Electrical stimulation to promote osseointegration of bone anchoring implants: a topical review

Bioelectronic Direct Current Stimulation at the Transition Between Reversible and Irreversible Charge Transfer

Many biological processes rely on endogenous electric fields (EFs), including tissue regeneration, cell development, wound healing, and cancer metastasis. Mimicking these biological EFs by applying external direct current stimulation (DCS) is therefore the key to many new therapeutic strategies. During DCS, the charge transfer from electrode to tissue relies on a combination of reversible and irreversible electrochemical processes, which may generate toxic or bio-altering substances, including metal ions and reactive oxygen species (ROS). Poly(3,4-ethylenedioxythiophene) (PEDOT) based electrodes are emerging as suitable candidates for DCS to improve biocompatibility compared to metals. This work addresses whether PEDOT electrodes can be tailored to favor reversible biocompatible charge transfer. To this end, different PEDOT formulations and their respective back electrodes are studied using cyclic voltammetry, chronopotentiometry, and direct measurements of H2O2 and O2. This combination of electrochemical methods sheds light on the time dynamics of reversible and irreversible charge transfer and the relationship between capacitance and ROS generation. The results presented here show that although all electrode materials investigated generate ROS, the onset of ROS can be delayed by increasing the electrode's capacitance via PEDOT coating, which has implications for future bioelectronic devices that allow longer reversibly driven pulse durations during DCS.

Active osseointegration in an ex vivo porcine bone model

Achieving osseointegration is a fundamental requirement for many orthopaedic, oral, and craniofacial implants. Osseointegration typically takes three to 6 months, during which time implants are at risk of loosening. The aim of this study was to investigate whether osseointegration could be actively enhanced by delivering controllable electromechanical stimuli to the periprosthetic bone. First, the osteoconductivity of the implant surface was confirmed using an in vitro culture with murine preosteoblasts. The effects of active treatment on osseointegration were then investigated in a 21-day ex vivo model with freshly harvested cancellous bone cylinders (n = 24; Ø10 mm × 5 mm) from distal porcine femora, with comparisons to specimens treated by a distant ultrasound source and static controls. Cell viability, proliferation and distribution was evident throughout culture. Superior ongrowth of tissue onto the titanium discs during culture was observed in the actively stimulated specimens, with evidence of ten-times increased mineralisation after 7 and 14 days of culture (p < 0.05) and 2.5 times increased expression of osteopontin (p < 0.005), an adhesive protein, at 21 days. Moreover, histological analyses revealed increased bone remodelling at the implant-bone interface in the actively stimulated specimens compared to the passive controls. Active osseointegration is an exciting new approach for accelerating bone growth into and around implants.

Electrical pulse stimulation parameters modulate N2a neuronal differentiation

Electrical pulse stimulation has been used to enhance the differentiation or proliferation of neuronal progenitor cells in tissue engineering and cancer treatment. Therefore, a comprehensive investigation of the effects caused by its parameters is crucial for improvements in those fields. We propose a study of pulse parameters, to allow the control of N2a cell line fate and behavior. We have focused on designing an experimental setup that allows for the knowledge and control over the environment and the stimulation signals applied. To map the effects of the stimulation on N2a cells, their morphology and the cellular and molecular reactions induced by the pulse stimulation have been analyzed. Immunofluorescence, rt-PCR and western blot analysis have been carried out for this purpose, as well as cell counting. Our results show that low-amplitude electrical pulse stimulation promotes proliferation of N2a cells, whilst amplitudes in the range 250 mV/mm-500 mV/mm induce differentiation. Amplitudes higher than 750 mV/mm produce cell damage at low frequencies. For high frequencies, large amplitudes are needed to cause cell death. An inverse relation has been found between cell density and pulse-induced neuronal differentiation. The best condition for neuronal differentiation was found to be 500 mV/mm at 100 Hz. These findings have been confirmed by up-regulation of the Neurod1 gene. Our preliminary study of the molecular effects of electrical pulse stimulation on N2a offers premonitory clues of the PI3K/Akt/GSK-3β pathway implications on the neuronal differentiation process through ES. In general, we have successfully mapped the sensitivity of N2a cells to electrical pulse stimulation parameters.

Bone morphogenetic protein-2 and pulsed electrical stimulation synergistically promoted osteogenic differentiation on MC-3T3-E1 cells

Electrical stimulation (ES) plays an important role in regulating cell osteoblast differentiation. As a noninvasive rehabilitation therapy method, Es has a unique role in postoperative recovery. Bone morphogenetic protein-2 (BMP-2) is the most commonly used bioactive molecule in in situ tissue engineering scaffolds, and it plays an important regulatory role in the whole process of bone injury repair. In this study, the osteogenic regulation of MC-3T3-E1 cells was studied by combining pulsed electrical stimulation (PES) and different concentrations of BMP-2. The results showed that PES and BMP-2 could synergically promote the proliferation of MC-3T3-E1 cells. The qPCR results of osteoblast-related genes showed that PES was synergistic with BMP-2 to promote osteoblast differentiation mainly through the regulation of the Smad/BMP and insulin like growth factor 1 (IGF1) signaling pathways. The expression level of alkaline phosphatase (ALP) and alizarin red staining further demonstrated the synergistic effect of PES and BMP-2 on promoting osteogenic differentiation and mineralization of cells. PES and BMP-2 could also synergically promote cell proliferation, expression of collagen I (COL-I) and ALP, and cell mineralization on the 3D-printed polylactic acid scaffold. These results suggest that the use of PES can enhance the osteogenic effect of in situ bone repair scaffolds containing BMP-2, reduce the dose of BMP-2 alone, and reduce the possible side effects of high-dose BMP-2 in vivo.

Smart stimuli-responsive strategies for titanium implant functionalization in bone regeneration and therapeutics

With the increasing and aging of global population, there is a dramatic rise in the demand for implants or substitutes to rehabilitate bone-related disorders which can considerably decrease quality of life and even endanger lives. Though titanium and its alloys have been applied as the mainstream material to fabricate implants for load-bearing bone defect restoration or temporary internal fixation devices for bone fractures, it is far from rare to encounter failed cases in clinical practice, particularly with pathological factors involved. In recent years, smart stimuli-responsive (SSR) strategies have been conducted to functionalize titanium implants to improve bone regeneration in pathological conditions, such as bacterial infection, chronic inflammation, tumor and diabetes mellitus, etc. SSR implants can exert on-demand therapeutic and/or pro-regenerative effects in response to externally applied stimuli (such as photostimulation, magnetic field, electrical and ultrasound stimulation) or internal pathology-related microenvironment changes (such as decreased pH value, specific enzyme secreted by bacterial and excessive production of reactive oxygen species). This review summarizes recent progress on the material design and fabrication, responsive mechanisms, and in vitro and in vivo evaluations for versatile clinical applications of SSR titanium implants. In addition, currently existing limitations and challenges and further prospective directions of these strategies are also discussed.

Effect of Er:YAG Pulsed Laser-Deposited Hydroxyapatite Film on Titanium Implants on M2 Macrophage Polarization In Vitro and Osteogenesis In Vivo

In a previous study, we successfully coated hydroxyapatite (HAp) onto titanium (Ti) plates using the erbium-doped yttrium aluminum garnet pulsed-laser deposition (Er:YAG-PLD) method. In this study, we performed further experiments to validate the in vitro osteogenic properties, macrophage polarization, and in vivo osseointegration activity of HAp-coated Ti (HAp-Ti) plates and screws. Briefly, we coated a HAp film onto the surfaces of Ti plates and screws via Er:YAG-PLD. The surface morphological, elemental, and crystallographic analyses confirmed the successful surface coating. The macrophage polarization and osteogenic induction were evaluated in macrophages and rat bone marrow mesenchymal stem cells, and the in vivo osteogenic properties were studied. The results showed that needle-shaped nano-HAp promoted the early expression of osteogenic and immunogenic genes in the macrophages and induced excellent M2 polarization properties. The calcium deposition and osteocalcin production were significantly higher in the HAp-Ti than in the uncoated Ti. The implantation into rat femurs revealed that the HAp-coated materials had superior osteoinductive and osseointegration activities compared with the Ti, as assessed by microcomputed tomography and histology. Thus, HAp film on sandblasted Ti plates and screws via Er:YAG-PLD enhances hard-tissue differentiation, macrophage polarization, and new bone formation in tissues surrounding implants both in vitro and in vivo.

Discrimination between the effects of pulsed electrical stimulation and electrochemically conditioned medium on human osteoblasts

BACKGROUND

Electrical stimulation is used for enhanced bone fracture healing. Electrochemical processes occur during the electrical stimulation at the electrodes and influence cellular reactions. Our approach aimed to distinguish between electrochemical and electric field effects on osteoblast-like MG-63 cells. We applied 20 Hz biphasic pulses via platinum electrodes for 2 h. The electrical stimulation of the cell culture medium and subsequent application to cells was compared to directly stimulated cells. The electric field distribution was predicted using a digital twin.

RESULTS

Cyclic voltammetry and electrochemical impedance spectroscopy revealed partial electrolysis at the electrodes, which was confirmed by increased concentrations of hydrogen peroxide in the medium. While both direct stimulation and AC-conditioned medium decreased cell adhesion and spreading, only the direct stimulation enhanced the intracellular calcium ions and reactive oxygen species.

CONCLUSION

The electrochemical by-product hydrogen peroxide is not the main contributor to the cellular effects of electrical stimulation. However, undesired effects like decreased adhesion are mediated through electrochemical products in stimulated medium. Detailed characterisation and monitoring of the stimulation set up and electrochemical reactions are necessary to find safe electrical stimulation protocols.

Novel Electroactive Mineralized Polyacrylonitrile/PEDOT:PSS Electrospun Nanofibers for Bone Repair Applications

Bone defect repair remains a critical challenge in current orthopedic clinical practice, as the available therapeutic strategies only offer suboptimal outcomes. Therefore, bone tissue engineering (BTE) approaches, involving the development of biomimetic implantable scaffolds combined with osteoprogenitor cells and native-like physical stimuli, are gaining widespread interest. Electrical stimulation (ES)-based therapies have been found to actively promote bone growth and osteogenesis in both in vivo and in vitro settings. Thus, the combination of electroactive scaffolds comprising conductive biomaterials and ES holds significant promise in improving the effectiveness of BTE for clinical applications. The aim of this study was to develop electroconductive polyacrylonitrile/poly(3,4-ethylenedioxythiophene):polystyrene sulfonate (PAN/PEDOT:PSS) nanofibers via electrospinning, which are capable of emulating the native tissue's fibrous extracellular matrix (ECM) and providing a platform for the delivery of exogenous ES. The resulting nanofibers were successfully functionalized with apatite-like structures to mimic the inorganic phase of the bone ECM. The conductive electrospun scaffolds presented nanoscale fiber diameters akin to those of collagen fibrils and displayed bone-like conductivity. PEDOT:PSS incorporation was shown to significantly promote scaffold mineralization in vitro. The mineralized electroconductive nanofibers demonstrated improved biological performance as observed by the significantly enhanced proliferation of both human osteoblast-like MG-63 cells and human bone marrow-derived mesenchymal stem/stromal cells (hBM-MSCs). Moreover, mineralized PAN/PEDOT:PSS nanofibers up-regulated bone marker genes expression levels of hBM-MSCs undergoing osteogenic differentiation, highlighting their potential as electroactive biomimetic BTE scaffolds for innovative bone defect repair strategies.

Bio-Piezoelectric Ceramic Composites for Electroactive Implants-Biological Performance

Barium titanate (BaTiO3) piezoelectric ceramic may be a potential alternative for promoting osseointegration due to its piezoelectric properties similar to bone electric potentials generated in loading function. In this sense, the aim of this in vitro study was to evaluate the cellular response of human osteoblasts and gingival fibroblasts as well as the impact on S. oralis when in contact with BaTiO3 functionalized zirconia implant surfaces with piezoelectric properties. Zirconia discs with BaTiO3 were produced and contact poling (piezo activation) was performed. Osteoblasts (hFOB 1.19), fibroblasts (HGF hTERT) and S. oralis were culture on discs. Cell viability and morphology, cell differentiation markers, bacterial adhesion and growth were evaluated. The present study suggests that zirconia composite surfaces with the addition of piezoelectric BaTiO3 are not cytotoxic to peri-implant cells. Also, they seem to promote a faster initial osteoblast differentiation. Moreover, these surfaces may inhibit the growth of S. oralis by acting as a bacteriostatic agent over time. Although the piezoelectric properties do not affect the cellular inflammatory profile, they appear to enable the initial adhesion of bacteria, however this is not significant over the entire testing period. Furthermore, the addition of non-poled BaTiO3 to zirconia may have a potential reduction effect on IL-6 mediated-inflammatory activity in fibroblasts.

MORPHOLOGICAL CHARACTERISTICS OF REPARATIVE OSTEOGENESIS IN THE RATS LOWER JAW UNDER THE CONDITIONS OF USING ELECTRICAL STIMULATION

OBJECTIVE

Aim: The purpose of the study was to identify the morphological features of reparative osteogenesis in the rats lower jaw under the conditions of using electrical stimulation.

PATIENTS AND METHODS

Materials and Methods: An experiment was conducted on 24 mature male rats of the WAG population. Two groups were formed. Group 1 included 12 rats that were modeled with a perforated defect of the lower jaw body. Group 2 included 12 animals that were modeled with a perforated defect similar to group 1. In animals, a microdevice for electrical action was implanted subcutaneously in the neck area on the side of the simulated bone defect (a temporary Videx AG 4 battery; a constant sinusoidal electric current of an unchanging nature 1 milliampere, frequency 30 W). The negative electrode connected to the negative pole of the battery was in contact with the bone defect. The battery and electrode were insulated with plastic heat shrink material. Morphological and statistical methods were used.

RESULTS

Results: The positive effect of electrical stimulation on reparative osteogenesis was due to a decrease in the severity of hemodynamic disorders, activation of angiogenesis in granulation tissue, which was one of the components of the regenerate that filled the bone defect, matured and turned into connective tissue; stimulation of the proliferative potential of fibroblastic cells and cells with osteoblastic activity in granulation tissue; increasing the proliferative potential of osteoblastic elements of bone tissue bordering the cavity; stimulation of macrophage cells and processes of cleansing the bone cavity from fragments of a blood clot and alteratively changed tissues; formation of clusters of adipocytes in the loci of connective and granulation tissue of the regenerate; the process of metaplasia of connective tissue into bone tissue; an increase of the foci of hematopoiesis in the intertrabecular spaces of lamellar bone tissue.

CONCLUSION

Conclusions: A comprehensive clinical and experimental study conducted by the authors proved that electrical stimulation activates the reparative osteogenesis in the lower jaw, which occurs through direct osteogenesis and does not finish on the 28th day of the experiment.

Pulsed Electrical Stimulation Affects Osteoblast Adhesion and Calcium Ion Signaling

An extensive research field in regenerative medicine is electrical stimulation (ES) and its impact on tissue and cells. The mechanism of action of ES, particularly the role of electrical parameters like intensity, frequency, and duration of the electric field, is not yet fully understood. Human MG-63 osteoblasts were electrically stimulated for 10 min with a commercially available multi-channel system (IonOptix). We generated alternating current (AC) electrical fields with a voltage of 1 or 5 V and frequencies of 7.9 or 20 Hz, respectively. To exclude liquid-mediated effects, we characterized the AC-stimulated culture medium. AC stimulation did not change the medium’s pH, temperature, and oxygen content. The H2O2 level was comparable with the unstimulated samples except at 5 V_7.9 Hz, where a significant increase in H2O2 was found within the first 30 min. Pulsed electrical stimulation was beneficial for the process of attachment and initial adhesion of suspended osteoblasts. At the same time, the intracellular Ca2+ level was enhanced and highest for 20 Hz stimulated cells with 1 and 5 V, respectively. In addition, increased Ca2+ mobilization after an additional trigger (ATP) was detected at these parameters. New knowledge was provided on why electrical stimulation contributes to cell activation in bone tissue regeneration.