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Use of p-nitrophenyl chloroformate chemistry to immobilize protein on orthopedic biomaterials.

Biochemical surface modification involves covalently immobilizing biomolecules onto biomaterial surfaces to induce specific biological responses. This approach may be useful for enhancing the fixation of orthopedic implants. p-Nitrophenyl chloroformate (p-NPC) was used to immobilize protein on bulk samples of Co-Cr-Mo and Ti-6Al-4V. Activation of both materials was dependent on the concentration of p-NPC, with a maximum of approximately 1.5 active groups/nm2 of nominal surface area. Trypsin was used as a model protein because much is known about its structure and mode of action. Derivatization with 0.65 mg p-NPC/cm2 resulted in significantly greater enzymatic activity (7.4 BAEE [N-(alpha)-benzoyl-L-arginine ethyl ester hydrochloride] units) on the Co-Cr-Mo samples compared with higher concentrations of p-NPC (5 BAEE units) and with simple adsorption of trypsin (1.5 BAEE units). An activity of 10.5 BAEE units was measured on both adsorbed and p-NPC-activated Ti-6Al-4V, with the exception of samples derivatized with 1.95 mg p-NPC/cm2, on which activity was significantly lower (4 BAEE units). In probing the linkages between trypsin and biomaterial by treatment with chaotropic agents, guanidine hydrochloride (GuHCl) was observed to eliminate more enzymatic activity than was urea. On Co-Cr-Mo samples, GuHCl removed nearly all the trypsin activity, while urea significantly decreased the activity only at a concentration of 0.65 mg p-NPC/cm2. Treatment of Ti-6Al-4V samples with GuHCl caused a trend of decreasing activity with increasing concentration of p-NPC, whereas urea had no effect on immobilized trypsin activity.

Adsorption↗

Adhesion of bacteria to stainless steel and silver-coated orthopedic external fixation pins.

Bacterial adhesion to silver-coated orthopedic external fixation pins was compared with stainless steel controls in an in vitro study. Using five bacterial isolates from wound infections, the silver coating was found to reduce adhesion for Escherichia coli, Pseudomonas aeruginosa, and two strains of Staphylococcus aureus while the converse applied for Staphylococcus haemolyticus. When placed in human serum, both surfaces were conditioned to a similar extent with serum proteins; this conditioning lead to further reductions in bacterial adhesion, ultimately approaching similar levels for both stainless steel and silver-coated samples.

Bacterial Adhesion↗

Effects of microstructure on the corrosion behavior of CoCr porous coatings on orthopedic implants.

Cobalt-chromium alloy porous coatings have become increasingly popular as a means of achieving a stable, longer lasting fixation on orthopedic implants. However, sintering heat treatments cause changes in the microstructure that result in changes in the corrosion behavior of the porous coatings. Experiments were conducted to examine the effects of microstructure on the corrosion of CoCr porous coatings. Four distinct microstructures were characterized. Light microscopy revealed microstructures A and B had relatively fewer carbides and a large-grain structure, microstructures C and D displayed a finer grain size with significant carbide formation, predominantly within grains and fusion zones. Accelerated anodic corrosion experiments were conducted to study the localized attack of each microstructure. Experiments were conducted using metallographically polished porous-coated disks for durations of 1, 4, 16, 24, and 72 h. The disks were examined with SEM and EDS to observe preferential attack and element depletion. Results showed a progressive dissolution of the matrix, with preferential attack of the grain boundaries and regions adjacent to the carbides due to sensitization. A precipitation layer was found to be Cr-rich and possibly composed of chromium hydroxide or a chromium orthophosphate. In addition, the solution became yellow in color with longer exposure times, possibly due to the presence of chromate ions, as indicated by an increased chromium level detected by AAS.

Alloys↗

Fluorescent microplate assay for respiratory burst of PMNs challenged in vitro with orthopedic metals.

This report describes a simple, rapid, automated microassay for measuring in vitro changes of oxidative burst of phagocytes following challenge with metals for orthopedic devices. The production of reactive oxygen species (ROS) by polymorphonuclear leukocytes (PMNs) was measured using 2',7'-dichlorofluorescin-diacetate (DCFH-DA) as fluorescent probe. DCFH-DA enters the cells and is oxidized by ROS to fluorescent DCF. The DCF generated was directly proportional to ROS produced intracellularly: The fluorescence intensity was read and converted to an index of ROS production by cells. In our experimental system, granulocytes (PMNs) were isolated from normal human blood and seeded in microplates. To verify if metals could influence ROS production, chromium, cobalt, nickel, molybdenum, titanium, aluminum, and vanadium prepared as aqueous extracts in phosphate-buffered saline were tested onto PMNs using phorbolmyristate acetate (PMA) as positive control. Molybdenum, aluminum, and vanadium increased ROS generation by PMNs, while signals not different from unstimulated PMNs were recorded for chromium, cobalt, nickel, and titanium. The DCFH-DA microplate-based assay provides an in vitro tool for the detection of oxygen-reactive species generated by PMNs as a response to metals.

Fluoresceins↗

Organoapatite growth on an orthopedic alloy surface.

We report here a method to coat orthopedic metals with the artificial bone material organoapatite. The growth of organoapatite on titanium alloy surfaces of foils and porous cylinders involves sequential preadsorption of poly(L-lysine) and poly(L-glutamic acid) on metal, followed by exposure to organoapatite-precipitating solutions. The organoapatite characterization of the coating was carried out by transmission electron microscopy, electron diffraction, scanning electron microscopy, energy-dispersive X-ray scattering, powder X-ray diffraction, FT-IR, and elemental analysis. The preadsorbed poly(amino acids) in the form of a self-assembled bilayer of oppositely charged macromolecules can lead to a surface coverage of titanium alloy in the range of 70-90%. The deposition mechanisms could involve the surface capture of embryonic crystals and the nucleation of apatite on the bilayer. Bioabsorbable organoapatite could serve as a tissue-engineering scaffold for bone regeneration into porous implants.

Apatites↗

Relationships between patient attitudes, subjective norms, perceived control, and analgesic use following elective orthopedic surgery.

The theory of planned behavior guided this exploration of postoperative analgesic use among adults (N = 137) undergoing elective orthopedic surgery. Patients who had a more positive attitude toward taking pain medication and had positive subjective norms intended to take more medication than those who had a negative attitude and had negative subjective norms. Perceived control over taking pain medications was not related to intentions. Intentions to take analgesics did not relate to the actual amount of analgesics used, but did relate to the subjective report of medication use. The discrepancy in association between intentions, objective behavior, and subjective behavior raises issues for examining complex behavior using the theory of planned behavior.

Adolescent↗

Declining use of orthopedic surgery in patients with rheumatoid arthritis? Results of a long-term, population-based assessment.

OBJECTIVE: To describe the use of orthopedic surgery, including joint replacement surgery, in a well-defined, population-based cohort of patients with rheumatoid arthritis (RA) and to identify characteristics that predict such use. METHODS: A retrospective medical record review was performed of cases of RA incident in Rochester, Minnesota, during the years 1955-1995. All joint surgeries were recorded. RESULTS: Of the total 609 RA incident cases, 242 patients underwent 1 or more (maximum of 20/patient) surgical procedures involving joints during their followup. Overall, this RA cohort had 7.4 surgeries per 100 person-years of followup; the cumulative incidence for joint surgery for RA-related joint disease at 30 years was 33.7% +/- SEM 3.8%. The risk of having a disease-related joint surgery for RA is increased in patients who are women, younger, positive for rheumatoid factor, and have rheumatoid nodules. When adjusted for duration of followup, patients with RA diagnosed after 1985 were significantly less likely to have undergone joint surgery for RA (P < 0.001). Survival of patients who underwent total joint arthroplasty was similar to those who did not. CONCLUSION: Reconstructive surgeries are common in RA, although patients diagnosed after 1985 are less likely to require joint surgery. These findings may reflect trends in medical disease management and have importance for health care resource utilization planning.

Adult↗

Differences between men and women undergoing major orthopedic surgery for degenerative arthritis.

OBJECTIVE: To determine whether women have worse functional status than men at the time of laminectomy for degenerative spinal stenosis or total joint arthroplasty for degenerative arthritis of the hip and knee. METHODS: Consecutive patients undergoing laminectomy for degenerative lumbar spinal stenosis or unilateral, primary hip or knee arthroplasty for advanced degenerative arthritis were recruited. Functional status was measured with self-administered questionnaires. We compared preoperative functional status scores of men and women, using linear regression models that adjusted for age, comorbid conditions, work status, education, living arrangement, and body mass index. We also compared the rates of in-hospital complications and 6-month followup functional status scores for men and women. RESULTS: Women had much worse functional status than men prior to laminectomy for spinal stenosis (P < 0.01) and prior to total hip arthroplasty (P < 0.001) and total knee arthroplasty (P < 0.0001). These differences persisted after statistical adjustment for demographic and clinical characteristics. Women had comparable or greater functional improvement following surgery and experienced a similar number of complications compared with men. CONCLUSIONS: The observed gender differences in functional status prior to major orthopedic surgery indicate that women are operated on at a more advanced stage in the course of their disease. These results are not due to gender differences in demographic or clinical characteristics of the patients, and cannot be justified by differences between men and women in the outcome of surgery. The role of patient preferences and differential access to these procedures should be explored in future studies.

Aged↗

A fast impingement detection algorithm for computer-aided orthopedic surgery.

OBJECTIVE: For simulation of computer-aided orthopedic interventions, the detection of impingement between parts of the patient's anatomy and/or implants is often of key importance. The impingement (collision) detection methods used in the existing literature seem to be unsuitable for two reasons. First, a polyhedral approximation of an anatomical model is not appropriate because medical images are quite irregular and are geometrically complex. Second, geometric and temporal coherences are not always available, because only the final results may be of interest. This article describes the development of a fast and accurate impingement detection algorithm for medical applications. MATERIALS AND METHODS: The presented algorithm takes implicit object models from reconstructions of anatomical CT data that represent complicated anatomical structures. To speed up the detection procedure, a lookup table and a linear transform are used so that searching for impingement between any two objects becomes a problem of calculating spatial indices and checking the lookup table. RESULTS: For any given transformation, the algorithm could perform impingement detection of two objects within 0.1 s on a 167 MHz Sun UltraSPARC1 workstation. Experimental results concerning accuracy, reliability and speed are given for a phantom and for a patient's data set. CONCLUSIONS: This algorithm provides a general-purpose impingement detection method in the sense that objects can be of any shape, and it can be extended to any number of objects in the scene.

Algorithms↗

Osteogenic stem cells and orthopedic engineering: summary and update.

The use of osteogenic stem cells or osteoprogenitors to reconstruct skeletal tissues is a popular area of research investigation with high potential for successful use of tissue-engineering principles in orthopedics. Recent studies demonstrate the migration of marrow-derived stem cells to skeletal sites and the proliferation and differentiation at local tissue sites and support possibilities for assessing the successful uses of human osteoprogenitors in the treatment of bone deficiency diseases. In addition, the development of gene therapy procedures in these and other conditions is now considered an achievable goal with the use of these primitive marrow cells.

Animals↗

Preparation and characterization of wear debris of orthopedic materials for biocompatibility studies.

In order to test the biocompatibility of wear debris of orthopedic materials, a method has been developed to produce artificial debris of stainless steel, cobalt-chromium alloy, and high-density polyethylene. In this process, called the accelerated rubbing process, two cylindrical blocks of the same alloy were held under normal pressure in triply distilled water. One block remained stationary while the other rotated at approximately 4000 rpm. The water with the metal debris was recirculated between the rubbing surfaces. To prepare debris from polyethylene, a stainless steel block was rubbed over a polyethylene block submersed in liquid nitrogen. The shape of the metal debris was granular, whereas the polyethylene debris had a shred-like shape. The size distributions were determined from scanning electron micrographs, and it was found that the particles of the metal debris (stainless steel or cobalt-chrome alloy) ranged in sizes from 0.1-10 mu with 75% of all particles less than 2 mu in diameter. The size of polyethylene debris, expressed as the volume of an ellipsoid, ranged from 10-20,000 mu3 with 45% of all particles in the range of 400-2500 mu3. The x-ray diffraction pattern revealed that the debris of stainless steel consisted primarily of the face-centered cubic (fcc) alloy with small amounts of body-centered cubic (bcc) alloy and Fe3O4, whereas the cobalt-chrome debris consisted of the fcc alloy with a small amount of Cr2O3. The structure of the polyethylene debris was quite similar to that of the solid sample used in its preparation. The percent crystallinity Pc and the size of the crystalline regions D were slightly smaller in the debris than in the solid sample, i.e., Pc = 52 and 55%, D = 90 and 130 A, in the debris and the solid, respectively. To test the suitability of the artificial debris for biocompatibility studies, stainless steel debris was implanted into knees of adult female New Zealand rabbits. Bacterial challenge studies indicated prolongation, but not increased susceptibility to infection.

Animals↗

Crevice corrosion in orthopedic implant metals.

Studies of orthopedic implant alloys in crevice configuration suggest that cobalt-chromium alloys such as Haynes-Stellite 25 are the best choice for multicomponent implants. It is also shown that severe crevice attack may result from use of mixed metals.

Biodegradation, Environmental↗

Osteoblast responses to orthopedic implant materials in vitro.

Responses of neonatal rat calvarial osteoblasts to a variety of orthopedic implant materials were examined in vitro. Attachment, proliferation, and collagen synthesis of a well-characterized line of osteoblasts with 316L stainless steel, Ti-6Al-4V, Co-Cr-Mo, PMMA, hydroxyapatite, borosilicate glass, and tissue culture polystyrene were studied. Cell adhesion and growth were similar on nonapatitic materials. In contrast, attachment and growth of osteoblasts were significantly lower and slower, respectively, on hydroxyapatite. Collagen synthesis per cell and relative collagen synthesis, however, were comparable on all the materials tested.

Animals↗

Formation of focal contacts by osteoblasts cultured on orthopedic biomaterials.

The nature of the contact sites formed during the adhesion of osteoblasts to orthopedic implant materials was investigated by fluorescence microscopy. More specifically, the cytoskeletal organization of and the focal contact formation by neonatal rat calvarial osteoblasts attaching to and spreading on 316L stainless steel, Ti-6Al-4V, Co-Cr-Mo, Synamel (hydroxyapatite), alumina, and borosilicate glass were examined. Focal contacts are regions where the plasma membrane approaches the substrate to within 10-15 nm and where bundles of cytoskeletal microfilaments terminate. Fluorescent-labeling of F-actin-containing microfilaments demonstrated a typical sequence of events as rounded, suspended osteoblasts spread onto the substrates. Immunofluorescent-labeling of the protein vinculin, which is found at the cytoplasmic face of focal contacts, initially showed the formation of streak-like focal patches. On the biomaterials, the vinculin staining subsequently extended up and along, but ventral to, the microfilament bundles. The fibrillar patterns observed at later times may evidence the formation of extracellular matrix contacts.

Actin Cytoskeleton↗

Bioactive hydroxyapatite coatings on polymer composites for orthopedic implants.

Hydroxyapatite [HA, Ca10(PO4)6(OH)2] coatings on polymer composite substrates were investigated for their bioactivity and their physicochemical and mechanical characteristics. HA holds key characteristics for use in orthopedic applications, such as for coating of the femoral stem in a hip replacement device. The plasma-spray technique was used to project HA onto a carbon fiber/polyamide 12 composite substrate. The resulting HA coatings exhibited mechanical adhesion as high as 23 MPa, depending on the surface treatment of the composite substrate. The purpose of this investigation was to evaluate the bioactivity of an HA-coated composite substrate. HA- coated samples have been immersed in simulated body fluid (SBF) and maintained within a shaker bath for periods of 1, 7, 14, 21, and 28 days at 37 degrees C. Scanning electron microscopy, energy dispersive X-ray spectroscopy, and X-ray diffraction techniques were performed on the samples before and after immersion into SBF. SBF was analyzed using inductively coupled plasma atomic emission spectrometry for element concentration and evaluation of the solution's purity. SBF conditioning led to the deposition of crystalline HA onto the surface of the coatings. The calcium-to-phosphorous ratios of initial HA coating and of newly deposited HA were respectively 1.72 and 1.65, close to the HA theoretical calcium/phosphorous value of 1.67. Results demonstrated that bioactive HA coatings were produced by plasma spraying, because SBF conditioning induced newly formed HA with high crystallinity. Mechanical adhesion of the HA coatings was not significantly affected upon SBF conditioning.

Arthroplasty, Replacement, Hip↗

Effect of synovial fluid, phosphate-buffered saline solution, and water on the dissolution and corrosion properties of CoCrMo alloys as used in orthopedic implants.

The corrosion and dissolution of high- and low-carbon CoCrMo alloys, as used in orthopedic joint replacements, were studied by immersing samples in phosphate-buffered saline (PBS), water, and synovial fluid at 37 degrees C for up to 35 days. Bulk properties were analyzed with a fine ion beam microscope. Surface analyses by X-ray photoelectron spectroscopy and Auger electron spectroscopy showed surprisingly that synovial fluid produced a thin oxide/hydroxide layer. Release of ions into solution from the alloy also followed an unexpected pattern where synovial fluid, of all the samples, had the highest Cr concentration but the lowest Co concentration. The presence of carbide inclusions in the alloy did not affect the corrosion or the dissolution mechanisms, although the carbides were a significant feature on the metal surface. Only one mechanism was recognized as controlling the thickness of the oxide/hydroxide interface. The analysis of the dissolved metal showed two mechanisms at work: (1) a protein film caused ligand-induced dissolution, increasing the Cr concentration in synovial fluid, and was explained by the equilibrium constants; (2) corrosion at the interface increased the Co in PBS. The effect of prepassivating the samples (ASTM F-86-01) did not always have the desired effect of reducing dissolution. The release of Cr into PBS increased after prepassivation. The metal-synovial fluid interface did not contain calcium phosphate as a deposit, typically found where samples are exposed to calcium rich bodily fluids.

Biocompatible Materials↗

Influence of the aspect ratio of bioactive nanofillers on rheological behavior of PMMA-based orthopedic materials.

In this investigation, calcium-deficient hydroxyapatite (CDHA) nanocrystals with needle-like geometry were synthesized and incorporated with Poly(methyl methacrylate), PMMA, to form CDHA-PMMA nanocomposites. Rheological behaviors of the PMMA-CDHA melting suspensions were systematically investigated in terms of solid loading and aspect ratio of the CDHA nanoparticles. The maximum solid loadings of nano-CDHA particles with aspect ratios of 7.2, 10.4, and 17 were determined to be 28, 31, and 57%, respectively. An increase in solid concentrations causes pronounced shear-thinning behavior. This result suggests that a strong interaction, including Van der Waals attraction and mechanical interlocking, between the nano-CDHA particles makes the nanocomposite mixture more non-Newtonian. Furthermore, it was found that packing efficiency and yield strength in the suspension were strongly influenced by the aspect ratio, especially above the critical value of 8.8. The obtained critical aspect ratio and solid content provide not only appropriate design in the PMMA-CDHA polymeric suspension for fabrication process but also optimal conditions for the fabrication of orthopedic devices via injection molding or extrusion.

Biocompatible Materials↗

In vitro evaluation of orthopedic composite cytotoxicity: assessing the potential for postsurgical production of hydroxyl radicals.

Hydroxyl radical (*OH)-induced inflammation is a primary mode for in vivo cytotoxicity. A legitimate concern is whether particulate wear debris from orthopedic composites can stimulate inflammation via ferrous ion (Fe2+)-mediated production of *OH. The purpose of this research was to utilize electron paramagnetic resonance (EPR) spin trapping in investigating and comparing the potential for postsurgical cytotoxicity induced specifically by *OH in the presence of two composites: Simplex P and the novel, hybrid, CORTOSS. Cytotoxicity is evaluated based on the composites competitively chelating catalytic Fe2+ or readily reducing ferric ions (Fe3+), in facilitating the Fenton reaction (FR). *OH that are produced were then validated by a radical scavenger to confirm a genuine radical signal and mechanism. Spin adduct peak areas decreased in the presence of CORTOSS as opposed to increasing in the presence of Simplex P, evaluated against their respective controls. A plausible theory elucidating this finding is that CORTOSS may sequester the Fe form, by virtue of its monomers. Principally, direct comparison of composites indicated that Simplex P had greater tendency to produce *OH, yielding 25.6 and 48.7% greater spin adduct peak areas when chelated and non-chelated Fe2+ are used, respectively. Moreover, the rate of FR accelerated when chelated Fe2+ was used, leading to the formation of a ternary complex with the composites. This was more prominent in Simplex P, as coordination of chelated Fe2+ occurs on its surface via an electrostatic attraction to allow a seventh coordination site for ligand exchange in the ternary complex, stabilized by Ba2+. Conversely, the silica found in CORTOSS possesses radical quenching abilities that deactivate generated *OH in impeding the efficiency of FR. Neither composite demonstrated a capacity to readily reduce Fe3+ to the relevant Fe2+, as validated by a non-radical pathway. Instead, the artificial spin adduct signal attained when employing chelated Fe3+ was due to the nucleophilic addition of water onto DMPO. Simplex P may also serve as a template for surface catalysis of the nucleophilic addition of water onto DMPO involving chelated Fe3+. CORTOSS is thought not to induce cytotoxicity, whereas the propensity of Simplex P in promoting Fenton chemistry is a serious issue that must be addressed.

Composite Resins↗