Está en la página 1de 14

Current Opinion in Solid State and Materials Science 5 (2001) 163176

Macrophage interactions with modified material surfaces


Peter Thomsen*, Christina Gretzer

University, Box 420, 405 30 Goteborg


, Sweden
Institute of Anatomy and Cell Biology, Goteborg

Abstract
An understanding of the biological response at material surfaces is a key biomaterials research area. Inflammation, tissue repair and
regeneration are hallmarks of this response. Macrophages are long-lived and versatile cells and have a pivotal role at surfaces of
implanted medical devices. The present review provides an update on macrophage behaviour at material surfaces. The interactions
between cells and material surfaces are dynamic processes which require additional experimental models with different degrees of
environmental complexity. It is concluded that both modifications of material surface properties and cellular signalling pathways will
provide strategies for optimising the performance of biomedical devices. 2001 Elsevier Science Ltd. All rights reserved.

1. Introduction
Inflammation in association with biomedical materials is
a result of the inflicting surgical trauma and the presence
of the implanted material. The inflammatory process is
closely linked to the subsequent repair / regeneration of
tissues. Although impressive long-term clinical results
have been achieved with modern treatment modalities, e.g.
arthroplasties and oral implants, the mechanisms which
govern success and failure of implants are not fully
understood. By virtue of the versatility and intimate
relationship with the surface of implanted materials, the
macrophage has been implicated as a pivotal cell in both
the normal healing of tissues around implants and in the
pathogenesis of implant failure.
The research area of cellular and molecular interactions
between implants and tissues is now rapidly expanding.
Defined chemical and topographical alterations of the
material surface in combination with the application of
techniques of cell and molecular biology are becoming
important tools to understand how material properties are
translated into different biological responses. Hitherto, the
majority of results have been obtained in vitro and
important information is still missing on the role of
material surface properties for inflammation and tissue
repair in vivo. The present text will provide an update on
the interactions between materials and the macrophage.

*Corresponding author. Tel.: 146-31-773-3316; fax: 146-31-7733308.


E-mail address: peter.thomsen@dof.se (P. Thomsen).

2. Monocytes and macrophages participate in the


integration and failure of implants
Bone marrow-derived monocytes migrate to tissues
where they differentiate into macrophages (reviewed by
van Furth) [1]. Monocytes are recruited to the site of
surgery and implant insertion, undergo maturation to
macrophages and persist at implant surfaces. Ultrastructurally, macrophages at implant surfaces have different
phenotypes [2] and express different surface antigens [3]
depending on time after implantation.
The importance of the environment and culture substrate
for monocyte differentiation and activation in vitro was
recognized early [4]. Accumulating evidence shows that
macrophages are found in relation to implant surfaces in
several in vivo situations. Macrophages are detected on
different types of material surfaces and in the peri-implant
tissue after implant insertion in soft tissues (reviewed in
Anderson [5] and Thomsen and Ericson [6], respectively).
Implant-adherent macrophages and multinuclear cells are
detected prior to bone formation at the surfaces of different
materials inserted in bone [7]. Macrophages are also
involved in the process of failure of implants in bone, e.g.
arthroplasties [8,9] and oral implants [10].

3. Modulatory effects of proteins adsorbed on


material surfaces
Proteins adsorb to material surfaces upon contact with
body fluids. Recent studies have shown that precoating of
IgG on modified glass, polystyrene and polyurethane
promote the adhesion of macrophages cultured for 10 days

1359-0286 / 01 / $ see front matter 2001 Elsevier Science Ltd. All rights reserved.
PII: S1359-0286( 01 )00004-3

164

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

in vitro [11]. Precoating with IgG, F ab and F(ab9) 2 but not


Fc fragments enhanced macrophage adhesion on a normally poor cellular substrate (oxygenated, hydrophilic polystyrene modified by glow discharge) [12]. Interactions
between human monocytes and polyetherurethanureas
using normal, complement factor 3 (C3)-depleted or
fibronectin-depleted sera indicated that the complement
system, and specifically C3, was critical for the initial
adhesion of macrophages [13]. Using polymer networks
and grafted peptides derived from extracellular matrix and
soluble proteins, higher densities of cells, macrophage
cell-line (IC-21), were revealed on residues of interleukin1b and C3a-grafted surfaces [14]. The b 1 integrin, and the
b 3 integrins to a lesser extent, were important for human
macrophage adhesion to oligopeptides formulated based on
the primary and tertiary structures of the cell- and heparinbinding domains of human plasma fibronectin [14].
Fibrinogen appears as fibrin strands at the fluid space
tissue border around titanium implants in soft tissues and
this expression appears to be transient during normal
healing conditions [15]. Macrophages, fibrin and fibrinogen immunoreactivity are co-localized at these sites [16].
Fibrinogen has been shown to mediate a pro-inflammatory
effect at implant surfaces, mainly by causing an increased
recruitment and adhesion of leukocytes [17,18] in inflammation and tissue repair at implant surfaces. A small
peptide (residues 192202 of the fibrinogen g chain) has
been suggested to mediate the proinflammatory effect [19].
This peptide interacts with the Mac-1 (CD11b / CD18)
receptor on PMN and monocytes [2022]. Fibrinogen may
have different effects on different cell types, since fibrinogen inhibits polymorphonuclear (PMN) leukocyte adhesion, redistribution of F-actin, spreading and activation on
polymer surfaces [23,24]. Additional effects of fibrinogen
on human monocytes have recently been detected, since
fibrin causes up-regulated expression of interleukin-1b
(IL-1b) in human monocytes [25] and fibrinogen modulates monocyte apoptosis and cell death, CD14 expression
and secretion of pro-inflammatory interleukin-1a (IL1a), tumour necrosis factor-a (TNF-a) and anti-inflammatory interleukin-10 (IL-10) cytokines in association with
polystyrene (PS) surfaces in vitro [26]. It is therefore
concluded that fibrinogen plays an important regulatory
role during the sequential stages of inflammation and tissue
repair at implant surfaces.

4. Apoptosis at material surfaces


Macrophages are long-lived cells. A marked reduction
of cell viability is observed when cells encounter material
particles in a high concentration (particle / cell ratio 100:1)
[2729]. Apoptosis has been considered a result of oxidative stress induced by a disturbance in the redox balance of
reactive oxygen species (ROS) [30,31]. In contrast to
necrosis, apoptosis leads to cellular shrinkage and frag-

mentation without inducing an inflammatory response [32


34]. Macrophages remove apoptotic cells and bodies [35].
Human monocytes undergo an apoptotic process when
cultured in the absence of growth or activation stimuli,
such as lipopolysaccharide (LPS), TNF-a or IL-1b
[36,37].
Modulatory effects on apoptosis by material surfaces
and adsorbed proteins have been indicated by in vitro
observations. Human adherent monocytes revealed apoptotic changes when cultured without any stimuli on
uncoated PS [26]. LPS stimulation reduced the proportion
of apoptotic monocytes on a PS surface [26,36,38].
Monocytes in suspension demonstrated apoptotic signs
when phagocytosing bacteria but not when challenged with
zymosan particles [39]. The adhesion and apoptosis of
PMN and monocytes was dependent on the nature of the
material surface protein layer [26,40,41]. Ceramic and
polyethylene (PE) particles induced apoptosis in J774 cells
depending on particle size and concentration. A plateau
effect was reached above 150 particles / cell when using
1.3-mm diameter particles, irrespective of material [42].
One mm particles caused a markedly higher mortality
(annexin-V1, propidium iodide1) than 3 mm particles of
human adherent monocytes [26].
The presence of apoptotic changes at implant surfaces in
vivo has been indicated by recent observations in retrieved
specimens. DNA fragmentation of macrophages was observed in the interface membrane around aseptically
loosened hip and knee [43]. In another study, apoptosis
was detected in tissue around loosened hip prostheses
containing metal debris but not in specimens with polymer
or ceramic wear [44].

5. Monocyte / macrophagematerial interactions and


cytokine secretion
Macrophage activation and cytokine expression and
secretion have mainly been studied in vitro. A rapid
up-regulation of IL-1 mRNA [45], TNF-a and interleukin6 (IL-6) [46] has been shown after adhesion of monocytes
to material surfaces. A stimulatory effect on monocyte /
macrophage secretion of IL-1a [47,48], IL-1b [9,49], IL-6
[9,50], IL-10 [26,50], and TNF-a [5052] is found after
the cellular adhesion to PS [5357], polydimethylsiloxane
(PDMS) and silicone [58], PE, Dacron, expanded polytetrafluoroethylene (ePTFE), and PDMS [51,59,60] and
titanium surfaces [61]. In general, relatively low levels of
secreted proteins are detected unless exogenous stimuli are
added [28,6165]. LPS induces an increased IL-1a, IL-1b,
IL-6, TNF-a and prostaglandin E 2 (PGE 2 ) release
[53,60,64].
Large quantities of micron and submicron-sized wear
particles are detected around aseptically loosened arthroplasties. The presence of particles is associated with
inflammatory cell infiltration, fibrous membrane formation,

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

increased bone resorption and / or decreased bone matrix


formation and mineralization [8,9,66]. An equally potent
stimulation of monocyte secretion of cytokines has been
demonstrated using material particles [42,4850,52,67
71,168] (the details and main findings of recent studies
using different types of materials, concentrations, particle
sizes, shapes and cell types are summarized in Table 1).
These studies show that small particles in high particle /
cell ratios cause a proinflammatory cytokine secretion.
Different cytokine patterns were obtained depending on
material, size and concentration of particles. Further, when
using human peripheral blood monocytes, the secretion
pattern varied between individuals [71], possibly indicating
a clinically important individual heterogeneity in the
handling of particles. A particle concentration-dependent
secretion of IL-1 has been reported with 3 mm PS and Ti
particles [28,46,50,61]. In contrast, both low (1:10 particle
cell ratio) and very high (1000:1 particle cell ratio)
concentrations of small (1 mm) PS particles induce a high
IL-1a secretion [26,28].
IL-10 is produced by T-cells [72], B cells [73], macrophages [7477] and keratinocytes [167]. IL-10 production
is stimulated by proinflammatory cytokines, including
TNF-a, IL-1 and PGE 2 [50,78]. Further, IL-10 has an
inhibitory effect on pro-inflammatory cytokine production
(IL-1a, IL-1b, IL-6, TNF-a and granulocyte-macrophage
colony stimulating factor (GM-CSF) in monocytes / macrophages [76,7981]) and down-regulates O 2
2 [81] and NO
[82] production. Further, IL-10 stimulates increased B cell
growth / proliferation [83] but inhibits APC function via
down-regulation of the MHC II complex [84]. IL-10
stimulates apoptosis in human monocytes, involving upregulation of the CD95 receptor [76].
IL-10 is also implicated in the regulation of inflammation at material surfaces. Recent studies have shown
secretion of IL-10 by human monocytes triggered by 13
mm titanium particles [50] and PS substrates and particles
[26].
IL-10 was found to inhibit particle-induced monocyte
secretion of TNF-a and IL-6 [50]. Further, a role of
material surface adsorbed proteins as modulatory factors
was suggested by observations that surface pre-coated
fibrinogen had an inhibitory effect on IL-10 secretion by
PS-adherent monocytes, irrespective of LPS- and particle
stimulation [26]. Taken together, these in vitro studies
indicate the possibility of IL-10 being a down-regulatory
molecule in the inflammatory response around implants as
well as in particle-induced inflammation during loosening
of implants.
So-far, in vivo studies in soft tissues have demonstrated
the presence of TNF-a protein and TNF-a mRNA in
association with macrophages around poly(ether)urethane
implants using immunohistochemistry and in situ hybridization [3]. Recent studies have shown IL-1b and TNF-a
expression around PDMS in mice, with maximum immunostaining at 14 days which remained elevated through-

165

out a 70-day observation period [85]. IL-1b and transforming growth factor (TGF-b) immunostaining were distributed adjacent to titanium implant 330 days after implantation in rats, but with no correlation to the number of
inflammatory cells [86].
It may therefore be concluded that peri-implant cells
express cytokines irrespective of implant types. The types
of cytokine-secreting cells and the cytokine levels obtained
in the interface around different types of materials have not
been established. Further, the precise modulatory effects of
cytokines on the inflammatory and reparative process
around implants are not known.

6. Monocyte / macrophagematerial interactions and


production of reactive oxygen species
The PMN has been the focus in the majority of studies
on oxygen metabolites generated after the encounter
between cells and material surfaces. Previous studies in
vitro have shown that the production of reactive oxygen
species by phagocytes and their ability to respond to
exogenous stimuli are dependent on the cells being adherent or suspended, the type of substrate and the type of
stimulus [8790]. The maturational change in monocyte to
macrophage phenotype is associated with a decrease in
scavengers of reactive oxygen species (myeloperoxidase,
catalase and glutathione peroxidase) and production of
2
reactive oxygen species, such as O 2
2 , H 2 O 2 and OH
[9193]. Interleukin-4 (IL-4) promotes monocyte differentiation and inhibits soluble and particle stimulated O 2
2
production in human monocytes [94]. Further, IL-4 inhibits
interferon-g (IFN-g)-mediated production of H 2 O 2 in
cultured human monocytes [95]. A dose-dependent increase in H 2 O 2 secretion was observed with material
particle-stimulated human monocytes in short term culture
but this response was totally abrogated after a prolonged
culture period concomitant with phenotypic alterations
(expression of CD14, 27E10 and RM3 / 1 surface antigens)
[28]. Few studies have focused on the measurement of
oxidative species generated by implant-adherent cells
under in vivo conditions. A mixed population of PMNs
and monocytes on functionalized (OH), hydrophilic
implant surfaces 3 h and 1 day after implantation responded with a higher generation of extracellularly secreted reactive oxygen species than on functionalized
(CH 3 ), hydrophobic surfaces [96]. In contrast, the role of
implant surface properties for the production of reactive
oxygen species by monocytes / macrophages is less well
understood. The results of the pioneering studies by
Camarero et al. [97] showed that macrophages on subcutaneously implanted glass in mice after 14 days secreted a
protease-sensitive, heat-stable factor with deactivating
effect on O 2
2 -release by phorbol ester-stimulated cells. A
crucial question is if the secretion of reactive oxygen
species by macrophages is modified by different implant

166

Particle
size (mm)

Particle/
cell ratio

Material

Cell species
Time

Results

Main findings

Reference

13
E

10 2

Ti

Ti310 2 IL-6, TNF-a,


IL-10

IL-10 neutralized the effect of pro-inflammatory


cytokines but also induce them

[50]

1
E

1, 10

cCoCr,
fCoCr,
TiAlV, SS

Monoc.
H
24 h
Monoc.
H
48 h

SS, CoCr were toxic to cells, SS310


induced IL-6, PGE 2 . Different materials
elicited different cytokine patterns

[67]

0.520
0.323
0.325
E

10 10

All materials310IL-1b, TNF-a


SS31IL-1b
CoCr31IL-6, PGE 2
TiAlV310IL-6, PGE 2
PWM, Ti, PMMA and PS
particl.thymidine uptake
in lymph. but not monoc.
PWM, Ti, PMMA and
PS particl.IL-1b

[69]

410
E

0.21, 0.49,
4.3, 7.2, 88

PWM or particles increased thymidine


uptake by lymphocytes but did not
alter the uptake by monocytes.
Ti, PMMA and PS did not inhibit the PWM
stimulation of IL-1b. Exposure of particles
do not prevent further activation by PWM
Donor heterogeneity in cytokine secretion
and pattern. IL-1b, TNF-a, IL-6 was released
from collagen surface control. Native or high
oxidized particles did not influence the release.
Low oxidized particles revealed small increase
in TNF-a and IL-6 release. Chemistry altered the
cytokine pattern due to protein adsorption
Heterogeneity of human individuals
in both profiles and amounts of released
cytokines

TiAlV
PMMA
PS

Mixed: lymph/monocyte
ratio 10:1
H
72 h

HDPE,
low and high oxidized HDPE
solidified collagen I

Monoc.
H
24, 48 h

High cytokine release with


collagen control without particles.
IL-1b, TNF-a, IL-6 increased with all particles
Low oxidized HDPE particles induced
highest cytokine levels

10, 10 2

PE

Monoc.
H
24 h

0.21 and 0.49 mm310 2 IL-1b,


TNF-a, IL-6, GM-CSF, PGE 2

[52]

[71]

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

Table 1
Recent in vitro studies on interactions between particles and monocytes / macrophages in single cell cultures

10 2

PMMA, 1 mm, 10 mm BaSO 4 ,


10 mm ZrO 2 , TCP 20, 30%

0.21, 0.49,
4.3, 7.2, 88

10 21 , 1, 10, 100

PE

1820
410

UHMWPE
HDPE solidified collagen I

0.6, 4.5

510 3

Al 2 O 3 , ZrO 2 , PE

2.2, 6.4

1, 16

PMMA, CoCr

4.73, 2.49

?
estimated
10

HDPE
CoCrMo

U937
H
24 h
C3H
M peritoneal
macrophages
24 h
IC-21
M
24 h
J774
M
24 h
J774
M
24 h, 48 h
IC-21
M
24 h

All particlesIL-1b, TNF-a, IL-6,


TCP 20 and 30%low Ca 45 release
0.217.23100TNF-a, IL-1b, IL-6
88low cytokines

410310IL-1a, b, TNF-a, IL-6, PGE 2

Al 2 O 3 , ZrO 2 0.6310 3
TNF-a
PE 4.5310 2
TNF-a
No IL-1a
TNF-a, IL-6 or IL-12 release
LPSrelease
No IL-1b, IL-6 TNF-a
LPSrelease

Lower levels of cytokines induced by


TCP 20 and 30% but no differences between
the particles at high conc.
0.310 mm PE particles were phagocytosable and
biologically active. Size and concentration were important

Large particles .10 mm induce MNGC formation.


HDPE 410 mm phagocytosed within 2 h. Inflammatory
cytokines were released
Plateau of phagocytosis after 15 h.
Mortality increased with particle size (.2 mm) and conc.
Small particles (0.6 mm) were toxic in high conc. (10 3 )
PE induced higher TNF-a than Al 2 O 3 , ZrO 2
Only high CoCr conc. .316 induced
cytokine release
Different cytokine pattern for metal and polymer particles.
Surface chemistry and microstructure affected the adherence of
macrophages and the cytokines released. Additional effect of LPS

[168]

[49]

[48]

[42]

[68]

[70]

Ti, titanium; PMMA, polymethylmethacrylate; cCoCr, cast cobalt chromium; fCoCR, forged CoCR; PE, polyethylene; HDPE, high density polyethylene; UHMWPE, ultra-high molecular weight
polyethylene; H, human; M, mouse; E, endotoxin tested; PWM, pokeweed mitogen; Al, aluminium; Zr, zirconium; LPS, lipopolysaccharide; TCP, tricalcium phosphate; Ba, barium.

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

0.1 (70%)10 (10%)

167

168

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

properties. Recent in vivo studies (rat subcutaneous model)


revealed a spontaneous generation of H 2 O 2 during the
128 day inflammation and healing phases and a higher
absolute level of H 2 O 2 produced by cells on PS surfaces
than titanium during the transient inflammatory phase (7
15 days) [26]. However, neither the amount of H 2 O 2
generated per cell, nor the attenuated responsiveness to
phorbol ester stimulation in maturating macrophages differed between cells on the two types of material.
Extracellularly secreted reactive oxygen species may
cause several effects in the implanttissue interface,
depending on the cell type and the types and amounts of
secreted species, and the relationship between the implant
surface, secreting cells and neighbouring effector cells.
The production of reactive oxygen species by phagocytes
is crucial for their microbicidal activities [98,99]. A
reduction of radical production capacity by long-term
adherent macrophages may therefore be important for the
efficiency whereby microorganisms are eliminated at implant surfaces. In numerous inflammatory diseases, toxic
oxygen metabolites have been implicated in the pathogenetic mechanisms [100]. However, interest is now also
moving towards the role of reactive oxygen species in
non-toxic cellcell signalling. In vitro studies have
shown that depending on the concentrations several cellular functions may be modulated by O 2
2 and H 2 O 2 , thus
expanding the properties of reactive oxygen to other
messenger molecules. In vitro, low concentrations (1 mM)
of H 2 O 2 stimulated the proliferation of fibroblasts, whereas
higher concentrations (100400 mM) induced senescence
or apoptosis [101,102]. In the rat, a spontaneous production of H 2 O 2 in the 40400 pmol / mg DNA range was
detected in titanium and PS adherent macrophages during a
40-min ex vivo incubation after retrieval [26]. These
values were higher than those detected with human monocytes on PS in vitro [28] and with cells adherent on
titanium and PTFE in a murine model after 1 and 6 days
[103].
Hitherto, pharmacological intervention aiming towards a
reduction of inflammation and the fibrous capsule formation around implant has not been successful. It is therefore
interesting that low molecular weight (500600 Da)
superoxide dismutase (SOD) mimetics, which inhibit
inflammation [104] reduced the material surface oxidation,
the number of macrophages and multinuclear cells on the
material surface and the thickness of the surrounding
fibrous capsule when covalently bound to ultra high
molecular weight polyethylene (UHMWPE), polyetherurethane and tantalum [105].
Taken together, both in vitro and in vivo observations
indicate an important role of reactive oxygen species for
the macrophage and tissue response at biomaterials implanted in soft tissues. Continued studies are therefore
required on cell activation and the production of reactive
oxygen species in the implanttissue interface. The effects
of modification of reactive oxygen species on phagocytosis

and killing of microorganisms during long-term implantation requires particular attention.

7. Fibrous capsule formation and the role of


macrophages
Several normal and pathologic conditions in the body
involve the production, degradation and remodelling of
extracellular matrix. The implant surface with adsorbed
molecules and the extracellular matrix constitute the
microenvironment of macrophages associated with implants in vivo. The extracellular matrix and its components
serve many functions such as adhesion sites, pathway for
cells and interstitial fluid. Further, signals for the differentiation and stimulation of cells reside in the matrix. The
organization of the surrounding cells and matrix into a
fibrous capsule around the implant may be regarded as the
creation of a barrier between the foreign material and the
body, leading to consequences for implant function. The
role of the macrophage, being present both at the surface
and in the surrounding tissue, in this process is yet
incompletely understood.

7.1. Material surface chemical properties


It is hypothesized that the material surface chemical
composition could stimulate inflammation, the secretion of
cytokines / fibrogenic factors and development of the fibrous capsule. Differences in surface chemistry were shown
to modulate fibronectin expression in vitro [106]. Polyurethane implants were surrounded by a thicker fibrous
capsule than silicone [107]. In contrast, the capsule thickness did not differ between titanium and titanium-6%
alumina-4% vanadium (Ti-6Al-4V) [2] and metal and
ceramic implants [108]. TNF-a expression in association
with macrophages was not influenced by the surface
charge of different polymers after implantation in rat
muscular tissue [3]. Further, observations using gold,
OH, and CH 3 (self-assembled monolayer, SAM) functionalized surfaces did not show any major influence on
the content of IL-1a, IL-1b and TNF-a, despite differences in inflammatory cell numbers and distribution in the
interface [109]. Recent morphometric and ultrastructural
studies using such SAM-modified surfaces did not reveal
any significant differences in the general tissue arrangement and fibrous capsule thickness after 7 and 28 days
[110]. Thus, material surface modification may influence
several inflammatory events in vivo [3,109], but the role of
material surface chemical properties as eliciting stimuli for
fibrogenesis around implants is yet unresolved.

7.2. Surface topography


Macrophages preferentially accumulate on rough surfaces in vitro [111,112]. Experimental studies in soft

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

tissues have indicated that a textured or porous surface


elicits a different tissue response than a smooth surface
[113116]. In recent studies [86,117] in the rat, the tissue
response to PE discs with smooth to coarse surface
topographies was evaluated 112 weeks after insertion.
After 12 weeks an inverse relation was found between
increasing material surface roughness and fibrous capsule
thickness. At all time periods, the smooth surface was
associated with a thicker fibrous capsule than the rough
PE. A correlation between a decreasing number of interfacial ED1 positive macrophages and increasing material
surface roughness was found after 1 week, but not at 6 and
12 weeks. Proposed mechanisms for the surface topographical modification of the repair process / foreign body
reaction include microtexture-induced effects on the material surface protein adsorption pattern [118], cell shape
[119,120] and mechanical stability [113,121123].

7.3. Growth factors, cytokines and fibrous capsule


formation
Activated macrophages produce at least six growth
factors IL-1, TNF-a, IL-6, fibroblast growth factor
(FGF), platelet-derived growth factor (PDGF) and transforming growth factor b (TGF-b), which have multiple
effects including the modulation of fibroblast proliferation
and connective tissue matrix production. Several of these
are implicated in wound healing and clinical and experimental fibrotic disorders (reviewed in Kovacs [124],
Rubin and Farber [125]).
TGF-b is a pleiotropic, homodimeric peptide with
stimulatory and inhibitory properties on different cell types
[126,127]. During wound healing, TGF-b has a bi-phasic
appearance, initially released by platelets, and later as a
macrophage-derived cytokine which modulates matrix
formation [128]. TGF-b stimulates collagen synthesis in
fibroblasts and inhibits its degradation [129]. TGF-b
increases the contractile effect of human fibroblasts on a
collagen matrix [130].
The fibrous capsule formation around silicone breast
implants has been the focus of several studies and is a
clinical example of a fibrotic process which involves
macrophagematerial interactions and cytokine secretion.
TGF-b, TGF-b1 and TGF-b2 are expressed in a higher
amount in the tissue adjacent to silicone breast implants
than in normal (breast) tissue controls [131,132]. No direct
correlation was found between TGF-b isoforms and the
degree of capsule formation [132]. An elevated expression
of immunoreactivity (restricted to sites of monocyte /
macrophage accumulation in peri-implant regions) for
peptide growth factor receptors (TGF-b receptor-I, PDGF
receptor-b and FGF receptor I), inducible nitric oxide
synthase (iNOS) and endothelial nitric oxide synthase
(eNOS) has recently been demonstrated in low-grade
chronically inflamed breast capsules [133]. Cooperative
effects of inflammatory and growth factor mediator sys-

169

tems may also influence myofibroblasts in the contracted


capsule [131,132]. A role of mechanical factors in the
development of the fibrous capsule has also been suggested
and some experimental support for this assumption has
been given. Tendons exposed to graded loading exhibit a
correlation between the content of myofibroblasts and
mechanically stressed regions of the scar capsule as well as
with peptide growth factors [134]. Another recent example
derives from the study of bone implant loosening. Aspenberg et al. found that a combination of material particles
and implant motion gave a strong signal for fibrosis [135].

7.4. Matrix metalloproteinases and tissue degradation


The matrix metalloproteinases (MMPs) are a family of
more than 20 zinc-dependent endoproteases which have
the capacity to degrade a variety of extracellular components [136,137]. MMP expression is regulated via
several mechanisms, at mRNA level transcriptionally by
cytokines, growth factors, and hormones. Most MMPs are
secreted as inactive zymogens. Activated enzymes are
inhibited by either specific tissue inhibitors of metalloproteinases (TIMPs) or more broad tissue inhibitors such as
the a-macroglobulin [136,137]. MMPs are involved in the
degradation and remodelling of tissues and are implicated
in various destructive diseases, such as tumour formation,
arthritis, periodontitis and osteoporosis. MMP inhibitory
activity is found with bisphosphonates and tetracycline.
The role of MMPs for infiltration of cells and fibrous
capsule remodelling around implants is not known. However, recent studies indicate that materials influence the
expression of MMPs. MMPs are involved in bone resorption by osteoclasts and bone remodelling during embryogenesis and skeletal growth. Also human osteoblasts
interacting with porous biphasic hydroxyapatite / tricalcium
phosphate granules secrete MMP-2 and MMP-9 [138],
indicating that in normal bone an increased synthesis of
MMPs in osteoblasts could be related to increased bone
synthesis. On the other hand, hydroxyapatite crystals
induce degradation of both precursor and active forms of
MMP-1 and MMP-3 [139]. MMPs and their inhibitors
have been proposed to be involved in aseptic loosening of
hip arthroplasties [140,141]. Both substratum surface
chemistry and topography-induced changes in cell shape
can alter MMP-2 expression in human fibroblasts, e.g.
grooved titanium showing greater MMP-2 mRNA levels
than smooth titanium [142].

7.5. Cellcell interactions in vivo


Accumulating evidence suggests that T cells and
lymphocyte-derived cytokines play a role in the pathogenesis of fibrosis [124]. T cells and macrophages are
located perivascularly around arthroplasties which have
undergone a failure process [143,144]. However, the
involvement of lymphocytes in fibrous capsule formation

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

170

around implants is not clear-cut. No T or B lymphocytes


were observed in the infiltrates around differently modified
poly(ether)urethanes at time points between 2 days and 12
weeks [3]. Fibrous capsule formation did not appear to be
dependent on T-cell function [145,146]. On the other hand,
T cells were required to amplify the inflammatory response
to UHMWPE particles [147].
IFN-g induces TNF-a expression and secretion in
macrophages [148,149] and TNF-a is up-regulated in lung
fibrosis [150,151]. On the other hand, IFN-g is able to
reduce the number of myofibroblasts, collagen content and
wound contraction in vivo [152,153] and reduces the
fibrous reaction to an implanted foreign body in mice
[154].

7.6. Multinuclear giant cells


The formation of foreign body multinuclear giant cells
(MNGC) is a feature of on-going chronic inflammation
and is observed in the presence of microorganisms and
nonphagocytosable materials under periods of up to 15
years [155]. MNGCs have a reduced phagocytic activity
[156]. In comparison with unfused macrophages, human
MNGC had a similar IL-1 secreting capacity and when
stimulated with zymosan particles revealed a 2030-fold
increase in chemiluminescence response, albeit not increased when related to the number of nuclei [157].
Macrophages are structurally and functionally distinct
from foreign body MNGCs [158,159]. IL-13 induces

macrophage fusion and foreign body MNGCs formation


[160]. In contrast to several other cytokines and growth
factors, IL-4 alone could induce the formation of foreign
body MNGCs from human monocyte-derived macrophages
in vitro [161]. Further, the injection of recombinant IL-4
and anti-IL-4 antibody at the implant site resulted in an
increase and decrease, respectively, in MNGC densities
[162]. A potentially negative effect of MNGC on the
underlying material was indicated by observations of
material surface cracks directly beneath multinuclear giant
cells adherent to retrieved polymeric materials [159].
In contrast to the possibilities to study interactions
between leukocytes and material surfaces in vitro, few
models have yet allowed a quantitative analysis of cell
recruitment, adhesion and activation on implant surfaces in
vivo. The net result of signalling between cells which
participate in the transition from inflammation to repair is
likely to be dependent on combined effects of different
types and concentrations of mediators. There is an obvious
necessity for a careful analysis of the temporal expression
and secretion of inflammatory and fibrogenic / bone resorptive mediators after implant insertion in vivo.

8. Monocyte / macrophagematerial interactions and


effects on co-cultured cells
An understanding of the roles of the macrophage during
inflammation and tissue formation and remodelling at

Table 2
Recent in vitro studies using different cell types in co-cultures
Stimuli
size

Concentration

E
1100 mg
13 mm
10 3 mmol/well

Material

Cell types and species Results


Time

Main findings

Reference

PMMA
cpTi
bisphosphonate

J774,
osteoblast
M
MC3T3, M
2496 h
J774,
osteoblast
M
MC3T3,
M
24 h

Ti particles in all conc. induced


TNF-a. PMMA in all conc. induced
IL-6, GM-CSF, PGE 2 . No IL-1a was detected

Both PMMA and Ti particles increased the Ca 45


release at all time periods indicating bone resorption.
Bisphosphonate inhibited the release at both
materials at all time periods

[163]

Control induced TNF-a, PGE 2 .


CoCr 0.5 mg/cm 2 induced high TNF-a,
PGE 2 . No IL-1b or IL-6 were detected

Thyroid epithelial cells


H
Monoc./macroph
H
24 h
Monoc./macroph
H
WI-38,
fibroblast
H

PS particles and LPS induced IL-1a release


in human monocytes. The epithelial resistance
(R) was decreased. Anti-IL-1a blocked the
decrease to 50%.

High levels of TNF-a and PGE 2 in the control


[164]
without particles. CoCr induced very high TNF-a and
PGE 2 levels. CoCr was toxic to macrophages also in low
45
conc. (LDH release). Ca release was higher in cocultures
versus medium from separately stimulated macrophages
indicating a PGE 2 production in the osteoblats. No
control with single osteoblast culture
Heterogeneity of blood donors. LDH was increased when [29]
100 particles/cell were used. IL-1a induced dissociation of
cellcell junctions. Morphological changes of the tight
junctions when cocultured with monocytes

E
7.863

0.055 mg/cm 2

E
3

10 and 100 particles/cell PS


10 mg/ml
LPS

cpCoCr

50 mg/ml
1000 U/ml
300 U/ml

LPS,
IFN-g
IL-4

5310 26 M

Gluco
corticoid

LPS, TH1 cytokines (IFN-g, IL-12) induce


TNF-a, MMP-7; inhibit fibrogenesis. Glucocorticoids
or TH2 cytokines (IL-4, IL-10, IL-13) induce TGF-b and
PDGF; induce fibrogenesis

Classical activation (LPS, IFN-g) induces expression of


[165]
TNF-a MMP-7 which inhibit fibrogenesis. TGF-b, PDGF
were elevated by IL-4 or glucocorticoid in alternatively
activated macrophages and increased the proliferation and
collagen synthesis of fibroblasts

H, human; M, mouse; cpCoCr, commercially pure cobalt chromium; cpTi, commercially pure titanium; E, endotoxin tested; LPS, lipopolysaccharide;
TNF, tumor necrosis factor; MMP, matrix metalloproteinase; IFN, interferon; IL, interleukin.

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

implanted surfaces have to include the activities of other


cell types. Co-culture of cells in bicameral chambers has
emerged as an important model system to examine cell
cell interactions in great detail. Recent studies on the
effects of macrophage activation (with and without material components as stimuli) on various target cells are
summarized in Table 2 [29,163165].
Although the profile of secreted cytokines suggested
polymethylmethacrylate (PMMA) particles to be more
inflammatory than titanium, 45 Ca release from rat calvaria, thus indicating bone resorption, was found after
exposure of macrophages to both PMMA and titanium
[163]. This was followed up using cobalt chromium and
co-cultures of macrophages and osteoblasts [164]. In
another study, the epithelial barrier function of human
thyroid cell monolayers was attenuated by human monocytes when co-cultured in opposite compartments of
bicameral chambers [29]. This effect was further attenuated by monocytes stimulated with LPS and polystyrene (PS) particles. Since the addition of anti-IL-1a
markedly reduced IL-1a-levels and prevented the drop in
transepithelial resistance induced by LPS- and particlestimulated monocytes, it was suggested that IL-1a was a
major diffusable factor which mediated the epithelial
barrier dysfunction.
IL-4 and IFN-g are secreted by two different T helper
(Th) lymphocyte subsets. IL-4 has previously been shown
to down-regulate IL-1 and TNF expression and secretion
[148,166]. Alternatively (IL-4 or dexamethasone) pre-activated human macrophages, secreting TGF-b1 and PDGF,
increased the proliferation and collagen synthesis of cocultured human WI-38 fibroblasts [165]. In contrast,
classically (LPS or IFN-g) activated macrophages, secreting TNF-a and MMP-7, decreased fibroblast proliferation.
These interesting observations indicate that depending on
the type of activating stimulus macrophages communicate
either pro- and anti-fibrogenic signals to fibroblasts. Although few studies so-far have addressed the influence of
material surface properties on macrophage activation and
subsequent signalling to neighbouring mesenchymal cells,
co-culture systems appear to have considerable potential in
such efforts.

171

bouring cell types. Additional important knowledge about


the effects of implant properties and changes in the local
environment for macrophage behaviour may be gained
from systematic, small changes in implant chemical and
topographical properties, in vitro co-culture models and a
detailed temporal and spatial resolution of participating
cells and mediator systems in experimental in vivo models
and retrieved human specimens. Key tasks include the
investigation of major molecules involved in inflammation
and tissue formation / remodelling at material surfaces
The rapidly growing area of material surface chemical
and topographic functionalization is likely to result in
future implants engineered to fulfil specific demands.
Several of these systems may be used to direct undifferentiated cells. Hitherto, few in vivo results of such designs
have been reported. However, it is likely that inflammatory
cells including macrophages will prevail also at such
implant surfaces. On the basis of animal experimental data,
the use of down-regulatory or de-activating cytokines, such
as IL-10, the employment of scavengers of oxygen radical
generation, the interference with growth factors, such as
TGF-b, and tissue degrading enzyme systems (such as
MMPs) represent interesting strategies in implant applications. However, due to the still unravelled complexity of
implantcell, cellcell and cellmatrix interactions (some

9. Conclusions
Several materials are presently used as components of
biomedical implants in the treatment of deranged or lost
tissue structure and function. Macrophages interact with
material surfaces and are suggested to be the cells which
orchestrate the inflammatory and repair phase of tissue
healing around implants, irrespective of material type.
Macrophage activation and secretion is modified by implant material properties, proteins adsorbed to surfaces and
factors released by other macrophages and other neigh-

Fig. 1. A schematic of the interface between a biomaterial and some of


the biological components. The monocyte / macrophage has an intimate
relationship with the implant surface and occupies a central position in a
network of established and suggested interactions between cells, extracellular matrix and material components.

172

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

of which are indicated in Fig. 1) it is likely that additional


biologic strategies for the optimization of implanttissue
integration will emerge.

Acknowledgements
The authors are grateful to other scientists for the
communication and discussion of recent results. This work
is supported by the Swedish Medical Research Council
(9495), the Swedish National Board for Technical Development (NUTEK) and the Swedish National Board for
Laboratory Animals (CFN) (00-61).

[16]

[17]
[18]
[19]

[20]

[21]

References
[1] van Furth R. Development and distribution of mononuclear
phagocytes. In: Gallin JI, Goldstein IM, Snyderman R, editors, 2nd
ed, Inflammation: basic principles and clinical correlates, New York:
Raven Press, 1992, pp. 32539.
[2] Johansson CB, Albrektsson T, Ericson LE, Thomsen P. A quantitative comparison of the cell response to commercially pure titanium
and Ti-6Al-4V implants in the abdominal wall of rats. J Mater Sci:
Mater Med 1992;3(3):12636.
[3] Hunt JA, Flanagan BF, McLaughlin PJ, Strickland I, Williams DF.
Effect of biomaterial surface charge on the inflammatory response:
evaluation of cellular infiltration and TNF-a production. J Biomed
Mater Res 1996;31:13944.
[4] Kaplan G, Gaudernack G. In vitro differentiation of human monocytes. Differences in monocyte phenotypes induced by cultivation
on glass or on collagen. J Exp Med 1982;156(4):110114.
[5] Anderson JM, Ziats NP. Human blood protein and cellular interactions in the healing responses of vascular prosthesis. J Vasc Surg
1991;13(5):7501.
[6] Thomsen P, Ericson LE. Inflammatory cell response to bone implant
surfaces. In: Davies JE, editor, The bonebiomaterial interface,
Toronto: University of Toronto Press, 1991, pp. 15363.
[7] Larsson C, Esposito M, Liao H, Thomsen P. The titaniumbone
interface in vivo. In: Brunette DM, Tengvall P, Textor M, Thomsen
P, editors, Titanium in medicine, Basel: Springer Verlag, 2001,
chapter 18.
[8] Al-Saffar N, Revell PA. Pathology of the boneimplant interfaces. J
Long Term Effect Med Implants 1999;9(4):31947.
[9] Ingham E, Fisher J. Biological reactions to wear debris in total
replacements. Proc Inst Mech Eng 2000;214(1):2137.
[10] Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors
contributing to failures of osseointegrated oral implants. (II)
Etiopathogenesis. Eur J Oral Sci 1998;106:72164.
[11] Jenney CR, Anderson JM. Adsorbed serum proteins responsible for
surface dependent human macrophage behavior. J Biomed Mater
Res 2000;49:43547.
[12] Jenney CR, Anderson JM. Adsorbed IgG: a potent adhesive
substrate for human macrophages. J Biomed Mater Res
2000;50:28190.
[13] Kao WJ. Evaluation of protein-modulated macrophage behaviour on
biomaterials: designing biomimetic materials for cellular engineering. Biomaterials 1999;20:221321.
[14] Kao WJ, Hubbell JA. Murine macrophage behavior on peptidegrafted polyethyleneglycol-containing networks. Biotech Bioeng
1998;59:29.
[15] Rosengren A, Johansson BR, Danielsen N, Thomsen P, Ericson LE,
Bjursten LM. Immunohistochemical studies on the distribution of

[22]

[23]

[24]

[25]

[26]
[27]

[28]
[29]

[30]
[31]

[32]

[33]
[34]

[35]
[36]

albumin, fibrinogen, fibronectin, IgG and collagen around PTFE and


titanium implants. Biomaterials 1996;17:177986.
Rosengren A, Johansson BR, Thomsen P, Ericson LE. Method for
immunohistochemical observations of extracellular proteins in association with titanium implantssoft tissue interface. Biomaterials
1994;15:1724.
Tang L, Eaton JW. Fibrin(ogen) mediates acute inflammatory
responses to biomaterials. J Exp Med 1993;178:214756.
Tang L, Eaton JW. Mechanism of acute inflammatory response to
biomaterials. Cells Mater 1994;4:42936.
Tang L, Ugarova TP, Plow EF, Eaton JW. Molecular determinants of
acute inflammatory responses to biomaterials. J Clin Invest
1996;97(5):132934.
Altieri DC, Bader R, Mannucci PM, Edgington TS. Oligospecificity
of the cellular adhesion receptor Mac-1 encompasses an induction of
recognition specificity for fibrinogen. J Cell Biol 1988;107:1893
900.
Trezzini C, Jungi TW, Kuhnert P, Peterhans E. Fibrinogen association with human monocytes: evidence for constitutive expression of
fibrinogen receptors and for involvement of Mac-1 (CD18,Cr3) in
the binding. Biochem Biophys Res Commun 1988;156:477.
Simon DI, Ezratty AM, Francis SA, Rennke H, Loscalzo J.
Fibrin(ogen) is internalized and degraded by activated human
monocytoid cells via Mac-1 (CD11 / CD18): a nonplasmin fibrinolytic pathway. Blood 1993;82:241422.

Nimeri G, Lassen B, Golander


KG, Nilsson U, Elwing H. Adsorption of fibrinogen and some other proteins from blood plasma at
a variety of solid surfaces. J Biomater Sci Polymer Edn
1994;6(6):57383.
Higazi AA, Barghouti II, Ayesh SK, Mayer M, Matzner Y.
Inhibition of neutrophils activation by fibrinogen. Inflammation
1994;18:52535.
Perez RL, Roman J. Fibrin enhances the expression of IL-1b by
human peripheral blood mononuclear cells. J Immunol
1995;154:187987.

Gretzer C. Macrophagematerial surface interactions, Goteborg:

Goteborg
University, 2000, Thesis.
Shanbhag AS, Jacobs JJ, Black J, Galante JO, Glant TT. Macrophage / particle interactions: effect of size, composition and surface
area. J Biomed Mater Res 1994;28:8190.
Gretzer C, Thomsen P. Secretion of IL-1 and H 2 O 2 by human
mononuclear cells in vitro. Biomaterials 2000;21:104755.
Gretzer C, Thomsen T, Jansson S, Nilsson M. Co-culture of human
monocytes and thyrocytes in bicameral chamber: monocyte-derived
IL-1a impairs the thyroid epithelial barrier. Cytokine
2000;12(1):3240.
Buttke TM, Sandstrom PA. Oxidative stress as a mediator of
apoptosis. Immunol Today 1994;15(1):710.
Iwaki K, Ohashi K, Ikeda M, Tsujioka K, Kajiya F, Kurimoto M.
Decrease in the amount of focal adhesion kinase (p125(FAK)) in
interleukin-1beta-stimulated human umbilical vein endothelial cells
by binding of human monocytic cell lines. J Biol Chem
1997;272(33):2066570.
Kerr JFR, Wyllie AH, Currie AR. Apoptosis: a basic biological
phenomenon with wide-ranging implications in tissue kinetics. Br J
Cancer 1972;26:23957.
Chen CS, Mrksich M, Huang S, Whitesides GM, Ingber DE.
Geometric control of cell life and death. Science 1997;276:14258.
Fadok V, Bratton D, Frasch S, Warner M, Henson P. The role of
phosphatidylserine in recognition of apoptotic cells by phagocytes.
Cell Death Differ 1998;5(7):55162.
Savill J, Fadok V, Henson P, Haslett C. Phagocyte recognition of
cells undergoing apoptosis. Immunol Today 1993;14(3):1316.
Mangan DF, Welch GR, Wahl SM. Lipopolysaccharide, tumor
necrosis factor-a, and IL-1b prevent programmed cell death (apoptosis) in human peripheral blood monocytes. J Immunol
1991;145(5):15416.

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176
[37] Flad H, Grage-Griebenow E, Scheuerer B et al. The role of
cytokines in monocyte apoptosis. Res Immunol 1998;149:7336.
[38] Heidenreich S. Monocyte CD 14: a multifunctional receptor engaged
in apoptosis from both sides. J Leukocyte Biol 1999;65:73743.
[39] Baran J, Guzik K, Hryniewicz W, Ernst M, Flad H-D, Pryjma J.
Apoptosis of monocytes and prolonged survival of granulocytes as a
result of phagocytosis of bacteria. Infect Immun 1996:42428,
October.
[40] Ginis I, Faller DV. Protection from apoptosis in human neutrophils
is determined by the surface of adhesion. Am J Physiol (Cell
Physiol) 1997;41:C295309.
M, Sellborn A, Kalltorp

[41] Werthen
M, Elwing H, Thomsen P. In vitro
study of monocyte viability during initial adhesion to albumin- and
fibrinogen-coated polystyrene surfaces. Biomaterials 2001;8:827
32.
[42] Catelas I, Huk OL, Petit A, Zukor DJ, Marchand R, Yahia L. Flow
cytometric analysis of macrophage response to ceramic and polyethylene particles: effect of size, concentration, and composition. J
Biomed Mater Res 1998;41:6007.
[43] Zhang XS, Revell PA. In situ localization of apoptotic changes in
the interface membrane of aseptically loosened orthopaedic implants. J Mater Sci: Mater Med 1999;10:87983.
[44] Stea S, Visentin M, Granchi D et al. Apoptosis in peri-implant
tissue. Biomaterials 2000;21:13938.
[45] Haskill S, Johnson C, Eierman D, Becker S, Warren K. Adherence
induces selective mRNA expression of monocyte mediators and
pro-oncogenes. J Immunol 1988;140:16904.
[46] Blaine TA, Rosier RN, Puzas EJ et al. Increased levels of tumor
necrosis factor-a and interleukin-6 protein and messenger RNA in
human peripheral blood monocytes due to titanium particles. J Bone
Joint Surg 1996;78A(8):118192.
[47] Shanbhag AS, Jacobs JJ, Black J, Galante JO, Glant TT. Human
monocyte response to particulate biomaterials generated in vivo and
in vitro. J Orthop Res 1995;13:792801.
[48] Voronov I, Santerre JP, Hinek A, Callahan JW, Sandhu J, Boynton
EL. Macrophage phagocytosis of polyethylene particulate in vitro. J
Biomed Mater Res 1998;39:4051.
[49] Green TR, Fisher M, Stone M, Wroblewski BM, Ingham E.
Polyethylene particles of a critical size are necessary for the
induction of cytokines by macrophages in vitro. Biomaterials
1998;19:2297302.
[50] Pollice PF, Hsu J, Hicks DG et al. Interleukin-10 inhibits cytokine
synthesis in monocytes stimulated by titanium particles: evidence of
an anti-inflammatory regulatory pathway. J Orthop Res
1998;16(6):697704.
[51] Cardona MA, Simmons RL, Kaplan SS. TNF and IL-1 generation
by human monocytes in response to biomaterials. J Biomed Mater
Res 1992;26:8519.
[52] Boynton EL, Waddell J, Meek E, Labow RS, Edwards V, Santerre JP.
The effect of polyethylene particle chemistry on human monocyte
macrophage function in vitro. J Biomed Mater Res 2000;52(2):239
45.
[53] Miller KM, Rose-Caprara V, Anderson JM. Generation of IL1-like
activity in response to biomedical polymer implants: a comparison
of in vitro and in vivo models. J Biomed Mater Res 1989;23:1007
26.
[54] Hogquist K, Unanue ER, Chaplin DD. Release of IL-1 from
mononuclear phagocytes. J Immunol 1991;147:21816.
[55] Hurme M, Serkola E. Different activation signals are required for
the expression of interleukin-1a and b genes in human monocytes.
Scand J Immunol 1991;33:7138.
[56] Bonfield TL, Colton RE, Marchant RE, Anderson JM. Cytokine and
growth factor production by monocytes / macrophages on protein
preadsorbed polymers. J Biomed Mater Res 1992;26(7):83750.
[57] Benahmed M, Heymann D, Pilet P, Bienvenu J, Daculsi C. LPS
increases biomaterial degradation by human monocytes in vitro. J
Biomed Mater Res 1997;34:1159.

173

[58] Anderson JM, Ziats NP, Azeez A, Brunstedt MR, Stack S, Bonfield
TL. Protein adsorption and macrophage activation on polydimethylsiloxane and silicone rubber. J Biomater Sci Polymer Edn
1995;7(2):15969.
[59] Miller KM, Huskey RA, Bigby LF, Anderson JM. Characterization
of biomedical polymer-adherent macrophages: interleukin 1 generation and scanning electron microscopy studies. Biomaterials
1988;10:18796.
[60] Miller KM, Anderson JM. In vitro stimulation of fibroblast activity
by factors generated from human monocytes activated by biomedical polymers. J Biomed Mater Res 1989;23:91130.
B, Ericson LE, Thomsen P.
[61] Gretzer C, Eriksson AS, Allden
Monocyte activation on titanium-sputtered polystyrene surfaces in
vitro: the effect of culture conditions on interleukin-1 release.
Biomaterials 1996;17:8518.
[62] De Fife KM, Yun JK, Azeez A et al. Adhesion and cytokine
production by monocytes on poly(2-methacryloyloxyethyl phosphorylcholine-co-alkyl methacrylate)-coated polymers. J Biomed
Mater Res 1995;29(4):4319.
[63] Yun JK, DeFife K, Colton E et al. Human monocyte / macrophage
adhesion and cytokine production on surface-modified poly(tetrafluoroethylene / hexafluoropropylene) polymers with and without
protein preadsorption. J Biomed Mater Res 1995;29(2):25768.

[64] Gonzales
O, Smith LR, Goodman SB. Effect of size, concentration,
surface area, and volume of polymethylmethacrylate particles on
human macrophages in vitro. J Biomed Mater Res 1996;30:46373.
[65] Harada Y, Wang JT, Doppalapudi VA et al. Differential effects of
different forms of hydroxyapatite and hydroxyapatite / tricalcium
phosphate particulates on human monocytes / macrophages in vitro. J
Biomed Mater Res 1996;31:1926.
[66] Savio IJA, Overcamp LM, Black J. Size and shape of biomaterial
wear debris. Clin Mater 1994;15:10147.
[67] Haynes DR, Boyle SJ, Rogers SD, Howie DW, Vernon-Roberts B.
Variation in cytokines induced by particles from different prosthetic
materials. Clin Orthop 1998;352:22330.
[68] Prabhu A, Shelburne CE et al. Cellular proliferation and cytokine
responses of murine macrophage cell line J774A1 to polymethylmethacrylate and coboltchrome alloy particles. J Biomed Mater
Res 1998;42:65563.
[69] Kohilas K, Lyons M, Lofthouse R, Frondoza CG, Jinnah R,
Hungerford DS. Effect of prosthetic titanium wear debris on
mitogen-induced monocyte and lymphoid activation. J Biomed
Mater Res 1999;47(1):95103.
[70] Daniels AU, Barnes FH, Charlebois SJ, Smith RA. Macrophage
cytokine response to particles and lipopolysaccharide in vitro. J
Biomed Mater Res 2000;49:46978.
[71] Matthews JB, Green TR, Stone MH, Wroblewski BM, Fisher J,
Ingham E. Comparison of the response of primary human peripheral
blood mononuclear phagocytes from different donors to challenge
with model polyethylene particles of known size and dose. Biomaterials 2000;21:203344.
[72] Fiorentino D, Bond MW, Mosmann TR. Two types of mouse T
helper cell. IV. Th2 clones secrete a factor that inhibits cytokine
production by Th1 clones. J Exp Med 1989;170(6):208195.
[73] OGarra A, Chang R, Go N, Hastings R, Haughton G, Howard M.
Ly-1 B (B-1) cells are the main source of B cell-derived interleukin
10. Eur J Immunol 1992;22(3):7117.
[74] Fiorentino DF, Zlotnik A, Mosmann TR, Howard M, OGarra A.
IL-10 inhibits cytokine production by activated macrophages. J
Immunol 1991;147(11):381522.
[75] Moore KW, OGarra A, de Waal Malefyt R, Viera P, Mosmann R.
Interleukin-10. Annu Rev Immunol 1993;11:16590.

[76] Schmidt M, Lugering


N, Pauels HG, Schulze-Osthoff K, Domschke
W, Kucharzik T. IL-10 induces apoptosis in human monocytes
involving the CD95 receptor / ligand pathway. Eur J Immunol
2000;30:176977.

[77] Wolk K, Docke


WD, von Baehr V, Volk HD, Sabat R. Impaired

174

[78]

[79]

[80]
[81]
[82]

[83]

[84]

[85]

[86]

[87]

[88]

[89]

[90]
[91]

[92]
[93]

[94]
[95]

[96]

[97]

[98]

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176
antigen presentation by human monocytes during endotoxin tolerance. Blood 2000;96(1):21823.

Volk HD, Reinke P, Docke


WD. Clinical aspects: from systemic
inflammation to immunoparalysis. In: Jack RS, editor, CD14 in the
inflammatory response, Basel: Karger, 2000, pp. 16277, (Adorini
L, Ken-ichi A, Berek C, Capra JD, Schmitt-Verhulst AM, Waksman
BH, eds. Chemical immunology, vol. 74).
de Waal Malefyt R, Abrams J, Bennett B, Figdor CG, Vries JE.
Interleukin 10 (IL-10) inhibits cytokine synthesis by human monocytes: an autoregulatory role of IL-10 produced by monocytes. J Exp
Med 1991;174:120920.
Dinarello CA. Interleukin-1. Cytokine Growth Factor Rev
1997;8(4):25365.
Bogdan C, Vodovotz Y, Nathan C. Macrophage deactivation by
interleukin 10. J Exp Med 1991;174(6):154955.
Gazzinelli RT, Oswald IP, James SL, Sher A. IL-10 inhibits parasite
killing and nitrogen oxide production by IFN-gamma-activated
macrophages. J Immunol 1992;148(6):17926.
Champaiboon C, Yongvanitchit K, Pichyangkul S, Mahanonda R.
The immune modulation of B-cell responses by Porphyromonas
ginginvalis and interleukin-10. Periodontology 2000;71(3):46875.
de Waal Malefyt R, Haanen J, Spits H et al. Interleukin-10 (IL-10)
and viral IL-10 strongly reduce antigen-specific human T cell
proliferation by diminishing the antigen-presenting capacity of
monocytes via downregulation of class II major histocompatibility
complex expression. J Exp Med 1991;174:91524.
Dalu A, Blaydes BS, Lomax LG, Delclos KB. A comparison of the
inflammatory response to a polydimethylsiloxane implant in male
and female Balb / c mice. Biomaterials 2000;21:194757.
Rosengren A, Danielsen N, Bjursten LM. Inflammatory reaction
dependence on implant localization in rat soft tissue models.
Biomaterials 1997;18(14):97987.
Hoffstein ST, Gennaro DE, Manzi RM. Surface contact inhibits
neutrophil superoxide generation induced by soluble stimuli. Lab
Invest 1985;52(5):51522.
Webster NR, Nunn JF. Molecular structure of free radicals and their
importance in biological reactions. Br J Anaesth 1988;60(1):98
108.
Nathan CF. Respiratory burst in adherent human neutrophils:
triggering by colony-stimulating factors CSF-GM and CSF-G.
Blood 1989;73(1):3016.
Ginis I, Tauber AI. Activation of adherent neutrophils. Blood
1990;76:12339.
Nakagawara A, Nathan CF, Conn ZA. Hydrogen peroxide metabolism in human monocytes during differentiation in vitro. J Clin
Invest 1981;68:124352.
Babior BM. Oxidants from phagocytes: agents of defence and
destruction. Blood 1984;64(5):95966.
DOnofrio C, Lohmann-Matthes M-L. Chemiluminescence of
macrophages depends upon their differentiation stage: dissociation
between phagocytosis and oxygen radical release. Immunobiology
1984;167:41430.
Abramson ST, Gallin JI. IL-4 inhibits superoxide production by
human mononuclear phagocytes. J Immunol 1990;144:62530.
Lehn M, Weiser WY, Engelhorn S, Gillis S, Remold HG. IL-4
inhibits H 2 O 2 production and antileishmanial capacity of human
cultured monocytes mediated by IFN-g. J Immunol 1989;143:3020
4.

Kalltorp
M, Askendal A, Thomsen P, Tengvall P. Inflammatory cell
recruitment, distribution and chemiluminescence response at IgG
precoated and thiol functionalized surfaces. J Biomed Mater Res
1999;47:2519.
Camarero VCPC, Junqueira VB, Colepicolo P, Karnovsky LM,
Mariano M. Epithelioid macrophages secrete a deactivating factor
for superoxide release. J Cell Physiol 1990;145:4817.
Badwey JA, Karnovsky ML. Active oxygen species and the
functions of phagocytic leukocytes. Annu Rev Biochem
1980;49:695726.

[99] Roos D. The involvement of oxygen radicals in microbicidal


mechanisms of leukocytes and macrophages. Klin Wochenschr
1991;69:97580.
[100] Oldham KT, Guice KS, Ward PA, Johnson KJ. The role of oxygen
radicals in immune complex injury. Free Rad Biol Med
1988;4(6):38797.
[101] Burdon RH, Gill V, Boyd PA, Rahim RA. Hydrogen peroxide and
sequence-specific DNA damage in human cells. FEBS Lett
1996;383(3):1504.
[102] Bladier C, Wolvetang EJ, Hutchinson P, de Haan JB, Kola I.
Response of a primary human fibroblast cell line to H 2 O 2 :
senescence-like growth arrest or apoptosis? Cell Growth Differ
1997;8(5):58998.
[103] Eriksson AS, Thomsen P. Ex vivo analysis of leukocyte hydrogen
peroxide production using a bi-plate model in mice. J Cell Physiol
1996;166:13843.
[104] Salvemini D, Wang Z-Q, Zweier JL et al. A nonpeptidyl mimic of
superoxide dismutase with therapeutic activity in rats. Science
1999;286:3046.
[105] Udipi K, Ornberg RL, Thurmond KB, Settle SL, Forster D, Riley
D. Modification of inflammatory response to implanted biomedical
materials in vivo by surface bound superoxide dismutase mimics. J
Biomed Mater Res 2000;51:54960.
[106] Chou L, Firth JD, Nathanson D, Uitto VJ, Brunette DM. Effects of
titanium on transcriptional regulation of fibronectin in human
fibroblasts. J Biomed Mater Res 1996;31:20913.
[107] Zhang YZ, Bjursten LM, Freij-Larsson C, Kober M, Wesslen B.
Tissue response to commercial silicone and polyurethane elastomers after different sterilization procedures. Biomaterials
1996;17:226572.
[108] Therin M, Christel P, Meunier M. An analysis of the general
features of the soft tissue response to some metals and ceramics
using quantitative histomorphometry. J Biomed Mater Res
1994;28:126776.

[109] Kalltorp
M, Oblogina S, Jacobsson S, Karlsson A, Tengvall P,
Thomsen P. In vivo cell recruitment, cytokine release and chemiluminescence response at gold, and thiol functionalized surfaces.
Biomaterials 1999;20:212337.

[110] Kalltorp
M, Ericson LE, Tengvall P, Thomsen P. Morphometric
analysis of the tissue formation around pure gold, hydroxyl- and
functionalized. Submitted, 2000.
[111] Rich A, Harris AK. Anomalous preferences of cultured macrophages for hydrophobic and roughened substrata. J Cell Sci
1981;50:17.
[112] Murray DW, Rae T, Rushton N. The influence of the surface
energy and roughness of implants on bone resorption. J Bone Joint
Surg 1989;71B:6327.
[113] Chehroudi B, Gould TR, Brunette DM. A light and electron
microscopic study of the effects of surface topography on the
behavior of cells attached to titanium-coated percutanous implants.
J Biomed Mater Res 1991;25:387405.
[114] Brohim RM, Foresman PA, Hildebrandt PK, Rodeheaver GT. Early
reaction to textured breast implant surfaces. Ann Plast Surg
1992;28:35462.
[115] Mohanty M, Hunt JA, Doherty PJ, Annis D, Williams DF.
Evaluation of soft tissue response to a poly (urethane urea).
Biomaterials 1992;13:6516.
[116] Picha GJ, Drake RF. Pillared-surface microstructure and soft-tissue
implants: effect of implant site and fixation. J Biomed Mater Res
1996;30:30512.
[117] Rosengren A, Bjursten LM, Danielsen N, Persson H, Kober M.
Tissue reactions to polyethylene implants with different surface
topography. J Mater Sci: Mater Med 1999;10:7582.

[118] Walliwaara
B, Aronsson BO, Rodahl M, Lausmaa J, Tengvall P.
Titanium with different oxides: in vitro studies of protein adsorption and contact activation. Biomaterials 1994;15:82734.
[119] Rovensky YA, Slavnaja IL, Vasiliev JM. Behaviour of fibroblastlike cells on grooved surfaces. Exp Cell Res 1971;65:193201.

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176
[120] Hong HL, Brunette DM. Effect of cell shape on proteinase
secretion by epithelial cells. J Cell Sci 1987;87:25967.
[121] Chehroudi B, Gould TR, Brunette DM. Titanium-coated micromachined grooves of different dimensions affect epithelial and
connective-tissue cells differently in vivo. J Biomed Mater Res
1990;24:120319.
[122] Brauker JH, Carr-Brendel VE, Martinson LA, Crudele J, Johnston
WD, Johnson RC. Neovascularization of synthetic membranes
directed by membrane microarchitecture. J Biomed Mater Res
1995;29:151724.
[123] Paquay YC, de Ruijter JE, van der Waerden JP, Jansen JA. Tissue
reaction to Dacron velour and titanium fibre mesh used for
anchorage
of
percutaneous
devices.
Biomaterials
1996;17(12):12516.
[124] Kovacs EJ. Fibrogenic cytokines: the role of immune mediators in
the development of scar tissue. Immunol Today 1991;12(1):1723.
[125] Rubin E, Faber JL. Pathology, Philadelphia: J.B. Lippincott, 1994.
[126] Sporn MB, Roberts AB. Transforming growth factor-beta. Multiple
actions and potential clinical applications. J Am Med Assoc
1989;262:93841.
[127] Kehrl JH. Transforming growth factor-beta: an important mediator
of immunoregulation. Int J Cell Cloning 1991;9:43850.
[128] Grotendorst GR, Smale G, Pencev D. Production of transforming
growth factor beta by human peripheral blood monocytes and
neutrophils. J Cell Physiol 1989;140(2):396402.
[129] Heine U, Munoz EF, Flanders KC et al. Role of transforming
growth factor-beta in the development of the mouse embryo. Cell
Biol 1987;105(6):286176.
[130] Montesano R, Orci L. Transforming growth factor stimulates
collagenmatrix contractions by fibroblasts: implications for
wound healing. Proc Natl Acad Sci USA 1988;85:48947.
[131] Lossing C, Hansson HA. Peptide growth factors and myofibroblasts in capsules around human breast implants. Plast Reconstr
Surg 1993;91:127786.
[132] Kuhn A, Singh S, Smith PD, Ko F, Falcone R, Lyle WG, Maggi
SP, Wells KE, Robson MC. Periprosthetic breast capsules contain
the fibrogenic cytokines TGF-beta1 and TGF-beta2, suggesting
possible new treatment approaches. Ann Plast Surg 2000;44:387
91.
[133] Lossing C, Hansson HA. Peptide growth factor receptors in
capsules around silicone breast implants. Scand J Plast Reconstr
Surg Hand Surg 2000;, submitted.

[134] Hansson HA, Engstrom


AM, Holm S, Rosenqvist AL.
Somatomedin C immunoreactivity in the Achilles tendon varies in
a dynamic manner with the mechanical load. Acta Physiol Scand
1988;134:199208.
[135] Aspenberg P, Herbertsson P. Periprosthetic bone resorption. J Bone
Joint Surg 1996;78B:6416.
[136] Nagase H, Woessner JFJ. Matrix metalloproteinases. J Biol Chem
1999;274(31):214914.
[137] Shapiro SD. Matrix metalloproteinase degradation of extracellular
matrix: biological consequences. Curr Opin Cell Biol
1998;10(5):6028.
[138] Zambonin G, Camerino C, Greco G, Patella V, Moretti B, Grano
M. Hydroxyapatite coated with hepatocyte growth factor (HGF)
stimulates human osteoblasts in vitro. J Bone Joint Surg Br
2000;82(3):45760.
[139] Kremer EA, Chen Y, Suzuki K, Nagase H, Gorski JP. Hydroxyapatite induces autolytic degradation and inactivation of matrix
metalloproteinase-1 and -3. J Bone Miner Res 1998;13:1890902.
[140] Takagi M, Konttinen YT, Kemppinen P et al. Tissue inhibitor of
metalloproteinases 1, collagenolytic and gelatinolytic activity in
loose hip endoprostheses. J Rheumatol 1995;22:228590.
[141] Ishiguro N, Ito T, Kurokouchi K et al. m-RNA expression of
matrix metalloproteinase in interface tissue around implants in
loosening total hip arthroplasty. J Biomed Mater Res 1996;32:611
7.

175

[142] Chou L, Firth JD, Uitto VJ, Brunette DM. Effects of titanium
substratum and grooved surface topography on metalloproteinase-2
expression in human fibroblasts. J Biomed Mater Res
1998;39(3):43745.
[143] Lalor P, Revell P, Gray AB. Sensitivity to titanium. A cause of
implant failure? J Bone Joint Surg 1991;73B:258.
[144] Santavirta S, Konttinen YT, Hoikka V. Immunopathological response to loose, cementless acetabular components. J Bone Joint
Surg 1991;73B:3842.
[145] Smetana K, Holub M, Slavcev A. Foreign body reaction against
cellophane in the athymic nude mice. J Biomed Mater Res
1989;23:94751.
[146] Jiranek W, Jasty M, Wang JT et al. Tissue response to particulate
polymethylmethacrylate in mice with various immune deficiencies.
J Bone Joint Surg Am 1995;77A:165061.
[147] Sandhu J, Waddell JE, Henry M, Boynton EL. The role of T cells
in polyethylene particulate induced inflammation. J Rheumatol
1998;25(9):17949.
[148] Hart PH, Vitti GF, Burgess DR, Whitty GA, Piccoli DS, Hamilton
JA. Potential antiinflammatory effects of interleukin-4: supression
of human monocyte tumor necrosis factor-a, interleukin-1 and
prostaglandin E2. Proc Natl Acad Sci USA 1989;86:38037.
[149] Hart PH, Whitty GA, Burgess DR, Croatto M, Hamilton JA.
Augmentation of glucocorticoid action on human monocytes by
interleukin-4. Lymphokine Res 1990;9:14753.
[150] Piguet PF, Collart MA, Grau GE, Sappino AP, Vassalli P. Requirement of tumour necrosis factor for development of silica-induced
pulmonary fibrosis. Nature 1990;344:2457.
[151] Phan SH, Kunkel SL. Lung cytokine production in bleomycininduced pulmonary fibrosis. Exp Lung Res 1992;18:2943.
[152] Moulin V, Castilloux G, Auger FA, Garrel D, OConnor-McCourt
MD, Germain L. Modulated response to cytokines of human
wound healing myofibroblasts compared to dermal fibroblasts. Exp
Cell Res 1998;238:28393.
[153] Cornelissen AMH, Maltha JC, van den Hoff JW, Kuijpers-Jagtman
AM. Local injection of IFN-g reduces the number of myofibroblasts and the collagen content in palatal wounds. J Dent Res
2000;79:17828.
[154] Granstein RD, Murphy GF, Margolis RJ, Byrne MH, Amento EP.
Gamma-interferon inhibits collagen synthesis in vivo in the mouse.
Clin Invest 1987;4:12548.
[155] Anderson JM. Inflammatory response to implants. ASAIO Trans
1988;11:1017.
[156] Papadimitriou JM, Robertson TA, Walters MN. An analysis of the
phagocytic potential of multinucleate foreign body giant cells. Am
J Pathol 1975;78(2):34358.
[157] Kreipe H, Razdun HJ, Rudolph P, Barth J. Multinucleated giant
cells generated in vitro: terminally-differentiated macrophages with
down-regulated c-fms expression. Am J Pathol 1988;130:23243.
[158] Vignery A. Macrophage multinucleation is accompanied by the
expression of new soluble and membrane antigens in mice. Am J
Pathol 1989;135(3):56570.
[159] Zhao Q, Topham NS, Anderson JM, Hiltner A, Lodoen G, Payet
CR. Foreign body giant cells and polyurethane biostability: in vivo
correlation of cell adhesion and surface cracking. J Biomed Mater
Res 1991;25:17783.
[160] DeFife KM, Jenney CR, McNally AK, Colton E, Anderson JM.
Interleukin-13 induces human monocyte / macrophage fusion and
macrophage mannose receptor expression. J Immunol
1997;158(7):338590.
[161] McNally AK, Anderson JM. Interleukin-4 induces foreign body
giant cells from monocytes / macrophages. Am J Pathol
1995;147(5):148799.
[162] Kao WJ, McNally AK, Hiltner A, Anderson JM. Role for
interleukin-4 in foreign-body giant cell formation on a poly(etherurethane urea) in vivo. J Biomed Mater Res 1995;19:1267
75.

176

P. Thomsen, C. Gretzer / Current Opinion in Solid State and Materials Science 5 (2001) 163 176

[163] Horowitz SM, Gonzales JB. Inflammatory response to implant


particulates in a macrophage / osteoblast coculture model. Calcif
Tissue Int 1996;59:3926.
[164] Horowitz SM, Luchetti WT, Gonzales JB, Ritchie CK. The effects
of cobalt chromium upon macrophages. J Biomed Mater Res
1998;41:46873.
[165] Song E, Ouyang N, Horbelt M, Antus B, Wang M, Exton MS.
Influence of alternatively and classically activated macrophages on
fibrogenic activities of human fibroblasts. Cell Immunol
2000;204(1):1928.

[166] Essner R, Rhoades K, McBride WH, Morton DL, Ekonomou JS.


IL-4 downregulates IL-1 and TNF gene expression in human
monocytes. J Immunol 1989;142:385761.
[167] Enk AH, Katz SI. Identification and induction of keratinocytederived IL-10. J Immunol 1992;149:925.
[168] Ingham E, Green TR, Stone MH, Kowalski R, Watkins N, Fisher J.
Production of TNF-a and bone resorbing activity by macrophages
in response to different types of bone cement particles. Biomaterials 2000;21:100513.