular, although benefiting from strong and broad-range antibacterial efficiency, have been frequently associated with mammalian cell toxicity when physically adsorbed on biomaterials. The majority of irreversible immobilization techniques employed to fabricate AgNP-functionalized surfaces are based on wet-chemistry methods. However, these methods are typically substrate-dependent, complex, and time-consuming. Here we present a simple and dry strategy for the development of polymeric coatings used as platforms for the direct, linker-free covalent attachment of AgNPs onto solid surfaces using ion-assisted plasma polymerization. The resulting coating not only exhibits long-term antibiofilm efficiency against adherent Staphylococcus aureus (S. aureus), but also enhances osteoblast adhesion and proliferation. High resolution X-ray photoelectron spectroscopy (XPS), before and after sodium dodecyl sulfate (SDS) washing, confirms covalent bonding. The development of such silver-functionalized surfaces through a simple, plasma-based process holds great promise for the fabrication of implantable devices with improved tissue-implant integration and reduced biomaterial associated infections.