Use of Biomaterials in 3D Printing as a Solution to Microbial Infections in Arthroplasty and Osseous Reconstruction

The incidence of microbial infections in orthopedic prosthetic surgeries is a perennial problem that increases morbidity and mortality, representing one of the major complications of such medical interventions. The emergence of novel technologies, especially 3D printing, represents a promising avenue of development for reducing the risk of such eventualities. There are already a host of biomaterials, suitable for 3D printing, that are being tested for antimicrobial properties when they are coated with bioactive compounds, such as antibiotics, or combined with hydrogels with antimicrobial and antioxidant properties, such as chitosan and metal nanoparticles, among others. The materials discussed in the context of this paper comprise beta-tricalcium phosphate (β-TCP), biphasic calcium phosphate (BCP), hydroxyapatite, lithium disilicate glass, polyetheretherketone (PEEK), poly(propylene fumarate) (PPF), poly(trimethylene carbonate) (PTMC), and zirconia. While the recent research results are promising, further development is required to address the increasing antibiotic resistance exhibited by several common pathogens, the potential for fungal infections, and the potential toxicity of some metal nanoparticles. Other solutions, like the incorporation of phytochemicals, should also be explored. Incorporating artificial intelligence (AI) in the development of certain orthopedic implants and the potential use of AI against bacterial infections might represent viable solutions to these problems. Finally, there are some legal considerations associated with the use of biomaterials and the widespread use of 3D printing, which must be taken into account.

There Are over 60 Ways to Produce Biocompatible Calcium Orthophosphate (CaPO4) Deposits on Various Substrates

A The present overview describes various production techniques for biocompatible calcium orthophosphate (abbreviated as CaPO4) deposits (coatings, films and layers) on the surfaces of various types of substrates to impart the biocompatible properties for artificial bone grafts. Since, after being implanted, the grafts always interact with the surrounding biological tissues at the interfaces, their surface properties are considered critical to clinical success. Due to the limited number of materials that can be tolerated in vivo, a new specialty of surface engineering has been developed to desirably modify any unacceptable material surface characteristics while maintaining the useful bulk performance. In 1975, the development of this approach led to the emergence of a special class of artificial bone grafts, in which various mechanically stable (and thus suitable for load-bearing applications) implantable biomaterials and artificial devices were coated with CaPO4. Since then, more than 7500 papers have been published on this subject and more than 500 new publications are added annually. In this review, a comprehensive analysis of the available literature has been performed with the main goal of finding as many deposition techniques as possible and more than 60 methods (double that if all known modifications are counted) for producing CaPO4 deposits on various substrates have been systematically described. Thus, besides the introduction, general knowledge and terminology, this review consists of two unequal parts. The first (bigger) part is a comprehensive summary of the known CaPO4 deposition techniques both currently used and discontinued/underdeveloped ones with brief descriptions of their major physical and chemical principles coupled with the key process parameters (when possible) to inform readers of their existence and remind them of the unused ones. The second (smaller) part includes fleeting essays on the most important properties and current biomedical applications of the CaPO4 deposits with an indication of possible future developments.

Manufacturing methods, properties, and potential applications in bone tissue regeneration of hydroxyapatite-chitosan biocomposites: A review

Hydroxyapatite (HA) and chitosan (CS) biopolymer are the major materials investigated for biomedical purposes. Both of these components play an important role in the orthopedic field as bone substitutes or drug release systems. Used separately, the hydroxyapatite is quite fragile, while CS mechanical strength is very weak. Therefore, a combination of HA and CS polymer is used, which provides excellent mechanical performance with high biocompatibility and biomimetic capacity. Moreover, the porous structure and reactivity of the hydroxyapatite-chitosan (HA-CS) composite allow their application not only as a bone repair but also as a drug delivery system providing controlled drug release directly to the bone site. These features make biomimetic HA-CS composite a subject of interest for many researchers. Through this review, we provide the important recent achievements in the development of HA-CS composites, focusing on manufacturing techniques, conventional and novel three-dimensional bioprinting technology, and physicochemical and biological properties. The drug delivery properties and the most relevant biomedical applications of the HA-CS composite scaffolds are also presented. Finally, alternative approaches are proposed to develop HA composites with the aim to improve their physicochemical, mechanical, and biological properties.

Surface modifications of titanium dental implants with strontium eucommia ulmoides to enhance osseointegration and suppress inflammation

BACKGROUND

Titanium (Ti) is now widely used as implant material due to its excellent mechanical properties and superior biocompatibilities, while its inert bioactivities might lead to insufficient osseointegration, and limit its performance in dental applications.

METHODS

We introduced a robust and simple approach of modifying titanium surfaces with polysaccharide complexes. Titanium samples were subjected to hydrothermal treatment to create a uniform porous structure on the surface, followed by coating with a bioinspired and self-assembly polydopamine layer. Strontium Eucommia Ulmoides Polysaccharide (EUP-Sr) complexes are then introduced to the polydopamine-coated porous titanium. Multiple morphological and physiochemical characterizations are employed for material evaluation, while cell proliferation and gene expression tests using macrophages, primary alveolar bone osteoblasts, and vascular endothelial cells are used to provide an overall insight into the functions of the product. The significances of statistical differences were analyzed using student's t-test.

RESULTS

Microscopic and spectrometric characterizations confirmed that the Ti surface formed a porous structure with an adequate amount of EUP-Sr loading. The attachment was attributed to hydrogen bonding between the ubiquitous glycosidic linkage of the polysaccharide complex and the ring structure of polydopamine, yet the loaded EUP-Sr complex can be gradually released, consequently benefiting the neighboring microenvironment. Cell experiments showed no cytotoxicity of the material, and the product showed promising anti-inflammation, osseointegration, and angiogenesis properties, which were further confirmed by in vivo evaluations.

CONCLUSION

We believe the EUP-Sr modified titanium implant is a promising candidate to be used in dental applications with notable osteoimmunomodulation and angiogenesis functions. And the novel technique proposed in this study would benefit the modification of metal/inorganic surfaces with polysaccharides for future research.

Freezing nitrogen ethanol composite reduces periprosthetic infection caused by Staphylococcus aureus contaminated metal implants: An animal study

BACKGROUND

Implant-associated infection remains a major complication of orthopedic surgery. The treatment of such infection is complicated by bacterial biofilm formation on the metal surfaces of implants. Biofilm surrounds and protects the bacteria against the organism's endogenous defense system and from external agents such as antibiotics and mechanical debridement. This study aims to evaluate whether freezing nitrogen ethanol composite (FNEC), the combination of liquid nitrogen and 95% ethanol in a 3 to 1 ratio, used frequently in bone tumor surgery, is capable of disinfecting Staphylococcus aureus contaminated implants.

METHODS

The femurs of six New Zealand white rabbits were implanted with S. aureus-contaminated screws, half of which were treated with FNEC before implantation. The femurs were harvested 14 days after implantation. Histological analysis and TUNEL assay were conducted. The autoclaved screw, contaminated screw, and FNEC-treated contaminated screw were investigated using scanning electron microscopy to evaluate the biofilm structure.

RESULTS

The FNEC-treated group had significantly lower relative C-reactive protein levels. An obvious periosteal reaction at the implant site was observed in all rabbits in the non-FNEC group but none was observed in the FNEC-treated group. The FNEC-treated group exhibited fewer empty lacunae, less inflammatory infiltration, and less bone necrosis. Immunohistochemical analysis showed no S. aureus in bone tissue from the FNEC-treated group. Scanning electron microscopy showed disruption of the biofilm on the contaminated screw treated with FNEC.

CONCLUSION

FNEC showed potential in disinfecting S.aureus-contaminated implants. Further investigation is warranted, such as the effect on the implant-cement-bone interface, for FNEC to be used clinically in treating implant-associated infection.

Design strategies for composite matrix and multifunctional polymeric scaffolds with enhanced bioactivity for bone tissue engineering

Over the past few decades, various bioactive material-based scaffolds were investigated and researchers across the globe are actively involved in establishing a potential state-of-the-art for bone tissue engineering applications, wherein several disciplines like clinical medicine, materials science, and biotechnology are involved. The present review article's main aim is to focus on repairing and restoring bone tissue defects by enhancing the bioactivity of fabricated bone tissue scaffolds and providing a suitable microenvironment for the bone cells to fasten the healing process. It deals with the various surface modification strategies and smart composite materials development that are involved in the treatment of bone tissue defects. Orthopaedic researchers and clinicians constantly focus on developing strategies that can naturally imitate not only the bone tissue architecture but also its functional properties to modulate cellular behaviour to facilitate bridging, callus formation and osteogenesis at critical bone defects. This review summarizes the currently available polymeric composite matrices and the methods to improve their bioactivity for bone tissue regeneration effectively.

Mussel‐Inspired Biomaterials: From Chemistry to Clinic

After several billions of years, nature still makes decisions on its own to identify, develop, and direct the most effective material for phenomena/challenges faced. Likewise, and inspired by the nature, we learned how to take steps in developing new technologies and materials innovations. Wet and strong adhesion by Mytilidae mussels (among which Mytilus edulis—blue mussel and Mytilus californianus—California mussel are the most well‐known species) has been an inspiration in developing advanced adhesives for the moist condition. The wet adhesion phenomenon is significant in designing tissue adhesives and surgical sealants. However, a deep understanding of engaged chemical moieties, microenvironmental conditions of secreted proteins, and other contributing mechanisms for outstanding wet adhesion mussels are essential for the optimal design of wet glues. In this review, all aspects of wet adhesion of Mytilidae mussels, as well as different strategies needed for designing and fabricating wet adhesives are discussed from a chemistry point of view. Developed muscle‐inspired chemistry is a versatile technique when designing not only wet adhesive, but also, in several more applications, especially in the bioengineering area. The applications of muscle‐inspired biomaterials in various medical applications are summarized for future developments in the field.

Surface Functionalities of Polymers for Biomaterial Applications

Changes of a material biointerface allow for specialized cell signaling and diverse biological responses. Biomaterials incorporating immobilized bioactive ligands have been widely introduced and used for tissue engineering and regenerative medicine applications in order to develop biomaterials with improved functionality. Furthermore, a variety of physical and chemical techniques have been utilized to improve biomaterial functionality, particularly at the material interface. At the interface level, the interactions between materials and cells are described. The importance of surface features in cell function is then examined, with new strategies for surface modification being highlighted in detail.

Preparation of citric acid-modified poly(vinyl alcohol) films for effectively precipitating calcium phosphate particles

Development of a technology for effectively controlling the precipitation of CP particles on PVA films via a biomimetic process was achieved using the CA-modification technique.

Surface Properties of Octacalcium Phosphate Nanocrystals Are Crucial for Their Bioactivities

The fundamental structure-biofunction relationship of calcium phosphates (CaPs) remains unclear despite their clinical successes as important biomaterials. Herein, a series of CaP coatings with gradual change of topography and crystallinity is constructed by electrochemical deposition, and the roles of the two basic physicochemical properties are scrutinized for further understanding the mechanism behind the superior bioactivities of octacalcium phosphate (OCP). We observe a distinct modulation on cell proliferation on the prepared CaP coatings for different cells. The magnitude of the modulation seems to depend on the cellular size, and the effect is attributed mainly to the microstructure of the coatings. On the other hand, the crystallinity manifests its significance for the osteogenic property of the OCP coatings. Further transmission electron microscopy analysis and density functional theory calculations reveal a surface rich in HPO₄ ^2- for the high-crystalline OCP nanocrystals. The results highlight that the nanocrystal surface properties of the OCP coatings, including the periodic structure and the HPO₄ ^2- composition, may play significant roles surpassing the ion release effect in determining its osteogenic property, probably via surface spatial and/or chemical recognitions. The present findings shed light on the fundamental understanding of the structure-biofunction relationship for CaP biomaterials.

Mg/Cu-doped TiO2 nanotube array: A novel dual-function system with self-antibacterial activity and excellent cell compatibility

Many studies were conducted to change the surface morphology and chemical composition of Ti implants for the improvement of antibacterial ability and osseointegration between medical Ti and surrounding bone tissue. In this study, we successfully prepared a novel dual-function coating on pure Ti surface, i.e. Cu and Mg-co-doped TiO₂ nanotube (TN) coating, by combining anodisation and hydrothermal treatment (HT), which could act as a delivery platform for the sustained release of Cu and Mg ions. Results showed that the amounts of Cu and Mg were about 5.43 wt%-6.55 wt% and 0.69 wt%-0.73 wt%, respectively. In addition, the surface morphology of Cu and Mg-co-doped TN (CuMTN) coatings transformed into nanoneedles after HT for 1 h. Compared with TN, CuMTN had no change in roughness and remarkable improved hydrophilicity. Antibacterial tests revealed that CuMTN had an antibacterial rate of more than 93% against Escherichia coli and Staphylococcus aureus, thereby showing excellent antibacterial properties. In addition, CuMTN could induce the formation of apatite well after being immersed in simulated body fluid, showing good biological activity. Preosteoblasts (MC3T3-E1) cultured on CuMTN-coated Ti demonstrated better proliferation and osteogenic differentiation than pristine and as-anodised specimens. To the best of our best knowledge, this study had successfully attempted to combine anodisation and HT, introduce Cu/Mg elements and functionalise Ti-based implant surfaces with enhanced hydrophilicity, osteogenesis and antimicrobial properties that can meet clinical needs for the first time.

Hydrothermally treated titanium surfaces for enhanced osteogenic differentiation of adipose derived stem cells

Implant surface plays a crucial role in improving osseointegration and long-term implant life. When the implant comes in contact with the bone tissue, the bone marrow mesenchymal cells interact with the implant surface and the surface properties such as morphology, wettability, mechanical properties and chemistry influences cell migration, proliferation and differentiation. Different surface modification strategies such as ceramic coatings, surface dealloying, and surface topography modifications for improving osteointegration have been investigated. However, studies have not yet established which of the surface property is more influential. In this study, titanium surfaces were treated hydrothermally with sodium hydroxide and sulfuric acid separately. This treatment led to the development of two unique surface topography at nanoscale. These modified surfaces were characterized for surface morphology, wettability, chemistry, and crystallinity. Cytotoxicity, cell adhesion, proliferation, morphology, and differentiation of adipose derived stem cells on modified surfaces was investigated. The results indicate that wettability does influence initial cell adhesion. However, the surface morphology can play major role in cell spreading, proliferation and differentiation. The results indicate that titanium surfaces treated hydrothermally with sodium hydroxide led to a nanoporous architecture that promoted appropriate cell interaction with the surface promoting osteoblastic lineage.

Silver Micro-Nanoparticle-Based Nanoarchitectures: Synthesis Routes, Biomedical Applications, and Mechanisms of Action

Silver has become a potent agent that can be effectively applied in nanostructured nanomaterials with various shapes and sizes against antibacterial applications. Silver nanoparticle (Ag NP) based-antimicrobial agents play a major role in different applications, including biomedical applications, as surface treatment and coatings, in chemical and food industries, and for agricultural productivity. Due to advancements in nanoscience and nanotechnology, different methods have been used to prepare Ag NPs with sizes and shapes reducing toxicity for antibacterial applications. Studies have shown that Ag NPs are largely dependent on basic structural parameters, such as size, shape, and chemical composition, which play a significant role in preparing the appropriate formulation for the desired applications. Therefore, this review focuses on the important parameters that affect the surface interaction/state of Ag NPs and their influence on antimicrobial activities, which are essential for designing future applications. The mode of action of Ag NPs as antibacterial agents will also be discussed.

Precipitation at Room Temperature as a Fast and Versatile Method for Calcium Phosphate/TiO2 Nanocomposites Synthesis

The constantly growing need for advanced bone regeneration materials has motivated the development of calcium phosphates (CaPs) composites with a different metal or metal-oxide nanomaterials and their economical and environmentally friendly production. Here, two procedures for the synthesis of CaPs composites with TiO₂ nanoplates (TiNPl) and nanowires (TiNWs) were tested, with the immersion of TiO₂ nanomaterials (TiNMs) in corrected simulated body fluid (c-SBF) and precipitation of CaP in the presence of TiNMs. The materials obtained were analyzed by powder X-ray diffraction, spectroscopic and microscopic techniques, Brunauer–Emmett–Teller surface area analysis, thermogravimetric analysis, dynamic and electrophoretic light scattering, and their hemocompatibility and ability to induce reactive oxygen species were evaluated. After 28 days of immersion in c-SBF, no significant CaP coating was formed on TiNMs. However, the composites with calcium-deficient apatite (CaDHA) were obtained after one hour in the spontaneous precipitation system. In the absence of TiNMs, CaDHA was also formed, indicating that control of the CaP phase formed can be accomplished by fine-tuning conditions in the precipitation system. Although the morphology and size of crystalline domains of CaDHA obtained on the different nanomaterials differed, no significant difference was detected in their local structure. Composites showed low reactive oxygen species (ROS) production and did not induce hemolysis. The results obtained indicate that precipitation is a suitable and fast method for the preparation of CaPs/TiNMs nanocomposites which shows great potential for biomedical applications.

Mesoporous Mn-doped hydroxyapatite nanorods obtained via pyridinium chloride enabled microwave-assisted synthesis by utilizing Donax variabilis seashells for implant applications

Manganese-doped mesoporous hydroxyapatite (MnHAp) nanorods, a bio-apatite were synthesized via pyridinium chloride mediated microwave approach using bio-waste Donax variabilis seashells to treat orthopedic infections. This is the first report on using pyridinium chloride mediated mesoporous MnHAp nanorods synthesis. Pure and Mn doped HAp samples were examined using Raman spectroscopy, X-ray powder diffraction (XRD) and Fourier transform infrared spectroscopy (FTIR) studies to confirm the prepared HAp nanorods. Furthermore, the fabrication of manganese-doped HAp was successful with the formation of a hexagonal crystal lattice without disturbing the HAp phase. It is because, at the time of synthesis, PO₄^3- ions form an electrostatic interaction with the Mn ions. Furthermore, Mn-doped HAp samples showed a reduction in their sizes of 15, 10-15, 5-10 nm width, and 80-100, 10-15, 20-30 nm length with varied pore diameters and surface area. The pure HAp, MnHAp-1, MnHAp-2, and MnHAp-3 nanorods disclose the surface area of 39.4, 18.0, 49.2, and 80.4 m² g^-1, with a pore volume of 0.0102, 0.0047, 0.0143, and 0.0447 cm³ g^-1, the corresponding pore diameter was estimated to be 6, 7, 6, and 4 nm, respectively. Moreover, antibacterial activity reveals effective bactericidal action against infections causing pathogens whereas cytotoxicity examination (MTT assay), and zebrafish results reveal their non-toxic behavior. Therefore, it is evident from the study, that rapid fabrication of mesoporous and diverse structured MnHAp nanorods could be convenient with pyridinium chloride enabled microwave-assisted method as a bactericidal biomaterial for implant applications.

Biosensitive and antibacterial coatings on metallic material for medical applications

Metallic materials are commonly used for load-bearing implants and as internal fixation devices. It is customary to use austenitic stainless steel, especially surgical grade type 316L SS as temporary and Ti alloys as permanent implants. However, long-term, poor bonding with bone, corrosion, and release of metal ions, such as chromium and nickel occur. These ions are powerful allergens and carcinogens and their uncontrolled leaching may be avoided by surface coatings. Therefore, bioactive glasses (BGs) became a vital biomedical material, which can form a biologically active phase of hydroxycarbonate apatite on their surface when in contact with physiological fluids. To reduce the high coefficient of friction and the brittle nature of BGs, polymers are normally incorporated to avoid the high-temperature sintering/densification of ceramic-only coatings. For medical application, electrophoretic deposition (EPD) is now used for polymer (organic) and ceramic (inorganic) components at room temperature due to its simplicity, control of coating thickness and uniformity, low cost of equipment, ability to coat substrates of intricate shape and to supply thick films in composite form, high purity of deposits as well as no phase transformation during coating. Although extensive research has been conducted on polymer/inorganic composite coatings, only some studies have reported multifunctional properties, such as biological antibacterial activity, enhanced cell adhesion, controlled drug release ability, and mechanical properties. This review will focus on biodegradable coatings, including zien, chitosan, gelatin, cellulose loaded with antibacterial drugs/metallic ions/natural herbs on biostable substrates (PEEK/PMMA/PCL/PLLA layers), which have the potential of multifunctional coating for metallic implants.

Silver Nanoparticle-Based Nanocomposites for Combating Infectious Pathogens: Recent Advances and Future Prospects

Silver nanoparticles (Ag NPs) and their nanocomposites with polymers are potent agents for antibacterial and disinfectant applications. The structural parameters of Ag-NPs, such as size, shape, and surface area, are very critical for developing appropriate formulations for the targeted applications. The impact of these factors on the performance of Ag NPs is analyzed. Ag NPs with a broad spectrum of antibacterial activities have already found applications in wound and burn dressing, food preservation, agricultural ponds, treatment for infected areas, coatings, water treatment, and other biomedical applications. Ag NPs are quite useful against antibiotic-resistant bacteria, but their level of toxicity needs careful investigation as their toxicity could be very harmful to human health and the environment. This review discusses the challenges and prospects of various Ag NPs and their composites. The review will enrich the knowledge about the efficiency and mechanism of various Ag nanoparticle-based antibacterial agents.

The Effect of Ti-6Al-4V Alloy Surface Structure on the Adhesion and Morphology of Unidirectional Freeze-Coated Gelatin

The modification of a metal implant surface with a biomimetic coating of bone-like anisotropic and graded porosity structures to improve its biological anchorage with the surrounding bone tissue at implanting, is still a high challenge. In this paper, we present an innovative way of a gelatin (GEL) dip-coating on Ti-6Al-4V substrates of different square-net surface textures by the unidirectional deep-freezing process at simultaneous cross-linking using carbodiimide chemistry. Different concentrations of GEL solution were used to study the changes in morphology, density, and mechanical properties of the coatings. In addition, the surface free energy and polarity of Ti-6Al-4V substrate surfaces and GEL solutions have been evaluated to assess the wetting properties at the substrate interfaces, and to describe the adhesion of GEL macromolecules with their surfaces, being supported by mechanical pull-out testing. The results indicate that the coating’s morphology depends primarily on the Ti-6Al-4V substrate’s surface texture and second, on the concentration of GEL, which further influences their adhesion properties, orientation, morphological arrangement, as well as compression strength. The substrate with a 300 × 300 μm2 texture resulted in a highly adhered GEL coating with ≥80% porosity, interconnected and well-aligned pores of 75–200 μm, required to stimulate the bone ingrowth, mechanically and histologically.

Recent advances and future perspectives of sol–gel derived porous bioactive glasses: a review

Sol–gel derived bioactive glasses have been extensively explored as a promising and highly porous scaffold materials for bone tissue regeneration applications owing to their exceptional osteoconductivity, osteostimulation and degradation rates.

Functionalization and Surface Modifications of Bioactive Glasses (BGs): Tailoring of the Biological Response Working on the Outermost Surface Layer

Bioactive glasses (BGs) are routinely being used as potent materials for hard and soft tissue engineering applications; however, improving their biological activities through surface functionalization and modification has been underestimated so far. The surface characteristics of BGs are key factors in determining the success of any implanted BG-based material in vivo since they regulate the affinity and binding of different biological macromolecules and thereby the interactions between cells and the implant. Therefore, a number of strategies using chemical agents (e.g., glutaraldehyde, silanes) and physical methods (e.g., laser treatment) have been evaluated and applied to design properly, tailor, and improve the surface properties of BGs. All these approaches aim at enhancing the biological activities of BGs, including the induction of cell proliferation and subsequent osteogenesis, as well as the inhibition of bacterial growth and adhesion, thereby reducing infection. In this study, we present an overview of the currently used approaches of surface functionalization and modifications of BGs, along with discussing the biological outputs induced by these changes.

Nano-scale modification of titanium implant surfaces to enhance osseointegration

The main aim of this review study was to report the state of art on the nano-scale technological advancements of titanium implant surfaces to enhance the osseointegration process. Several methods of surface modification are chronologically described bridging ordinary methods (e.g. grit blasting and etching) and advanced physicochemical approaches such as 3D-laser texturing and biomimetic modification. Functionalization procedures by using proteins, peptides, and bioactive ceramics have provided an enhancement in wettability and bioactivity of implant surfaces. Furthermore, recent findings have revealed a combined beneficial effect of micro- and nano-scale modification and biomimetic functionalization of titanium surfaces. However, some technological developments of implant surfaces are not commercially available yet due to costs and a lack of clinical validation for such recent surfaces. Further in vitro and in vivo studies are required to endorse the use of enhanced biomimetic implant surfaces. STATEMENT OF SIGNIFICANCE: Grit-blasting followed by acid-etching is currently used for titanium implant modifications, although recent technological biomimetic physicochemical methods have revealed enhanced osteoconductive and anti-microbial outcomes. An improvement in wettability and bioactivity of titanium implant surfaces has been accomplished by combining micro and nano-scale modification and functionalization with protein, peptides, and bioactive compounds. Such morphological and chemical modification of the titanium surfaces induce the migration and differentiation of osteogenic cells followed by an enhancement of the mineral matrix formation that accelerate the osseointegration process. Additionally, the incorporation of bioactive molecules into the nanostructured surfaces is a promising strategy to avoid early and late implant failures induced by the biofilm accumulation.

From the laboratory concept to clinical trials: the journey of Otoimplant so far

INTRODUCTION

Nowadays, the role of alloplastic prostheses has become more important in ossicular chain reconstruction. Especially, bioactive medical devices may be an alternative for those currently used on the market. Areas covered: Medical devices which are implanted for over 30 days in the body are required to fulfill strict requirements. It is crucial to ensure the proper level of biocompatibility, biological stability and lack of cytotoxicity of the implanted material. If a medical device is expected to play an additional role, e.g. act as a bioactive or bactericidal agent, supplementary tests should be conducted to assess the relevant qualities. The aim of this article is to present the sequence of procedures leading to the success of a middle ear prosthesis called Otoimplant - from a theoretical concept to the clinical trial. Expert commentary: However, to introduce a new prosthesis into the market, research such as, in vitro, in vivo and clinical trials are required to keep medical devices approved. This article describes a research path that medical device ought to negotiate before the clinical trials may start.

Effects of Pre-Treatments on Bioactivity of High-Purity Titanium

Titanium and its alloys are frequently employed in medical and dental clinics due to their good tissue compatibility, including commercially available pure Ti, Ti6A4V, or Ti-15Zr-4Ta-4Nb. Yet, they may behave very differently when in contact with our plasma because of their own chemical composition. The present study was designed to compare the in vitro behavior of highly pure Ti (>99.99%; hpTi) with those of the above titanium specimens when they were subjected to heating in air (HT), H₂O₂ and heating (CHT), and heating in air after forming grooves on the surface (GT). Since one of the measures of material-tissue compatibility has been in vitro apatite formation in artificial plasma, like simulated body fluid (SBF) of the Kokubo recipe, the apatite deposition in SBF on their surface and in their grooves were examined in terms of the X-ray diffraction, scanning electron microscopy, and energy dispersion X-ray analysis. The results showed that hpTi was as active in in vitro apatite deposition as the other reference titanium samples mentioned above. Moreover, GT specimens of hpTi induced apatite deposition on the platform of the grooves as well as in the grooves. Therefore, hpTi was concluded to have better activity, and to be clinically applicable.

Functionalized biomimetic calcium phosphates for bone tissue repair

The design and development of novel materials for biomineralized tissues is an extremely attractive field of research where calcium phosphates (CaPs)-based materials for biomedical applications play a leading role. The biological performance of these compounds can be enhanced through functionalization with biologically active ions and molecules. This review reports on some important recent achievements in creating functionalized biomimetic CaP materials for applications in the musculoskeletal field. Particular attention is focused on the modifications of these inorganic compounds with bioactive ions, growth factors and drugs, as well as on recent trends in some important CaP applications as biomaterials - namely, as bone cements, coatings of metallic implants and scaffolds for regenerative medicine.

Proliferation and osteogenic differentiation of rat BMSCs on a novel Ti/SiC metal matrix nanocomposite modified by friction stir processing

The aims of this study were to fabricate a novel titanium/silicon carbide (Ti/SiC) metal matrix nanocomposite (MMNC) by friction stir processing (FSP) and to investigate its microstructure and mechanical properties. In addition, the adhesion, proliferation and osteogenic differentiation of rat bone marrow stromal cells (BMSCs) on the nanocomposite surface were investigated. The MMNC microstructure was observed by both scanning and transmission electron microscopy. Mechanical properties were characterized by nanoindentation and Vickers hardness testing. Integrin β1 immunofluorescence, cell adhesion, and MTT assays were used to evaluate the effects of the nanocomposite on cell adhesion and proliferation. Osteogenic and angiogenic differentiation were evaluated by alkaline phosphatase (ALP) staining, ALP activity, PCR and osteocalcin immunofluorescence. The observed microstructures and mechanical properties clearly indicated that FSP is a very effective technique for modifying Ti/SiC MMNC to contain uniformly distributed nanoparticles. In the interiors of recrystallized grains, characteristics including twins, fine recrystallized grains, and dislocations formed concurrently. Adhesion, proliferation, and osteogenic and angiogenic differentiation of rat BMSCs were all enhanced on the novel Ti/SiC MMNC surface. In conclusion, nanocomposites modified using FSP technology not only have superior mechanical properties under stress-bearing conditions but also provide improved surface and physicochemical properties for cell attachment and osseointegration.

Bioactivity and biocompatibility of hydroxyapatite-based bioceramic coatings on zirconium by plasma electrolytic oxidation

In the present work, hydroxyapatite (HAP)-based plasma electrolytic oxide (PEO) coatings were produced on zirconium at different current densities in a solution containing calcium acetate and β-calcium glycerophosphate by a single step. The phase structure, surface morphology, functional groups, thickness and roughness of the coatings were characterized by X-ray diffraction (XRD), scanning electron microscopy (SEM), attenuated total reflectance-Fourier transform infrared spectroscopy (ATR-FTIR), eddy current method and surface profilometer, respectively. The phases of cubic-zirconia, calcium zirconate and HAP were detected by XRD. The amount of HAP and calcium zirconate increased with increasing current density. The surface of the coatings was very porous and rough. Moreover, bioactivity and biocompatibility of the coatings were analyzed in vitro immersion simulated body fluid (SBF) and MTT (3-(4,5-dimethyl thiazol-2yl)-2,5-diphenyl tetrazolium bromide) assay, hemolysis assay and bacterial formation. The apatite-forming ability of the coatings was evaluated after immersion in SBF up to 28days. After immersion, the bioactivity of HAP-based coatings on zirconium was greater than the ones of uncoated zirconium and zirconium oxide-based surface. The bioactivity of PEO surface on zirconium was significantly improved under SBF conditions. The bacterial adhesion of the coatings decreased with increasing current density. The bacterial adhesion of the coating produced at 0.370A/cm² was minimum compared to uncoated zirconium coated at 0.260 and 0.292A/cm². The hemocompatibility of HAP-based surfaces was improved by PEO. The cell attachment and proliferation of the PEO coatings were better than the one of uncoated zirconium according to MTT assay results.

Photocatalytic Deposition of Hydroxyapatite onto a Titanium Dioxide Nanotubular Layer with Fine Tuning of Layer Nanoarchitecture

A new effective method of photocatalytic deposition of hydroxyapatite (HA) onto semiconductor substrates is proposed. A highly ordered nanotubular TiO2 (TNT) layer formed on titanium via its anodization is chosen as the photoactive substrate. The method is based on photodecomposition of the phosphate anion precursor, triethylphosphate (TEP), on the semiconductor surface with the following reaction of formed phosphate anions with calcium cations presented in the solution. HA can be deposited only on irradiated areas, providing the possibility of photoresist-free HA patterning. It is shown that HA deposition can be controlled via pH, light intensity, and duration of the process. Energy-dispersive X-ray spectroscopy profile analysis and glow discharge optical emission spectroscopy of HA-modified TNT prove that HA deposits over the entire TNT depth. High biocompatibility of the surfaces is proven by protein adsorption and pre-osteoblast cell growth.

Nanofibers used for delivery of antimicrobial agents

Nanotechnology has gained an increased interest in several different areas of biotechnology including the drug delivery via nanofibers. Self-assembly, phase separation and electrospinning can all be used to successfully generate nanofibers with sizes well within the range of those of the fibers present in the native extracellular matrix (50-500 nm). In this article, the authors introduced the most popular applications of nanofibers related to the delivery of antimicrobial agents for infectious diseases. To date, only a few in-vivo studies are available at present to demonstrate its clinical potential; most of the studies are of exploratory nature and rely mostly on in-vitro experiments. Therefore, further advancement in the production and clinical performance of drug-loaded nanofibrous matrices seems necessary.

Preparation and evaluation of an Arg-Gly-Asp-modified chitosan/hydroxyapatite scaffold for application in bone tissue engineering

Bone tissue engineering has become a promising method for the repair of bone defects, and the production of a scaffold with high cell affinity and osseointegrative properties is crucial for successful bone substitute. Chitosan (CS)/hydroxyapatite (HA) composite was prepared by in situ compositing combined with lyophilization, and further modified by arginine‑glycine‑aspartic acid (RGD) via physical adsorption. In order to evaluate the cell adhesion rate, viability, morphology, and alkaline phosphatase (ALP) activity, the RGD‑CS/HA scaffold was seeded with bone marrow stromal cells (BMSCs). The osseointegrative properties of the RGD‑CS/HA scaffold were evaluated by in vivo heterotopic ossification and in vivo bone defect repair. After 4 h culture with the RGD‑CS/HA scaffold, the adhesion rate of the BMSCs was 80.7%. After 3 days, BMSCs were fusiform in shape and evenly distributed on the RGD‑CS/HA scaffold. Formation of extracellular matrix and numerous cell‑cell interactions were observed after 48 h of culture, with an ALP content of 0.006 ± 0.0008 U/l/ng. Furthermore, the osseointegrative ability and biomechanical properties of the RGD‑CS/HA scaffold were comparable to that of normal bone tissue. The biocompatibility, cytocompatibility, histocompatibility and osseointegrative properties of the RGD‑CS/HA scaffold support its use in bone tissue engineering applications.

In vitro apatite formation on nano-crystalline titania layer aligned parallel to Ti6Al4V alloy substrates with sub-millimeter gap

Pure titanium substrates were chemically oxidized with H2O2 and subsequent thermally oxidized at 400 °C in air to form anatase-type titania layer on their surface. The chemically and thermally oxidized titanium substrate (CHT) was aligned parallel to the counter specimen such as commercially pure titanium (cpTi), titanium alloy (Ti6Al4V) popularly used as implant materials or Al substrate with 0.3-mm gap. Then, they were soaked in Kokubo's simulated body fluid (SBF, pH 7.4, 36.5 °C) for 7 days. XRD and SEM analysis showed that the in vitro apatite-forming ability of the contact surface of the CHT specimen decreased in the order: cpTi > Ti6Al4V > Al. EDX and XPS surface analysis showed that aluminum species were present on the contact surface of the CHT specimen aligned parallel to the counter specimen such as Ti6Al4V and Al. This result indicated that Ti6Al4V or Al specimens released the aluminum species into the SBF under the spatial gap. The released aluminum species might be positively or negatively charged in the SBF and thus can interact with calcium or phosphate species as well as titania layer, causing the suppression of the primary heterogeneous nucleation and growth of apatite on the contact surface of the CHT specimen under the spatial gap. The diffusion and adsorption of aluminum species derived from the half-sized counter specimen under the spatial gap resulted in two dimensionally area-selective deposition of apatite particles on the contact surfaces of the CHT specimen.

Calcium orthophosphate deposits: Preparation, properties and biomedical applications

Since various interactions among cells, surrounding tissues and implanted biomaterials always occur at their interfaces, the surface properties of potential implants appear to be of paramount importance for the clinical success. In view of the fact that a limited amount of materials appear to be tolerated by living organisms, a special discipline called surface engineering was developed to initiate the desirable changes to the exterior properties of various materials but still maintaining their useful bulk performances. In 1975, this approach resulted in the introduction of a special class of artificial bone grafts, composed of various mechanically stable (consequently, suitable for load bearing applications) implantable biomaterials and/or bio-devices covered by calcium orthophosphates (CaPO4) to both improve biocompatibility and provide an adequate bonding to the adjacent bones. Over 5000 publications on this topic were published since then. Therefore, a thorough analysis of the available literature has been performed and about 50 (this number is doubled, if all possible modifications are counted) deposition techniques of CaPO4 have been revealed, systematized and described. These CaPO4 deposits (coatings, films and layers) used to improve the surface properties of various types of artificial implants are the topic of this review.

Enhanced MC3T3-E1 preosteoblast response and bone formation on the addition of nano-needle and nano-porous features to microtopographical titanium surfaces

Micro/nanotopographical modifications on titanium surfaces constitute a new process to increase osteoblast response to enhance bone formation. In this study, we utilized alkali heat treatment at high (SB-AH1) and low temperatures (SB-AH2) to nano-modify sandblasted titanium with microtopographical surfaces. Then, we evaluated the surface properties, biocompatibility and osteogenic capability of SB-AH1 and SB-AH2 in vitro and in vivo, and compared these with conventional sandblast-acid etching (SLA) and Ti control surfaces. SB-AH1 and SB-AH2 surfaces exhibited micro/nanotopographical modifications of nano-needle structures and nano-porous network layers, respectively, compared with the sole microtopographical surface of macro and micro pits on the SLA surface and the relatively smooth surface on the Ti control. SB-AH1 and SB-AH2 showed different roughness and elemental components, but similar wettability. MC3T3-E1 preosteoblasts anchored closely on the nanostructures of SB-AH1 and SB-AH2 surfaces, and these two surfaces more significantly enhanced cell proliferation and alkaline phosphatase (ALP) activity than others, while the SB-AH2 surface exhibited better cell proliferation and higher ALP activity than SB-AH1. All four groups of titanium domes with self-tapping screws were implanted in rabbit calvarial bone models, and these indicated that SB-AH1 and SB-AH2 surfaces achieved better peri-implant bone formation and implant stability, while the SB-AH2 surface achieved the best percentage of bone-implant contact (BIC%). Our study demonstrated that the micro/nanotopographical surface generated by sandblasting and alkali heat treatment significantly enhanced preosteoblast proliferation, ALP activity and bone formation in vitro and in vivo, and nano-porous network topography may further induce better preosteoblast proliferation, ALP activity and BIC%.

Electrophoretic deposition of gentamicin-loaded bioactive glass/chitosan composite coatings for orthopaedic implants

Despite their widespread application, metallic orthopaedic prosthesis failure still occurs because of lack of adequate bone-bonding and the incidence of post-surgery infections. The goal of this research was to develop multifunctional composite chitosan/Bioglass coatings loaded with gentamicin antibiotic as a suitable strategy to improve the surface properties of metallic implants. Electrophoretic deposition (EPD) was applied as a single-step technology to simultaneously deposit the biopolymer, bioactive glass particles, and the antibiotic on stainless steel substrate. The microstructure and composition of the coatings were characterized using SEM/EDX, XRD, FTIR, and TGA/DSC, respectively. The in vitro bioactivity of the coatings was demonstrated by formation of hydroxyapatite after immersion in simulated body fluid (SBF) in a short period of 2 days. High-performance liquid chromatography (HPLC) measurements indicated the release of 40% of the loaded gentamicin in phosphate buffered saline (PBS) within the first 5 days. The developed composite coating supported attachment and proliferation of MG-63 cells up to 10 days. Moreover, disc diffusion test showed improved bactericidal effect of gentamicin-loaded composite coatings against S. aureus compared to control non-gentamicin-loaded coatings.

Peri- and intra-implant bone response to microporous Ti coatings with surface modification

Bone growth on and into implants exhibiting substantial surface porosity is a promising strategy in order to improve the long-term stable fixation of bone implants. However, the reliability in clinical applications remains a point of discussion. Most attention has been dedicated to the role of macroporosity, leading to the general consensus of a minimal pore size of 50-100 μm in order to allow bone ingrowth. In this in vivo study, we assessed the feasibility of early bone ingrowth into a predominantly microporous Ti coating with an average thickness of 150 μm and the hypothesis of improving the bone response through surface modification of the porous coating. Implants were placed in the cortical bone of rabbit tibiae for periods of 2 and 4 weeks and evaluated histologically and histomorphometrically using light microscopy and scanning electron microscopy. Bone with osteocytes encased in the mineralized matrix was found throughout the porous Ti coating up to the coating/substrate interface, highlighting that osseointegration of microporosities (<10 μm) was achievable. The bone trabeculae interweaved with the pore struts, establishing a large contact area which might enable an improved load transfer and stronger implant/bone interface. Furthermore, there was a clear interconnection with the surrounding cortical bone, suggesting that mechanical interlocking of the coating in the host bone in the long term is possible. When surface modifications inside the porous structure further reduced the interconnective pore size to the submicrometer level, bone ingrowth was impaired. On the other hand, application of a sol-gel-derived bioactive glass-ceramic coating without altering the pore characteristics was found to significantly improve bone regeneration around the coating, while still supporting bone ingrowth.

Liquid phase deposited titania coating to enable in vitro apatite formation on Ti6Al4V alloy

A recently developed "GRAPE(®) technology" provides titanium or titanium alloy implants with spontaneous apatite-forming ability in vitro, which requires properly designed gaps and optimum heat treatment in air. In this study, titanium alloy and commercially pure (cp) titanium substrates were thermally oxidized in air before aligning pairs of specimens in the GRAPE(®) set-up, i.e., titanium alloy and cp titanium substrates were aligned parallel to each other with optimum gap width (spatial design). A liquid phase deposition (LPD) technique was employed for titania coatings on titanium alloy substrate. Then, they were soaked in Kokubo's simulated body fluid (SBF, pH 7.4, 36.5 °C) for 7 days to confirm the in vitro apatite formation on the substrates under the specific spatial design. Anatase-type titania coatings fabricated by using LPD technique led to the deposition of apatite particles within 7 days and showed apatite X-ray diffraction. On the other hand, thermally oxidized titanium alloy substrate in air and non-treated specimens did not show any apatite X-ray diffraction. These results indicated that the heterogeneous nucleation of apatite induced on anatase-type titania coating prepared by LPD technique when it was aligned parallel to thermally oxidized cp titanium substrate with optimum gap width.

Design of biomimetic and bioactive cold plasma-modified nanostructured scaffolds for enhanced osteogenic differentiation of bone marrow-derived mesenchymal stem cells

The objective of this study was to design a biomimetic and bioactive tissue-engineered bone construct via a cold atmospheric plasma (CAP) treatment for directed osteogenic differentiation of human bone morrow mesenchymal stem cells (MSCs). Porous nanocrystalline hydroxyapatite/chitosan scaffolds were fabricated via a lyophilization procedure. The nanostructured bone scaffolds were then treated with CAP to create a more favorable surface for cell attachment, proliferation, and differentiation. The CAP-modified scaffolds were characterized via scanning electron microscope, Raman spectrometer, contact angle analyzer, and white light interferometer. In addition, optimal CAP treatment conditions were determined. Our in vitro study shows that MSC adhesion and infiltration were significantly enhanced on CAP modified scaffolds. More importantly, it was demonstrated that CAP-modified nanostructured bone constructs can greatly promote total protein, collagen synthesis, and calcium deposition after 3 weeks of culture, thus making them a promising implantable scaffold for bone regeneration. Moreover, the fibronectin and vitronection adsorption experiments by enzyme-linked immunosorbent assay demonstrated that more adhesion-mediated protein adsorption on the CAP-treated scaffolds. Since the initial specific protein absorption on scaffold surfaces can lead to further recruitment as well as activation of favorable cell functions, it is suggested that our enhanced stem cell growth and osteogenic function may be related to more protein adsorption resulting from surface roughness and wettability modification. The CAP modification method used in this study provides a quick one-step process for cell-favorable tissue-engineered scaffold architecture remodeling and surface property alteration.

Single-step electrochemical deposition of antimicrobial orthopaedic coatings based on a bioactive glass/chitosan/nano-silver composite system

Composite orthopaedic coatings with antibacterial capability containing chitosan, Bioglass® particles (9.8μm) and silver nanoparticles (Ag-np) were fabricated using a single-step electrophoretic deposition (EPD) technique, and their structural and preliminary in vitro bactericidal and cellular properties were investigated. Stainless steel 316 was used as a standard metallic orthopaedic substrate. The coatings were compared with EPD coatings of chitosan and chitosan/Bioglass®. The ability of chitosan as both a complexing and stabilizing agent was utilized to form uniformly deposited Ag-np. Due to the presence of Bioglass® particles, the coatings were bioactive in terms of forming carbonated hydroxyapatite in simulated body fluid (SBF). Less than 7wt.% of the incorporated silver was released over the course of 28days in SBF and the possibility of manipulating the release rate by varying the deposition order of coating layers was shown. The low released concentration of Ag ions (<2.5ppm) was efficiently antibacterial against Staphyloccocus aureus up to 10days. Although chitosan and chitosan/Bioglass® coating supported proliferation of MG-63 osteoblast-like cells up to 7days of culture, chitosan/Bioglass®/Ag-np coatings containing 342 μg of Ag-np showed cytotoxic effects. This was attributed to the relatively high concentration of Ag-np incorporated in the coatings.

Infection of orthopedic implants with emphasis on bacterial adhesion process and techniques used in studying bacterial-material interactions

Staphylococcus comprises up to two-thirds of all pathogens in orthopedic implant infections and they are the principal causative agents of two major types of infection affecting bone: septic arthritis and osteomyelitis, which involve the inflammatory destruction of joint and bone. Bacterial adhesion is the first and most important step in implant infection. It is a complex process influenced by environmental factors, bacterial properties, material surface properties and by the presence of serum or tissue proteins. Properties of the substrate, such as chemical composition of the material, surface charge, hydrophobicity, surface roughness and the presence of specific proteins at the surface, are all thought to be important in the initial cell attachment process. The biofilm mode of growth of infecting bacteria on an implant surface protects the organisms from the host immune system and antibiotic therapy. The research for novel therapeutic strategies is incited by the emergence of antibiotic-resistant bacteria. This work will provide an overview of the mechanisms and factors involved in bacterial adhesion, the techniques that are currently being used studying bacterial-material interactions as well as provide insight into future directions in the field.