A systematic review of the use of titanium versus stainless steel implants for fracture fixation

Stainless Steel Versus Titanium Miniplates in the Treatment of Mandibular Fractures: A Comparative Study

Introduction The fast-paced lifestyle of modern society has led to an increase in maxillofacial trauma, particularly in the mandible, which is prone to fracture due to its prominent position among facial bones. Mandibular fractures are one of the most common facial injuries and require effective treatment to ensure proper healing and function. A study conducted at the Department of Oral and Maxillofacial Surgery of Buddha Institute of Dental Sciences and Hospital investigated the adaptability, impact on fracture line difficulties, and facial outcomes of fracture therapy using stainless steel and titanium miniplates. The research aimed to compare these two materials in terms of their effectiveness, patient outcomes, and any complications that might arise from their use. Methodology The study included 20 adult patients with mandibular fractures, divided into two groups for open reduction and internal fixation using either titanium or stainless steel miniplates. All patients underwent comprehensive diagnostics, including blood tests and virus screenings, prior to the operation to ensure they were suitable candidates for surgery. The surgical procedure was followed by a meticulous postoperative care plan, which included a soft diet to minimize strain on the jaw, chlorhexidine mouth rinse to maintain oral hygiene, and guided elastics to support proper alignment during healing. The study meticulously recorded the operating times, fracture stability, and any complications to provide a thorough comparison between the two materials. Results The results showed that patients in the titanium miniplate group had significantly shorter operating times, averaging 32 minutes compared to 45.10 minutes in the stainless steel group (p < 0.0001). This difference highlights the efficiency of titanium plates in surgical procedures. Additionally, using a bimanual examination to assess fracture stability, the titanium plate group exhibited superior stability compared to the stainless steel plate group. The stability of the fractured segments in the titanium group was statistically significant with a p-value of 0.474. Conclusion Titanium miniplates provide several advantages over stainless steel in the treatment of mandibular fractures. These advantages include increased postoperative stability, lower complication rates, and higher biocompatibility. The study concludes that titanium miniplates are a more effective option for mandibular fracture treatment, offering better patient outcomes and reducing the overall burden on healthcare resources. This finding is significant for oral and maxillofacial surgery, as it supports the use of titanium miniplates for improved surgical results and patient care.

Synthetic nanointerfacial bioengineering of Ti implants: on-demand regulation of implant-bone interactions for enhancing osseointegration

Titanium and its alloys are the most commonly used biometals for developing orthopedic implants to treat various forms of bone fractures and defects, but their clinical performance is still challenged by the unfavorable mechanical and biological interactions at the implant-tissue interface, which substantially impede bone healing at the defects and reduce the quality of regenerated bones. Moreover, the impaired osteogenesis capacity of patients under certain pathological conditions such as diabetes and osteoporosis may further impair the osseointegration of Ti-based implants and increase the risk of treatment failure. To address these issues, various modification strategies have been developed to regulate the implant-bone interactions for improving bone growth and remodeling in situ. In this review, we provide a comprehensive analysis on the state-of-the-art synthetic nanointerfacial bioengineering strategies for designing Ti-based biofunctional orthopedic implants, with special emphasis on the contributions to (1) promotion of new bone formation and binding at the implant-bone interface, (2) bacterial elimination for preventing peri-implant infection and (3) overcoming osseointegration resistance induced by degenerative bone diseases. Furthermore, a perspective is included to discuss the challenges and potential opportunities for the interfacial engineering of Ti implants in a translational perspective. Overall, it is envisioned that the insights in this review may guide future research in the area of biometallic orthopedic implants for improving bone repair with enhanced efficacy and safety.

Antibacterial evaluation of antibiotic-coated titanium and stainless steel implants in orthopaedic application: a dip-coating approach

BACKGROUND

Despite their biocompatibility, metal implants are susceptible to infections, leading to implant failure and patient complications. The purpose of this study was to investigate the antibacterial potential of antibiotic-coated titanium and stainless steel implants.

METHODS

The study was designed as an experimental in vitro study, and it was conducted at the Department of Immunology of the University of Health Sciences, Istanbul/ Turkiye in January and February 2024. Pieces of titanium and stainless steel were coated with gentamicin, teicoplanin, rifampicin and a combination of rifampicin and gentamicin using a dipping method. Antibacterial activity against Staphylococcus epidermidis and Staphylococcus aureus was assessed using zone of inhibition (ZOI) measurements.

RESULTS

Both titanium and stainless steel implants displayed significant ZOI values for all antibiotic treatments, indicating effective inhibition of bacterial growth. The combination of gentamicin and rifampicin exhibited the largest ZOI for both implants.

CONCLUSIONS

Antibiotic-coated titanium and stainless steel implants demonstrate promising potential for reducing implant-associated infections. Further research is needed to optimise the coating method, explore combination therapies and evaluate the long-term efficacy of this approach in clinical settings.

Rise of implantable drugs: A chronicle of breakthroughs in drug delivery systems

In recent years, implantable drug delivery systems (IDDSs) have undergone significant advancements because they offer many advantages to patients and health care professionals. Miniaturization has reduced the size of these devices, making them less invasive and easier to implant. Remote control provides more precise medication delivery and dosage. Biodegradable implants are an additional advancement in implantable drug delivery systems that eliminate the need for surgical removal. Smart implants can monitor a patient's condition and adjust their drug doses. Long-acting implants also provide sustained drug delivery for months or even years, eliminating the need for regular medication dosing, and wireless power and data transmission technology enables the use of devices that are more comfortable and less invasive. These innovations have enhanced patient outcomes by enabling more precise administration, sustained drug delivery, and improved health care monitoring. With continued research and development, it is anticipated that IDDSs will become more effective and provide patients with improved health outcomes. This review categorizes and discusses the benefits and limitations of recent novel IDDSs for their potential therapeutic use.

Performance evaluation of a low-cost Ti-Mo-Fe (TMF8) as a replacement for Ti-6Al-4V for internal fixation implants used in mandibular angular fractures: a finite element analysis study

Stainless steel and titanium-based alloys have been the gold standard when it comes to permanent implants and magnesium-based alloys have been the best option for bioresorbable alloys. Ti-6Al-4V, Ti-64, with its 110 GPa Young's Modulus is the most commonly employed alloy to manufacture biomedical implants used for treatment of fractures of skeleton. Recently, researchers have developed a new low-cost and toxic Vanadium-free alternative to this alloy, Ti-3Mo-0.5Fe at.%, namely TMF8. This alloy has a 25% lesser Young's Modulus compared to Ti-6Al-4V and also demonstrated acceptable mechanical properties while possessing better cell proliferation results. The lower Young's Modulus can aid in lowering stress shielding effects while its cytocompatibility could enhance healing. This work, therefore, tries to use finite element analyses to compare these two alloys (Ti-64 and TMF8) from a practical structural point of view to analyse the advantages and disadvantages of this new alloy and how a low-cost biocompatible alternative (TMF8) can actually prove to be a more viable option. The analyses confirm that TMF8 shows almost similar biomechanics performance to Ti-64 alloy (and in acceptable range) in bone plate fixation of mandibular angular fracture treatment.

Insights into heat treatments of biodegradable Mg-Y-Nd-Zr alloys in clinical settings: Unveiling roles of β' and β1 nanophases and latent in vivo hydrogen evolution

Heat treatment serves as a viable strategy to effectively mitigate the intense corrosion of biodegradable WE43 alloys. However, limited comprehension of the passivation mechanisms underlying heat treatment and the dilemma to quantitatively examine the evolution of hydrogen gas in vivo introduce uncertainties in designing heat treatments for developing clinically applicable WE43. This work aims to advance this knowledge by applying cutting-edge atom probe tomography to provide atomic-scale insights into the passivation roles of rare earth (RE)-rich β1 (Mg3(Y, Nd)) and β' (Mg12NdY) nanophases induced by T6 heat treatment at 250 °C, and employing machine learning-based image analysis techniques to quantitatively unveil WE43's in vivo gas evolution during a 12-week implantation. It was found that nanosized β1 and β' phases can effectively improve WE43's corrosion resistance by inducing an accelerated passivation effect on the surface and confining the distribution of hydrogen ions in the matrix. Female rats presented slightly higher corrosion rates than male rats in weeks 1 and 4 but lower hydrogen gas volumes in vivo, while male rats possessed a superior ability to metabolise hydrogen gas in vivo. Notably, latent gas evolution against the corrosion rates was found which peaked at week 4 and subsided at week 12 despite the gradually decreased corrosion rates from week 1 to 12. This study offers insights for engineering heat treatments to develop clinically applicable WE43 with acceptable corrosion rates and in vivo gas generation at various implantation stages. STATEMENT OF SIGNIFICANCE: The study aimed to reveal the role of β1 and β' nanophases on the good corrosion resistance of WE43. The influence of these nanophases on WE43's corrosion performance has not been totally understood. Similarly, the understanding of hydrogen gas evolution as it relates to the magnesium implant's corrosion rate lacks clarity. Atom probe tomography (APT) indicates β1 and β' nanophases trap hydrogen, removing H2 from the lattice and disabling its catalytic role in Mg oxidation. Machine learning-aided analyses of computed tomography (CT) scan images indicate latent gas evolution, contradicting the monotonic in vivo H2 evolution that is widely accepted.

Biomechanical Principles of Intramedullary Nails in Veterinary and Human Medicine

Intramedullary nails are specialized metal rods inserted into the medullary cavity of a fractured bone and secured to reduce load on the fracture site, provide stability, and permit healing. The purpose of this review is to highlight the biomechanics of orthopaedic intramedullary nailing, as well as discuss the biomechanical considerations that have shaped implant design and fixation technique in veterinary and human medicine. Relevant studies were included from the PubMed database and Google Scholar for discussion on the basic science and nail design of intramedullary nails. Implant design and implementation continues to progress, with new innovative designs currently under investigation. A lack of consensus remains on the superior implant material. Recent studies, particularly in human populations, have supported the use of reaming based on reoperation rates, nonunion rates, and dynamization. Design modifications, such as the expandable intramedullary nails and angle-stable interlocking designs, have been investigated as methods of improving cortical contact and resisting torsional stress. Intramedullary nailing is a valuable stabilization technique for long bone fractures across a variety of species. The technology continues to undergo design improvements in both veterinary and human medicine.

Nanoetched Stainless Steel Architecture Enhances Cell Uptake of Biomacromolecules and Alters Protein Corona Abundancy

Nanotexture on biocompatible surfaces promotes cell adhesion and proliferation. High aspect ratio nanoachitecture serves as an ideal interface between implant materials and host cells that is well-suited for localized therapeutic delivery. Despite this potential, nanotextured surfaces have not been widely applied for biomacromolecule delivery. Here, we employed a low-cost, industrially relevant nanoetching process to modify the surface of biocompatible stainless steel 316 (SS316L), creating nanotextured SS316L (NT-SS316L) as a material for intracellular biomacromolecule delivery. As biomacromolecule cargoes are adsorbed to the steel and ultimately would be used in protein-rich environments, we performed serum protein corona analysis on unmodified SS316L and NT-SS316L using tandem mass spectrometry. We observed an increase in proteins associated with cell adhesion on the surface of NT-SS316L compared to that of SS316L, supporting literature reports of enhanced adhesion on nanotextured materials. For delivery to adherent cells, a "hard corona" of model biomacromolecule cargoes including superfolder green fluorescent protein (sfGFP) charge variants, cytochrome c, and siRNA was adsorbed on NT-SS316L to assess delivery. Nanotextured surfaces enhanced cellular biomacromolecule uptake and delivered cytosolic-functional proteins and nucleic acids through energy-dependent endocytosis. Collectively, these findings indicate that NT-SS316L holds potential as a surface modification for implants to achieve localized drug delivery for a variety of biomedical applications.

Titanium Cable Cerclage Increases the Load to Failure in Plate Osteosynthesis for Distal Femoral Fractures

Background and Objectives: The reduction of two-part oblique or spiral fractures of the distal femur using steel wire cerclage prior to plate osteosynthesis is a proven procedure. In addition to being useful in fracture reduction, wire cerclage was also shown to increase the stability of osteosynthesis. Nevertheless, metal corrosion and the allergenic potency of steel remain problematic disadvantages of this method. A biomechanical study was carried out to evaluate titanium cable cerclage as an alternative supplement for plate osteosynthesis of a distal femoral two-part fracture. Materials and Methods: An unstable AO/OTA 32-A2.3 fracture was created in eleven pairs of nonosteoporotic human cadaver femora. All the samples were treated with polyaxial angular stable plate osteosynthesis. One femur from each pair was randomly selected for an additional fracture fixation with multifilament titanium cable cerclage. Stepwise cyclic axial loading was applied in a load-to-failure mode using a servohydraulic testing machine. Results: All specimens (mean age: 80 years; range: 57-91 years) withstood a cycling force of at least 1800 N. With a mean load of 2982 N (95% CI: 2629-3335 N), the pressure forces resulting in osteosynthesis failure were significantly higher in specimens with an additional titanium cerclage (Group 1) than in samples that were solely treated with plate osteosynthesis (Group 2) at 2545 N (95% CI: 2257-2834 N) (p = 0.024). In both groups, cutting out the distal screws at the condyle region, resulting in shearing of the distal fragment proximal to the fracture line, was the most frequent cause of construct failure. Among the specimens assigned to Group 1, 36% exhibited a specific fracture pattern, namely, a fracture of the dorsal buttress above the cerclage. Analysis of axial stiffness (p = 0.286) and irreversible deformity of the specimens revealed no differences between the groups (p = 0.374). Conclusion: Titanium cable cerclage application, as a supplement to an angular stable plate, resulted in an increased load to failure. In terms of stability, the use of this adjunct for fracture fixation of supracondylar two-part oblique femoral fractures might, therefore, be an option, especially in patients who are sensitive to nickel.

Antibacterial Immunonegative Coating with Biocompatible Materials on a Nanostructured Titanium Plate for Orthopedic Bone Fracture Surgery

Periprosthetic infections resulting from bacterial biofilm formation following surgical bone fracture fixation present important clinical challenges. Conventional orthopedic implant materials, such as titanium, are prone to biofilm formation. This study introduces a novel surface for orthopedic titanium plates, optimized for clinical application in human bone fractures. Leveraging nanostructure-based surface coating technology, the plate achieves an antibacterial/immunonegative surface using biocompatible materials, including poloxamer 407, epigallocatechin gallate, and octanoic acid. These materials demonstrate high biocompatibility and thermal stability after autoclaving. The developed plate, named antibacterial immunonegative surface, releases antibacterial agents and prevents adhesion between human tissue and metal surfaces. Antibacterial immunonegative surface plates exhibit low cell toxicity, robust antibacterial effects against pathogens such as Staphylococcus aureus and Pseudomonas aeruginosa, high resistance to biofilm formation on the implant surface and surrounding tissues, and minimal immune reaction in a rabbit femoral fracture model. This innovation holds promise for addressing periprosthetic infections and improving the performance of orthopedic implants.

Amorphous TiO2nano-coating on stainless steel to improve its biological response

This study delves into the potential of amorphous titanium oxide (aTiO2) nano-coating to enhance various critical aspects of non-Ti-based metallic orthopedic implants. These implants, such as medical-grade stainless steel (SS), are widely used for orthopedic devices that demand high strength and durability. The aTiO2nano-coating, deposited via magnetron sputtering, is a unique attempt to improve the osteogenesis, the inflammatory response, and to reduce bacterial colonization on SS substrates. The study characterized the nanocoated surfaces (SS-a TiO2) in topography, roughness, wettability, and chemical composition. Comparative samples included uncoated SS and sandblasted/acid-etched Ti substrates (Ti). The biological effects were assessed using human mesenchymal stem cells (MSCs) and primary murine macrophages. Bacterial tests were carried out with two aerobic pathogens (S. aureusandS. epidermidis) and an anaerobic bacterial consortium representing an oral dental biofilm. Results from this study provide strong evidence of the positive effects of the aTiO2nano-coating on SS surfaces. The coating enhanced MSC osteoblastic differentiation and exhibited a response similar to that observed on Ti surfaces. Macrophages cultured on aTiO2nano-coating and Ti surfaces showed comparable anti-inflammatory phenotypes. Most significantly, a reduction in bacterial colonization across tested species was observed compared to uncoated SS substrates, further supporting the potential of aTiO2nano-coating in biomedical applications. The findings underscore the potential of magnetron-sputtering deposition of aTiO2nano-coating on non-Ti metallic surfaces such as medical-grade SS as a viable strategy to enhance osteoinductive factors and decrease pathogenic bacterial adhesion. This could significantly improve the performance of metallic-based biomedical devices beyond titanium.

Research status and prospects of biodegradable magnesium-based metal guided bone regeneration membranes

Biodegradable magnesium-based metal guided bone regeneration (GBR) membranes possess excellent mechanical properties, biodegradability, and osteopromotive capabilities, making them ideal implants for the treatment of maxillofacial bone defects. This review summarizes the current status and future research trends related to magnesium-based GBR membranes. First, the research history and application fields of magnesium-based metals are introduced, and the advantages of the use of magnesium-based materials for GBR membranes, including their mechanical properties, biocompatibility, osteopromotive performance, and underlying mechanisms are discussed. Finally, this review addresses the current limitations of magnesium-based GBR membranes and their applications and prospects in the field of dentistry. In conclusion, considerable advancements have been in fundamental and translational research on magnesium-based GBR membranes, which lays a crucial foundation for the treatment of maxillofacial bone defects.

Manual Instruments as an Alternative to Drilling for Bony Exposure in Skull Base Surgery: Concept and Technique

Background  Drilling in neurosurgery is an integral part of surgical exposure, especially in skull base approaches and craniovertebral junction (CVJ) surgeries. Most of such drillings are done in close proximity to the neurovascular structures in skull base surgeries and cervical-medullary junction or facet/pedicle in CVJ surgeries. Reluctance to drilling among young neurosurgeons is due to less hands-on experience during training and also, in the early part of the career, due to fear of injury to neurovascular structures. Methods  Five commonest bone removals for skull base region and CVJ surgeries that can be safely done using manual instruments were identified based on experiences of senior authors. The authors highlight key technical nuances to widen surgical corridors using manual instruments safely for skull base surgical approaches. Results  Basic neuroanatomical concepts and basic physics help in using manual instruments safely for bone removals in various skull base surgical approaches. Conclusions  Manual instruments may be used for bone removals in selected skull base surgical approaches, which help young neurosurgeons to perform these surgeries in limited-resource settings.

A review on antimicrobial strategies in mitigating biofilm-associated infections on medical implants

Biomedical implants are crucial in providing support and functionality to patients with missing or defective body parts. However, implants carry an inherent risk of bacterial infections that are biofilm-associated and lead to significant complications. These infections often result in implant failure, requiring replacement by surgical restoration. Given these complications, it is crucial to study the biofilm formation mechanism on various biomedical implants that will help prevent implant failures. Therefore, this comprehensive review explores various types of implants (e.g., dental implant, orthopedic implant, tracheal stent, breast implant, central venous catheter, cochlear implant, urinary catheter, intraocular lens, and heart valve) and medical devices (hemodialyzer and pacemaker) in use. In addition, the mechanism of biofilm formation on those implants, and their pathogenesis were discussed. Furthermore, this article critically reviews various approaches in combating implant-associated infections, with a special emphasis on novel non-antibiotic alternatives to mitigate biofilm infections.

Distal femur fractures: basic science and international perspectives

Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.

Risk Factors for Hardware Removal Following Bimaxillary Surgery: A National Database Analysis

Orthognathic surgery typically relies on the rigid fixation of fracture fragments using metal hardware. Though hardware is usually intended to be implanted permanently, the removal of hardware (ROH) is sometimes indicated for a variety of reasons. The authors sought to identify risk factors for ROH following orthognathic surgery. The authors conducted a retrospective analysis of the Merative MarketScan Research Databases, 2007-2021 using Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9 and ICD-10) codes to identify patients who underwent an index Le Fort 1 osteotomy and bilateral sagittal split osteotomy operation on the same day. Statistical analysis involved χ 2 , Shapiro-Wilk, Wilcoxon-Mann-Whitney, Poisson regression, and multivariable logistic regression tests. 4698 patients met the inclusion criteria. The mean age at surgery was 25 years, and 57% were female. ROH occurred in 5.9% of patients. The mean time to hardware removal was 190.5±172.4 days. In a multivariate logistic regression, increased odds of ROH were associated with older patient age [OR: 1.02 (1.01-1.03), P =0.046], sleep apnea [OR: 1.62 (1.13-2.32), P =0.018], and craniofacial syndrome and/or cleft diagnoses [OR: 1.88 (1.14-2.55), P <0.001]. In the same model, postoperative oral antibiotic prophylaxis was not associated with ROH ( P =0.494). The incidence of all-cause complications [IRR: 1.03 (1.01-1.05), P <0.001] rose over the study period, while the incidence of ROH did not change significantly ( P =0.281). Patients at elevated risk should be counseled on the increased possibility of a second operation for ROH before having orthognathic surgery to ensure expectations and health care utilization decisions align with the evidence.

Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated With Lateral Locked Plating: A Risk-Stratified Analysis

OBJECTIVE

To identify technical factors associated with nonunion after operative treatment with lateral locked plating.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Ten Level I trauma centers.

PATIENT SELECTION CRITERIA

Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019.

OUTCOME MEASURES AND COMPARISONS

Surgery for nonunion stratified by risk for nonunion.

RESULTS

The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. ( P > 0.05).

CONCLUSIONS

Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Application of Artificial Intelligence at All Stages of Bone Tissue Engineering

The development of artificial intelligence (AI) has revolutionized medical care in recent years and plays a vital role in a number of areas, such as diagnostics and forecasting. In this review, we discuss the most promising areas of AI application to the field of bone tissue engineering and prosthetics, which can drastically benefit from AI-assisted optimization and patient personalization of implants and scaffolds in ways ranging from visualization and real-time monitoring to the implantation cases prediction, thereby leveraging the compromise between specific architecture decisions, material choice, and synthesis procedure. With the emphasized crucial role of accuracy and robustness of developed AI algorithms, especially in bone tissue engineering, it was shown that rigorous validation and testing, demanding large datasets and extensive clinical trials, are essential, and we discuss how through developing multidisciplinary cooperation among biology, chemistry with materials science, and AI, these challenges can be addressed.

Biomedical Applications of Titanium Alloys: A Comprehensive Review

Titanium alloys have emerged as the most successful metallic material to ever be applied in the field of biomedical engineering. This comprehensive review covers the history of titanium in medicine, the properties of titanium and its alloys, the production technologies used to produce biomedical implants, and the most common uses for titanium and its alloys, ranging from orthopedic implants to dental prosthetics and cardiovascular devices. At the core of this success lies the combination of machinability, mechanical strength, biocompatibility, and corrosion resistance. This unique combination of useful traits has positioned titanium alloys as an indispensable material for biomedical engineering applications, enabling safer, more durable, and more efficient treatments for patients affected by various kinds of pathologies. This review takes an in-depth journey into the inherent properties that define titanium alloys and which of them are advantageous for biomedical use. It explores their production techniques and the fabrication methodologies that are utilized to machine them into their final shape. The biomedical applications of titanium alloys are then categorized and described in detail, focusing on which specific advantages titanium alloys are present when compared to other materials. This review not only captures the current state of the art, but also explores the future possibilities and limitations of titanium alloys applied in the biomedical field.

Screw Stress Distribution in a Clavicle Fracture with Plate Fixation: A Finite Element Analysis

Clavicle midshaft fractures are mostly treated surgically by open internal reduction with a superior or anteroinferior plate and screws or by intramedullary nailing. Screw positioning plays a critical role in determining the stress distribution. There is a lack of data on the screw position and the appropriate number of cortices required for plate fixation. The aim of this study is to evaluate the mechanical behavior of an anterior plate implanted in a fractured bone subjected to 120° of lateral elevation compared to a healthy clavicle using numerical simulations. Contact forces and moments used were obtained from literature data and applied to the healthy and fractured finite element models. Stresses of about 9 MPa were found on the healthy clavicle, while values of about 15 MPa were calculated on the plate of the fractured one; these stress peaks were reached at about 30° and 70° of elevation when the stress shielding on the clavicle sums all the three components of the solicitation: compression, flexion, and torsion. The stress distribution in a clavicle fracture stabilized with plates and screws is influenced by several factors, including the plate's position and design, the type of screw, and the biomechanical forces applied during movements.

Linking the distal humerus columns in articular fracture fixation

INTRODUCTION

Concerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture.

MATERIALS AND METHODS

Ten matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths.

RESULTS

Mean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94).

DISCUSSION

Our results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments.

Reduced Cell Adhesion on LightPLAS-Coated Implant Surfaces in a Three-Dimensional Bioreactor System

Most implants used in trauma surgery are made of steel and remain inside the body only temporarily. The strong tissue interaction of such implants sometimes creates problems with their explantation. Modified implant surfaces, which decrease tissue attachment, might allow an easier removal and therefore a better outcome. Such a modification must retain the implant function, and needs to be biocompatible and cost-effective. Here, we used a novel VUV-light (Vacuum-Ultraviolett)-based coating technology (LightPLAS) to generate coated stainless-steel plates. The tested LightPLAS coating only had an average thickness of around 335 nm, making it unlikely to interfere with implant function. The coated plates showed good biocompatibility according to ISO 10993-5 and ISO 10993-12, and reduced cell adhesion after four different time points in a 2D cell culture system with osteoblast-like MG-63 cells. Furthermore, we could show decreased cell adhesion in our 3D cell culture system, which mimics the fluid flow above the implant materials as commonly present in the in vivo environment. This new method of surface coating could offer extended options to design implant surfaces for trauma surgery to reduce cell adhesion and implant ingrowth. This may allow for a faster removal time, resulting in shorter overall operation times, thereby reducing costs and complication rates and increasing patient wellbeing.

The Clinical Use of Osteobiologic and Metallic Biomaterials in Orthopedic Surgery: The Present and the Future

As the area and range of surgical treatments in the orthopedic field have expanded, the development of biomaterials used for these treatments has also advanced. Biomaterials have osteobiologic properties, including osteogenicity, osteoconduction, and osteoinduction. Natural polymers, synthetic polymers, ceramics, and allograft-based substitutes can all be classified as biomaterials. Metallic implants are first-generation biomaterials that continue to be used and are constantly evolving. Metallic implants can be made from pure metals, such as cobalt, nickel, iron, or titanium, or from alloys, such as stainless steel, cobalt-based alloys, or titanium-based alloys. This review describes the fundamental characteristics of metals and biomaterials used in the orthopedic field and new developments in nanotechnology and 3D-printing technology. This overview discusses the biomaterials that clinicians commonly use. A complementary relationship between doctors and biomaterial scientists is likely to be necessary in the future.

Improving the Surface Integrity of 316L Steel in the Context of Bioimplant Applications

Bioimplants should meet important surface integrity criteria, with the main goal of the manufacturing process to improve wear and corrosion resistance properties. This requires a special approach at the cutting stage. During this research, the impact of the cutting parameters on improving the surface integrity of AISI 316L steel was evaluated. In this context of bioimplant applications, the mean roughness Sa value was obtained in the range of 0.73-4.19 μm. On the basis of the results obtained, a significant effect was observed of both the cutting speed and the feed rate on changes in the microstructure of the near-surface layer. At a cutting speed of 150 m/min, the average grain size was approximately 31 μm. By increasing the cutting speed to 200 m/min, the average grain size increased to approximately 52 μm. The basic austenitic microstructure of AISI 316L steel with typical precipitation of carbides on the grain boundaries was refined at the near-surface layer after the machining process. Changing the cutting speed determined the hardness of the treated and near-surface layers. The maximum value of hardness is reached at a depth of 20 μm and decreases with the depth of measurement. It was also noted that at a depth of up to 240 μm, the maximum hardness of 270-305 HV1 was reached, hence the height of the machining impact zone can be determined, which is approximately 240 μm for almost all machining conditions.

Advances in Multifunctional Bioactive Coatings for Metallic Bone Implants

To fix the bone in orthopedics, it is almost always necessary to use implants. Metals provide the needed physical and mechanical properties for load-bearing applications. Although widely used as biomedical materials for the replacement of hard tissue, metallic implants still confront challenges, among which the foremost is their low biocompatibility. Some of them also suffer from excessive wear, low corrosion resistance, infections and shielding stress. To address these issues, various coatings have been applied to enhance their in vitro and in vivo performance. When merged with the beneficial properties of various bio-ceramic or polymer coatings remarkable bioactive, osteogenic, antibacterial, or biodegradable composite implants can be created. In this review, bioactive and high-performance coatings for metallic bone implants are systematically reviewed and their biocompatibility is discussed. Updates in coating materials and formulations for metallic implants, as well as their production routes, have been provided. The ways of improving the bioactive coating performance by incorporating bioactive moieties such as growth factors, osteogenic factors, immunomodulatory factors, antibiotics, or other drugs that are locally released in a controlled manner have also been addressed.

Effective Treatment of Femur Diaphyseal Fracture with Compression Plate - A Finite Element and In Vivo Study Comparing the Healing Outcomes of Nailing and Plating

BACKGROUND

The rigidity in osteosynthesis causes primary healing, and it takes longer to heal. The flexibility provided to the fixation allows micromotion between fragments which accelerates secondary healing.

METHODS

In this study, the healing outcomes of nailing and plating in different fixation stabilities were investigated and compared by using a finite element tool. The clinical observational study was also performed to verify the results of the finite element analysis. The nonlinear contact analysis was performed on 5 different fixation configurations capturing nail and plate in immediate post-surgery.

RESULTS

The finite element analysis results showed that flexibility instead of rigidity in interlock nail implantation increases the axial and shear micromotion near the fracture site by 47.4% (P < 0.05) and 12.4% (P < 0.05), respectively. For LCDCP implantation, the flexible fixation increases the axial and shear micromotion near fracture site by 75.7% (P < 0.05) and 25.3% (P < 0.05), respectively.

CONCLUSION

Our findings suggest that flexible fixations of interlock nail and LCDCP provide a preferred mechanical environment for healing, and hence, the LCDCP in flexible mode can be an effective alternative to interlock nail for the femur diaphyseal fracture.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00795-1.

Early peri-implant fractures after distal femur fracture locked plating?

PURPOSE

To report the peri-implant fracture rates after locked plating of distal femur fractures and examine risk factors.

METHODS

Over a 7 year period, 89 AO/OTA 33A/C distal femur fractures were identified and reviewed. After excluding treatment with intramedullary nails, age under 50, those with the proximal femur protected, or those without 6 months of follow-up, 42 distal femur fractures in 41 patients, mean age 72.3 were studied. All were treated with lateral locked plating of distal femur fractures. The details of the constructs were recorded. Mean follow-up was 562 days (18.7 months).

RESULTS

3/42 were open injuries, 9/42 were type C, 16/42 were type A, and 17 were periprosthetic above a knee arthroplasty. Two patients were treated with a dynamic plating construct using all far-cortical locking (FCL) screws in the diaphysis. 40 patients were treated with a variety of non-dynamic diaphyseal constructs including locking, non-locking, and four with 1-2 FCL screws distally. There was one asymptomatic nonunion. 2/2 patients in the dynamically plated group experienced a peri-implant fracture versus 1/40 in the non-dynamically plated group (p = 0.001). 3/9 with an all-locked construct versus 0/25 patients with a most proximal non-locking screw experienced a fracture.

CONCLUSIONS

The overall peri-implant fracture risk was 7.1% (3/42), 3/17 patients with a locking screw most proximal experienced a peri-implant fracture, 3/9 with an all-locking construct, and 2/2 patients with a dynamic construct experienced a fracture. These findings merit additional clinical and biomechanical study.

Assessing Microleakage at 2 Different Implant-Healing Abutment Interfaces

OBJECTIVES

This study aimed to evaluate implants from different manufacturers and determine whether implant-healing abutment interface has a significant impact on implant seal.

METHODS

An air-injection pressure measurement test was performed on implants with either line-contact (modified TSIII [TSM] and Bone Level Tapered [BLT]) or partial face-contact (BlueDiamond [BD], SuperLine [SL], ISII, and UFII) interface design from 6 different manufacturers. Forty implants per implant type were analysed. Pressure data were evaluated with Kruskal-Wallis test and Dunn's post hoc analysis (statistical significance was set at P < .05).

RESULTS

BLT implants leaked when the mean pressure was increased to 199.9 kPa. The following implants showed mean leakage pressures of 182.9 (TSM), 157.4 (BD), 112.9 (SL), 101.8 (ISII), and 30.6 (UFII). There was a significant difference between line-contact and partial face-contact implants (P < .001).

CONCLUSIONS

The implant interface design has a significant impact on implant microbial leakage. Implants with a line-contact interface exhibited a higher resistance to leakage than those with partial face-contact.

The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates

Background

Distal femoral non-unions are challenging, and frequently associated with short distal fragments, poor bone stock, and with issues from previous implants.

Materials and methods

A retrospective study of 31 patients admitted with distal femoral non-unions treated using anatomical lateral locking plates. Non-union scores were used. The Knee Society and Neer's scores were used for the comparison of results. The mean follow-up was 39.5 months (from 24 months to 60 months).

Results

Stable union was accomplished in all. There was a significant improvement in the average Neer's score (24 preoperative to 82 post-operatively at final follow-up), the Part 1 Knee Society score from an average of 46 preoperatively to 84 post-operatively, and Part 2 Knee Society score from 36 preoperatively to 80 post-operatively.

Conclusion

Optimal stability, good compression at the non-union site (either by lag screws or a compression device or both), maintaining the axial alignment strictly, freshening of bone ends, using an adequate amount of cortico-cancellous bone graft, respecting the biology along with the correct choice of the implant (including the size) are essential to achieve union at the fracture site.

Clinical significance

Paying attention to the basic principles of management, good contact, stability and maintaining biology is essential in the treatment of non-union.

How to cite this article

Mukhopadhaya J, Ranjan R, Sinha AK, et al. The Management of Aseptic Non-unions of Distal Femur Fractures with Anatomical Lateral Locking Plates. Strategies Trauma Limb Reconstr 2022;17(3):137-143.

Double Pre-Bending of an Intramedullary Nail Is the Minimal Invasive Osteosynthesis Solution for Dia-Metaphyseal Fractures of the Radius in Children: Technical Note and Case Series

Whereas in paediatric traumatology for diaphyseal fractures of the radius (intramedullary nail), as well as metaphyseal fractures (K-wire), minimal invasive methods for osteosynthesis were established as gold standard, the ideal osteosynthesis of fractures of the dia-metaphyseal area remains controversial. In this article, the author describes his own minimal invasive technique, using an intramedullary nail that must be pre-bent twice to achieve a stable reduction, with three-point support. The material used for this new surgical technique is an ordinary intramedullary nail. If not available, the operation can also be performed with a sufficiently lengthy K-wire. The intramedullary nail needs to be pre-bent twice, which follows a standardised procedure. A small case series is included to visualise the scope of this minimal-invasive method.