The effect of hydroxyapatite coating on bone growth into porous titanium alloy implants

High subsidence rate in primary total hip arthroplasty with a taper wedge stem featuring a three-dimensionally printed porous structure

INTRODUCTION

Femoral stem subsidence (FSS) following total hip arthroplasty (THA) can lead to complications such as aseptic loosening and early implant failure. This study evaluated the subsidence and clinical outcomes of the GS-Taper stem, a taper wedge stem using a three-dimensional (3D)-printed porous structure, in primary THA cases.

MATERIALS AND METHODS

This retrospective analysis was conducted in 112 hips that underwent THA using the GS-Taper stem between October 2020 and May 2023, with follow-up at 1 year postoperatively. The primary outcome was the evaluation of FSS and its relationship with neck length, canal fill ratio, and stem alignment. Secondary outcomes included clinical scores assessed using the modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and University of California, Los Angeles activity scores, as well as radiographic findings such as periprosthetic bone reactions, including stress shielding, radiolucent lines, and spot welds.

RESULTS

The mean subsidence at 1 year postoperatively was 3.4 ± 3.0 mm, with 55 hips showing subsidence ≥ 3 mm (FSS group) and 57 hips showing subsidence < 3 mm (non-FSS group). The FSS group demonstrated significantly shorter neck length, lower canal fill ratio, valgus positioning, and a higher proportion of medial gaps compared to the non-FSS group. Radiographic analysis revealed increased radiolucent lines and stress shielding in Gruen zone 1 in the FSS group. The FSS group had significantly worse clinical outcomes and a higher incidence of thigh pain than the non-FSS group.

CONCLUSIONS

The GS-Taper stem exhibited a high rate of subsidence, potentially due to its 3D-printed porous structure and micro-spike configuration. These findings highlight the need for design modifications to improve initial stability and biological fixation.

Osteoblast Attachment on Titanium Coated with Hydroxyapatite by Atomic Layer Deposition

Background: The increasing demand for bone implants with improved osseointegration properties has prompted researchers to develop various coating types for metal implants. Atomic layer deposition (ALD) is a method for producing nanoscale coatings conformally on complex three-dimensional surfaces. We have prepared hydroxyapatite (HA) coating on titanium (Ti) substrate with the ALD method and analyzed the biocompatibility of this coating in terms of cell adhesion and viability. Methods: HA coatings were prepared on Ti substrates by depositing CaCO₃ films by ALD and converting them to HA by wet treatment in dilute phosphate solution. MC3T3-E1 preosteoblasts were cultured on ALD-HA, glass slides and bovine bone slices. ALD-HA and glass slides were either coated or non-coated with fibronectin. After 48h culture, cells were imaged with scanning electron microscopy (SEM) and analyzed by vinculin antibody staining for focal adhesion localization. An 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) test was performed to study cell viability. Results: Vinculin staining revealed similar focal adhesion-like structures on ALD-HA as on glass slides and bone, albeit on ALD-HA and bone the structures were thinner compared to glass slides. This might be due to thin and broad focal adhesions on complex three-dimensional surfaces of ALD-HA and bone. The MTT test showed comparable cell viability on ALD-HA, glass slides and bone. Conclusion: ALD-HA coating was shown to be biocompatible in regard to cell adhesion and viability. This leads to new opportunities in developing improved implant coatings for better osseointegration and implant survival.

Development of a Bone-Mimetic 3D Printed Ti6Al4V Scaffold to Enhance Osteoblast-Derived Extracellular Vesicles' Therapeutic Efficacy for Bone Regeneration

Extracellular Vesicles (EVs) are considered promising nanoscale therapeutics for bone regeneration. To date, EVs are typically procured from cells on 2D tissue culture plastic, an artificial environment that limits cell growth and does not replicate in situ biochemical or biophysical conditions. This study investigated the potential of 3D printed titanium scaffolds coated with hydroxyapatite to promote the therapeutic efficacy of osteoblast-derived EVs. Ti6Al4V titanium scaffolds with different pore sizes (500 and 1000 µm) and shapes (square and triangle) were fabricated by selective laser melting. A bone-mimetic nano-needle hydroxyapatite (nnHA) coating was then applied. EVs were procured from scaffold-cultured osteoblasts over 2 weeks and vesicle concentration was determined using the CD63 ELISA. Osteogenic differentiation of human bone marrow stromal cells (hBMSCs) following treatment with primed EVs was evaluated by assessing alkaline phosphatase activity, collagen production and calcium deposition. Triangle pore scaffolds significantly increased osteoblast mineralisation (1.5-fold) when compared to square architectures (P ≤ 0.001). Interestingly, EV yield was also significantly enhanced on these higher permeability structures (P ≤ 0.001), in particular (2.2-fold) for the larger pore structures (1000 µm). Furthermore osteoblast-derived EVs isolated from triangular pore scaffolds significantly increased hBMSCs mineralisation when compared to EVs acquired from square pore scaffolds (1.7-fold) and 2D culture (2.2-fold) (P ≤ 0.001). Coating with nnHA significantly improved osteoblast mineralisation (>2.6-fold) and EV production (4.5-fold) when compared to uncoated scaffolds (P ≤ 0.001). Together, these findings demonstrate the potential of harnessing bone-mimetic culture platforms to enhance the production of pro-regenerative EVs as an acellular tool for bone repair.

Beneficial osseointegration effect of hydroxyapatite coating on cranial implant - FEM investigation

A firm connection of the bone-implant-fixation system is of utmost importance for patients with cranial defects. In order to improve the connection reliability, the current research focuses on finding the optimal fixation method, as well as selection of the implant manufacturing methods and the used materials. For the latter, implementation of bioactive materials such as hydroxyapatite or other calcium phosphates has also been considered in the literature. The aim of this study was to investigate the effect of gradual osseointegration on the biomechanical performance of cranial Ti6Al4V implants with a deposited HA coating as the osseointegration agent. This effect was assessed by two different computational approaches using finite element method (FEM) modeling. The values of key input parameters necessary for FEM were obtained from experimental plasma spray deposition of HA layers onto Ti6Al4V samples. Immediately upon implantation, the HA layer at the bone-implant contact area brought only a slight decrease in the values of von Mises stress in the implant and the micro-screws when compared to a non-coated counterpart; importantly, this was without any negative trade-off in other important characteristics. The major benefit of the HA coatings was manifested upon the modeled osseointegration: the results of both approaches confirmed a significant reduction of investigated parameters such as the total implant displacements (reduced from 0.050 mm to 0.012 mm and 0.002 mm while using Approach I and II, respectively) and stresses (reduced from 52 MPa to 10 MPa and 1 MPa) in the implanted components in comparison to non-coated variant. This is a very promising result for potential use of thermally sprayed HA coatings for cranial implants.

Modifications of Dental Implant Surfaces at the Micro- and Nano-Level for Enhanced Osseointegration

This review paper describes several recent modification methods for biocompatible titanium dental implant surfaces. The micro-roughened surfaces reviewed in the literature are sandblasted, large-grit, acid-etched, and anodically oxidized. These globally-used surfaces have been clinically investigated, showing survival rates higher than 95%. In the past, dental clinicians believed that eukaryotic cells for osteogenesis did not recognize the changes of the nanostructures of dental implant surfaces. However, research findings have recently shown that osteogenic cells respond to chemical and morphological changes at a nanoscale on the surfaces, including titanium dioxide nanotube arrangements, functional peptide coatings, fluoride treatments, calcium–phosphorus applications, and ultraviolet photofunctionalization. Some of the nano-level modifications have not yet been clinically evaluated. However, these modified dental implant surfaces at the nanoscale have shown excellent in vitro and in vivo results, and thus promising potential future clinical use.

A Review on the Use of Hydroxyapatite-Carbonaceous Structure Composites in Bone Replacement Materials for Strengthening Purposes

Biomedical materials constitute a vast scientific research field, which is devoted to producing medical devices which aid in enhancing human life. In this field, there is an enormous demand for long-lasting implants and bone substitutes that avoid rejection issues whilst providing favourable bioactivity, osteoconductivity and robust mechanical properties. Hydroxyapatite (HAp)-based biomaterials possess a close chemical resemblance to the mineral phase of bone, which give rise to their excellent biocompatibility, so allowing for them to serve the purpose of a bone-substituting and osteoconductive scaffold. The biodegradability of HAp is low (Ksp ≈ 6.62 × 10-126) as compared to other calcium phosphates materials, however they are known for their ability to develop bone-like apatite coatings on their surface for enhanced bone bonding. Despite its favourable bone regeneration properties, restrictions on the use of pure HAp ceramics in high load-bearing applications exist due to its inherently low mechanical properties (including low strength and fracture toughness, and poor wear resistance). Recent innovations in the field of bio-composites and nanoscience have reignited the investigation of utilising different carbonaceous materials for enhancing the mechanical properties of composites, including HAp-based bio-composites. Researchers have preferred carbonaceous materials with hydroxyapatite due to their inherent biocompatibility and good structural properties. It has been demonstrated that different structures of carbonaceous material can be used to improve the fracture toughness of HAp, as they can easily serve the purpose of being a second phase reinforcement, with the resulting composite still being a biocompatible material. Nanostructured carbonaceous structures, especially those in the form of fibres and sheets, were found to be very effective in increasing the fracture toughness values of HAp. Minor addition of CNTs (3 wt.%) has resulted in a more than 200% increase in fracture toughness of hydroxyapatite-nanorods/CNTs made using spark plasma sintering. This paper presents a current review of the research field of using different carbonaceous materials composited with hydroxyapatite with the intent being to produce high performance biomedically targeted materials.

Biological evaluation and finite-element modeling of porous poly(para-phenylene) for orthopaedic implants

Poly(para-phenylene) (PPP) is a novel aromatic polymer with higher strength and stiffness than polyetheretherketone (PEEK), the gold standard material for polymeric load-bearing orthopaedic implants. The amorphous structure of PPP makes it relatively straightforward to manufacture different architectures, while maintaining mechanical properties. PPP is promising as a potential orthopaedic material; however, the biocompatibility and osseointegration have not been well investigated. The objective of this study was to evaluate biological and mechanical behavior of PPP, with or without porosity, in comparison to PEEK. We examined four specific constructs: 1) solid PPP, 2) solid PEEK, 3) porous PPP and 4) porous PEEK. Pre-osteoblasts (MC3T3) exhibited similar cell proliferation among the materials. Osteogenic potential was significantly increased in the porous PPP scaffold as assessed by ALP activity and calcium mineralization. In vivo osseointegration was assessed by implanting the cylindrical materials into a defect in the metaphysis region of rat tibiae. Significantly more mineral ingrowth was observed in both porous scaffolds compared to the solid scaffolds, and porous PPP had a further increase compared to porous PEEK. Additionally, porous PPP implants showed bone formation throughout the porous structure when observed via histology. A computational simulation of mechanical push-out strength showed approximately 50% higher interfacial strength in the porous PPP implants compared to the porous PEEK implants and similar stress dissipation. These data demonstrate the potential utility of PPP for orthopaedic applications and show improved osseointegration when compared to the currently available polymeric material.

STATEMENT OF SIGNIFICANCE

PEEK has been widely used in orthopaedic surgery; however, the ability to utilize PEEK for advanced fabrication methods, such as 3D printing and tailored porosity, remain challenging. We present a promising new orthopaedic biomaterial, Poly(para-phenylene) (PPP), which is a novel class of aromatic polymers with higher strength and stiffness than polyetheretherketone (PEEK). PPP has exceptional mechanical strength and stiffness due to its repeating aromatic rings that provide strong anti-rotational biaryl bonds. Furthermore, PPP has an amorphous structure making it relatively easier to manufacture (via molding or solvent-casting techniques) into different geometries with and without porosity. This ability to manufacture different architectures and use different processes while maintaining mechanical properties makes PPP a very promising potential orthopaedic biomaterial which may allow for closer matching of mechanical properties between the host bone tissue while also allowing for enhanced osseointegration. In this manuscript, we look at the potential of porous and solid PPP in comparison to PEEK. We measured the mechanical properties of PPP and PEEK scaffolds, tested these scaffolds in vitro for osteocompatibility with MC3T3 cells, and then tested the osseointegration and subsequent functional integration in vivo in a metaphyseal drill hole model in rat tibia. We found that PPP permits cell adhesion, growth, and mineralization in vitro. In vivo it was found that porous PPP significantly enhanced mineralization into the construct and increased the mechanical strength required to push out the scaffold in comparison to PEEK. This is the first study to investigate the performance of PPP as an orthopaedic biomaterial in vivo. PPP is an attractive material for orthopaedic implants due to the ease of manufacturing and superior mechanical strength.

A Bioactive Hydrogel and 3D Printed Polycaprolactone System for Bone Tissue Engineering

In this study, a hybrid system consisting of 3D printed polycaprolactone (PCL) filled with hydrogel was developed as an application for reconstruction of long bone defects, which are innately difficult to repair due to large missing segments of bone. A 3D printed gyroid scaffold of PCL allowed a larger amount of hydrogel to be loaded within the scaffolds as compared to 3D printed mesh and honeycomb scaffolds of similar volumes and strut thicknesses. The hydrogel was a mixture of alginate, gelatin, and nano-hydroxyapatite, infiltrated with human mesenchymal stem cells (hMSC) to enhance the osteoconductivity and biocompatibility of the system. Adhesion and viability of hMSC in the PCL/hydrogel system confirmed its cytocompatibility. Biomineralization tests in simulated body fluid (SBF) showed the nucleation and growth of apatite crystals, which confirmed the bioactivity of the PCL/hydrogel system. Moreover, dissolution studies, in SBF revealed a sustained dissolution of the hydrogel with time. Overall, the present study provides a new approach in bone tissue engineering to repair bone defects with a bioactive hybrid system consisting of a polymeric scaffold, hydrogel, and hMSC.

Bioactive macroporous titanium implants highly interconnected

Intervertebral implants should be designed with low load requirements, high friction coefficient and low elastic modulus in order to avoid the stress shielding effect on bone. Furthermore, the presence of a highly interconnected porous structure allows stimulating bone in-growth and enhancing implant-bone fixation. The aim of this study was to obtain bioactive porous titanium implants with highly interconnected pores with a total porosity of approximately 57 %. Porous Titanium implants were produced by powder sintering route using the space holder technique with a binder phase and were then evaluated in an in vivo study. The size of the interconnection diameter between the macropores was about 210 μm in order to guarantee bone in-growth through osteblastic cell penetration. Surface roughness and mechanical properties were analyzed. Stiffness was reduced as a result of the powder sintering technique which allowed the formation of a porous network. Compression and fatigue tests exhibited suitable properties in order to guarantee a proper compromise between mechanical properties and pore interconnectivity. Bioactivity treatment effect in novel sintered porous titanium materials was studied by thermo-chemical treatments and were compared with the same material that had undergone different bioactive treatments. Bioactive thermo-chemical treatment was confirmed by the presence of sodium titanates on the surface of the implants as well as inside the porous network. Raman spectroscopy results suggested that the identified titanate structures would enhance in vivo apatite formation by promoting ion exchange for the apatite formation process. In vivo results demonstrated that the bioactive titanium achieved over 75 % tissue colonization compared to the 40 % value for the untreated titanium.

Osteoconductive phosphoserine-modified poly({varepsilon}-lysine) dendrons: synthesis, titanium oxide surface functionalization and response of osteoblast-like cell lines

The lack of direct bonding between the surface of an implant and the mineralized bony tissue is among the main causes of aseptic loosening in titanium-based implants. Surface etching and ceramic coatings have led to improved osteointegration, but their clinical performance is still limited either by partial bonding or by coating delamination. In this work, a solid-phase synthesis method has been optimized to produce poly(ε-lysine) dendrons, the outermost branching generation of which is functionalized by phosphoserine (PS), a known catalyst of the biomineralization process. The dendrons were deposited onto etched titanium oxide surfaces as a near-to-monolayer film able to induce the formation of a homogeneous calcium phosphate phase in a simulated body fluid over 3 days. The dendron films also stimulated MG63 and SAOS-2 osteoblast-like cells to proliferate at a rate significantly higher than etched titanium, with SAOS-2 also showing a higher degree of differentiation over 14 days. PS-tethered dendron films were not affected by various sterilization methods and UV treatment appeared to improve the cell substrate potential of these films, thus suggesting their potential as a surface functionalization method for bone implants.

Kinetics of hydrothermal crystallization under saturated steam pressure and the self-healing effect by nanocrystallite for hydroxyapatite coatings

Hydroxyapatite coatings (HACs) with a low crystalline state were prepared using the plasma spraying process followed by hermetic autoclaving hydrothermal treatment at 100, 150 and 200 degrees C. Experimental evidence confirmed that the HACs became significantly crystallized and the content of amorphous calcium phosphate decreased by performing the autoclaving hydrothermal treatment in an ambient saturated steam pressure system. The obvious chemisorbed hydroxy groups (OH) peak in the X-ray photoelectron spectra detected from the hydrothermally crystallized HAC specimens means that the hydroxyl-deficient state of plasma-sprayed HACs is significantly improved by the abundant replenished OH groups. The HA nanocrystallite observed from scanning electron microscopy and transmission electron microscopy images within hydrothermally treated HACs is the result of nucleation and grain growth through the replenishment of OH groups into the hydroxyl-deficient HA crystal structure. The microstructural self-healing effect is a result of reduction in defects (pores, microcracks and lamellar boundaries) due to new-growth HA nanocrystallite. According to the systematic derivation of the Arrhenius equation, the HA crystallization is a second-order Arrhenius reaction kinetics. Besides the effects of heating temperature and an atmosphere with abundant water molecules, the saturated steam pressure is a crucial factor which significantly improves the crystallization rate constant and further reduces the activation energy for the hydrothermal HA crystallization.

Revision of total hip arthroplasty using the Kerboull and KT plates

We reviewed 42 hips which had undergone revision THA between 1995 and 2005 (the Kerboull plate in 24 hips, and the KT plate in 18 hips). Patients were followed-up for a mean of 7.5 years (range 3-13). In the Kerboull plate group, the five- and ten-year survival rates were 89.9% and 79.4%, respectively. In the KT plate group, the five-year survival rate was 87.5%. The Kerboull and KT plates are placed as close as possible to the original acetabular position and used in combination with a bone graft for bone defects. In Japan, for patients with large bone defects, femoral heads with good quality which have been resected due to osteoarthritis are difficult to prepare as bone grafts. Therefore, use of the KT plate can reduce the bone graft volume to a certain extent by high placement, which was effective in our cases.

Effects of a novel calcium titanate coating on the osseointegration of blasted endosseous implants in rabbit tibiae

OBJECTIVE

The purpose of this study was to investigate the effects of a nanostructured calcium coating on the surfaces of blasted Ti implants on peri-implant bone formation in the rabbit tibiae.

MATERIAL AND METHODS

Threaded implants (3.75 mm in diameter, 6 mm in length) were roughened by hydroxyapatite (HA) blasting (control; blasted implants). The implants were then hydrothermally treated in a Ca-containing solution for 24 h to prepare Ca-incorporated Ti surfaces (experimental; blasted/Ca implants). Surface characterizations were performed by scanning electron microscopy and stylus profilometry before and after Ca coating. Forty-two implants (21 control and 21 experimental) were placed in the proximal tibiae of seven New Zealand White rabbits. Each rabbit received six implants. To evaluate the effects of the nanostructured Ca coating on the peri-implant bone-healing response, removal torque tests and histomorphometric analyses were performed 6 weeks after surgery.

RESULTS

The Ca coating did not significantly change the surface properties produced by blasting at the micron level. Histologically, active bone apposition was observed in the blasted/Ca implants in the marrow space. Compared with the blasted implants, the blasted/Ca implants showed significantly increased bone-to-implant contact over the total implant length (P<0.01) and greater mean removal torque values (P<0.05).

DISCUSSION AND CONCLUSION

The nanostructured, Ca-incorporated surface significantly enhanced the peri-implant bone-healing response of HA-blasted Ti implants. It may be concluded that the use of nanostructured, Ca-coated surfaces may have synergic effects in enhancing osseointegration of blasted Ti implants due to their micron-scaled surface properties and biologically active surface chemistry.

Specific response of osteoblast-like cells on hydroxyapatite layer containing serum protein

Accelerations of bone-like apatite deposition and cell growth on an electrically polarized ceramic hydroxyapatite have been reported. A relationship between these phenomena was investigated in a previous report, and then it was suggested that osteoblast-like cell's (MC3T3-E1) growth had relevance to the mineral growth. The effect of the formed apatite layer especially appeared to be on the cell adhesion. The acceleration of cell proliferation on the polarized HAp has been shown using fibroblastic cell (L929) and nerve cell (SK-N-SH) lines, therefore the effect of the layer on L929 and SK-N-SH was investigated to support the mechanism of acceleration of cell proliferation by polarization of HAp. In this study, the effect of the bone-like apatite layer was not confirmed on L929 cell's growth. On the other hand, the acceleration of nerve cell's proliferation was confirmed on the formed apatite layer. However, the remarkable improvement of the cell adhesion of SK-N-SH was not confirmed on the apatite layer. Consequently, it was considered that the bone-like apatite containing serum protein obtained by the coprecipitation of bone-like apatite and serum protein has a pronounced role only in the activity of osteoblast-like cells.

Histological and scanning electron microscopy analyses of bone/implant interface using the novel Bonelike synthetic bone graft

Synthetic bone grafts provide an alternative to autografts and allografts. Bonelike is a patented synthetic bone graft that mimics the mineral composition of bone. The aim of the present work was to assess the biological behavior of Bonelike graft in humans, before using the material in orthopedic applications of bone regeneration, for example, in opening wedge high tibial osteotomies for medial knee osteoarthritis. Bonelike granules were implanted in cortical bone of 11 patients undergoing osteotomies, and new bone formation, osteoconductive properties, and resorption characteristics of the granules were analyzed. The granules ranged from 500 to 1000 microm and were implanted in the lateral aspect of the tibia. The patients' mean age was 59 years (range 48 to 70 years); there were eight women and three men, all suffering from medial compartment osteoarthritis of the knee. At surgery, a 1 x 1 x 1-cm cortical defect was created 3 cm distal to the entry point of the screws, in line with the long axis of tibia. The implanted Bonelike graft sample was extracted for analysis during removal of the metallic prosthesis after implantation times of 6, 9, and 12 months. Radiological follow-up, scanning electron microscopy, histological analysis, and histomorphometric measurements were conducted on the retrieved samples to assess bone regeneration in the defect area. Osteoconductive capacity was demonstrated by extensive mature bone formation around the implanted granules and high levels of percentage bone-to-graft contact (from 67-84%). Bonelike acted as an excellent bioactive scaffold, allowing the migration, proliferation, and differentiation of bone cells on its surface, and therefore regeneration of the defects was achieved in a rapid, controlled manner. Our results suggest that Bonelike graft is an excellent candidate for orthopedic applications where rapid new bone formation is a fundamental requirement.

Early bone in-growth ability of alumina ceramic implants loaded with tissue-engineered bone

To enhance early bonding of an alumina ceramic implant to bone, we evaluated a method of seeding the implant surface with bone marrow mesenchymal cells that differentiated to osteoblasts and bone matrix prior to implantation. The usefulness of the method was evaluated in Japanese white rabbits. In our study, an alumina ceramic test piece loaded with differentiated osteoblasts and bone matrix by a tissue engineering technique was implanted into rabbit bones. Three weeks after the procedure, evaluation of mechanical bonding and histological examination were performed. Histological examination of the noncell-loaded implant surfaces showed no bone infiltration into the implant gap. However, the cell-loaded implant surfaces exhibited new bone infiltration into the implant gap with mechanical bonding. In the mechanical test, the average failure load was 0.60 kgf for the noncell-loaded side and 1.49 kgf for the cell-loaded side. Preculturing mesenchymal cells on the surface of the alumina ceramic prior to implantation increased the debonding strength by two and half times. The present findings indicate early bonding between the implant and bone three weeks after the procedure.

Incorporation of growth factors into medical devices via biomimetic coatings

Orthopaedic and dental surgeons are fully aware of the need for implants to bond well with the surrounding living bone if long-lasting clinical success is to be achieved. For example, well-bonded hip implants have a 10 year failure rate, which is lowered fivefold if bonding is poor or absent. The techniques that are currently available to impart implant surfaces with the desired osteoconductive properties are essentially limited. To overcome the inherent difficulties, we have developed a 'biomimetic' coating process. By this means, implants with complex surface geometries, such as porous spinal implants, can be furnished with a bone-bonding surface. Furthermore, these coatings can be rendered osteoinductive as well as osteoconductive (by incorporating osteogenic agents). Using this facility, we have induced bone formation at an ectopic site in rats, and have accelerated osseointegration (bone bonding) at an orthotopic dental site in adult miniature pigs. Our preliminary results indicated that these osteoinductive dental implants bond with surrounding bone within one week instead of the usual three weeks. We believe that surfaces coated with biomimetic coatings into which osteogenic growth factors are incorporated hold great potential for use in clinical orthopaedics and dentistry.

Control of phase composition in hydroxyapatite/tetracalcium phosphate biphasic thin coatings for biomedical applications

Biphasic calcium phosphates comprising well-controlled mixtures of nonresorbable hydroxyapatite and other resorbable calcium phosphate phases often exhibit a combination of enhanced bioactivity and mechanical stability that is difficult to achieve in single-phase materials. This makes these biphasic bioceramics promising substrate materials for applications in bone tissue regeneration and repair. In this paper we report the synthesis of highly crystalline, biphasic coatings of hydroxyapatite/tetracalcium phosphate with control over the weight fraction of the constituent phases. The coatings were produced by pulsed laser deposition using ablation targets of pure crystalline hydroxyapatite. The fraction of tetracalcium phosphate phase in the coatings was controlled by varying the substrate temperature and the partial pressure of water vapor in the deposition chamber. A systematic study of phase composition in the hydroxyapatite/tetracalcium phosphate biphasic coatings was performed with X-ray diffraction. Tetracalcium phosphate in the coatings obtained at high substrate temperature is not formed by partial conversion of previously deposited hydroxyapatite. Instead, it is produced by nucleation and growth of tetracalcium phosphate itself from the ablation products of the hydroxyapatite target or by accretion of tetracalcium phosphate grains formed during ablation. This finding was confirmed by formation of calcium oxide, not tetracalcium phosphate, after annealing of pure hydroxyapatite coatings at high temperatures of 700-850 degrees C.

Synthesis of a poly(L-lysine)-calcium phosphate hybrid on titanium surfaces for enhanced bioactivity

Titanium has been a successful implant material owing to its excellent strength to weight ratio, toughness, and bioinert oxide surface. Significant progress has been made on the improvement of titanium's bioactivity by coating its oxide surface with calcium phosphates and bioactive molecules. Here, we report on the coating of titanium with a poly(L-lysine)-calcium phosphate hybrid material with a nanoscale texture. This hybrid coating was grown by first nucleating seed crystals of calcium phosphate, directly on the Ti surface and then exposing this surface to solutions containing Ca(2+), PO(4)(3-), and poly(L-lysine). The resultant hybrid coating was characterized by electron microscopy, X-ray diffraction, Fourier transform infrared spectroscopy, thermogravimetric analysis, X-ray photoelectron spectroscopy, and elemental analysis. This material contained 14% by weight poly(L-lysine), and this organic component decreased greatly the dimensions of the surface features, thus enhancing surface area relative to the inorganic control. The highly textured hybrid material was more susceptible than the control to acidic and enzymatic degradation. The amino acid cysteine was covalently linked to the hybrid material, demonstrating the potential of this coating for further functionalization. These hybrid coatings may prove useful in enhancing the bioactivity of titanium.

A bioactive titanium foam scaffold for bone repair

While titanium has been clinically successful as an orthopedic or dental implant material, performance problems still persist related to implant-bone interfacial strength and mechanical modulus mismatch between titanium and tissue. We describe here the preparation of a titanium foam as a better mechanical match to tissue with surfaces attractive to bone cells through deposition of an organically-modified apatite layer (organoapatite). In a rotating bioreactor, these organoapatite-coated foams are successfully colonized by preosteoblastic cells. Finite element analyses suggest that ingrown tissue in these systems may improve both implant performance and tissue formation through load-sharing and stress distribution. The novel metal-ceramic-polymer hybrid materials described here hold great promise for bone tissue engineering.

Microstructures and bond strengths of plasma-sprayed hydroxyapatite coatings on porous titanium substrates

Hydroxyapatite (HA) coating was carried out by plasma spraying on bulk Ti substrates and porous Ti substrates having a Young's modulus similar to that of human bone. The microstructures and bond strengths of HA coatings were investigated in this study. The HA coatings with thickness of 200-250 microm were free from cracks at interfaces between the coating and Ti substrates. XRD analysis revealed that the HA powder used for plasma spraying had a highly crystallized apatite structure, while the HA coating contained several phases other than HA. The bond strength between the HA coating and the Ti substrates evaluated by standard bonding test (ASTM C633-01) were strongly affected by the failure behavior of the HA coating. A mechanism to explain the failure is discussed in terms of surface roughness of the plasma-sprayed HA coatings on the bulk and porous Ti substrates.

The effect of three different calcium phosphate implant coatings on bone deposition and coating resorption: a long-term histological study in sheep

The present study investigated the hypothesis that hydroxyapatite (HA), tricalcium phosphate (TCP), and a HA-gel coated on endosseous titanium (Ti) implants by spark discharging (SD) and dip coating would achieve predictable osseointegration without evident bioresorption of the coatings on the long term. A costal sheep model was used for the implantation of the HA/SD, HA/TCP/SD, and HA-gel/SD specimens, which were retrieved 6 and 12 months following implantation. HA and Ti coatings on implants obtained by conventional plasma spraying (HA/PS, Ti/PS) were used as controls. Microscopy showed that osseointegration was achieved from all types of implants. No evidence for bioresorption of the HA/SD, HA/TCP/SD, and HA-gel/SD coatings was present but cohesive failure with disruption of the coating/implant interface was seen. A statistical analysis of the histomorphometrical data showed no time-dependent effect, however. HA/PS coatings achieved significantly higher bone-implant contact (BIC) percentages of the total implant surface (toBIC) than the other types of coatings (P=0.01). If the BIC percentages were traced separately for implant portions placed into cortical and cancellous bone (coBIC and caBIC, respectively), detailed analysis showed that the caBIC values of HA-gel/SD and HA/PS coatings were significantly higher than that of the other types of coatings (P=0.01). CaBIC values were highly correlated with toBIC values (P<0.001). The present study showed that the preparation techniques used produced thin, dense, and unresorbable coatings that achieved osseointegration. Compared with the control coatings, however, only HA-gel/SD coating can be recommended from the investigated preparation techniques for a future clinical use if a better coating cohesion is achieved.

Enhanced fixation of implants by bone ingrowth to titanium fiber mesh: Effect of incorporation of hydroxyapatite powder

Tight fixation between bone and implant materials is of great importance for a successful outcome of procedures such as total knee arthroplasty (TKA) and total hip arthroplasty (THA). Titanium fiber mesh is an attractive structure for the establishment of tight fixation between bone and implant by bone ingrowth into the spaces among the fibers. Enhancement of bone ingrowth is desired not only for tight fixation but also for a fast recovery. Our hypothesis is that just the presence of hydroxyapatite (HA) particles ensures improved bone ingrowth, and that long-term stability can be obtained by mechanical anchoring of bone in the spaces among titanium fibers. In this study, we examine our hypothesis by in vivo experiment using dog femur. HA particles were incorporated in titanium fiber mesh coated on titanium alloy rod by dipping in a slurry of HA with hydroxy-propyl-cellulose in an ethanol solution. Specimens were implanted for 3, 5, and 8 weeks, and were then compared with the results from specimens without the use of HA. Bonding strength was evaluated by push-out test, and histomorphometric measurements were made with analysis software to calculate the average value of bone ingrowth. A significantly higher bonding strength was observed for the specimens with HA-incorporated implant at 3 and 5 weeks, and larger bone ingrowth deep inside the titanium fiber mesh was measured at 3 weeks. Our proposed method has the additional advantage of not requiring a high temperature that may result in changes in characters of HA powder such as phase transition, grain growth, and decomposition. Moreover, this technique of HA powder incorporation without high-temperature treatment allows the use of several types of metallic fiber mesh, as well as the application to fiber mesh made of organic polymers. We conclude that this simple modification of titanium fiber mesh with HA powder can improve the fixation of implant to bone in the initial stage after operation.

Biologic fixation and bone ingrowth

Total hip arthroplasty has provided thousands of patients with pain relief and has improved their quality of life. Advances in orthopaedic surgical techniques and implant biomaterials now allow predictable surgical results in most patients. Despite the overwhelming success of this surgical procedure, the debate continues surrounding the optimal choice of implants. Femoral and acetabular implants with varying geometries and fixation methods are currently available. Acrylic bone cement has been used extensively in the past for acetabular and femoral fixation. This mode of component fixation currently remains the technique used most frequently throughout Europe and has shown excellent long-term results. Problems inherent with acrylic bone cement, however, have encouraged other surgeons to use alternative surfaces to allow biologic fixation.

Bone bonding to hydroxyapatite and titanium surfaces on femoral stems retrieved from human subjects at autopsy

The success of clinical results obtained with many hydroxyapatite (HA)-coated prosthetic designs has deflected attention from the need to extend the life of the HA coating on the device. In the current study the percentages of HA and titanium surfaces to which bone was bonded, on HA-coated and non-coated titanium femoral stems retrieved from human subjects, were evaluated. Plasma-sprayed hydroxyapatite (PSHA)-coated devices demonstrated wide variability in the percentage of the PSHA coating remaining on the stems. The coating was missing from a substantial portion of a stem after only about 6 months of implantation. The percentage of revealed metal to which bone was bonded was significantly less than the percentage of the HA coating demonstrating such bonding. The revealed metal to which bone was bonded was comparable to the same value for a separate group of non-PSHA-coated titanium stems. If HA-coatings degrade over time precipitous decline in performance may occur even after several functional years. Many ultrastructural features of the bone bonded to the HA coatings on these implants from human subjects were comparable to those found on HA-coated devices implanted in a canine model.

Osseointegration of a hydroxyapatite-coated multilayered mesh stem

A new type of porous coating for hip prostheses called "multilayered mesh" was tested under weight-bearing conditions. The surface of the stem is constructed of titanium mesh produced by etching. The hip stems of hydroxyapatite (HA)-coated multilayered mesh and conventional beads were implanted into canine right hips, and animals were killed 3, 6 and 10 weeks and 6 and 12 months after implantation. Shear strength between the implant and the bone was evaluated by the push-out test. Bone ingrowth was calculated from backscattered electron imaging-scanning electron microscopy (BEI-SEM) images of transverse sections. Toluidine blue stained sections and the BEI-SEM images were evaluated histologically. The break sites of the specimens after the push-out test were evaluated on BEI-SEM images of longitudinal sections. The mean push-out strength of the HA-coated multilayered mesh samples was greater than that of the beads-coated samples every time tested, and the HA-coated multilayered mesh implants had significantly stronger push-out strength at 3 and 6 weeks (p<0.05). The strength of the HA-coated multilayered mesh implants was even greater at 6 and 12 months, whereas the strength of the beads-coated samples decreased. The HA-coated multilayered mesh implants showed significantly higher percentages of bone ingrowth than the beads-coated implants every time tested, except at 6 months (p<0.05). At 6 and 12 months, the bone ingrowth data for the HA-coated multilayered mesh implants increased, whereas it decreased for the beads-coated implants. The new bone formation had reached the bottom of the porous area of the HA-coated multilayered mesh surface by 3 weeks, but not had reached the bottom of the conventional beads surface. At 6 and 12 months, the smaller pores of the bead surface stopped the thickening of trabecular bone, and at 12 months, the break sites were at the bone-implant interface of the bead surface, whereas they were on the bone side of the HA-coated multilayered mesh surface. The difference between the break sites was significant at 12 months (p<0.05). The HA-coated multilayered mesh stem provided faster, stronger, and more durable osseointegration than the conventional bead stem.

Hydroxyapatite does not improve the outcome of a bipolar hemiarthroplasty

In a one-surgeon study the clinical and radiographic results of 30 cementless bipolar hip prostheses in 24 patients younger than 55 years were evaluated. Eleven noncoated prostheses (Noncoated Group) and 19 hydroxyapatite-coated prostheses (Hydroxyapatite Group) were compared after a mean followup of 10.4 years. The Harris hip score increased from a preoperative average of 41 points to 76 points at final followup (Noncoated Group, 70 points; Hydroxyapatite Group, 80 points). Thigh or groin pain was present in 15 patients (16 hips) (Noncoated Group, 55%; Hydroxyapatite Group, 53%). Radiographically, subsidence was the major problem at the noncoated prostheses (Noncoated Group, 91%; Hydroxyapatite Group, 5%), whereas osteolysis mainly was seen at the hydroxyapatite-coated prostheses (Noncoated Group, 18%; Hydroxyapatite Group, 89%). The obtained aseptic revision rate of 27% (Noncoated Group, 27%; Hydroxyapatite Group, 26%) is too high to use this implant in young patients. The large amounts of polyethylene wear debris generated by the bipolar system play an important role in this limited success. In the initially well-fixed hydroxyapatite-coated prostheses the sealing effect of a hydroxyapatite coating creates high concentrations of polyethylene in the limited joint space, resulting in massive proximal femoral osteolysis. Consequently, a hydroxyapatite coating introduces a new failure mechanism. Therefore, hydroxyapatite does not improve the outcome of a cementless bipolar hemiarthroplasty in the long-term.

Significance of melt-fraction in HVOF sprayed hydroxyapatite particles, splats and coatings

Microstructure characterization and property evaluation of high velocity oxy-fuel (HVOF) sprayed hydroxyapatite (HA) splats and coatings were conducted in the present study as a function of the proportion of melting that occurred in HA particles during HVOF spray. In vitro behavior of single and folded HA splats in simulated body fluid was also investigated. Results showed that phase composition of as-sprayed HA coatings was influenced significantly by the melt fraction in HVOF sprayed particles. Melt fraction of the HA powders were experimentally determined from particle morphology analysis. It was found that the spray parameters and starting powder size influenced the melt fraction of the particles. In vitro investigation of individual HA splats made from different HA particles revealed decisive role of local phase composition in influencing their dissolution/precipitation behavior during the test. Furthermore, Raman spectroscopy qualitative inspection on the sprayed HA particles (partial melted) revealed that thermal decomposition occurred within the melted part rather than the unmelted zone. Young's modulus and micro-hardness of the as-sprayed particles and coatings were determined using nano-indentation technique. The resolidified zone of the sprayed HA particles exhibited an average Young's modulus value of 41.25 GPa. The measured values ranged from 23.1 to 65.3 GPa. The unmelted part of the HA powders showed a markedly narrower range. Young's modulus value of 83.9 GPa (+/-9.4 GPa) was recorded for this region. This succinctly highlight the difference between the unmelted region and melted regions of a HA particle. Young's moduli values measured on HVOF coatings were found to mirror the trend found in the spheroidised particles and splats with apt fidelity.

Biology of alkali- and heat-treated titanium implants

In cementless fixation systems, surface character is an important factor. Alkali and heat treatments of titanium metal have been shown to produce strong bonding to bone and a higher ongrowth rate. In this study we examined the effect of alkali and heat treatments on titanium rods in an intramedullary rabbit femur model, in regard to the cementless hip stem. The implant rods were 5 mm in diameter and 25 mm in length. Half of the implants were immersed in 5 mol/L sodium hydroxide solution and heated at 600 degrees C for 1 h (AH implants), and the other half were untreated (CL implants). The rods were implanted into the distal femur of the rabbits; AH implants into the left femur and CL implants into the right. The bone-implant interfaces were evaluated at 3, 6, and 12 weeks after implantation. Pull-out tests showed that the AH implants had a significantly higher bonding strength to bone than the CL implants at each time point. As postoperative time elapsed, histological examination revealed that new bone formed on the surface of both types of implants, but significantly more bone made direct contact with the surface of the AH implants. At 12 weeks, approximately 56% of the whole surface of the AH implants was covered with the bone. In conclusion, alkali- and heat-treated titanium offers strong bone bonding and a high affinity to bone as opposed to a conventional mechanical interlocking mechanism. Alkali and heat treatments of titanium may be suitable surface treatments for cementless joint replacement implants.

Acetabular reconstruction using a Kerboull-type acetabular reinforcement device and hydroxyapatite granules: a 3- to 8-year follow-up study

Between 1993 and 1997, 21 consecutive revision total hip arthroplasties were performed in 20 patients using hydroxyapatite (HA) granules supported by a Kerboull-type reinforcement acetabular device. Acetabular bone loss according to the American Academy of Orthopaedic Surgeons (AAOS) system was type II for 5 hips and type III for 16 hips. Autografts were used to reconstruct the major segmental defects in 6 hips. The mean follow-up period of the series was 5 years and 4 months. No migration of the socket was seen. Slight inclination of the acetabular device was noted in 1 hip without functional deficits. The mean preoperative Merle d'Aubigné hip functional score was 9.3 versus 15.4 at the latest follow-up evaluation. Acetabular reconstruction with HA granules and a Kerboull-type acetabular device provided satisfactory 3- to 8-year clinical and radiographic results.

Colonization of organoapatite-titanium mesh by preosteoblastic cells

Titanium (Ti) and its alloys continue to serve as successful implant materials for skeletal repair because of their physical properties and biocompatibility. This study investigates the influence of organoapatite (OA), grown directly onto an L-shaped Ti mesh, on preosteoblastic cellular colonization. Unseeded mesh samples were placed on subconfluent layers of MC3T3-E1 murine calvaria cells and cultured for up to 2 weeks. Cells demonstrated accelerated colonization of the three-dimensional OA-Ti mesh substrates over bare Ti controls. Cells also showed significantly increased proliferation on the OA-Ti mesh over bare Ti controls. Cellular differentiation, measured by alkaline phosphatase and osteocalcin expression, was observed at late stages of the experiment with no notable differences between OA-Ti mesh and bare Ti controls. These results suggest that OA grown onto porous Ti substrates is capable of inducing accelerated colonization of unseeded implant structures by osteogenic cells.

The effect of demineralized bone matrix gel on bone ingrowth and fixation of porous implants

The presence of demineralized bone matrix (DBM) gel did not enhance or accelerate attachment strength or bone ingrowth and resulted in a significant decrease in implant interface attachment strength at 3 weeks. Hydroxyapatite (HA) coating resulted in significant increases in interface shear strength and bone ingrowth compared with non-HA-coated porous implants at all time periods. The HA-coated implants achieved greater attachment strength and bone ingrowth at earlier time periods and maintained greater attachment strength at long-term periods. The results of this study indicate that in the presence of a good bone-implant interference fit, there is no beneficial effect in applying DBM gel to a porous-coated or HA-coated porous implant surface. The small amount that can be applied and the degree of osteoinductivity of DBM seem to preclude it from having a significant biologic effect.

The effect of hydroxyapatite on bone ingrowth into porous-coated titanium implants

Two different groups of hydroxyapatite (HA) coated and uncoated porous titanium implants, 250-350 m and 500-700 m diameter beads, were press-fit in femoral canine cancellous bone. After 12 weeks, the dogs were euthanized and histomorphometric backscattered electron microscopy studies were carried out. Comparing HA-coated versus uncoated implants in the 250-350 m bead diameter group percentage of bone (P=0.01) and bone index (P=0.01), were higher in the HA-coated implants. Comparing HA-coated versus uncoated implants in the 500-700 m bead diameter group bone ingrowth (P=0.01) and bone depth penetration (P=0.008), were higher in HA-coated samples. It can be concluded that the HA coating was an effective method to improve bone formation and ingrowth in the porous implants. (Hip International 2002; 2: 153-7).

Histologic evaluation of a threaded hydroxyapatite-coated root-form implant located at a dehisced maxillary site and retrieved from a human subject: a clinical report

This clinical report describes the microscopic analysis of a threaded hydroxyapatite-coated root-form implant retrieved from an 89-year-old subject after 10 months of service. The implant was never loaded and was removed because it was nonrestorable. Clinically, the buccal area of the implant was covered by soft tissue, whereas the palatal side was covered by bone. Light microscopic evaluation revealed tight contact between hydroxyapatite and bone with no sign of coating dissolution. Osteocytes were present, and Haversian canals were in close proximity to the implant surface. The buccal side of the implant demonstrated mild to moderate inflammatory infiltrate and signs of hydroxyapatite coating dissolution. These observations suggest that hydroxyapatite coatings can resist degradation in contact with bone but may be more prone to dissolution in contact with soft tissue.

Material fundamentals and clinical performance of plasma-sprayed hydroxyapatite coatings: a review

The clinical use of plasma-sprayed hydroxyapatite (HA) coatings on metal implants has aroused as many controversies as interests over the last decade. Although faster and stronger fixation and more bone growth have been revealed, the performance of HA-coated implants has been doubted. This article will initially address the fundamentals of the material selection, design, and processing of the HA coating and show how the coating microstructure and properties can be a good predictor of the expected behavior in the body. Further discussion will clarify the major concerns with the clinical use of HA coatings and introduce a comprehensive review concerning the outcomes experienced with respect to clinical practice over the past 5 years. A reflection on the results indicates that HA coatings can promote earlier and stronger fixation but exhibit a durability that can be related to the coating quality. Specific relationships between coating quality and clinical performance are being established as characterization methods disclose more information about the coating.