Transforaminal lumbar interbody fusion with a silicon nitride cage demonstrates early radiographic fusion.

Background: Degeneration of the lumbar spine is common in aging adults and reflects a significant morbidity burden in this population. In selected patients that prove unresponsive to non-surgical treatment, posterior lumbar fusion (PLF) surgery, with or without adjunctive transforaminal lumbar interbody fusion (TLIF) can relieve pain and improve function. We describe here the radiographic fusion rates for PLF versus TLIF, using an intervertebral spinal cage made of silicon nitride ceramic (chemical formula Si3N4). Methods: This retrospective cohort analysis enrolled 99 patients from August 2013 to January 2017; 17 had undergone PLF at 24 levels, while 82 had undergone TLIF at 104 levels. All operations were performed by a single surgeon at one institution. Radiographic and clinical outcomes were compared between PLF and TLIF at 2 and 6 weeks and then at 3, 6, 12, and 24 months. Results: TLIF patients fused at higher rates compared to PLF at the 3-month (38.5% vs. 8.3%, P=0.006), 6-month (78.7% vs. 35.0%, P<0.001) and 12-month time periods (97.9% vs. 81.3%, P=0.018), with no difference at 24 months (100% vs. 94.4%, P=0.102). Index level segmental motion was significantly less and intervertebral disc height was improved in TLIF over PLF at all follow up intervals. Foraminal height was only greater in early follow up periods (2 weeks, 6 weeks and 3 months). TLIF patients experienced lover rates of PI-LL mismatch which was maintained across long term follow-up. Pelvic tilt was lower following TLIF compared to PLF, with no differences in complication rates between study groups. Conclusions: Our retrospective series demonstrated that TLIF performed with silicon nitride interbody cages led to earlier radiographic fusion, greater restoration of disc and foraminal height, increased segmental rigidity and improved sagittal alignment when compared to PLF alone.

Antifungal activity of polymethyl methacrylate/Si3N4 composites against Candida albicans.

Previous studies using gram-positive and -negative bacteria demonstrated that hydrolysis of silicon nitride (Si3N4) in aqueous suspensions elutes nitrogen and produces gaseous ammonia while buffering pH. According to immunochemistry assays, fluorescence imaging, and in situ Raman spectroscopy, we demonstrate here that the antipathogenic surface chemistry of Si3N4 can be extended to polymethylmethacrylate (PMMA) by compounding it with a minor fraction (~8 vol.%) of Si3N4 particles without any tangible loss in bulk properties. The hydrolytic products, which were eluted from partly exposed Si3N4 particles at the composite surface, exhibited fungicidal action against Candida albicans. Using a specific nitrative stress sensing dye and highly resolved fluorescence micrographs, we observed in situ congestion of peroxynitrite (ONOO-) radicals in the mitochondria of the Candida cells exposed to the PMMA/Si3N4 composite, while these radicals were absent in the mitochondria of identical cells exposed to monolithic PMMA. These in situ observations suggest that the surface chemistry of Si3N4 mimics the antifungal activity of macrophages, which concurrently produce NO radicals and superoxide anions (O2•-) resulting in the formation of candidacidal ONOO-. The fungicidal properties of PMMA/Si3N4 composites could be used in dental appliances to inhibit the uncontrolled growth of Candida albicans and ensuing candidiasis while being synergic with chemoprophylaxis. STATEMENT OF SIGNIFICANCE: In a follow-up of previous studies of gram-positive and gram-negative bacteria, we demonstrate here that the antipathogenic surface chemistry of Si3N4 could be extended to polymethylmethacrylate (PMMA) containing a minor fraction (~8 vol.%) of Si3N4 particles without tangible loss in bulk properties. Hydrolytic products eluted from Si3N4 particles at the composite surface exhibited fungicidal action against Candida albicans. Highly resolved fluorescence microscopy revealed congestion of peroxynitrite (ONOO-) radicals in the mitochondria of the Candida cells exposed to the PMMA/Si3N4 composite, while radicals were absent in the mitochondria of identical cells exposed to monolithic PMMA. The fungicidal properties of PMMA/Si3N4 composites could be used in dental appliances to inhibit uncontrolled growth of Candida albicans and ensuing candidiasis in synergy with chemoprophylaxis.

Silicon nitride: a potent solid-state bioceramic inactivator of ssRNA viruses.

Surface inactivation of human microbial pathogens has a long history. The Smith Papyrus (2600 ~ 2200 B.C.) described the use of copper surfaces to sterilize chest wounds and drinking water. Brass and bronze on doorknobs can discourage microbial spread in hospitals, and metal-base surface coatings are used in hygiene-sensitive environments, both as inactivators and modulators of cellular immunity. A limitation of these approaches is that the reactive oxygen radicals (ROS) generated at metal surfaces also damage human cells by oxidizing their proteins and lipids. Silicon nitride (Si3N4) is a non-oxide ceramic compound with known surface bacterial resistance. We show here that off-stoichiometric reactions at Si3N4 surfaces are also capable of inactivating different types of single-stranded RNA (ssRNA) viruses independent of whether their structure presents an envelop or not. The antiviral property of Si3N4 derives from a hydrolysis reaction at its surface and the subsequent formation of reactive nitrogen species (RNS) in doses that could be metabolized by mammalian cells but are lethal to pathogens. Real-time reverse transcription (RT)-polymerase chain reaction (PCR) tests of viral RNA and in situ Raman spectroscopy suggested that the products of Si3N4 hydrolysis directly react with viral proteins and RNA. Si3N4 may have a role in controlling human epidemics related to ssRNA mutant viruses.

Activity and Mechanism of Action of the Bioceramic Silicon Nitride as an Environmentally Friendly Alternative for the Control of the Grapevine Downy Mildew Pathogen Plasmopara viticola.

Downy mildew of grapevine, caused by Plasmopara viticola (Berk. and Curt.) Berl. and de Toni, is one of the most devastating diseases of grapevine, severely affecting grape and wine production and quality worldwide. Infections are usually controlled by the intensive application of synthetic fungicides or by copper-based products in organic farming, rising problems for soil contamination and adverse impacts on environment and human health. While strict regulations attempt to minimize their harmful consequences, the situation calls for the development of alternative fungicidal strategies. This study presents the unprecedented case of a bioceramic, silicon nitride, with antimicrobial properties against P. viticola, but without adverse effects on human cells and environment, opening the way to the possible extension of silicon nitride applications in agriculture. Raman spectroscopic assessments of treated sporangia in conjunction with microscopic observations mechanistically showed that the nitrogen-chemistry of the bioceramic surface affects pathogen's biochemical components and cell viability, thus presenting a high potential for host protection from P. viticola infections.

Two-year results of a double-blind multicenter randomized controlled non-inferiority trial of polyetheretherketone (PEEK) versus silicon nitride spinal fusion cages in patients with symptomatic degenerative lumbar disc disorders.

BACKGROUND: During lumbar spinal fusion, spacer cages are implanted to provide vertebral stability, restore sagittal alignment, and maintain disc and foraminal height. Polyetheretherketone (PEEK) is commonly used by most spine surgeons. Silicon nitride (Si3N4) is a less well-known alternative although it was first used as a spacer in lumbar fusion over 30 years ago. The present study was designed to see if Si3N4 cages would perform similarly to PEEK in a randomized controlled trial. METHODS: A non-inferiority multicenter 100-patient study was designed where both the observer and patient were blinded. Single- or double-level transforaminal lumbar interbody fusion with pedicle screw fixation using an oblique PEEK or Si3N4 cage was performed. The primary non-inferiority outcome was the Roland-Morris Disability Questionnaire (RMDQ). Secondary measures included the Oswestry Disability Questionnaire, Visual Analogue Scales (VAS) for back and leg pain, SF-36 Physical and Mental Function indices, patient and surgeon Likert scores on perceived recovery, and X-ray and CT radiological evaluations for subsidence, segmental motion, and fusion. Follow-up evaluations occurred at 3, 6, 12, and 24 months. RESULTS: After exclusions for protocol violations and canceled surgeries, 92 patients were randomized (i.e., 48 for PEEK and 44 for Si3N4). There were no differences in baseline demographics, pre-operative disabilities, or pain scores between the groups. Both treatment arms showed significant improvements in disability, pain, and recovery scores. No significant differences were observed for subsidence, segmental motion, or fusion. For the primary outcome (i.e., RMDQ scores), the non-inferiority of Si3N4 compared to PEEK could not be established using the original protocol criteria. However, the comparison was undermined by larger than anticipated patient fallout coupled with higher than expected RMDQ score standard deviations. A post hoc analysis coupled with a more extensive review of the literature was conducted which resulted in the selection of a revised clinically justified non-inferiority margin; and using this method, the non-inferiority of Si3N4 was affirmed. CONCLUSIONS: This study demonstrated that the use of either PEEK or Si3N4 cages is safe and effective for patients undergoing lumbar spine fusion for chronic degenerative disc disease.

Surface functionalization of PEEK with silicon nitride.

Surface roughness, bioactivity, and antibacterial properties are desirable in skeletal implants. We hot-pressed a mix of particulate sodium chloride (NaCl) salt and silicon nitride (ß-Si3N4) onto the surface of bulk PEEK. NaCl grains were removed by leaching in water, resulting in a porous PEEK surface embedded with sim15 vol% ß-Si3N4particles. This functionalized surface showed the osteogenic and antibacterial properties previously reported in bulk silicon nitride implants. Surface enhancement of PEEK with ß-Si3N4could improve the performance of spinal fusion cages, by facilitating arthrodesis and resisting bacteria.

Clinical outcomes for lumbar fusion using silicon nitride versus other biomaterials.

BACKGROUND: In lumbar fusion surgery, intervertebral spacer cages made of silicon nitride (Si3N4) ceramic are an available option among other biomaterials. While the surface chemistry of Si3N4 is known to favor bone fusion, large-scale clinical studies attesting to its efficacy are lacking. This multicenter retrospective study compared lumbar fusion outcomes for Si3N4 cages to previously reported data for other cage materials. METHODS: Pre-operative patient demographics, comorbidities, changes in visual analog scale (ΔVAS) pain scores, complications, adverse events, and secondary surgical interventions (SSI) were compiled from the records of 450 patients who underwent Si3N4 lumbar spinal fusion at four separate U.S. surgical centers. For comparison, MEDLINE/PubMed and Google Scholar searches identified studies reporting similar outcomes for other biomaterials. A total of 1,025 patients from 26 cohorts reported in 14 publications met inclusion criteria for this control group. RESULTS: Overall, the mean last-follow-up for all patients was 341±293 days (11.4±9.8 months), with the longest follow-up being 6.4 years. Patients with Si3N4 implants were similar in gender and age distribution to the control group but had higher BMI values (30.9±6.1 vs. 25.8±4.1, P<0.01) and lower tobacco use (15.8% vs. 30.0%, P<0.01). Both the Si3N4 and control groups showed significant improvements in VAS pain scores from preoperative to last follow-up. For the Si3N4 group, ΔVAS was 36.8±35.4 points compared to 37.6±22.5 points (P=0.63) for the metadata group. Complications and reoperations for the Si3N4 and the control groups were similar (i.e., 9.8% and 3.1% versus 12.4% and 2.9%, P=0.16 and P=0.84, respectively). CONCLUSIONS: Lumbar fusion with Si3N4 spacers compared favorably with the improvements reported with other commonly used biomaterial cages.

3D-additive deposition of an antibacterial and osteogenic silicon nitride coating on orthopaedic titanium substrate.

A 3D-additive manufacturing approach produced a dense Si3N4 ceramic coating on a biomedical grade commercially pure titanium (cp-Ti) substrate by an automatic laser-sintering procedure. Si3N4 coatings could be prepared with thicknesses from the single to the tens of microns. A coating thickness, t = 15 ± 5 µm, was selected for this study, based on projections of homogeneity and scratching resistance. The Si3N4 coating met the 20 N threshold required for biomaterial applications, according to the standard scratch testing (ASTM C1624-05). The Si3N4 coating imparted both the antibacterial and osteogenic properties of bulk Si3N4 to the cp-Ti substrate. Both properties were comparable to those previously described for bulk Si3N4 biomedical implants. The newly developed Si3N4-coating was applied to commercially available Ti-alloy acetabular shells for total hip arthroplasty. A "glowing" test based on luciferase gene transformation was applied to visualize the colonization of gram-negative Escherichia coli on Si3N4-coated and uncoated Ti-alloy acetabular shells. The results showed that the coating technology conferred resistance to Staphylococcus epidermidis and Escherichia coli adhesion onto the bulk acetabular sockets.

Burst Strength of BIOLOX®delta Femoral Heads and Its Dependence on Low-Temperature Environmental Degradation.

Zirconia-toughened alumina (ZTA) currently represents the bioceramic gold standard for load-bearing components in artificial hip joints. ZTA is long known for its high flexural strength and fracture toughness, both properties arising from a microscopic crack-tip shielding mechanism due to the stress-induced tetragonal-to-monoclinic (t→m) polymorphic transformation of zirconia. However, there have been concerns over the years regarding the long-term structural performance of ZTA since the t→m transformation also spontaneously occurs at the material's surface under low-temperature environmental conditions with a concomitant degradation of mechanical properties. Spontaneous surface degradation has been extensively studied in vitro, but predictive algorithms have underestimated the extent of in vivo degradation observed in retrievals. The present research focused on burst-strength assessments of Ø28 mm ZTA femoral before and after long-term in vitro hydrothermal ageing according to ISO 7206-10. An average burst strength of 52 kN was measured for pristine femoral heads. This value was ~36% lower than results obtained under the same standard conditions by other authors. A further loss of burst strength (~13% in ultimate load) was observed after hydrothermal ageing, with increased surface monoclinic content ranging from ~6% to >50%. Nevertheless, the repetitively stressed and hydrothermally treated ZTA heads exceeded the minimum burst strength stipulated by the US Food and Drug Administration (FDA) despite severe test conditions. Lastly, Raman spectroscopic assessments of phase transformation and residual stresses on the fracture surface of the femoral heads were used to clarify burst-strength fluctuations and the effect of hydrothermal ageing on the material's overall strength degradation.

Enhanced bioactivity of Si3N4 through trench-patterning and back-filling with Bioglass®.

Using a simple and innovative sandblasting process, disks of monolithic biomedical silicon nitride (ß-Si3N4) were texturized with a matrix of regular, discrete square trenches with a total depth in the range of hundreds of microns. The process consisted of sandblasting Si3N4 substrates through a stainless-steel wire-mesh (150 or 200 µm) using abrasive silicon carbide powders (α-SiC, ∼40 µm) under 1,034 kPa (150 psi) of gas pressure. The depth of the porosities could be controlled varying both the treatment time and the distance from the surface. Part of the samples were then filled with 45S5 Bioglass® powders to improve the osteointegration and stimulate the production of bone tissue. Due to the increased macroscopic and microscopic roughness, biological testing using human osteosarcoma cells (SaOS-2) showed improved cell proliferation and greater production of both mineral (hydroxyapatite) and organic (collagen) phases on the patterned surfaces compared to untreated ß-Si3N4 or to the biomedical titanium control samples. Both of these effects were further enhanced when the porosities were filled with Bioglass®.

The role of nitrogen off-stoichiometry in the osteogenic behavior of silicon nitride bioceramics.

The surface chemistry of silicon nitride plays an important role in stimulating osteoblasts to proliferate and produce bone tissue with improved efficiency. This property, which is advantageous in spinal fusion surgery has a chemical origin and is a direct consequence of the cleavage of covalent SN bonds in an aqueous environment. Building upon a wealth of published research on the stimulation of osteoblastic activity by silicon, the aim of this paper is to explore the role of nitrogen and, more specifically, the N/Si atomic ratio on the osteogenic response of Si3N4. The surface stoichiometry of Si3N4 was gradually altered toward a silicon-rich composition by systematically treating the Si3N4 surface with a high-power pulsed laser in an Ar gas atmosphere (i.e., operated at different pulse times, spot sizes, and voltages). Different analytical probes were used to characterize the surface including X-ray photoelectron spectroscopy (XPS), Raman spectroscopy, and energy dispersive X-ray spectroscopy (EDS). Osteoconductivity was tested in vitro using SaOS-2 osteosarcoma cells, and samples with different surface stoichiometry were compared for their osteogenic response. These experiments clearly indicated a fundamental role for nitrogen off-stoichiometry in osteogenesis, and showed that both cell proliferation and growth of bone tissue diminished with decreasing nitrogen content.

Off-Stoichiometric Reactions at the Cell-Substrate Biomolecular Interface of Biomaterials: In Situ and Ex Situ Monitoring of Cell Proliferation, Differentiation, and Bone Tissue Formation.

The availability of osteoinductive biomaterials has encouraged new therapies in bone regeneration and has potentially triggered paradigmatic shifts in the development of new implants in orthopedics and dentistry. Among several available synthetic biomaterials, bioceramics have gained attention for their ability to induce mesenchymal cell differentiation and successive bone formation when implanted in the human body. However, there is currently a lack of understanding regarding the fundamental biochemical mechanisms by which these materials can induce bone formation. Phenomenological studies of retrievals have clarified the final effect of bone formation, but have left the chemical interactions at the cell-material interface uncharted. Accordingly, the knowledge of the intrinsic material properties relevant for osteoblastogenesis and osteoinduction remains incomplete. Here, we systematically monitored in vitro the chemistry of mesenchymal cell metabolism and the ionic exchanges during osteoblastogenesis on selected substrates through conventional biological assays as well as via in situ and ex situ spectroscopic techniques. Accordingly, the chemical behavior of different bioceramic substrates during their interactions with mesenchymal cells could be unfolded and compared with that of biomedical titanium alloy. Our goal was to clarify the cascade of chemical equations behind the biological processes that govern osteoblastogenic effects on different biomaterial substrates.

In situ molecular vibration insights into the antibacterial behavior of silicon nitride bioceramic versus gram-negative Escherichia coli.

Gram-negative bacteria represent a substantial fraction of pathogens responsible for periprosthetic infections. Given the increasing resistance of such bacteria to antibiotics, significant efforts are nowadays paid in developing new biomaterial surfaces, which offer resistance against bacterial adhesion and/or possess inherent antibacterial effects. Non-oxide silicon nitride (Si3N4) bioceramic in its polycrystalline form is a biomaterial with inherent antibacterial properties. Building upon previous phenomenological findings, the present study focuses on vibrational analyses of the metabolic response of Escherichia coli at the molecular level. A time-lapse study is conducted upon exposing the bacteria in vitro to Si3N4 bioceramic surfaces. A comparison is carried out with the as-cultured bacterial strain and with bacteria exposed to other commercially available biomaterials, namely, Ti-alloy (Ti6Al4V-ELI) and zirconia-toughened alumina (ZTA) oxide bioceramic tested under exactly the same experimental conditions. The metabolic pathways before and after exposure to different substrates were monitored by means of Raman and FTIR spectroscopies. Results indicated the development of significant osmotic stress in the bacterial strain and constant concentration decreases of its cellular compounds markers over time upon exposure to Si3N4. This ultimately led to bacterial lysis (also confirmed by conventional fluorescence microscopy assays). The main antibacterial effect was of chemical origin and driven by the elution of nitrogen ions from the Si3N4 surface, successively converted into ammonia (NH3) or ammonium (NH4)+ in aqueous solution, depending on environmental pH. The presence of these nitrogen species created osmotic stress in the cytoplasmic space. In answer to the osmotic stress, metabolic rates changed rapidly, the bacterial membrane was damaged, and lysis occurred almost completely within 48 h exposure. The antibacterial behavior exerted by the Si3N4 substrate on E. coli was more effective than that observed on the biomedical Ti6Al4V alloy. Conversely, no lysis but bacterial proliferation was recorded for E. coli exposed to ZTA bioceramic oxide substrates.

Clinical outcomes for anterior cervical discectomy and fusion with silicon nitride spine cages: a multicenter study.

BACKGROUND: Intervertebral spacers made of silicon nitride (Si3N4) are currently used in cervical and thoracolumbar fusion. While basic science data demonstrate several advantages of Si3N4 over other biomaterials, large-scale clinical results on its safety and efficacy are lacking. This multicenter retrospective study examined outcomes for anterior cervical discectomy and fusion (ACDF) using Si3N4 cages. Results were compared to compiled metadata for other ACDF materials. METHODS: Pre-operative patient demographics, comorbidities, changes in visual analog scale (VAS) pain scores, complications, adverse events, and secondary surgical interventions were collected from the medical records of 860 patients who underwent Si3N4 ACDF at four surgical centers. For comparison, MEDLINE/PubMed and Google Scholar searches were performed for ACDF using other cage or spacer materials. Nine studies with 13 cohorts and 736 patients met the inclusion criteria for this control group. RESULTS: Overall, the mean last-follow-up for all patients was 319±325 days (10.6±10.8 months), with the longest follow-up being 6.5 years. In comparison to the metadata, patients from the Si3N4 groups were older (57.9±12.2 vs. 56.8±11.1 y, P=0.06) and had higher BMI values (30.0±6.3 vs. 28.1±6.5, P<0.01), but gender and smoking were not different. The Si3N4 patients reported significant improvements in VAS pain scores at last follow-up (i.e., pre-op of 71.0±22.1 vs. follow-up of 36.4±31.5, P<0.01). Although both preoperative and last-follow-up pain scores were higher for Si3N4 patients than the control, the overall change in scores (ΔVAS) was similar. From pre-op to last-follow up, ΔVAS values were 35.4±34.3 for patients receiving the Si3N4 implants versus 34.4±27.3 for patients from the meta-analysis (P=0.56). The complication and reoperation rate for the Si3N4 and the metadata were also comparable (i.e., 7.39% and 0.31% versus 9.79% and 0%, P=0.17 and 0.25, respectively). CONCLUSIONS: ACDF outcomes using Si3N4 implants matched the clinical efficacy of other cage biomaterials.

Bioglass functionalization of laser-patterned bioceramic surfaces and their enhanced bioactivity.

The surfaces of silicon nitride (ß-Si3N4) and zirconia toughened alumina (ZTA) were patterned using a high-energy laser source, which operated at a wavelength of 1064 nm. The patterning procedure yielded a series regular, cylindrical cavities 500 and 300 µm in diameter and depth, respectively. These cavities were subsequently filled with bioglass mixed with different fractions of Si3N4 powder (0, 5, and 10 mol.%) to obtain bioactive functionalized bioceramic surfaces. The laser-patterned samples were first characterized using several spectroscopic techniques before and after functionalization, and then tested in vitro with respect to their osteoconductivity using a human osteosarcoma cell line (SaOS-2). After in vitro testing, fluorescence microscopy was used to address the biological response and to estimate osteopontin and osteocalcin protein contents and distributions. The presence of bioglass greatly enhanced the biological response of both ceramic surfaces, but mainly induced production of inorganic apatite. On the other hand, the addition of minor fraction of Si3N4 into the bioglass-filled holes greatly enhanced bio-mineralization and stimulated the SaOS-2 cells to produce higher amounts of bone extracellular matrix (collagen and proteins), thus enhancing the osteopontin to osteocalcin ratio. It was also observed that the presence of a fraction of Si3N4 in the powder mixture filling the holes bestowed more uniform cell colonization on the otherwise bioinert ZTA surface.

A single center retrospective clinical evaluation of anterior cervical discectomy and fusion comparing allograft spacers to silicon nitride cages.

BACKGROUND: Iliac crest autograft or allograft spacers have been traditionally utilized in anterior cervical discectomy and fusion (ACDF) to provide vertebral stabilization and enhanced osteogenesis. However, abiotic cages have largely replaced these allogenic sources due to host-site morbidities and disease transmission risks, respectively. Although devices made of polyetheretherketone (PEEK) or titanium-alloys (Ti) have gained wide popularity, they lack osteoinductive or conductive capabilities. In contrast, silicon nitride (Si3N4) is a relatively new implant material that also provides structural stability and yet purportedly offers osteopromotive and antimicrobial behavior. This study compared radiographic outcomes at ≥12 months of follow-up for osseous integration, fusion rate, time to fusion, and subsidence in ACDF patients with differing intervertebral spacers. METHODS: Fifty-eight ACDF patients (108 segments) implanted with Si3N4 cages were compared to thirty-four similar ACDF patients (61 segments) implanted with fibular allograft spacers. Lateral radiographs (normal, flexion, and extension) were obtained at 3, 6, 12, and 24 months to assess osseous integration, the presence of bridging bone, the absence of peri-implant radiolucencies, subsidence, and fusion using both interspinous distance (ISD) and Cobb angle methods. RESULTS: In patients with ≥12 months of follow-up, fusion for the allograft spacers and Si3N4 cages was 86.84% and 96.83%, respectively (ISD method, P=0.10), and 67.65% and 84.13%, respectively (Cobb angle method P=0.07), while osseointegration was 76.32% and 93.65%, respectively (P=0.02). The time to fusion significantly favored the Si3N4 cages (4.08 vs. 8.64 months (ISD method, P=0.01), and 6.76 vs. 11.74 months (Cobb angle method, P=0.04). The assessed time for full osseointegration was 7.83 and 19.24 months for Si3N4 and allograft, respectively (P=0.00). Average subsidence at 1-year follow-up was 0.51 and 2.71 mm for the Si3N4 and allograft cohorts, respectively (P=0.00). CONCLUSIONS: In comparison to fibular allograft spacers, Si3N4 cages showed earlier osseointegration and fusion, higher fusion rates, and less subsidence.

In vitro antibacterial activity of oxide and non-oxide bioceramics for arthroplastic devices: I. In situ time-lapse Raman spectroscopy.

Over the next two decades, a strong demographic demand for arthroplastic devices coupled with a decreased efficacy of antibiotics has been predicted to result in an exponential increase in the number of periprosthetic joint infections (PJIs). Advanced strategies are therefore required to improve the local peri-implant immune response and curb the pathogenic events of bacterial adhesion and biofilm formation. The use of biomaterials that autonomously counter infections is one approach to improve orthopedic outcomes. Using conventional molecular biology characterization methods and advanced Raman spectroscopy, this study examined the bacteriostatic response of two bioceramic materials commonly employed as prosthetic implants: zirconia-toughened alumina (ZTA) and silicon nitride (Si3N4). Unlike the ZTA, it was found that non-oxide Si3N4 possesses an inherently anti-infective surface chemistry, which acts in a responsive way against bacterial loading. The mechanistic details of its behavior are elucidated. Non-oxide bioceramics appear to be promising, but their full development requires a transitional approach that integrates the fundamental biochemical concepts with clinical outcomes.

Incorporating Si3 N4 into PEEK to Produce Antibacterial, Osteocondutive, and Radiolucent Spinal Implants.

Polyetheretherketone (PEEK) is a popular polymeric biomaterial which is primarily used as an intervertebral spacer in spinal fusion surgery; but it is developed for trauma, prosthodontics, maxillofacial, and cranial implants. It has the purported advantages of an elastic modulus which is similar to native bone and it can be easily formed into custom 3D shapes. Nevertheless, PEEK's disadvantages include its poor antibacterial resistance, lack of bioactivity, and radiographic transparency. This study presents a simple approach to correcting these three shortcomings while preserving the base polymer's biocompatibility, chemical stability, and elastic modulus. The proposed strategy consists of preparing a PEEK composite by dispersing a minor fraction (i.e., 15 vol%) of a silicon nitride (Si3 N4 ) powder within its matrix. In vitro tests of PEEK composites with three Si3 N4 variants-ß-Si3 N4 , α-Si3 N4 , and ß-SiYAlON-demonstrate significant improvements in the polymer's osteoconductive versus SaOS-2 cells and bacteriostatic properties versus gram-positive Staphylococcus epidermidis bacteria. These properties are clearly a consequence of adding the bioceramic dispersoids, according to chemistry similar to that previously demonstrated for bulk Si3 N4 ceramics in terms of osteogenic behavior (vs both osteosarcoma and mesenchymal progenitor cells) and antibacterial properties (vs both gram-positive and gram-negative bacteria).

In vitro antibacterial activity of oxide and non-oxide bioceramics for arthroplastic devices: II. Fourier transform infrared spectroscopy.

The metabolic response of Gram-positive Staphylococcus epidermidis (S. epidermidis) bacteria to bioceramic substrates was probed by means of Fourier transform infrared spectroscopy (FTIR). Oxide zirconia-toughened alumina (ZTA) and non-oxide silicon nitride (Si3N4) substrates were tested. Bacteria exposed to silica glass substrates were used as a control. S. epidermidis, a major cause of periprosthetic infections, was screened to obtain a precise time-lapse knowledge of its molecular composition and to mechanistically understand its interaction with different substrates. At the molecular level, the structure of proteins, lipids, nucleic acid, and aromatic amino acids evolved with time in response to different substrates. In combination with statistical validation and local pH measurements, a chemical lysis mechanism was spectroscopically observed in situ on the Si3N4 substrates. Utilization of FTIR in this study avoided fluorescence noise which occurred while probing the ZTA samples with Raman spectroscopy in a companion paper. The substrate-driven dynamics of polysaccharide and peptide variations in the bacterial cell wall, peculiar to Si3N4 bioceramics, are elucidated.

Oxide ceramic femoral heads contribute to the oxidation of polyethylene liners in artificial hip joints.

Experimental evidence demonstrates that a loss of stoichiometry at the surface of oxide bioceramic femoral heads enhances the oxidation rate of polyethylene acetabular liners in artificial hip joints. Contradicting the common notion that ceramics are bioinert, three independent experiments confirmed substantial chemical interactions between the ceramic femoral heads and their polyethylene counterparts. The experiments reported herein included hydrothermal tests, frictional tests, and hip-simulator experiments. It was discovered that oxide and non-oxide femoral heads differently affected the oxidation processes at the surface of the polyethylene liners, all other testing parameters being equal. Analytical data from X-ray photoelectron (XPS), cathodoluminescence (CL), Fourier-transform infrared (FTIR), and Raman spectroscopies unequivocally and consistently showed that the oxidation rate of polyethylene liners was greater when coupled with oxide as opposed to non-oxide ceramic heads. XPS analyses of O-Al-O bond fractions at the surface of a zirconia-toughened alumina (ZTA) short-term (20 months in vivo) femoral heads retrieval showed a ~50% reduction in favor of oxygen vacancy O-Al-VO and hydroxylated Al-O-H bonds. Off-stoichiometry drifts were confirmed in vitro under both static and dynamic conditions. They triggered oxidation and tangibly affected an advanced highly cross-linked sequentially irradiated and annealed ultra-high molecular weight polyethylene (UHMWPE) liner (increase in oxidation index up to ΔOI~1.2 after 5 × 105 cycles under dynamic swing conditions). Second-generation UHMWPE liners infused with vitamin E were also affected by the free flow of oxygen from the oxide femoral heads, although to a lesser extent. The fundamental findings of this study, which were also confirmed on retrievals, call for revised standards in material design and testing. Adopting these new criteria will provide an improved understanding of the importance of off-stoichiometry at the head/liner interface and may lead to significant extensions in artificial joint lifetimes.