3D-ink-extruded titanium scaffolds with porous struts and bioactive supramolecular polymers for orthopedic implants
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Misiaszek, John P. (ORCID:0000000254789292)↗
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Screening for extractables in additive-manufactured acrylonitrile butadiene styrene orthopedic cast
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Nahan, Keaton↗
Enhanced biomechanical performance of additively manufactured Ti-6Al-4V bone plates
As the global trauma fixation devices market expands rapidly, it is imperative to improve the production of fixation devices through enhanced design accuracy and fit for best performance and maximum patient comfort. Selective laser melting (SLM) is one of the mature additive manufacturing methods, which provides a viable route for the rapid production of such devices. In this work, the ability of SLM to produce near-net-shape parts, as desired for medical implants, was utilized for the fabrication of bone plates from Ti-6Al-4V alloy powder. Martensitic microstructure obtained after the printing of alloy resulted in poor ductility, limiting its application in the field of orthopedics. A specially designed repeated cyclic heating and cooling close to but below the β-transus was used to transform from acicular to a bimodal microstructure without the need for plastic deformation prior to heat treatment for improving the ductility. Bone plates subjected to this heat treatment were mechanically tested by means of tensile and 3-point bend tests and demonstrated large improvement in ductility, and the values were comparable to those similar plates prepared from wrought alloy. Other important properties required for implants were assessed, such as corrosion resistance in simulated body fluid and cytocompatibility in vitro using MC3T3-E1 cells. These results for the bone plate after heat treatment were excellent and similar to those of the additively manufactured and wrought plates. Taken together, the performance of the additively manufactured bone plates after subjecting to heat treatment was similar to those of bone plate manufactured using wrought alloy. These results have important implications for the fabrication of patient-specific metallic orthopedic devices using SLM without compromising their biomechanical performance by subjecting them to a tailored heat treatment.
36 MATERIALS SCIENCE↗
Characterization of the fatigue threshold behavior of UHMWPE
Ultra-high-molecular-weight-polyethylene (UHMWPE) has been the material of choice for bearings in total joint replacements (TJRs) for decades as a result of its excellent wear resistance, chemical inertness, energetic toughness, low friction, and biocompatibility. Utilization of this polymer in orthopedic devices requires oxidation, wear, and fatigue resistance. Balancing these important properties by tailoring processing techniques and modulating microstructural features has been an ongoing endeavor in the field. Research into the clinical applications of UHMWPE has primarily focused on the challenges of wear and oxidation while studies into the realm of fatigue have been more limited. Literature gaps exist in fully understanding the fatigue crack initiation near notches or propagation of small existing flaws in UHMWPE used in TJRs. In particular, the characterization of the fatigue thresholds and near-threshold fatigue behavior of orthopedic grade UHMWPE has yet to be thoroughly explored. In this work, we characterized the fatigue crack arrest threshold of clinically-relevant UHMWPE formulations. Correlations between the fatigue thresholds and bulk mechanical properties as well as microstructural properties were examined across these medical resins. The important role played by crosslinking in influencing the fatigue performance of UHMWPE is highlighted in this study. In addition, it is established that J-integral fracture toughness is the best predictor of fatigue thresholds and could possibly be used as a stand-in metric for fatigue performance if thresholds cannot be directly ascertained. Finally, this study corroborates that the true constitutive parameters best describe the mechanical behavior of UHMWPE.
Cross-linking↗
Improving radiograph analysis throughput through transfer learning and object detection
SIGN Fracture Care International partners with surgeons in low-resource hospitals worldwide to provide access to effective orthopedic care by donating educational materials and innovatively designed surgical implants. Over two decades, SIGN’s Online Surgical Database (SOSD) has grown to contain over 500,000 medical images, with radiographs holding the majority share. One challenge in working with hospitals worldwide is that both the radiographs uploaded to the SOSD and the data entry accompanying the uploads vary in quality. To improve the accuracy of data in the SOSD, we trained a model to detect surgical implants in radiographs. We first developed a tool to automatically detect radiographs, then trained an object detection model to determine the number and placement of surgical implants visible in the radiograph. Active learning was used to generate a training set containing 2,510 radiographs with screws, nails, and plates labeled by bounding boxes. Training a model to simultaneously recognize all three classes of implants gave a low average precision (AP) for the plate class, likely due to the low number of plate instances in our training set and the large variety of surgical plates used by SIGN-partnered surgeons. Applying standard image augmentation techniques to increase the plate count in our training set did not appreciably increase the AP of plate detection. To improve plate detection, we redrew the bounding boxes to account for correlations between the screw and plate classes. Training one model to detect nails and screws and a separate model to detect plates increased the AP of plate detection by 78.8 percentage points. The AP of each class was 80.7% for screws, 93.6% for nails, and 92.6% for plates; meanwhile, the sensitivity was 92% for screws, 86% for nails, and 81% for plates. We show that object detection methods can be used to detect surgical implants in radiographs of varying quality; however, the detection ability is dependent on the type of implant, and some implants, in our case plates, must be treated differently than others. Such tools can improve the throughput of radiograph analysis, assisting physicians and surgeons with the treatment of bone fractures.
60 APPLIED LIFE SCIENCES↗
Stereochemical Control of Water Transport Properties in Thiol‐yne Polymers
Barrier polymers underpin almost every commercial sector, yet the needs of several emerging areas remain unmet by commercially‐available materials, including temporary orthopedic implants, transient health monitors, neural implants, and other long‐term implants. The ability to tune polymer composition independently of polymer structure positions thiol‐yne click chemistry as a promising platform to serve these emerging technologies. Here, this work describes the differences in the hierarchical structure of stoichiometrically identical materials which differ only in the proportion of the cis versus trans backbone alkene stereochemistry. Varying the isomer content in this way directs different temperature and rate dependent crystallization behavior, which affords control over micron‐scale structure. This investigation focuses on how these stereochemical features affect the water vapor permeation process by several methods and develops an understanding of how this unique structural regularity improves barrier performance relative to a commercially available water barrier polymer, poly(ethylene terephthalate).
77 NANOSCIENCE AND NANOTECHNOLOGY↗
Interplay of strain and phase evolution of laser powder bed fusion Ti–6Al–4V
While additive manufacturing (AM) provides a method of producing geometrically complex and highly detailed structures, the generation of residual strain in AM processes like laser powder bed fusion (L-PBF) can negatively impact performance-enabling properties. In applications such as orthopedic implants, specific performance windows require optimized microstructures in order to obtain desirable properties from multi-phase alloys like Ti–6Al–4V. This research aims to quantify the microscale origins of strain in L-PBF manufactured Ti–6Al–4V by understanding how strain is distributed at the grain and sub-grain scale, the interplay between phase evolution and strain, and examining post-processing strain relief strategies to control these features. Model spinal cage implants were manufactured from Ti–6Al–4V powder via L-PBF and then subjected to strain relieving heat treatment cycles above and below the Ti–6Al–4V β transus as a function of time and cooling rate. Residual strain was then studied via high resolution electron backscatter diffraction (HR-EBSD), and 2D strain maps with sub-micron resolution were generated for each post-processing state. It was found that macroscale thermal strains decreased with heat treatment time, but additional contributions from phase stabilizing residual strains retained primarily in the α' grains as lattice distortive strain remained. Additionally, the retention of β phase significantly changed the strain and dislocation distribution while reducing overall residual strain. In conclusion, these results were validated and reinforced with 3D mesoscopic micromechanical modeling of strain behavior across simulated microstructures, confirming that the local lattice dilation of α’ martensite is a primary contributor of microscale strain generation and retention in L-PBF Ti–6Al–4V.
36 MATERIALS SCIENCE↗
Effects of gamma, electron beam, and X-ray irradiation on the plastic components of a universal bone cement mixer medical device
Due to market and regulatory pressures, many healthcare manufacturers are considering alternatives to cobalt-60 gamma radiation, including accelerator-based electron beam (E-beam) and X-ray radiation for product sterilization. In this work, the effects of irradiation on a representative medical product, comprised of eight distinct polymer materials, were directly compared for three radiation technologies – cobalt-60 gamma, E-beam, and X-ray – at four dose levels (15, 25, 50, and 70 kGy). The objective was to determine how radiation effects (deleterious or beneficial) are influenced by source and dose level, with the specific goal of determining whether E-beam radiation and/or X-ray radiation could be viable alternatives to gamma radiation for device sterilization. Here, the specific product considered is a single-use medical device for orthopedic surgery, the Stryker Instruments MixeVac III bone cement mixer, which is currently sterilized using gamma radiation from cobalt-60 sources. Following ASTM International standards and input from the manufacturer, we characterized the effects of the three radiation sources on product functionality as well as on the mechanical and optical properties of the constituent polymers. Results indicate that although measurable differences in properties between the standard gamma irradiated materials and the alternative E-beam and X-ray irradiated materials were observed, those differences were small. Statistically significant differences were noted in the case of yellowness index for polyvinyl chloride, high-density polyethylene, and polycarbonate, and in the case of tensile elongation at break for high impact polystyrene and polyvinyl chloride. In general, the results of this study support the viability of E-beam and X-ray radiation as alternative options to cobalt-60 gamma radiation for sterilization of Stryker single-use universal bone cement mixer medical devices.
46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗
Downregulation of miR-892b inhibits the progression of osteoarthritis via targeting cyclin D1 and cyclin D2
Highlights: • miR-892b antagomir reversed IL-1β-induced chondrocyte growth inhibition. • miR-892b directly targeted cyclin D1 and cyclin D2. • miR-892b antagomir inhibited the symptom of osteoarthritis in vivo. Osteoarthritis (OA) is an orthopedic inflammatory disease which can cause functional disability and chronic pain. MiRNAs are known to play important roles in OA. To identify the targets for the treatment of OA, bioinformatics analysis was performed to explore differentially expressed miRNAs between OA and normal samples.
60 APPLIED LIFE SCIENCES↗
Machine learning unifies flexibility and efficiency of spinodal structure generation for stochastic biomaterial design
Abstract Porous biomaterials design for bone repair is still largely limited to regular structures (e.g. rod-based lattices), due to their easy parameterization and high controllability. The capability of designing stochastic structure can redefine the boundary of our explorable structure–property space for synthesizing next-generation biomaterials. We hereby propose a convolutional neural network (CNN) approach for efficient generation and design of spinodal structure—an intriguing structure with stochastic yet interconnected, smooth, and constant pore channel conducive to bio-transport. Our CNN-based approach simultaneously possesses the tremendous flexibility of physics-based model in generating various spinodal structures (e.g. periodic, anisotropic, gradient, and arbitrarily large ones) and comparable computational efficiency to mathematical approximation model. We thus successfully design spinodal bone structures with target anisotropic elasticity via high-throughput screening, and directly generate large spinodal orthopedic implants with desired gradient porosity. This work significantly advances stochastic biomaterials development by offering an optimal solution to spinodal structure generation and design.
59 BASIC BIOLOGICAL SCIENCES↗
A Novel Anatomic Reconstruction for Posterior Tibialis Tendon in Treatment of Flexible Adult‐Acquired Flatfoot Deformity
Objective To present a novel approach for the anatomic reconstruction of the posterior tibialis tendon (PTT) in restoring plantar insertions and evaluate its efficiency in treating flexible adult‐acquired flatfoot deformity (AAFD) caused by PTT dysfunction. Methods For AAFD treatment, a novel PTT reconstruction method was presented. The current study involved 16 patients, including three men, and 13 women, from August 2017 to July 2019. The mean age was 43.2 ± 15.1 years (21–64 years). The innovative PTT repair method was used on all patients. The treatment involved performing a traditional Flexor Digitorum Longus (FDL) transfer in the navicular tuberosity and suturing the plantar insertions to FDL as tension was applied to tighten the plantar structures of the foot. The results were retrospectively analyzed. The clinical outcome was assessed using the pain visual analogue scale (VAS), the satisfaction VAS, and the American Orthopedic Foot and Ankle Society ankle–hindfoot scale (AOFAS‐AH). Isokinetic testing was performed using a dynamometer at 60°/s and 120°/s for inversion/eversion and plantarflexion/dorsiflexion, respectively, to determine the mean peak torque. Radiographic measurements were employed to assess the outcomes. Results Bone surgeries combined with the modified anatomic PTT reconstruction were performed on patients with medializing calcaneal osteotomy in 12 (75%) patients and subtalar joint fusion in four (25%) patients. The branch linking to the plantar insertions was detected in every case, with an average width of 3.5 ± 0.8 mm (3.1–4.3 mm). All patients were followed up for the mean of 16.8 ± 1.8 months (range, 15–20 months). The average postoperative functional scores, including pain VAS, satisfaction VAS, total AOFAS‐AH, and all AOFAS‐AH sub‐scales, steadily improved during the follow‐up. In the last follow‐up, isokinetic testing revealed no loss of plantarflexion strength ( p = 0.350 and 0.098) and significant improvement in the inversion strength ( p = 0.007 and 0.008) in the operated ankles at 60°/s and 120°/s. Radiographic outcomes, particularly the talar head uncovering, improved significantly after more than a year ( p < 0.001 for all). Conclusions The novel technique for PTT reconstruction in restoring the plantar insertions serves as an effective procedure in treating AAFD caused by PTT dysfunction in terms of delivering a consistent improvement in ankle inversion strength, medial longitudinal arch restoring, and satisfactory clinical outcomes.
Hu, Yong↗
A microCT-based platform to quantify drug targeting
Abstract Background Heterotopic ossification (HO) is a frequent and debilitating complication of traumatic musculoskeletal injuries and orthopedic procedures. Prophylactic dosing of botulinum toxin type A (BTxA) holds potential as a novel treatment option if accurately distributed throughout soft-tissue volumes where protection is clinically desired. We developed a high-resolution, microcomputed tomography (microCT)-based imaging strategy to assess drug distribution and validated this platform by quantifying distribution achieved via a prototype delivery system versus a single-bolus injection. Methods We injected an iodine-containing contrast agent (iodixanol 320 mg I/mL) into dissected rabbit musculature followed by microCT imaging and analysis. To contrast the performance of distributed versus bolus injections, a three-dimensional (3D) 64-cm 3 -printed soft-tissue holder was developed. A centered 2-cm 3 volume of interest (VOI) was targeted with a single-bolus injection or an equal volume distributed injection delivered via a 3D-printed prototype. VOI drug coverage was quantified as a percentage of the VOI volume that was < 1.0 mm from the injected fluid. Results The microCT-based approach enabled high-resolution quantification of injection distribution within soft tissue. The distributed dosing prototype provided significantly greater tissue coverage of the targeted VOI (72 ± 3%, mean ± standard deviation) when compared to an equal volume bolus dose (43 ± 5%, p = 0.031) while also enhancing the precision of injection targeting. Conclusions A microCT-based imaging technique precisely quantifies drug distribution within a soft-tissue VOI, providing a path to overcome a barrier for clinical translation of prophylactic inhibition of HO by BTxA. Relevance statement This platform will facilitate rapid optimization of injection parameters for clinical devices used to effectively and safely inhibit the formation of heterotopic ossification. Key points • MicroCT provides high-resolution quantification of soft-tissue drug distribution. • Distributed dosing is required to maximize soft-tissue drug coverage. • Imaging platform will enable rapid screening of 3D-printed drug distribution prototypes. Graphical Abstract
Ausk, Brandon J. (ORCID:0000000335338303)↗
Postmortem and Antemortem Forensic Assessment of Pediatric Fracture Healing from Radiographs and Machine Learning Classification
A timeline of pediatric bone healing using fracture healing characteristics that can be assessed solely using radiographs would be practical for forensic casework, where the fracture event may precede death by days, months, or years. However, the dating of fractures from radiographs is difficult, imprecise, and lacks consensus, as only a few aspects of the healing process are visible on radiographs. Multiple studies in both the clinical and forensic literature have attempted to develop a usable scale to assess pediatric bone healing on radiographs using various healing characteristics. In contrast to the orthopedic definition, a fracture in forensic casework is only considered to be healed when the area around the fracture has been remodeled to the point that the fracture is difficult to detect on a radiograph or on the surface of the bone itself, a process that can take several years. We subjectively assessed visible characteristics of healing in radiograms of fractures occurring in 942 living children and adolescents. By dividing these assessments into learning and test (validation) sets, the accuracy of a newly proposed fracture healing scale was compared to a previous study. Two machine learning models were used to test predictions of the new scale. All three models produced similar estimates with substantial imprecision. Results corroborate the Malone model with an independent dataset and support the efficacy of using less complex models to estimate fracture age in children.
60 APPLIED LIFE SCIENCES↗
A comparative study on the physicochemical characteristics of nanoparticles released in vivo from CoCrMo tapers and cement–stem interfaces of total hip replacements
The good biocompatibility and corrosion resistance of the bulk CoCrMo alloy has resulted in it being used in the manufacture of implants and load bearing medical devices. These devices, however, can release wear and corrosion products which differ from the composition of the bulk CoCrMo alloy. The physicochemical characteristics of the particles and the associated in vivo reactivity are dictated by the wear mechanisms and electrochemical conditions at the sites of material loss. Debris released from CoCrMo hip bearings, taper junctions, or cement–stem interfaces can, therefore, have different chemical and morphological characteristics, which provide them with different in vivo toxicities. Here, we propose to assess and compare the characteristics of the particles released in vivo from CoCrMo tapers and cement–stem interfaces which have received less attention compared to debris originating from the hip bearings. The study uses state–of–art characterization techniques to provide a detailed understanding of the size, morphology, composition, and chemistry of the particles liberated from the wear and corrosion flakes from revised hip replacements, with an enzymatic treatment. The phase analyses identified Cr 2 O 3 nanoparticles released from tapers and cement–stem interfaces, whose composition did not vary with origin or particle morphology. The size distributions showed significantly smaller particles were released from the stems, compared to the particles originating from the corresponding tapers. Furthermore, the investigation demonstrates that the tribocorrosive processes occurring at the taper and stem interfaces both result in Cr 2 O 3 nanoparticle formation.
37 INORGANIC, ORGANIC, PHYSICAL, AND ANALYTICAL CH↗
Intramedullary Unicortical Button and All-Suture Anchors Provide Similar Maximum Strength for Onlay Distal Biceps Tendon Repair
To evaluate the biomechanical profile of onlay distal biceps repair with an intramedullary unicortical button versus all-suture anchors under cyclic loading and maximal load to failure. Twenty paired fresh-frozen human cadaveric elbows were randomized to onlay distal biceps repair with either a single intramedullary button or with two 1.35-mm all-suture anchors. A 1.3-mm high tensile strength tape was used in a Krackow stitch to suture the tendons in both groups. Specimens and repair constructs were loaded for 3,000 cycles and then loaded to failure. Maximum load to failure, mode of failure, and construct elongation were recorded. Mean (± standard deviation) maximum load to failure for the unicortical intramedullary button and all-suture anchor repairs were 503.23 ± 141.77 N and 537.33 ± 262.13 N (P = .696), respectively. Mean maximum displacement after 3,000 cycles (± standard deviation) was 4.17 ± 2.05 mm in the button group and 2.06 ± 1.05 mm in the suture anchor group (P = .014). Mode of failure in the button group was suture tape rupture in 7 specimens, failure at the tendon–suture interface in 2 specimens, and button pullout in 1 specimen. Anchor pullout was the mode of failure in all suture anchor specimens. There were no tendon ruptures or radial tuberosity fractures in either group. In conclusion, this study demonstrates that onlay distal biceps repair with 2 all-suture anchors has similar maximum strength to repair with an intramedullary button and that both are viable options for fixation.
60 APPLIED LIFE SCIENCES↗
Differences in Outcomes between Patellar Dislocations Managed in Emergent versus Non-Emergent Care Settings
Abstract Patellar dislocations occur at a much higher rate in military than civilian populations. Past population-level studies have shown that surgical management is as good as or superior to conservative care and may reduce future reoccurrences. Although in acute cases and in civilian clinics, patellar dislocations are usually managed first in an emergent care setting, previous work suggests this can lead to increased costs. This study compared differences in downstream care type and intensity of services based on whether initial care occurred in emergent or non-emergent care settings. In our sample of 1,523 Military Health System (MHS) beneficiaries with patellar dislocation and 2-year follow-up, we found non-significant differences in costs, intensity of services, and rates of surgical repair regardless of whether the patient was initially seen in an emergent versus non-emergent care setting. Although we found significant increases in the use of imaging, patellar dislocation-related medical visits, and frequency of closed treatment approaches in emergent care settings, these values were very small and likely not clinically significant. These findings, which included all the patellar dislocations reported across the entire MHS in a 24-month period, suggest that neither emergent nor non-emergent care settings are likely to influence the long-term care received by the individual.
Orthopedics↗
A Population-Level Summary of Health Care Utilization for the Management of Patellar Tendinopathy in the Military Health System
Abstract Patellar tendinopathy (PT) is a common nontraumatic orthopaedic disorder of the knee suffered by many service members. Understanding the make-up of usual care for PT at the system level can better frame current clinical gaps and areas that need improvement. Exercise therapy is recommended as a core treatment for PT, but it is unclear how often it is used as a part of usual care for PT within the Military Health System (MHS). The purpose of the study was to identify interventions used in the management of PT and the timing of these interventions. A secondary purpose was to determine if exercise therapy use was associated with reduced recurrence of knee pain. In total, 4,719 individuals aged 17 to 50 years in the MHS diagnosed with PT between 2010 and 2011 were included. Pharmacological and nonpharmacological interventions, visits to specialty providers, and imaging services were captured. Descriptive statistics were used to report the findings. Interventions were further categorized as being part of initial care (within the first 7 days), the initial episode of care (within the first 60 days), or the 2-year time period after diagnosis. Linear regression assessed the relationship between the number of exercise therapy visits in the initial episode of care and recurrences of knee pain. In total, 50.6% of this cohort had no more than one medical visit total for PT. Exercise therapy (18.2%) and nonsteroidal anti-inflammatory drugs (4.3%) were the two most used interventions in the initial episode of care. Radiographs were ordered for 23.1% of the cohort in the initial episode of care. The number of exercise therapy visits a patient received during the initial episode of care was not associated with recurrences of knee pain. Half of the individuals received no further care beyond an initial visit for the diagnosis of PT. Exercise therapy was the most common intervention used during the initial episode of care, but exercise therapy did not influence the recurrence of knee pain.
Orthopedics↗