Cobalt-Chromium Alloy Has Superior Antibacterial Effect Than Titanium Alloy: In Vitro and In Vivo Studies.

STUDY DESIGN: In vitro and in vivo laboratory studies. OBJECTIVE: This study aimed to compare bacterial survival on titanium alloy (Ti) and cobalt-chromium alloy (CC) using in vitro and in vivo experiments. SUMMARY OF BACKGROUND DATA: Spinal implants are frequently manufactured from Ti and CC. These foreign materials are thought to be susceptible to biofilm formation that contributes to the development of surgical site infections. Certain metals (i.e., silver, cobalt) are known to have antibacterial properties. METHODS: In the in vitro study, discs made of Ti or CC were incubated with one of two common bacteria: Staphylococcus aureus (S. aureus) and Propionibacterium acnes (P. acnes). After incubation, discs were assessed to determine the number of viable bacterial cells. In the in vivo study, the discs that were made of CC or Ti were implanted into the subcutaneous layer of BALB/c mice. After skin closure, a suspension including either S. aureus or P. acnes was directly inoculated on the implanted discs. The discs were retrieved and analyzed to determine the number of viable bacteria at 0.5, 1, and 3 days after inoculation. RESULTS: The number of viable S. aureus cultured from the CC discs was 0.9 ±â€Š0.2 × 103 CFU/disc, which was significantly lower than the cultured Ti discs (114.8 ±â€Š18.3 × 103 CFU/disc). Moreover, a significantly lower mean number of P. acnes were cultured with CC (1.9 ±â€Š1.2 × 103 CFU/disc) compared with the Ti (180.0 ±â€Š72.1 × 103 CFU/disc). The in vivo infection model testing against S. aureus or P. acnes showed a significantly lower number of viable S. aureus or P. acnes on CC discs than Ti discs. The result was seen at all measured time points. CONCLUSION: CC suppressed S. aureus and P. acnes proliferation compared with Ti in vitro and in an in vivo infection model.Level of Evidence: N/A.

Effects of an internet-based cognitive behavioral therapy (iCBT) intervention on improving depressive symptoms and work-related outcomes among nurses in Japan: a protocol for a randomized controlled trial.

BACKGROUND: Depression is a major problem among nurses; hence, it is important to develop a primary prevention strategy to manage depression among nurses. This randomized controlled trial (RCT) study aims to investigate the effects of a newly developed internet-based cognitive behavioral therapy (iCBT) program on depressive symptoms, measured at baseline and three- and six-month follow-ups, among nurses in Japan. METHODS: Nurses working at three university hospitals, one public hospital, and twelve private hospitals who meet inclusion criteria will be recruited and randomized either to the intervention group or the control group (planned N = 525 for each group). The newly developed iCBT program for nurses consists of six modules, which cover different components of cognitive behavioral therapy (CBT); transactional stress model (in module 1), self-monitoring skills (in module 2), behavioral activation skills (in module 3), cognitive restructuring skills (in modules 4 and 5), relaxation skills (in module 5), and problem-solving skills (in module 6). Participants in the intervention group will be asked to read these modules within 9 weeks. The primary outcome will be depressive symptoms as assessed by the Beck Depression Inventory-II (BDI-II) at baseline, three-, and six-month follow-ups. DISCUSSION: The greatest strength of this study is that it is the first RCT to test the effectiveness of the iCBT program in improving depressive symptoms among nurses. A major limitation is that all measurements, including major depressive episodes, are self-reported and may be affected by situational factors at work and participants' perceptions. TRIAL REGISTRATION: This trial was registered at the University Hospital Medical Information Network clinical trials registry (UMIN-CTR; ID = UMIN000033521 ) (Date of registration: August 1, 2018).

Effect of spatial design and thermal oxidation on apatite formation on Ti-15Zr-4Ta-4Nb alloy.

Apatite formation on the surface of titanium and its alloys is effective for inducing osteoconductivity when implanted in bony defects. The aim of this study was to investigate the effects of thermal oxidation on apatite formation in macro-grooves on Ti-15Zr-4Ta-4Nb. Thermal oxidation at 500 and 600 degrees C in air led to modification of the Ti-15Zr-4Ta-4Nb surface to rutile phase titanium oxide. Ti-15Zr-4Ta-4Nb thermally oxidized at 500 degrees C in air showed no changes in metallographic structure, but not at 600 degrees C. After soaking in a simulated body fluid for 7days, the formation of apatite could be observed on the internal surfaces of macro-grooves 500mum deep and wide on Ti-15Zr-4Ta-4Nb thermally oxidized at 500 and 600 degrees C in air. These results indicate the potential for osteoconductivity of Ti-15Zr-4Ta-4Nb without changing its metallographic structure, by fabricating only the macro-grooves, i.e., spatial design, and by performing thermal oxidation at 500 degrees C.

Bioactive composites consisting of PEEK and calcium silicate powders.

Bioactive bone-repairing materials with mechanical properties analogous to those of natural bone can be obtained through the combination of bioactive ceramic fillers with organic polymers. Previously, we developed novel bioactive microspheres in a binary CaO-SiO2 system produced through a sol-gel process as filler for the fabrication of composites. In this study, we fabricate bioactive composites in which polyetheretherketone is reinforced with 0-50 vol% 30CaO x 70SiO2 (CS) microspheres. The prepared composites reinforced with CS particles form hydroxyapatite on their surfaces in simulated body fluid. The induction periods of hydroxyapatite formation on the composites decrease with increasing amount of CS particles. The mechanical properties of the composites are evaluated by three-point bending test. The composites reinforced with 20 vol% CS particles show 123.5 MPa and 6.43 GPa in bending strength and Young's modulus, respectively.

In vivo response of bioactive PMMA-based bone cement modified with alkoxysilane and calcium acetate.

The use of polymethylmethacrylate (PMMA)-based bone cement is popular in orthopedics for the fixation of artificial joints with bone. However, it has a major problem with prostheses loosening because of coverage by fibrous tissue after long-term implantation. Recently, a bioactive bone cement has been developed that shows direct bonding to living bone through modification of PMMA resin with gamma-methacryloxypropyltrimethoxysilane (MPS) and calcium acetate. The cement is designed to exhibit bioactivity, through incorporation of silanol groups and calcium ions. Thus, it has the potential to form a layer of bone-like hydroxyapatite, which is essential for achieving direct bonding to living bone. This type of modification allows the cement to show spontaneous hydroxyapatite formation on its surface in a simulated body fluid after one day, and there is evidence of osteoconduction of the cement in rabbit tibia for periods of more than three weeks. However, the influence of the dissolved ions from the modified cement has not yet been clarified. Thus, the authors focused on the dissolution of the modified PMMA-based bone cement and its tissue response in muscle and bone by comparison with the behavior of non-modified PMMA-based bone cement. One week after implantation in the latissimus dorsi of a rabbit, the modified PMMA-based bone cement showed more inflammatory width than the commercial cement. However, four weeks after implantation, the inflammatory width of both cements was essentially the same. The osteoconductivity around the modified cement was higher than that for the conventional cement after four weeks implantation. These results indicate that the initial dissolution of calcium acetate from the modified cement to form the hydroxyapatite induced the acute inflammation around tissue, but also developed the osteoconductivity. It is suggested that the initial inflammation can be effective for inducing osteoconduction through a bone healing reaction when the material provides an environment that promotes bone formation.

Apatite-forming ability of polyglutamic acid hydrogels in a body-simulating environment.

Artificial joints can replace damaged joints provided the surrounding bone is sufficiently dense. However, elderly patients generally have reduced osteoporosis-associated bone density. Therefore, restitution of bone density is essential to ensure implantation. Injectable and resorbable bioactive fillers with bone-bonding ability (osteoconductivity) are promising, as osteoporosis can be reversed with minimal invasion. Osteoconduction occurs through the surface formation of biologically active hydroxyapatite via reactions with body fluids. Heterogeneous nucleation of the hydroxyapatite is catalysed by specific surface functional groups. In addition, release of Ca2+ ions into the surrounding fluids enhances apatite nucleation by increasing its degree of supersaturation. We tested injectable bioactive filler made from cross-linked polyglutamic acid (PGA). This has many carboxyl groups that facilitate apatite nucleation. An insoluble hydrogel can be formed by cross-linkage. We exposed PGA gels to a simulated body fluid for 7 days. Trace amounts of calcium phosphate were formed, but were not identified as bone-like apatite by X-ray diffraction. However, formation of a bone-like apatite layer was detected using pre-treatment with CaCl2 solutions (>0.01 mol dm(-3)) dose dependently. Thus, this chemically cross-linked PGA gel could induce the heterogeneous nucleation of hydroxyapatite in a body environment, and this was enhanced by pre-treatment with CaCl2.

Relationship between apatite-forming ability and mechanical properties of bioactive PMMA-based bone cement modified with calcium salts and alkoxysilane.

Polymethylmethacrylate (PMMA)-based bone cement is used for the fixation of artificial joints in orthopaedics. However, the fixation is liable to loosen in the body, because the cement does not bond to living bone. So-called bioactive ceramics bond directly to living bone through the apatite layer formed on their surfaces in the body. We previously revealed that modification using gamma-methacryloxypropyltrimethoxysilane (MPS) and water-soluble calcium salts such as calcium acetate and calcium hydroxide was effective for providing the PMMA-based bone cement with apatite-forming ability in a simulated body fluid (SBF, Kokubo solution) that closely reproduces the body environment. However, the effect of the chemical reaction forming the apatite on the mechanical properties of the cements has not been clarified. The present work aimed to investigate this issue from the viewpoint of the interface structure between the apatite and the cement. The surface of the cement modified with calcium acetate and MPS was fully covered with newly formed apatite after soaking in Kokubo solution within 7 days, while half of the surface area of the cement modified with calcium hydroxide and MPS was covered with the apatite. The bending strength of the modified cements decreased after soaking in Kokubo solution. Porous structure was observed in the region about 50-100 microm in depth from the top surface because of release of the Ca2+ ions by both modified cements after soaking in Kokubo solution. The decrease in bending strength of the modified cements could be attributed to the formation of the pores. In addition, the pores on the top surfaces of the cements were filled with the newly formed apatite. The apatite formation would be effective not only for bioactivity but also for decreasing the reduction of mechanical strength.

Mechanical and histological evaluation of a PMMA-based bone cement modified with gamma-methacryloxypropyltrimethoxysilane and calcium acetate.

Polymethylmethacrylate (PMMA) bone cement is widely used for prosthetic fixation in orthopaedic surgery; however, the interface between bone and cement is a weak zone. We developed a bioactive PMMA cement through modification with gamma-methacryloxypropyltrimethoxysilane (MPS) and calcium acetate. The purpose of this study was to compare the handling, mechanical and histological properties of the modified bone cement with those of the conventional cement. The modified specimens exhibited higher bonding strength between bone and implant. Histological observation and micro-focus X-ray computed tomogram (micro-CT) images showed that the modified cement exhibited osteoconduction, which the conventional PMMA bone cement lacked. The modification was found to be effective in enabling osteoconduction with PMMA bone cement, thus providing stable fixation for a long period after implantation.

Enhanced fixation of implants by bone ingrowth to titanium fiber mesh: effect of incorporation of hydroxyapatite powder.

Tight fixation between bone and implant materials is of great importance for a successful outcome of procedures such as total knee arthroplasty (TKA) and total hip arthroplasty (THA). Titanium fiber mesh is an attractive structure for the establishment of tight fixation between bone and implant by bone ingrowth into the spaces among the fibers. Enhancement of bone ingrowth is desired not only for tight fixation but also for a fast recovery. Our hypothesis is that just the presence of hydroxyapatite (HA) particles ensures improved bone ingrowth, and that long-term stability can be obtained by mechanical anchoring of bone in the spaces among titanium fibers. In this study, we examine our hypothesis by in vivo experiment using dog femur. HA particles were incorporated in titanium fiber mesh coated on titanium alloy rod by dipping in a slurry of HA with hydroxy-propyl-cellulose in an ethanol solution. Specimens were implanted for 3, 5, and 8 weeks, and were then compared with the results from specimens without the use of HA. Bonding strength was evaluated by push-out test, and histomorphometric measurements were made with analysis software to calculate the average value of bone ingrowth. A significantly higher bonding strength was observed for the specimens with HA-incorporated implant at 3 and 5 weeks, and larger bone ingrowth deep inside the titanium fiber mesh was measured at 3 weeks. Our proposed method has the additional advantage of not requiring a high temperature that may result in changes in characters of HA powder such as phase transition, grain growth, and decomposition. Moreover, this technique of HA powder incorporation without high-temperature treatment allows the use of several types of metallic fiber mesh, as well as the application to fiber mesh made of organic polymers. We conclude that this simple modification of titanium fiber mesh with HA powder can improve the fixation of implant to bone in the initial stage after operation.