Ectopic bone formation by 3D porous calcium phosphate-Ti6Al4V hybrids produced by perfusion electrodeposition

Advanced surface engineering of titanium materials for biomedical applications: From static modification to dynamic responsive regulation

Titanium (Ti) and its alloys have been widely used as orthopedic implants, because of their favorable mechanical properties, corrosion resistance and biocompatibility. Despite their significant success in various clinical applications, the probability of failure, degradation and revision is undesirably high, especially for the patients with low bone density, insufficient quantity of bone or osteoporosis, which renders the studies on surface modification of Ti still active to further improve clinical results. It is discerned that surface physicochemical properties directly influence and even control the dynamic interaction that subsequently determines the success or rejection of orthopedic implants. Therefore, it is crucial to endow bulk materials with specific surface properties of high bioactivity that can be performed by surface modification to realize the osseointegration. This article first reviews surface characteristics of Ti materials and various conventional surface modification techniques involving mechanical, physical and chemical treatments based on the formation mechanism of the modified coatings. Such conventional methods are able to improve bioactivity of Ti implants, but the surfaces with static state cannot respond to the dynamic biological cascades from the living cells and tissues. Hence, beyond traditional static design, dynamic responsive avenues are then emerging. The dynamic stimuli sources for surface functionalization can originate from environmental triggers or physiological triggers. In short, this review surveys recent developments in the surface engineering of Ti materials, with a specific emphasis on advances in static to dynamic functionality, which provides perspectives for improving bioactivity and biocompatibility of Ti implants.

In vivo evaluation of osseointegration ability of sintered bionic trabecular porous titanium alloy as artificial hip prosthesis

Hydroxyapatite (HA) coatings have been widely used for improving the bone-implant interface (BII) bonding of the artificial joint prostheses. However, the incidence of prosthetic revisions due to aseptic loosening remains high. Porous materials, including three-dimensional (3D) printing, can reduce the elastic modulus and improve osseointegration at the BII. In our previous study, we identified a porous material with a sintered bionic trabecular structure with in vitro and in vivo bio-safety as well as in vivo mechanical safety. This study aimed to compare the difference in osseointegration ability of the different porous materials and HA-coated titanium alloy in the BII. We fabricated sintered bionic trabecular porous titanium acetabular cups, 3D-printed porous titanium acetabular cups, and HA-coated titanium alloy acetabular cups for producing a hip prosthesis suitable for beagle dogs. Subsequently, the imaging and histomorphological analysis of the three materials under mechanical loading in animals was performed (at months 1, 3, and 6). The results suggested that both sintered bionic porous titanium alloy and 3D-printed titanium alloy exhibited superior performances in promoting osseointegration at the BII than the HA-coated titanium alloy. In particular, the sintered bionic porous titanium alloy exhibited a favorable bone ingrowth performance at an early stage (month 1). A comparison of the two porous titanium alloys suggested that the sintered bionic porous titanium alloys exhibit superior bone in growth properties and osseointegration ability. Overall, our findings provide an experimental basis for the clinical application of sintered bionic trabecular porous titanium alloys.

Sustained local ionic homeostatic imbalance caused by calcification modulates inflammation to trigger heterotopic ossification

Heterotopic ossification (HO) is a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues. Despite being a frequent complication of orthopedic and trauma surgery, brain and spinal injury, the etiology of HO is poorly understood. The aim of this study is to evaluate the hypothesis that a sustained local ionic homeostatic imbalance (SLIHI) created by mineral formation during tissue calcification modulates inflammation to trigger HO. This evaluation also considers the role SLIHI could play for the design of cell-free, drug-free osteoinductive bone graft substitutes. The evaluation contains five main sections. The first section defines relevant concepts in the context of HO and provides a summary of proposed causes of HO. The second section starts with a detailed analysis of the occurrence and involvement of calcification in HO. It is followed by an explanation of the causes of calcification and its consequences. This allows to speculate on the potential chemical modulators of inflammation and triggers of HO. The end of this second section is devoted to in vitro mineralization tests used to predict the ectopic potential of materials. The third section reviews the biological cascade of events occurring during pathological and material-induced HO, and attempts to propose a quantitative timeline of HO formation. The fourth section looks at potential ways to control HO formation, either acting on SLIHI or on inflammation. Chemical, physical, and drug-based approaches are considered. Finally, the evaluation finishes with a critical assessment of the definition of osteoinduction. STATEMENT OF SIGNIFICANCE: The ability to regenerate bone in a spatially controlled and reproducible manner is an essential prerequisite for the treatment of large bone defects. As such, understanding the mechanism leading to heterotopic ossification (HO), a condition triggered by an injury leading to the formation of mature lamellar bone in extraskeletal soft tissues, would be very useful. Unfortunately, the mechanism(s) behind HO is(are) poorly understood. The present study reviews the literature on HO and based on it, proposes that HO can be caused by a combination of inflammation and calcification. This mechanism helps to better understand current strategies to prevent and treat HO. It also shows new opportunities to improve the treatment of bone defects in orthopedic and dental procedures.

Graphene-Oxide Porous Biopolymer Hybrids Enhance In Vitro Osteogenic Differentiation and Promote Ectopic Osteogenesis In Vivo

Over the years, natural-based scaffolds have presented impressive results for bone tissue engineering (BTE) application. Further, outstanding interactions have been observed during the interaction of graphene oxide (GO)-reinforced biomaterials with both specific cell cultures and injured bone during in vivo experimental conditions. This research hereby addresses the potential of fish gelatin/chitosan (GCs) hybrids reinforced with GO to support in vitro osteogenic differentiation and, further, to investigate its behavior when implanted ectopically. Standard GCs formulation was referenced against genipin (Gp) crosslinked blend and 0.5 wt.% additivated GO composite (GCsGp/GO 0.5 wt.%). Pre-osteoblasts were put in contact with these composites and induced to differentiate in vitro towards mature osteoblasts for 28 days. Specific bone makers were investigated by qPCR and immunolabeling. Next, CD1 mice models were used to assess de novo osteogenic potential by ectopic implantation in the subcutaneous dorsum pocket of the animals. After 4 weeks, alkaline phosphate (ALP) and calcium deposits together with collagen synthesis were investigated by biochemical analysis and histology, respectively. Further, ex vivo materials were studied after surgery regarding biomineralization and morphological changes by means of qualitative and quantitative methods. Furthermore, X-ray diffraction and Fourier-transform infrared spectroscopy underlined the newly fashioned material structuration by virtue of mineralized extracellular matrix. Specific bone markers determination stressed the osteogenic phenotype of the cells populating the material in vitro and successfully differentiated towards mature bone cells. In vivo results of specific histological staining assays highlighted collagen formation and calcium deposits, which were further validated by micro-CT. It was observed that the addition of 0.5 wt.% GO had an overall significant positive effect on both in vitro differentiation and in vivo bone cell recruitment in the subcutaneous region. These data support the GO bioactivity in osteogenesis mechanisms as being self-sufficient to elevate osteoblast differentiation and bone formation in ectopic sites while lacking the most common osteoinductive agents.

In Vitro bioactivity, biocompatibility and corrosion resistance of multi-ionic (Ce/Si) co-doped hydroxyapatite porous coating on Ti-6Al-4 V for bone regeneration applications

Dual-doped hydroxyapatite (Ce⁴⁺/Si⁴⁺ doped HAP) coating with admirable bacterial resistance and enriched bioactivity was fabricated via spin-coating technique. In this study, Ce/Si co-doped hydroxyapatite was coated on Ti-6Al-4 V substrates as a triple layer with extreme centrifugal force (2000 RPM, 3000 RPM and 4000 RPM) to improve the biological performance of the coating in terms of enhanced bone apposition. Further, the coated substrate was characterized by XRD, FTIR and SEM-EDS techniques. The contact angle of the coating was measured through the sessile drop method and in vitro biomineralization was carried out in SBF solution to predict the apatite formation on the surface of the coated implant. Pathogen restriction behaviour of the coating was studied using gram-negative and gram-positive bacteria such as Staphylococcus aureus, Bacillus subtilis, Escherichia coli and Pseudomonas aeruginosa respectively. Among these, gram-negative bacteria, Escherichia coli revealed greater inhibition than other bacteria. In vitro cell viability assay using MG-63 osteoblast cell was performed for the optimised coating acquired at 4000 RPM and the result showed excellent biocompatibility towards the cell line. Corrosion resistance behaviour of the coating using Polarization and EIS study exhibited excellent corrosion resistance. Therefore, based on the in vitro studies, the designed multifunctional coating can act as a potential biomaterial in the field of biomedical engineering.

A prospective randomized cohort study on 3D-printed artificial vertebral body in single-level anterior cervical corpectomy for cervical spondylotic myelopathy

Background

This was a prospective randomized cohort study aiming at examining the safety and efficacy of artificial vertebral body (AVB) fabricated by electron beam melting (EBM) in comparison to conventional titanium mesh cage (TMC) used in single-level anterior cervical corpectomy and fusion (SL-ACCF).

Methods

Forty patients with cervical spondylotic myelopathy (CSM) underwent SL-ACCF using either the EBM-AVB or the TMC. Patients were evaluated for their demographics, radiological characteristics, neurologic function [using the Japanese Orthopaedic Association (JOA) scale], and health-related quality-of-life (HRQoL) aspects [using the Short Form 36 (SF-36)] before and after the surgery and comparison was made between the two groups both at baseline and the last follow-up. The Student t-text, paired-sample t-text, and Fisher's exact test were used when appropriate to detect any statistical significance at the level of α=0.05.

Results

Post-operative recovery was uneventful for all patients and no revision surgery was required. There were no significant differences between the EBM-AVB group and the TMC group at baseline. Patients in both groups demonstrated significant improvement in cervical alignment, JOA score, and SF-36 score after the surgery. Six months post-operatively, patients in the EBM-AVB group were found to have significantly less loss of fusion height and lower incidence for severe implant subsidence compared with the TMC group. Patients in the two groups were comparable at the last follow-up regarding their rate of fusion, cervical alignment, JOA recovery rate, SF-36 score, and by Odom's criteria.

Conclusions

For CSM patients undergoing SL-ACCF, the EBM-AVB group demonstrated comparable outcomes regarding patient cervical alignment, neurologic function, and HRQoL in comparison with the TMC group. Furthermore, the use of EBM-AVB was associated with decreased loss of the height of the fusion mass and a lower rate for severe implant subsidence.

Electrodeposition of Hydroxyapatite on a Metallic 3D-Woven Bioscaffold

In this study, we demonstrate that a uniform coating of hydroxyapatite (HAp, Ca10(PO4)6(OH)2) can be electrochemically deposited onto metallic 3D-woven bone scaffolds to enhance their bioactivity. The HAp coatings were deposited onto metallic scaffolds using an electrolyte containing Ca(NO3)2·4H2O, NH4H2PO4, and NaNO3. The deposition potential was varied to maximize the uniformity and adhesion of the coating. Using X-ray diffraction (XRD), Raman spectroscopy, and energy-dispersive spectroscopy (EDS), we found crystallized HAp on the 3D-woven lattice under all deposition potentials, while the −1.5 V mercury sulfate reference electrode potential provided the best local uniformity with a satisfactory deposition rate. The coatings generated under this optimized condition were approximately 5 µm thick and uniform throughout the internal and external sections of the woven lattice. We seeded and cultured both coated and uncoated scaffolds with human adipose-derived stromal/stem cells (ASCs) for 12 h and 4 days. We observed that the HAp coating increased the initial cell seeding efficiency by approximately 20%. Furthermore, after 4 days of culture, ASCs cultured on HAp-coated stainless-steel scaffolds increased by 32% compared to only 17% on the uncoated scaffold. Together, these results suggest that the HAp coating improves cellular adhesion.

In vitro and in vivo biocompatibility and bio-tribological properties of the calcium/amorphous-C composite films for bone tissue engineering application

Carbon-and diamond-like-carbon coated Ti alloys hold great promise for tissue engineering applications. Unfortunately, their strong intrinsic stress leads to the adhesion failure of the films. Herein, a series of a-C films with different Ca content were prepared on Ti₆Al₄V via co-sputtering deposition technology. Homogeneous spherical Ca nanoclusters, with an inner diameter of 2-6 nm, were formed in an amorphous carbon matrix. The addition of Ca induced indistinctive variation in either phase composition or topography. However, the introduction of Ca not only improved the mechanical properties of a-C film but also significantly strengthened its adhesion to osteoblasts. The bio-tribological properties of Ca/a-C films were also assessed using a tribometer in FBS solution. The Ca/a-C films exhibited a low friction coefficient of 0.083 and a low wear rate of 1.02-1.24×10^-6 mm³/Nm. The low coefficient of friction (COF) of the Ca/a-C films indicates their superior mechanical properties, making them the promising target of nanocomposite films used in bio-tribological applications. Well-stretched cells and the developed actin filaments were distinctly observed on the Ca/a-C films in the osteoblast cell adhesion experiments. In addition, the Ca/a-C films promoted cell proliferation and showed high cell viability. After being implanted for 4 weeks, the Ca/a-C implant material still adhered well to the muscle tissue, without inducing hyperergic or inflammatory reactions. Collectively, our results suggest that the Ca/a-C film is an ideal mounting material for bone tissue engineering.

Additive manufacturing of bone scaffolds

Additive manufacturing (AM) can obtain not only customized external shape but also porous internal structure for scaffolds, both of which are of great importance for repairing large segmental bone defects. The scaffold fabrication process generally involves scaffold design, AM, and post-treatments. Thus, this article firstly reviews the state-of-the-art of scaffold design, including computer-aided design, reverse modeling, topology optimization, and mathematical modeling. In addition, the current characteristics of several typical AM techniques, including selective laser sintering, fused deposition modeling (FDM), and electron beam melting (EBM), especially their advantages and limitations are presented. In particular, selective laser sintering is able to obtain scaffolds with nanoscale grains, due to its high heating rate and a short holding time. However, this character usually results in insufficient densification. FDM can fabricate scaffolds with a relative high accuracy of pore structure but with a relative low mechanical strength. EBM with a high beam-material coupling efficiency can process high melting point metals, but it exhibits a low-resolution and poor surface quality. Furthermore, the common post-treatments, with main focus on heat and surface treatments, which are applied to improve the comprehensive performance are also discussed. Finally, this review also discusses the future directions for AM scaffolds for bone tissue engineering.

Effect of Hydroxyapatite Formation on Titanium Surface with Bone Morphogenetic Protein-2 Loading through Electrochemical Deposition on MG-63 Cells

Calcium phosphate ceramics used in dentistry and orthopedics are some of the most valuable biomaterials, owing to their excellent osteoconduction, osteoinduction, and osseointegration. Osteoconduction and osteoinduction are critical targets for bone regeneration, and osseointegration is essential for any dental implantations. In this study, a hydroxyapatite (HAp) hybrid coating layer with the sequential release of bone morphogenetic protein 2 (BMP-2) was deposited onto an etched titanium substrate by electrochemical deposition. The resulting release of BMP-2 from Ti⁻HAp was assessed by immersing samples in a simulated buffer fluid solution. Through coculture, human osteosarcoma cell proliferation and alkaline phosphatase activity were assessed. The characteristics and effect on cell proliferation of the hybrid coatings were investigated for their functionality through X-ray diffraction (XRD) and cell proliferation assays. Findings revealed that -0.8 V vs. Ag/AgCl (3 M KCl) exhibited the optimal HAp properties and a successfully coated HAp layer. XRD confirmed the crystallinity of the deposited HAp on the titanium surface. Ti-0.8 V Ti⁻HAp co-coating BMP sample exhibited the highest cell proliferation efficiency and was more favorable for cell growth. A successful biocompatible hybrid coating with optimized redox voltage enhanced the osseointegration process. The findings suggest that this technique could have promising clinical applications to enhance the healing times and success rates of dental implantation.

Electrophoretic Deposition of Gentamicin-Loaded Silk Fibroin Coatings on 3D-Printed Porous Cobalt-Chromium-Molybdenum Bone Substitutes to Prevent Orthopedic Implant Infections

In addition to customizing shapes of metal bone substitutes for patients, the 3D printing technique can reduce the modulus of the substitutes through the design and manufacture of interconnected porous structures, achieving the modulus match between substitute and surrounding bone to improve implant longevity. However, the porous bone substitutes take more risks of postoperative infection due to its much larger surface area compared with the traditional casting solid bone substitute. Here, we prepared of gentamicin-loaded silk fibroin coatings on 3D-printed porous cobalt-chromium-molybdenum (CoCrMo) bone substitutes via electrophoretic deposition technique. Through optimization, relatively intact, continuous, homogeneous, and conformal coatings with a thickness of 2.30 ± 0.58 μm were deposited around the struts with few pore blocked. The porous metal structures exhibited no loss in mechanical properties after the anode galvanic corrosion in EPD process. The initial osteoblastic response on coatings was better than that on metal surface, including cell spreading, proliferation and cytotoxicity. Antibacterial efficacy experiments showed that the coatings had an antibacterial effect on both adherent and planktonic bacteria within 1 week. These results suggested that the beneficial properties of anode electrophoretic deposited silk fibroin coatings could be exploited to improve the biological functionality of porous structures made of medical metals.

Enhanced cell attachment and hemocompatibility of titanium by nanoscale surface modification through severe plastic integration of magnesium-rich islands and porosification

Besides the wide applications of titanium and its alloys for orthopedic and biomedical implants, the biocompatible nature of titanium has emerged various surface modification techniques to enhance its bioactivity and osteointegration with living tissues. In this work, we present a new procedure for nanoscale surface modification of titanium implants by integration of magnesium-rich islands combined with controlled formation of pores and refinement of the surface grain structure. Through severe plastic deformation of the titanium surface with fine magnesium hydride powder, Mg-rich islands with varying sizes ranging from 100 nm to 1000 nm can be integrated inside a thin surface layer (100-500 µm) of the implant. Selective etching of the surface forms a fine structure of surface pores which their average size varies in the range of 200-500 nm depending on the processing condition. In vitro biocompatibility and hemocompatibility assays show that the Mg-rich islands and the induced surface pores significantly enhance cell attachment and biocompatibility without an adverse effect on the cell viability. Therefore, severe plastic integration of Mg-rich islands on titanium surface accompanying with porosification is a new and promising procedure with high potential for nanoscale modification of biomedical implants.

Evaluation of carbonate apatite blocks fabricated from dicalcium phosphate dihydrate blocks for reconstruction of rabbit femoral and tibial defects

This study aimed to evaluate in vivo behavior of a carbonate apatite (CO₃Ap) block fabricated by compositional transformation via a dissolution-precipitation reaction using a calcium hydrogen phosphate dihydrate [DCPD: CaHPO₄·2H₂O] block as a precursor. These blocks were used to reconstruct defects in the femur and tibia of rabbits, using sintered dense hydroxyapatite (HAp) blocks as the control. Both the CO₃Ap and HAp blocks showed excellent tissue response and good osteoconductivity. HAp block maintained its structure even after 24 weeks of implantation, so no bone replacement of the implant was observed throughout the post-implantation period in either femoral or tibial bone defects. In contrast, CO₃Ap was resorbed with increasing time after implantation and replaced with new bone. The CO₃Ap block was resorbed approximately twice as fast at the metaphysis of the proximal tibia than at the epiphysis of the distal femur. The CO₃Ap block was resorbed at an approximately linear change over time, with complete resorption was estimated by extrapolation of data at approximately 1-1.5 years. Hence, the CO₃Ap block fabricated in this study has potential value as an ideal artificial bone substitute because of its resorption and subsequent replacement by bone.

Optimal Zn-Modified Ca–Si-Based Ceramic Nanocoating with Zn Ion Release for Osteoblast Promotion and Osteoclast Inhibition in Bone Tissue Engineering

We investigated the slow release of Zn ion (Zn2+) from nanocoatings and compared the in vitro response of osteoblasts (MC3T3-E1) and proosteoclasts (RAW 264.7) cultured on Ca2ZnSi2O7 nanocoated with different Zn/Ca molar ratios on a Ti-6Al-4V (i.e., Ti) substrate to optimize cell behaviors and molecule levels. Significant morphology differences were observed among samples. By comparing with pure Ti and CaSiO3 nanocoating, the morphology of Ca2ZnSi2O7 ceramic nanocoatings was rough and contained small nanoparticles or aggregations. Slow Zn2+ release from nanocoatings was observed and Zn2+ concentration was regulated by varying the Zn/Ca ratios. The cell-response results showed Ca2ZnSi2O7 nanocoating at different Zn/Ca molar ratios for osteoblasts and osteoclasts. Compared to other nanocoatings and Ti, sample Zn/Ca (0.3) showed the highest cell viability and upregulated expression of the osteogenic differentiation genes ALP, COL-1, and OCN. Additionally, sample Zn/Ca (0.3) showed the greatest inhibition of RAW 264.7 cell growth and decreased the mRNA levels of osteoclast-related genes OAR, TRAP, and HYA1. Therefore, the optimal Zn-Ca ratio of 0.3 in Ca2ZnSi2O7 ceramic nanocoating on Ti had a dual osteoblast-promoting and osteoclast-inhibiting effect to dynamically balance osteoblasts/osteoclasts. These optimal Zn-Ca ratios are valuable for Ca2ZnSi2O7 ceramic nanocoating on Ti-coated implants for potential applications in bone tissue regeneration.

Ectopic osteogenesis and angiogenesis regulated by porous architecture of hydroxyapatite scaffolds with similar interconnecting structure in vivo

The macro-pore sizes of porous scaffold play a key role for regulating ectopic osteogenesis and angiogenesis but many researches ignored the influence of interconnection between macro-pores with different sizes. In order to accurately reveal the relationship between ectopic osteogenesis and macro-pore sizes in dorsal muscle and abdominal cavities of dogs, hydroxyapatite (HA) scaffolds with three different macro-pore sizes of 500–650, 750–900 and 1100–1250 µm were prepared via sugar spheres-leaching process, which also had similar interconnecting structure determined by keeping the d/s ratio of interconnecting window diameter to macro-pore size constant. The permeability test showed that the seepage flow of fluid through the porous scaffolds increased with the increase of macro-pore sizes. The cell growth in three scaffolds was not affected by the macro-pore sizes. The in vivo ectopic implantation results indicated that the macro-pore sizes of HA scaffolds with the similar interconnecting structure have impact not only the speed of osteogenesis and angiogenesis but also the space distribution of newly formed bone. The scaffold with macro-pore sizes of 750–900 µm exhibited much faster angiogenesis and osteogenesis, and much more uniformly distribution of new bone than those with other macro-pore sizes. This work illustrates the importance of a suitable macro-pore sizes in HA scaffolds with the similar interconnecting structure which provides the environment for ectopic osteogenesis and angiogenesis.

A Long-Acting BMP-2 Release System Based on Poly(3-hydroxybutyrate) Nanoparticles Modified by Amphiphilic Phospholipid for Osteogenic Differentiation

We explored a novel poly(3-hydroxybutyrate) (PHB) nanoparticle loaded with hydrophilic recombinant human BMP-2 with amphiphilic phospholipid (BPC-PHB NP) for a rapid-acting and long-acting delivery system of BMP-2 for osteogenic differentiation. The BPC-PHB NPs were prepared by a solvent evaporation method and showed a spherical particle with a mean particle size of 253.4 nm, mean zeta potential of −22.42 mV, and high entrapment efficiency of 77.18%, respectively. For BPC-PHB NPs, a short initial burst release of BMP-2 from NPs in 24 h was found and it has steadily risen to reach about 80% in 20 days for in vitro test. BPC-PHB NPs significantly reduced the burst release of BMP-2, as compared to that of PHB NPs loading BMP-2 without PL (B-PHB NPs). BPC-PHB NPs maintained the content of BMP-2 for a long-term osteogenic differentiation. The OCT-1 cells with BPC-PHB NPs have high ALP activity in comparison with others. The gene markers for osteogenic differentiation were significantly upregulated for sample with BPC-PHB NPs, implying that BPC-PHB NPs can be used as a rapid-acting and long-acting BMP-2 delivery system for osteogenic differentiation.

Hybrid Macro-Porous Titanium Ornamented by Degradable 3D Gel/nHA Micro-Scaffolds for Bone Tissue Regeneration

Porous titanium is a kind of promising material for bone substitution, while its bio-inert property results in demand of modifications to improve the osteointegration capacity. In this study, gelatin (Gel) and nano-hydroxyapatite (nHA) were used to construct 3D micro-scaffolds in the pores of porous titanium in the ratios of Gel:nHA = 1:0, Gel:nHA = 1:1, and Gel:nHA = 1:3, respectively. Cell attachment and proliferation, and gene and protein expression levels of osteogenic markers were evaluated in MC3T3-E1 cells, followed by bone regeneration assessment in a rabbit radius defect model. All hybrid scaffolds with different composition ratio were found to have significant promotional effects in cell adhesion, proliferation and differentiation, in which the group with Gel:nHA = 1:1 showed the best performance in vitro, as well as the most bone regeneration volume in vivo. This 3D micro-scaffolds modification may be an innovative method for porous titanium ornamentation and shows potential application values in clinic.

Combining microCT-based characterization with empirical modelling as a robust screening approach for the design of optimized CaP-containing scaffolds for progenitor cell-mediated bone formation

Biomaterials are a key ingredient to the success of bone tissue engineering (TE), which focuses on the healing of bone defects by combining scaffolds with cells and/or growth factors. Due to the widely variable material characteristics and patient-specificities, however, current bone TE strategies still suffer from low repeatability and lack of robustness, which hamper clinical translation. Hence, optimal TE construct (i.e. cells and scaffold) characteristics are still under debate. This study aimed to reduce the material-specific variability for cell-based construct design, avoiding trial-and-error, by combining microCT characterization and empirical modelling as an innovative and robust screening approach. Via microCT characterization we have built a quantitative construct library of morphological and compositional properties of six CE approved CaP-based scaffolds (CopiOs®, BioOss™, Integra Mozaik™, chronOS Vivify, MBCP™ and ReproBone™), and of their bone forming capacity and in vivo scaffold degradation when combined with human periosteal derived cells (hPDCs). The empirical model, based on the construct library, allowed identification of the construct characteristics driving optimized bone formation, i.e. (a) the percentage of β-TCP and dibasic calcium phosphate, (b) the concavity of the CaP structure, (c) the average CaP structure thickness and (d) the seeded cell amount (taking into account the seeding efficiency). Additionally, the model allowed to quantitatively predict the bone forming response of different hPDC-CaP scaffold combinations, thus providing input for a more robust design of optimized constructs and avoiding trial-and error. This could improve and facilitate clinical translation.

STATEMENT OF SIGNIFICANCE

Biomaterials that support regenerative processes are a key ingredient for successful bone tissue engineering (TE). However, the optimal scaffold structure is still under debate. In this study, we have provided a useful innovative approach for robust screening of potential biomaterials or constructs (i.e. scaffolds seeded with cells and/or growth factors) by combining microCT characterization with empirical modelling. This novel approach leads to a better insight in the scaffold parameters influencing progenitor cell-mediated bone formation. Additionally, it serves as input for more controlled and robust design of optimized CaP-containing bone TE scaffolds. Hence, this novel approach could improve and facilitate clinical translation.

A Novel High Mechanical Property PLGA Composite Matrix Loaded with Nanodiamond-Phospholipid Compound for Bone Tissue Engineering

A potential bone tissue engineering material was produced from a biodegradable polymer, poly(lactic-co-glycolic acid) (PLGA), loaded with nanodiamond phospholipid compound (NDPC) via physical mixing. On the basis of hydrophobic effects and physical absorption, we modified the original hydrophilic surface of the nanodiamond (NDs) with phospholipids to be amphipathic, forming a typical core-shell structure. The ND-phospholipid weight ratio was optimized to generate sample NDPC50 (i.e., ND-phospholipid weight ratio of 100:50), and NDPC50 was able to be dispersed in a PLGA matrix at up to 20 wt %. Compared to a pure PLGA matrix, the introduction of 10 wt % of NDPC (i.e., sample NDPC50-PF10) resulted in a significant improvement in the material's mechanical and surface properties, including a decrease in the water contact angle from 80 to 55°, an approximately 100% increase in the Young's modulus, and an approximate 550% increase in hardness, thus closely resembling that of human cortical bone. As a novel matrix supporting human osteoblast (hFOB1.19) growth, NDPC50-PFs with different amounts of NDPC50 demonstrated no negative effects on cell proliferation and osteogenic differentiation. Furthermore, we focused on the behaviors of NDPC-PFs implanted into mice for 8 weeks and found that NDPC-PFs induced acceptable immune response and can reduce the rapid biodegradation of PLGA matrix. Our results represent the first in vivo research on ND (or NDPC) as nanofillers in a polymer matrix for bone tissue engineering. The high mechanical properties, good in vitro and in vivo biocompatibility, and increased mineralization capability suggest that biodegradable PLGA composite matrices loaded with NDPC may potentially be useful for a variety of biomedical applications, especially bone tissue engineering.

Topological design and additive manufacturing of porous metals for bone scaffolds and orthopaedic implants: A review

One of the critical issues in orthopaedic regenerative medicine is the design of bone scaffolds and implants that replicate the biomechanical properties of the host bones. Porous metals have found themselves to be suitable candidates for repairing or replacing the damaged bones since their stiffness and porosity can be adjusted on demands. Another advantage of porous metals lies in their open space for the in-growth of bone tissue, hence accelerating the osseointegration process. The fabrication of porous metals has been extensively explored over decades, however only limited controls over the internal architecture can be achieved by the conventional processes. Recent advances in additive manufacturing have provided unprecedented opportunities for producing complex structures to meet the increasing demands for implants with customized mechanical performance. At the same time, topology optimization techniques have been developed to enable the internal architecture of porous metals to be designed to achieve specified mechanical properties at will. Thus implants designed via the topology optimization approach and produced by additive manufacturing are of great interest. This paper reviews the state-of-the-art of topological design and manufacturing processes of various types of porous metals, in particular for titanium alloys, biodegradable metals and shape memory alloys. This review also identifies the limitations of current techniques and addresses the directions for future investigations.

Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion

External fixation has become an important tool in orthopedic surgery. Technology has improved the design and material as well as the construct of the fixator. As most patients are converted from external fixation to definite stabilization during later clinical course, prevention of complications such as infection is of high importance. Based on the current literature, principles of temporary external fixation were summarized. We focused on minimizing the risk of infection and introduce a standardized algorithm how to proceed when converting from external to internal fixation, which also was examined for effectiveness.

Human periosteum cell osteogenic differentiation enhanced by ionic silicon release from porous amorphous silica fibrous scaffolds

Current synthetic grafts for bone defect filling in the sinus can support new bone formation but lack the ability to stimulate or enhance osteogenic healing. To promote such healing, osteoblast progenitors such as human periosteum cells must undergo osteogenic differentiation. In this study, we tested the hypothesis that degradation of porous amorphous silica fibrous (PASF) scaffolds can enhance human periosteum cell osteogenic differentiation. Two types of PASF were prepared and evaluated according to their densities (PASF99, PASF98) with 99 and 98% porosity, respectively. Silicon (Si) ions were observed to rapidly release from both scaffolds within 24 h in vitro. PASF99 Si ion release rate was estimated to be nearly double that of PASF98 scaffolds. Mechanical tests revealed a lower compressive strength in PASF99 as compared with PASF98. Osteogenic expression analysis showed that PASF99 scaffolds enhanced the expression of activating transcription factor 4, alkaline phosphatase, and collagen (Col(I)α1, Col(I)α2). Scanning electron microscopy showed cellular and extracellular matrix (ECM) ingress into both scaffolds within 16 days and the formation of Ca-P precipitates within 85 days. In conclusion, this study demonstrated that PASF scaffolds enhance human periosteum cell osteogenic differentiation by releasing ionic Si, and structurally supporting cellular and ECM ingress.

In vivo ectopic bone formation by devitalized mineralized stem cell carriers produced under mineralizing culture condition

Functionalization of tissue engineering scaffolds with in vitro–generated bone-like extracellular matrix (ECM) represents an effective biomimetic approach to promote osteogenic differentiation of stem cells in vitro. However, the bone-forming capacity of these constructs (seeded with or without cells) is so far not apparent. In this study, we aimed at developing a mineralizing culture condition to biofunctionalize three-dimensional (3D) porous scaffolds with highly mineralized ECM in order to produce devitalized, osteoinductive mineralized carriers for human periosteal-derived progenitors (hPDCs). For this, three medium formulations [i.e., growth medium only (BM1), with ascorbic acid (BM2), and with ascorbic acid and dexamethasone (BM3)] supplemented with calcium (Ca²⁺) and phosphate (PO₄³⁻) ions simultaneously as mineralizing source were investigated. The results showed that, besides the significant impacts on enhancing cell proliferation (the highest in BM3 condition), the formulated mineralizing media differentially regulated the osteochondro-related gene markers in a medium-dependent manner (e.g., significant upregulation of BMP2, bone sialoprotein, osteocalcin, and Wnt5a in BM2 condition). This has resulted in distinguished cell populations that were identifiable by specific gene signatures as demonstrated by the principle component analysis. Through devitalization, mineralized carriers with apatite crystal structures unique to each medium condition (by X-ray diffraction and SEM analysis) were obtained. Quantitatively, BM3 condition produced carriers with the highest mineral and collagen contents as well as human-specific VEGF proteins, followed by BM2 and BM1 conditions. Encouragingly, all mineralized carriers (after reseeded with hPDCs) induced bone formation after 8 weeks of subcutaneous implantation in nude mice models, with BM2-carriers inducing the highest bone volume, and the lowest in the BM3 condition (as quantitated by nano-computed tomography [nano-CT]). Histological analysis revealed different bone formation patterns, either bone ossicles containing bone marrow surrounding the scaffold struts (in BM2) or bone apposition directly on the struts' surface (in BM1 and BM3). In conclusion, we have presented experimental data on the feasibility to produce devitalized osteoinductive mineralized carriers by functionalizing 3D porous scaffolds with an in vitro cell-made mineralized matrix under the mineralizing culture conditions.

Bone tissue engineering via nanostructured calcium phosphate biomaterials and stem cells

Tissue engineering is promising to meet the increasing need for bone regeneration. Nanostructured calcium phosphate (CaP) biomaterials/scaffolds are of special interest as they share chemical/crystallographic similarities to inorganic components of bone. Three applications of nano-CaP are discussed in this review: nanostructured calcium phosphate cement (CPC); nano-CaP composites; and nano-CaP coatings. The interactions between stem cells and nano-CaP are highlighted, including cell attachment, orientation/morphology, differentiation and in vivo bone regeneration. Several trends can be seen: (i) nano-CaP biomaterials support stem cell attachment/proliferation and induce osteogenic differentiation, in some cases even without osteogenic supplements; (ii) the influence of nano-CaP surface patterns on cell alignment is not prominent due to non-uniform distribution of nano-crystals; (iii) nano-CaP can achieve better bone regeneration than conventional CaP biomaterials; (iv) combining stem cells with nano-CaP accelerates bone regeneration, the effect of which can be further enhanced by growth factors; and (v) cell microencapsulation in nano-CaP scaffolds is promising for bone tissue engineering. These understandings would help researchers to further uncover the underlying mechanisms and interactions in nano-CaP stem cell constructs in vitro and in vivo, tailor nano-CaP composite construct design and stem cell type selection to enhance cell function and bone regeneration, and translate laboratory findings to clinical treatments.

In vivo study of a self-stabilizing artificial vertebral body fabricated by electron beam melting

STUDY DESIGN

In vivo assessment of a novel artificial vertebral body fabricated by electron beam melting (EBM) for cervical vertebral body replacement in a sheep model.

OBJECTIVE

To investigate the feasibility of a novel artificial vertebral body: a "self-stabilizing artificial vertebral body" (SSAVB) fabricated by EBM in a sheep model.

SUMMARY OF BACKGROUND DATA

Artificial vertebral body is widely used for vertebral body replacement and spinal fusion, but research on an artificial vertebral body fabricated by EBM has not been reported.

METHODS

An SSAVB made of porous Ti6Al4V was implanted into a sheep cervical spine to replace the C4 vertebral body for 6 and 12 weeks. Bone ingrowth and implant stability were radiologically evaluated, and histological and biomechanical tests were performed.

RESULTS

No screw loosening, implant dislocation, or bone fractures occurred during the experimental period. A significant difference (P = 0.001) in bone ingrowth between the 6- and 12-week groups was noted. Comparison of the range of motion of C3-C5 segments between the in vivo group and the control groups (intact C2-C6 segment and fresh sheep cervical spines from C2 to C6 segments that underwent C4 subtotal corpectomy with the posterior vertebral wall retention by SSAVB implantation) suggests that the implant can stably replace this area of the cervical spine.

CONCLUSION

The open porous structure of Ti6Al4V fabricated by EBM facilitated bone ingrowth and the SSAVB can maintain cervical spine stability of the sheep. A porous metal implant can be used for load-bearing applications in a sheep model. It is hoped that these results will stimulate further study in human.

LEVEL OF EVIDENCE

4.

Peri- and intra-implant bone response to microporous Ti coatings with surface modification

Bone growth on and into implants exhibiting substantial surface porosity is a promising strategy in order to improve the long-term stable fixation of bone implants. However, the reliability in clinical applications remains a point of discussion. Most attention has been dedicated to the role of macroporosity, leading to the general consensus of a minimal pore size of 50-100 μm in order to allow bone ingrowth. In this in vivo study, we assessed the feasibility of early bone ingrowth into a predominantly microporous Ti coating with an average thickness of 150 μm and the hypothesis of improving the bone response through surface modification of the porous coating. Implants were placed in the cortical bone of rabbit tibiae for periods of 2 and 4 weeks and evaluated histologically and histomorphometrically using light microscopy and scanning electron microscopy. Bone with osteocytes encased in the mineralized matrix was found throughout the porous Ti coating up to the coating/substrate interface, highlighting that osseointegration of microporosities (<10 μm) was achievable. The bone trabeculae interweaved with the pore struts, establishing a large contact area which might enable an improved load transfer and stronger implant/bone interface. Furthermore, there was a clear interconnection with the surrounding cortical bone, suggesting that mechanical interlocking of the coating in the host bone in the long term is possible. When surface modifications inside the porous structure further reduced the interconnective pore size to the submicrometer level, bone ingrowth was impaired. On the other hand, application of a sol-gel-derived bioactive glass-ceramic coating without altering the pore characteristics was found to significantly improve bone regeneration around the coating, while still supporting bone ingrowth.

Surface Roughness and Morphology Customization of Additive Manufactured Open Porous Ti6Al4V Structures

Additive manufacturing (AM) is a production method that enables the building of porous structures with a controlled geometry. However, there is a limited control over the final surface of the product. Hence, complementary surface engineering strategies are needed. In this work, design of experiments (DoE) was used to customize post AM surface treatment for 3D selective laser melted Ti6Al4V open porous structures for bone tissue engineering. A two-level three-factor full factorial design was employed to assess the individual and interactive effects of the surface treatment duration and the concentration of the chemical etching solution on the final surface roughness and beam thickness of the treated porous structures. It was observed that the concentration of the surface treatment solution was the most important factor influencing roughness reduction. The designed beam thickness decreased the effectiveness of the surface treatment. In this case study, the optimized processing conditions for AM production and the post-AM surface treatment were defined based on the DoE output and were validated experimentally. This allowed the production of customized 3D porous structures with controlled surface roughness and overall morphological properties, which can assist in more controlled evaluation of the effect of surface roughness on various functional properties.

Three-dimensional characterization of tissue-engineered constructs by contrast-enhanced nanofocus computed tomography

To successfully implement tissue-engineered (TE) constructs as part of a clinical therapy, it is necessary to develop quality control tools that will ensure accurate and consistent TE construct release specifications. Hence, advanced methods to monitor TE construct properties need to be further developed. In this study, we showed proof of concept for contrast-enhanced nanofocus computed tomography (CE-nano-CT) as a whole-construct imaging technique with a noninvasive potential that enables three-dimensional (3D) visualization and quantification of in vitro engineered extracellular matrix (ECM) in TE constructs. In particular, we performed a 3D qualitative and quantitative structural and spatial assessment of the in vitro engineered ECM, formed during static and perfusion bioreactor cell culture in 3D TE scaffolds, using two contrast agents, namely, Hexabrix® and phosphotungstic acid (PTA). To evaluate the potential of CE-nano-CT, a comparison was made to standardly used techniques such as Live/Dead viability/cytotoxicity, Picrosirius Red staining, and to net dry weight measurements of the TE constructs. When using Hexabrix as the contrast agent, the ECM volume fitted linearly with the net dry ECM weight independent from the flow rate used, thus suggesting that it stains most of the ECM. When using PTA as the contrast agent, comparing to net weight measurements showed that PTA only stains a part of the ECM. This was attributed to the binding specificity of this contrast agent. In addition, the PTA-stained CE-nano-CT data showed pronounced distinction between flow conditions when compared to Hexabrix, indicating culture-specific structural ECM differences. This novel type of information can contribute to optimize bioreactor culture conditions and potentially critical quality characteristics of TE constructs such as ECM quantity and homogeneity, facilitating the gradual transformation of TE constructs in well-characterized TE products.

Process quality engineering for bioreactor-driven manufacturing of tissue-engineered constructs for bone regeneration

The incorporation of Quality-by-Design (QbD) principles in tissue-engineering bioprocess development toward clinical use will ensure that manufactured constructs possess prerequisite quality characteristics addressing emerging regulatory requirements and ensuring the functional in vivo behavior. In this work, the QbD principles were applied on a manufacturing process step for the in vitro production of osteogenic three-dimensional (3D) hybrid scaffolds that involves cell matrix deposition on a 3D titanium (Ti) alloy scaffold. An osteogenic cell source (human periosteum-derived cells) cultured in a bioinstructive medium was used to functionalize regular Ti scaffolds in a perfusion bioreactor, resulting in an osteogenic hybrid carrier. A two-level three-factor fractional factorial design of experiments was employed to explore a range of production-relevant process conditions by simultaneously changing value levels of the following parameters: flow rate (0.5-2 mL/min), cell culture duration (7-21 days), and cell-seeding density (1.5×10(3)-3×10(3) cells/cm(2)). This approach allowed to evaluate the individual impact of the aforementioned process parameters upon key quality attributes of the produced hybrids, such as collagen production, mineralization level, and cell number. The use of a fractional factorial design approach helped create a design space in which hybrid scaffolds of predefined quality attributes may be robustly manufactured while minimizing the number of required experiments.

Current views on calcium phosphate osteogenicity and the translation into effective bone regeneration strategies

Calcium phosphate (CaP) has traditionally been used for the repair of bone defects because of its strong resemblance to the inorganic phase of bone matrix. Nowadays, a variety of natural or synthetic CaP-based biomaterials are produced and have been extensively used for dental and orthopaedic applications. This is justified by their biocompatibility, osteoconductivity and osteoinductivity (i.e. the intrinsic material property that initiates de novo bone formation), which are attributed to the chemical composition, surface topography, macro/microporosity and the dissolution kinetics. However, the exact molecular mechanism of action is unknown. This review paper first summarizes the most important aspects of bone biology in relation to CaP and the mechanisms of bone matrix mineralization. This is followed by the research findings on the effects of calcium (Ca²⁺) and phosphate (PO₄³⁻) ions on the migration, proliferation and differentiation of osteoblasts during in vivo bone formation and in vitro culture conditions. Further, the rationale of using CaP for bone regeneration is explained, focusing thereby specifically on the material's osteoinductive properties. Examples of different material forms and production techniques are given, with the emphasis on the state-of-the art in fine-tuning the physicochemical properties of CaP-based biomaterials for improved bone induction and the use of CaP as a delivery system for bone morphogenetic proteins. The use of computational models to simulate the CaP-driven osteogenesis is introduced as part of a bone tissue engineering strategy in order to facilitate the understanding of cell-material interactions and to gain further insight into the design and optimization of CaP-based bone reparative units. Finally, limitations and possible solutions related to current experimental and computational techniques are discussed.