Composites Science and Technology 71 (2011) 1791–1803

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Composites Science and Technology

journal homepage: www.elsevier.com/locate/compscitech

Review

The use of composite materials in modern orthopaedic medicine

and prosthetic devices: A review
M.-S. Scholz ⇑, J.P. Blanchfield, L.D. Bloom, B.H. Coburn, M. Elkington, J.D. Fuller, M.E. Gilbert,
S.A. Muflahi, M.F. Pernice, S.I. Rae, J.A. Trevarthen, S.C. White, P.M. Weaver, I.P. Bond
Advanced Composites Centre for Innovation and Science (ACCIS), University of Bristol, Queen’s Building, University Walk, Bristol BS8 1TR, UK

a r t i c l e i n f o a b s t r a c t

Article history: The use of fibre reinforced composite materials for biomedical purposes is reviewed. The development of
Received 21 April 2011 polymer composite materials has, in recent years, led to technological advances across a wide range of
Received in revised form 18 August 2011 applications in modern orthopaedic medicine and prosthetic devices. Composites typically possess a
Accepted 19 August 2011
superior strength to weight characteristic compared to monolithic materials and offer excellent biocom-
Available online 30 August 2011
patibility. They are, therefore, favourable for both hard- and soft-tissue applications as well as the design
of prostheses. In particular, the development of specifically designed carbon fibre sports prostheses now
Keywords:
allows lower-limb amputees to actively participate in competitive sports. Sensory feedback systems, por-
A. Polymer-matrix composites (PMCs)
A. Polymers
ous composite materials for tissue engineering and functional coatings for metallic implants are further
B. Interface developments anticipated to be introduced in next generation orthopaedic medicine.
B. Mechanical properties Ó 2011 Elsevier Ltd. All rights reserved.
Orthopaedics

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1792
2. Hard-tissue applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1793
2.1. Bone fracture repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1793
2.2. Total knee replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1795
2.3. Total hip replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1795
2.4. Dental applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1795
3. Soft-tissue applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1796
4. Tissue engineering applications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1796
5. Special prosthetics for application in professional sports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1797
6. Commercial prosthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1799
7. Biomimetic sensors, actuators and artificial muscles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1800
7.1. Biomedical applications of ionic polymer-metal composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1800
7.2. Challenges faced with ionic polymer-metal composites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1800
8. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1800
9. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1801
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1801
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1801

⇑ Corresponding author.
E-mail address: [email protected] (M.-S. Scholz).

0266-3538/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.compscitech.2011.08.017
1792 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803

1. Introduction must be considered in order to ensure practicability. Stresses expe-

rienced by bones in the human body are of the order of 4 MPa,
Advances in the development of composite materials have, in while tendons and ligaments may be subjected to stresses as high
recent years, enabled major improvements in the design of modern as 80 MPa [5]. Moreover, loads vary and are applied repeatedly;
orthopaedics and prosthetic devices. Composites are engineered stress cycles of finger or hip joint motion are estimated to be of
materials made from two or more constituents, each offering dif- the order of 1  106 cycles a year [5]. Consequently, prosthetics
ferent physical properties, which can be combined synergistically. that are to be in direct skeletal contact require a low elastic mod-
Properties and architectures of biological materials can thus be re- ulus to be structurally compatible, but a high level of strength to
flected more accurately by means of tailoring [1,2]. Fibre reinforced ensure practicability and durability. Additionally, surface compat-
polymer composites are, at present, the most widely used multi- ibility must also be achieved. For instance, designing a prosthetic
phase materials in orthopaedics. In addition, most of today’s device from purely polymeric materials may seem appropriate
upper- and lower-limb prostheses are now made from composites (due to their low elastic modulus), however, their low strength im-
with underlying polymer matrix. These types of materials are pairs their usability [5]. Equally, the performance of metallic artifi-
favourable due to their exceptional strength to weight characteris- cial limbs in terms of surface compatibility often proves to be
tics [3] as well as their superior biocompatibility [4,5]. unsatisfactory [5].
The simultaneous exhibition of relatively low elastic modulus Fibre reinforced polymer composites are able to accomplish
and high strength is of particular importance in the case of direct both low elastic modulus as well as high strength, in an efficient
skeletal attachment (osseointegration) of artificial limbs [3,5]. manner (Fig. 1). Furthermore, corrosion and fatigue resistance
The comfort and ease of control of an artificial limb critically de- characteristics are greatly improved due to the application of com-
pend on the quality of the interface between stump and prosthesis posite materials [16]. The properties of these materials can be
[3,6]. For example, a mismatch in stiffness between implant and adapted in a number of ways. For instance, changing the arrange-
host tissue can cause severe stress shielding [5]. In order to mini- ment of reinforcing fibres or varying the volume fraction can
mise such effects, the development and application of biocompat- change the material characteristics significantly [5,17]. Thus, fibre
ible materials is essential. reinforced polymer composites in particular have the potential to
The biocompatibility of a material indicates its ability to per- be highly biocompatible, whilst maintaining suitable mechanical
form in conjunction with a living system [5]. Specifically, one dis- properties as it is possible to produce a wide range of material
tinguishes between the chemical, biological and physical architectures. Moreover, making implants for bone replacement
suitability of a material (surface compatibility) and its compatibil- or fixation from fibre reinforced polymers permits the creation of
ity in terms of mechanical properties (structural compatibility) useful X-ray, magnetic resonance imaging (MRI) and computed
such as stiffness, strength and optimal load transmission, at the tomography (CT) images, commonly used for diagnostic interpre-
implant/tissue interface [5,7]. Optimal material performance is tation [7].
achieved by maximising both surface and structural compatibility Conceptually, one distinguishes between three classes of bio-
whilst maintaining the material’s ability to withstand the some- materials: biologically inert materials (first generation), bioactive
times harsh in vivo environment; levels of pH can range from 1– and biodegradable materials (second generation), and materials
9 [5]. Nevertheless, it is not solely biocompatibility that influences aiming to achieve specific cellular responses on a molecular level
whether implants or osseointegrated prostheses are accepted by (third generation) [18,19]. First generation materials are, at pres-
the human body but many other aspects, including surgical tech- ent, still being widely used, specifically in hard-tissue applications,
nique and patients’ health, must also be considered [5]. and their research and development continues. Second and third
In nature, mechanical function and structural support is pro- generation materials are not intended to simply replace what
vided by the musculoskeletal system, consisting of hard- and evolved from previous generations but meant to create categori-
soft-tissues. The most frequently implanted tissue after blood is cally novel, ameliorated methods of treatment. Composites are
bone [8] with approximately 500,000 operations a year in the US thought to be particularly beneficial in the development of com-
alone [9]. A good understanding of bone in terms of its structure plex, third generation biomaterials forming biodegradable scaf-
and physical behaviour is therefore needed in order to successfully folds and hierarchically organised structures [12,19,20].
design various types of implants. Bone is a natural, highly hierar- With the incorporation of more expensive materials in a design
chical composite material made up of collagen fibrils with and the increasing complexity of manufacture, costs clearly consti-
hydroxyapatite (HAP) nanocrystals interspersed along the collagen tute a limiting factor to the commercial availability of state of the
fibres. Despite the high elastic modulus of HAP (100 GPa) [10], art technology. Moreover, it should be noted that prior to a product
the combined elastic modulus of cortical bone falls between 10 reaching successful commercialisation numerous trials are re-
and 20 GPa [5,11,12], a relatively low elastic modulus compared quired due to a necessarily slow acceptance of new devices partic-
to that of metals, conventionally used for bone fixation; titanium ularly within surgical practices [5,21,22]. The consideration of less
and stainless steel having elastic moduli of around 118 GPa [13] effective but financially more feasible solutions using traditional
and 206 GPa [14], respectively. The stiffness, strength and fracture engineering materials must, therefore, not be neglected as compos-
toughness of metals, technical ceramics, composites and fibre rein- ites are often only available at relatively high economic cost.
forced plastics in relation with bone are illustrated schematically Within this review, the uses of fibre reinforced polymer com-
in Fig. 1a–c. It is clear that appropriately tailored polymer matrix posite materials are discussed separately for hard- and soft-tissue
composites can match the properties of bone and so have signifi- as well as tissue engineering applications. With particular empha-
cant potential as a replacement material. Of course, other aspects sis on elite sports, the recent impact of composites on the design of
including biocompatibility, practicality and costs are also impor- upper- and lower-limb prostheses is reviewed. The use of compos-
tant drivers. Finally, it is noted that bone remodelling takes place ites within the field of biomimetic sensors and actuators is briefly
according to the principles set out in ‘Wolff’s Law’: ‘‘Bone is depos- examined together with their potential applications. Future objec-
ited and reinforced at areas of greatest stress’’ [15]. tives for next generation orthopaedic medicine are briefly outlined
The environmental impact on prosthetics due to everyday activ- prior to an analysis of the key innovations responsible for the re-
ities such as walking, running, stretching, jumping and climbing cent technological advances in modern orthopaedics.
 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803 1793

Fig. 1. Comparison of (a) stiffness, (b) strength and (c) fracture toughness for metals, technical ceramics, composites and fibre reinforced plastics with respect to those of bone
[23–31]. CF: carbon fibre, GF: glass fibre, PA12: polyamide12, PC: polycarbonate, PE: polyethylene, PEEK: poly ether ether ketone, PLGA: poly(l-lactic-co-glycolic acid), PLLA:
poly(l-lactic acid), PP: polypropylene, PSU: polysulfone, PTFE: polytetrafluoroethylene, PUR: polyurethane.

2. Hard-tissue applications 2.1. Bone fracture repair

Hard-tissue applications of fibre reinforced composite materials There are two distinct types of bone fracture repair, namely
include: skull reconstruction, bone fracture repair, total knee, an- external and internal fixation.
kle, hip and other joint replacements, as well as dental applica- External fixation keeps the bone fragments aligned by means of
tions. An overview of some exemplar applications is given below. casts, splints, braces or similar fixation systems. Traditional casting
1794 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803

Fig. 3. Bone fragment fixation via plates and screws. Reproduced from DePuy [35] with courtesy of DePuy Orthopaedics, Inc.

materials are generally made from plaster of calcium sulphate with systems, made from stainless steel or aluminium caused artefacts
woven cotton fabrics or fabrics of glass and polyester fibres provid- in radiographs, non-metallic designs permit the more effective
ing the necessary reinforcement [5]. To prevent scorching or weak- use of medical imaging [5], a technique often used to monitor
ening of the patient’s skin, breathable casts have been developed the healing process. The major shortcoming of all external systems
[32]. Other external fixation systems (Fig. 2) have only recently currently lies within their inability to seamlessly adjust the stiff-
gained popularity as lightweight carbon fibre designs have become ness analogous to human muscle.
more readily available. In the particular case of carbon fibre ortho- Internal fixation entails the use of implants such as plates,
ses a 10% reduction in patient heart rate and oxygen consumption screws, pins and wires holding the bone fragments in place; for ri-
was reported, following weight savings of around 29% compared to gid fixation, plates and screws are more commonly used (Fig. 3). A
stainless steel equivalents [33]. Furthermore, due to the low den- variety of polymer composites including both thermoset and ther-
sity of carbon fibre reinforced plastic, an improvement in agility, moplastic materials are available for these applications. Polymer
gait and walking speed can be noticed [34]. While previous fixation composites are divided into two classes: avital/avital and vital/avi-
tal. Avital/avital composites comprise ‘non-living’ matrix and rein-
forcement phases only, while vital/avital composites are made
from both ‘living’ as well as ‘non-living’ materials. In the group of
avital/avital composites one distinguishes further between non-
resorbable, partially-resorbable and fully-resorbable compositions
[5,36]. Resorbable bone plates have become of particular interest
because they permit the gradual increase of stress on the bone as
it progresses through healing; thus stress shielding can be reduced
and osteopenia may be eradicated. Fully-resorbable composite im-
plants provide a major advantage over conventional metallic plates
as they do not need to be removed during a second surgical proce-
dure. A number of resorbable polymers including poly(l-lactic acid)
(PLLA), poly(glycolic acid) (PGA) or their copolymers and poly(l-
lactic-co-glycolic acid) (PLGA) have readily been approved for hu-
man clinical uses [37]. However, it generally proves difficult to
achieve non-toxic degradation at an acceptable rate and yet retain
good mechanical properties. To enhance mechanical performance,
resorbable polymers have recently been fibre-reinforced (making
them partially-resorbable) and finite element analysis has been ap-
plied to assist in optimising volume fractions [36].
In the manufacture of early, non-resorbable composite bone
Fig. 2. External bone fixation systems. Adapted from DePuy [35] with courtesy of plates the material combinations of carbon fibre/epoxy (CF/epoxy)
DePuy Orthopaedics, Inc. and glass fibre/epoxy (GF/epoxy) were trialled. Due to concerns
 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803 1795

raised over the toxicity of monomers in partially cured epoxy resin,

however, researchers have largely turned their attention to ther-
moplastic composites and carbon fibre/poly ether ether ketone
(CF/PEEK) designs in particular [5,38]. CF/PEEK is considered to
be biologically inert yet able to maintain high mechanical strength
and good fatigue resistance at plate thicknesses comparable to
those of conventional metallic types – approximately 3.8 mm
[39]. At present, inadequate manufacturing methods producing
poor quality CF/PEEK bone plates pose the major challenge [39].
A first step to overcome these issues has been taken by Fujihara
et al. [39,40] in fabricating knitted and braided CF/PEEK compres-
sion plates. Aspects such as axial tension following pre-loading of
the healing callus as well as local stresses at the screw holes must
also be considered. The mechanical design of multilayer knitted
fabric-reinforced laminates on the basis of progressive failure anal-
ysis has been discussed by Huang et al. [41].
Finally, intramedullary nails may be used for stabilising long
bone fractures such as those of the femoral neck or intertrochan-
teric bone [5]. Carbon fibre reinforced liquid crystalline polymer
(LCP/CF) and GF/PEEK material combinations have been investi-
gated for this less common application [5,42,43].
Fig. 4. Reduced stiffness, composite femoral stem. Adapted from Zimmer [48] with
permission of Zimmer, Inc.
2.2. Total knee replacement

The application of composites in total knee replacements has can be minimised and stress can be transferred more effectively
proven to be extremely difficult. Attempts to improve wear resis- at the bone/prosthesis interface [5].
tance of ultra high molecular weight polyethylene (UHMWPE) by However, while a more compliant hip implant reduces stress
means of reinforcing carbon fibres failed due to poor bonding be- shielding it must maintain a minimum level of stiffness in order
tween the two constituents [5]. Similarly, other efforts such as not to cause residual pain due to low-amplitude oscillatory micro-
reinforcing UHMWPE with UHMWPE fibres did not lead to in- motion [49]. Micromotion describes the deformation and relative
creases in wear resistance; however, improved stiffness, strength movement between prosthesis and bone under loading. Further,
and creep resistance were achieved [5]. In a recent study Utzschne- investigations on the response of laminated composite prostheses
ider et al. [44] tested the wear resistance of crosslinked polyethyl- that were, in shape, based on the standard metal alloy hip design,
ene in a number of different knee joints and reported statistically suggest that these may not be structurally adequate [50]. Finite
significant lower wear rates compared to UHMWPE. In contrast, element analysis is, therefore, often employed to test and optimise
Fisher et al. [45] have suggested alterations in knee joint designs artificial hip joints. Following multiscale, structural analysis, a set
to achieve reduced wear. of guidelines for designing future composite hip implants has been
A number of desirable characteristics for materials employed as proposed by Srinivasan et al. [51].
the articulating surfaces in any type of total joint replacement have Computational methods have also been applied to simulate and
been summarised by Rahaman et al. [46] and are laid out below: analyse the performance of novel, carbon fibre/polyamide12 (CF/
PA12) and carbon fibre/polyamide 12/hydroxyapatite (CF/PA12/
– High strength, elastic modulus, fracture toughness, and fatigue HAP) composite hip stems [47,56–58]. Bone density distributions
resistance to sustain mechanical reliability whilst resisting have been obtained and are presented visually, at a proximal sec-
deformation under loading; loads in the body range from 3 kN tion, in three cases (Fig. 5): for an intact femur, a femur with CF/
during normal walking to 8 kN when jogging or stumbling. PA12 stem, and a femur with Ti–6-Al–4V stem. Compared with
– High corrosion resistance for bioinertness and biocompatibility their metallic counterparts, the new materials have been predicted
in vivo. to result in more adaptive bone remodelling producing around 20–
– High hardness and good surface finish supporting wear resis- 40% greater bone density in the proximal femur and 10–20% less
tance in the long-term together with low friction. bone density in the distal end [57]. Stress shielding effects and
– Good wetting at the bearing surface/synovial fluid interface for fracture risk are thus thought to be reduced.
lubrication in the body. In addition to design and mechanical performance, fixation
techniques play an important role in total hip replacements. The
development of composite materials for use in hip joint fixation
2.3. Total hip replacement currently concentrates mostly on the approaches of cementing
and bone ingrowth [52–55].
Total hip replacements are the most common joint replace-
ments with more than 150,000 operations a year in the US alone
[5]. At present, metal hip implants are still predominantly used 2.4. Dental applications
as clinical success rates of 93% at 10 years and 85% at 15 years
post-surgery are high [47]. Nevertheless, problems of prosthesis In dental applications, including orthodontic archwires, brack-
loosening and induced non-physiological stresses in the bone, di- ets and dental posts, conventional restorative materials such as
rectly affecting bone remodelling, have been reported repeatedly, amalgam, gold, alumina, zirconia and many others have essentially
following the implantation of artificial hip joints. Modern prosthe- been fully replaced by composite resins. Modern composite resins
ses (Fig. 4) made from polymer composites have the potential to have a refractive index matching that of enamel and can thus not
meet spatially varying mechanical requirements such as strength only restore the function but also the appearance of biological tis-
and stiffness. Consequently, regions of high stress concentration sue [59]. In addition, composite post-insertion proves less time
1796 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803

Fig. 5. Cross-sectional view of the bone density distribution in units of g/cm3 for (a) an intact femur, (b) a femur with CF/PA12 stem, and (c) a femur with titanium stem.
Adapted from Bougherara et al. [57] with permission of John Wiley and Sons.

consuming, making surgical procedures less traumatic for the pa- organisation [66,67]. Despite numerous manufacturing techniques,
tient [60]. The main shortcoming of these materials is their life- including self-assembly, phase separation, melt-blown and tem-
time; issues such as polymerisation shrinkage, shrinkage-stress plate synthesis, electrospinning has emerged as the leading tech-
development, thermal expansion mismatch, wear resistance or nique for nanofibre scaffold fabrication as it is cost effective and
toxicity are yet to be resolved, leaving large scope for advancement provides a user friendly approach, allowing versatility [66,68]. It
[59,61]. Furthermore, typical orthodontic prosthetic composites further permits scaffold refinement by aligning fibres to create
have poor thermal conductivity leading to altered perception of structural anisotropy with the forming network. Nevertheless,
taste [62,63]. A viable solution to this problem has been proposed problems relating to inadequate cell infiltration are often encoun-
by Messersmith et al. [62] who incorporated ceramic microwires of tered with this technique, clearly limiting their in vivo application.
aluminium oxide into poly(methyl methacrylate) (PMMA) in order It has recently been suggested that enhanced cell infiltration may
to attain a higher diffusivity. be achieved through the selective removal of sacrificial fibres in
electrospun, fibre-aligned composite scaffolds [69].
3. Soft-tissue applications
4. Tissue engineering applications
The application of fibre reinforced composites to soft-tissue has,
over the past two decades, proven to be difficult. Many kinds of Fibrous, scaffold-like structures are of particular interest not
soft-tissue, including skin, nerves, tendons, ligaments and vascular only in the field of soft-tissue engineering but moreover for the
grafts, do not obey Hooke’s law when subjected to a physiological specific purposes of advanced bone tissue engineering. Tradition-
load; instead, their stress–strain behaviour is represented by a ally, defective bones are managed by employing well established
non-linear, convex, ‘j-shaped’ curve [5]. treatment methods such as autografting, allografting, the applica-
Composite materials to replace soft-tissue are generally tion of vascularised grafts, and bone marrow replacement. Present
founded on naturally occurring polymer-based systems such as approaches are increasingly focused on the application of biocom-
polysaccharide proteins [64]. Moreover, the intrinsic properties patible, osteoinductive, osteoconductive and mechanically com-
(molecular weight, charge, etc.) of the constituent parts are patible scaffolding constructs, potentially able to integrate with
increasingly important when developing these materials [64]. In native tissue whilst stimulating contiguous bone formation
the case of vascular grafts, for example, the optimisation of poros- [70,71]. Scaffolding material may further act to carry implanted
ity plays an important role. Excessive porosity may lead to blood bone cells and other agents [71]. Some scaffolds capable of drug
leakage, but at the same time a certain threshold is required in or- delivery, and able to locally release both growth factors and antibi-
der to encourage tissue growth and acceptance by the host tissue otics, promise to enhance bone ingrowth in conjunction with
[5]. The suitability of different polymer composites for soft-tissue wound healing [72–76].
applications has been reviewed in recent articles by Silva et al. Modern bone tissue engineering provides a number of propi-
[64] and Boccaccini et al. [65]. tious advantages [70]:
The structure of natural extracellular matrix (ECM) can be mim-
icked by manufacturing fibres that are within a similar size range. – The amount of donor tissue required over any given period
Cells seeded onto fibrous scaffolds tend to adhere to nanofibres of time would be reduced, as skeletal cells may be engi-
whose culture modulates cell morphology and cytoskeletal neered in vitro.
 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803 1797

Fig. 6. Tartrate-resistant acid phosphatase haematoxylin counterstaining micrographs of (a) commercial HAP, (b) PGA/b-TCP (1:1), and (c) PGA/b-TCP (1:3) at 0, 14, 30, and
90 days post-surgery, respectively. Images are taken at a magnification of 200, insets are enlarged with a zoom factor of 600. Red colour: osteoclast; blue colour: cell
nucleus; NB: new bone; M: material; black scale bar: 200 lm; red scale bar: 50 lm. Reproduced from Cao and Kuboyama [77] with permission of Elsevier. (For interpretation
of the references to colour in this figure legend, the reader is referred to the web version of this article.)

– The integration of biomaterials, whose mechanical proper- between the material chemistry and the structural design of poly-
ties closely match those of the defective bone, may in the meric composite scaffolds, if any dynamic changes associated with
future see a strong decrease not only in the rate of implant the progressive evolution of the hydrolytic degradation mecha-
failure but also with respect to secondary surgery. nism are to be predicted.
– Affections could be relieved and diseased tissue potentially Besides, a number of nanometric bioactive glasses have recently
cured if early treatment with mesenchymal stem cells was attracted significant attention. Specifically, osteochondral, carti-
pursued. Consequently, the need for life-long treatment for lage and dentin regeneration but also bone tissue engineering are
the patient would be reduced. reported to be major contenders for the application of novel com-
posite materials, that bring together biodegradable polymers with
To optimise the integration process of newly formed bone into nanosize bioactive glass particles or fibres [65]. Complementary
the surrounding tissue, scaffolds synthesised for osteogenesis are design features on the nanoscale are particularly thought to create
expected to closely match bone morphology, structure and func- extra flexibility in adapting both elastic modulus and strength. An
tion [77]. A series of three-dimensional composite scaffolds origi- exemplar graphic of typical submicron bioactive glass fibres is pro-
nating from PGA and b-tricalcium phosphate (b-TCP) compounds vided in Fig. 7. A scanning electron micrograph, characteristic of
has recently emerged, following a study by Cao and Kuboyama the morphology associated with poly(hydroxybutyrate-2-co-2-
[77]. Their properties were found to mimic the natural bone com- hydroxyvalerate)/biomimetically synthesised nano-sized bioactive
ponents whilst permitting a close fit of samples to bone defects. glass (PHBV/BMBG) porous composites immersed in simulated
Further, advances in the bone formation rate have been observed. body-fluid (SBF) is shown in Fig. 8.
Fig. 6 compares, over a 90 day period, the extent of bioresorption While mechanical strength constitutes the primary design dri-
and bone remodelling for commercial HAP, PGA/b-TCP (1:1), and ver in the case of bone tissue engineering, scaffold structures serv-
PGA/b-TCP (1:3). It was concluded that PGA/b-TCP scaffolds in a ing to support nerve regeneration are additionally required to
weight ratio of 1:3 prove most effective, clearly demonstrating enable the direction of the axonal growth cone to the distal stump
their ability for mineralisation, osteogenesis and biodegradation via biological signalling [64,81,82]. Accordingly, design complexity
at a rate comparable to that of tissue regeneration. is promoted further and the need for multifunctional material
Further composite materials based on poly(e-caprolactone) solutions readily becomes apparent.
(PCL) and esters of hyaluronic acid have been derived by Guarino
et al. [78]. Their work primarily focused on the fabrication of repro-
ducible scaffolding networks that are tailorable with respect to 5. Special prosthetics for application in professional sports
both physical and chemical properties. Scaffolds are moreover
anticipated to maintain structural integrity under load-bearing The amputee’s ability to participate in competitive sport was
conditions and for a predictable period of time [73,78]. Impor- revolutionized by the introduction of carbon fibre reinforced poly-
tantly, it was noted however, that a compromise must be reached mer (CFRP) composites into the structural design of artificial limbs
1798 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803

Fig. 7. Scanning electron microscopy images of (a–c) electrospun submicron bioactive glass 70S30C fibres at different magnification, (d) a single fibre. Reproduced from Lu
et al. [79] with permission of Springer.

Fig. 8. Scanning electron micrographs of PHBV/BMBG composite scaffolds immersed in SBF. (a) Porous structure before immersion, (b) locally enlarged morphology of pore
wall prior to immersion, (c) scaffold at 8 h immersion, (d) porous network at 24 h immersion. Adapted from Zheng et al. [80] with permission of Trans Tech Publications.

[83]. CFRP is an extremely lightweight material and making use of foot in 1981 [87]. Shifting body weight onto the CFRP structure in-
its great flexibility yet high strength, it is possible to embed an en- duces compressive loads and thus energy is stored. Lifting the body
ergy return system within lower-limb prostheses [84–86]. The weight off results in decompression, allowing the material to re-
need for such a system was recognised following advances in gait turn to its original shape; consequently, energy is returned. As
analysis and biomechanics, and was first introduced in the Seattle the dynamic response of the amputee/prosthetic system depends
 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803 1799

Fig. 9. Examples of different sprint foot designs: (a) Cheetah (Össur), (b) Flex-Run (Össur), (c) Flex-Sprint (Össur), (d) C-Sprint (Otto Bock), (e) Sprinter (Otto Bock) [86].

appearance in professional sport followed shortly after at the

Paralympic Games in 1988 [86]. Since then a diverse range of mod-
els has been developed to better meet the various needs of ampu-
tees. To further customise these designs, adjustments may be made
by differing laminate lay up, fibre orientation and/or laminate
thickness.
A selection of different sprint foot designs is exemplified in
Fig. 9. Modern sprint prostheses no longer incorporate a heel – as
elite runners have been observed to only run on their toes [91] –
and generally comprise an articulated, long keel design [92]. Work
by Nolan [86] suggests that the design of CFRP sprint prostheses
can be optimised using a mathematical expression for the sprint
speed in terms of foot shape and stiffness.
Despite the numerous, specialised designs today’s sports pros-
theses are almost all made from CFRP, in particular those used in
running and jumping events [86]. Recent devices enable athletes
to complete the 100 m in just under 11 s; approximately one sec-
ond off the men’s Olympic record [3,86].
In 2008, when Oscar Pistorius, a bilateral lower limb amputee,
requested to compete in both the Olympic and Paralympic Games,
the International Association of Athletics Federation initially ruled
Fig. 10. Schematic representation of the Flex Foot design, as derived by Phillips that modern prostheses provide an unfair advantage [85], suggest-
[90]. ing that current designs of composite prostheses may even be able
to outperform the human limb. This decision has since been over-
on patient height, weight and activity level, it is important to take
turned as research has in fact shown that, despite great advances in
the system’s natural frequency into consideration when designing
the design of lower limb prosthetics, biomechanical asymmetries
any energy store and return (ESAR) foot. In a simple model of the
still lead to inferior performance of lower-limb prostheses in both
behaviour, one could assume ideal conditions i.e. if there is no en-
walking and running [85,93–95]. Nevertheless, it clearly demon-
ergy loss within the structure, the CFRP foot may be treated like a
strates how fibre composite materials have greatly influenced the
perfect spring, and Hooke’s law can be applied. Clearly, more real-
development of modern artificial limbs.
istic scenarios have to account for friction as well as other forms of
While composites are predominantly found in lower limb pros-
energy loss including heat and noise. Brüggemann et al. [88] mea-
thetics their application is by no means limited to this market. To
sured the dynamic hysteresis for the case of Össur’s Cheetah foot
give an example, Riel et al. [96] developed an arm prosthetic kit for
(Fig. 9a). They calculated the energy return to be approximately
racing cyclists, partly made from fibreglass and nylon which was suc-
95%. Previous models such as the Silent Ankle Cushion Heel
cessfully used by a Canadian athlete at the 2008 Paralympic Games.
(SACH), Seattle and Flex Foot have been reported to attain energy
efficiencies of only 31%, 52% and 84% respectively [89]. Of course,
these values depend directly on the accuracy of the model and 6. Commercial prosthetics
are likely to be an overestimate due to idealisations.
The first below-knee prosthesis made purely from CFRP – the As a disproportionate number of lower-leg amputees live in
Flex Foot (Fig. 10) – was developed by Philips in 1985 [85,90]. Its developing countries, where the traditional causes of amputation
1800 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803

are often added to by war and in particular land mines, custom fit,
highly expensive CF/epoxy prosthetics are not always feasible
[3,97]. Less expensive polypropylene plastic and glass fibre/high-
density polyethylene (GF/HDPE) types (Fig. 11) have thus been
derived at the expense of comfort, mechanical performance and
manufacturing reliability [3,97]. Furthermore, knitted fabrics made
from Kevlar fibres suspended in an ultraviolet curable resin have
evolved in order to ease the conformation of direct sockets to the
patient’s stump [98]. Nevertheless, advances being made in the
development of costly prosthetics specifically designed for elite
and highly specialised applications are widely accepted to contrib-
ute to both the recovery of previously inconceivable levels of sport-
ing and recreational function as well as the quality of commercially
available prostheses in general [86,89].
In a push to rapidly produce highly tailored designs, South et al.
[84] recently investigated selective laser sintering (SLS) tech-
niques. One should note that despite the radically different charac-
teristics of Rilsan™ D80 in comparison with CFRP, prosthetic feet
with similar mechanical properties could be achieved.

7. Biomimetic sensors, actuators and artificial muscles

While the field of biomimetic actuators and polymer-based sen-

sors is immature, electro-active polymers are becoming progres-
sively more popular as components of prostheses as well as
implant feedback systems and biochips for personalised medicine
[99]. Among the vast variety of electrically conducting polymeric
materials, ionic polymer-metal composites (IPMCs) have recently
attracted particular attention owing to their combined sensing
and actuating ability as well as an array of prominent properties
Fig. 11. GF/HDPE prosthetics as developed by Dubois [97]. Reproduced from Dubois
including softness, flexibility, lightweight, excellent biocompatibil-
[97] with permission of Dubois.
ity, large bending deformation, low power consumption and high
frequency operation [100–104]. Furthermore, IPMCs have been
shown to have a high level of performance under wet conditions candidate for applications in this field as a direct consequence of
[101,104]. For details regarding the chemical structure, manufac- their combined sensing and actuating characteristics. Furthermore,
turing techniques, computer modelling and industrial applications IPMCs fulfil the need for a lightweight material, able to undergo
of IPMCs the reader is referred to a series of review articles by large bending deformations. Because IPMCs do not rely on the pro-
Shahinpoor and Kim [105–108]. Some exemplar biomedical appli- vision of power from external sources [111], enhanced practicabil-
cations are discussed below, alongside a number of challenges ity may also be achieved.
which IPMCs are facing in their development. Other applications have been explored by Fang et al. [113] who
developed an IPMC actuator for active catheter systems as well as
7.1. Biomedical applications of ionic polymer-metal composites Nguyen et al. [114] in the fabrication of a flap valve IPMC micro-
pump. Li et al. [104] very recently investigated the radius control
Biomedical applications of IPMCs include artificial ventricular, of biomedical active stents using helical IPMC actuators.
sphincter and ocular muscles, artificial smooth muscle actuators,
correction of refractive index in the human eye, peristaltic pumps, 7.2. Challenges faced with ionic polymer-metal composites
incontinence assist devices, and surgical tools [104,108].
Shahinpoor [109] has developed an implantable, electrically Despite the many advantages of IPMCs, a number of concerns
controlled, heart compression device that, based on the sensing are yet to be addressed ahead of clinical approval and broad com-
capabilities of IPMCs, allows for the continual monitoring of ap- mercial application. One of the major problems relates to the lim-
plied ventricular stroke volume and/or pressure. The apparatus is itation of accuracy and positioning bandwidth at high operating
lightweight and external to the heart so as to avoid thrombogene- frequencies due to the exhibition of relaxation behaviour and non-
sis and other complications. Through the ability of IPMCs to act as linearities in IPMCs [103]. Furthermore, IPMCs are sensitive to
both a sensor and an actuator, actuation and control of the device changes in stress/strain as well as temperature, pressure, and
are readily enabled. A simpler IPMC heart assist device, in the form humidity [99,101,111]. Subsequent instabilities in terms of ther-
of a compression band, has also been proposed [108,110]. mal, mechanical and chemical properties may also be observed
The potential benefits of utilising IPMCs for the development of depending on the application. Typical Nafion-based IPMC actuators
modern sensory feedback systems, specifically in hand prostheses, often come at a high price, thus recent developments have led to
have been investigated by Biddis and Chau [111]. Direct sensory alternative novel actuators based on sulfonated poly(ether ether
feedback is essential in equipping future upper limb prosthetics ketone) (SPEEK) and poly(vinylidene fluoride) (PVDF) [100].
with attributes such as reflex capabilities, adaptive grasp, preven-
tion of slip and tactile exploration [111,112]. Integrating these fea- 8. Future directions
tures into modern prostheses is likely to provide the amputee with
more control and thus the ability to respond to the external envi- Extensive research is currently focused on the development of
ronment in a more natural way. Clearly, IPMCs appear a promising various porous composite materials [12,20,54,78,115] that are
 M.-S. Scholz et al. / Composites Science and Technology 71 (2011) 1791–1803 1801

thought likely to prove extremely beneficial, particularly in tissue porous materials and coatings that are better suited to biomedical
engineering applications. Their sponge-like structure allows for applications, as well as advanced manufacturing and material pro-
human mesenchymal stem cells to grow into the scaffolding cessing techniques. Future generations of prosthetic devices are
[12,54] and as a result, implant loosening and stress shielding aiming to provide enhanced control of upper-limb prostheses
can be reduced significantly [12]. In addition, cellular structures through the inclusion of sensory feedback systems, offering ampu-
imply material and weight savings, both undoubtedly desirable tees the prospect of a more natural response.
attributes.
While some porous materials exhibit excellent properties in Acknowledgments
terms of their biocompatibility they often do not meet the mechan-
ical requirements that make them suitable for bone tissue engi- The authors gratefully acknowledge the support of the EPSRC
neering [73]. In some cases these may be established via the under its ACCIS Doctoral Training Centre grant, EP/G036772/1.
introduction of fibre reinforcement; however, depending on the
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