State of the art review on design and manufacture of hybrid biomedical materials: Hip and knee prostheses

Optimizing functionally graded tibial components for total knee replacements: a finite element analysis and multi-objective optimization study

The optimal design of complex engineering systems requires tracing precise mathematical modeling of the system's behavior as a function of a set of design variables to achieve the desired design. Despite the success of current tibial components of knee implants, the limited lifespan remains the main concern of these complex systems. The mismatch between the properties of engineered biomaterials and those of biological materials leads to inadequate bonding with bone and the stress-shielding effect. Exploiting a functionally graded material for the stem of the tibial component of knee implants is attractive because the properties can be designed to vary in a certain pattern, meeting the desired requirements at different regions of the knee joint system. Therefore, in this study, a Ti6Al4V/Hydroxyapatite functionally graded stem with a laminated structure underwent simulation-based multi-objective design optimization for a tibial component of the knee implant. Employing finite element analysis and response surface methodology, three material design variables (stem's central diameter, gradient factor, and number of layers) were optimized for seven objective functions related to stress-shielding and micro-motion (including Maximum stress on the cancellous bone, maximum and mean stresses on predefined paths, the standard deviation of mean stress on paths, maximum and mean micro-motions at the bone-implant interface and the standard deviation of mean micro-motion). Then, the optimized functionally graded stem with 6 layers, a central diameter of 5.59 mm, and a gradient factor of 1.31, was compared with a Ti6Al4V stem for various responses. In stress analysis, the optimal stem demonstrated a 1.92% improvement in cancellous bone stress while it had no considerable influence on the maximum, mean, and standard deviation of stresses on paths. In micro-motion analysis, the maximum, mean, and standard deviation of mean micro-motion at the interface were enhanced by 24.31%, 39.53%, and 19.77%, respectively.

Effect of calcium phosphate/bovine serum albumin coated Al2O3-Ti biocomposites on osteoblast response

OBJECTIVES

The biological performance of aluminum oxide-titanium (Al2O3-Ti) composites requires special attention to achieve improved osteoblastic differentiation, and subsequent osseointegration/strong anchorage with the surrounding bone. Therefore, the aim of this study was to improve them by providing calcium phosphate (Ca-P)/bovine serum albumin (BSA) coating on their surfaces.

METHODS

Ca-P)/BSA coatings were prepared on the surfaces of 75vol.%Ti composites (75Ti-BSA) and pure Ti (100Ti-BSA as a control). The surface characteristics, phase analysis, micro-hardness, BSA release profile and biological responses including cytotoxicity, cell viability, differentiation, mineralization, and cell adhesion were evaluated.

RESULTS

The results showed that lower cytotoxicity% and higher mitochondrial activity or viability % were associated with the samples with Ca-P/BSA coatings (particularly 75Ti-BSA having 21.3% cytotoxicity, 111.4% and 288.6% viability at day 1 and 7, respectively). Furthermore, the Ca-P/BSA coating could highly enhance the differentiation of pre-osteoblast cells into osteoblasts in 75Ti-BSA group (ALP concentration of 4.8 ng/ml). However, its influence on cell differentiation in 100Ti-BSA group was negligible. Similar results were also obtained from mineralization assay. The results on cell adhesion revealed that the Ca-P/BSA coated samples differently interacted with MC3T3-E1 cells; enlarged flat cells on 75Ti-BSA vs more spindle-shaped cells on 100Ti-BSA.

CONCLUSIONS

Ca-P/BSA coated Al2O3-Ti provided promising biological performance, superior to that of uncoated composites. Therefore, they have the potential to improve implant osseointegration.

An additively manufactured titanium tilting suture anchor: a biomechanical assessment on human and ovine bone specimens

Introduction

A novel titanium tilting suture anchor was designed and fabricated using additive manufacturing. The anchor enjoyed a nonsymmetrical structure to facilitate its insertion procedure through a weight-induced tilt, a saw-teeth penetrating edge to provide a strong initial fixation into cancellous bones of various densities, and an appropriate surface texture to enhance the longterm fixation strength through bone ingrowth.

Methods

Biomechanical tests were performed on 10 ovine and 10 human cadaveric humeri to examine the insertion procedure and assess the initial fixation strength of the anchor, in comparison with a standard screw-type anchor as control.

Results

This study indicated a simple yet reliable insertion procedure for the tilting anchor. All anchors survived after 400 cycles of cyclic loadings and failed in the load-to-failure step. There were no significant differences between the displacements and fixation stiffnesses of the anchors in either group. The ultimate failure load was significantly smaller (p<0.05) for tilting anchors in ovine group (273.7 ± 129.72 N vs. 375.6 ± 106.36 N), but not different in human group (311.8 ± 82.55 N vs. 281.9 ± 88.35). Also, a larger number of tilting anchors were pulled out in ovine group (6 vs. 3) but a smaller number in human group (4 vs. 6).

Conclusion

It was concluded that the biomechanical performance of the designed tilting anchor is comparable with that of the standard screw-type anchors.

Enhanced and Stem-Cell-Compatible Effects of Nature-Inspired Antimicrobial Nanotopography and Antimicrobial Peptides to Combat Implant-Associated Infection

Nature-inspired antimicrobial surfaces and antimicrobial peptides (AMPs) have emerged as promising strategies to combat implant-associated infections. In this study, a bioinspired antimicrobial peptide was functionalized onto a nanospike (NS) surface by physical adsorption with the aim that its gradual release into the local environment would enhance inhibition of bacterial growth. Peptide adsorbed on a control flat surface exhibited different release kinetics compared to the nanotopography, but both surfaces showed excellent antibacterial properties. Functionalization with peptide at micromolar concentrations inhibited Escherichia coli growth on the flat surface, Staphylococcus aureus growth on the NS surface, and Staphylococcus epidermidis growth on both the flat and NS surfaces. Based on these data, we propose an enhanced antibacterial mechanism whereby AMPs can render bacterial cell membranes more susceptible to nanospikes, and the membrane deformation induced by nanospikes can increase the surface area for AMPs membrane insertion. Combined, these effects enhance bactericidal activity. Since functionalized nanostructures are highly biocompatible with stem cells, they make promising candidates for next generation antibacterial implant surfaces.

Bioactive Hydroxyapatite-Magnesium Phosphate Coatings Deposited by MAPLE for Preventing Infection and Promoting Orthopedic Implants Osteointegration

In this study, we used the matrix-assisted pulsed laser evaporation (MAPLE) technique to obtain hydroxyapatite (Ca₁₀(PO₄)₆(OH)₂) and magnesium phosphate (Mg₃(PO₄)₂) thin coatings containing bone morphogenetic protein (BMP4) for promoting implants osteointegration and further nebulized with the antibiotic ceftriaxone (CXF) to prevent peri-implant infections. The samples were characterized by X-ray diffraction (XRD), scanning electron microscopy (SEM), transmission electron microscopy (TEM), selected area electron diffraction (SAED), infrared microscopy (IRM) and Fourier-transform infrared spectroscopy (FT-IR). Furthermore, the antimicrobial properties were evaluated on Staphylococcus aureus biofilms and the cytocompatibility on the MC3T3-E1 cell line. The obtained results proved the potential of the obtained coatings for bone implant applications, providing a significant antimicrobial and antibiofilm effect, especially in the first 48 h, and cytocompatibility in relation to murine osteoblast cells.

State-of-the-art literature review methodology: A six-step approach for knowledge synthesis

INTRODUCTION

Researchers and practitioners rely on literature reviews to synthesize large bodies of knowledge. Many types of literature reviews have been developed, each targeting a specific purpose. However, these syntheses are hampered if the review type's paradigmatic roots, methods, and markers of rigor are only vaguely understood. One literature review type whose methodology has yet to be elucidated is the state-of-the-art (SotA) review. If medical educators are to harness SotA reviews to generate knowledge syntheses, we must understand and articulate the paradigmatic roots of, and methods for, conducting SotA reviews.

METHODS

We reviewed 940 articles published between 2014-2021 labeled as SotA reviews. We (a) identified all SotA methods-related resources, (b) examined the foundational principles and techniques underpinning the reviews, and (c) combined our findings to inductively analyze and articulate the philosophical foundations, process steps, and markers of rigor.

RESULTS

In the 940 articles reviewed, nearly all manuscripts (98%) lacked citations for how to conduct a SotA review. The term "state of the art" was used in 4 different ways. Analysis revealed that SotA articles are grounded in relativism and subjectivism.

DISCUSSION

This article provides a 6-step approach for conducting SotA reviews. SotA reviews offer an interpretive synthesis that describes: This is where we are now. This is how we got here. This is where we could be going. This chronologically rooted narrative synthesis provides a methodology for reviewing large bodies of literature to explore why and how our current knowledge has developed and to offer new research directions.

Effects of plate contouring quality on the biomechanical performance of high tibial osteotomy fixation: A parametric finite element study

Locking plates have threaded holes, in which threaded-head screws are affixed. Hence, they do not need to be in intimate contact with underlying bone to provide fixation. There are, however, reports that a large distance between the plate and the bone might cause clinical complications such as delayed union or nonunion, screw pull out, and screw and plate breakage. Considering the diversity in the capabilities and costs of different plate customization techniques, the purpose of this study was to investigate the effect of the plate contouring quality on the biomechanical performance of high tibial osteotomy (HTO) fixation. A finite element model of proximal tibia was developed in Abaqus, using the QCT data of a cadaver. The model was then subjected to open-wedge HTO (correction angle 12°) with TomoFix plate fixation. The sagittal curvature of the plate was changed parametrically to provide certain levels of geometrical fit, and the biomechanical performance parameters of fixation were assessed. Results indicated 5%, 9% and 38% increase in the stiffness of the construct, and the von Mises stress in the plate and locking screw just above the osteotomy site, respectively, when the level of fit of plate changed from 0% (initial non-contoured initial shape) to 100% (fully adapted shape). The same change decreased the pressure at the lateral hinge of the osteotomy by 61%, and the mean of the tensile stress on the screw shaft by 12%. It was concluded that the level of fit has conflicting effects on the biomechanical parameters of the HTO fixation system, that is, the structural stiffness, the pressure at the lateral hinge, the stresses in the plate and screws, and the pull out resistance of the screws. In particular, for HTO patients with high quality bone, the optimal level of fit should provide a tradeoff between these parameters.

Cytotoxicity and Ion Release of Functionally Graded Al₂O₃- Ti Orthopedic Biomaterial

The aim of this study was to evaluate the biocompatibility of Al2O3-Ti functionally graded material (FGM) successfully fabricated by Spark Plasma Sintering (SPS) technology, and to compare with pure Ti and alumina. Pre-osteoblast MC3T3-E1 cells were used to examine cell viability, proliferation and differentiation using lactate dehydrogenase (LDH) cytotoxicity detection kit, MTT assay and Alkaline Phosphatase (ALP) colorimetric test at different time points. Furthermore, ion release from the materials into the culture medium was assessed. The results showed cell viability over 80% for FGM and alumina which dismissed any cytotoxicity risk due to materials or manufacturing. The results of MTT tests identified superiority of FGM than Ti and alumina, particularly in late proliferation. Nevertheless, in cell differentiation, all materials performed similarly with no statistical differences. Furthermore, it was indicated that Ti had no ion release, while alumina had small amount of Al ion dissolution. FGM, however, had more ions detachment, particularly Al ions.

Bone Scaffolds: An Incorporation of Biomaterials, Cells, and Biofactors

Large injuries to bones are still one of the most challenging musculoskeletal problems. Tissue engineering can combine stem cells, scaffold biomaterials, and biofactors to aid in resolving this complication. Therefore, this review aims to provide information on the recent advances made to utilize the potential of biomaterials for making bone scaffolds and the assisted stem cell therapy and use of biofactors for bone tissue engineering. The requirements and different types of biomaterials used for making scaffolds are reviewed. Furthermore, the importance of stem cells and biofactors (growth factors and extracellular vesicles) in bone regeneration and their use in bone scaffolds and the key findings are discussed. Lastly, some of the main obstacles in bone tissue engineering and future trends are highlighted.

Osteoblastic cell response to Al2O3-Ti composites as bone implant materials

Introduction: Alumina-titanium (Al₂O₃-Ti) composites with enhanced mechanical and corrosion properties have been recently developed for potential applications in orthopaedics and hard tissue replacements. However, before any clinical use, their interactions with biological environment must be examined. Methods: The aim of this study, therefore, was to assess the biocompatibility of three Al₂O₃-Ti composites having 25, 50, and 75 volume percentages of titanium. These materials were made by spark plasma sintering (SPS), and MC3T3-E1 cells were cultured onto the sample discs to evaluate the cell viability, proliferation, differentiation, mineralization, and adhesion. Furthermore, the apatite formation ability and wettability of the composites were analysed. Pure Ti (100Ti) and monolithic Al₂O₃ (0Ti) were also fabricated by SPS and biological characteristics of the composites were compared with them. Results: The results showed that cell viability to 75Ti (95.0%), 50Ti (87.3%), and 25Ti (63.9%) was superior when compared with 100Ti (42.7%). Pure Al₂O₃ also caused very high cell viability (89.9%). Furthermore, high cell proliferation was seen at early stage for 50Ti, while the cells exposed to 75Ti proliferated more at late stages. Cell differentiation was approximately equal between different groups, and increased by time. Matrix mineralization was higher on the composite surfaces rather than on 0Ti and 100Ti. Moreover, the cells adhered differently to the surfaces of different biomaterials where more spindle-shaped configuration was found on 100Ti, slightly enlarged cells with dendritic shape and early pseudopodia were observed on 75Ti, and more enlarged cells with long dendritic extensions were found on 0Ti, 25Ti, and 50Ti. The results of EDS analysis showed that both Ca and P deposited on the surfaces of all materials, after 20 days of immersion in SBF. Conclusion: Our in-vitro findings demonstrated that the 75Ti, 50Ti, and 25Ti composites have high potential to be used as load-bearing orthopedic materials.

Cubic Lattice Structures of Ti6Al4V under Compressive Loading: Towards Assessing the Performance for Hard Tissue Implants Alternative

Porous Lattice Structure (PLS) scaffolds have shown potential applications in the biomedical domain. These implants’ structural designs can attain compatibility mechanobiologically, thereby avoiding challenges related to the stress shielding effect. Different unit cell structures have been explored with limited work on the fabrication and characterization of titanium-based PLS with cubic unit cell structures. Hence, in the present paper, Ti6Al4V (Ti64) cubic PLS scaffolds were analysed by finite element (FE) analysis and fabricated using selective laser melting (SLM) technique. PLS of the rectangular shape of width 10 mm and height 15 mm (ISO: 13314) with an average pore size of 600–1000 μm and structure porosity percentage of 40–70 were obtained. It has been found that the maximum ultimate compressive strength was found to be 119 MPa of PLS with a pore size of 600 μm and an overall relative density (RD) of 57%. Additionally, the structure’s failure begins from the micro-porosity formed during the fabrication process due to the improper melting along a plane inclined at 45 degree.

Multiple-Criteria Decision-Making and Sensitivity Analysis for Selection of Materials for Knee Implant Femoral Component

Total knee replacement (TKR) is a remarkable achievement in biomedical science that enhances human life. However, human beings still suffer from knee-joint-related problems such as aseptic loosening caused by excessive wear between articular surfaces, stress-shielding of the bone by prosthesis, and soft tissue development in the interface of bone and implant due to inappropriate selection of TKR material. The choice of most suitable materials for the femoral component of TKR is a critical decision; therefore, in this research paper, a hybrid multiple-criteria decision-making (MCDM) tactic is applied using the degree of membership (DoM) technique with a varied system, using the weighted sum method (WSM), the weighted product method (WPM), the weighted aggregated sum product assessment method (WASPAS), an evaluation based on distance from average solution (EDAS), and a technique for order of preference by similarity to ideal solution (TOPSIS). The weights of importance are assigned to different criteria by the equal weights method (EWM). Furthermore, sensitivity analysis is conducted to check the solidity of the projected tactic. The weights of importance are varied using the entropy weights technique (EWT) and the standard deviation method (SDM). The projected hybrid MCDM methodology is simple, reliable and valuable for a conflicting decision-making environment.

In vivo performance of Al2O3-Ti bone implants in the rat femur

Background

Alumina-titanium (Al₂O₃-Ti) biocomposites have been recently developed with improved mechanical properties for use in heavily loaded orthopedic sites. Their biological performance, however, has not been investigated yet.

Methods

The aim of the present study was to evaluate the in vivo biological interaction of Al₂O₃-Ti. Spark plasma sintering (SPS) was used to fabricate Al₂O₃-Ti composites with 25 vol.%, 50 vol.%, and 75 vol.% Ti content. Pure alumina and titanium were also fabricated by the same procedure for comparison. The fabricated composite disks were cut into small bars and implanted into medullary canals of rat femurs. The histological analysis and scanning electron microscopy (SEM) observation were carried out to determine the bone formation ability of these materials and to evaluate the bone-implant interfaces.

Results

The histological observation showed the formation of osteoblast, osteocytes with lacuna, bone with lamellar structures, and blood vessels indicating that the healing and remodeling of the bone, and vasculature reconstruction occurred after 4 and 8 weeks of implantation. However, superior bone formation and maturation were obtained after 8 weeks. SEM images also showed stronger interfaces at week 8. There were differences between the composites in percentages of bone area (TB%) and the number of osteocytes. The 50Ti composite showed higher TB% at week 4, while 25Ti and 75Ti represented higher TB% at week 8. All the composites showed a higher number of osteocytes compared to 100Ti, particularly 75Ti.

Conclusions

The fabricated composites have the potential to be used in load-bearing orthopedic applications.

Challenges on optimization of 3D-printed bone scaffolds

Advances in biomaterials and the need for patient-specific bone scaffolds require modern manufacturing approaches in addition to a design strategy. Hybrid materials such as those with functionally graded properties are highly needed in tissue replacement and repair. However, their constituents, proportions, sizes, configurations and their connection to each other are a challenge to manufacturing. On the other hand, various bone defect sizes and sites require a cost-effective readily adaptive manufacturing technique to provide components (scaffolds) matching with the anatomical shape of the bone defect. Additive manufacturing or three-dimensional (3D) printing is capable of fabricating functional physical components with or without porosity by depositing the materials layer-by-layer using 3D computer models. Therefore, it facilitates the production of advanced bone scaffolds with the feasibility of making changes to the model. This review paper first discusses the development of a computer-aided-design (CAD) approach for the manufacture of bone scaffolds, from the anatomical data acquisition to the final model. It also provides information on the optimization of scaffold's internal architecture, advanced materials, and process parameters to achieve the best biomimetic performance. Furthermore, the review paper describes the advantages and limitations of 3D printing technologies applied to the production of bone tissue scaffolds.

The role of biomaterials in the treatment of meniscal tears

Extensive investigations over the recent decades have established the anatomical, biomechanical and functional importance of the meniscus in the knee joint. As a functioning part of the joint, it serves to prevent the deterioration of articular cartilage and subsequent osteoarthritis. To this end, meniscus repair and regeneration is of particular interest from the biomaterial, bioengineering and orthopaedic research community. Even though meniscal research is previously of a considerable volume, the research community with evolving material science, biology and medical advances are all pushing toward emerging novel solutions and approaches to the successful treatment of meniscal difficulties. This review presents a tactical evaluation of the latest biomaterials, experiments to simulate meniscal tears and the state-of-the-art materials and strategies currently used to treat tears.

Development and in vitro validation of a simplified numerical model for the design of a biomimetic femoral stem

BACKGROUND

Dense and stiff metallic femoral stems implanted into femurs for total hip arthroplasties produce a stress shielding effect since they modify the original load sharing path in the bony structure. Consequently, in the long term, the strain adaptive nature of bones leads to bone resorption, implant loosening, and the need for arthroplasty revision. The design of new cementless femoral stems integrating open porous structures can reduce the global stiffness of the stems, allowing them a better match with that of bones and provide their firm fixation via bone ingrowth, and, thus reduce the risk of implantation failure.

METHODS

This paper aims to develop and validate a simplified numerical model of stress shielding, which calculates the levels of bone resorption or formation by comparing strain distributions on the surface of the intact and the implanted femurs subjected to a simulated biological loading. Two femoral stems produced by laser powder-bed fusion using Ti-6Al-4V alloy are employed: the first is fully dense, while the second features a diamond cubic lattice structure in its core. The validation consists of a comparison of the numerically calculated force-displacement diagrams, and displacement and strain fields with their experimental equivalents obtained using the digital image correlation technique.

RESULTS AND CONCLUSIONS

The numerical models showed reasonable agreement between the force-displacement diagrams. Also, satisfactory results for the correlation analyses of the total displacement and equivalent strain fields were obtained. The stress shielding effect of the implant was assessed by comparing the equivalent strain fields of the implanted and intact femurs. The results obtained predicted less bone resorption in the femur implanted with the porous stem than with its dense counterpart.