Faculty Bibliography

Orthopedic implants often loosen due to the invasion of fibrous tissue. The aim of this study was to devise a novel implant surface that would speed healing adjacent to the surface, and create a stable interface for bone integration, by using a chemoattractant for bone precursor cells, and by controlling tissue migration at implant surfaces via specific surface microgeometry design. Experimental surfaces were tested in a canine implantable chamber that simulates the intramedullary bone response around total joint implants. Titanium and alloy surfaces were prepared with specific microgeometries, designed to optimize tissue attachment and control fibrous encapsulation. TGF beta, a mitogen and chemoattractant (Hunziker EB, Rosenberg LC. J Bone Joint Surg Am 1996;78:721-733) for osteoprogenitor cells, was used to recruit progenitor cells to the implant surface and to enhance their proliferation. Calcium sulfate hemihydrate (CS) was the delivery vehicle for TGF beta; CS resorbs rapidly and appears to be osteoconductive. Animals were sacrificed at 6 and 12 weeks postoperatively. Results indicated that TGFbeta can be reliably released in an active form from a calcium sulfate carrier in vivo. The growth factor had a significant effect on bone ingrowth into implant channels at an early time period, although this effect was not seen with higher doses at later periods. Adjustment of dosage should render TGF beta more potent at later time periods. Calcium sulfate treatment without TGF beta resulted in a significant increase in bone ingrowth throughout the 12-week time period studied. Bone response to the microgrooved surfaces was dramatic, causing greater ingrowth in 9 of the 12 experimental conditions. Microgrooves also enhanced the mechanical strength of CS-coated specimens. The grooved surface was able to control the direction of ingrowth. This surface treatment may result in a clinically valuable implant design to induce rapid ingrowth and a strong bone-implant interface, contributing to implant longevity.

The volitional control of prosthetic devices could be greatly enhanced if the information formerly supplied by peripheral nerves to the amputated limb could be utilized. So that practical access to this information could be gained, a method was established to form a stable biological interface with fascicles of lesioned nerves. A small strip of an intact muscle was isolated in rats with the use of a silicone tube cuff electrode and innervated by the lesioned peroneal branch of the sciatic nerve. After 4 weeks survival, stimulation of the nerve fascicle produced reliable signals from the neuromuscular platform in the range of 0.5 to 2.0 mV. Histologically, myotubes remained intact and axons could be identified growing in and over the surfaces of the isolated muscle strips. These or similar interface techniques may supply electrophysiological signals of sufficient amplitude and reliability to provide peripheral nerve-based guidance information for prosthetic devices.

While it has been demonstrated that such low-molecular-weight cyclic silicones as octamethylcyclotetrasiloxane (D4) exhibit adjuvant activity, the mechanism of immunological response to silicone is still not clear. This study therefore used fluorescence and circular dichroism (CD) spectroscopy to investigate the denaturation and conformational change of two proteins, fibronectin (Fn) and fibrinogen (Fbg), induced by D4 in vitro. Incubating D4 with Fbg or Fn at D4-to-protein ratios of > 100 or for > 10 h yielded white and mould-like precipitates of the proteins, indicating massive denaturation and aggregation. The fact that the decrease in fluorescence intensity of D4-treated Fn and Fbg was accompanied by a red shift in the maximum wavelength also indicated that denaturation of the proteins had taken place. These changes in fluorescence might result from exposure of tryptophan residuals in the proteins to polar water molecules inasmuch as the denaturation would lead to changes in the tertiary structures of the proteins and rearrangement of the tryptophan residues. The loss of the tertiary structure leads to protein denaturation and, consequently, precipitation. The difference in CD spectra between control Fbg (or Fn) and D4-treated Fbg (or Fn) indicated conformational changes of the proteins when incubated with D4. Thus it has been demonstrated that D4 can induce denaturation and conformational changes in Fbg and Fn and it can be expected that protein molecules that have undergone denaturation or conformational change induced by D4 may act as antigens and stimulate the immune system to generate antibodies, ultimately resulting in autoimmune disease.

Bioresorbable materials overcome two major disadvantages of the metal alloys most commonly used in fracture-fixation devices: their extreme stiffness, which causes stress shielding of the underlying bone, and the necessity, in a significant number of cases, of removing metallic implants after fracture healing is complete. The orthopedic surgeon now has the use of polylactic acid, polyglycolic acid, and polydioxanone implants for the fixation of small cancellous bone fractures. The currently available bioresorbable materials lack strength and stiffness and are associated with inflammatory reactions and osteolysis in a significant number of cases. Surgeons should use the available pins and screws with extreme care and attention to the characteristics of each individual injury, particularly its healing characteristics, as well as to the material's initial mechanical properties, degradation rates, and associated complications

Metal alloys are currently the most popular materials for manufacture of fracture-fixation devices. Two major disadvantages of these materials are their extreme stiffness, which causes stress shielding of the underlying bone, and the necessity, in a significant number of cases, of removing metallic implants after fracture healing is complete. These shortcomings of metal alloys have led to the study of bioresorbable materials for use in fracture fixation. Currently, polylactic acid, polyglycolic acid, and polydioxanone implants are available to the orthopedic surgeon for the fixation of small cancellous bone fractures. Part I of this article provides an overview of the basic science of bioresorbable materials and presents a comprehensive review of preclinical studies reported in the orthopedic literature. Clinical studies will be reviewed in Part II

Early reconstruction of large osseous defects in children is often delayed due to limited availability of autogenous bone graft donor sites. With the advent of growth factors, osteoinductive proteins, and delivery matrices, it is possible to fabricate new bone at extraskeletal sites. Due to their own blood supply, adequate bony volume, and decreased resorption, vascularized bone flaps have demonstrated greater success in restoring large bony defects compared with nonvascularized bone grafts. The purpose of this study is to prefabricate a vascularized bone flap in the immature-age rabbit using the auricularis anterior muscle as a muscle pedicle. Sixteen female New Zealand White rabbits, 2.0 to 2.5 kg, were divided into two groups. Group 1 contained 8 animals that had T-shaped, 10 x 6 x 4-mm hydroxyapatite (HA) implants combined with 100-microgram bovine-derived bone morphogenetic protein (BMP) placed supraperiosteally and fixed deep to the auricularis anterior muscle. Implants with HA alone were placed in the same animal and secured to the contralateral auricularis anterior muscle. Group 2 contained 8 animals that had HA/BMP placed subperiosteally and fixed deep to the auricularis anterior muscle, while implants with HA alone were secured in the same animal to the contralateral auricularis anterior muscle. In each group, 4 animals were sacrificed at 4 and 8 weeks. The animals underwent randomized bilateral carotid artery injection with micropaque barium suspension just prior to sacrifice to help maintain vascularity. At harvest the implants and surrounding muscle and cranium were removed en bloc. New bone formation in the HA implants was examined by using routine histology and scanning electron microscopic backscattering image (quantitative) analysis. Microradiographs were performed on representative specimens. At 4 weeks postimplantation, backscattering analysis in the subperiosteal HA/BMP showed a mean 17.1% bone ingrowth vs. 11.3% of HA alone (p < 0.05). Supraperiosteal HA/BMP showed a mean 12.9% bone ingrowth vs. 0% of HA alone (p < 0.05). At 8 weeks, backscatter analysis of supraperiosteal HA/BMP showed a mean 19.33% bone ingrowth vs. 0% of HA alone (p < 0.05). Subperiosteal HA/BMP showed a mean 22% bone ingrowth vs. 20.85% of HA alone. This was the only group that did not have statistically significant results. Implant histology demonstrated woven bone within the interstices of HA/BMP placed either supra- or subperiosteally. In the HA-alone implants placed supraperiosteally, fibrovascular ingrowth was seen without any evidence of bone formation. In the HA-alone implant placed subperiosteally, woven bone was seen at the calvarium-implant junction. Microradiographs also demonstrated vascularization and bone formation similar to that seen on scanning electron microscopy. BMP-treated specimens appeared to have slightly greater vascularity than the nontreated specimens. The greatest bone formation occurred with the HA/BMP implant placed subperiosteally in the immature rabbit. Furthermore, these results demonstrate the potential prefabrication of vascularized bone flaps as early as 4 to 8 weeks. The clinical advantage of HA permits the surgeon to design osseous flaps that are customized in shape, fill all contour defects, and have little resorptive properties. Such prefabricated bone with an axial blood supply may allow for ultimate transfer as a pedicle or free flap to reconstruct osseous defects in children

Rat tendon fibroblast (RTF) and rat bone marrow (RBM) osteoprogenitor cells were cultured and exposed to AC and/or DC magnetic fields in a triaxial Helmholtz coil in an incubator for up to 13 days. The AC fields were at 60 and 1000 Hz and up to 0.25 mT peak to peak, and the DC fields were up to 0.25 mT. At various combinations of field strengths and frequencies, AC and/or DC fields resulted in extensive detachment of preattached cells and prevented the normal attachment of cells not previously attached to substrates. In addition, the fields resulted in altered cell morphologies. When RTF and RBM cells were removed from the fields after several days of exposure, they partially reattached and assumed more normal morphologies. An additional set of experiments described in the Appendix corroborates these findings and also shows that low-frequency EMF also initiates apoptosis, i.e., programmed cell death, at the onset of cell detachment. Taken together, these results suggest that the electromagnetic fields result in significant alterations in cell metabolism and cytoskeleton structure. Further work is required to determine the relative effect of the electric and magnetic fields on these phenomena. The research has implications for understanding the role of fields in affecting bone healing in fracture nonunions, in cell detachment in cancer metastasis, and in the effect of EMF on organisms generally