High-strength, surface-porous polyether-ether-ketone for load-bearing orthopedic implants

A Mechanically Resilient Soft Hydrogel Improves Drug Delivery for Treating Post-Traumatic Osteoarthritis in Physically Active Joints

Intra-articular delivery of disease-modifying osteoarthritis drugs (DMOADs) is likely to be most effective in early post-traumatic osteoarthritis (PTOA) when symptoms are minimal and patients are physically active. DMOAD delivery systems therefore must withstand repeated mechanical loading without affecting the drug release kinetics. Although soft materials are preferred for DMOAD delivery, mechanical loading can compromise their structural integrity and disrupt drug release. Here, we report a mechanically resilient soft hydrogel that rapidly self-heals under conditions resembling human running while maintaining sustained release of the cathepsin-K inhibitor L-006235 used as a proof-of-concept DMOAD. Notably, this hydrogel outperformed a previously reported hydrogel designed for intra-articular drug delivery, used as a control in our study, which neither recovered nor maintained drug release under mechanical loading. Upon injection into mouse knee joints, the hydrogel showed consistent release kinetics of the encapsulated agent in both treadmill-running and non-running mice. In a mouse model of aggressive PTOA exacerbated by treadmill running, L-006235 hydrogel markedly reduced cartilage degeneration. To our knowledge, this is the first hydrogel proven to withstand human running conditions and enable sustained DMOAD delivery in physically active joints, and the first study demonstrating reduced disease progression in a severe PTOA model under rigorous physical activity, highlighting the hydrogel's potential for PTOA treatment in active patients.

Surface characteristics of 3D printed PEEK polymer using atomic force microscopy

High-performance polymer three-dimensional printing is becoming more popular for producing unique parts suitable for different applications. It has been utilized extensively in biomedical applications such as dental prosthetics, surgical equipment, and implants. However, the performance of the material is significantly influenced by its surface qualities, particularly in aspects of its adhesion and biocompatibility. This study involves the fabrication of PEEK specimens S1, S2, S3, and S4 with different printing parameters such as layer height of 0.10 and 0.15 mm and printing speed of 20 and 25 mm/s using a fused deposition modeling process. The surface roughness of the fabricated specimens is measured using atomic force microscopy. The results showed that the printing parameters significantly impact the surface roughness of the PEEK specimens. The surface roughness of specimen S3, printed at a layer height of 0.15 mm and a speed of 20 mm/s, has a low roughness value of 0.017 μm, which is considerable in comparison to the other specimens. In addition to the measurement of surface roughness from roughness profile, the force curve separation graph was plotted and the adhesion force values were calculated for all the specimens to determine the interlayer bonding strength.

High-Cycle Fatigue Behaviour of Polyetheretherketone (PEEK) Produced by Additive Manufacturing

Polyetheretherketone (PEEK) is the leading high-performance thermoplastic biomaterial that can be processed through material extrusion (ME) additive manufacturing (AM), also known as three-dimensional (3D) printing, for patient-specific load-bearing implant manufacture. Considering the importance of cyclic loading for load-bearing implant design, this work addresses the high-cycle fatigue behaviour of 3D-printed PEEK. In this work, printed PEEK specimens are cyclically loaded under stress-controlled tension-tension using different stress levels between 75% and 95% of printed PEEK's tensile strength. The experimental results are used to document 3D-printed PEEK's fatigue behaviour using Basquin's power law, which was compared with previous fatigue research on bulk PEEK and other 3D-printing materials. As a pioneering study on its fatigue behaviour, the results from this work show that 3D-printed PEEK exhibits an above-average fatigue strength of 65 MPa, corresponding to about 75% of its tensile strength. Fracture surface analysis suggests that a transition can occur from ductile to brittle fracture with maximum stresses between 85% and 95% of the tensile strength. Evidence of crack propagation features on fracture surfaces under scanning electron microscope (SEM) observation suggests crack initiation in void defects created by printing deposition that propagates longitudinally through line bonding interfaces along layers. Considering this, 3D-printed PEEK's fatigue behaviour can be strongly related to printing conditions. Further research on the fatigue behaviour of 3D-printed PEEK is necessary to support its use in load-bearing implant applications.

Latest advances: Improving the anti-inflammatory and immunomodulatory properties of PEEK materials

Excellent biocompatibility, mechanical properties, chemical stability, and elastic modulus close to bone tissue make polyetheretherketone (PEEK) a promising orthopedic implant material. However, biological inertness has hindered the clinical applications of PEEK. The immune responses and inflammatory reactions after implantation would interfere with the osteogenic process. Eventually, the proliferation of fibrous tissue and the formation of fibrous capsules would result in a loose connection between PEEK and bone, leading to implantation failure. Previous studies focused on improving the osteogenic properties and antibacterial ability of PEEK with various modification techniques. However, few studies have been conducted on the immunomodulatory capacity of PEEK. New clinical applications and advances in processing technology, research, and reports on the immunomodulatory capacity of PEEK have received increasing attention in recent years. Researchers have designed numerous modification techniques, including drug delivery systems, surface chemical modifications, and surface porous treatments, to modulate the post-implantation immune response to address the regulatory factors of the mechanism. These studies provide essential ideas and technical preconditions for the development and research of the next generation of PEEK biological implant materials. This paper summarizes the mechanism by which the immune response after PEEK implantation leads to fibrous capsule formation; it also focuses on modification techniques to improve the anti-inflammatory and immunomodulatory abilities of PEEK. We also discuss the limitations of the existing modification techniques and present the corresponding future perspectives.

Powder Bed Fusion Versus Material Extrusion: A Comparative Case Study on Polyether-Ether-Ketone Cranial Implants

As the choice of additive manufacturing (AM) technologies is becoming wider with reliable processes and a wider range of materials, the selection of the right technology to fabricate a certain product is becoming increasingly difficult from a technical and cost perspective. In this study polyether-ether-ketone cranial implants were manufactured by two AM techniques: powder bed fusion (PBF) and fused filament fabrication (FFF) and their dimensional accuracy, compression performance, and drop tower impact behavior were evaluated and compared. The results showed that both types of specimens differed from the original computer-aided design; although the origin of the deviation was different, the PBF samples were slightly inaccurate owing to the printing process where the accuracy of the FFF samples was influenced by postprocessing and removal of the scaffolds. The cranial implants fabricated using the FFF method absorbed more energy during the compression and impact tests in comparison with the PBF process. The failure mechanisms revealed that FFF samples have a higher ability to deform and a more consistent failure mechanisms, with the damage localized around the puncture head region. The brittle nature of the PBF samples, a feature observed with other polymers as well, led to complete failure of the cranial implants into several pieces.

Optimization and manufacture of polyetheretherketone patient specific cranial implants by material extrusion - A clinical perspective

Polyetheretherketone (PEEK) is a high performing thermoplastic that has established itself as a 'gold-standard' material for cranial reconstruction. Traditionally, milled PEEK patient specific cranial implants (PSCIs) exhibit uniform levels of smoothness (excusing suture/drainage holes) to the touch (<1 μm) and homogenous coloration throughout. They also demonstrate predictable and repeatable levels of mechanical performance, as they are machined from isotropic material blocks. The combination of such factors inspires confidence from the surgeon and in turn, approval for implantation. However, manufacturing lead-times and affiliated costs to fabricate a PSCI are high. To simplify their production and reduce expenditure, hospitals are exploring the production of in-house PEEK PSCIs by material extrusion-based additive manufacturing. From a geometrical and morphological perspective, such implants have been produced with good-to-satisfactory clinical results. However, lack of clinical adoption persists. To determine the reasoning behind this, it was necessary to assess the benefits and limitations of current printed PEEK PSCIs in order to establish the status quo. Afterwards, a review on individual PEEK printing variables was performed in order to identify a combination of parameters that could enhance the aesthetics and performance of the PSCIs to that of milled implants/cranial bone. The findings from this review could be used as a baseline to help standardize the production of PEEK PSCIs by material extrusion in the hospital.

Polyetheretherketone implants with hierarchical porous structure for boosted osseointegration

BACKGROUND

Good osseointegration is the key to the long-term stability of bone implants. Thermoplastic polyetheretherketone (PEEK) has been widely used in orthopedics; however, its inherent biological inertia causes fibrous tissue to wrap its surface, which leads to poor osseointegration and thus greatly limits its clinical applications.

METHODS

Herein, we developed a facile yet effective surface modification strategy. A commonly used sulfonation coupled with "cold pressing" treatment in the presence of porogenic agent formed a three-dimensional hierarchical porous structure on PEEK surface. Subsequently, the effects of porous surface on the in vitro adhesion, proliferation and differentiation of rat bone marrow-derived mesenchymal stem cells (BMSCs) were evaluated. Finally, the osteoinduction and osseointegration of surface-porous PEEK implant were examined in the rat distal femoral defect model.

RESULTS

In vitro results showed that the surface modification did not significantly affect the mechanical performance and cytocompatibility of PEEK substance, and the porous structure on the modified PEEK substrate provided space for cellular ingrowth and enhanced osteogenic differentiation and mineralization of BMSCs. In vivo tests demonstrated that the surface-porous PEEK implant could effectively promote new bone formation and had higher bone-implant contact rate, thereby achieving good bone integration with the surrounding host bone. In addition, this modification technique was also successfully demonstrated on a medical PEEK interbody fusion cage.

CONCLUSION

The present study indicates that topological morphology plays a pivotal role in determining implant osseointegration and this facile and effective modification strategy developed by us is expected to achieve practical applications quickly.

3D printed PEKK bone analogs with internal porosity and surface modification for mandibular reconstruction: An in vivo rabbit model study

Polyetheretherketone (PEEK) and its derivative polyetherketoneketone (PEKK) have been used as implant materials for spinal fusing and enjoyed their success for many years because of their mechanical properties similar to bone and their chemical inertness. The osseointegration of PEEKs is datable. Our strategy was to use custom-designed and 3D printed bone analogs with an optimized structure design and a modified PEKK surface to augment bone regeneration for mandibular reconstruction. Those bone analogs had internal porosities and a bioactive titanium oxide surface coating to promote osseointegration between native bone and PEKK analogs. Our workflow was 3D modeling, bone analog designing, structural optimization, mechanical analysis via finite element modeling, 3D printing of bone analogs and subsequently, an in vivo rabbit model study on mandibular reconstruction and histology evaluation. Our results showed the finite element analysis validated that the porous PEKK analogs provided a mechanical-sound structure for functional loadings. The bone analogs offered a perfect replacement for segmented bones in the terms of shape, form and volume for surgical reconstruction. The in vivo results showed that bioactive titanium oxide coating enhanced new bone in-growth into the porous PEKK analogs. We have validated our new approach in surgical mandibular reconstruction and we believe our strategy has a significant potential to improve mechanical and biological outcomes for patients who require mandibular reconstruction procedures.

Impact of surface roughness and bulk porosity on spinal interbody implants

Spinal fusion surgeries are performed to treat a multitude of cervical and lumbar diseases that lead to pain and disability. Spinal interbody fusion involves inserting a cage between the spinal vertebrae, and is often utilized for indirect neurologic decompression, correction of spinal alignment, anterior column stability, and increased fusion rate. The long-term success of interbody fusion relies on complete osseointegration between the implant surface and vertebral end plates. Titanium (Ti)-based alloys and polyetheretherketone (PEEK) interbody cages represent the most commonly utilized materials and provide sufficient mechanics and biocompatibility to assist in fusion. However, modification to the surface and bulk characteristics of these materials has been shown to maximize osseointegration and long-term stability. Specifically, the introduction of intrinsic porosity and surface roughness has been shown to affect spinal interbody mechanics, vascularization, osteoblast attachment, and ingrowth potential. This narrative review synthesizes the mechanical, in vitro, in vivo, and clinical effects on fusion efficacy associated with introduction of porosity in Ti (neat and alloy) and PEEK intervertebral implants.

Synergistic effect of sulfonation followed by precipitation of amorphous calcium phosphate on the bone-bonding strength of carbon fiber reinforced polyetheretherketone

Sulfonation and applications of amorphous calcium phosphate are known to make polyetheretherketone (PEEK) bioactive. Sulfonation followed by precipitation of amorphous calcium phosphate (AN-treatment) may provide PEEK with further bone-bonding strength. Herein, we prepared a carbon-fiber-reinforced PEEK (CPEEK) with similar tensile strength to cortical bone and a CPEEK subjected to AN-treatment (CPEEK-AN). The effect of AN-treatment on the bone-bonding strength generated at the interface between the rabbit's tibia and a base material was investigated using a detaching test at two time-points (4 and 8 weeks). At 4 weeks, the strength of CPEEK-AN was significantly higher than that of CPEEK due to the direct bonding between the interfaces. Between 4 and 8 weeks, the different bone forming processes showed that, with CPEEK-AN, bone consolidation was achieved, thus improving bone-bonding strength. In contrast, with CPEEK, a new bone was absorbed mainly on the interface, leading to poor strength. These observations were supported by an in vitro study, which showed that pre-osteoblast on CPEEK-AN caused earlier maturation and mineralization of the extracellular matrix than on CPEEK. Consequently, AN-treatment, comprising a combination of two efficient treatments, generated a synergetic effect on the bonding strength of CPEEK.

A novel injectable hydrogel containing polyetheretherketone for bone regeneration in the craniofacial region

Polyetheretherketone (PEEK) is an organic material introduced as an alternative for titanium implants. Injectable hydrogels are the most promising approach for bone regeneration in the oral cavity to fill the defects with irregular shapes and contours conservatively. In the current study, injectable Aldehyde-cellulose nanocrystalline/silk fibroin (ADCNCs/SF) hydrogels containing PEEK were synthesized, and their bone regeneration capacity was evaluated. Structure, intermolecular interaction, and the reaction between the components were assessed in hydrogel structure. The cytocompatibility of the fabricated scaffolds was evaluated on human dental pulp stem cells (hDPSCs). Moreover, the osteoinduction capacity of ADCNCs/SF/PEEK hydrogels on hDPSCs was evaluated using Real-time PCR, Western blot, Alizarin red staining and ALP activity. Bone formation in critical-size defects in rats' cranial was assessed histologically and radiographically. The results confirmed the successful fabrication of the hydrogel and its osteogenic induction ability on hDPSCs. Furthermore, in in vivo phase, bone formation was significantly higher in ADCNCs/SF/PEEK group. Hence, the enhanced bone regeneration in response to PEEK-loaded hydrogels suggested its potential for regenerating bone loss in the craniofacial region, explicitly surrounding the dental implants.

Use of Piranha Solution as An Alternative Route to Promote Bioactivation of PEEK Surface with Low Functionalization Times

This study aimed to achieve bioactivity on the PEEK surface using piranha solution through a lower functionalization time. For this purpose, the functionalization occurred with piranha solution and 98% sulfuric acid in the proportions of 1:2, 1:1, and 2:1 at periods of 30, 60, and 90 s. The samples treated for longer times at higher concentrations registered the characteristic spectroscopy band associated with sulfonation. Additionally, both chemical treatments allowed the opening of the aromatic ring, increasing the number of functional groups available and making the surface more hydrophilic. The piranha solution treatments with higher concentrations and longer times promoted greater heterogeneity in the surface pores, which affected the roughness of untreated PEEK. Furthermore, the treatments induced calcium deposition on the surface during immersion in SBF fluid. In conclusion, the proposed chemical modifications using sulfuric acid SPEEK 90 and, especially, the piranha solution PEEK-PS 2:1-90, were demonstrated to be promising in promoting the rapid bioactivation of PEEK-based implants.

Surface Modifications of High-Performance Polymer Polyetheretherketone (PEEK) to Improve Its Biological Performance in Dentistry

This comprehensive review focuses on polyetheretherketone (PEEK), a synthetic thermoplastic polymer, for applications in dentistry. As a high-performance polymer, PEEK is intrinsically robust yet biocompatible, making it an ideal substitute for titanium-the current gold standard in dentistry. PEEK, however, is also inert due to its low surface energy and brings challenges when employed in dentistry. Inert PEEK often falls short of achieving a few critical requirements of clinical dental materials, such as adhesiveness, osseoconductivity, antibacterial properties, and resistance to tribocorrosion. This study aims to review these properties and explore the various surface modification strategies that enhance the performance of PEEK. Literatures searches were conducted on Google Scholar, Research Gate, and PubMed databases using PEEK, polyetheretherketone, osseointegration of PEEK, PEEK in dentistry, tribology of PEEK, surface modifications, dental applications, bonding strength, surface topography, adhesive in dentistry, and dental implant as keywords. Literature on the topics of surface modification to increase adhesiveness, tribology, and osseointegration of PEEK were included in the review. The unavailability of full texts was considered when excluding literature. Surface modifications via chemical strategies (such as sulfonation, plasma treatment, UV treatment, surface coating, surface polymerization, etc.) and/or physical approaches (such as sandblasting, laser treatment, accelerated neutral atom beam, layer-by-layer assembly, particle leaching, etc.) discussed in the literature are summarized and compared. Further, approaches such as the incorporation of bioactive materials, e.g., osteogenic agents, antibacterial agents, etc., to enhance the abovementioned desired properties are explored. This review presents surface modification as a critical and essential approach to enhance the biological performance of PEEK in dentistry by retaining its mechanical robustness.

Strategies to Mitigate and Treat Orthopaedic Device-Associated Infections

Orthopaedic device implants play a crucial role in restoring functionality to patients suffering from debilitating musculoskeletal diseases or to those who have experienced traumatic injury. However, the surgical implantation of these devices carries a risk of infection, which represents a significant burden for patients and healthcare providers. This review delineates the pathogenesis of orthopaedic implant infections and the challenges that arise due to biofilm formation and the implications for treatment. It focuses on research advancements in the development of next-generation orthopaedic medical devices to mitigate against implant-related infections. Key considerations impacting the development of devices, which must often perform multiple biological and mechanical roles, are delineated. We review technologies designed to exert spatial and temporal control over antimicrobial presentation and the use of antimicrobial surfaces with intrinsic antibacterial activity. A range of measures to control bio-interfacial interactions including approaches that modify implant surface chemistry or topography to reduce the capacity of bacteria to colonise the surface, form biofilms and cause infections at the device interface and surrounding tissues are also reviewed.

Mechanical behavior of 3D-printed PEEK and its application for personalized orbital implants with various infill patterns and densities

This study proposed a 3D-printed PEEK with a specific design to restore the damaged orbit shape. Such printed personalized implants are greatly affected by the process parameters, wherefore the effects of the nozzle temperatures, printing speed and layer thickness on the tensile properties were investigated based on the Taguchi approach. The optimal mechanical properties, i.e., the tensile strength and Young's modulus, were found to be 54.97 MPa and 2.67 GPa, respectively. These properties were obtained by adjusting the nozzle temperature to its high level (450 °C), while the layer thickness (0.1 mm) and printing speed (20 mm/s) were set to their low levels. Secondly, the mechanical behavior of a personalized orbital implant with these optimized properties was evaluated via finite elements analysis with various infill patterns and densities, at three thicknesses: 0.3, 0.5 and 0.7 mm. It was found that all thicknesses were acceptable for the 100% filling. For the honeycomb pattern, the thicknesses 0.5 and 0.7 mm were satisfactory with a fill rate of 70% and 55% whereas only the thickness of 0.7 mm was suitable for the 40% filling. The honeycomb pattern with 40% filling and a maximum stress (7.186 MPa) and strain (0.00627 mm) should be beneficial for light-weight orbital implants.

Bio-Activated PEEK: Promising Platforms for Improving Osteogenesis through Modulating Macrophage Polarization

The attention on orthopedic biomaterials has shifted from their direct osteogenic properties to their osteoimmunomodulation, especially the modulation of macrophage polarization. Presently, advanced technologies endow polyetheretherketone (PEEK) with good osteoimmunomodulation by modifying PEEK surface characteristics or incorporating bioactive substances with regulating macrophage polarization. Recent studies have demonstrated that the fabrication of a hydrophilic surface and the incorporation of bioactive substances into PEEK (e.g., zinc, calcium, and phosphate) are good strategies to promote osteogenesis by enhancing the polarization of M2 macrophages. Furthermore, the modification by other osteoimmunomodulatory composites (e.g., lncRNA-MM2P, IL-4, IL-10, and chitosan) and their controlled and desired release may make PEEK an optimal bio-activated implant for regulating and balancing the osteogenic system and immune system. The purpose of this review is to comprehensively evaluate the potential of bio-activated PEEK in polarizing macrophages into M2 phenotype to improve osteogenesis. For this objective, we retrieved and discussed different kinds of bio-activated PEEK regarding improving osteogenesis through modulating macrophage polarization. Meanwhile, the relevant challenges and outlook were presented. We hope that this review can shed light on the development of bio-activated PEEK with more favorable osteoimmunomodulation.

A bioactive poly(ether-ether-ketone) nanocomposite scaffold regulates osteoblast/osteoclast activity for the regeneration of osteoporotic bone

Due to the lower regeneration capacity of the osteoporotic bone, the treatment of osteoporotic defects is extremely challenging in clinics. In this study, strontium-doped bioactive glass nanoparticles loaded with sodium alendronate (ALN), namely A-SrBG, were incorporated into the poly(ether-ether-ketone) matrix to fabricate a bioactive composite scaffold (ASP), which was expected to both inhibit bone resorption and promote bone regeneration. The results showed that such a composite scaffold with interconnected macropores (200-400 μm) could release Ca²⁺, Sr²⁺, and ALN in vitro. The proliferation, alkaline phosphatase (ALP) activity, expression of osteogenesis-related genes, and formation of calcified nodules of rat bone marrow stromal cells (rBMSCs) were clearly evidenced, and the reduction in the proliferation, tartrate-resistant acid phosphatase (TRAP) activity, cell fusion, and expression of osteoclastogenesis-related genes of osteoclasts was observed as well. In the presence of the ASP scaffold, enhanced osteogenesis along with inhibiting osteoclastogenesis was observed by modulating the osteoprotegerin (OPG)/receptor activator for nuclear factor κB ligand (RANKL) ratio. The efficacy of the composite scaffold in the regeneration of osteoporotic critical-sized cranial defect in a rat model was evaluated. Therefore, the bioactive composite scaffold with excellent biocompatibility and osteogenic potential could be a promising material for the repair of osteoporotic bone defects.

Biomechanical Tests on Long-Bone Elliptical Medullary-Canal Endoprostheses for Limb Salvage in Dogs

Simple Summary

Currently, more owners look for offering a better quality of life to their pets. In fact, the complete limb amputation seems to be the last option considered by pet owners in surgeries to save their pets’ lives. Although this field is under development in veterinary medicine, we believe that 3D-printed implants for this market sector will improve the advancement in its research by reducing production costs. This would allow the pet owners to select this solution without large expenses, allowing at the same time, advances in this field. For this purpose, mechanical tests have been carried out on implants printed in a high-performance plastic that resembles the resistance of metals—that are traditionally used in veterinary surgery—and the properties of dogs’ bones as well. The results obtained have confirmed that the implants could withstand the dog weight in its different gaits, although further comparative studies on the effect of rotation forces applied during the animal’s change of direction (evaluated at different paces) are required to confirm their suitability.

Abstract

Exo-endoprosthesis is a limb salvage procedure poorly described for animals, as only expensive metal devices have been used so far. Currently, additive manufacturing (AM) can make this type of implant affordable by exploring a wide new range of materials. However, safety factors should be considered and could be related to kinetic and kinematic studies of canine natural gaits. The suitability of a novel inner part of an exo-endoprosthesis manufactured by fuse deposition modeling (FDM) was assessed for long canine bones with an elliptical medullary canal. Polyether ether ketone (PEEK) was the material used as an alternative to metal for veterinary traumatology. Poisson’s ratio of 3D-printed PEEK material and ex vivo mechanical tests of the customized endoprosthesis were performed for the evaluation. The customized endoprostheses had promising outcomes for the radii of 20 kg dogs. Quasistatic mechanical tests of bone-inserted endoprostheses—pure compression tests—reached a maximum force of 1045.0 ± 78.0 N. In fatigue tests, the samples reached 500,000 cycles without failure or detriment to their quasistatic results. These outcomes surpass the natural weight-bearing of dogs, even during a galloping pace. Furthermore, torque tests with different adhesives were performed to obtain reference data for future assessments comparing with natural dog movements.

A unique biomimetic modification endows polyetherketoneketone scaffold with osteoinductivity by activating cAMP/PKA signaling pathway

Osteoinductivity of a biomaterial scaffold can notably enhance the bone healing performance. In this study, we developed a biomimetic and hierarchically porous polyetherketoneketone (PEKK) scaffold with unique osteoinductivity using a combined surface treatment strategy of a sulfonated process and a nano bone-like apatite deposition. In a beagle intramuscular model, the scaffold induced bone formation ectopically after 12-week implantation. The better bone healing ability of the scaffold than the original PEKK was also confirmed in orthotopic sites. After culturing with bone marrow-derived mesenchymal stem cells (BMSCs), the scaffold induced osteogenic differentiation of BMSCs, and the new bone formation could be mainly depending on cell signaling through adenylate cyclase 9, which activates the cyclic adenosine monophosphate/protein kinase A signaling cascade pathways. The current work reports a new osteoinductive synthetic polymeric scaffold with its detailed molecular mechanism of action for bone repair and regeneration.

Biomechanical comparison of subsidence performance among three modern porous lateral cage designs

BACKGROUND

Cage subsidence remains a major complication after spinal surgery. The goal of this study was to compare the subsidence performance of three modern porous cage designs.

METHODS

Three porous cages were evaluated: a porous titanium cage, a porous polyetheretherketone cage and a truss titanium cage. Mechanical testing was performed for each cage per the American Society for Testing and Materials F2077 and F2267 standards to evaluate cage stiffness and block stiffness, and per a novel clinically relevant dynamic subsidence testing method simulating cyclic spine loading during 3-months postoperatively to evaluate the subsidence displacement.

FINDINGS

The porous polyetheretherketone cage demonstrated the lowest cage stiffness (21.0 ± 1.1 kN/mm), less than half of both titanium cages (truss titanium cage, 49.1 kN/mm; porous titanium cage, 43.6 kN/mm). The block stiffness was greatest for the porous titanium cage (2867.7 ± 105.3 N/mm), followed by the porous polyetheretherketone (2563.4 ± 72.9 N/mm) and truss titanium cages (2213.7 ± 21.8 N/mm). The dynamic subsidence displacement was greatest for the truss titanium cage, which was 1.5 and 2.5 times the subsidence displacement as the porous polyetheretherketone and porous titanium cages respectively.

INTERPRETATIONS

Specific porous cage design plays a crucial role in the cage subsidence performance, to a greater degree than the selection of cage materials. A porous titanium cage with body lattice and microporous endplates significantly outperformed a truss titanium cage with a similar cage stiffness in subsidence performance, and a porous polyetheretherketone cage with half of its stiffness.

Human osteoblasts response to different dental implant abutment materials: An in-vitro study

OBJECTIVES

This study aimed to investigate human osteoblasts (HOB) response towards different dental implant abutment materials.

METHODS

Five dental implant abutment materials were investigated: (1) titanium (Ti), (2) titanium coated nitride (TiN), (3) cobalt chromium (CoCr), (4) zirconia (ZrO₂), and (5) modified polyether ether ketone (m-PEEK). HOBs were cultured, expanded, and seeded according to the supplier's protocol (PromoCell, UK). Cell proliferation and cytotoxicity were evaluated at days 1, 3, 5, and 10 using Alamar Blue (alamarBlue) and lactate dehydrogenase (LDH) colorimetric assays. Data were analysed via two-way ANOVA, one-way ANOVA and Tukey's post hoc test (significance was determined as p < 0.05 for all tests).

RESULTS

All the investigated materials showed high and comparable initial proliferation activities apart from ZrO₂ (46.92%), with P% of 79.91%, 68.77%, 73.20%, and 65.46% for Ti, TiN, CoCr, and m-PEEK, respectively. At day 10, all materials exhibited comparable and lower P% than day 1 apart from TiN (70.90%) with P% of 30.22%, 40.64%, 37.27%, and 50.65% for Ti, CoCr, ZrO₂, and m-PEEK, respectively. The cytotoxic effect of the investigated materials was generally low throughout the whole experiment. At day 10, the cytotoxicity % was 7.63%, 0.21%, 13.30%, 5.32%, 8.60% for Ti, TiN, CoCr, ZrO₂, and m-PEEK. The Two-way ANOVA and Tukey's Multiple Comparison Method highlighted significant material and time effects on cell proliferation and cytotoxicity, and a significant interaction (p < 0.0001) between the tested materials. Notably, TiN and m-PEEK showed improved HOB proliferation activity and cytotoxic levels than the other investigated materials. In addition, a non-significant negative correlation between viability and cytotoxicity was found for all tested materials. Ti (p = 0.07), TiN (p = 0.28), CoCr (p = 0.15), ZrO₂ (p = 0.17), and m-PEEK (p = 0.12).

SIGNIFICANCE

All the investigated materials showed excellent biocompatibility properties with more promising results for the newly introduced TiN and m-PEEK as alternatives to the traditionally used dental implant and abutment materials.

Additive manufactured polyether-ether-ketone implants for orthopaedic applications: a narrative review

Polyether-ether-ketone (PEEK) is believed to be the next-generation biomedical material for orthopaedic implants that may replace metal materials because of its good biocompatibility, appropriate mechanical properties and radiolucency. Currently, some PEEK implants have been used successfully for many years. However, there is no customised PEEK orthopaedic implant made by additive manufacturing licensed for the market, although clinical trials have been increasingly reported. In this review article, design criteria, including geometric matching, functional restoration, strength safety, early fixation, long-term stability and manufacturing capability, are summarised, focusing on the clinical requirements. An integrated framework of design and manufacturing processes to create customised PEEK implants is presented, and several typical clinical applications such as cranioplasty patches, rib prostheses, mandibular prostheses, scapula prostheses and femoral prostheses are described. The main technical challenge faced by PEEK orthopaedic implants lies in the poor bonding with bone and soft tissue due to its biological inertness, which may be solved by adding bioactive fillers and manufacturing porous architecture. The lack of technical standards is also one of the major factors preventing additive-manufactured customised PEEK orthopaedic implants from clinical translation, and it is good to see that the abundance of standards in the field of additive-manufactured medical devices is helping them enter the clinical market.

Biomimetic Implant Surfaces and Their Role in Biological Integration—A Concise Review

Background: The increased use of dental implants in oral rehabilitation has been followed by the development of new biomaterials as well as improvements in the performance of biomaterials already in use. This triggers the need for appropriate analytical approaches to assess the biological and, ultimately, clinical benefits of these approaches. Aims: To address the role of physical, chemical, mechanical, and biological characteristics in order to determine the critical parameters to improve biological responses and the long-term effectiveness of dental implant surfaces. Data sources and methods: Web of Science, MEDLINE and Lilacs databases were searched for the last 30 years in English, Spanish and Portuguese idioms. Results: Chemical composition, wettability, roughness, and topography of dental implant surfaces have all been linked to biological regulation in cell interactions, osseointegration, bone tissue and peri-implant mucosa preservation. Conclusion: Techniques involving subtractive and additive methods, especially those involving laser treatment or embedding of bioactive nanoparticles, have demonstrated promising results. However, the literature is heterogeneous regarding study design and methodology, which limits comparisons between studies and the definition of the critical determinants of optimal cell response.

Mapping Macrophage Polarization and Origin during the Progression of the Foreign Body Response to a Poly(ethylene glycol) Hydrogel Implant

Poly(ethylene glycol) (PEG) hydrogels hold promise for in vivo applications but induce a foreign body response (FBR). While macrophages are key in the FBR, many questions remain. This study investigates temporal changes in the transcriptome of implant-associated monocytes and macrophages. Proinflammatory pathways are upregulated in monocytes compared to control monocytes but subside by day 28. Macrophages are initially proinflammatory but shift to a profibrotic state by day 14, coinciding with fibrous capsule emergence. Next, this study assesses the origin of macrophages responsible for fibrous encapsulation using wildtype, C-C Motif Chemokine Receptor 2 (CCR2)^-/- mice that lack recruited macrophages, and Macrophage Fas-Induced Apoptosis (MaFIA) mice that enable macrophage ablation. Subpopulations of recruited and tissue-resident macrophages are identified. Fibrous encapsulation proceeds in CCR2^-/- mice similar to wildtype mice. However, studies in MaFIA mice indicate that macrophages are necessary for fibrous capsule formation. These findings suggest that macrophage origin impacts the FBR progression and provides evidence that tissue-resident macrophages and not the recruited macrophages may drive fibrosis in the FBR to PEG hydrogels. This study demonstrates that implant-associated monocytes and macrophages have temporally distinct transcriptomes in the FBR and that profibrotic pathways associated with macrophages may be enriched in tissue-resident macrophages.

Modification of polyether ether ketone for the repairing of bone defects

Bone damage as a consequence of disease or trauma is a common global occurrence. For bone damage treatment - bone implant materials are necessary across three classifications of surgical intervention (i.e. fixation, repair, and replacement). Many types of bone implant materials have been developed to meet the requirements of bone repair. Among them, polyether ether ketone (PEEK) has been considered as one of the next generation of bone implant materials, owing to its advantages related to good biocompatibility, chemical stability, X-ray permeability, elastic modulus comparable to natural bone, as well as the ease of processing and modification. However, as PEEK is a naturally bioinert material, some modification is needed to improve its integration with adjacent bones after implantation. Therefore, it has become a very hot topic of biomaterials research and various strategies for the modification of PEEK including blending, 3D printing, coating, chemical modification and the introduction of bioactive and/or antibacterial substances have been proposed. In this systematic review, the recent advances in modification of PEEK and its application prospect as bone implants are summarized, and the remaining challenges are also discussed.

Characterization of Porous Titanium-Hydroxyapatite Composite Biological Coating on Polyetheretherketone (PEEK) by Vacuum Plasma Spraying

Titanium powders and hydroxyapatite powders were used to fabricate the titanium and hydroxyapatite composite coating (Ti/Ti/HA) on the Polyetheretherketone (PEEK) by vacuum plasma spraying (VPS). The phase composition and morphology of the Ti/Ti/HA coating were analyzed by XRD, SEM, industrial CT, and three-dimensional contour profiler (DEKTAK XT). The results showed that the phase composition of the Ti/Ti/HA coating was dominated by the HA phase and a small amount of the Ti phase. The Ti/Ti/HA composite coating presented an obvious three-layer structure with different roughness and porosity. The bottom was Ti coating with a porosity less than 10%; the middle was porous Ti coating with a porosity of 35% ± 10%; the surface coating was HA coating with the crystallinity near 95%, a porosity of 32% ± 10%, a roughness Ra = 30 ± 10 μm. Moreover, the TG-DSC and ATR-FTIR results showed that VPS coating has no effect on thermochemical properties of PEEK material. The average bond strength of the composite coating was achieved 32 MPa.

Modification of polyetheretherketone (PEEK) physical features to improve osteointegration

Polyetheretherketone (PEEK) has been widely applied in orthopedics because of its excellent mechanical properties, radiolucency, and biocompatibility. However, the bioinertness and poor osteointegration of PEEK have greatly limited its further application. Growing evidence proves that physical factors of implants, including their architecture, surface morphology, stiffness, and mechanical stimulation, matter as much as the composition of their surface chemistry. This review focuses on the multiple strategies for the physical modification of PEEK implants through adjusting their architecture, surface morphology, and stiffness. Many research findings show that transforming the architecture and incorporating reinforcing fillers into PEEK can affect both its mechanical strength and cellular responses. Modified PEEK surfaces at the macro scale and micro/nano scale have positive effects on cell-substrate interactions. More investigations are necessary to reach consensus on the optimal design of PEEK implants and to explore the efficiency of various functional implant surfaces. Soft-tissue integration has been ignored, though evidence shows that physical modifications also improve the adhesion of soft tissue. In the future, ideal PEEK implants should have a desirable topological structure with better surface hydrophilicity and optimum surface chemistry.

Endowing Polyetheretherketone Implants with Osseointegration Properties: In Situ Construction of Patterned Nanorod Arrays

Polyetheretherketone (PEEK) is widely used in orthopedic and craniomaxillofacial surgeries as it exhibits excellent biocompatibility, mechanical property, and chemical stability. However, its clinical application is limited by the biological inertness of PEEK. Numerous efforts have been made to improve the bioactivity of this polymer over the years. However, modification methods that can not only promote osteogenesis but also maintain excellent properties are still limited. Hence, a facile hot die formation technique is developed for establishing patterned nanorod arrays on the PEEK surface in situ. This method can maintain the excellent properties of PEEK and can be used in implantation as it can facilitate osteogenic activity in the absence of any organic/inorganic differentiation-inducing factors. PEEK with 200-nm patterned nanorod arrays on the surface exhibits excellent osteogenic properties. This result is obtained by assessing the osteogenic differentiation properties of rat adipose-derived stem cells at the gene and protein levels in vitro. In vivo experimental results reveal that the surface-modified cylindrical PEEK 200 implants present with excellent osseointegration properties. Moreover, they can tightly bind with the surrounding bone tissue. A practical method for manufacturing single-component PEEK implants with excellent osseointegration properties is reported, and the materials can be possibly used as orthopedic implants.

Morphology and properties of foamed high crystallinity PEEK prepared by high temperature thermally induced phase separation

Polyetheretherketone (PEEK) is a high‐performance semi‐crystalline thermoplastic polymer with outstanding mechanical properties, high thermal stability, resistance to most common solvents, and good biocompatibility. A high temperature thermally induced phase separation technique was used to produce PEEK foams with controlled foam density from PEEK in 4‐phenylphenol (4PPH) solutions. Physical and mechanical properties, foam and bulk density, surface area, and pore morphology of foamed PEEK were characterized and the role of PEEK concentration and cooling rate was investigated. Porous PEEK with densities ranging from 110 to 360 kg/m³ with elastic moduli and crush strength ranging from 13 to 125 MPa and 0.8 to 7 MPa, respectively, was produced.

The Surface Characteristics, Microstructure and Mechanical Properties of PEEK Printed by Fused Deposition Modeling with Different Raster Angles

Additive manufacturing provides a novel and robust way to prepare medical product with anatomic matched geometry and tailored mechanical performance. In this study, the surface characteristics, microstructure, and mechanical properties of fused deposition modeling (FDM) prepared polyether-ether-ketone (PEEK) were systematically studied. During the FDM process, the crystal unit cell and thermal attribute of PEEK material remained unchanged, whereas the surface layer generally became more hydrophilic with an obvious reduction in surface hardness. Raster angle has a significant effect on the mechanical strength but not on the failure mechanism. In practice, FDM fabricated PEEK acted more like a laminate rather than a unified structure. Its main failure mechanism was correlated to the internal voids. The results show that horizontal infill orientation with 30° raster angle is promising for a better comprehensive mechanical performance, and the corresponding tensile, flexural, and shear strengths are (76.5 ± 1.4) MPa, (149.7 ± 3.0) MPa, and (55.5 ± 1.8) MPa, respectively. The findings of this study provide guidelines for FDM-PEEK to enable its realization in applications such as orthopedic implants.

Genistein loaded into microporous surface of nano tantalum/PEEK composite with antibacterial effect regulating cellular response in vitro, and promoting osseointegration in vivo

Poly(ether-ether-ketone) (PEEK) with good biocompatibility exhibits high mechanical strengths but bioinert. In addition, tantalum (Ta) possesses outstanding osteogenesis but high density and elastic modulus, and cost. In this study, by blending Ta nanoparticles with PEEK, Ta/PEEK composite (TP) was prepared, which was then treated by concentrated sulfuric acid to form a microporous surface containing Ta particles on TP (TPS). Moreover, genistein (GS) with antibacterial property was loaded into the microporous surface of TPS (TPSG). Compared with TP, the surface properties (e.g., surface roughness and hydrophilicity) of TPS was obviously improved because of the microporous surface including Ta nanoparticles. Moreover, TPS showed low antibacterial properties because of presence of sulfonic group while TPSG exhibited excellent antibacterial properties due to GS loaded into the microporous surface. Furthermore, compared with TP, TPS obviously promoted attachment and proliferation of MG63 cells, while TPSG with GS remarkably inducing osteogenic differentiation of the cells compared with TPS in vitro. Moreover, in comparison with TP, TPS with optimized surface properties promoted new bone regeneration and osseointegration, while TPSG loading GS further enhanced bone regeneration as well as osseointegration in vivo. In summary, the GS loaded into microporous surface including Ta nanoparticles of TPSG exhibited antibacterial and osteogenic activity, which would have great potential for bone tissue repair.

Electronic Drugs: Spatial and Temporal Medical Treatment of Human Diseases

Recent advances in diagnostics and medicines emphasize the spatial and temporal aspects of monitoring and treating diseases. However, conventional therapeutics, including oral administration and injection, have difficulties meeting these aspects due to physiological and technological limitations, such as long-term implantation and a narrow therapeutic window. As an innovative approach to overcome these limitations, electronic devices known as electronic drugs (e-drugs) have been developed to monitor real-time body signals and deliver specific treatments to targeted tissues or organs. For example, ingestible and patch-type e-drugs could detect changes in biomarkers at the target sites, including the gastrointestinal (GI) tract and the skin, and deliver therapeutics to enhance healing in a spatiotemporal manner. However, medical treatments often require invasive surgical procedures and implantation of medical equipment for either short or long-term use. Therefore, approaches that could minimize implantation-associated side effects, such as inflammation and scar tissue formation, while maintaining high functionality of e-drugs, are highly needed. Herein, the importance of the spatial and temporal aspects of medical treatment is thoroughly reviewed along with how e-drugs use cutting-edge technological innovations to deal with unresolved medical challenges. Furthermore, diverse uses of e-drugs in clinical applications and the future perspectives of e-drugs are discussed.

Grafting Polymer Brushes by ATRP from Functionalized Poly(ether ether ketone) Microparticles

Poly(ether ether ketone) (PEEK) is a semi-crystalline thermoplastic with excellent mechanical and chemical properties. PEEK exhibits a high degree of resistance to thermal, chemical, and bio-degradation. PEEK is used as biomaterial in the field of orthopaedic and dental implants; however, due to its intrinsic hydrophobicity and inert surface, PEEK does not effectively support bone growth. Therefore, new methods to modify PEEK's surface to improve osseointegration are key to next generation polymer implant materials. Unfortunately, PEEK is a challenging material to both modify and subsequently characterize thus stymieing efforts to improve PEEK osseointegration. In this manuscript, we demonstrate how surface-initiated atom transfer radical polymerization (SI-ATRP) can be used to modify novel PEEK microparticles (PMP). The hard core-soft shell microparticles were synthesized and characterized by DLS, ATR-IR, XPS and TEM, indicating the grafted materials increased solubility and stability in a range of solvents. The discovered surface grafted PMP can be used as compatibilizers for the polymer-tissue interface.

Surface Bioactivation of Polyether Ether Ketone (PEEK) by Sulfuric Acid and Piranha Solution: Influence of the Modification Route in Capacity for Inducing Cell Growth

The aim of this study was to promote bioactivity of the PEEK surface using sulfuric acid and piranha solution. PEEK was functionalized by a sulfuric acid treatment for 90 s and by piranha solution for 60 and 90 s. Chemical modification of the PEEK surface was evaluated by infrared spectroscopy, contact angle analysis, cytotoxicity, cell adhesion and proliferation. The spectroscopy characteristic band associated with sulfonation was observed in all treated samples. PEEK with piranha solution 60 s showed an increase in the intensity of the bands, which was even more significant for the longer treatment (90 s). The introduction of the sulfonic acid functional group reduced the contact angle. In cytotoxicity assays, for all treatments, the number of viable cells was higher when compared to those of untreated PEEK. PEEK treated with sulfuric acid and piranha solution for 60 s were the treatments that showed the highest percentage of cell viability with no statistically significant differences between them. The modified surfaces had a greater capacity for inducing cell growth, indicative of effective cell adhesion and proliferation. The proposed chemical modifications are promising for the functionalization of PEEK-based implants, as they were effective in promoting bioactivation of the PEEK surface and in stimulating cell growth and proliferation.

The effect of a novel pillar surface morphology and material composition demonstrates uniform osseointegration

Long-term survival of orthopedic implants requires a strong and compliant interface between the implant and surrounding bone. This paper further explores the in-vivo response to a novel, macro-scale osseointegration surface morphology. In this study, we examine the effects of material composition on osseointegration in relation to the controlled surface geometry. The pillared surface is constructed of discontinuous surface geometry which creates an open space for unencumbered bone migration. In creating an open, macro-scale morphology we have demonstrated a bone migration and integration that is less dependent on the underlying implant material and is substantially driven thru surface geometry. In this in-vivo study an established ovine model was used to examine the effects of implant material composition on bone ingrowth and mechanical performance. Cortical and cancellous sites in the tibia and distal femur were examined at 6 and 12 weeks with μCT, histology, histomorphometry, and mechanical performance. Implant materials tested included PEEK (Evonik, VISTAKEEP®), PEEK HA (Invibio, PEEK-OPTIMA HA Enhanced), Titanium coated PEEK, Titanium (Ti-6Al-4V, Grade 5), and Ultra-High Molecular Weight Polyethylene (UHMWPE). Extensive bone ingrowth was noted in all implant materials at 12 weeks with maturation of the bone within the pillar structure from 6 weeks to 12 weeks. Histology demonstrated little fibrous deposition at the implant interface with no adverse cellular reactions. Histomorphometric review of cortical sites revealed greater than 60% bone ingrowth at 6 weeks increasing to nearly 80% by the 12 week timepoint. Cancellous sites yielded a mean of 30% ingrowth at 6 weeks increasing to 35% by 12 weeks. Pushout testing of cortical site samples demonstrated increase in pushout force between the 6 and 12 week timepoints. Increases were significant in all but the UHMWPE samples. Stiffness likewise increased in all samples between the two times. These results demonstrated the effectiveness of the pillar morphology with full integrating from the surrounding bony tissue regardless of the material.

Modification of polyetheretherketone implants: From enhancing bone integration to enabling multi-modal therapeutics

Polyetheretherketone (PEEK) is a popular thermoplastic material widely used in engineering applications due to its favorable mechanical properties and stability at high temperatures. With the first implantable grade PEEK being commercialized in 1990s, the use of PEEK has since grown exponentially in the biomedical field and has rapidly transformed a large section of the medical devices landscape. Nowadays, PEEK is a standard biomaterial used across a wide range of implant applications, however, its bioinertness remains a limitation for bone repair applications. The increasing demand for enhanced treatment efficacy/improved patient quality of life, calls for next-generation implants that can offer fast bone integration as well as other desirable therapeutic functions. As such, modification of PEEK implants has progressively shifted from offering desirable mechanical properties, enhancing bioactivity/fast osteointegration, to more recently, tackling post-surgery bacterial infection/biofilm formation, modulation of inflammation and management of bone cancers. Such progress is also accompanied by the evolution of the PEEK manufacturing technologies, to meet the ever increasing demand for more patient specific devices. However, no review has comprehensively covered the recently engaged application areas to date. This paper provides an up-to-date review on the development of PEEK-based biomedical devices in the past 10 years, with particularly focus on modifying PEEK for multi-modal therapeutics. The aim is to provide the peers with a timely update, which may guide and inspire the research and development of next generation PEEK-based healthcare products. STATEMENT OF SIGNIFICANCE: Significant progress has been made in PEEK processing and modification techniques in the past decades, which greatly contributed to its wide applications in the biomedical field. Despite the high volume of published literature on PEEK implant related research, there is a lack of review on its emerging applications in multi-modal therapeutics, which involve bone regeneration, anti-bacteria/anti-inflammation, and cancer inhibition, etc. This timely review covers the state-of-the-art in these exciting areas and provides the important guidance for next generation PEEK based biomedical device research and development.

Mechanical, Chemical, and Processing Properties of Specimens Manufactured from Poly-Ether-Ether-Ketone (PEEK) Using 3D Printing

As part of the experiments herein, the mechanical properties of specimens made of poly-ether-ether-ketone (PEEK) material using 3D printing technology were determined. Two populations of specimens were investigated, the first of which contained an amorphous structure, while the other held a crystal structure. The studies also investigated the influence of the print directionality on the mechanical properties obtained. Static tensile, three-point bending, and impact tests were carried out. The results for the effect of the structure type on the tensile properties showed that the modulus of elasticity was approximately 20% higher for the crystal than for the amorphous PEEK form. The Poisson’s ratios were similar, but the ratio was slightly higher for the amorphous samples than the crystalline ones. Furthermore, the studies included a chemical PEEK modification to increase the hydrophilicity. For this purpose, nitrite and hydroxyl groups were introduced into the chain by chemical reactions. The results demonstrate that the modified PEEK specimens had worse thermoplastic properties than the unmodified specimens.

Surface porous poly-ether-ether-ketone based on three-dimensional printing for load-bearing orthopedic implant

Poly-ether-ether-ketone (PEEK) possesses excellent biocompatibility and similar elastic modulus as bones but yet suffers from poor osseointegration. In order to balance PEEK's mechanical and osseointegration properties, a novel surface porous PEEK (SP-PEEK) is successfully fabricated by fused deposition modelling three-dimensional printing (FDM 3DP) and characterized by mechanical and osteogenesis in vitro tests. Moreover, the effects of pore diameter and pore layer number on the mechanical behaviors of SP-PEEK are investigated by theoretical model and numerical simulation. Comparison among experimental, theoretical and simulation results show good agreement. As pore diameter decreases, the equivalent strength and modulus become more sensitive to the decrease of pore layer number. In addition, the SP-PEEK exhibits the mechanical properties within the range of human trabecular bone and cortical bone, and thus can be tailored to mimic human bone by adjusting the pore diameter and pore layer number, which is benefit to mitigate stress shielding. The effects of pore diameter on the cell proliferation and osteogenic differentiation of SP-PEEK are tested by the co-culture of osteoblast precursor cells (MC3T3-E1) and SP-PEEK round discs. Results showcase that porous surface improves the osteogenesis in vitro, and the SP-PEEK group that the pore diameter is 0.6 mm exhibits optimal-performance osteogenesis in vitro.

Surface modifications to enhance osseointegration-Resulting material properties and biological responses

As life expectancy and the age of the general population increases so does the need for improved implants. A major contributor to the failure of implants is poor osseointegration, which is typically described as the direct connection between bone and implant. This leads to unnecessary complications and an increased burden on the patient population. Modification of the implant surfaces through novel techniques, such as varying topography and/or applying coatings, has become a popular method to enhance the osseointegration capability of implants. Recent research has shown that particular surface features influence how bone cells interact with a material; however, it is unknown which exact features achieve optimal bone integration. In this review, current methods of modifying surfaces will be highlighted, and the resulting surface characteristics and biological responses are discussed. Review of the current strategies of surface modifications found that many coating types are more advantageous when used in combination; however, finding a surface modification that utilizes the mutual beneficial effects of important surface characteristics while still maintaining commercial viability is where future challenges exist.

Effects of printing path and material components on mechanical properties of 3D-printed polyether-ether-ketone/hydroxyapatite composites

Polyether-ether-ketone (PEEK) exhibits excellent mechanical properties and biocompatibility. Three-dimensional (3D) printing of PEEK bone substitutes has been widely used in clinical application. However, the inertness of pure PEEK hinders its integration with the surrounding bone tissue. In this study, for the first time, PEEK/hydroxyapatite (HA) composite specimens were fabricated using fused filament fabrication (FFF) technology. PEEK/HA filaments with HA contents of 0-30 wt% were fabricated via mechanical mixing and extrusion. The HA distributions inside the composite matrix and the surface morphology characteristics of the PEEK/HA composites were examined. The effects of the printing path and HA content on the mechanics of the PEEK/HA composites were systematically investigated. The results indicated that the HA particles were uniformly distributed on the composite matrix. With an increase in the HA content, the modulus of the PEEK/HA composite increased, while the strength and failure strain concomitantly decreased. When the HA content increased to 30 wt%, the tensile modulus of the composite increased by 68.6% compared with that of pure PEEK printed along the horizontal 90° path, while the tensile strength decreased by 48.2% compared with that of pure PEEK printed along the vertical 90° path. The fracture elongation of the printed specimens with different HA contents decreased in the following order: horizontal 0° > horizontal 90° > vertical 90°. The best comprehensive mechanical properties were achieved for pure PEEK fabricated along the horizontal 0° path. The results indicate that FFF technology is applicable for additive manufacturing of PEEK/HA composites with controllable compositions. Printed PEEK/HA composites have potential for applications in the design and manufacturing of personalized bone substitutes.

Exosome-functionalized polyetheretherketone-based implant with immunomodulatory property for enhancing osseointegration

The host immune response effecting on biomaterials is critical to determine implant fates and bone regeneration property. Bone marrow stem cells (BMSCs) derived exosomes (Exos) contain multiple biosignal molecules and have been demonstrated to exhibit immunomodulatory functions. Herein, we develop a BMSC-derived Exos-functionalized implant to accelerate bone integration by immunoregulation. BMSC-derived Exos were reversibly incorporated on tannic acid (TA) modified sulfonated polyetheretherketone (SPEEK) via the strong interaction of TA with biomacromolecules. The slowly released Exos from SPEEK can be phagocytosed by co-cultured cells, which could efficiently improve the biocompatibilities of SPEEK. In vitro results showed the Exos loaded SPEEK promoted macrophage M2 polarization via the NF-κB pathway to enhance BMSCs osteogenic differentiation. Further in vivo rat air-pouch model and rat femoral drilling model assessment of Exos loaded SPEEK revealed efficient macrophage M2 polarization, desirable new bone formation, and satisfactory osseointegration. Thus, BMSC-derived Exos-functionalized implant exerted osteoimmunomodulation effect to promote osteogenesis.

Strategies for Bone Regeneration: From Graft to Tissue Engineering

Bone is a regenerative organ characterized by self-renewal ability. Indeed, it is a very dynamic tissue subjected to continuous remodeling in order to preserve its structure and function. However, in clinical practice, impaired bone healing can be observed in patients and medical intervention is needed to regenerate the tissue via the use of natural bone grafts or synthetic bone grafts. The main elements required for tissue engineering include cells, growth factors and a scaffold material to support them. Three different materials (metals, ceramics, and polymers) can be used to create a scaffold suitable for bone regeneration. Several cell types have been investigated in combination with biomaterials. In this review, we describe the options available for bone regeneration, focusing on tissue engineering strategies based on the use of different biomaterials combined with cells and growth factors.

Bioinspired Modifications of PEEK Implants for Bone Tissue Engineering

In recent years, polyetheretherketone (PEEK) has been increasingly employed as an implant material in clinical applications. Although PEEK is biocompatible, chemically stable, and radiolucent and has an elastic modulus similar to that of natural bone, it suffers from poor integration with surrounding bone tissue after implantation. To improve the bioactivity of PEEK, numerous strategies for functionalizing the PEEK surface and changing the PEEK structure have been proposed. Inspired by the components, structure, and function of bone tissue, this review discusses strategies to enhance the biocompatibility of PEEK implants and provides direction for fabricating multifunctional implants in the future.

Both Phosphonic Acid- and Fluorine-Containing Poly(aryl ether)-hydroxyapatite Biocomposites: Toward Enhanced Biocompatibility and Bonelike Elastic Modulus

Metal-based implants possess excellent mechanical strength, corrosion resistance, and biocompatibility and can deliver favorable performances in clinic treatments. However, modulus mismatching is considered a common defect for metal-based materials, while polymer-based materials with a bonelike elastic modulus have been regarded as one of the most promising candidates for bone replacement implants. In this work, a phosphonic acid- and fluorine-containing poly(aryl ether) (PAE) resin is designed and synthesized, which is determined to be an amorphous polymer with excellent thermostability. The elastic modulus of composites is improved to 15.7 GPa by reinforcing with 60 wt % hydroxyapatite (HA), which demonstrates admirable protein adsorption and hydrophilicity. After 14 days of immersion in simulated body fluid, a layer of HA deposition can be observed, indicating favorable bioactivity in advance, and the preliminary in vitro cell experiments also suggest that PAE-HA composites possess favorable cell responses on adhesion, proliferation, and differentiation, which reveal the feasibility of synthesized polymers to be employed as bone replacement materials, while the adjustability in molecular chains also leaves room for further investigations.

Conducting Polyetheretherketone Nanocomposites with an Electrophoretically Deposited Bioactive Coating for Bone Tissue Regeneration and Multimodal Therapeutic Applications

The use of polyetheretherketone (PEEK) has grown exponentially in the biomedical field in recent decades because of its outstanding biomechanical properties. However, its lack of bioactivity/osteointegration remains an unresolved issue toward its wide use in orthopedic applications. In this work, graphene nanosheets have been incorporated into PEEK to obtain multifunctional nanocomposites. Because of the formation of an electrical percolation network and the π-π* conjugation between graphene and PEEK, the resulting composites have achieved 12 orders of magnitude enhancement in their electrical conductivity and thereby enabled electrophoretic deposition of a bioactive/antibacterial coating consisting of stearyltrimethylammonium chloride-modified hydroxyapatite. The coated composite implant shows significant boosting of bone marrow mesenchymal stem cell proliferation in vitro. In addition, the strong photothermal conversion effect of the graphene nanofillers has enabled laser-induced heating of our nanocomposite implants, where the temperature of the implant can reach 45 °C in 150 s. The unique multifunctionality of the implant has also been demonstrated for photothermal applications such as enhancing bacterial eradication and tumor cell inhibition, as well as bone tissue regeneration in vivo. The results suggest the strong potential of our multifunctional implant in bone repair applications as well as multimodal therapy of challenging bone diseases such as osteosarcoma and osteomyelitis.

Polyetheretherketone and Its Composites for Bone Replacement and Regeneration

In this article, recent advances in the development, preparation, biocompatibility and mechanical properties of polyetheretherketone (PEEK) and its composites for hard and soft tissue engineering are reviewed. PEEK has been widely employed for fabricating spinal fusions due to its radiolucency, chemical stability and superior sterilization resistance at high temperatures. PEEK can also be tailored into patient-specific implants for treating orbital and craniofacial defects in combination with additive manufacturing process. However, PEEK is bioinert, lacking osseointegration after implantation. Accordingly, several approaches including surface roughening, thin film coating technology, and addition of bioactive hydroxyapatite (HA) micro-/nanofillers have been adopted to improve osseointegration performance. The elastic modulus of PEEK is 3.7-4.0 GPa, being considerably lower than that of human cortical bone ranging from 7-30 GPa. Thus, PEEK is not stiff enough to sustain applied stress in load-bearing orthopedic implants. Therefore, HA micro-/nanofillers, continuous and discontinuous carbon fibers are incorporated into PEEK for enhancing its stiffness for load-bearing applications. Among these, carbon fibers are more effective than HA micro-/nanofillers in providing additional stiffness and load-bearing capabilities. In particular, the tensile properties of PEEK composite with 30wt% short carbon fibers resemble those of cortical bone. Hydrophobic PEEK shows no degradation behavior, thus hampering its use for making porous bone scaffolds. PEEK can be blended with hydrophilic polymers such as polyglycolic acid and polyvinyl alcohol to produce biodegradable scaffolds for bone tissue engineering applications.

Osteointegration of 3D-Printed Fully Porous Polyetheretherketone Scaffolds with Different Pore Sizes

Polyetheretherketone (PEEK) constitutes a preferred alternative material for orthopedic implants owing to its good mechanical properties and biocompatibility. However, the poor osseointegration property of PEEK implants has limited their clinical applications. To address this issue, in this study, we investigated the mechanical and biological properties of fully porous PEEK scaffolds with different pore sizes both in vitro and in vivo. PEEK scaffolds with designed pore sizes of 300, 450, and 600 μm and a porosity of 60% were manufactured via fused deposition modeling (FDM) to explore the optimum pore size. Smooth solid PEEK cylinders (PEEK-S) were used as the reference material. The mechanical, cytocompatibility, proliferative, and osteogenic properties of PEEK scaffolds were characterized in comparison to those of PEEK-S. In vivo dynamic contrast-enhanced magnetic resonance imaging, microcomputed tomography, and histological observation were performed after 4 and 12 weeks of implantation to evaluate the microvascular perfusion and bone formation afforded by the various PEEK implants using a New Zealand white rabbit model with distal femoral condyle defects. Results of in vitro testing supported the good biocompatibility of the porous PEEK scaffolds manufactured via FDM. In particular, the PEEK-450 scaffolds were most beneficial for cell adhesion, proliferation, and osteogenic differentiation. Results of in vivo analysis further indicated that PEEK-450 scaffolds exhibited preferential potential for bone ingrowth and vascular perfusion. Together, our findings support that porous PEEK implants designed with a suitable pore size and fabricated via three-dimensional printing constitute promising alternative biomaterials for bone grafting and tissue engineering applications with marked potential for clinical applications.