An overview of the histology of skeletal substitute materials

The effects of bone-substitute augmentation on treatment of osteoporotic intertrochanteric fractures

Background

Methods

Results

Conclusions

Level of evidence

Diagnostic guidelines for the histological particle algorithm in the periprosthetic neo-synovial tissue

BACKGROUND

The identification of implant wear particles and non-implant related particles and the characterization of the inflammatory responses in the periprosthetic neo-synovial membrane, bone, and the synovial-like interface membrane (SLIM) play an important role for the evaluation of clinical outcome, correlation with radiological and implant retrieval studies, and understanding of the biological pathways contributing to implant failures in joint arthroplasty. The purpose of this study is to present a comprehensive histological particle algorithm (HPA) as a practical guide to particle identification at routine light microscopy examination.

METHODS

The cases used for particle analysis were selected retrospectively from the archives of two institutions and were representative of the implant wear and non-implant related particle spectrum. All particle categories were described according to their size, shape, colour and properties observed at light microscopy, under polarized light, and after histochemical stains when necessary. A unified range of particle size, defined as a measure of length only, is proposed for the wear particles with five classes for polyethylene (PE) particles and four classes for conventional and corrosion metallic particles and ceramic particles.

RESULTS

All implant wear and non-implant related particles were described and illustrated in detail by category. A particle scoring system for the periprosthetic tissue/SLIM is proposed as follows: 1) Wear particle identification at light microscopy with a two-step analysis at low (× 25, × 40, and × 100) and high magnification (× 200 and × 400); 2) Identification of the predominant wear particle type with size determination; 3) The presence of non-implant related endogenous and/or foreign particles. A guide for a comprehensive pathology report is also provided with sections for macroscopic and microscopic description, and diagnosis.

CONCLUSIONS

The HPA should be considered a standard for the histological analysis of periprosthetic neo-synovial membrane, bone, and SLIM. It provides a basic, standardized tool for the identification of implant wear and non-implant related particles at routine light microscopy examination and aims at reducing intra-observer and inter-observer variability to provide a common platform for multicentric implant retrieval/radiological/histological studies and valuable data for the risk assessment of implant performance for regional and national implant registries and government agencies.

Magnesium alloys: A stony pathway from intensive research to clinical reality. Different test methods and approval-related considerations

The first degradable implant made of a magnesium alloy, a compression screw, was launched to the clinical market in March 2013. Many different complex considerations are required for the marketing authorization of degradable implant materials. This review gives an overview of existing and proposed standards for implant testing for marketing approval. Furthermore, different common in vitro and in vivo testing methods are discussed. In some cases, animal tests are inevitable to investigate the biological safety of a novel medical material. The choice of an appropriate animal model is as important as subsequent histological examination. Furthermore, this review focuses on the results of various mechanical tests to investigate the stability of implants for temporary use. All the above aspects are examined in the context of development and testing of magnesium-based biomaterials and their progress them from bench to bedside. A brief history of the first market launch of a magnesium-based degradable implant is given. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 329-347, 2017.

Horizontal Resorption of Fresh-Frozen Corticocancellous Bone Blocks in the Reconstruction of the Atrophic Maxilla at 5 Months

Background

Reliable implant-supported rehabilitation of an alveolar ridge needs sufficient volume of bone. In order to achieve a prosthetic-driven positioning, bone graft techniques may be required.

Purpose

This prospective cohort study aims to clinically evaluate the amount of resorption of corticocancellous fresh-frozen allografts bone blocks used in the reconstruction of the severe atrophic maxilla.

Materials and Methods

Twenty-two partial and totally edentulous patients underwent bone augmentation procedures with fresh-frozen allogenous blocks from the iliac crest under local anesthesia. Implants were inserted into the grafted sites after a healing period of 5 months. Final fixed prosthesis was delivered ± 4 months later. Ridge width analysis and measurements were performed with a caliper before and after grafting and at implant insertion. Bone biopsies were performed in 16 patients.

Results

A total of 98 onlay block allografts were used in 22 patients with an initial mean alveolar ridge width of 3.41 ± 1.36 mm. Early exposure of blocks was observed in four situations and one of these completely resorbed. Mean horizontal bone gain was 3.63 ± 1.28 mm (p < .01). Mean buccal bone resorption between allograph placement and the reopening stage was 0.49 ± 0.54 mm, meaning approximately 7.1% (95% confidence interval: [5.6%, 8.6%]) of total ridge width loss during the integration period. One hundred thirty dental implants were placed with good primary stability (≥ 30 Ncm). Four implants presented early failure before the prosthetic delivery (96.7% implant survival). All patients were successfully rehabilitated. Histomorphometric analysis revealed 20.9 ± 5.8% of vital bone in close contact to the remaining grafted bone. A positive strong correlation (adjusted R² = 0.44, p = .003) was found between healing time and vital bone percentage.

Conclusions

Augmentation procedures performed using fresh-frozen allografts from the iliac crest are a suitable alternative in the reconstruction of the atrophic maxilla with low resorption rate at 5 months, allowing proper stability of dental implants followed by fixed prosthetic rehabilitation.

Perfusion flow enhances osteogenic gene expression and the infiltration of osteoblasts and endothelial cells into three-dimensional calcium phosphate scaffolds

Maintaining cellular viability in vivo and in vitro is a critical issue in three-dimensional bone tissue engineering. While the use of osteoblast/endothelial cell cocultures on three-dimensional constructs has shown promise for increasing in vivo vascularization, in vitro maintenance of cellular viability remains problematic. This study used perfusion flow to increase osteogenic and angiogenic gene expression, decrease hypoxic gene expression, and increase cell and matrix coverage in osteoblast/endothelial cell co-cultures. Mouse osteoblast-like cells (MC3T3-E1) were cultured alone and in co-culture with mouse microvascular endothelial cells (EOMA) on three-dimensional scaffolds for 1, 2, 7, and 14 days with or without perfusion flow. mRNA levels were determined for several osteogenic, angiogenic, and hypoxia-related genes, and histological analysis was performed. Perfusion flow downregulated hypoxia-related genes (HIF-1α, VEGF, and OPN) at early timepoints, upregulated osteogenic genes (ALP and OCN) at 7 days, and downregulated RUNX-2 and VEGF mRNA at 14 days in osteoblast monocultures. Perfusion flow increased cell number, coverage of the scaffold perimeter, and matrix area in the center of scaffolds at 14 days. Additionally, perfusion flow increased the length of endothelial cell aggregations within co-cultures. These suggest perfusion stimulated co-cultures provide a means of increasing osteogenic and angiogenic activity.

Hematoma-inspired alginate/platelet releasate/CaPO4 composite: initiation of the inflammatory-mediated response associated with fracture repair in vitro and ex vivo injection delivery

A clinical need continues for consistent bone remodeling within problematic sites such as those of fracture nonunion, avascular necrosis, or irregular bone formations. In attempt to address such needs, a biomaterial system is proposed to induce early inflammatory responses after implantation and to provide later osteoconductive scaffolding for bone regeneration. Biomaterial-induced inflammation would parallel the early stage of hematoma-induced fracture repair and allow scaffold-promoted remodeling of osseous tissue to a healthy state. Initiation of the wound healing cascade by two human concentrated platelet releasate-containing alginate/β-tricalcium phosphate biocomposites has been studied in vitro using the TIB-71™ RAW264.7 mouse monocyte cell line. Inflammatory responses inherent to the base material were found and could be modulated through incorporation of platelet releasate. Differences in hydrogel wt% (2 vs. 8 %) and/or calcium phosphate granule vol.% (20 vs. 10 %) allowed for tuning the response associated with platelet releasate-associated growth factor elution. Tunability from completely suppressing the inflammatory response to augmenting the response was observed through varied elution profiles of both releasate-derived bioagents and impurities inherent to alginate. A 2.5-fold upregulation of inducible-nitric oxide synthase gene expression followed by a tenfold increase in nitrite media levels was induced by inclusion of releasate within the 8 wt%/10 vol.% formulation and was comparable to an endotoxin positive control. Whereas, near complete elimination of inflammation was seen when releasate was included within the 2 wt%/20 vol.% formulation. These in vitro results suggested tunable interactions between the multiple platelet releasate-derived bioagents and the biocomposites for enhancing hematoma-like fracture repair. Additionally, minimally invasive delivery for in situ curing of the implant system via injection was demonstrated in rat tail vertebrae using microcomputed tomography.

Severe maxillary atrophy treatment with Le Fort I, allografts, and implant-supported prosthetic rehabilitation

PURPOSE

Recently, several authors have described that autologous and fresh-frozen bones are effective materials to correct jaw bone defects before endosseous implant positioning. The aim of this study was to report a multistep oral rehabilitation of severe atrophic maxilla by means of Le Fort I osteotomy for maxillary downward and forward repositioning, allografts, implant insertion, and prosthetic loading.

METHODS

Patients with severe maxillary atrophy underwent Le Fort I osteotomy associated to fresh-frozen interpositional bone allografts. At 7 months after reconstructive procedure, 2 biopsies for each patient have been taken, and in the same surgical procedure, endosseous implants were placed. Five months afterward, abutments were connected for the final prosthodontic restauration. Each patient was evaluated at 1-year follow-up after prosthetic loading.

RESULTS

At 1-year follow-up after functional prosthetic loading, no infection of the allografts or implant failure has been reported. Clinical and radiologic follow-up showed no sign of bone resorption in all the osteotomic sites and in the grafted areas. Histological analysis showed evidence of allograft osteointegration and healing.

CONCLUSIONS

Multistep oral rehabilitation of severe atrophic maxilla with Le Fort and interpositional bone allografts represents a reliable surgical technique. According to this clinical, radiologic, and histologic reports, interpositional fresh-frozen bone allograft seems to be a valuable material for grafting jaw as it is cheaper than other materials and is safe, and it avoids donor site, decreasing the morbidity of the treatment

Effect of low-level laser therapy on incorporation of block allografts

OBJECTIVE

To assess the effect of low-level laser therapy (LLLT) on the incorporation of deep-frozen block allografts in a rabbit model.

BACKGROUND DATA

Studies have shown that LLLT has beneficial effects on tissue repair and new bone formation.

METHODS

Bone tissue was harvested from two rabbits, processed by deep-freezing and grafted into the calvaria of 12 animals, which were then randomly allocated into two groups: experimental (L) and control (C). Rabbits in group L were irradiated with an aluminum gallium arsenide diode laser (AlGaAs; wavelength 830 nm, 4 J/cm(2)), applied to four sites on the calvaria, for a total dose of 16 J/cm(2) per session. The total treatment dose after eight sessions was 128 J/cm(2). Animals were euthanized at 35 (n = 6) or 70 days (n = 6) postoperatively.

RESULTS

Deep-freeze-processed block allografts followed by LLLT showed incorporation at the graft-host interface, moderate bone remodeling, partial filling of osteocyte lacunae, less inflammatory infiltrate in the early postoperative period, and higher collagen deposition than the control group.

CONCLUSION

Optical microscopy and scanning electron microscopy showed that allograft bone processed by deep-freezing plus LLLT is suitable as an alternative for the treatment of bone defects. Use of the deep-freezing method for processing of bone grafts preserves the structural and osteoconductive characteristics of bone tissue.

Osteogenic response to BMP-2 of hMSCs grown on apatite-coated scaffolds

Osteoconductive materials play a critical role in promoting integration with surrounding bone tissue and resultant bone repair in vivo. However, the impact of 3D osteoconductive substrates coupled with soluble signals on progenitor cell differentiation is not clear. In this study, we investigated the influence of bone morphogenetic protein-2 (BMP-2) concentration on the osteogenic differentiation of human mesenchymal stem cells (hMSCs) when seeded in carbonated apatite-coated polymer scaffolds. Mineralized scaffolds were more hydrophilic and adsorbed more BMP-2 compared to non-mineralized scaffolds. Changes in alkaline phosphatase (ALP) activity within stimulated hMSCs were dependent on the dose of BMP-2 and the scaffold composition. We detected more cell-secreted calcium on mineralized scaffolds at all time points, and higher BMP-2 concentrations resulted in increased ALP and calcium levels. RUNX2 and IBSP gene expression within hMSCs was affected by both substrate and soluble signals, SP7 by soluble factors, and SPARC by substrate-mediated cues. The present data indicate that a combination of apatite and BMP-2 do not simply enhance the osteogenic response of hMSCs, but act through multiple pathways that may be both substrate- and growth factor-mediated. Thus, multiple signaling strategies will likely be necessary to achieve optimal bone regeneration.

Delivery of lyophilized Nell-1 in a rat spinal fusion model

Nell-1 (Nel-like molecule-1; Nel: protein strongly expressed in neural tissue containing epidermal growth factor-like domain) is a promising osteoblast-specific growth factor for osteoinductive therapies that may circumvent adverse effects, such as nonspecific function and ectopic bone formation, associated with more established osteogenic growth factors such as bone morphogenetic proteins. Beta-tricalcium phosphate (beta-TCP), an osteoconductive, biodegradable ceramic biomaterial, has been used successfully to deliver osteoinducers for bone regeneration. The aim of this study was to develop a carrier system for efficiently delivering biologically active Nell-1 protein. After a 40% initial burst release, beta-TCP particles retained the majority of adsorbed Nell-1 protein in vitro. To test this system in vivo, L4/L5 spinal fusion was performed in three groups of rats (n = 8 each): (1) 5 microg Nell-1 in beta-TCP/demineralized bone matrix putty (DBX); (2) 2.5 microg Nell-1 in beta-TCP/DBX; (3) beta-TCP/DBX only. Fusion was assessed by radiography, palpation, microcomputed tomography, and histological analysis. After 4 weeks, 75% of Nell-1-treated animals exhibited fusion, with a significant increase in new bone volume, whereas only 25% of Nell-free control animals exhibited fusion. Our findings suggest that beta-TCP/DBX can increase both the biochemical stability and biological efficiency of Nell-1 protein.

Bone grafting options in children

STUDY DESIGN

Retrospective review of the literature.

OBJECTIVE

To review the current literature as well as recent trends in bone grafting techniques available for children.

SUMMARY OF BACKGROUND DATA

The currently accepted gold standard in bone grafting for adolescent idiopathic scoliosis (AIS) is autogenous iliac crest. Due to questions concerning complications such as donor site pain, other options have been explored, including various allograft sources, demineralized bone matrix, and bone morphogenetic protein.

METHODS

A review of the current medical literature was completed and additional case examples are presented.

RESULTS

A review of the literature reveals that up to 31% of patients have persistent pain at 2 years post surgery when autogenous iliac crest bone graft is harvested. Allograft supplementation of local autograft has been demonstrated in the literature to be as effective as autogenous iliac crest bone grafting in contributing to a successful posterior spinal fusion in patients with AIS. Modern demineralized bone matrix formulations have been found in both animal models as well as in a recent retrospective clinical review to contribute to a successful posterior spinal fusion in AIS. Bone morphogenetic protein has been shown to contribute to a successful posterior spinal fusion in complex pediatric spinal deformity patients. At 2 years follow-up, patients who underwent a posterior instrumented spinal fusion that was not augmented with any bone graft appear to have successful spinal fusions.

CONCLUSION

Although autogenous iliac bone graft remains the benchmark to which bone grafting materials are compared, other options including the placement of no bone graft at all provides similar fusion rates in patients with AIS.

Biomimetic calcium phosphate coatings on recombinant spider silk fibres

Calcium phosphate ceramic coatings, applied on surfaces of metallic and polymeric biomaterials, can improve their performance in bone repair and regeneration. Spider silk is biocompatible, strong and elastic, and hence an attractive biomaterial for applications in connective tissue repair. Recently, artificial spider silk, with mechanical and structural characteristics similar to those of native spider silk, has been produced from recombinant minispidroins. In the present study, supersaturated simulated body fluid was used to deposit calcium phosphate coatings on recombinant spider silk fibres. The mineralization process was followed in time using scanning electron microscopy equipped with an energy dispersive x-ray (EDX) detector and Raman spectroscope. Focused ion beam technology was used to produce a cross section of a coated fibre, which was further analysed by EDX. Preliminary in vitro experiments using a culture of bone marrow-derived human mesenchymal stem cells (hMSCs) on coated fibres were also performed. This study showed that recombinant spider silk fibres were successfully coated with a homogeneous and thick crystalline calcium phosphate layer. In the course of the mineralization process from modified simulated body fluid, sodium chloride crystals were first deposited on the silk surface, followed by the deposition of a calcium phosphate layer. The coated silk fibres supported the attachment and growth of hMSCs.

Mechanical strength of extrusion freeformed calcium phosphate filaments

Hydroxyapatite-tricalcium phosphate mixtures of various compositions were extruded by a solid free-forming process to form lattice structures to serve as hard tissue scaffolds. The unwelded filaments, sintered at temperatures from 1100 to 1300 degrees C, had radii from 115 to 135 microm and were tested in three point flexural loading using a purpose-built fixture. Flexural strength ranged from 20 to 100 MPa depending on composition and sintering temperature. Weibull moduli up to 13 were obtained. Compositions with 50% or more tri-calcium phosphate did not develop strengths much above 40 MPa and the strength of most compositions fell when the sintering temperature exceeded 1250 degrees C. Multiple layer lattice structures were created and tested in compression.

Evaluation of a silica-containing bone graft substitute in a vertebral defect model

Orthopedic and spine surgeons are in need of supplements or replacements for autograft. We investigated the histological properties of three formulations of Calcium Sodium Phosphosilicate [calcium sodium phosphosilicate putty with or without autograft and NovaBone 45S5 Bioglass particulate (NovaBone, LLC, Jacksonville, FL)] using a sheep vertebral bone void model. Bone voids were surgically created in L3, L4, and L5 in each of 22 sheep, and the voids were filled with one of the tested biomaterials or left empty as a control. Histological evaluations were performed at either: 0, 6, or 12 weeks after surgery. Undecalcified sections were digitized, and the areas of the original defect and new bone were quantified. Decalcified sections were evaluated qualitatively. Histomorphometry showed a significant increase in the amount of bone between 6 and 12 weeks in all groups, but there was no significant difference in new bone formation among the formulations or between any formulation and the empty defects. The granules of all three formulations were associated with an inflammatory reaction. Many of the particles appear to have a hollow center, and the narrow tunnel through the center of the particles was sometimes associated with acute inflammation especially at 6 weeks. These particles were also associated with chronic inflammation at both 6 and 12 weeks, although the extent of inflammation decreased between 6 and 12 weeks. The search for the optimum bone graft substitute/extender will continue.

Effect of recombinant human bone morphogenetic protein-2 on bone regeneration in large defects of the growing canine skull after dura mater replacement with a dura mater substitute

OBJECT

This study was designed to evaluate the bone regeneration potential of the dura mater and dura mater substitute (Durepair) in the presence of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered in a collagen sponge-collagen-ceramic matrix (CCM; MasterGraft Matrix) in a large skull defect in growing canines.

METHODS

Forty immature male beagles were used to create two 2.5 x 4-cm cranial defects on each side of the sagittal suture. The dura mater on the left side was cut to make a 1 x 3-cm defect and replaced with bovine skin collagen (Durepair). The dura mater on the right side remained intact. Different doses of rhBMP-2 (none [8 animals], 0.11 mg/ml [4 animals], 0.21 mg/ml [4 animals], and 0.43 mg/ml [8 animals]) were infused on 2 Type I bovine absorbable collagen sponge (ACS) strips. The strips were layered with the CCM (15% hydroxyapatite [HA]/85% tricalcium phosphate [TCP]) to reconstruct both cranial defects. In a fifth group (8 animals), 0.43 mg/ml rhBMP-2 was directly infused into the CCM. Demineralized canine cancellous freeze-dried demineralized bone matrix (DBM; 8 animals) was used as a control in a sixth group. All materials were fixed under 2 resorbable protective sheets (MacroPore). Skulls were resected 16 weeks after operation. Histological and histomorphometric analyses on the percentage of the defect spanned by bone, and the percentage of residual HA-TCP granules and collagen were analyzed.

RESULTS

Calcified seroma was the only complication observed and only occurred in the 0.43-mg/ml rhBMP-2 groups (Groups 4 and 5). Dura mater repair appeared complete at 4 months in all animals. New bone was formed sporadically throughout the skull defect in the ACS+CCM and DBM groups without rhBMP-2. In all rhBMP-2 groups, mature new bone (compact and trabecular) was uniformly formed across the defect on both the repaired and intact dura mater sides. There was significant new compact bone formation on top of the repaired dura mater, which did not appear in the ACS+CCM and DBM groups lacking rhBMP-2. Greater HA-TCP and collagen scaffold resorption was noted in rhBMP-2 groups compared with non-rhBMP-2 groups. Statistical analysis showed there was a significantly lower percentage of bone spanning the defect in the ACS+CCM group compared with groups with rhBMP-2, with more residual HA-TCP and collagen on the repaired dura mater side than the intact dura mater side (p < 0.05). In all rhBMP-2 groups, there were no significant differences in new bone formation between the repaired and intact dura mater sides (p > 0.05).

CONCLUSIONS

The ACS+CCM combination had an effect similar to demineralized bone-on-bone regeneration in craniofacial reconstruction. The addition of rhBMP-2 to CCM directly or with ACS induces mature new bone formation in large cranial defects both in the presence of intact dura mater and repaired dura mater.

Fractures of the hip and osteoporosis: the role of bone substitutes

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised. Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.