Functional Ultra-High Molecular Weight Polyethylene Composites for Ligament Reconstructions and Their Targeted Applications in the Restoration of the Anterior Cruciate Ligament

The selection of biomaterials as biomedical implants is a significant challenge. Ultra-high molecular weight polyethylene (UHMWPE) and composites of such kind have been extensively used in medical implants, notably in the bearings of the hip, knee, and other joint prostheses, owing to its biocompatibility and high wear resistance. For the Anterior Cruciate Ligament (ACL) graft, synthetic UHMWPE is an ideal candidate due to its biocompatibility and extremely high tensile strength. However, significant problems are observed in UHMWPE based implants, such as wear debris and oxidative degradation. To resolve the issue of wear and to enhance the life of UHMWPE as an implant, in recent years, this field has witnessed numerous innovative methodologies such as biofunctionalization or high temperature melting of UHMWPE to enhance its toughness and strength. The surface functionalization/modification/treatment of UHMWPE is very challenging as it requires optimizing many variables, such as surface tension and wettability, active functional groups on the surface, irradiation, and protein immobilization to successfully improve the mechanical properties of UHMWPE and reduce or eliminate the wear or osteolysis of the UHMWPE implant. Despite these difficulties, several surface roughening, functionalization, and irradiation processing technologies have been developed and applied in the recent past. The basic research and direct industrial applications of such material improvement technology are very significant, as evidenced by the significant number of published papers and patents. However, the available literature on research methodology and techniques related to material property enhancement and protection from wear of UHMWPE is disseminated, and there is a lack of a comprehensive source for the research community to access information on the subject matter. Here we provide an overview of recent developments and core challenges in the surface modification/functionalization/irradiation of UHMWPE and apply these findings to the case study of UHMWPE for ACL repair.

Home FES: An Exploratory Review

This review of literature focuses on the multiple uses of Functional Electrical Stimulation (FES) and how this modality may be a valuable home-based therapy. Papers pertaining to home FES exercise were collected using the Web of Science, Google Scholar databases and collegial hints. In our opinion, the following statements summarize the results. FES may be used to induce health benefits in populations with paralysis, and in persons with musculoskeletal, cardiorespiratory and renal pathology. The EU Project Rise showed how FES could have a variety of encouraging outcomes for patients with denervated muscles following traumatic injuries. As suggested by recent literature, FES has proven to be a viable form of exercise for elderly individuals. Thus, Home FES may be an option for patients looking for an additional form of muscle and cardiopulmonary physical therapy.

Mechanical and Cytocompatibility Evaluation of UHMWPE/PCL/Bioglass® Fibrous Composite for Acetabular Labrum Implant

In this study, a fibrous composite was developed as synthetic graft for labral reconstruction treatment, comprised of ultra-high molecular weight polyethylene (UHMWPE) fabric, ultrafine fibre of polycaprolactone (PCL), and 45S5 Bioglass®. This experiment aimed to examine the mechanical performance and cytocompatibility of the composite. Electrospinning and a slurry dipping technique were applied for composite fabrication. To assess the mechanical performance of UHMWPE, tensile cyclic loading test was carried out. Meanwhile, cytocompatibility of the composite on fibroblastic cells was examined through a viability assay, as well as SEM images to observe cell attachment and proliferation. The mechanical test showed that the UHMWPE fabric had a mean displacement of 1.038 mm after 600 cycles, approximately 4.5 times greater resistance compared to that of natural labrum, based on data obtained from literature. A viability assay demonstrated the predominant occupation of live cells on the material surface, suggesting that the composite was able to provide a viable environment for cell growth. Meanwhile, SEM images exhibited cell adhesion and the formation of cell colonies on the material surface. These results indicated that the UHMWPE/PCL/Bioglass® composite could be a promising material for labrum implants.

The duty cycle in Functional Electrical Stimulation research. Part II: Duty cycle multiplicity and domain reporting

In part I of this review, we introduced the duty cycle as a fundamental parameter in controlling the effect of electrical stimulation pulse trains on muscle structural and functional properties with special emphasis on fatigue. Following on from a survey of the literature, we discuss here the relative ability of intermittent and continuous stimulation to fatigue muscle. In addition, pertinent literature is explored on a more deeper level, highlighting contentions regarding the duty cycle across studies. In response to literature inconsistencies, we propose frameworks upon which the duty cycle parameter may be specified. We present the idea of domain reporting for the duty cycle, and illustrate with practical examples. In addition we dig further into the literature and present a set of notations that have been used by different researchers to report the duty cycle. We also propose the idea of the duty cycle multiple, which together with domain reporting, will help researchers understand more precisely duty cycles of electrical stimulation. As a case study, we also show how the duty cycle has been looked at by researchers in the context of pressure sore attenuation in patients. Together with part I, it is hoped that the frameworks suggested provide a complete picture of how duty cycle has been discussed across the literature, and gives researchers a more trans-theoretical basis upon which they may report the duty cycle in their studies. This may also lead to a more precise specification of electrical stimulation protocols used in patients.

Reporting for Duty: The duty cycle in Functional Electrical Stimulation research. Part I: Critical commentaries of the literature

There are several parameters that can be modulated during electrical stimulation-induced muscle contraction to obtain external work, i.e., Functional Electrical Stimulation (FES). The literature has several reports of the relationships of parameters such as frequency, pulse width, amplitude and physiological or biomechanical outcomes (i.e., torque) when these parameters are changed. While these relationships are well-described, lesser known across the literature is how changing the duty cycle (time ON and time OFF) of stimulation affects the outcomes. This review provides an analysis of the literature pertaining to the duty cycle in electrical stimulation experiments. There are two distinct sections of this review - an introduction to the duty cycle and definitions from literature (part I); and contentions from the literature and proposed frameworks upon which duty cycle can be interpreted (part II). It is envisaged that the two reviews will highlight the importance of modulating the duty cycle in terms of muscle fatigue in mimicking physiological activities. The frameworks provided will ideally assist in unifying how researchers consider the duty cycle in electrical stimulation (ES) of muscles.

Patient-Specific Simulated Dynamics After Total Knee Arthroplasty Correlate With Patient-Reported Outcomes

BACKGROUND

Component alignment variation following total knee arthroplasty (TKA) does not fully explain the instance of long-term postoperative pain. Joint dynamics following TKA vary with component alignment and patient-specific musculoskeletal anatomy. Computational simulations allow joint dynamics outcomes to be studied across populations. This study aims to determine if simulated postoperative TKA joint dynamics correlate with patient-reported outcomes.

METHODS

Landmarking and 3D registration of implants was performed on 96 segmented postoperative computed tomography scans of TKAs. A cadaver rig-validated platform for generating patient-specific simulation of deep knee bend kinematics was run for each patient. Resultant dynamic outcomes were correlated with a 12-month postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS). A Classification and Regression Tree (CART) was used for determining nonlinear relationships.

RESULTS

Nonlinear relationships between the KOOS pain score and rollback and dynamic coronal alignment were found to be significant. Combining a dynamic coronal angular change from extension to full flexion between 0° and 4° varus (long leg axis) and measured rollback of no more than 6 mm without rollforward formed a "kinematic safe zone" of outcomes in which the postoperative KOOS score is 10.5 points higher (P = .013).

CONCLUSION

The study showed statistically significant correlations between kinematic factors in a simulation of postoperative TKA and postoperative KOOS scores. The presence of a dynamic safe zone in the data suggests a potential optimal target for any given individual patient's joint dynamics and the opportunity to preoperatively determine a patient-specific alignment target to achieve those joint dynamics.

Light treatments of nail fungal infections

Nail fungal infections are notoriously persistent and difficult to treat which can lead to severe health impacts, particularly in the immunocompromized. Current antifungal treatments, including systemic and topical drugs, are prolonged and do not effectively provide a complete cure. Severe side effects are also associated with systemic antifungals, such as hepatotoxicity. Light treatments of onychomycosis are an emerging therapy that has localized photodynamic, photothermal or photoablative action. These treatments have shown to be an effective alternative to traditional antifungal remedies with comparable or better cure rates achieved in shorter times and without systemic side effects. This report reviews significant clinical and experimental studies in the field, highlighting mechanisms of action and major effects related to light therapy; in particular, the impact of light on fungal genetics.

Patient Variation Limits Use of Fixed References for Femoral Rotation Component Alignment in Total Knee Arthroplasty

BACKGROUND

Optimal rotational alignment of the femoral component is a common goal during total knee arthroplasty. The posterior condylar axis (PCA) is thought to be the most reproducible reference in surgery, while the transepicondylar axis (TEA) seems to better approximate the native kinematic flexion axis. This study sought to determine if rules based on patient gender or coronal alignment could allow reliable reproduction of the TEA from the PCA.

METHODS

Three-dimensional models based on preoperative computed tomography were made representing a patient's arthritic knee joint. The landmarks were defined and angular relationships determined.

RESULTS

The population group of 726 patients contained large anatomic variation. When applying the standard reference rule of 3° external rotation from the PCA, 36.9% of patients would have a rotational target greater than ±2° from their TEA. When applying the mean external rotation of the TEA from the PCA (1.85°) from this population, this proportion dropped to 26.0% of patients. The use of statistically significant gender and coronal alignment relationships to define the femoral rotation did not reduce the proportion of patients in ±2° error.

CONCLUSION

This study shows that gender and coronal alignment relationships to the TEA to PCA angle are not clinically significant as a quarter of patients would still have a target for rotation greater than ±2° from the TEA using these relationships. Superior tools for orienting rotational cuts directly to the TEA in surgery or preoperative identification of relevant patient-specific angles might capture the proportion of patients for whom standard reference angles are not appropriate.

The Vienna FES Interview Protocol - A mixed-methods protocol to elucidate the opinions of various individuals responsible for the provision of FES exercise

Functional Electrical Stimulation (FES) is the production of electrically elicited muscle contractions to perform a function or task. It has been used as a method to regain lost body functions or support weak body functions, and as such, has been clinically available since the early seventies. Some methods are applied routinely while others have not been translated to the bedside, or are still largely restricted to laboratory use. Progress in this field might be achieved by a strong cooperation of patients, clinicians, therapists and engineers. A better insight into multiple perspectives may help in understanding the shortcomings of current FES technology. This will help direct future research efforts into design of systems and potential application in relevant populations. In addition, these findings can assist with the translation of FES technology into a community context. We outline an interview protocol designed for use at the 12th Vienna International Workshop on Functional Electrical Stimulation where the mentioned experts from the field of FES met.

A plasma-sprayed titanium proximal coating reduces the risk of periprosthetic femoral fracture in cementless hip arthroplasty

BACKGROUND

The design of femoral component used in total hip arthroplasty is known to influence the incidence of periprosthetic femoral fractures (PFFs) in cementless hip arthroplasty.

OBJECTIVE

This study was undertaken to determine if 2 potential changes to an existing ABG II-standard cementless implant - addition of a roughened titanium plasma-sprayed proximal coating (ABG II-plasma) and lack of medial scales (ABG II-NMS) could decrease the risk of PFF in the intraoperative and early postoperative periods.

METHODS

Six pairs of human cadaveric femurs were harvested and divided into 2 groups, each receiving either of the altered implants and ABG II-standard (control). Each implant was tested in a biomechanical setup in a single-legged stance orientation. Surface strains were measured in intact femurs, during implant insertion, cyclic loading of the bone with the implant, and loading to failure. Strains with the ABG II-standard and the altered implants were compared.

FINDINGS

ABG II-plasma showed better load-bearing capacity, with an average 42% greater failure load than that of ABG II-standard. The cortical hoop, axial and mean strains ABG II-plasma were less than those of ABG II-standard, demonstrating decreased tensile behaviour and better load transfer to the proximal femur. The final residual hoop strains in ABG II-plasma were closer to those of intact bone as compared to the standard stem. No differences in strains were observed between the standard stem and ABG II-NMS.

CONCLUSION

The increased load-bearing capacity and decreased proximal surface strains on femurs implanted with ABG II-plasma stem should reduce the risks of intraoperative and early postoperative PFF.

Biomechanical optimization of subject-specific implant positioning for femoral head resurfacing to reduce fracture risk

Peri-prosthetic femoral neck fracture after femoral head resurfacing can be either patient-related or surgical technique-related. The study aimed to develop a patient-specific finite element modelling technique that can reliably predict an optimal implant position and give minimal strain in the peri-prosthetic bone tissue, thereby reducing the risk of peri-prosthetic femoral neck fracture. The subject-specific finite element modelling was integrated with optimization techniques including design of experiments to best possibly position the implant for achieving minimal strain for femoral head resurfacing. Sample space was defined by varying the floating point to find the extremes at which the cylindrical reaming operation actually cuts into the femoral neck causing a notch during hip resurfacing surgery. The study showed that the location of the maximum strain, for all non-notching positions, was on the superior femoral neck, in the peri-prosthetic bone tissue. It demonstrated that varus positioning resulted in a higher strain, while valgus positioning reduced the strain, and further that neutral version had a lower strain.

Fabrication of Semiordered Nanopatterned Diamond-like Carbon and Titania Films for Blood Contacting Applications

Biomaterials with the ability to interface with, but not activate, blood components are essential for a multitude of medical devices. Diamond-like carbon (DLC) and titania (TiO2) have shown promise for these applications; however, both support platelet adhesion and activation. This study explored the fabrication of nanostructured DLC and TiO2 thin film coatings using a block copolymer deposition technique that produced semiordered nanopatterns with low surface roughness (5-8 nm Rrms). These surfaces supported fibrinogen and plasma protein adsorption that predominantly adsorbed between the nanofeatures and reduced the overall surface roughness. The conformation of the adsorbed fibrinogen was altered on the nanopatterned surfaces as compared with the planar surfaces to reveal higher levels of the platelet binding region. Planar DLC and TiO2 coatings supported less platelet adhesion than nanopatterned DLC and TiO2. However, platelets on the nanopatterned DLC coatings were less spread indicating a lower level of platelet activation on the nanostructured DLC coatings compared with the planar DLC coatings. These data indicated that nanostructured DLC coatings may find application in blood contacting medical devices in the future.

A dynamic perfusion bioreactor approach for engineering respiratory tissues in-vitro

In vitro culture of respiratory tissues poses many challenges due to the intrinsic complexity of the respiratory system. Multiple cellular phenotypes comprise the respiratory epithelium and operate under dynamic, gas-interchanging conditions that should be replicated for near-physiologic cultivation of functional tissues in vitro. A novel biomimetic perfusion bioreactor system has been proposed to reconstitute key functional conditions of the human lung. This portable system consists of several biologically-inspired components: (i) a 3-dimensional (3-D) elastomeric soft tissue scaffold construct, (ii) a mechanical actuator, (iii) a perfusion system and (iv) gaseous exchange capabilities. These integrated components operate synergistically to create a unique, dynamic air-liquid interface (ALI) environment that allows controlled application of physiological and pathological strain while complementing standard cell culture techniques. This system holds potential for engineering 3-D tissues to meet growing demand for a range of applications, from more ethical and efficient pharmaceutical screening to clinical graft transplants.

Subject specific finite element modeling of periprosthetic femoral fracture using element deactivation to simulate bone failure

Subject-specific finite element (FE) modeling methodology could predict peri-prosthetic femoral fracture (PFF) for cementless hip arthoplasty in the early postoperative period. This study develops methodology for subject-specific finite element modeling by using the element deactivation technique to simulate bone failure and validate with experimental testing, thereby predicting peri-prosthetic femoral fracture in the early postoperative period. Material assignments for biphasic and triphasic models were undertaken. Failure modeling with the element deactivation feature available in ABAQUS 6.9 was used to simulate a crack initiation and propagation in the bony tissue based upon a threshold of fracture strain. The crack mode for the biphasic models was very similar to the experimental testing crack mode, with a similar shape and path of the crack. The fracture load is sensitive to the friction coefficient at the implant-bony interface. The development of a novel technique to simulate bone failure by element deactivation of subject-specific finite element models could aid prediction of fracture load in addition to fracture risk characterization for PFF.

Subject-specific finite element model with an optical tracking system in total hip replacement surgery

Intra-operative peri-prosthetic femoral fractures are a significant concern in total hip arthroplasty and can occur at any time during surgery, with the highest incidence during implant insertion. This study combines subject-specific finite element analysis modeling with an optical tracking system to characterize the resultant strain in the bone and results of impaction during total hip replacement surgery. The use of ABG II femoral stem (Stryker Orthopaedics, Mahwah, NJ, USA) in the model yielded the following results. Hammer velocity was measured experimentally using a three-dimensional optical tracking system and these data were input into the finite element analysis model so that intra-operative loading scenario could be simulated. A quasi-static explicit simulation and a dynamic loading step using two implant-bone interface friction (0.1 and 0.4 friction coefficients) states were simulated. The maximum swing velocity of a mallet was experimentally measured at 1.5 m/s and occurred just before impaction of the hammer with implant introducer. Two friction states resulted in different results with the lower friction coefficient generating higher strains in the anterior regions of the model and higher displacement of the implant with respect to the femur when compared to the high friction state.

Cellular Response to Doping of High Porosity Foamed Alumina with Ca, P, Mg, and Si

Foamed alumina was previously synthesised by direct foaming of sulphate salt blends varying ammonium mole fraction (AMF), foaming heating rate and sintering temperature. The optimal product was produced with 0.33AMF, foaming at 100 °C/h and sintering at 1600 °C. This product attained high porosity of 94.39%, large average pore size of 300 µm and the highest compressive strength of 384 kPa. To improve bioactivity, doping of porous alumina by soaking in dilute or saturated solutions of Ca, P, Mg, CaP or CaP + Mg was done. Saturated solutions of Ca, P, Mg, CaP and CaP + Mg were made with excess salt in distilled water and decanted. Dilute solutions were made by diluting the 100% solution to 10% concentration. Doping with Si was done using the sol gel method at 100% concentration only. Cell culture was carried out with MG63 osteosarcoma cells. Cellular response to the Si and P doped samples was positive with high cell populations and cell layer formation. The impact of doping with phosphate produced a result not previously reported. The cellular response showed that both Si and P doping improved the biocompatibility of the foamed alumina.

Physical and mechanical characterisation of 3D-printed porous titanium for biomedical applications

The elastic modulus of metallic orthopaedic implants is typically 6-12 times greater than cortical bone, causing stress shielding: over time, bone atrophies through decreased mechanical strain, which can lead to fracture at the implantation site. Introducing pores into an implant will lower the modulus significantly. Three dimensional printing (3DP) is capable of producing parts with dual porosity features: micropores by process (residual pores from binder burnout) and macropores by design via a computer aided design model. Titanium was chosen due to its excellent biocompatibility, superior corrosion resistance, durability, osteointegration capability, relatively low elastic modulus, and high strength to weight ratio. The mechanical and physical properties of 3DP titanium were studied and compared to the properties of bone. The mechanical and physical properties were tailored by varying the binder (polyvinyl alcohol) content and the sintering temperature of the titanium samples. The fabricated titanium samples had a porosity of 32.2-53.4% and a compressive modulus of 0.86-2.48 GPa, within the range of cancellous bone modulus. Other physical and mechanical properties were investigated including fracture strength, density, fracture toughness, hardness and surface roughness. The correlation between the porous 3DP titanium-bulk modulus ratio and porosity was also quantified.

Osteoblast attachment to hydroxyapatite micro-tube scaffolds

Tissue engineering offers a novel route for repairing damaged or diseased tissue by incorporating the patient's own healthy cells or donated cells into temporary scaffolds that act as a matrix for cell cultivation. Tissue scaffolds that are biocompatible and are porous with interconnected porous channels for cell ingrowth with a suitable degradation rate would be advantageous. In this study hydroxyapatite micro-tubes produced using the biomimetic coating technique will be pressed into a tissue scaffold. A compaction and sintering study will be done to observe appropriate pressure and heat treatment to produce a mechanically stable scaffold material. The ideal pressure was found to be 2.5 MPa where the tube-like structure was maintained, high porosity was achieved and suitable strength was possible. Sintering between 1,000 and 1,100 °C was found to produce good results. The average porosity for the chosen pressure of 2.5 MPa was 68%. The scaffold was observed with SEM, micro tomography (micro-CT), chemical analysis and degradation testing. Porous channels were established using micro-CT where the porous channels were roughly 100 µm. Chemical analysis showed constant release of calcium and phosphorous, and far below toxic levels of heavy metals from the die. Degradation testing showed high degradation compared to tested commercially available materials. Cell culturing was done on the scaffold to characterise the biological performance of the scaffolds. Cell culturing was done in a 7 and 24 day cell culture to examine cell morphology and cell ingrowth. The results showed cell ingrowth into a micro-tube and cell orientation in a longitudinal direction. SEM, confocal microscopy and histology were employed as characterisation tools for observing cell ingrowth.

Spatial control of bone formation using a porous polymer scaffold co-delivering anabolic rhBMP-2 and anti-resorptive agents

Current clinical delivery of recombinant human bone morphogenetic proteins (rhBMPs) utilises freeze-dried collagen. Despite effective new bone generation, rhBMP via collagen can be limited by significant complications due to inflammation and uncontrolled bone formation. This study aimed to produce an alternative rhBMP local delivery system to permit more controllable and superior rhBMP-induced bone formation. Cylindrical porous poly(lactic-co-glycolic acid) (PLGA) scaffolds were manufactured by thermally-induced phase separation. Scaffolds were encapsulated with anabolic rhBMP-2 (20 µg) ± anti-resorptive agents: zoledronic acid (5 µg ZA), ZA pre-adsorbed onto hydroxyapatite microparticles, (5 µg ZA/2% HA) or IkappaB kinase (IKK) inhibitor (10 µg PS-1145). Scaffolds were inserted in a 6-mm critical-sized femoral defect in Wistar rats, and compared against rhBMP-2 via collagen. The regenerate region was examined at 6 weeks by 3D microCT and descriptive histology. MicroCT and histology revealed rhBMP-induced bone was more restricted in the PLGA scaffolds than collagen scaffolds (-92.3% TV, p < 0.01). The regenerate formed by PLGA + rhBMP-2/ZA/HA showed comparable bone volume to rhBMP-2 via collagen, and bone mineral density was +9.1% higher (p < 0.01). Local adjunct ZA/HA or PS-1145 significantly enhanced PLGA + rhBMP-induced bone formation by +78.2% and +52.0%, respectively (p ≤ 0.01). Mechanistically, MG-63 human osteoblast-like cells showed cellular invasion and proliferation within PLGA scaffolds. In conclusion, PLGA scaffolds enabled superior spatial control of rhBMP-induced bone formation over clinically-used collagen. The PLGA scaffold has the potential to avoid uncontrollable bone formation-related safety issues and to customise bone shape by scaffold design. Moreover, local treatment with anti-resorptive agents incorporated within the scaffold further augmented rhBMP-induced bone formation.

Modulation of anabolic and catabolic responses via a porous polymer scaffold manufactured using thermally induced phase separation

We describe two studies encompassing the iterative refinement of a polymer-based rhBMP-2 delivery system for bone tissue engineering. Firstly, we compared the bone-forming capacity of porous poly(D,L-lactic-co-glycolic acid) (PLGA) scaffolds produced by thermally induced phase separation (TIPS) with non-porous solvent cast poly(D,L-lactic acid) (PDLLA) used previously. Secondly, we examined the potential synergy between rhBMP-2 and local bisphosphonate in the PLGA scaffold system. In vivo ectopic bone formation studies were performed in C57BL6/J mice. Polymer scaffolds containing 0, 5, 10 or 20 µg rhBMP-2 were inserted into the dorsal musculature. At all rhBMP-2 doses, porous PLGA produced significantly higher bone volume (BV, mm3) than the solid PDLLA scaffolds. Next, porous PLGA scaffolds containing 10 µg rhBMP-2 ± 0.2, or 2 µg zoledronic acid (ZA) were inserted into the hind-limb musculature. Co-delivery of local 10 µg rhBMP-2/2 µg ZA significantly augmented bone formation compared with rhBMP-2 alone (400 % BV increase, p < 0.01). Hydroxyapatite microparticle (HAp) addition (2 % w/w) to the 10 µg rhBMP-2/0.2 µg ZA group increased BV (200 %, p < 0.01). We propose that this was due to controlled ZA release of HAp-bound ZA. Consistent with this, elution analyses showed that HAp addition did not alter the rhBMP-2 elution, but delayed ZA release. Moreover, 2 % w/w HAp addition reduced the scaffold's compressive properties, but did not alter ease of surgical handling. In summary, our data show that refinement of the polymer selection and scaffold fabrication can enhance rhBMP-2 induced bone formation in our bone tissue engineering implant, and this can be further optimised by the local co-delivery of ZA/HAp.

Use of BMPs and bisphosphonates in improving bone fracture healing

In orthopaedics, focus is often placed on increasing bone formation by an anabolic drug like the recombinant human bone morphogenetic protein (rhBMP). However, premature or excessive bone resorption, due to stress-shielding, instability or infection/inflammation can lead to poor, delayed, or absent bone union. Anti-catabolic drugs such as bisphosphonates have therefore been explored to improve bone repair. This short review discusses the current literature underlying the anabolic-catabolic paradigm for bone repair with a focus on BMP and bisphosphonate combination approaches.

In vivo local co-delivery of recombinant human bone morphogenetic protein-7 and pamidronate via poly-D, L-lactic acid

The effects of bone anabolic agents such as bone morphogenetic proteins (BMPs) have the potential to be augmented by co-treatment with an anti-catabolic such as a bisphosphonate. We hypothesised that the effects of bisphosphonates on BMP-induced bone anabolism would be dose dependent, and we aimed to test this in a small animal model. Agents were delivered locally using a biodegradable poly-D, L-lactic-acid (PDLLA) polymer delivery system. Recombinant human BMP-7 (25 µg) was tested with a range of doses of the bisphosphonate pamidronate (0.02 mg, 0.2 mg and 2 mg local PAM; 0.3 mg/kg and 3 mg/kg thrice-weekly systemic PAM) versus BMP-7 alone. Polymer pellets were surgically implanted in the hind limbs of female C57BL6/J mice (8-10 week) and ectopic bone nodules were harvested at 3 and 8 weeks post-operatively. At 3 weeks, local low dose PAM (0.02 mg) induced a 102% increase in rhBMP-7 induced bone volume (p<0.01) as measured by miroCT, and this was comparable to systemic PAM (0.3 mg/kg thrice-weekly). In contrast, local high dose PAM (2 mg) resulted in a 97% decrease in bone volume (p<0.01). Radiography and histology indicated that the polymer vehicle was still largely present at 8 weeks indicating inefficient biodegradation. This is the first study to validate the utility of local co-delivery of BMP/bisphosphonate via biodegradable polymer and supports the continued refinement of more advanced bioresorbable delivery systems for clinical applications.

Biodegradable poly(alpha-hydroxy acid) polymer scaffolds for bone tissue engineering

Synthetic graft materials are emerging as a viable alternative to autogenous bone graft and bone allograft for the treatment of critical-sized bone defects. These materials can be osteoconductive but are rarely intrinsically osteogenic, although this can be greatly enhanced by the application of bone morphogenetic proteins (BMPs). This review will discuss the versatility of biodegradable poly(alpha-hydroxy acids) for the delivery of BMPs for bone tissue engineering. Poly(alpha-hydroxy acids) have a considerable potential for customization and adaptability via modification of design parameters, including scaffold architecture, composition, and biodegradability. Different fabrication techniques will also be discussed.

Rapid cell culture and pre-clinical screening of a transforming growth factor-beta (TGF-beta) inhibitor for orthopaedics

Background

Transforming growth factor-β (TGF-β) and bone morphogenetic proteins (BMPs) utilize parallel and related signaling pathways, however the interaction between these pathways in bone remains unclear. TGF-β inhibition has been previously reported to promote osteogenic differentiation in vitro, suggesting it may have a capacity to augment orthopaedic repair. We have explored this concept using an approach that represents a template for the testing of agents with prospective orthopaedic applications.

Methods

The effects of BMP-2, TGF-β1, and the TGF-β receptor (ALK-4/5/7) inhibitor SB431542 on osteogenic differentiation were tested in the MC3T3-E1 murine pre-osteoblast cell line. Outcome measures included alkaline phosphatase staining, matrix mineralization, osteogenic gene expression (Runx2, Alp, Ocn) and phosphorylation of SMAD transcription factors. Next we examined the effects of SB431542 in two orthopaedic animal models. The first was a marrow ablation model where reaming of the femur leads to new intramedullary bone formation. In a second model, 20 μg rhBMP-2 in a polymer carrier was surgically introduced to the hind limb musculature to produce ectopic bone nodules.

Results

BMP-2 and SB431542 increased the expression of osteogenic markers in vitro, while TGF-β1 decreased their expression. Both BMP-2 and SB431542 were found to stimulate pSMAD1 and we also observed a non-canonical repression of pSMAD2. In contrast, neither in vivo system was able to provide evidence of improved bone formation or repair with SB431542 treatment. In the marrow ablation model, systemic dosing with up to 10 mg/kg/day SB431542 did not significantly increase reaming-induced bone formation compared to vehicle only controls. In the ectopic bone model, local co-administration of 38 μg or 192 μg SB431542 did not increase bone formation.

Conclusions

ALK-4/5/7 inhibitors can promote osteogenic differentiation in vitro, but this may not readily translate to in vivo orthopaedic applications.

Bisphosphonate-laden acrylic bone cement: mechanical properties, elution performance, and in vivo activity

Cemented total hip replacements generally fail after 10-20 years, often due to implant loosening from bone resorption. Bisphosphonates such as zoledronic acid (ZA) and pamidronate (PAM) are potent inhibitors of bone resorption. The local delivery of bisphosphonates via acrylic bone cement could decrease osteolysis and prolong implant lifespan. Conflicting studies suggest that bisphosphonate loading may or may not reduce the mechanical properties of acrylic bone cement. We assayed acrylic bone cement laden with ZA or PAM at different concentrations and diluent volumes. Four-point bend testing and compressive testing indicated that high volumes of diluent (with or without bisphosphonate) significantly reduced bending modulus and compressive strength. Radiography and electron microscopy indicated that high diluent volumes generated abnormal acrylic bone cement structure. After 6 weeks of incubation in saline, only 0.9% w/w of the total bisphosphonate incorporated in acrylic bone cement eluted in vitro, indicating a slow elution rate. In vivo testing was performed using a rat model. Cement cylinders were inserted into incisions in rat distal femora and ZA delivered locally (via elution from acrylic bone cement) or systemically (via injection). At 4 weeks postoperatively, dual energy X-ray absorptiometry demonstrated no significant increase in local bone mineral density (BMD) adjacent to ZA-laden implants. In contrast, systemic ZA delivery (0.1 mg/kg) led to a large (48.6%) and significant increase in BMD. Thus, systemic delivery appears more effective than local delivery.

The influence of surface chemistry and topography on the contact guidance of MG63 osteoblast cells

The purpose of the present study was to determine in vitro the effects of different surface topographies and chemistries of commercially pure titanium (cpTi) and diamond-like carbon (DLC) surfaces on osteoblast growth and attachment. Microgrooves (widths of 2, 4, 8 and 10 microm and a depth of 1.5-2 microm) were patterned onto silicon (Si) substrates using microlithography and reactive ion etching. The Si substrates were subsequently vapor coated with either cpTi or DLC coatings. All surfaces were characterized using atomic force microscopy (AFM), scanning electron microscopy (SEM), X-ray photoelectron spectroscopy (XPS) and contact angle measurements. Using the MG63 Osteoblast-Like cell line, we determined cell viability, adhesion, and morphology on different substrates over a 3 day culture period. The results showed cpTi surfaces to be significantly more hydrophilic than DLC for groove sizes larger than 2 microm. Cell contact guidance was observed for all grooved samples in comparison to the unpatterned controls. The cell viability tests indicated a significantly greater cell number for 8 and 10 microm grooves on cpTi surfaces compared to other groove sizes. The cell adhesion study showed that the smaller groove sizes, as well as the unpatterned control groups, displayed better cell adhesion to the substrate.

DLC coatings: effects of physical and chemical properties on biological response

Recent trials on diamond-like carbon (DLC) coated medical devices have indicated promise for blood interfacing applications. The literature is sparse regarding structural and compositional effects of DLC on cellular response. An important goal in optimizing blood-interfacing implants is minimal macrophage attachment, and maximal albumin:fibrinogen adsorption ratio. DLC coatings deposited by PACVD and FAD, were analysed with respect to sp3 content (EELS), hydrogen content (ERDA), surface composition (XPS), surface roughness (AFM), surface energy, albumin:fibrinogen adsorption ratio, and macrophage viability and attachment. We found that increasing surface roughness and surface energy enhanced the macrophage viability and the albumin:fibrinogen adsorption ratio. We also found that the higher the hydrogen content for a-C:Hs deposited by PACVD, the lower the albumin:fibrinogen adsorption ratio, and macrophage attachment. This suggests that hydrogen content may be an important factor for influencing the biological response of DLC surfaces. Macrophage cells spread well on all DLC surfaces, and the surface results indicated the non-toxic nature of the surfaces on the cells at the time points tested.

Calcium phosphate fibres synthesized from a simulated body fluid

The biomimetic coating method was used for fabricating calcium phosphate fibres for biomedical applications such as bone defect fillers. Natural cotton substrate was pre-treated with phosphorylation and a Ca(OH)2 saturated solution. The pre-treated samples were then soaked in simulated body fluid (SBF) of two different concentrations, 1.5 times and 5.0 times the ion concentration of blood plasma. The cotton was then burnt out via sintering of the ceramic coating at 950 degrees C, 1050 degrees C, 1150 degrees C, and 1250 degrees C. The results demonstrated that osteoblastic cells were able to cover the entire surface cotton fibres, and the cell coverage appeared to be independent of surface roughness and Ca/P ratio of fibres.

Precipitation of hydroxyapatite nanoparticles: effects of precipitation method on electrophoretic deposition

Electrophoretic deposition is a low-cost, simple, and flexible coating method for producing hydroxyapatite (HA) coatings on metal implants with a broad range of thicknesses, from < 1 microm to > 500 microm. As for many other HA coating techniques, densification of electrophoretically deposited coatings involves heating the coated metal to temperatures above 1000 degrees C. Metal substrates tend to react with HA coatings at such temperatures inducing decomposition at temperatures below 1050 degrees C (decomposition for pure HA normally occurs above 1300 degrees C). Therefore, densification of these coatings needs to be conducted at temperatures lower than 1050 degrees C, and this necessitates the use of high-surface-area HA nano-precipitates, rather than commercially available pre-calcined powders, which densify at temperatures typically higher than 1200 degrees C. HA nano-precipitates were prepared by three methods and deposited on metal substrates by electrophoresis: (1) the acid base method, which produced plate-like nano-particles with a 2.5:1 aspect ratio, and severely cracked coatings; (2) the calcium acetate method, which produced needle-like nano-particles with a 10:1 aspect ratio, and slightly cracked coatings; (3) the metathesis method, which produced rounded nano-particles with a 2:1 aspect ratio, and high-quality crack-free coatings. The results suggested that the less equiaxed the nano-particles, the more cracked the coatings obtained by the electrophoretic deposition technique.

Hydroxyapatite-coated metals: interfacial reactions during sintering

Electrophoretic deposition (EPD) is a low cost flexible process for producing HA coatings on metal implants. Its main limitation is that it requires heating the coated implant in order to densify the HA. HA typically sinters at a temperature below 1150 degrees C, but metal implants are degraded above 1000 degrees C. Further, the metal induces the decomposition of the HA coating upon sintering. Recent developments have enabled EPD of metathesis-synthesised uncalcined HA which sinters at approximately 1000 degrees C. The effects of temperature on HA-coated Ti, Ti6Al4V, and 316L stainless steel were investigated for dual coatings of metathesis HA sintered at 1000 degrees C. The use of dual HA coatings (coat, sinter, coat, sinter) enabled decomposition to be confined to the "undercoat" (HA layer 1), with the surface coating decomposition free. The tensile strength of the three metals was not significantly affected by the high sintering temperatures (925 degrees C < T < 1000 degrees C). XRD/SEM/EDS analyses of the interfacial zones revealed that 316L had a negligible HA:metal interfacial zone (approximately 1 microm) while HA:Ti and HA:Ti6Al4V had large interfacial zones (>10 microm) comprising a TiO2 oxidation zone and a CaTiO2 reaction zone.

Interfacial bond strength of electrophoretically deposited hydroxyapatite coatings on metals

Hydroxyapatite (HAp) coatings were deposited onto substrates of metal biomaterials (Ti, Ti6Al4V, and 316L stainless steel) by electrophoretic deposition (EPD). Only ultra-high surface area HAp powder, prepared by the metathesis method 10Ca(NO3)2 + 6(NH4)2HPO4 + 8NH4OH), could produce dense coatings when sintered at 875-1000degreesC. Single EPD coatings cracked during sintering owing to the 15-18% sintering shrinkage, but the HAp did not decompose. The use of dual coatings (coat, sinter, coat, sinter) resolved the cracking problem. Scanning electron microscopy/energy dispersive spectroscopy (SEM/EDS) inspection revealed that the second coating filled in the "valleys" in the cracks of the first coating. The interfacial shear strength of the dual coatings was found, by ASTM F1044-87, to be approximately 12 MPa on a titanium substrate and approximately 22 MPa on 316L stainless steel, comparing quite favorably with the 34 MPa benchmark (the shear strength of bovine cortical bone was found to be 34 MPa). Stainless steel gave the better result since -316L (20.5 microm mK(-1)) > alpha-HAp (approximately 14 microm mK(-1)), resulting in residual compressive stresses in the coating, whereas alpha-titanium (approximately 10.3 microm mK(-1)) < alpha-HAp, resulting in residual tensile stresses in the coating.

Solution ripening of hydroxyapatite nanoparticles: effects on electrophoretic deposition

Electrophoretic deposition is a low-cost, simple, and flexible coating method for producing hydroxyapatite (Hap) coatings on metal implants. However, densification requires heating the coated metal to high temperatures, which, for commercial HAp powders, generally means at least 1200 degrees C. At such temperatures, the metal tends to react with the HAp coating, inducing decomposition, and the strength of titanium and stainless steel implants is severely degraded. With the use of raw uncalcined nanoparticulate Hap, densification can occur at 900 degrees -1050 degrees C; however, such coatings are prone to cracking due to the high drying shrinkage. This problem was solved by precipitating nanoparticulate HAp by the metathesis process [10Ca(NO3)2 + 6NH4H2PO4 + 8NH4OH] and optimizing the approximately 30 nm of nanoprecipitates by an Ostwald ripening approach, that is, by boiling and/or ambient aging in the mother liquor. While the as-precipitated nanoparticles produced severely cracked coatings, 2 h of boiling or 10 days of ambient aging ripened the "gel-like" mass into unagglomerated nanoparticles, which produced crack-free coatings. Since boiling enhanced particle size but ambient aging did not, crack elimination probably was due to the transition from the highly agglomerated gel-like state to the dispersed nanoparticulate state rather than to particle growth. Furthermore, boiling only reduced the amount of cracking whereas aging completely eliminated cracking.

Solution ripening of hydroxyapatite nanoparticles: effects on electrophoretic deposition

Electrophoretic deposition is a low-cost, simple, and flexible coating method for producing hydroxyapatite (Hap) coatings on metal implants. However, densification requires heating the coated metal to high temperatures, which, for commercial HAp powders, generally means at least 1200 degrees C. At such temperatures, the metal tends to react with the HAp coating, inducing decomposition, and the strength of titanium and stainless steel implants is severely degraded. With the use of raw uncalcined nanoparticulate Hap, densification can occur at 900 degrees -1050 degrees C; however, such coatings are prone to cracking due to the high drying shrinkage. This problem was solved by precipitating nanoparticulate HAp by the metathesis process [10Ca(NO3)2 + 6NH4H2PO4 + 8NH4OH] and optimizing the approximately 30 nm of nanoprecipitates by an Ostwald ripening approach, that is, by boiling and/or ambient aging in the mother liquor. While the as-precipitated nanoparticles produced severely cracked coatings, 2 h of boiling or 10 days of ambient aging ripened the "gel-like" mass into unagglomerated nanoparticles, which produced crack-free coatings. Since boiling enhanced particle size but ambient aging did not, crack elimination probably was due to the transition from the highly agglomerated gel-like state to the dispersed nanoparticulate state rather than to particle growth. Furthermore, boiling only reduced the amount of cracking whereas aging completely eliminated cracking.

Sintering effects on the strength of hydroxyapatite

Mechanisms underlying temperature-strength interrelations for dense (> 95% dense, pores closed) hydroxyapatite (HAp) were investigated by comparative assessment of temperature effects on tensile strength, Weibull modulus, apparent density, decomposition (HAp:tricalcium phosphate ratio), dehydroxylation and microstructure. Significant dehydroxylation occurred above approximately 800 degrees C. Strength peaked at approximately 80 MPa just before the attainment of closed porosity (approximately 95% dense). For higher temperatures (closed porosity), the strength dropped sharply to approximately 60 MPa due to the closure of dehydroxylation pathways, and then stabilized at approximately 60 MPa. At very high temperatures (> 1350 degrees C), the strength dropped catastrophically to approximately 10 MPa corresponding to the decomposition of HAp to tricalcium phosphate and the associated sudden release of the remaining bonded water.