Abstract
Metallic implants are commonly used in various orthopaedic surgeries, like fracture fixation, spinal instrumentation, joint replacement and bone tumour surgery. Patients may need to adapt to the fixed dimensions of the standard implants. It may result in suboptimal fit to the host bones and possible adverse clinical results. The standard traditional implants may not address the reconstructive challenges such as severe bone deformity or bone loss after implant loosening and bone tumour resection. With the advent of digital technologies in medical imaging, computer programming in three-dimensional (3D) modelling and computer-assisted tools in precise placement of implants, patient-specific implants (PSI) have gained more attention in complex orthopaedic reconstruction. Additive manufacturing technology, in contrast to the conventional subtractive manufacturing, is a flexible process that can fabricate anatomically conforming implants that match the patients’ anatomy and surgical requirements. Complex internal structures with porous scaffold can also be built to enhance osseointegration for better implant longevity. Although basic studies have suggested that additive manufactured (AM) metal structures are good engineered biomaterials for bone replacement, not much peer-reviewed literature is available on the clinical results of the new types of implants. The article gives an overview of the metallic materials commonly used for fabricating orthopaedic implants, describes the metal-based additive manufacturing technology and the processing chain in metallic implants; discusses the features of AM implants; reports the current status in orthopaedic surgical applications and comments on the challenges of AM implants in orthopaedic practice.
摘要
金属植入物通常用于各种矫形外科手术, 如骨折固定、 脊柱内置物、 关节置换和骨肿瘤手术等. 患者需要适应标准植入物的固定尺寸, 这可能会导致对宿主骨的不匹配和其他临床副作用. 标准的传统植入物可能无法解决骨骼重建的挑战, 如种植体松动和骨肿瘤切除后严重的骨骼畸形或骨质流失. 随着数字技术应用于医学成像, 如三维(3D)建模中的计算机编程和精确植入种植体的计算机辅助工具, 患者特异性植入物在复杂的骨科重建中获得了更多关注. 与传统的减材制造相比, 增材制造技术是一种灵活的工艺, 它可以制备符合解剖学标准的植入物以匹配患者解剖结构和手术要求, 还可以建立复杂的内部结构与多孔支架, 以促进骨整合和延长植入寿命. 尽管基础研究表明增材制造(AM)金属结构是良好的骨替代生物材料, 但关于此类新型植入物临床结果的同行评议文献还不是很多. 本文概述了通常用于制造矫形外科植入物的金属材料, 描述了基于金属的增材制造技术和金属植入物的加工链, 介绍了AM植入物的特征及其在矫形手术中的应用现状, 最后讨论了AM植入物在矫形外科应用中存在的挑战.
Article PDF
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
References
Neal ML, Kerckhoffs R. Current progress in patient-specific modeling. Briefings Bioinf, 2010, 11: 111–126
Laine T, Lund T, Ylikoski M, et al. Accuracy of pedicle screw insertion with and without computer assistance: a randomised controlled clinical study in 100 consecutive patients. Eur Spine J, 2000, 9: 235–240
Anderson KC, Buehler KC, Markel DC. Computer assisted navigation in total knee arthroplasty. J Arthroplasty, 2005, 20: 132–138
Wong KC, Kumta SM. Computer-assisted tumor surgery in malignant bone tumors. Clin Orthop Rel Res, 2013, 471: 750–761
Wong KC, Kumta SM, Sze KY, et al. Use of a patient-specific CAD/CAM surgical jig in extremity bone tumor resection and custom prosthetic reconstruction. Comput Aided Surgery, 2012, 17: 284–293
Colen S, Harake R, Haan JDE, Mulier M. A modified custom-made tri-flanged acetabular reconstruction ring (MCTARR) for revision hip arthroplasty with severe acetabular defects. Acta Orthop Belg, 2013, 79: 71–75
Baauw M, van Hellemondt GG, van Hooff ML, et al. The accuracy of positioning of a custom-made implant within a large acetabular defect at revision arthroplasty of the hip. Bone Joint J, 2015, 97-B: 780–785
Fan H, Fu J, Li X, et al. Implantation of customized 3-D printed titanium prosthesis in limb salvage surgery: a case series and review of the literature. World J Surg Onc, 2015, 13: 308
Imanishi J, Choong PFM. Three-dimensional printed calcaneal prosthesis following total calcanectomy. Int J Surgery Case Rep, 2015, 10: 83–87
Wong KC, Kumta SM, Geel NV, et al. One-step reconstruction with a 3D-printed, biomechanically evaluated custom implant after complex pelvic tumor resection. Comput Aided Surgery, 2015, 20: 14–23
Wyatt MC. Custom 3D-printed acetabular implants in hip surgery–innovative breakthrough or expensive bespoke upgrade? Hip Int, 2015, 25: 375–379
Phan K, Sgro A, Maharaj MM, et al. Application of a 3D custom printed patient specific spinal implant for C1/2 arthrodesis. J Spine Surg, 2016, 2: 314–318
Mobbs RJ, Coughlan M, Thompson R, et al. The utility of 3D printing for surgical planning and patient-specific implant design for complex spinal pathologies: case report. J Neurosurgery-Spine, 2017, 26: 513–518
Wei R, Guo W, Ji T, et al. One-step reconstruction with a 3Dprinted, custom-made prosthesis after total en bloc sacrectomy: a technical note. Eur Spine J, 2017, 26: 1902–1909
Merema BJ, Kraeima J, Ten Duis K, et al. The design, production and clinical application of 3D patient-specific implants with drilling guides for acetabular surgery. Injury, 2017, 48: 2540–2547
Tetsworth K, Block S, Glatt V. Putting 3D modelling and 3D printing into practice: virtual surgery and preoperative planning to reconstruct complex post-traumatic skeletal deformities and defects. SICOT-J, 2017, 3: 16
Wong KC. 3D-printed patient-specific applications in orthopedics. Orthop Res Rev, 2016, Volume 8: 57–66
Sing SL, An J, Yeong WY, et al. Laser and electron-beam powderbed additive manufacturing of metallic implants: A review on processes, materials and designs. J Orthop Res, 2016, 34: 369–385
International Organization for Standardization, ISO 5832:2016: Implants for surgery: metallic materials. https://www.iso.org/standard/66637.html
Balazic M, Kopac J, Jackson MJ, et al. Review: titanium and titanium alloy applications in medicine. IJNBM, 2007, 1: 3–34
Pattanayak DK, Fukuda A, Matsushita T, et al. Bioactive Ti metal analogous to human cancellous bone: Fabrication by selective laser melting and chemical treatments. Acta Biomater, 2011, 7: 1398–1406
Rapuano BE, Lee JJE, MacDonald DE. Titanium alloy surface oxide modulates the conformation of adsorbed fibronectin to enhance its binding to α5β1 integrins in osteoblasts. Eur J Oral Sci, 2012, 120: 185–194
Olivares-Navarrete R, Gittens RA, Schneider JM, et al. Osteoblasts exhibit a more differentiated phenotype and increased bone morphogenetic protein production on titanium alloy substrates than on poly-ether-ether-ketone. Spine J, 2012, 12: 265–272
Ryan G, Pandit A, Apatsidis DP. Fabrication methods of porous metals for use in orthopaedic applications. Biomaterials, 2006, 27: 2651–2670
Sieber HP, Rieker CB, Köttig P. Analysis of 118 second-generation metal-on-metal retrieved hip implants. J Bone Joint Surgery, 1999, 81: 46–50
Rieker C, Köttig P. In vivo tribological performance of 231 metalon-metal hip articulations. HIP Int, 2002, 12: 73–76
Arcam EBM, Metal Powders. http://www.arcam.com/technology/products/metal-powders/
Tal-Gutelmacher E, Eliezer D. The hydrogen embrittlement of titanium-based alloys. JOM, 2005, 57: 46–49
Murr LE, Martinez E, Amato KN, et al. Fabrication of metal and alloy components by additive manufacturing: examples of 3D materials science. J Mater Res Tech, 2012, 1: 42–54
Song B, Zhao X, Li S, et al. Differences in microstructure and properties between selective laser melting and traditional manufacturing for fabrication of metal parts: A review. Front Mech Eng, 2015, 10: 111–125
Wang P, Sin WJ, Nai MLS, et al. Effects of processing parameters on surface roughness of additive manufactured Ti-6Al-4V via electron beam melting. Materials, 2017, 10: 1121
Wang D, Liu Y, Yang Y, et al. Theoretical and experimental study on surface roughness of 316L stainless steel metal parts obtained through selective laser melting. Rapid Prototyping J, 2016, 22: 706–716
Karageorgiou V, Kaplan D. Porosity of 3D biomaterial scaffolds and osteogenesis. Biomaterials, 2005, 26: 5474–5491
Kumar A, Nune KC, Murr LE, et al. Biocompatibility and mechanical behaviour of three-dimensional scaffolds for biomedical devices: process–structure–property paradigm. Int Mater Rev, 2016, 61: 20–45
Shim JH, Kim SE, Park JY, et al. Three-dimensional printing of rhBMP-2-loaded scaffolds with long-term delivery for enhanced bone regeneration in a rabbit diaphyseal defect. Tissue Eng Part A, 2014, 20: 1980–1992
Sanz-Herrera JA, García-Aznar JM, Doblaré M. On scaffold designing for bone regeneration: A computational multiscale approach. Acta Biomater, 2009, 5: 219–229
Klawitter JJ, Hulbert SF. Application of porous ceramics for the attachment of load bearing internal orthopedic applications. J Biomed Mater Res, 1971, 5: 161–229
Griffon DJ, Sedighi MR, Schaeffer DV, et al. Chitosan scaffolds: Interconnective pore size and cartilage engineering. Acta Biomater, 2006, 2: 313–320
Bragdon CR, Jasty M, Greene M, et al. Biologic fixation of total hip implants. J Bone Joint Surgery, 2004, 86: 105–117
Harrysson OLA, Cansizoglu O, Marcellin-Little DJ, et al. Direct metal fabrication of titanium implants with tailored materials and mechanical properties using electron beam melting technology. Mater Sci Eng-C, 2008, 28: 366–373
Li X, Wang C, Zhang W, et al. Fabrication and characterization of porous Ti6Al4V parts for biomedical applications using electron beam melting process. Mater Lett, 2009, 63: 403–405
Arabnejad S, Burnett Johnston R, Pura JA, et al. High-strength porous biomaterials for bone replacement: A strategy to assess the interplay between cell morphology, mechanical properties, bone ingrowth and manufacturing constraints. Acta Biomater, 2016, 30: 345–356
Muller P, Mognol P, Hascoet JY. Modeling and control of a direct laser powder deposition process for Functionally Graded Materials (FGM) parts manufacturing. J Mater Proc Tech, 2013, 213: 685–692
Bobbio LD, Otis RA, Borgonia JP, et al. Additive manufacturing of a functionally graded material from Ti-6Al-4V to Invar: Experimental characterization and thermodynamic calculations. Acta Mater, 2017, 127: 133–142
Fujibayashi S, Neo M, Kim HM, et al. Osteoinduction of porous bioactive titanium metal. Biomaterials, 2004, 25: 443–450
Fukuda A, Takemoto M, Saito T, et al. Osteoinduction of porous Ti implants with a channel structure fabricated by selective laser melting. Acta Biomater, 2011, 7: 2327–2336
Tamaddon M, Samizadeh S, Wang L, et al. Intrinsic osteoinductivity of porous titanium scaffold for bone tissue engineering. Int J Biomater, 2017, 2017: 1–11
Warnke PH, Douglas T, Wollny P, et al. Rapid prototyping: porous titanium alloy scaffolds produced by selective laser melting for bone tissue engineering. Tissue Eng Part C-Methods, 2009, 15: 115–124
Van der Stok J, Van der Jagt OP, Amin Yavari S, et al. Selective laser melting-produced porous titanium scaffolds regenerate bone in critical size cortical bone defects. J Orthop Res, 2013, 31: 792–799
Yang S, Leong KF, Du Z, et al. The design of scaffolds for use in tissue engineering. Part I. Traditional factors. Tissue Eng, 2001, 7: 679–689
Reigstad O, Franke-Stenport V, Johansson CB, et al. Improved bone ingrowth and fixation with a thin calcium phosphate coating intended for complete resorption. J Biomed Mater Res, 2007, 83B: 9–15
3D printing and advanced manufacturing: Getting the most out of metal 3D printing: Understanding design & Process controls for DMLS. Stratasys Direct Manufacturing. Accessed on Oct 22, 2017: https://www.stratasysdirect.com/content/white_papers/DMLS_White_Paper_201509_v3.pdf
Liang H, Ji T, Zhang Y, et al. Reconstruction with 3D-printed pelvic endoprostheses after resection of a pelvic tumour. Bone Joint J, 2017, 99-B: 267–275
Wang S, Wang L, Liu Y, et al. 3D printing technology used in severe hip deformity. Exp Therap Med, 2017, 14: 2595–2599
Bartels W, Gelaude F, Delport H, Jonkers I, Sloten JV. Patientspecific Reconstruction of Large Bone Defects: Clinical Success Due to an Integrated Bioengineering Workflow. In: Kyriacou E, et al. (eds.), XIV Mediterranean Conference on Medical and Biological Engineering and Computing 2016, IFMBE Proceedings, 2016, 57: 659–662
Martelli N, Serrano C, van den Brink H, et al. Advantages and disadvantages of 3-dimensional printing in surgery: A systematic review. Surgery, 2016, 159: 1485–1500
Trace AP, Ortiz D, Deal A, et al. Radiology’s emerging role in 3-D printing applications in health care. J Am College Rad, 2016, 13: 856–862.e4
Morrison RJ, Kashlan KN, Flanangan CL, et al. Regulatory considerations in the design and manufacturing of implantable 3D-printed medical devices. Clinical Translational Sci, 2015, 8: 594–600
Author information
Authors and Affiliations
Corresponding author
Additional information
Kwok-Chuen Wong, MBChB, MD (CUHK) and FRCSEd (Ortho), has specialised in orthopaedic oncology since 2004 with a research interest in applying advanced technology in orthopaedics. He was one of the pioneers in developing computer navigation application and 3D-printed patient-specific instruments in orthopaedic oncology surgery and has extensively published in the field. Currently, he is Clinical Associate Professor (Honorary) and the chief of Orthopaedic Oncology, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong.
Peter Scheinemann is an engineer with more than 20 years’ industrial experience in design and development of orthopaedic implants. Currently, he is the head of research and development in Implantcast GmbH company. He has been in charge of producing MUTARS tumour and revision prostheses, noninvasive growing prostheses in orthopaedics. Since 2013, he has introduced additive manufacturing for custom made implants and instruments and is one of the key opinion leaders in the field.
Rights and permissions
About this article
Cite this article
Wong, KC., Scheinemann, P. Additive manufactured metallic implants for orthopaedic applications. Sci. China Mater. 61, 440–454 (2018). https://doi.org/10.1007/s40843-017-9243-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40843-017-9243-9