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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

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: (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.
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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
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
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
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-


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
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
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


size (mm)

cell ratio


Cell species


Main findings



10 2


Ti310 2 IL-6, TNF-a,


IL-10 neutralized the effect of pro-inflammatory

cytokines but also induce them



1, 10


24 h
48 h

SS, CoCr were toxic to cells, SS310

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



10 10

All materials310IL-1b, TNF-a

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



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


Mixed: lymph/monocyte
ratio 10:1
72 h

low and high oxidized HDPE
solidified collagen I

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


24 h

0.21 and 0.49 mm310 2 IL-1b,

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



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



HDPE solidified collagen I

0.6, 4.5

510 3

Al 2 O 3 , ZrO 2 , PE

2.2, 6.4

1, 16


4.73, 2.49



24 h
M peritoneal
24 h
24 h
24 h
24 h, 48 h
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
PE 4.5310 2
No IL-1a
TNF-a, IL-6 or IL-12 release
No IL-1b, IL-6 TNF-a

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







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%)



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
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

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

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-


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


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

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


1100 mg
13 mm
10 3 mmol/well


Cell types and species Results


Main findings



MC3T3, M
2496 h
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


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

24 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

without particles. CoCr induced very high TNF-a and
PGE 2 levels. CoCr was toxic to macrophages also in low
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


0.055 mg/cm 2


10 and 100 particles/cell PS

10 mg/ml


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


5310 26 M


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

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.


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.


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.

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).





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