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Osseointegration of Orthopaedic Implants
Osseointegration of Orthopaedic Implants
Osseointegration of Orthopaedic Implants
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Osseointegration of Orthopaedic Implants

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Osseointegration of Orthopaedic Implants helps product developers at orthopedic implant manufacturers enhance the effectiveness of orthopedic implants and reduce complications, particularly in patients with osteoporotic bones. The book's expert contributors provide cutting-edge information on the latest technologies and advances available. Biomaterial researchers can use the book for basic data in the further development of orthopedic implant materials with better osseointegration. Biomechanical researchers can review related challenges and concepts of osseointegration for use in the development of implants. The book is suitable for readers from academia and industry, bridging the knowledge gap between academic based researchers, industrial based engineers, and clinical based surgeons.

  • Reviews and discusses all aspects of orthopedic implant osseointegration
  • Provides conceptual implants for bone fracture fixation and joint replacement
  • Offers novel ideas for the development of orthopedic implants with superior osseointegration
LanguageEnglish
Release dateMar 16, 2019
ISBN9780128133958
Osseointegration of Orthopaedic Implants
Author

Amirhossein Goharian

Amirhossein Goharian is a Senior Engineer working in the orthopedic implant industry. He earned his Bachelor’s degree from the University of Kashan in 2007, and his completed his Master’s in Mechanical Engineering in Biomechanics at the University Technology Malaysia (UTM) in 2012. He joined the R&D department of LEONIX Sdn. Bhd., Penang, Malaysia, in 2012, rising to Senior R&D Leader in Jan 2015. In 2017, he joined Isfahan Orthopedic Implant Development Co., an orthopedic implant manufacturer in Isfahan, Iran, as the QA-R&D leader until Sep 2020. Since then, he has been developing innovations in the field of orthopedic implants, based on ideas set out in his published work. Goharian has previously published three books with Elsevier, covering trauma plating systems, osseointegration and surface engineering of orthopedic implants.

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    Osseointegration of Orthopaedic Implants - Amirhossein Goharian

    industry.

    Preface

    Historically, integration of the implant to the bone tissue has been a major challenge for effective internal implantation. Due to the compact and high mechanical properties of the cortical bone, gripping of the implant to the cortical segment of the bone would be achievable. In fact, cortical bone acts as the tough material to secure fixation of the implant. However, tapping of the implant to the cortical bone might be affected by physiological dynamic loading conditions which would be created through normal daily activities. In some cases, the thickness of the cortical bone is not sufficiently large to provide effective tapping or gripping of the implant for long-term resistance to dynamic shear stress between the bone and the implant. Furthermore, tapping strength of the implant to the low mineral density bone would be significantly reduced compared to the natural compact cortical bone. The risk of implant migration, loosening, or dislocation is increased in cases with poor or ineffective tapping of the implant to the cortical bone. In majority of the implantations, the implant is purchased through both the cortical and the trabecular bone. Purchasing through the cortical bone would provide fixation strength while purchasing through the trabecular bone would enhance stability of the implantation. Integration of the implant with trabecular bone would be crucial to enhance the shear strength at the interface of bone-implant. The trabecular bone is highly affected after the implantation of an artificial device and the rate of the bone resorption at the peri-implant zone is significant. The response of cortical bone at the peri-implant zone is thickening of the cortical section of the bone tissue. Therefore, enhancement of osseointegration of the implant at the trabecular bone is greatly crucial for effective and long-term implantation of the orthopedic implants. Nowadays, various types of processing methods are utilized to enhance the bioactivity of the implant surfaces which are in direct contact with the bone, particularly trabecular bone. In majority of these methods, an osseoconductive layer or structure is established to conduct the adherence of osteogenic cells and the growth factors, thus its proliferation and differentiation on the implant surface. This conductivity would be enhanced with flow of blood through the osseoconductive layer for mineralization and maturation of the created osteocyte cells to be formed as woven bone tissue and ultimately as lamellar bone. The concepts of osseointegration in various types of orthopedic implants might be different in some specific aspects. According to the type of implantation and treatment of bone injuries, integration of the bone and implant would have specific mechanical and biological considerations. For instance, in placement of cementless prosthesis in total replacements, thickness of osseoconductive layer in microscale on the implant surface is desired, while in placement of titanium (Ti)-coated fusion cages in spinal fusion surgery, thickness in the nanoscale with higher adhesion strength is advantageous. Thus, such biological and mechanical requirements would necessitate various types of processing methods for the creation of osseoconductive or osseointegrated layer on the surface of the implant.

    With consideration of various aspects of osseointegration in orthopedic implants, having a compact book in this topic has been found necessary to be written to review, discuss, and challenge the current concepts of osseointegration in the development of orthopedic implants which is now available as Osseointegration of Orthopedic Implants. In first section, the fundamental of osseointegration along with implant loosening are expressed to clarify the main concepts of osseointegration of orthopedic implants. Likewise, the effective mechanical and biological parameters that would influence the promotion or deterioration of the osseointegration are explained. In the second section, the orthopedic implants (categorized as trauma fracture fixation implants, total joint replacements, spinal implants, and bone tissue scaffolds) are presented in general characteristics along with specific aspects of osseointegration in each category of the implants. The concepts of osseoconductivity are reviewed in third section to explore the development challenges for enhancement of osseointegration. Based on the explored aspects of osseoconductivity, the main industrial processing techniques that are utilized commercially or has potential advantages to be marketed, are reviewed and discussed afterwards. Coating or layering of bioactive or osseoconductive materials on the surface of the orthopedic implants are currently two main techniques for enhancement of the osseointegration. Expression of these techniques along with their challenging aspects and long-term effectiveness are provided in this section. In the final section, conception of the osseointegration in the development process of the orthopedic implants is represented. In this section, the involved mechanical, biological, and clinical aspects of the bone-implant integration are deeply elaborated to provide comprehensive outlook of bioactivity enhancement of the implant in contact surfaces with the bone. Furthermore, engineering aspects of osseointegration in conjunction with evaluation methods are discussed to explore the effects of processing and testing methods on effectiveness of the osseointegration in real physiological conditions. In the last chapter of the book, the concept of transition layer as the new technique of osseointegration enhancement is presented and discussed from which some novel ideas (e.g., bulk-porous transition layer, transition-osseoconductive transition layer, and Mg-PEEK transition layer) have been hypothesized.

    Overall, Osseointegration of Orthopedic Implants would be a compact reference for various aspects of the osseointegration and associated development strategies, techniques, and methods for mechanical and biological enhancement of the orthopedic implants in contact surfaces with the bone. This book is recommended to biomedical researchers, mechanobiological investigators, implant developers, and particularly orthopedic and neurospine surgeons to get familiar with osseointegration benefits of the orthopedic implants in the enhancement of clinical outcomes. All relevant audiences and readers are welcome to share their notes and comments with the author via orthoimplant.develop@gmail.com for improvement of the book in the next editions. The author would like to offer technical cooperation in the topic of the book with the institutes which are interested in enhancing the bioactivity characteristics of the orthopedic implants in contact surfaces with the bone.

    Chapter 1

    Fundamentals in Loosening and Osseointegration of Orthopedic Implants

    Abstract

    Various concepts and parameters have been addressed in the literature for the evaluation and assessment of integration between the bone and the implant for implantation of orthopedic implants to the bone tissue. In order to treat the severe bone injuries, losses, fractures, and even deformities, it would be inevitable to use internal implantation of orthopedic implants. Therefore the integration of bone tissue to/through the implant surface is the main concern that is currently being investigated by the researchers and product developers in the development of new generation of orthopedic implants. In this chapter, history of osseointegration concept was first reviewed, and then the effective parameters on integration of bone to the implant were discussed in view of biological and mechanobiological aspects. Poor osseointegration of orthopedic implant is associated with loosening of the implant after implantation to the bone. There would be some factors which originate from the implant that would have significant effect on osseointegration such as contact wear particles, bone loss during implantation, implant design, implant surface roughness, early mechanical integration to the cortical and trabecular bones, etc. It was observed that contact wear particles would induce expression of macrophages to phagocytosis the contact wear particles or any released particles from the implant, from which bone remodeling process is affected. Likewise, damage to the bone tissue during bone drilling and insertion of implant to the bone has been found to be effective parameter in early osseointegration. Furthermore, design feature for early mechanical integration to the bone was reported to influence the early biological integration of bone to the implant. In this chapter, the fundamentals of osseointegration in orthopedic implants and loosening of the implant are deeply reviewed. Reading of this chapter is recommended for effective pursuing of the reviewed contents in the following chapters.

    Keywords

    Osseointegration; Bone-implant integration; Bone-implant interface; Gene expression; Osteoblastic genes; Endosseous concept; Implant loosening

    1.1 Introduction

    The concept of osseointegration was first developed for dental implants to address the in-growth and on-growth of bone tissue to the surface of titanium dental implants. Gradually, this biological advantage was addressed for the development of orthopedic implants and for the evaluation of implant bioactivity aspects. In majority of implantation cases, osseointegration of implant is greatly beneficial; however, there would be some cases at which poor osseointegration is desired. Generally, better osseointegration of implant could enhance implantation of the implant to the bone, which results in better treatment of bone injuries. It has been clinically reported that poor integration of bone and implant would cause loosening of implant or even suppression of the bone to the implant.

    Osseointegration is a scientific term that is going to be of a practical-scientific development concept [1–9]. The understanding of interaction between the bone and the implant has opened various fields of researches and investigations. Undesired biological response of human body after the implantation of implant was the initial side effect of internal treatment utilizing various types of materials in fabrication of implants. Therefore, the standard ISO 10993 was developed to determine the essential biological requirements for the biological evaluation of materials aimed to be used in fabrication of implants. It would be very crucial to assure no biological effects (e.g., toxicity, cytotoxicity, sensitization, and genotoxicity) of implant materials in human body fluid and in contact with bone tissue for the development of orthopedic implants. In fact, implant must be without chemical reaction in ionized body fluid or blood if undesired release of implant materials causes biological signs or symptoms. Other factors such as low bacterial adhesion have also been highlighted to enhance biological safety or biocompatibility of the implant.

    In majority of the implantations, the bonding of the implant to the bone is strongly beneficial. Indeed, good biocompatible implant without enhanced clinical benefits would not be a superior solution for the treatment of bone injuries. It has been observed that without effective bonding or integration of orthopedic implants to the bone tissue, various types of clinical complications arise postoperatively. Thus, bone-implant integration with high level of shear strength under dynamic loading conditions (which is transferred to the bone-implant interfaces) is the key factor of implant stability inside the bone and ultimately enhances clinical outcomes. Ineffective osseointegration of implant and bone may result in loosening or dislocation of the implant from the original implanted location [10–20]. Poor integration of bone and implant may occur because of various reasons. In fact, whatever would affect the bone resorption and deposition process at the bone-implant interface could cause loosening of integrity between the bone and the implant.

    In this chapter, first the history of osseointegration concept is reviewed to clarify how this biological interaction could enhance the clinical results. Then various parameters that could influence the better integration of bone-implant are elaborated. Following that, the differentiation and formation of bone tissue at the bone-implant interface is discussed, then the effective expression of osteoblastic genes in promoting osseointegration is expressed. In second part of this chapter, the loosening of the implant is reviewed from various aspects. The effects of contact wear, the level of mechanical stimulation, and implant-related factors on implant loosening are discussed. Due to high risk of implant loosening in total joint replacements (TJRs), the interaction between the bone cement and the bone is deeply expressed and development concepts that could reduce the risk of implant loosening are highlighted in general.

    1.2 History of Osseointegration

    Osseointegration was first introduced by Professor Per-Ingvar Branemark in the 1950s as the attachment of human bone cells to the surface of metallic implants. Initially, reaction of the bone to the titanium alloy was seen in investigations carried out by Beaton and Davenport in 1940 and Gottlieb Leventhal in 1951. Through their research, potential use of titanium in orthopedic and dental implants has been addressed due to good strength, no body reaction, and growth of bone tissue on the surface of the titanium. In 1952, Per-Ingvar Branemark implanted a titanium chamber to the rabbit bone to investigate the effect of blood flow on progression of bone formation on the surface of the titanium chamber. After completion of the test, when he wanted to remove the chamber, he recognized that the chamber had integrated with bone and could not be removed easily. At that point, he discovered bone growth into the titanium chamber and good integration of bone and titanium implant. After that, he called this phenomenon osseointegration to be used as a material characteristic to be used in the development of implants for the better treatment of bone injuries. Later on in 1965, Branemark developed dental implant using the osseointegration ability of the titanium. Based on the description of Nishimura [5] from Branemark's definition, osseointegration is stable connecting of the bone and implant without sign of infection, inflammation, and clinical undesirable issues. Today, the concept of osseointegration is used extensively in the development of orthopedic, spine, and dental implants to promote bone in-growth and on-growth through the implant. Osseointegration may start with bone resorption at the interface of bone-implant, then formation of bone tissue on the implant surface or through in the implant body, and ultimately integration of the bone and implant at the contact

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