Quantitative analysis of near-implant magnesium accumulation for a Si-containing coated AZ31 cage from a goat cervical spine fusion model

An overview of magnesium-based implants in orthopaedics and a prospect of its application in spine fusion

Due to matching biomechanical properties and significant biological activity, Mg-based implants present great potential in orthopedic applications. In recent years, the biocompatibility and therapeutic effect of magnesium-based implants have been widely investigated in trauma repair. In contrast, the R&D work of Mg-based implants in spinal fusion is still limited. This review firstly introduced the general background for Mg-based implants. Secondly, the mechanical properties and degradation behaviors of Mg and its traditional and novel alloys were reviewed. Then, different surface modification techniques of Mg-based implants were described. Thirdly, this review comprehensively summarized the biological pathways of Mg degradation to promote bone formation in neuro-musculoskeletal circuit, angiogenesis with H-type vessel formation, osteogenesis with osteoblasts activation and chondrocyte ossification as an integrated system. Fourthly, this review followed the translation process of Mg-based implants via updating the preclinical studies in fracture fixation, sports trauma repair and reconstruction, and bone distraction for large bone defect. Furthermore, the pilot clinical studies were involved to demonstrate the reliable clinical safety and satisfactory bioactive effects of Mg-based implants in bone formation. Finally, this review introduced the background of spine fusion surgeryand the challenges of biological matching cage development. At last, this review prospected the translation potential of a hybrid Mg-PEEK spine fusion cage design.

Application of 3D‑printed porous titanium interbody fusion cage vs. polyether ether ketone interbody fusion cage in anterior cervical discectomy and fusion: A systematic review and meta‑analysis update

The present study aimed to compare the differences between 3D-printed porous titanium and polyether ether ketone (PEEK) interbody fusion cages for anterior cervical discectomy and fusion (ACDF). Literature on the application of 3D-printed porous titanium and PEEK interbody fusion cages for ACDF was searched in the PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang and VIP databases. A total of 1,181 articles were retrieved and 12 were finally included. The Cochrane bias risk assessment criteria and Newcastle-Ottawa scale were used for quality evaluation and Review Manager 5.4 was used for data analysis. The 3D cage group was superior to the PEEK cage group in terms of operative time [mean difference (MD): -7.68; 95% confidence interval (CI): -11.08, -4.29; P<0.00001], intraoperative blood loss (MD: -6.17; 95%CI: -10.56, -1.78; P=0.006), hospitalization time (MD: -0.57; 95%CI: -0.86, -0.28: P=0.0001), postoperative complications [odds ratio (OR): 0.35; 95%CI: 0.15, 0.80; P=0.01], C2-7 Cobb angle (MD: 2.85; 95%CI: 1.45, 4.24; P<0.0001), intervertebral space height (MD: 1.20; 95%CI: 0.54, 1.87; P=0.0004), Japanese Orthopaedic Association Assessment of Treatment (MD: 0.69; 95%CI: 0.24, 1.15; P=0.003) and visual analogue scale score (MD: -0.43; 95%CI: -0.78, -0.07; P=0.02). The difference was statistically significant, while there was no significant difference between the two groups in terms of fusion rate (OR: 1.74; 95%CI: 0.71, 4.27; P=0.23). The use of 3D-printed porous titanium interbody fusion cage in ACDF has the advantages of short operation time, less bleeding loss, shorter hospitalization time and fewer postoperative complications. It can better maintain the cervical curvature and intervertebral height, relieve pain and accelerate postoperative functional recovery.

Anatomical Brushite-Coated Mg-Nd-Zn-Zr Alloy Cage Promotes Cervical Fusion: One-Year Results in Goats

In this study, an anatomical brushite-coated Mg-Nd-Zn-Zr alloy cage was fabricated for cervical fusion in goats. The purpose of this study was to investigate the cervical fusion effect and degradation characteristics of this cage in goats. The Mg-Nd-Zn-Zr alloy cage was fabricated based on anatomical studies, and brushite coating was prepared. Forty-five goats were divided into three groups, 15 in each group, and subjected to C2/3 anterior cervical decompression and fusion with tricortical bone graft, Mg-Nd-Zn-Zr alloy cage, or brushite-coated Mg-Nd-Zn-Zr alloy cage, respectively. Cervical radiographs and computed tomography (CT) were performed 3, 6, and 12 months postoperatively. Blood was collected for biocompatibility analysis and Mg2+ concentration tests. The cervical spine specimens were obtained at 3, 6, and 12 months postoperatively for biomechanical, micro-CT, scanning electron microscopy coupled with energy dispersive spectroscopy, laser ablation-inductively coupled plasma-time-of-flight mass spectrometry, and histological analysis. The liver and kidney tissues were obtained for hematoxylin and eosin staining 12 months after surgery for biosafety analysis. Imaging and histological analysis showed a gradual improvement in interbody fusion over time; the fusion effect of the brushite-coated Mg-Nd-Zn-Zr alloy cage was comparable to that of the tricortical bone graft, and both were superior to that of the Mg-Nd-Zn-Zr alloy cage. Biomechanical testing showed that the brushite-coated Mg-Nd-Zn-Zr alloy cage achieved better stability than the tricortical bone graft at 12 months postoperatively. Micro-CT showed that the brushite coating significantly decreases the corrosion rate of the Mg-Nd-Zn-Zr alloy cage. In vivo degradation analysis showed higher Ca and P deposition in the degradation products of the brushite-coated Mg-Nd-Zn-Zr alloy cage, and no hyperconcentration of Mg was detected. Biocompatibility analysis showed that both cages were safe for cervical fusion surgery in goats. To conclude, the anatomical brushite-coated Mg-Nd-Zn-Zr alloy cage can promote cervical fusion in goats, and the brushite-coated Mg-Nd-Zn-Zr alloy is a potential material for developing absorbable fusion cages.

Magnesium-based alloys with adapted interfaces for bone implants and tissue engineering

Magnesium and its alloys are one of the most used materials for bone implants and tissue engineering. They are characterized by numerous advantages such as biodegradability, high biocompatibility and mechanical properties with values close to the human bone. Unfortunately, the implant surface must be adequately tuned, or Mg-based alloys must be alloyed with other chemical elements due to their increased corrosion effect in physiological media. This article reviews the clinical challenges related to bone repair and regeneration, classifying bone defects and presenting some of the most used and modern therapies for bone injuries, such as Ilizarov or Masquelet techniques or stem cell treatments. The implant interface challenges are related to new bone formation and fracture healing, implant degradation and hydrogen release. A detailed analysis of mechanical properties during implant degradation is extensively described based on different literature studies that included in vitro and in vivo tests correlated with material properties' characterization. Mg-based trauma implants such as plates and screws, intramedullary nails, Herbert screws, spine cages, rings for joint treatment and regenerative scaffolds are presented, taking into consideration their manufacturing technology, the implant geometrical dimensions and shape, the type of in vivo or in vitro studies and fracture localization. Modern technologies that modify or adapt the Mg-based implant interfaces are described by presenting the main surface microstructural modifications, physical deposition and chemical conversion coatings. The last part of the article provides some recommendations from a translational perspective, identifies the challenges associated with Mg-based implants and presents some future opportunities. This review outlines the available literature on trauma and regenerative bone implants and describes the main techniques used to control the alloy corrosion rate and the cellular environment of the implant.

Brushite-coated Mg-Nd-Zn-Zr alloy promotes the osteogenesis of vertebral laminae through IGF2/PI3K/AKT signaling pathway

Biodegradable magnesium (Mg) alloys have been extensively investigated in orthopedic implants due to their suitable mechanical strength and high biocompatibility. However, no studies have reported whether Mg alloys can be used to repair lamina defects, and the biological mechanisms regulating osteogenesis are not fully understood. The present study developed a lamina reconstruction device using our patented biodegradable Mg-Nd-Zn-Zr alloy (JDBM), and brushite (CaHPO₄·2H₂O, Dicalcium phosphate dihydrate, DCPD) coating was developed on the implant. Through in vitro and in vivo experiments, we evaluated the degradation behavior and biocompatibility of DCPD-JDBM. In addition, we explored the potential molecular mechanisms by which it regulates osteogenesis. In vitro, ion release and cytotoxicity tests revealed that DCPD-JDBM had better corrosion resistance and biocompatibility. We found that DCPD-JDBM extracts could promote MC3T3-E1 osteogenic differentiation via the IGF2/PI3K/AKT pathway. The lamina reconstruction device was implanted on a rat lumbar lamina defect model. Radiographic and histological analysis showed that DCPD-JDBM accelerated the repair of rat lamina defects and exhibited lower degradation rate compared to uncoated JDBM. Immunohistochemical and qRT-PCR results showed that DCPD-JDBM promoted osteogenesis in rat laminae via IGF2/PI3K/AKT pathway. This study shows that DCPD-JDBM is a promising biodegradable Mg-based material with great potential for clinical applications.

Technical Notes for Establishing a Cervical Fusion Model in Goats Based on Distinctive Anatomy

Goat is an adequate experimental model for cervical spine testing. However, studies on the anatomy of the cervical spine in goats are limited, and there is no uniform standard for establishing a single-segment anterior cervical discectomy and fusion (ACDF) model in goats. To address this issue, we investigated the cervical spine anatomy of goats and provided a technical basis for establishing a single-segment ACDF model in goats. We measured the imaging anatomical parameters using Mimics Medical 20.0 software. We then performed histological analysis of the cervical spine segment 2-3 (C2-3) segment of six goat cervical spine specimens. Based on the measurements and histological analysis, the fusion cage was designed to be wedge-shaped, the length of the plate was 25 mm, and the length of the screw was 15 mm. Based on the anatomical characteristics of goats, we believed that the C2-3 segment of goats was most suitable for a single-segment ACDF model in goats, and the decompression should be performed medial to the pterygoid joint on both sides, the thickness of the removed endplate was ∼0.6 mm, the cage implanted in the anterior two-thirds of the intervertebral space could maximize the contact area of the cage-endplate interface, and the location of the midline spur could position the implantation of the internal fixtures. Radiological examination at 12 weeks postoperatively suggested that the internal fixtures were in place and new bone formation was visible. These results demonstrated that these technical notes based on anatomical features were practical and could minimize damage to animals.

Biodegradable interbody cages for lumbar spine fusion: Current concepts and future directions

Lumbar fusion often remains the last treatment option for various acute and chronic spinal conditions, including infectious and degenerative diseases. Placement of a cage in the intervertebral space has become a routine clinical treatment for spinal fusion surgery to provide sufficient biomechanical stability, which is required to achieve bony ingrowth of the implant. Routinely used cages for clinical application are made of titanium (Ti) or polyetheretherketone (PEEK). Ti has been used since the 1980s; however, its shortcomings, such as impaired radiographical opacity and higher elastic modulus compared to bone, have led to the development of PEEK cages, which are associated with reduced stress shielding as well as no radiographical artefacts. Since PEEK is bioinert, its osteointegration capacity is limited, which in turn enhances fibrotic tissue formation and peri-implant infections. To address shortcomings of both of these biomaterials, interdisciplinary teams have developed biodegradable cages. Rooted in promising preclinical large animal studies, a hollow cylindrical cage (Hydrosorb™) made of 70:30 poly-l-lactide-co-d, l-lactide acid (PLDLLA) was clinically studied. However, reduced bony integration and unfavourable long-term clinical outcomes prohibited its routine clinical application. More recently, scaffold-guided bone regeneration (SGBR) with application of highly porous biodegradable constructs is emerging. Advancements in additive manufacturing technology now allow the cage designs that match requirements, such as stiffness of surrounding tissues, while providing long-term biomechanical stability. A favourable clinical outcome has been observed in the treatment of various bone defects, particularly for 3D-printed composite scaffolds made of medical-grade polycaprolactone (mPCL) in combination with a ceramic filler material. Therefore, advanced cage design made of mPCL and ceramic may also carry initial high spinal forces up to the time of bony fusion and subsequently resorb without clinical side effects. Furthermore, surface modification of implants is an effective approach to simultaneously reduce microbial infection and improve tissue integration. We present a design concept for a scaffold surface which result in osteoconductive and antimicrobial properties that have the potential to achieve higher rates of fusion and less clinical complications. In this review, we explore the preclinical and clinical studies which used bioresorbable cages. Furthermore, we critically discuss the need for a cutting-edge research program that includes comprehensive preclinical in vitro and in vivo studies to enable successful translation from bench to bedside. We develop such a conceptual framework by examining the state-of-the-art literature and posing the questions that will guide this field in the coming years.

Biomaterials for Interbody Fusion in Bone Tissue Engineering

In recent years, interbody fusion cages have played an important role in interbody fusion surgery for treating diseases like disc protrusion and spondylolisthesis. However, traditional cages cannot achieve satisfactory results due to their unreasonable design, poor material biocompatibility, and induced osteogenesis ability, limiting their application. There are currently 3 ways to improve the fusion effect, as follows. First, the interbody fusion cage is designed to facilitate bone ingrowth through the preliminary design. Second, choose interbody fusion cages made of different materials to meet the variable needs of interbody fusion. Finally, complete post-processing steps, such as coating the designed cage, to achieve a suitable osseointegration microstructure, and add other bioactive materials to achieve the most suitable biological microenvironment of bone tissue and improve the fusion effect. The focus of this review is on the design methods of interbody fusion cages, a comparison of the advantages and disadvantages of various materials, the influence of post-processing techniques and additional materials on interbody fusion, and the prospects for the future development of interbody fusion cages.

Bioabsorbable high-purity magnesium interbody cage: degradation, interbody fusion, and biocompatibility from a goat cervical spine model

Background

Bioabsorbable Mg-based implants have been a focus of orthopedic researches due to their intrinsic advantages in orthopedics surgeries. This study aimed to investigate the performance of bioabsorbable high-purity magnesium (HP Mg, 99.98 wt.%) interbody cages in anterior cervical discectomy and fusion (ACDF) and to evaluate the degradation of HP Mg cages under an interbody microenvironment.

Methods

ACDF was performed at C2–3 and C4–5, and a HP Mg cage or autologous iliac bone was randomly implanted. At 3, 6, 12 and 24 weeks after surgery, the cervical specimens were harvested to evaluate the fusion status, degradation and biocompatibility by CT, micro-CT, histological examinations and blood tests.

Results

There was no significant difference in the CT fusion score between cage group and autogenous ilium group at 3 and 6 weeks. At 12 and 24 weeks, the mean CT fusion score in the cage group was markedly lower than in the autogenous ilium group. CT and histological examinations showed bony junctions formed through the middle hole of the cage between upper and lower vertebral bodies in the cage group, but the total fusion area was less than 30%. The degradation rate of cages was relatively rapid within the first 3 weeks and thereafter became stable and slow gradually. The HP Mg cage had good biosecurity and biomechanical characteristics.

Conclusions

Implantation of Mg-based interbody cage achieves successful histological fusion, while the total fusion area needs to be improved. More studies are needed to improve the bone-cage interface.

Biological evaluation of bone substitute

Critical-sized defects (CSDs) caused by trauma, tumor resection, or skeletal abnormalities create a high demand for bone repair materials (BRMs). Over the years, scientists have been trying to develop BRMs and evaluate their efficacy using numerous developed methods. BRMs are characterized by osteogenesis and angiogenesis promoting properties, the latter of which has rarely been studied in vitro and in vivo. While blood vessels are required to provide nutrients. Bone mass maintains a dynamic balance under the joint action of osteolytic and osteogenic activity in which monocytes differentiate into osteolytic cells, and osteoprogenitor cells differentiate into osteogenic cells. This review would be helpful for inexperienced researchers as well as present a comprehensive overview of methods used to investigate the effect of BRMs on osteogenic cells, osteolytic cells, and blood vessels, as well as their biocompatibility and biological performance. This review is expected to facilitate further research and development of new BRMs.

Hypoxia influences the effects of magnesium degradation products on the interactions between endothelial and mesenchymal stem cells

Biodegradable materials like well-documented Magnesium (Mg) are promising for their biocompatibility and tissue regeneration. Since Mg degradation is reported to be oxygen related, the effects of Mg were hypothesised to be influenced by oxygen. As two vital components of bone marrow, endothelial cells (EC) and mesenchymal stem cells (MSC), their interactions represent high scientific interest for tissue engineering and biodegradable Mg application. Human umbilical cord perivascular (HUCPV) and umbilical vein endothelial cell (HUVEC) were selected as sources of MSC and EC, respectively. Two types of coculture models were established to represent different phases of MSC-EC interaction: (i) where cells were physically separated thanks to a transwell and (ii) where cells were allowed to have heterotypic cellular contacts. Cell migration, gene, cytokines, and proliferation were investigated in HUCPV-HUVEC coculture using DNA, flow cytometry, wound healing assay, semi-quantitative real-time polymerase chain reaction (qRT-PCR), and enzyme-linked immunosorbent assay (ELISA). Mg degradation products increased HUCPV migration in transwell under hypoxia. Oxygen tension changed the gene regulation of migratory, angiogenetic or osteogenic regulators. Under contacting coculture and hypoxia, Mg degradation products remarkably increased cytokines (e.g., c-c motif chemokine ligand 2 and vascular endothelial growth factor) and MSC mineralisation. Mg degradation products decreased and increased the MSC proliferation in transwell and in heterotypic-contact coculture, respectively. In summary, this study indicates the roles of low oxygen and heterotypic contact to effects of Mg materials facilitating HUVEC and HUCPV. STATEMENT OF SIGNIFICANCE.