Achieving stomal continence with an ileal pouch and a percutaneous implant

In this study, a soft-tissue-anchored, percutaneous port used as a mechanical continence-preserving valve in reservoir ileo- and urostomies was functionally and morphologically evaluated in eight dogs. During follow-up, the skin failed to attach to the implant, but the intestine inside the stoma port appeared to be attached to the mesh. After reaching adequate reservoir volume, the urostomies were rendered continent by attaching a lid to the implant. The experiments were ended at different time intervals due to implant-related adverse events. In only one case did the histological evaluation reveal integration at both the implant-intestine and implant-skin interfaces, with a low degree of inflammation and the absence of bacterial colonisation. In the remaining cases, integration was not obtained and instead mucosal downgrowth and biofilm formation were observed. The skin-implant junction was characterised by the absence of direct contact between the epidermis and the implant. Varying degrees of epidermal downgrowth, granulation tissue formation, inflammatory cell infiltration and bacterial growth and biofilm formation were prominent findings. In contrast, the subcutaneously located anchor part of the titanium port was well integrated and encapsulated by fibrous tissue. These results demonstrate the opportunity to achieve integration between a soft-tissue-anchored titanium port, skin and intestine. However, predictable long-term function could not be achieved in these animal models due to implant- and non-implant-related adverse events. Unless barriers at both the implant-skin and implant-intestine junctions are created, epidermal and mucosal downward migration and biofilm formation will jeopardise implant performance.

Histological evaluation of titanium fiber mesh-coated implants in a rabbit femoral condyle model

OBJECTIVES

This study was aimed to comparatively evaluate new bone formation into the pores of a flexible titanium fiber mesh (TFM) applied on the surface of implant.

METHODS

Twenty-eight custom made cylindrical titanium implants (4 ×10 mm) with and without a layer of two different types of TFM (fiber diameter of 22 µm and 50 µm, volumetric porosity ~70%) were manufactured and installed bilaterally in the femoral condyles of 14 rabbits. The elastic modulus for these two TFM types was ~20 GPa and ~5 GPa respectively, whereas the solid titanium was ~110 GPa. The implants (Control, TFM-22, TFM-50) were retrieved after 14 weeks of healing and prepared for histological assessment. The percentage of the bone area (BA%), the bone-to-implant contact (BIC%) and amount were determined.

RESULTS

Newly formed bone into mesh porosity was observed for all three types of implants. Histomorphometric analyses revealed significantly higher (~2.5 fold) BA% values for TFM-22 implants (30.9 ± 9.5%) compared to Control implants (12.7 ± 6.0%), whereas BA% for TMF-50 did not significantly differ compared with Control implants. Furthermore, both TFM-22 and TFM-50 implants showed significantly higher BIC% values (64.9 ± 14.0%, ~2.5 fold; 47.1 ± 14.1%, ~2 fold) compared to Control (23.6 ± 17.4%). Finally, TFM-22 implants showed more and thicker trabeculae in the peri-implant region.

SIGNIFICANCE

This in vivo study demonstrated that implants with a flexible coating of TFM improve bone formation within the inter-fiber space and the peri-implant region.

Chitosan-based sleeves loaded with silver and chlorhexidine in a percutaneous rabbit tibia model with a repeated bacterial challenge

Various strategies have been explored to prevent pin tract infections (PTI), including the use of antibacterial sleeves. However, an ideal animal model to evaluate the efficacy of antibacterial strategies is still lacking. This study aimed to construct an animal model with a consistent induction of infection after bacterial challenge. Further, the efficacy of silver and chlorhexidine loaded chitosan sleeves was evaluated to prevent PTI around a percutaneous implant. Titanium pins wrapped with sleeves were implanted in anterior lateral rabbit tibia. After 2 weeks, Staphylococcus aureus suspensions (1 × 10⁶ CFU) were injected weekly to the exit site, and the clinical infection status was recorded. After 6 weeks, all rabbits were euthanized to evaluate the bacterial colonization microbiologically and histomorphometrically. Results showed that the implant screw bilaterally penetrated the tibia and kept the implant stable. A rod length of twice the thickness of the soft-tissue layer was necessary to maintain the percutaneous penetration of the implants. A 100% infection rate was obtained by the bacterial inoculation. Silver loaded sleeves reduced significantly the bacterial density and reduced the inflammatory symptoms of the percutaneous pin tract. However, the addition of chlorhexidine to the sleeves had no added value in terms of further reduction of bacteria and inflammation. In conclusion, a consistent animal model was designed to evaluate strategies to prevent PTI. In addition, the use of silver loaded chitosan sleeves can be pursued for further (pre-)clinical exploration for the prevention of PTI. STATEMENT OF SIGNIFICANCE: This study constructed a bacterial challenged percutaneous rabbit tibia model to evaluate the potential of antibacterial strategies for the prevention of pin tract infections. The model was applied to evaluate a silver and chlorhexidine loaded membranes as an antibacterial sleeve. Our results demonstrate that the rabbit tibia model is suitable to evaluate antibacterial strategies for the prevention of pin tract infection as evidenced by the stable, bone fixed percutaneous implant and a 100% infection rate of the percutaneous pin tract. Silver loaded sleeves can lower the bacterial density of the percutaneous pin tract, but the addition of chlorhexidine to the silver-loaded sleeves does not contribute to an enhanced antibacterial effect. Such experiments are of considerable interest to those in the research community, industry, and clinicians involved the occurrence of infection of skin penetrating medical devices.

Histological investigation of the titanium fiber mesh with one side sealed with non-porous material for its application to the artificial heart system

In this study, we investigated tissue-inducing characteristics of a titanium fiber mesh disk with one surface sealed with a non-porous material. We used sintered titanium fiber mesh (Hi-Lex Co., Zellez™, Hyogo, Japan) having a titanium fiber diameter of 50 µm and volumetric porosity of the titanium fiber mesh of 87% with an average pore size of 200 µm. The titanium fiber mesh is disk-shaped with a dimeter of 5 mm and a thickness of 1.5 mm. One side of the titanium fiber mesh disk was sealed with silicone rubber adhesive that has no venomousness and the sealed titanium fiber mesh disks were implanted in rats under the skin of the dorsal region, and they were extracted in the 4th and 12th postoperative weeks. We investigated the distribution of capillaries; also we estimated the extent of the spread of oxygen from capillaries using the diffusion equation. Microscopic observation showed that the distribution of capillaries was mainly confined to the area around the sealed titanium fiber mesh disk and that connective tissue inside the sealed titanium fiber mesh disk seemed to be in a poor condition. From estimation of the extent of the spread of oxygen from capillaries, an area in which oxygen was poorly supplied may exist in the center of the sealed titanium fiber mesh disk. In conclusion, for application of the sealed titanium fiber mesh to an artificial heart system, the thickness of the titanium fiber mesh is an important factor for keeping the inside tissue in a healthy condition.

Toward a skin-material interface with vacuum-integrated capped macroporous scaffolds

Avulsion, epidermal marsupialization, and infection cause failure at the skin-material interface. A robust interface would permit implantable robotics, prosthetics, and other medical devices; reconstruction of surgical defects, and long-term access to blood vessels and body cavities. Torus-shaped cap-scaffold structures were designed to work in conjunction with negative pressure to address the three causes of failure. Six wounds were made on the backs of each of four 3-month old pigs. Four unmodified (no caps) scaffolds were implanted along with 20 cap-scaffolds. Collagen type 4 was attached to 21 implants. Negative pressure then was applied. Structures were explanted and assessed histologically at day 7 and day 28. At day 28, there was close tissue apposition to scaffolds, without detectable reactions from defensive or interfering cells. Three cap-scaffolds explanted at day 28 showed likely attachment of epidermis to the cap or cap-scaffold junction, without deeper marsupialization. The combination of toric-shaped cap-scaffolds with negative pressure appears to be an intrinsically biocompatible system, enabling a robust skin-material interface. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1307-1318, 2017.

Electrical characteristic of the titanium mesh electrode for transcutaneous intrabody communication to monitor implantable artificial organs

We have developed a tissue-inducing electrode using titanium mesh to obtain mechanically and electrically stable contact with the tissue for a new transcutaneous communication system using the human body as a conductive medium. In this study, we investigated the electrical properties of the titanium mesh electrode by measuring electrode-tissue interface resistance in vivo. The titanium mesh electrode (Hi-Lex Co., Zellez, Hyogo, Japan) consisted of titanium fibers (diameter of 50 μm), and it has an average pore size of 200 μm and 87 % porosity. The titanium mesh electrode has a diameter of 5 mm and thickness of 1.5 mm. Three titanium mesh electrodes were implanted separately into the dorsal region of the rat. We measured the electrode-electrode impedance using an LCR meter for 12 weeks, and we calculated the tissue resistivity and electrode-tissue interface resistance. The electrode-tissue interface resistance of the titanium mesh electrode decreased slightly until the third POD and then continuously increased to 75 Ω. The electrode-tissue interface resistance of the titanium mesh electrode is stable and it has lower electrode-tissue interface resistance than that of a titanium disk electrode. The extracted titanium mesh electrode after 12 weeks implantation was fixed in 10 % buffered formalin solution and stained with hematoxylin-eosin. Light microscopic observation showed that the titanium mesh electrode was filled with connective tissue, inflammatory cells and fibroblasts with some capillaries in the pores of the titanium mesh. The results indicate that the titanium mesh electrode is a promising electrode for the new transcutaneous communication system.

Biological characterization of woven fabric using two- and three-dimensional cell cultures

The integration and long-term functional retention of tissue implants are both strongly linked to the implant material characteristics. As a first approach, the cytocompatibility and bioactivity of such materials are evaluated using in vitro-based cell culture models. Typically, in vitro bioactivity is assessed by seeding single cells onto the test material to evaluate certain parameters such as cell adhesion, survival, proliferation, and functional differentiation. Probably, due to the reduction from three dimensional (3D) toward the two dimensional (2D) situation the data obtained from 2D culture models falls short of predicting the in vivo behavior of the biomaterial in question. In this study, a three dimensional (3D) in vitro cell culture model was applied to evaluate the bioactivity of well characterized fiber-based scaffolds using scaffold colonization as a bioactivity indicator. Cell behavior in this culture model was evaluated against a classical comparable, 2D cell culture system using polyethylene terephthalat and polyamide 6.6 fabrics. By using the 3D culture model, however, differences in cell population performance as a function of fiber diameter and mesh angle were evident. The use of 3D cell culture model clearly outperformed typical cell culture setup as means to evaluate cell population-scaffold interaction.

Integration between a percutaneous implant and the porcine small bowel

Inflammatory bowel diseases, cancer or trauma may require removal of all or part of the intestines, leaving the patient with a need to wear external stoma appliances for collection of bowel contents. By connecting the small bowel to a percutaneous port, equipped with a sealing lid, a fully continent and leak proof stoma can be created without a need for permanently wearing stoma appliance. The prerequisites for a connection between a permanent, transabdominal implant and a visceral organ are largely unexplored. Stoma ports made of titanium were implanted in the abdominal wall of domestic pigs and a branch of distal ileum was inserted through the ports. After being followed for 1-3 weeks, the ports were removed and subjected to histological evaluation to study the influence of their shape, structure, and position on the tissue response. Particular focus was attended to the attachment of the ileal serosal surface to the implants inner structure consisting of a titanium mesh. Macroscopic examination revealed fistulas and formation of abscesses in 4 of 11 the retrieved implants. Histological examination revealed regenerated and well-vascularized collagenous tissue around the mesh structure inside the implant. The integration was complete or partial for 10 of 11 ports. Despite various degrees of inflammation and tissue ingrowth, it was demonstrated for the first time that the serosal surface of ileum was firmly attached to the internal structure of the implant. These experiments provide a basis for optimization of the implant and surgical procedure before long-term functional animal experiments.

In vivo experiments with tracheostoma tissue connector prototypes

In cancer patients who have undergone total surgical removal of the larynx, ideally voice rehabilitation should be performed using a shunt valve (placed in a fistula of the tracheo-esophageal wall) and a tracheostoma valve (TSV) to enable hands-free tracheo-esophageal speech. A tracheostoma is created by suturing the trachea into the lower anterior part of the neck, and a TSV is a device that can be placed at the stoma. Unfortunately, many patients are unable to use a TSV, mainly due to fixation difficulties. To improve the fixation of the TSV, tracheostoma tissue connector (TS-TC) prototypes have been designed. Prototype 1 consisted of a titanium ring, inner diameter 30 mm, with a circular polypropylene mesh glued to it with silicone adhesive. Four holes had been drilled into the ring for the insertion of sub- and percutaneous screws. Prototype 2 consisted of a silicone rubber ring, inner diameter 30 mm, combined with polypropylene mesh and four titanium inserts that functioned as a base plate for the insertion of sub- and percutaneous screws. In adult female goats a tracheostoma was created and the prototypes were implanted. After 6 weeks of subcutaneous implantation, percutaneous screws were inserted. After twelve weeks, the experiment was terminated and the implants with the surrounding tissues were processed and examined histologically. The clinical appearance during weeks 7-12 varied from very poor to relatively good. Histologically, the implants showed a uniform inflammatory response. We found that all the tissue surrounding the screws showed signs of epithelial down growth. It was concluded that the two-stage implantation procedure of our prototype TS-TCs in this animal model was unsuccessful. Additional research efforts are necessary to improve tissue immobilization and to devise reliable fixation systems for TSVs.

Fibroblastic interactions with high-porosity Ti-6Al-4V metal foam

A novel metallic Ti-6Al-4V foam in development at the National Research Council of Canada was investigated for its ability to foster cell attachment and growth using a fibroblast cell culture model. The foam was manufactured via a powder metallurgical process that could produce interconnected porosity greater than 70%. Cell attachment was assessed after 6 and 24 h, while proliferation was examined after 3 and 7 days. Ingrown fibroblasts displayed a number of different morphologies; some fibroblasts were spread thinly in close apposition with the irregular surface, or more often had several anchorage points and extended in three dimensions as they spanned pore space. It was also demonstrated that fibroblasts were actively migrating through the porous scaffold over a 14-day period. In a 60-day extended culture, fibroblasts were bridging and filling macropores and had extensively infiltrated the foams. Overall, it was established that this foam was supportive of cell attachment and proliferation, migration through the porous network, and that it was capable of sustaining a large cell population.

Experimental results of the tracheoesophageal tissue connector for improved fixation of shunt valves in laryngectomized patients

BACKGROUND

After total laryngectomy and voice rehabilitation using a tracheoesophageal shunt valve, patients often have valve-related complications such as leakage. To solve these problems, a tracheoesophageal tissue connector (TE-TC) was devised to serve as an interface between the patient's tissue (trachea and esophagus) and the shunt valve.

METHODS

The TE-TC is a permucosal connection constructed from a titanium ring (filled with a silicon rubber plug) combined with polypropylene or titanium mesh. After implantation in adult goats for 12 weeks the implants were submitted to histologic investigation.

RESULTS

Firm implant fixation was achieved. In nearly all (18/19), no signs of infection of the implant were seen; 11 of 19 animals died before the end of the experiment owing to complications not related to the implant.

CONCLUSIONS

The TE-TC is a new device with potential in the solution for fixation-related problems in tracheoesophageal voice rehabilitation.

Histological assessment of titanium and polypropylene fiber mesh implantation with and without fibrin tissue glue

Polypropylene (PP) and titanium (Ti) meshes are well-known surgical implants that provoke a relative low foreign body reaction. Firm stabilization of the implant is important to prevent migration and subsequent failure of the operation. Fibrin tissue glues are commercially available adhesives and are widely accepted and applied in the medical field for hemorrhage, surgical bleeding, support of wound healing, wound and tissue gluing, sealing, and closure but also as antiadhesive agent in certain applications. The objective of this study was to evaluate the additional histological effect of fibrin glue application combined with two different types of meshes. Six pieces of mesh of each were subcutaneously implanted for 3, 6, and 12 weeks, with and without fibrin glue. After excision, processing, and staining, light microscopic analysis was performed on the sections, using subjective histological description and histomorphometry. Capsule quality, capsule thickness, interstitial quality, and total score were evaluated. To compare the samples with glue and without glue, analysis of variance (ANOVA) tests were carried out. No complications were observed. In general, the glue remnants remained visible at 3 and 6 weeks of implantation, accompanied by an inflammatory reaction and macrophage activity. At 12 weeks, all samples showed good tissue integration without evidence of glue. Evidently, the samples with glue demonstrated a prolonged inflammatory response and were surrounded by fibrous tissue capsules that were significantly thicker compared with the samples without glue (p < 0.05).

Hydrodynamic compression of young and adult rat osteoblast-like cells on titanium fiber mesh

Living bone cells are responsive to mechanical loading. Consequently, numerous in vitro models have been developed to examine the application of loading to cells. However, not all systems are suitable for the fibrous and porous three-dimensional materials, which are preferable for tissue repair purposes, or for the production of tissue engineering scaffolds. For three-dimensional applications, mechanical loading of cells with either fluid flow systems or hydrodynamic pressure systems has to be considered. Here, we aimed to evaluate the response of osteoblast-like cells to hydrodynamic compression, while growing in a three-dimensional titanium fiber mesh scaffolding material. For this purpose, a custom hydrodynamic compression chamber was built. Bone marrow cells were obtained from the femora of young (12-day-old) or old (1-year-old) rats, and precultured in the presence of dexamethasone and beta-glycerophosphate to achieve an osteoblast-like phenotype. Subsequently, cells were seeded onto the titanium mesh scaffolds, and subjected to hydrodynamic pressure, alternating between 0.3 to 5.0 MPa at 1 Hz, at 15-min intervals for a total of 60 min per day for up to 3 days. After pressurization, cell viability was checked. Afterward, DNA levels, alkaline phosphatase (ALP) activity, and extracellular calcium content were measured. Finally, all specimens were observed with scanning electron microscopy. Cell viability studies showed that the applied pressure was not harmful to the cells. Furthermore, we found that cells were able to detect the compression forces, because we did see evident effects on the cell numbers of the cells derived from old animals. However, there were no other changes in the cells under pressure. Finally, it was also noticeable that cells from old animals did not express ALP activity, but did show similar calcified extracellular matrix formation to the cells from young animals. In conclusion, the difference in DNA levels as reaction toward pressure, and the difference in ALP levels, suggest that the osteogenic properties of bone marrow-derived osteoblast-like cells are different with respect to the age of the donor.

Effect of microtextured surfaces on the performance of percutaneous devices

Along the percutaneous part of implantable devices, like (semi-)permanent catheters, epithelial downgrowth can occur. This process can eventually lead to implant loss. Various treatments for the catheter surface have been proposed, to improve their performance. The purpose of the current study was to investigate the effect of a microgroove pattern on the tube surface, on epithelial downgrowth. Catheterlike implants were made of silicone tubes, with anchoring cuffs made of titanium-fiber mesh. A thin sheet of silicone with microgrooves was applied on the tubes. Two types of texturing were used, a square groove of 10 microm wide and 1 microm deep; or a V-shaped groove of 40 microm wide. The grooves were directed either along the long axis of the catheter tube (grooves perpendicular to the skin surface) or circling around the catheter (grooves directed parallel to the skin surface). As controls, catheters with a smooth outer surface were used. Implants were placed in 30 rats, with a follow-up period of 9 weeks. During this time, animals were inspected biweekly, and catheter exit sites were evaluated using a scoring system. At the end of the 9-week period the implants and surrounding tissues were processed for histological evaluation. For the clinical evaluation of the exit sites, no statistical differences were found between the study groups. Histologically, epithelial downgrowth was observed for all samples. The histomorphometrical measurements showed that there were no differences in downgrowth between the smooth and parallel-grooved catheters. However, there was increased epithelial downgrowth along the catheters with grooves perpendicular to the skin. In conclusion, a grooved microtexture can direct epithelial tissue ingrowth, but this study found no beneficial effects of the guidance phenomenon.