Laryngotracheal reconstruction with porous titanium in rabbits: are vascular carriers and mucosal grafts really necessary?

Biomedical Applications of Titanium Alloys: A Comprehensive Review

Titanium alloys have emerged as the most successful metallic material to ever be applied in the field of biomedical engineering. This comprehensive review covers the history of titanium in medicine, the properties of titanium and its alloys, the production technologies used to produce biomedical implants, and the most common uses for titanium and its alloys, ranging from orthopedic implants to dental prosthetics and cardiovascular devices. At the core of this success lies the combination of machinability, mechanical strength, biocompatibility, and corrosion resistance. This unique combination of useful traits has positioned titanium alloys as an indispensable material for biomedical engineering applications, enabling safer, more durable, and more efficient treatments for patients affected by various kinds of pathologies. This review takes an in-depth journey into the inherent properties that define titanium alloys and which of them are advantageous for biomedical use. It explores their production techniques and the fabrication methodologies that are utilized to machine them into their final shape. The biomedical applications of titanium alloys are then categorized and described in detail, focusing on which specific advantages titanium alloys are present when compared to other materials. This review not only captures the current state of the art, but also explores the future possibilities and limitations of titanium alloys applied in the biomedical field.

A Fluidic Culture Platform for Spatially Patterned Cell Growth, Differentiation, and Cocultures

Stem cell cultures within perfusion bioreactors, while efficient in obtaining cell numbers, often lack the similarity to native tissues and consequently cell phenotype. We develop a three-dimensional (3D)-printed fluidic chamber for dynamic stem cell culture, with emphasis on control over flow and substrate curvature in a 3D environment, two physiologic features of native tissues. The chamber geometry, consisting of an array of vertical cylindrical pillars, facilitates actin-mediated localization of human mesenchymal stem cells (hMSCs) within ∼200 μm distance from the pillars, enabling spatial patterning of hMSCs and endothelial cells in cocultures and subsequent modulation of calcium signaling between these two essential cell types in the bone marrow microenvironment. Flow-enhanced osteogenic differentiation of hMSCs in growth media imposes spatial variations of alkaline phosphatase expression, which positively correlates with local shear stress. Proliferation of hMSCs is maintained within the chamber, exceeding the cell expansion in conventional static culture. The capability to manipulate cell spatial patterning, differentiation, and 3D tissue formation through geometry and flow demonstrates the culture chamber's relevant chemomechanical cues in stem cell microenvironments, thus providing an easy-to-implement tool to study interactions among substrate curvature, shear stress, and intracellular actin machinery in the tissue-engineered construct.

A systematic review of simulated laryngotracheal reconstruction animal models

OBJECTIVES

Review of the literature to identify practical, high-fidelity, commercially available animal models for simulation training and surgical skills maintenance in laryngotracheal reconstruction (LTR).

METHODS

A systematic review of PubMed and Embase databases was conducted independently by two authors, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included "laryngotracheal reconstruction," "laryngotracheoplasty," "pig and larynx," "sheep and larynx," and "rabbit and larynx." Articles were then assessed, identifying model cost and availability, model validation, feasibility as a training tool, and verisimilitude to pediatric LTR.

RESULTS

In total, 79 articles were considered suitable for inclusion in the study, incorporating both in vitro and in vivo models. Models utilized included rabbit (n = 69), pig (n = 7), sheep (n = 1), and goat (n = 2). The rabbit model was similar in size to the neonate, but differences in laryngeal anatomy and cartilage texture made graft insertion difficult. The anatomy of the pig, sheep, and goat larynges more closely resembled the pediatric patient, allowing improved grafting, but corresponded more in size to that of an older child. Commercial availability of the pig and sheep was considered greatest, and was reflected in cost. None of the animal models identified in the literature have been validated as a simulation tool.

CONCLUSIONS

The rabbit, sheep and pig models seemed to demonstrate the greatest potential for use as advanced pediatric airway surgery simulation models, with the rabbit model being most utilized in the literature. However, as yet there have been no models formally validated as a simulation training tool. Laryngoscope, 129:235-243, 2019.

Engineering in-vitro stem cell-based vascularized bone models for drug screening and predictive toxicology

The production of veritable in-vitro models of bone tissue is essential to understand the biology of bone and its surrounding environment, to analyze the pathogenesis of bone diseases (e.g., osteoporosis, osteoarthritis, osteomyelitis, etc.), to develop effective therapeutic drug screening, and to test potential therapeutic strategies. Dysregulated interactions between vasculature and bone cells are often related to the aforementioned pathologies, underscoring the need for a bone model that contains engineered vasculature. Due to ethical restraints and limited prediction power of animal models, human stem cell-based tissue engineering has gained increasing relevance as a candidate approach to overcome the limitations of animals and to serve as preclinical models for drug testing. Since bone is a highly vascularized tissue, the concomitant development of vasculature and mineralized matrix requires a synergistic interaction between osteogenic and endothelial precursors. A number of experimental approaches have been used to achieve this goal, such as the combination of angiogenic factors and three-dimensional scaffolds, prevascularization strategies, and coculture systems. In this review, we present an overview of the current models and approaches to generate in-vitro stem cell-based vascularized bone, with emphasis on the main challenges of vasculature engineering. These challenges are related to the choice of biomaterials, scaffold fabrication techniques, and cells, as well as the type of culturing conditions required, and specifically the application of dynamic culture systems using bioreactors.

Tissue-Engineered Larynx: Future Applications in Laryngeal Cancer

Purpose of Review

This article reviews the latest developments in tissue engineering for the larynx with a specific focus on the treatment of laryngeal cancer.

Recent Findings

Challenges in tissue engineering a total larynx can be divided into scaffold design, methods of re-mucosalization, and how to restore laryngeal function. The literature described a range of methods to deliver a laryngeal scaffold including examples of synthetic, biomimetic, and biological scaffolds. Methods to regenerate laryngeal mucosa can be divided into examples that use a biological dressing and those that engineer a new mucosal layer de novo. Studies aiming to restore laryngeal function have been reported, but to date, the optimum method for achieving this as part of a total laryngeal transplant is yet to be determined.

Summary

There is great potential for tissue engineering to improve the treatments available for laryngeal cancer within the next 10 years. A number of challenges exist however and advances in restoring function must keep pace with developments in scaffold design.

Artificial Bone via Bone Tissue Engineering: Current Scenario and Challenges

Bone provides mechanical support, and flexibility to the body as a structural frame work along with mineral storage, homeostasis, and blood pH regulation. The repair and/or replacement of injured or defective bone with healthy bone or bone substitute is a critical problem in orthopedic treatment. Recent advances in tissue engineering have shown promising results in developing bone material capable of substituting the conventional autogenic or allogenic bone transplants. In the present review, we have discussed natural and synthetic scaffold materials such as metal and metal alloys, ceramics, polymers, etc. which are widely being used along with their cellular counterparts such as stem cells in bone tissue engineering with their pros and cons.

Controlled implant/soft tissue interaction by nanoscale surface modifications of 3D porous titanium implants

Porous titanium implants are widely employed in the orthopaedics field to ensure good bone fixation. Recently, the use of porous titanium implants has also been investigated in artificial larynx development in a clinical setting. Such uses necessitate a better understanding of the interaction of soft tissues with porous titanium structures. Moreover, surface treatments of titanium have been generally evaluated in planar structures, while the porous titanium implants have complex 3 dimensional (3D) architectures. In this study, the determining factors for soft tissue integration of 3D porous titanium implants were investigated as a function of surface treatments via quantification of the interaction of serum proteins and cells with single titanium microbeads (300-500 μm in diameter). Samples were either acid etched or nanostructured by anodization. When the samples are used in 3D configuration (porous titanium discs of 2 mm thickness) in vivo (in subcutis of rats for 2 weeks), a better integration was observed for both anodized and acid etched samples compared to the non-treated implants. If the implants were also pre-treated with rat serum before implantation, the integration was further facilitated. In order to understand the underlying reasons for this effect, human fibroblast cell culture tests under several conditions (directly on beads, beads in suspension, beads encapsulated in gelatin hydrogels) were conducted to mimic the different interactions of cells with Ti implants in vivo. Physical characterization showed that surface treatments increased hydrophilicity, protein adsorption and roughness. Surface treatments also resulted in improved adsorption of serum albumin which in turn facilitated the adsorption of other proteins such as apolipoprotein as quantified by protein sequencing. The cellular response to the beads showed considerable difference with respect to the cell culture configuration. When the titanium microbeads were entrapped in cell-laden gelatin hydrogels, significantly more cells migrated towards the acid etched beads. In conclusion, the nanoscale surface treatment of 3D porous titanium structures can modulate in vivo integration by the accumulative effect of the surface treatment on several physical factors such as protein adsorption, surface hydrophilicity and surface roughness. The improved protein adsorption capacity of the treated implants can be further exploited by a pre-treatment with autologous serum to render the implant surface more bioactive. Titanium microbeads are a good model system to observe these effects in a 3D microenvironment and provide a better representation of cellular responses in 3D.

Automating the processing steps for obtaining bone tissue-engineered substitutes: from imaging tools to bioreactors

Bone diseases and injuries are highly incapacitating and result in a high demand for tissue substitutes with specific biomechanical and structural features. Tissue engineering has already proven to be effective in regenerating bone tissue, but has not yet been able to become an economically viable solution due to the complexity of the tissue, which is very difficult to be replicated, eventually requiring the utilization of highly labor-intensive processes. Process automation is seen as the solution for mass production of cellularized bone tissue substitutes at an affordable cost by being able to reduce human intervention as well as reducing product variability. The combination of tools such as medical imaging, computer-aided fabrication, and bioreactor technologies, which are currently used in tissue engineering, shows the potential to generate automated production ecosystems, which will, in turn, enable the generation of commercially available products with widespread clinical application.

In vitro mesenchymal trilineage differentiation and extracellular matrix production by adipose and bone marrow derived adult equine multipotent stromal cells on a collagen scaffold

Directed differentiation of adult multipotent stromal cells (MSC) is critical for effective treatment strategies. This study was designed to evaluate the capability of equine MSC from bone marrow (BMSC) and adipose tissue (ASC) on a type I collagen (COLI) scaffold to undergo chondrogenic, osteogenic and adipogenic differentiation and form extracellular matrix (ECM) in vitro. Following determination of surface antigen expression, MSC were loaded into scaffolds in a perfusion bioreactor and loading efficiency was quantified. Cell-scaffold constructs were assessed after loading and 7, 14 and 21 days of culture in stromal or induction medium. Cell number was determined with DNA content, cell viability and spatial uniformity with confocal laser microscopy and cell phenotype and matrix production with light and scanning electron microscopy and mRNA levels. The MSC were positive for CD29 (>90 %), CD44 (>99 %), and CD105 (>60 %). Loading efficiencies were >70 %. The ASC and BMSC cell numbers on scaffolds were affected by culture in induction medium differently. Viable cells remained uniformly distributed in scaffolds for up to 21 days and could be directed to differentiate or to maintain an MSC phenotype. Micro- and ultrastructure showed lineage-specific cell and ECM changes. Lineage-specific mRNA levels differed between ASC and BMSC with induction and changed with time. Based on these results, equine ASC and BMSC differentiate into chondrogenic, osteogenic and adipogenic lineages and form ECM similarly on COLI scaffolds. The collected data supports the potential for equine MSC-COLI constructs to support diverse equine tissue formation for controlled biological studies.

Titanium microbead-based porous implants: bead size controls cell response and host integration

Openly porous structures in implants are desirable for better integration with the host tissue. Sintered microbead-based titanium implants for oto-rhinolaryngology applications, which create an environment where the cells can migrate in the areas between the microbeads, are developed. This structure promotes fibrovascular tissue formation within the implant in vivo. In this study, it is determine to what extent these events can be controlled by changing the physical environment of the implants both in vitro and in vivo. By cell tracking, it is observed that the size of the beads and the distance between the neighboring beads significantly affect the ability of cells to develop cell-to-cell contacts and to bridge the pores. Live cell staining shows that as the bead size gets smaller, the probability to observe cells that fill the porous areas is higher. This also affects the initial attachment and distribution of the cells and collagen secretion by fibroblasts. Obtaining a fast coverage of the system also enables co-culture systems where, the number and the distribution of the second cell type are boosted by the presence of the first. This concept is utilized to increase the attachment of vascular endothelial cells by an initial layer of fibroblasts. By decreasing the bead diameter, the overall colonization of the implant can be significantly increased in vivo. The effect of bead size has a similar pattern both in rats and rabbits, with faster colonization of smaller bead-based structures. Using smaller beads would improve clinical outcomes as faster integration facilitates the attainment of functionality by the implant.

Repair of segmental long bone defect in a rabbit radius nonunion model: comparison of cylindrical porous titanium and hydroxyapatite scaffolds

A segmental long bone defect in a rabbit radius nonunion model was repaired using cylindrical porous titanium (Ti) and hydroxyapatite (HA) scaffolds. Each scaffold was produced using the same method, namely, a slurry foaming method. Repairing ability was characterized using x-radiographic score 12 and 24 weeks postprocedure; failure load of the radius-ulna construct, under three-point bending, 12 weeks postprocedure; and the percentage of newly formed bone within the implant, 12 and 24 weeks after postprocedure. For each of these parameters, the difference in the results when porous Ti scaffold was used compared with when HA scaffolds were used was not significant; both porous scaffolds showed excellent repairing ability. Because the trabecular bone is a porous tissue, the interconnected porous scaffolds have the advantages of natural bone, and vasculature can grow into the porous structure to accelerate the osteoconduction and osteointegration between the implant and bone. The porous Ti scaffold not only enhanced the bone repair process, similar to porous HA scaffolds, but also has superior biomechanical properties. The present results suggest that porous Ti scaffolds may have promise for use in the clinical setting.

Use of perfusion bioreactors and large animal models for long bone tissue engineering

Tissue engineering and regenerative medicine (TERM) strategies for generation of new bone tissue includes the combined use of autologous or heterologous mesenchymal stem cells (MSC) and three-dimensional (3D) scaffold materials serving as structural support for the cells, that develop into tissue-like substitutes under appropriate in vitro culture conditions. This approach is very important due to the limitations and risks associated with autologous, as well as allogenic bone grafiting procedures currently used. However, the cultivation of osteoprogenitor cells in 3D scaffolds presents several challenges, such as the efficient transport of nutrient and oxygen and removal of waste products from the cells in the interior of the scaffold. In this context, perfusion bioreactor systems are key components for bone TERM, as many recent studies have shown that such systems can provide dynamic environments with enhanced diffusion of nutrients and therefore, perfusion can be used to generate grafts of clinically relevant sizes and shapes. Nevertheless, to determine whether a developed tissue-like substitute conforms to the requirements of biocompatibility, mechanical stability and safety, it must undergo rigorous testing both in vitro and in vivo. Results from in vitro studies can be difficult to extrapolate to the in vivo situation, and for this reason, the use of animal models is often an essential step in the testing of orthopedic implants before clinical use in humans. This review provides an overview of the concepts, advantages, and challenges associated with different types of perfusion bioreactor systems, particularly focusing on systems that may enable the generation of critical size tissue engineered constructs. Furthermore, this review discusses some of the most frequently used animal models, such as sheep and goats, to study the in vivo functionality of bone implant materials, in critical size defects.

In vivo bone regeneration using tubular perfusion system bioreactor cultured nanofibrous scaffolds

The use of bioreactors for the in vitro culture of constructs for bone tissue engineering has become prevalent as these systems may improve the growth and differentiation of a cultured cell population. Here we utilize a tubular perfusion system (TPS) bioreactor for the in vitro culture of human mesenchymal stem cells (hMSCs) and implant the cultured constructs into rat femoral condyle defects. Using nanofibrous electrospun poly(lactic-co-glycolic acid)/poly(ε-caprolactone) scaffolds, hMSCs were cultured for 10 days in vitro in the TPS bioreactor with cellular and acellular scaffolds cultured statically for 10 days as a control. After 3 and 6 weeks of in vivo culture, explants were removed and subjected to histomorphometric analysis. Results indicated more rapid bone regeneration in defects implanted with bioreactor cultured scaffolds with a new bone area of 1.23 ± 0.35 mm(2) at 21 days compared to 0.99 ± 0.43 mm(2) and 0.50 ± 0.29 mm(2) in defects implanted with statically cultured scaffolds and acellular scaffolds, respectively. At the 21 day timepoint, statistical differences (p<0.05) were only observed between defects implanted with cell containing scaffolds and the acellular control. After 42 days, however, defects implanted with TPS cultured scaffolds had the greatest new bone area with 1.72 ± 0.40 mm(2). Defects implanted with statically cultured and acellular scaffolds had a new bone area of 1.26 ± 0.43 mm(2) and 1.19 ± 0.33 mm(2), respectively. The increase in bone growth observed in defects implanted with TPS cultured scaffolds was statistically significant (p<0.05) when compared to both the static and acellular groups at this timepoint. This study demonstrates the efficacy of the TPS bioreactor to improve bone tissue regeneration and highlights the benefits of utilizing perfusion bioreactor systems to culture MSCs for bone tissue engineering.

Poor osteoinductive potential of subcutaneous bone cement-induced membranes for tissue engineered bone

BACKGROUND

Large segmental bone defects remain a challenge for reconstructive surgeons. A two-stage repair strategy may offer a potential solution. Here, we sought to evaluate the osteoinductive potential of bone cement-induced membranes in an ectopic site.

METHODS

First, bone cements were inserted into the subcutaneous tissues of 16 rabbits to induce membrane formation. After 2, 4, 6 and 8 weeks, the induced membranes were harvested to assess their vascularization and osteoinductive potential. Next, bone cements were subcutaneously inserted into 12 rabbits for 4 weeks. These bone cements were then harvested from the newly formed membranes and replaced with granular porous β-TCP, with or without bone mesenchymal stem cells. New bone formation was then evaluated after 3, 6 and 9 weeks.

RESULTS

The highest level of blood vessel formation and bone morphogenetic protein-2 expression in the membranes were found at 4 weeks (p < 0.05). In addition, vascular endothelial growth factor concentration was highest after 2 weeks (p < 0.001), persisting until 8 weeks. However, the results showed little ectopic bone formation at these time points.

CONCLUSION

While bone cement-induced membranes appear to provide a suitable environment for bone formation, they fail to drive osteoinduction in non-osseous sites for the purposes of bone tissue engineering.

Multi-scale modification of metallic implants with pore gradients, polyelectrolytes and their indirect monitoring in vivo

Metallic implants, especially titanium implants, are widely used in clinical applications. Tissue in-growth and integration to these implants in the tissues are important parameters for successful clinical outcomes. In order to improve tissue integration, porous metallic implants have being developed. Open porosity of metallic foams is very advantageous, since the pore areas can be functionalized without compromising the mechanical properties of the whole structure. Here we describe such modifications using porous titanium implants based on titanium microbeads. By using inherent physical properties such as hydrophobicity of titanium, it is possible to obtain hydrophobic pore gradients within microbead based metallic implants and at the same time to have a basement membrane mimic based on hydrophilic, natural polymers. 3D pore gradients are formed by synthetic polymers such as Poly-L-lactic acid (PLLA) by freeze-extraction method. 2D nanofibrillar surfaces are formed by using collagen/alginate followed by a crosslinking step with a natural crosslinker (genipin). This nanofibrillar film was built up by layer by layer (LbL) deposition method of the two oppositely charged molecules, collagen and alginate. Finally, an implant where different areas can accommodate different cell types, as this is necessary for many multicellular tissues, can be obtained. By, this way cellular movement in different directions by different cell types can be controlled. Such a system is described for the specific case of trachea regeneration, but it can be modified for other target organs. Analysis of cell migration and the possible methods for creating different pore gradients are elaborated. The next step in the analysis of such implants is their characterization after implantation. However, histological analysis of metallic implants is a long and cumbersome process, thus for monitoring host reaction to metallic implants in vivo an alternative method based on monitoring CGA and different blood proteins is also described. These methods can be used for developing in vitro custom-made migration and colonization tests and also be used for analysis of functionalized metallic implants in vivo without histology.

Experimental study on the osseointegration of foam TiC/Ti composites

Macroporous ceramics have demonstrated osteoconductive properties because of their biocompatibility and 3D macroporous structure, and these materials have recently been widely studied as bone replacement materials. The foam TiC/Ti composites discussed in this study have good mechanical properties, balancing out metallic toughness and ceramic strength. Furthermore, because of the high porosity and pore connectivity of these TiC/Ti composites, they have the potential to be a new bone replacement material. The purpose of this study was to evaluate the osseointegration of foam TiC/Ti composites, preliminarily discuss the TiC/Ti ossification mechanism, and to obtain reliable data on the use of foam TiC/Ti composites as bone replacement materials. The foam TiC/Ti composites were sited in 40 Japanese white rabbits for 4, 8, 12 and 24 weeks. The foam TiC/Ti composites were compared to foam SiC. M-CT (micro-computed tomography) analysis, histological analysis, SEM (scanning electron microscopy) observation and EDS (energy-dispersive x-ray spectrometer) analysis were conducted to estimate the osseointegration of the materials. The histological observations and quantitative analysis exhibited significantly more ossification area (volume), trabeculae maturity, and calcium and phosphorus content in the foam TiC/Ti composites compared to the foam SiC (p < 0.05). The results from this study suggest that the foam TiC/Ti composites possess good osseointegration capacity and have the potential to be a new bone replacement material.

Scaffold/Extracellular matrix hybrid constructs for bone-tissue engineering

The limited natural ability of the body to fully repair large bone defects often necessitates the implantation of a replacement material to promote healing. While the current clinical strategies to address such bone defects generally carry associated limitations, bone-tissue engineering approaches seek to minimize any adverse effects and facilitate complete regeneration of the lost tissue. Of particular interest are hybrid constructs that incorporate multiple components found within the native bone matrix to enhance the osteogenicity of biocompatible materials, which might otherwise be non-osteogenic. This Progress Report will focus on such hybrid constructs that incorporate multiple components from native bone matrix for bone-tissue engineering and will highlight the synthesis and characterization of the hybrid constructs, cellular attachment and proliferation within the constructs, in vitro osteogenicity of the constructs, and the biological response to in vivo implantation of the constructs at ectopic and orthotopic sites.

Modification of macroporous titanium tracheal implants with biodegradable structures: tracking in vivo integration for determination of optimal in situ epithelialization conditions

Previously, we showed that macroporous titanium implants, colonized in vivo together with an epithelial graft, are viable options for tracheal replacement in sheep. To decrease the number of operating steps, biomaterial-based replacements for epithelial graft and intramuscular implantation were developed in the present study. Hybrid microporous PLLA/titanium tracheal implants were designed to decrease initial stenosis and provide a surface for epithelialization. They have been implanted in New Zealand white rabbits as tracheal substitutes and compared to intramuscular implantation samples. Moreover, a basement membrane like coating of the implant surface was also designed by Layer-by-Layer (LbL) method with collagen and alginate. The results showed that the commencement of stenosis can be prevented by the microporous PLLA. For determination of the optimum time point of epithelialization after implantation, HPLC analysis of blood samples, C-reactive protein (CRP), and Chromogranin A (CGA) analyses and histology were carried out. Following 3 weeks the implant would be ready for epithelialization with respect to the amount of tissue integration. Calcein-AM labeled epithelial cell seeding showed that after 3 weeks implant surfaces were suitable for their attachment. CRP readings were steady after an initial rise in the first week. Cross-linked collagen/alginate structures show nanofibrillarity and they form uniform films over the implant surfaces without damaging the microporosity of the PLLA body. Human respiratory epithelial cells proliferated and migrated on these surfaces which provided a better alternative to PLLA film surface. In conclusion, collagen/alginate LbL coated hybrid PLLA/titanium implants are viable options for tracheal replacement, together with in situ epithelialization.