Optimization of hyaluronic acid-tyramine/silk-fibroin composite hydrogels for cartilage tissue engineering and delivery of anti-inflammatory and anabolic drugs

Bioactive silk fibroin hydrogels: Unraveling the potential for biomedical engineering

Silk fibroin (SF) has received special attention from the scientific community due to its noteworthy properties. Its unique chemical structure results in an uncommon combination of macroscopically useful properties, yielding a strong, fine and flexible material which, in addition, presents good biodegradability and better biocompatibility. Therefore, silk fibroin in various formats, appears as an ideal candidate for supporting biomedical applications. In this review, we will focus on the hydrogels obtained from silk fibroin or in combination with it, paying special attention to the synthesis procedures, characterization methodologies and biomedical applications. Tissue engineering and drug-delivery systems are, undoubtedly, the two main areas where silk fibroin hydrogels find their place.

Polysaccharide-protein based scaffolds for cartilage repair and regeneration

Cartilage repair and regeneration have become a global issue that millions of patients from all over the world need surgical intervention to repair the articular cartilage annually due to the limited self-healing capability of the cartilage tissues. Cartilage tissue engineering has gained significant attention in cartilage repair and regeneration by integration of the chondrocytes (or stem cells) and the artificial scaffolds. Recently, polysaccharide-protein based scaffolds have demonstrated unique and promising mechanical and biological properties as the artificial extracellular matrix of natural cartilage. In this review, we summarize the modification methods for polysaccharides and proteins. The preparation strategies for the polysaccharide-protein based hydrogel scaffolds are presented. We discuss the mechanical, physical and biological properties of the polysaccharide-protein based scaffolds. Potential clinical translation and challenges on the artificial scaffolds are also discussed.

Advanced PEG-tyramine biomaterial ink for precision engineering of perfusable and flexible small-diameter vascular constructs via coaxial printing

Vascularization is crucial for providing nutrients and oxygen to cells while removing waste. Despite advances in 3D-bioprinting, the fabrication of structures with void spaces and channels remains challenging. This study presents a novel approach to create robust yet flexible and permeable small (600-1300 μm) artificial vessels in a single processing step using 3D coaxial extrusion printing of a biomaterial ink, based on tyramine-modified polyethylene glycol (PEG-Tyr). We combined the gelatin biocompatibility/activity, robustness of PEG-Tyr and alginate with the shear-thinning properties of methylcellulose (MC) in a new biomaterial ink for the fabrication of bioinspired vessels. Chemical characterization using NMR and FTIR spectroscopy confirmed the successful modification of PEG with Tyr and rheological characterization indicated that the addition of PEG-Tyr decreased the viscosity of the ink. Enzyme-mediated crosslinking of PEG-Tyr allowed the formation of covalent crosslinks within the hydrogel chains, ensuring its stability. PEG-Tyr units improved the mechanical properties of the material, resulting in stretchable and elastic constructs without compromising cell viability and adhesion. The printed vessel structures displayed uniform wall thickness, shape retention, improved elasticity, permeability, and colonization by endothelial-derived - EA.hy926 cells. The chorioallantoic membrane (CAM) and in vivo assays demonstrated the hydrogel's ability to support neoangiogenesis. The hydrogel material with PEG-Tyr modification holds promise for vascular tissue engineering applications, providing a flexible, biocompatible, and functional platform for the fabrication of vascular structures.

Recent advancements in cartilage tissue engineering innovation and translation

Articular cartilage was expected to be one of the first successfully engineered tissues, but today, cartilage repair products are few and they exhibit considerable limitations. For example, of the cell-based products that are available globally, only one is marketed for non-knee indications, none are indicated for severe osteoarthritis or rheumatoid arthritis, and only one is approved for marketing in the USA. However, advances in cartilage tissue engineering might now finally lead to the development of new cartilage repair products. To understand the potential in this field, it helps to consider the current landscape of tissue-engineered products for articular cartilage repair and particularly cell-based therapies. Advances relating to cell sources, bioactive stimuli and scaffold or scaffold-free approaches should now contribute to progress in therapeutic development. Engineering for an inflammatory environment is required because of the need for implants to withstand immune challenge within joints affected by osteoarthritis or rheumatoid arthritis. Bringing additional cartilage repair products to the market will require an understanding of the translational vector for their commercialization. Advances thus far can facilitate the future translation of engineered cartilage products to benefit the millions of patients who suffer from cartilage injuries and arthritides.

Nano-Micron Combined Hydrogel Microspheres: Novel Answer for Minimal Invasive Biomedical Applications

Hydrogels, key in biomedical research for their hydrophilicity and versatility, have evolved with hydrogel microspheres (HMs) of micron-scale dimensions, enhancing their role in minimally invasive therapeutic delivery, tissue repair, and regeneration. The recent emergence of nanomaterials has ushered in a revolutionary transformation in the biomedical field, which demonstrates tremendous potential in targeted therapies, biological imaging, and disease diagnostics. Consequently, the integration of advanced nanotechnology promises to trigger a new revolution in the realm of hydrogels. HMs loaded with nanomaterials combine the advantages of both hydrogels and nanomaterials, which enables multifaceted functionalities such as efficient drug delivery, sustained release, targeted therapy, biological lubrication, biochemical detection, medical imaging, biosensing monitoring, and micro-robotics. Here, this review comprehensively expounds upon commonly used nanomaterials and their classifications. Then, it provides comprehensive insights into the raw materials and preparation methods of HMs. Besides, the common strategies employed to achieve nano-micron combinations are summarized, and the latest applications of these advanced nano-micron combined HMs in the biomedical field are elucidated. Finally, valuable insights into the future design and development of nano-micron combined HMs are provided.

Evolution of Hybrid Hydrogels: Next-Generation Biomaterials for Drug Delivery and Tissue Engineering

Hydrogels, being hydrophilic polymer networks capable of absorbing and retaining aqueous fluids, hold significant promise in biomedical applications owing to their high water content, permeability, and structural similarity to the extracellular matrix. Recent chemical advancements have bolstered their versatility, facilitating the integration of the molecules guiding cellular activities and enabling their controlled activation under time constraints. However, conventional synthetic hydrogels suffer from inherent weaknesses such as heterogeneity and network imperfections, which adversely affect their mechanical properties, diffusion rates, and biological activity. In response to these challenges, hybrid hydrogels have emerged, aiming to enhance their strength, drug release efficiency, and therapeutic effectiveness. These hybrid hydrogels, featuring improved formulations, are tailored for controlled drug release and tissue regeneration across both soft and hard tissues. The scientific community has increasingly recognized the versatile characteristics of hybrid hydrogels, particularly in the biomedical sector. This comprehensive review delves into recent advancements in hybrid hydrogel systems, covering the diverse types, modification strategies, and the integration of nano/microstructures. The discussion includes innovative fabrication techniques such as click reactions, 3D printing, and photopatterning alongside the elucidation of the release mechanisms of bioactive molecules. By addressing challenges, the review underscores diverse biomedical applications and envisages a promising future for hybrid hydrogels across various domains in the biomedical field.

Injectable hydrogels as promising in situ therapeutic platform for cartilage tissue engineering

Injectable hydrogels are gaining prominence as a biocompatible, minimally invasive, and adaptable platform for cartilage tissue engineering. Commencing with their synthesis, this review accentuates the tailored matrix formulations and cross-linking techniques essential for fostering three-dimensional cell culture and melding with complex tissue structures. Subsequently, it spotlights the hydrogels' enhanced properties, highlighting their augmented functionalities and broadened scope in cartilage tissue repair applications. Furthermore, future perspectives are advocated, urging continuous innovation and exploration to surmount existing challenges and harness the full clinical potential of hydrogels in regenerative medicine. Such advancements are crucial for validating the long-term efficacy and safety of hydrogels, positioning them as a promising direction in regenerative medicine to address cartilage-related ailments.

Cartilage regeneration using transforming growth factor-beta 3-loaded injectable crosslinked hyaluronic acid hydrogel

Cartilage defects can be difficult to heal, potentially leading to complications such as osteoarthritis. Recently, a tissue engineering approach that uses scaffolds and growth factors has been proposed to regenerate new cartilage tissues. Herein, we investigated the application of hyaluronic acid (HA) gel loaded with transforming growth factor-beta 3 (TGF-β3) for enhanced cartilage regeneration. We assessed the clinical conditions required to efficiently enhance the ability of the modified HA gel to repair defective cartilage. Based on our findings, the prepared HA gel exhibited good physicochemical and mechanical properties and was non-toxic and non-inflammatory. Moreover, HA gel-loaded TGF-β3 (HAT) had improved biocompatibility and promoted the synthesis of cartilage-specific matrix and collagen, further improving its ability to repair defects. The application of HAT resulted in an initial burst release of HA, which degraded slowly in vivo. Finally, HAT combined with microfracture-inducing bone marrow stem cells could significantly improve the cartilage microenvironment and regeneration of cartilage defects. Our results indicate that HA is a suitable material for developing growth factor carriers, whereas HAT is a promising candidate for cartilage regeneration. Furthermore, this differentiated strategy provides a rapid and effective clinical approach for next-generation cartilage regeneration.

Injectable smart stimuli-responsive hydrogels: pioneering advancements in biomedical applications

Hydrogels have established their significance as prominent biomaterials within the realm of biomedical research. However, injectable hydrogels have garnered greater attention compared with their conventional counterparts due to their excellent minimally invasive nature and adaptive behavior post-injection. With the rapid advancement of emerging chemistry and deepened understanding of biological processes, contemporary injectable hydrogels have been endowed with an "intelligent" capacity to respond to various endogenous/exogenous stimuli (such as temperature, pH, light and magnetic field). This innovation has spearheaded revolutionary transformations across fields such as tissue engineering repair, controlled drug delivery, disease-responsive therapies, and beyond. In this review, we comprehensively expound upon the raw materials (including natural and synthetic materials) and injectable principles of these advanced hydrogels, concurrently providing a detailed discussion of the prevalent strategies for conferring stimulus responsiveness. Finally, we elucidate the latest applications of these injectable "smart" stimuli-responsive hydrogels in the biomedical domain, offering insights into their prospects.

Advanced Applications of Silk-Based Hydrogels for Tissue Engineering: A Short Review

Silk has been consistently popular throughout human history due to its enigmatic properties. Today, it continues to be widely utilized as a polymer, having first been introduced to the textile industry. Furthermore, the health sector has also integrated silk. The Bombyx mori silk fibroin (SF) holds the record for being the most sustainable, functional, biocompatible, and easily produced type among all available SF sources. SF is a biopolymer approved by the FDA due to its high biocompatibility. It is versatile and can be used in various fields, as it is non-toxic and has no allergenic effects. Additionally, it enhances cell adhesion, adaptation, and proliferation. The use of SF has increased due to the rapid advancement in tissue engineering. This review comprises an introduction to SF and an assessment of the relevant literature using various methods and techniques to enhance the tissue engineering of SF-based hydrogels. Consequently, the function of SF in skin tissue engineering, wound repair, bone tissue engineering, cartilage tissue engineering, and drug delivery systems is therefore analysed. The potential future applications of this functional biopolymer for biomedical engineering are also explored.

Injectable hydrogels: An emerging therapeutic strategy for cartilage regeneration

The impairment of articular cartilage due to traumatic incidents or osteoarthritis has posed significant challenges for healthcare practitioners, researchers, and individuals suffering from these conditions. Due to the absence of an approved treatment strategy for the complete restoration of cartilage defects to their native state, the tissue condition often deteriorates over time, leading to osteoarthritic (OA). However, recent advancements in the field of regenerative medicine have unveiled promising prospects through the utilization of injectable hydrogels. This versatile class of biomaterials, characterized by their ability to emulate the characteristics of native articular cartilage, offers the distinct advantage of minimally invasive administration directly to the site of damage. These hydrogels can also serve as ideal delivery vehicles for a diverse range of bioactive agents, including growth factors, anti-inflammatory drugs, steroids, and cells. The controlled release of such biologically active molecules from hydrogel scaffolds can accelerate cartilage healing, stimulate chondrogenesis, and modulate the inflammatory microenvironment to halt osteoarthritic progression. The present review aims to describe the methods used to design injectable hydrogels, expound upon their applications as delivery vehicles of biologically active molecules, and provide an update on recent advances in leveraging these delivery systems to foster articular cartilage regeneration.

Viability of Collagen Matrix Grafts Associated with Nanohydroxyapatite and Elastin in Bone Repair in the Experimental Condition of Ovariectomy

Bone lesions have the capacity for regeneration under normal conditions of the bone metabolism process. However, due to the increasing incidence of major traumas and diseases that cause bone-mineral deficiency, such as osteoporosis, scaffolds are needed that can assist in the bone regeneration process. Currently, natural polymeric scaffolds and bioactive nanoparticles stand out. Therefore, the objective of the study was to evaluate the osteoregenerative potential in tibiae of healthy and ovariectomized rats using mineralized collagen and nanohydroxyapatite (nHA) scaffolds associated with elastin. The in-vivo experimental study was performed with 60 20-week-old Wistar rats, distributed into non-ovariectomized (NO) and ovariectomized (O) groups, as follows: Controls (G1-NO-C and G4-O-C); Collagen with nHA scaffold (G2-NO-MSH and G5-O-MSH); and Collagen with nHA and elastin scaffold (G3-NO-MSHC and G6-O-MSHC). The animals were euthanized 6 weeks after surgery and the samples were analyzed by macroscopy, radiology, and histomorphometry. ANOVA and Tukey tests were performed with a 95% CI and a significance index of p < 0.05. In the histological analyses, it was possible to observe new bone formed with an organized and compact morphology that was rich in osteocytes and with maturity characteristics. This is compatible with osteoconductivity in both matrices (MSH and MSHC) in rats with normal conditions of bone metabolism and with gonadal deficiency. Furthermore, they demonstrated superior osteogenic potential when compared to control groups. There was no significant difference in the rate of new bone formation between the scaffolds. Ovariectomy did not exacerbate the immune response but negatively influenced the bone-defect repair process.

A comprehensive review of silk-fibroin hydrogels for cell and drug delivery applications in tissue engineering and regenerative medicine

Hydrogel scaffolds hold great promise for developing novel treatment strategies in the field of regenerative medicine. Within this context, silk fibroin (SF) has proven to be a versatile material for a wide range of tissue engineering applications owing to its structural and functional properties. In the present review, we report on the design and fabrication of different forms of SF-based scaffolds for tissue regeneration applications, particularly for skin, bone, and neural tissues. In particular, SF hydrogels have emerged as delivery systems for a wide range of bio-actives. Given the growing interest in the field, this review has a primary focus on the fabrication, characterization, and properties of SF hydrogels. We also discuss their potential for the delivery of drugs, stem cells, genes, peptides, and growth factors, including future directions in the field of SF hydrogel scaffolds.

A Photopolymerizable Biocompatible Hyaluronic Acid Hydrogel Promotes Early Articular Cartilage Repair in a Minipig Model In Vivo

Articular cartilage defects represent an unsolved clinical challenge. Photopolymerizable hydrogels are attractive candidates supporting repair. This study investigates the short-term safety and efficacy of two novel hyaluronic acid (HA)-triethylene glycol (TEG)-coumarin hydrogels photocrosslinked in situ in a clinically relevant large animal model. It is hypothesized that HA-hydrogel-augmented microfracture (MFX) is superior to MFX in enhancing early cartilage repair, and that the molar degree of substitution and concentration of HA affects repair. Chondral full-thickness defects in the knees of adult minipigs are treated with either 1) debridement (No MFX), 2) debridement and MFX, 3) debridement, MFX, and HA hydrogel (30% molar derivatization, 30 mg mL-1 HA; F3) (MFX+F3), and 4) debridement, MFX, and HA hydrogel (40% molar derivatization, 20 mg mL-1 HA; F4) (MFX+F4). After 8 weeks postoperatively, MFX+F3 significantly improves total macroscopic and histological scores compared with all other groups without negative effects, besides significantly enhancing the individual repair parameters "defect architecture," "repair tissue surface" (compared with No MFX, MFX), and "subchondral bone" (compared with MFX). These data indicate that photopolymerizable HA hydrogels enable a favorable metastable microenvironment promoting early chondrogenesis in vivo. This work also uncovers a mechanism for effective HA-augmented cartilage repair by combining lower molar derivatization with higher concentrations.

Injectable hydrogels for cartilage and bone tissue regeneration: A review

Annually, millions of patients suffer from irreversible injury owing to the loss or failure of an organ or tissue caused by accident, aging, or disease. The combination of injectable hydrogels and the science of stem cells have emerged to address this persistent issue in society by generating minimally invasive treatments to augment tissue function. Hydrogels are composed of a cross-linked network of polymers that exhibit a high-water retention capacity, thereby mimicking the wet environment of native cells. Due to their inherent mechanical softness, hydrogels can be used as needle-injectable stem cell carrier materials to mend tissue defects. Hydrogels are made of different natural or synthetic polymers, displaying a broad portfolio of eligible properties, which include biocompatibility, low cytotoxicity, shear-thinning properties as well as tunable biological and physicochemical properties. Presently, novel ongoing developments and native-like hydrogels are increasingly being used broadly to improve the quality of life of those with disabling tissue-related diseases. The present review outlines various future and in-vitro applications of injectable hydrogel-based biomaterials, focusing on the newest ongoing developments of in-situ forming injectable hydrogels for bone and cartilage tissue engineering purposes.

3D-biofabricated chondrocyte-laden decellularized extracellular matrix-contained gelatin methacrylate auxetic scaffolds under cyclic tensile stimulation for cartilage regeneration

Three-dimensional (3D) hydrogel constructs can mimic features of the extracellular matrix (ECM) and have tailorable physicochemical properties to support and maintain the regeneration of articular cartilage. Various studies have shown that mechanical cues affect the cellular microenvironment and thereby influence cellular behavior. In this study, we fabricated an auxetic scaffold to investigate the effect of 3D tensile stimulation on chondrocyte behavior. Different concentrations of decellularized extracellular matrix (dECM) were mixed with fish gelatin methacrylate (FGelMa) and employed for the preparation of dECM/FGelMa auxetic bio-scaffolds using 3D biofabrication technology. We show that when human chondrocytes (HCs) were incorporated into these scaffolds, their proliferation and the expression of chondrogenesis-related markers increased with dECM content. The function of HC was influenced by cyclic tensile stimulation, as shown by increased production of the chondrogenesis-related markers, collagen II and glycosaminoglycans, with the involvement of the yes-associated protein 1 signaling pathway. The biofabricated auxetic scaffold represents an excellent platform for exploring interactions between cells and their mechanical microenvironment.

An injectable hydrogel based on hyaluronic acid prepared by Schiff base for long-term controlled drug release

Drug-loaded injectable hydrogels have been studied widely in biomedical technology while the stable long-term controlled drug release and cytotoxicity are challenges. In this work, an injectable hydrogel with good swelling resistance was in situ synthetized using aminated hyaluronic acid (NHA) and aldehyde β-cyclodextrin (ACD) via Schiff-base reaction. The composition, morphology and mechanical property were characterized with FTIR, ¹³C NMR, SEM and rheology test, respectively. Voriconazole (VCZ) and Endophthalmitis was selected as a model drug and disease, respectively. The drug release, cytotoxicity and antifungal properties were detected in vitro. The results showed a long-term (> 60 days) drug release was realized, the NHA/ACD2/VCZ presented a zero-order release in the later stage. The cytotoxicity of NHA/ACD was detected by live/dead staining assay and Cell Counting Kit-8 (CCK-8). The survival rate of adult retina pigment epithelial cell line-19 (ARPE-19) was over 100 % after 3 d, it indicated a good cytocompatibility. The antifungal experiment presented samples had antifungal property. Biocompatibility in vivo proved NHA/ACD2 had no adverse effects on ocular tissues. Consequently, the injectable hydrogel based on hyaluronic acid prepared by Schiff base reaction provides a new option for long-term controlled drug release in the course of disease treatment from a material perspective.

Optimizing phenol-modified hyaluronic acid for designing shape-maintaining biofabricated hydrogel scaffolds in soft tissue engineering

In this study, we developed a well-printable biomaterial ink for 3D printing of shape-maintaining hydrogel scaffolds. The hydrogel base comprised tyramine-modified hyaluronic acid (HA-Tyr) and gelatin methacrylate (GelMA) and was dually cross-linked. Using the Box-Behnken design, we explored how varying the ink composition affected fiber formation and shape preservation. By adjusting the polymer ratios, we produced a stable hydrogel with varying responses, from a viscous liquid to a thick gel, and optimized 3D scaffolds that were structurally stable both during and after printing, offering precision and flexibility. Our ink exhibited shear-thinning behavior and high swelling capacity, as well as ECM-like characteristics and biocompatibility, making it an ideal candidate for soft tissues matrices with storage modulus of around 300 Pa. Animal trials and CAM assays confirmed its biocompatibility and integration with host tissue.

Tissue engineering modalities in skeletal muscles: focus on angiogenesis and immunomodulation properties

Muscular diseases and injuries are challenging issues in human medicine, resulting in physical disability. The advent of tissue engineering approaches has paved the way for the restoration and regeneration of injured muscle tissues along with available conventional therapies. Despite recent advances in the fabrication, synthesis, and application of hydrogels in terms of muscle tissue, there is a long way to find appropriate hydrogel types in patients with congenital and/or acquired musculoskeletal injuries. Regarding specific muscular tissue microenvironments, the applied hydrogels should provide a suitable platform for the activation of endogenous reparative mechanisms and concurrently deliver transplanting cells and therapeutics into the injured sites. Here, we aimed to highlight recent advances in muscle tissue engineering with a focus on recent strategies related to the regulation of vascularization and immune system response at the site of injury.

Comprehensive review on biosynthesis of hyaluronic acid with different molecular weights and its biomedical applications

Hyaluronic acid (HA), an anionic and nonsulfated glycosaminoglycan, is the main structural component of various tissues and plays an important role in various biological processes. Given the promising properties of HA, such as high cellular compatibility, moisture retention, antiaging, proper interaction with cells, and CD44 targeting, HA can be widely used extensively in drug delivery, tissue engineering, wound healing, and cancer therapy. HA can obtain from animal tissues and microbial fermentation, but its applications depend on its molecular weight. Microbial fermentation is a common method for HA production on an industrial scale and S. zooepidemicus is the most frequently used strain in HA production. Culture conditions including pH, temperature, agitation rate, aeration speed, shear stress, dissolved oxygen, and bioreactor type significantly affect HA biosynthesis properties. In this review all the HA production methods and purification techniques to improve its physicochemical and biological properties for various biomedical applications are discussed in details. In addition, we showed that how HA molecular weight can significantly affect its properties and applications.

Printable hyaluronic acid hydrogel functionalized with yeast-derived peptide for skin wound healing

Targeted delivery of bioactive agents, growth factors, and drugs to skin wounds is a growing trend in biomaterials development for wound healing. This study presents a printable hyaluronic acid (HA) based hydrogel to deliver yeast-derived ACE-inhibitory peptide of VLSTSFPPW (VW-9) to the wound site. We first conjugated tyramine (Ty) on the carboxyl groups of the HA to form a phenol-functionalized HA (HA-Ty); then, the carboxylic acid groups of HA-Ty were aminated with ethylenediamine (HA-Ty-NH2). The primary amine groups of the HA-Ty-NH2 could then react with the carboxylic acids of the peptide. The hydrogel was then 3D printed and crosslinked with visible light. The modification of HA was confirmed by 1H NMR and FTIR. The swelling capacity of the conjugated hydrogels was 1.5-fold higher compared to the HA-Ty-NH2 hydrogel. The conjugated peptide did not affect on rheological properties and morphology of the hydrogels. The 3T3-L1 fibroblast cells seeded on the peptide-modified hydrogels exhibited higher viability than the hydrogels without the peptide, indicating that the peptide-enriched hydrogels may have the potential for wound healing applications.

Alginate-Gelatin Self-Healing Hydrogel Produced via Static-Dynamic Crosslinking

Alginate-gelatin hydrogels mimicking extracellular matrix (ECM) of soft tissues have been generated by static-dynamic double crosslinking, allowing fine control over the physical and chemical properties. Dynamic crosslinking provides self-healing and injectability attributes to the hydrogel and promotes cell migration and proliferation, while the static network improves stability. The static crosslinking was performed by enzymatic coupling of the tyrosine residues of gelatin with tyramine residues inserted in the alginate backbone, catalyzed by horseradish peroxidase (HRP). The dynamic crosslinking was obtained by functionalizing alginate with 3-aminophenylboronic acid which generates a reversible bond with the vicinal hydroxyl groups of the alginate chains. Varying the ratio of alginate and gelatin, hydrogels with different properties were obtained, and the most suitable for 3D soft tissue model development with a 2.5:1 alginate:gelatin molar ratio was selected. The selected hydrogel was characterized with a swelling test, rheology test, self-healing test and by cytotoxicity, and the formulation resulted in transparent, reproducible, varying biomaterial batch, with a fast gelation time and cell biocompatibility. It is able to modulate the loss of the inner structure stability for a longer time with respect to the formulation made with only covalent enzymatic crosslinking, and shows self-healing properties.

Hyaluronic acid-based hydrogels: As an exosome delivery system in bone regeneration

Exosomes are extracellular vesicles (EVs) containing various ingredients such as DNA, RNA, lipids and proteins, which play a significant role in intercellular communication. Numerous studies have demonstrated the important role of exosomes in bone regeneration through promoting the expression of osteogenic-related genes and proteins in mesenchymal stem cells. However, the low targeting ability and short circulating half-life of exosomes limited their clinical application. In order to solve those problems, different delivery systems and biological scaffolds have been developed. Hydrogel is a kind of absorbable biological scaffold composed of three-dimensional hydrophilic polymers. It not only has excellent biocompatibility and superior mechanical strength but can also provide a suitable nutrient environment for the growth of the endogenous cells. Thus, the combination between exosomes and hydrogels can improve the stability and maintain the biological activity of exosomes while achieving the sustained release of exosomes in the bone defect sites. As an important component of the extracellular matrix (ECM), hyaluronic acid (HA) plays a critical role in various physiological and pathological processes such as cell differentiation, proliferation, migration, inflammation, angiogenesis, tissue regeneration, wound healing and cancer. In recent years, hyaluronic acid-based hydrogels have been used as an exosome delivery system for bone regeneration and have displayed positive effects. This review mainly summarized the potential mechanism of HA and exosomes in promoting bone regeneration and the application prospects and challenges of hyaluronic acid-based hydrogels as exosome delivery devices in bone regeneration.

Engineering Inflammation-Resistant Cartilage: Bridging Gene Therapy and Tissue Engineering

Articular cartilage defects caused by traumatic injury rarely heal spontaneously and predispose into post-traumatic osteoarthritis. In the current autologous cell-based treatments the regenerative process is often hampered by the poor regenerative capacity of adult cells and the inflammatory state of the injured joint. The lack of ideal treatment options for cartilage injuries motivated the authors to tissue engineer a cartilage tissue which would be more resistant to inflammation. A clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9 knockout of TGF-β-activated kinase 1 (TAK1) gene in polydactyly chondrocytes provides multivalent protection against the signals that activate the pro-inflammatory and catabolic NF-κB pathway. The TAK1-KO chondrocytes encapsulate into a hyaluronan hydrogel deposit copious cartilage extracellular matrix proteins and facilitate integration onto native cartilage, even under proinflammatory conditions. Furthermore, when implanted in vivo, compared to WT fewer pro-inflammatory M1 macrophages invade the cartilage, likely due to the lower levels of cytokines secreted by the TAK1-KO polydactyly chondrocytes. The engineered cartilage thus represents a new paradigm-shift for the creation of more potent and functional tissues for use in regenerative medicine.

Green Chemistry Principles for Nano- and Micro-Sized Hydrogel Synthesis

The growing demand for drug carriers and green-technology-based tissue engineering materials has enabled the fabrication of different types of micro- and nano-assemblies. Hydrogels are a type of material that have been extensively investigated in recent decades. Their physical and chemical properties, such as hydrophilicity, resemblance to living systems, swelling ability and modifiability, make them suitable to be exploited for many pharmaceutical and bioengineering applications. This review deals with a brief account of green-manufactured hydrogels, their characteristics, preparations, importance in the field of green biomedical technology and their future perspectives. Only hydrogels based on biopolymers, and primarily on polysaccharides, are considered. Particular attention is given to the processes of extracting such biopolymers from natural sources and the various emerging problems for their processing, such as solubility. Hydrogels are catalogued according to the main biopolymer on which they are based and, for each type, the chemical reactions and the processes that enable their assembly are identified. The economic and environmental sustainability of these processes are commented on. The possibility of large-scale processing in the production of the investigated hydrogels are framed in the context of an economy aimed at waste reduction and resource recycling.

Accelerated Simple Preparation of Curcumin-Loaded Silk Fibroin/Hyaluronic Acid Hydrogels for Biomedical Applications

The development of new biomaterials from natural fibres in the field of biomedicine have attracted great interest in recent years. One of the most studied fibres has been silk fibroin produced by the Bombyx mori worm, due to its excellent mechanical properties and its biodegradability and bioavailability. Among the different biomaterials that can be prepared from silk fibroin, hydrogels have attracted considerable attention due to their potential use in different fields, such as scaffolding, cell therapy and biomedical application. Hydrogels are essentially a three-dimensional network of flexible polymer chains that absorb considerable amounts of water and can be loaded with drugs and/or cells inside to be used in a wide variety of applications. Here we present a simple sonication process for the preparation of curcumin-hyaluronic acid-silk fibroin hydrogels. Different grades of hydrogels were prepared by controlling the relative amounts of their components. The hydrogels were physically and morphologically characterised by Fourier transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), thermogravimetric analysis (TGA) and field emission scanning electron microscopy (FESEM) and their biological activity was tested in terms of cell viability in a fibroblast cell line.

Nano-Hydroxyapatite Composite Scaffolds Loaded with Bioactive Factors and Drugs for Bone Tissue Engineering

Nano-hydroxyapatite (n-HAp) is similar to human bone mineral in structure and biochemistry and is, therefore, widely used as bone biomaterial and a drug carrier. Further, n-HAp composite scaffolds have a great potential role in bone regeneration. Loading bioactive factors and drugs onto n-HAp composites has emerged as a promising strategy for bone defect repair in bone tissue engineering. With local delivery of bioactive agents and drugs, biological materials may be provided with the biological activity they lack to improve bone regeneration. This review summarizes classification of n-HAp composites, application of n-HAp composite scaffolds loaded with bioactive factors and drugs in bone tissue engineering and the drug loading methods of n-HAp composite scaffolds, and the research direction of n-HAp composite scaffolds in the future is prospected.

Research progress of natural silk fibroin and the appplication for drug delivery in chemotherapies

Silk fibroin has been widely used in biological fields due to its biocompatibility, mechanical properties, biodegradability, and safety. Recently, silk fibroin as a drug carrier was developed rapidly and achieved remarkable progress in cancer treatment. The silk fibroin-based delivery system could effectively kill tumor cells without significant side effects and drug resistance. However, few studies have been reported on silk fibroin delivery systems for antitumor therapy. The advancement of silk fibroin-based drug delivery systems research and its applications in cancer therapy are highlighted in this study. The properties, applications, private opinions, and future prospects of silk fibroin carriers are discussed to understand better the development of anti-cancer drug delivery systems, which may also contribute to advancing silk fibroin innovation.

Regeneration of articular cartilage defects: Therapeutic strategies and perspectives

Articular cartilage (AC), a bone-to-bone protective device made of up to 80% water and populated by only one cell type (i.e. chondrocyte), has limited capacity for regeneration and self-repair after being damaged because of its low cell density, alymphatic and avascular nature. Resulting repair of cartilage defects, such as osteoarthritis (OA), is highly challenging in clinical treatment. Fortunately, the development of tissue engineering provides a promising method for growing cells in cartilage regeneration and repair by using hydrogels or the porous scaffolds. In this paper, we review the therapeutic strategies for AC defects, including current treatment methods, engineering/regenerative strategies, recent advances in biomaterials, and present emphasize on the perspectives of gene regulation and therapy of noncoding RNAs (ncRNAs), such as circular RNA (circRNA) and microRNA (miRNA).

Swelling-Dependent Shape-Based Transformation of a Human Mesenchymal Stromal Cells-Laden 4D Bioprinted Construct for Cartilage Tissue Engineering

3D bioprinting is usually implemented on flat surfaces, posing serious limitations in the fabrication of multilayered curved constructs. 4D bioprinting, combining 3D bioprinting with time-dependent stimuli-induced transformation, enables the fabrication of shape-changing constructs. Here, a 4D biofabrication method is reported for cartilage engineering based on the differential swelling of a smart multi-material system made from two hydrogel-based materials: hyaluronan and alginate. Two ink formulations are used: tyramine-functionalized hyaluronan (HAT, high-swelling) and alginate with HAT (AHAT, low-swelling). Both inks have similar elastic, shear-thinning, and printability behavior. The inks are 3D printed into a bilayered scaffold before triggering the shape-change by using liquid immersion as stimulus. In time (4D), the differential swelling between the two zones leads to the scaffold's self-bending. Different designs are made to tune the radius of curvature and shape. A bioprinted formulation of AHAT and human bone marrow cells demonstrates high cell viability. After 28 days in chondrogenic medium, the curvature is clearly present while cartilage-like matrix production is visible on histology. A proof-of-concept of the recently emerged technology of 4D bioprinting with a specific application for the design of curved structures potentially mimicking the curvature and multilayer cellular nature of native cartilage is demonstrated.

Prospective bacterial and fungal sources of hyaluronic acid: A review

The unique biological and rheological properties make hyaluronic acid a sought-after material for medicine and cosmetology. Due to very high purity requirements for hyaluronic acid in medical applications, the profitability of streptococcal fermentation is reduced. Production of hyaluronic acid by recombinant systems is considered a promising alternative. Variations in combinations of expressed genes and fermentation conditions alter the yield and molecular weight of produced hyaluronic acid. This review is devoted to the current state of hyaluronic acid production by recombinant bacterial and fungal organisms.

Designing functional hyaluronic acid-based hydrogels for cartilage tissue engineering

Damage to cartilage tissues is often difficult to repair owing to chronic inflammation and a lack of bioactive factors. Therefore, developing bioactive materials, such as hydrogels acting as extracellular matrix mimics, that can inhibit the inflammatory microenvironment and promote cartilage repair is crucial. Hyaluronic acid, which exists in cartilage and synovial fluid, has been extensively investigated for cartilage tissue engineering because of its promotion of cell adhesion and proliferation, regulation of inflammation, and enhancement of cartilage regeneration. However, hyaluronic acid-based hydrogels have poor degradation rates and unfavorable mechanical properties, limiting their application in cartilage tissue engineering. Recently, various multifunctional hyaluronic acid-based hydrogels, including alkenyl, aldehyde, thiolated, phenolized, hydrazide, and host–guest group-modified hydrogels, have been extensively studied for use in cartilage tissue engineering. In this review, we summarize the recent progress in the multifunctional design of hyaluronic acid-based hydrogels and their application in cartilage tissue engineering. Moreover, we outline the future research prospects and directions in cartilage tissue regeneration. This would provide theoretical guidance for developing hyaluronic acid-based hydrogels with specific properties to satisfy the requirements of cartilage tissue repair.

Biomaterials and Extracellular Vesicle Delivery: Current Status, Applications and Challenges

In this review, we will discuss the current status of extracellular vesicle (EV) delivery via biopolymeric scaffolds for therapeutic applications and the challenges associated with the development of these functionalized scaffolds. EVs are cell-derived membranous structures and are involved in many physiological processes. Naïve and engineered EVs have much therapeutic potential, but proper delivery systems are required to prevent non-specific and off-target effects. Targeted and site-specific delivery using polymeric scaffolds can address these limitations. EV delivery with scaffolds has shown improvements in tissue remodeling, wound healing, bone healing, immunomodulation, and vascular performance. Thus, EV delivery via biopolymeric scaffolds is becoming an increasingly popular approach to tissue engineering. Although there are many types of natural and synthetic biopolymers, the overarching goal for many tissue engineers is to utilize biopolymers to restore defects and function as well as support host regeneration. Functionalizing biopolymers by incorporating EVs works toward this goal. Throughout this review, we will characterize extracellular vesicles, examine various biopolymers as a vehicle for EV delivery for therapeutic purposes, potential mechanisms by which EVs exert their effects, EV delivery for tissue repair and immunomodulation, and the challenges associated with the use of EVs in scaffolds.

Engineering Hyaluronic Acid for the Development of New Treatment Strategies for Osteoarthritis

Osteoarthritis (OA) is a degenerative joint disease that is characterized by inflammation of the joints, degradation of cartilage, and the remodeling of other joint tissues. Due to the absence of disease-modifying drugs for OA, current clinical treatment options are often only effective at slowing down disease progression and focus mainly on pain management. The field of tissue engineering has therefore been focusing on developing strategies that could be used not only to alleviate symptoms of OA but also to regenerate the damaged tissue. Hyaluronic acid (HA), an integral component of both the synovial fluid and articular cartilage, has gained widespread usage in developing hydrogels that deliver cells and biomolecules to the OA joint thanks to its biocompatibility and ability to support cell growth and the chondrogenic differentiation of encapsulated stem cells, providing binding sites for growth factors. Tissue-engineering strategies have further attempted to improve the role of HA as an OA therapeutic by developing diverse modified HA delivery platforms for enhanced joint retention and controlled drug release. This review summarizes recent advances in developing HA-based hydrogels for OA treatment and provides additional insights into how HA-based therapeutics could be further improved to maximize their potential as a viable treatment option for OA.

Bioinspired silk fibroin materials: From silk building blocks extraction and reconstruction to advanced biomedical applications

Silk fibroin has become a promising biomaterial owing to its remarkable mechanical property, biocompatibility, biodegradability, and sufficient supply. However, it is difficult to directly construct materials with other formats except for yarn, fabric and nonwoven based on natural silk. A promising bioinspired strategy is firstly extracting desired building blocks of silk, then reconstructing them into functional regenerated silk fibroin (RSF) materials with controllable formats and structures. This strategy could give it excellent processability and modifiability, thus well meet the diversified needs in biomedical applications. Recently, to engineer RSF materials with properties similar to or beyond the hierarchical structured natural silk, novel extraction and reconstruction strategies have been developed. In this review, we seek to describe varied building blocks of silk at different levels used in biomedical field and their effective extraction and reconstruction strategies. This review also present recent discoveries and research progresses on how these functional RSF biomaterials used in advanced biomedical applications, especially in the fields of cell-material interactions, soft tissue regeneration, and flexible bioelectronic devices. Finally, potential study and application for future opportunities, and current challenges for these bioinspired strategies and corresponding usage were also comprehensively discussed. In this way, it aims to provide valuable references for the design and modification of novel silk biomaterials, and further promote the high-quality-utilization of silk or other biopolymers.

Anionic exopolysaccharide from Cryptococcus laurentii 70766 as an alternative for alginate for biomedical hydrogels

Alginates are widely used polysaccharides for biomaterials engineering, which functional properties depend on guluronic and mannuronic acid as the building blocks. In this study, enzymatically crosslinked hydrogels based on sodium alginate (Na-Alg) and the exopolysaccharide (EPS) derived from Cryptococcus laurentii 70766 with glucuronic acid residues were synthesized and characterized as a new potential source of polysaccharide for biomaterials engineering. The EPS was extracted (1.05 ± 0.57 g/L) through ethanol precipitation. Then the EPS and Na-Alg were functionalized with tyramine hydrochloride to produce enzymatically crosslinked hydrogels in the presence of horseradish peroxidase (HRP) and H₂O₂. Major characteristics of the hydrogels such as gelling time, swelling ratio, rheology, cell viability, and biodegradability were studied. The swelling ratio and degradation profile of both hydrogels showed negative values, indicating an increased crosslinking degree and a lower water uptake percentage. The EPS hydrogel showed similar gelation kinetics compared to the Alg hydrogel. The EPS and its hydrogel were found cytocompatible. The results indicate the potential of EPS from C. laurentii 70766 for biomedical engineering due to its biocompatibility and degradability. Further studies are needed to confirm this EPS as an alternative for Alg in tissue engineering applications, particularly in the development of wound dressing products.

Injectable hydrogels for bone and cartilage tissue engineering: a review

Tissue engineering, using a combination of living cells, bioactive molecules, and three-dimensional porous scaffolds, is a promising alternative to traditional treatments such as the use of autografts and allografts for bone and cartilage tissue regeneration. Scaffolds, in this combination, can be applied either through surgery by implantation of cell-seeded pre-fabricated scaffolds, or through injection of a solidifying precursor and cell mixture, or as an injectable cell-seeded pre-fabricated scaffold. In situ forming and pre-fabricated injectable scaffolds can be injected directly into the defect site with complex shape and critical size in a minimally invasive manner. Proper and homogeneous distribution of cells, biological factors, and molecular signals in these injectable scaffolds is another advantage over pre-fabricated scaffolds. Due to the importance of injectable scaffolds in tissue engineering, here different types of injectable scaffolds, their design challenges, and applications in bone and cartilage tissue regeneration are reviewed.

Biomimetic hydrogel scaffolds via enzymatic reaction for cartilage tissue engineering

Objective

We aimed to evaluate cytocompatibility of hyaluronic acid (HA) and gelatin (Gela) conjugation with phenolic groups (Phs) via enzyme-mediated crosslinking. Phenolic moieties were substituted on the backbone of HA (HA-Ph) and Gela (Gela-Ph) and subsequently were subjected for horseradish peroxidase crosslinking in the presence of H₂O₂ as an electron donor to create a stable hybrid microenvironment for cellular behavior and cartilage tissue engineering.

Results

Successful synthesis of biopolymers confirmed by NRM and UV–Vis spectrophotometry. The physical characteristic of hydrogels including mechanical properties and water contact angle of hydrogels enhanced with addition of Gela-Ph in HA-based hydrogel. The Gela-Ph showed longest gelation time and highest degradation rate. The cellular studies showed cells did not attach to HA-Ph hydrogel. While, proper cell attachment and proliferation observed on blend hydrogel surface compared with the neat hydrogels which interpret by the existence of cell-adhesive motifs of utilized Gela-Ph in this hydrogel. The encapsulated cells in HA-Ph hydrogel were spheroid and just maintained their viability. Hydrogels containing Gela-Ph, the cells were spindle shape with high degrees of cytoplasmic extension. Overall, the results suggest that hybrid biomimetic hydrogel can provide a superior biological microenvironment for chondrocytes in 3D cartilage tissue engineering.

Silk Fibroin Hydrogels Could Be Therapeutic Biomaterials for Neurological Diseases

Silk fibroin, a natural macromolecular protein without physiological activity, has been widely used in different fields, such as the regeneration of bones, cartilage, nerves, and other tissues. Due to irrevocable neuronal injury, the treatment and prognosis of neurological diseases need to be investigated. Despite attempts to propel neuroprotective therapeutic approaches, numerous attempts to translate effective therapies for brain disease have been largely unsuccessful. As a good candidate for biomedical applications, hydrogels based on silk fibroin effectively amplify their advantages. The ability of nerve tissue regeneration, inflammation regulation, the slow release of drugs, antioxidative stress, regulation of cell death, and hemostasis could lead to a new approach to treating neurological disorders. In this review, we introduced the preparation of SF hydrogels and then delineated the probable mechanism of silk fibroin in the treatment of neurological diseases. Finally, we showed the application of silk fibroin in neurological diseases.

A novel multifunctional Salecan/κ-carrageenan composite hydrogel with anti-freezing properties: Advanced rheology, thermal analysis and model fitting

The multifunctional hydrogels (HGs) have attracted intensive concern in biomedicine, food, and flexible devices. Nevertheless, chemically crosslinked synthetic HGs are commonly under specific restrictions because of their possible biotoxicity. This study focuses on the employment of physical approaches to prepare novel Salecan/κ-carrageenan composites HGs (CHGs) without changing their basic structures. Comprehensive rheological and thermal studies have been performed to investigate their distinctive properties. The data obtained from the tests and model fitting confirmed that the highest activation energy of CHGs was 172,142.2 J/mol, and the maximum equilibrium creep compliance was 0.0085 1/Pa. The sample recovery rate could reach 92.6%, while the anti-freezing temperature can be as low as -20 °C. It is the first report focusing on novel CHGs made from Salecan and κ-carrageenan with ideal anti-freezing ability, enhanced thermostability, good injectability, self-recovery, and other rheological properties that will provide effective support for various future applications.

Calcium peroxide aids tyramine-alginate gel to crosslink with tyrosinase for efficient cartilage repair

The innate cartilage extracellular matrix is avascular and plays a vital role in innate chondrocytes. Recapping the crucial components of the extracellular matrix in engineered organs via polymeric gels and bioinspired approaches is promising for improving the regenerative aptitude of encapsulated cartilage/chondrocytes. Conventional gel formation techniques for polymeric materials rely on employing oxidative crosslinking, which is constrained in this avascular environment. Further, poor mechanical properties limit the practical applications of polymeric gels and reduce their therapeutic efficacy. Herein, the purpose of this study was to develop a bioadhesive gel possessing dual crosslinking for engineering cartilage. Tyramine (TYR) was first chemically conjugated to the alginate (ALG) backbone to form an ALG-TYR precursor, followed by the addition of calcium peroxide (CaO₂); calcium ions of CaO₂ physically crosslink with ALG, and oxygen atoms of CaO₂ chemically crosslink TYR with tyrosinase, thus enabling dual/enhanced crosslinking and possessing injectability. The ALG-TYR/tyrosinase/CaO₂ gel system was chemically, mechanically, cellularly, and microscopically characterized. The gel system developed herein was biocompatible and showed augmented mechanical strength. The results showed, for the first time, that CaO₂ supplementation preserved cell viability and enhanced the crosslinking ability, bioadhesion, mechanical strength, chondrogenesis, and stability for cartilage regeneration.

Silk fibroin hydrogel containing Sesbania sesban L. extract for rheumatoid arthritis treatment

Purpose

Rheumatoid arthritis, a chronic and progressive inflammation condition in the joints, has significantly reduced the patient quality of life and life expectancy. Crucially, there is no complete therapy for this disease, and the current treatments possess numerous side effects. Thus, novel therapeutic approach is necessary. To that end, this study developed novel silk fibroin in-situ hydrogel containing Sesbania sesban L. extract, a plant with high anti-inflammatory actions that are beneficial for rheumatoid arthritis treatments.

Methods

The hydrogels were manufactured using simple method of spontaneous gelation at different temperature. The gel properties of morphology, gelation time, viscosity, gel strength, stability, drug loading capacity, drug release rate, and in-vitro anti-inflammatory activity were investigated with appropriate methods.

Results

The optimal formulation had highly porous structure, with a gelation time of 0.5 h at room temperature and bodily temperature of 37 °C, a viscosity of 2530 ± 50 cP, a gel strength of 1880.14 ± 35.10 g, and a physical stability of >6 months. Moreover, the hydrogel contained the Sesbania sesban L. leaf extract with a total phenolic content of 92.8 ± 8.30 mg GAE/g, and sustained the release rate for >20 dạys, followed the Higuchi model. Regarding the in-vitro activities, all formulations were nontoxic to the RAW 264.7 cell line and demonstrated comparable anti-inflammatory activity to the free extract, in terms of the NO reduction levels.

Conclusion

Conclusively, the systems possessed potential properties to be further investigated to become a prospective rheumatoid arthritis treatment.

Drug Delivery Strategies and Biomedical Significance of Hydrogels: Translational Considerations

Hydrogels are a promising and attractive option as polymeric gel networks, which have immensely fascinated researchers across the globe because of their outstanding characteristics such as elevated swellability, the permeability of oxygen at a high rate, good biocompatibility, easy loading, and drug release. Hydrogels have been extensively used for several purposes in the biomedical sector using versatile polymers of synthetic and natural origin. This review focuses on functional polymeric materials for the fabrication of hydrogels, evaluation of different parameters of biocompatibility and stability, and their application as carriers for drugs delivery, tissue engineering and other therapeutic purposes. The outcome of various studies on the use of hydrogels in different segments and how they have been appropriately altered in numerous ways to attain the desired targeted delivery of therapeutic agents is summarized. Patents and clinical trials conducted on hydrogel-based products, along with scale-up translation, are also mentioned in detail. Finally, the potential of the hydrogel in the biomedical sector is discussed, along with its further possibilities for improvement for the development of sophisticated smart hydrogels with pivotal biomedical functions.

Polymeric Hydrogels for Controlled Drug Delivery to Treat Arthritis

Rheumatoid arthritis (RA) and osteoarthritis (OA) are disabling musculoskeletal disorders that affect joints and cartilage and may lead to bone degeneration. Conventional delivery of anti-arthritic agents is limited due to short intra-articular half-life and toxicities. Innovations in polymer chemistry have led to advancements in hydrogel technology, offering a versatile drug delivery platform exhibiting tissue-like properties with tunable drug loading and high residence time properties This review discusses the advantages and drawbacks of polymeric materials along with their modifications as well as their applications for fabricating hydrogels loaded with therapeutic agents (small molecule drugs, immunotherapeutic agents, and cells). Emphasis is given to the biological potentialities of hydrogel hybrid systems/micro-and nanotechnology-integrated hydrogels as promising tools. Applications for facile tuning of therapeutic drug loading, maintaining long-term release, and consequently improving therapeutic outcome and patient compliance in arthritis are detailed. This review also suggests the advantages, challenges, and future perspectives of hydrogels loaded with anti-arthritic agents with high therapeutic potential that may alter the landscape of currently available arthritis treatment modalities.