Background:Highly porous surfaces promoting biologic fixation have renewed interest in cementless total knee arthroplasty (TKA), but the potential for failed biologic fixation remains. The purpose of this study was to compare the clinical outcomes of cemented and cementless versions of the same TKA

/pdf/cemented-versus-cementless-total-knee-arthroplasty-of-the-5dujxhqe1w.pdf

Cemented Versus Cementless Total Knee Arthroplasty of the Same Modern Design: A Prospective, Randomized Trial.

Currently, metal implants are widely used in orthopedic surgeries, including fracture fixation, spinal fusion, joint replacement, and bone tumor defect repair. However, conventional implants are difficult to be customized according to the recipient's skeletal anatomy and defect characteristics, leading to difficulties in meeting the individual needs of patients. Additive manufacturing (AM) or three-dimensional (3D) printing technology, an advanced digital fabrication technique capable of producing components with complex and precise structures, offers opportunities for personalization. We systematically reviewed the literature on 3D printing orthopedic metal implants over the past 10 years. Relevant animal, cellular, and clinical studies were searched in PubMed and Web of Science. In this paper, we introduce the 3D printing method and the characteristics of biometals and summarize the properties of 3D printing metal implants and their clinical applications in orthopedic surgery. On this basis, we discuss potential possibilities for further generalization and improvement. 3D printing technology has facilitated the use of metal implants in different orthopedic procedures. By combining medical images from techniques such as CT and MRI, 3D printing technology allows the precise fabrication of complex metal implants based on the anatomy of the injured tissue. Such patient-specific implants not only reduce excessive mechanical strength and eliminate stress-shielding effects, but also improve biocompatibility and functionality, increase cell and nutrient permeability, and promote angiogenesis and bone growth. In addition, 3D printing technology has the advantages of low cost, fast manufacturing cycles, and high reproducibility, which can shorten patients' surgery and hospitalization time. Many clinical trials have been conducted using customized implants. However, the use of modeling software, the operation of printing equipment, the high demand for metal implant materials, and the lack of guidance from relevant laws and regulations have limited its further application. There are advantages of 3D printing metal implants in orthopedic applications such as personalization, promotion of osseointegration, short production cycle, and high material utilization. With the continuous learning of modeling software by surgeons, the improvement of 3D printing technology, the development of metal materials that better meet clinical needs, and the improvement of laws and regulations, 3D printing metal implants can be applied to more orthopedic surgeries. Precision, intelligence, and personalization are the future direction of orthopedics. It is reasonable to believe that 3D printing technology will be more deeply integrated with artificial intelligence, 4D printing, and big data to play a greater role in orthopedic metal implants and eventually become an important part of the digital economy. We aim to summarize the latest developments in 3D printing metal implants for engineers and surgeons to design implants that more closely mimic the morphology and function of native bone. 

3D printing metal implants in orthopedic surgery: Methods, applications and future prospects

Additive manufacture of low melting point metal porous materials: Capabilities, potential applications and challenges

three-dimensional (3D) printing is a highly automated platform that facilitates material deposition in a layer-by-layer approach to fabricate pre-defined 3D complex structures on demand. It is a highly promising technique for the fabrication of personalized medical devices or even patient-specific tissue constructs. Each type of 3D printing technique has its unique advantages and limitations, and the selection of a suitable 3D printing technique is highly dependent on its intended application. In this review paper, we present and highlight some of the critical processes (printing parameters, build orientation, build location, and support structures), material (batch-to-batch consistency, recycling, protein adsorption, biocompatibility, and degradation properties), and regulatory considerations (sterility and mechanical properties) for 3D printing of personalized medical devices. The goal of this review paper is to provide the readers with a good understanding of the various key considerations (process, material, and regulatory) in 3D printing, which are critical for the fabrication of improved patient-specific 3D printed medical devices and tissue constructs. 

Process, Material, and Regulatory Considerations for 3D Printed Medical Devices and Tissue Constructs

Functional outcomes and complications experienced by adult patients who underwent iliac crest bone grafting were evaluated to assess the effect of bone grafts on patient function. In addition to retrospective chart reviews, patients completed the Sickness Impact Profile and a detailed questionnaire on pain. One hundred ninety-two patients met study inclusion criteria. Major complications were recorded in four (2.4%) patients in whom infections developed requiring readmission. Thirty-seven (21.8%) patients had minor complications. One hundred nineteen of 170 patients were available for followup; of these 119 patients, 87 (73.1%) returned completed questionnaires. Thirty-three of 87 (37.9%) patients reported pain 6 months postoperatively. The incidence of pain decreased with time, with 16 of 87 (18.7%) patients continuing to report pain more than 2 years postoperatively. Proportionately more spine patients reported pain at all time points. The mean Sickness Impact Profile score for patients completing questionnaires was nine, suggesting most patients were functioning well 2 years postoperatively. The morbidity of iliac crest grafting remains substantial. Pain symptoms in this study sample seemed to last longer in more patients than earlier series have indicated. Minimizing muscle dissection around donor sites and the advent of bone graft substitutes may help alleviate these problems.

Autogenous iliac crest bone graft : Complications and functional assessment : Orthopaedic trauma education: A tribute to the university of California, Davis orthopaedic trauma fellowship

Direct energy deposition (DED) technology has gained increasing attention as a new implant surface technology that replicates the porous structure of natural bones facilitating osteoblast colonization and bone ingrowth. However, concerns have arisen over osteolysis or chronic inflammation that could be caused by Cobalt-chrome (CoCr) alloy and Titanium (Ti) nanoparticles produced during the fabrication process. Here, we evaluated whether a DED Ti-coated on CoCr alloy could improve osteoblast colonization and osseointegration in vitro and in vivo without causing any significant side effects. Three types of implant CoCr surfaces (smooth, sand-blasted and DED Ti-coated) were tested and compared. Three cell proliferation markers and six inflammatory cytokine markers were measured using SaOS2 osteoblast cells. Subsequently, X-ray and bone histomorphometric analyses were performed after implantation into rabbit femur. There were no differences between the DED group and positive control in cytokine assays. However, in the 5-bromo-2'-deoxyuridine (BrdU) assay the DED group exhibited even higher values than the positive control. For bone histomorphometry, DED was significantly superior within the 1000 µm bone area. The results suggest that DED Ti-coated metal printing does not affect the osteoblast viability or impair osseointegration in vitro and in vivo. Thus, this technology is biocompatible for coating the surfaces of cementless total knee arthroplasty (TKA) implants.

Osteo-Compatibility of 3D Titanium Porous Coating Applied by Direct Energy Deposition (DED) for a Cementless Total Knee Arthroplasty Implant: In Vitro and In Vivo Study

Because of the recent technological advances, the cementless total knee arthroplasty (TKA) implant showed satisfactory implant survival rate. Newly developed 3D printing direct energy deposition (DED) has superior resistance to abrasion as compared to traditional methods. However, there is still concern about the mechanical stability and the risk of osteolysis by the titanium (Ti) nanoparticles. Therefore, in this work, we investigated whether DED Ti-coated cobalt-chrome (CoCr) alloys induce chronic inflammation reactions through in vitro and in vivo models. We studied three types of implant surfaces (smooth, sand-blasted, and DED Ti-coated) to compare their inflammatory reaction. We conducted the in vitro effect of specimens using the cell counting kit-8 (CCK-8) assay and an inflammatory cytokine assay. Subsequently, in vivo analysis of the immune profiling, cytokine assay, and histomorphometric evaluation using C57BL/6 mice were performed. There were no significant differences in the CCK-8 assay, the cytokine assay, and the immune profiling assay. Moreover, there were no difference for semi-quantitative histomorphometry analysis at 4 and 8 weeks among the sham, smooth, and DED Ti-coated samples. These results suggest that DED Ti-coated printing technique do not induce chronic inflammation both in vitro and in vivo. It has biocompatibility for being used as a surface coating of TKA implant.

https://www.mdpi.com/1996-1944/13/2/472/pdf

Titanium Porous Coating Using 3D Direct Energy Deposition (DED) Printing for Cementless TKA Implants: Does It Induce Chronic Inflammation?

With the developments in the arthroscopic technique, anterior cruciate ligament (ACL) remnant-preserving reconstruction is gradually gaining attention with respect to improving proprioception and enhancing early revascularization of the graft. To evaluate the mechanical pull-out strength of three different methods for remnant-preserving and re-tensioning reconstruction during ACL reconstruction. Twenty-seven fresh knees from mature pigs were used in this study. Each knee was dissected to isolate the femoral attachment of ACL and cut the attachment. An MTS tensile testing machine with dual-screw fixation clamp with 30° flexion angle was used. The 27 specimens were tested after applying re-tensioning sutures with No. 0 polydioxanone (PDS), using the single stitch (n = 9), loop stitch (n = 9), and triple stitch (n = 9) methods. We measured the mode of failure, defined as (1) ligament failure (longitudinal splitting of the remnant ACL) or (2) suture failure (tearing of the PDS stitch); load-to-failure strength; and stiffness for the three methods. Kruskal-Wallis test and Mann-Whitney U-test were used to compare the variance of load-to-failure strength and stiffness among the three groups. Ligament failure occurred in all cases in the single stitch group and in all but one case in the triple stitch group. Suture failure occurred in all cases in the loop stitch group and in one case in the triple stitch group. The load-to-failure strength was significantly higher with loop stich (91.52 ± 8.19 N) and triple stitch (111.1 ± 18.15 N) than with single stitch (43.79 ± 11.54 N) (p = 0.002). With respect to stiffness, triple stitch (2.50 ± 0.37 N/mm) yielded significantly higher stiffness than the other methods (p = 0.001). The results suggested that loop stitch or triple stitch would be a better option for increasing the mechanical strength when applying remnant-preserving and re-tensioning reconstruction during ACL reconstruction.

/pdf/anterior-cruciate-ligament-remnant-preserving-and-re-d09mz8zcss.pdf

Anterior cruciate ligament remnant-preserving and re-tensioning reconstruction: a biomechanical comparison study of three different re-tensioning methods in a porcine model.

Bone graft is required in various surgical procedures. Although autograft is the gold standard, it has limited availability. Various compounds have been proposed as alternatives such as biphasic calcium phosphate (BCP), which is the most widely used compound. The newly synthesized microporous sphere-shaped BCP has the advantage of increasing contact surface, and it can induce the formation of microbone structures. A putty-type contains the addition of a fluid carrier to the sphere-shaped BCP and can be easily used for a small orifice large bone defect. To compare the widely used BCP products, new bone formation and residual graft materials (RGM) were evaluated for 6 and 12 weeks in a rabbit calvarial bone defect model. Although existing BCP products and the microporous sphere-type product did not differ significantly with respect to new bone formation and RGM, the putty-type product was largely washed out and had low new bone formation at 6 and 12 weeks. Overall, the results suggest that microporous sphere-shaped BCP showed similar bone formation capability to existing products and was able to maintain higher initial mechanical stability.

Efficacy of bone formation of microporous sphere-shaped biphasic calcium phosphate in a rabbit skull bone defect model.

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Osteo-Compatibility of 3D Titanium Porous Coating Applied by Direct Energy Deposition (DED) for a Cementless Total Knee Arthroplasty Implant: In Vitro and In Vivo Study

Titanium Porous Coating Using 3D Direct Energy Deposition (DED) Printing for Cementless TKA Implants: Does It Induce Chronic Inflammation?

Anterior cruciate ligament remnant-preserving and re-tensioning reconstruction: a biomechanical comparison study of three different re-tensioning methods in a porcine model.

Efficacy of bone formation of microporous sphere-shaped biphasic calcium phosphate in a rabbit skull bone defect model.