SilkBridge™: a novel biomimetic and biocompatible silk-based nerve conduit

Advanced nerve regeneration enabled by neural conformal electronic stimulators enhancing mitochondrial transport

Addressing peripheral nerve defects remains a significant challenge in regenerative neurobiology. Autografts emerged as the gold-standard management, however, are hindered by limited availability and potential neuroma formation. Numerous recent studies report the potential of wireless electronic system for nerve defects repair. Unfortunately, few has met clinical needs for inadequate electrode precision, poor nerve entrapment and insufficient bioactivity of the matrix material. Herein, we present an advanced wireless electrical nerve stimulator, based on water-responsive self-curling silk membrane with excellent bioabsorbable and biocompatible properties. We constructed a unique bilayer structure with an oriented pre-stretched inner layer and a general silk membrane as outer layer. After wetting, the simultaneous contraction of inner layer and expansion of outer layer achieved controllable super-contraction from 2D flat surface to 3D structural reconfiguration. It enables shape-adaptive wrapping to cover around nerves, overcomes the technical obstacle of preparing electrodes on the inner wall of the conduit, and prevents electrode breakage caused by material expansion in water. The use of fork capacitor-like metal interface increases the contact points between the metal and the regenerating nerve, solving the challenge of inefficient and rough electrical stimulation methods in the past. Newly developed electronic stimulator is effective in restoring 10 mm rat sciatic nerve defects comparable to autologous grafts. The underlying mechanism involves that electric stimulation enhances anterograde mitochondrial transport to match energy demands. This newly introduced device thereby demonstrated the potential as a viable and efficacious alternative to autografts for enhancing peripheral nerve repair and functional recovery.

Silk fibroin-based scaffolds for tissue engineering

Silk fibroin is an important natural fibrous protein with excellent prospects for tissue engineering applications. With profound studies in recent years, its potential in tissue repair has been developed. A growing body of literature has investigated various fabricating methods of silk fibroin and their application in tissue repair. The purpose of this paper is to trace the latest developments of SF-based scaffolds for tissue engineering. In this review, we first presented the primary and secondary structures of silk fibroin. The processing methods of SF scaffolds were then summarized. Lastly, we examined the contribution of new studies applying SF as scaffolds in tissue regeneration applications. Overall, this review showed the latest progress in the fabrication and utilization of silk fibroin-based scaffolds.

Facilitation of Cell Cycle and Cellular Migration of Rat Schwann Cells by O-Carboxymethyl Chitosan to Support Peripheral Nerve Regeneration

O-carboxymethyl chitosan (CM-chitosan), holds high potential as a valuable biomaterial for nerve guidance conduits (NGCs). However, the lack of explicit bioactivity on neurocytes and poor duration that does not match nerve repair limit the restorative effects. Herein, CM-chitosan-based NGC is designed to induce the reconstruction of damaged peripheral nerves without addition of other activation factors. CM-chitosan possesses excellent performance in vitro for nerve tissue engineering, such as increasing the organization of filamentous actin and the expression of phospho-Akt, and facilitating the cell cycle and migration of Schwann cells. Moreover, CM-chitosan exhibits increased longevity upon cross-linking (C-CM-chitosan) with 1, 4-Butanediol diglycidyl ether, and C-CM-chitosan fibers possess appropriate biocompatibility. In order to imitate the structure of peripheral nerves, multichannel bioactive NGCs are prepared from lumen fillers of oriented C-CM-chitosan fibers and outer warp-knitted chitosan pipeline. Implantation of the C-CM-chitosan NGCs to rats with 10-mm defects of peripheral nerves effectively improve nerve function reconstruction by increasing the sciatic functional index, decreasing the latent periods of heat tingling, enhancing the gastrocnemius muscle, and promoting nerve axon recovery, showing regenerative efficacy similar to that of autograft. The results lay a theoretical foundation for improving the potential high-value applications of CM-chitosan-based bioactive materials in nerve tissue engineering.

A brief review on the mechanisms and approaches of silk spinning-inspired biofabrication

Silk spinning, observed in spiders and insects, exhibits a remarkable biological source of inspiration for advanced polymer fabrications. Because of the systems design, silk spinning represents a holistic and circular approach to sustainable polymer fabrication, characterized by renewable resources, ambient and aqueous processing conditions, and fully recyclable "wastes." Also, silk spinning results in structures that are characterized by the combination of monolithic proteinaceous composition and mechanical strength, as well as demonstrate tunable degradation profiles and minimal immunogenicity, thus making it a viable alternative to most synthetic polymers for the development of advanced biomedical devices. However, the fundamental mechanisms of silk spinning remain incompletely understood, thus impeding the efforts to harness the advantageous properties of silk spinning. Here, we present a concise and timely review of several essential features of silk spinning, including the molecular designs of silk proteins and the solvent cues along the spinning apparatus. The solvent cues, including salt ions, pH, and water content, are suggested to direct the hierarchical assembly of silk proteins and thus play a central role in silk spinning. We also discuss several hypotheses on the roles of solvent cues to provide a relatively comprehensive analysis and to identify the current knowledge gap. We then review the state-of-the-art bioinspired fabrications with silk proteins, including fiber spinning and additive approaches/three-dimensional (3D) printing. An emphasis throughout the article is placed on the universal characteristics of silk spinning developed through millions of years of individual evolution pathways in spiders and silkworms. This review serves as a stepping stone for future research endeavors, facilitating the in vitro recapitulation of silk spinning and advancing the field of bioinspired polymer fabrication.

Use of Bombyx mori silk fibroin in tissue engineering: From cocoons to medical devices, challenges, and future perspectives

Silk fibroin has become a prominent material in tissue engineering (TE) over the last 20 years with almost 10,000 published works spanning in all the TE applications, from skeleton to neuronal regeneration. Fibroin is an extremely versatile biopolymer that, due to its ease of processing, has enabled the development of an entire plethora of materials whose properties and architectures can be tailored to suit target applications. Although the research and development of fibroin TE materials and devices is mature, apart from sutures, only a few medical products made of fibroin are used in the clinical routines. <40 clinical trials of Bombyx mori silk-related products have been reported by the FDA and few of them resulted in a commercialized device. In this review, after explaining the structure and properties of silk fibroin, we provide an overview of both fibroin constructs existing in the literature and fibroin devices used in clinic. Through the comparison of these two categories, we identified the burning issues faced by fibroin products during their translation to the market. Two main aspects will be considered. The first is the standardization of production processes, which leads both to the standardization of the characteristics of the issued device and the correct assessment of its failure. The second is the FDA regulations, which allow new devices to be marketed through the 510(k) clearance by demonstrating their equivalence to a commercialized medical product. The history of some fibroin medical devices will be taken as a case study. Finally, we will outline a roadmap outlining what actions we believe are needed to bring fibroin products to the market.

Biomaterials for Regenerative Medicine in Italy: Brief State of the Art of the Principal Research Centers

Regenerative medicine is the branch of medicine that effectively uses stem cell therapy and tissue engineering strategies to guide the healing or replacement of damaged tissues or organs. A crucial element is undoubtedly the biomaterial that guides biological events to restore tissue continuity. The polymers, natural or synthetic, find wide application thanks to their great adaptability. In fact, they can be used as principal components, coatings or vehicles to functionalize several biomaterials. There are many leading centers for the research and development of biomaterials in Italy. The aim of this review is to provide an overview of the current state of the art on polymer research for regenerative medicine purposes. The last five years of scientific production of the main Italian research centers has been screened to analyze the current advancement in tissue engineering in order to highlight inputs for the development of novel biomaterials and strategies.

Implantable nerve guidance conduits: Material combinations, multi-functional strategies and advanced engineering innovations

Nerve guidance conduits (NGCs) have attracted much attention due to their great necessity and applicability in clinical use for the peripheral nerve repair. Great efforts in recent years have been devoted to the development of high-performance NGCs using various materials and strategies. The present review provides a comprehensive overview of progress in the material innovation, structural design, advanced engineering technologies and multi functionalization of state-of-the-art nerve guidance conduits NGCs. Abundant advanced engineering technologies including extrusion-based system, laser-based system, and novel textile forming techniques in terms of weaving, knitting, braiding, and electrospinning techniques were also analyzed in detail. Findings arising from this review indicate that the structural mimetic NGCs combined with natural and synthetic materials using advanced manufacturing technologies can make full use of their complementary advantages, acquiring better biomechanical properties, chemical stability and biocompatibility. Finally, the existing challenges and future opportunities of NGCs were put forward aiming for further research and applications of NGCs.

A Route to Translate a Silk-Based Medical Device from Lab to Clinic: The Silk Biomaterials Srl Experience

The medical device is a nerve conduit entirely made of Bombyx mori silk fibroin. It is a tubular scaffold used for repairing peripheral nerve gaps, whose function is to protect the severed nerves and to favor their natural healing process. As any implantable medical device, the conduit must perform its function without causing adverse effects to the patient, meaning that it must be compliant with a range of regulations aimed at evaluating the risks related to the constituent materials and the manufacturing process, the toxicological impact of the processing aids, the biological safety, the functional performance, and the ability to sustain tissue regeneration processes. An exhaustive on-bench testing plan has been performed for the determination of the morphological, geometrical, physical, structural, and mechanical properties. For the toxicological analysis, the device was extracted with solvent and the number of leachable substances was determined by suitable chromatographic techniques. The biological safety was assessed by means of a set of tests, including cytotoxicity, delayed hypersensitivity, intracutaneous reactivity, pyrogen test, LAL (Limulus Amebocyte Lysate) test, acute systemic toxicity, and genotoxicity. Overall, the accumulated results demonstrated the suitability of the device for the intended use and supported the starting of a first-in-human clinical trial.

Electrospun Silk Fibroin Scaffolds for Tissue Regeneration: Chemical, Structural, and Toxicological Implications of the Formic Acid-Silk Fibroin Interaction

The dissolution of Bombyx mori silk fibroin (SF) films in formic acid (FA) for the preparation of electrospinning dopes is widely exploited to produce electrospun SF scaffolds. The SILKBridge^® nerve conduit is an example of medical device having in its wall structure an electrospun component produced from an FA spinning dope. Though highly volatile, residual FA remains trapped into the bulk of the SF nanofibers. The purpose of this work is to investigate the type and strength of the interaction between FA and SF in electrospun mats, to quantify its amount and to evaluate its possible toxicological impact on human health. The presence of residual FA in SF mats was detected by FTIR and Raman spectroscopy (new carbonyl peak at about 1,725 cm⁻¹) and by solid state NMR, which revealed a new carbonyl signal at about 164.3 ppm, attributed to FA by isotopic ¹³C substitution. Changes occurred also in the spectral ranges of hydroxylated amino acids (Ser and Thr), demonstrating that FA interacted with SF by forming formyl esters. The total amount of FA was determined by HS-GC/MS analysis and accounted for 247 ± 20 μmol/g. The greatest part was present as formyl ester, a small part (about 3%) as free FA. Approximately 17% of the 1,500 μmol/g of hydroxy amino acids (Ser and Thr) theoretically available were involved in the formation of formyl esters. Treatment with alkali (Na₂CO₃) succeeded to remove the greatest part of FA, but not all. Alkali-treated electrospun SF mats underwent morphological, physical, and mechanical changes. The average diameter of the fibers increased from about 440 nm to about 480 nm, the mat shrunk, became stiffer (the modulus increased from about 5.5 MPa to about 7 MPa), and lost elasticity (the strain decreased from about 1 mm/mm to about 0.8 mm/mm). Biocompatibility studies with human adult dermal fibroblasts did not show significant difference in cell proliferation (313 ± 18 and 309 ± 23 cells/mm² for untreated and alkali-treated SF mat, respectively) and metabolic activity. An in-depth evaluation of the possible toxicological impact of residual FA was made using the SILKBridge^® nerve conduit as case study, following the provisions of the ISO 10993-1 standard. The Potential Patient Daily Intake, calculated from the total amount of FA determined by HS-GC/MS, was 2.4 mg/day and the Tolerable Exposure level was set to 35.4 mg/day. This allowed to obtain a value of the Margin of Safety of 15, indicating that the amount of FA left on SF mats after electrospinning does not raise concerns for human health.

Perspective Insights to Bio-Nanomaterials for the Treatment of Neurological Disorders

The significance of biomaterials is well appreciated in nanotechnology, and its use has resulted in major advances in biomedical sciences. Although, currently, very little data is available on the clinical trial studies for treatment of neurological conditions, numerous promising advancements have been reported in drug delivery and regenerative therapies which can be applied in clinical practice. Among the commonly reported biomaterials in literature, the self-assembling peptides and hydrogels have been recognized as the most potential candidate for treatment of common neurological conditions such as Alzheimer's, Parkinson's, spinal cord injury, stroke and tumors. The hydrogels, specifically, offer advantages like flexibility and porosity, and mimics the properties of the extracellular matrix of the central nervous system. These factors make them an ideal scaffold for drug delivery through the blood-brain barrier and tissue regeneration (using stem cells). Thus, the use of biomaterials as suitable matrix for therapeutic purposes has emerged as a promising area of neurosciences. In this review, we describe the application of biomaterials, and the current advances, in treatment of statistically common neurological disorders.

Poly(amino acid) based fibrous membranes with tuneable in vivo biodegradation

In this work two types of biodegradable polysuccinimide-based, electrospun fibrous membranes are presented. One contains disulfide bonds exhibiting a shorter (3 days) in vivo biodegradation time, while the other one has alkyl crosslinks and a longer biodegradation time (more than 7 days). According to the mechanical measurements, the tensile strength of the membranes is comparable to those of soft the connective tissues and visceral tissues. Furthermore, the suture retention test suggests, that the membranes would withstand surgical handling and in vivo fixation. The in vivo biocompatibility study demonstrates how membranes undergo in vivo hydrolysis and by the 3rd day they become poly(aspartic acid) fibrous membranes, which can be then enzymatically degraded. After one week, the disulfide crosslinked membranes almost completely degrade, while the alkyl-chain crosslinked ones mildly lose their integrity as the surrounding tissue invades them. Histopathology revealed mild acute inflammation, which diminished to a minimal level after seven days.

The Materiobiology of Silk: Exploring the Biophysical Influence of Silk Biomaterials on Directing Cellular Behaviors

Biophysical properties of the extracellular environment dynamically regulate cellular fates. In this review, we highlight silk, an indispensable polymeric biomaterial, owing to its unique mechanical properties, bioactive component sequestration, degradability, well-defined architectures, and biocompatibility that can regulate temporospatial biochemical and biophysical responses. We explore how the materiobiology of silks, both mulberry and non-mulberry based, affect cell behaviors including cell adhesion, cell proliferation, cell migration, and cell differentiation. Keeping in mind the novel biophysical properties of silk in film, fiber, or sponge forms, coupled with facile chemical decoration, and its ability to match functional requirements for specific tissues, we survey the influence of composition, mechanical properties, topography, and 3D geometry in unlocking the body's inherent regenerative potential.

A biodegradable block polyurethane nerve-guidance scaffold enhancing rapid vascularization and promoting reconstruction of transected sciatic nerve in Sprague-Dawley rats

Reconstruction of peripheral nerve defects with tissue engineered nerve scaffolds is an exciting field of biomedical research and holds potential for clinical application. However, due to poor neovascularization after the implantation, nerve regeneration is still not satisfactory, especially for large nerve defects. These obstacles hinder the investigation of basic neurobiological principles and development of a wide range of treatments for peripheral nerve diseases. Herein, we designed an amphiphilic alternating block polyurethane (abbreviated as PU) copolymer-based nerve guidance scaffold, which has good Schwann cell compatibility, and more importantly, a rapid vascularization of the scaffold in vivo. In the sciatic nerve transection model of SD rats, vascularized PU nerve guidance scaffolds induced rapid regeneration of nerve fibers and axons along the scaffold. Through the analysis of nerve electrophysiology, sciatic nerve functional index, histology, and immunofluorescence related to angiogenesis, we determined that PU with rapid vascularization function enhances recovery and re-obtains nerve conduction function. Our study points out a new strategy of using nerve tissue engineering scaffolds to treat large nerve defects.

Characterization of Physical, Mechanical, and Biological Properties of SilkBridge Nerve Conduit after Enzymatic Hydrolysis

The in vitro degradation profile and the cytotoxicity of the degradation products of a silk fibroin (SF)-based nerve conduit (SilkBridge), with a complex three-layered wall architecture comprising both native and regenerated (electrospun) fibers, are reported. The bacterial protease type XIV from Streptomyces griseus was used as a hydrolytic agent at three different enzyme/substrate ratios (1:8, 1:80, and 1:800 w/w) to account for the different susceptibility to degradation of the native and regenerated components. The incubation time was extended up to 91 days. At fixed time points, the remaining device, the insoluble debris, and the incubation buffers containing soluble degradation products were separated and analyzed. The electrospun fibers forming the inner and outer layers of the conduit wall were almost completely degraded within 10 days of incubation at an enzyme/substrate ratio of 1:80 w/w. The progression of degradation was highlighted by the emergence of zones of erosion and discontinuity along the electrospun fibers, weakening of the electrospun layers, and decrease in resistance to compressive stress. Native SF microfibers forming the middle layer of the conduit wall displayed a higher resistance to enzymatic degradation. When incubated at an enzyme/substrate ratio of 1:8 w/w, the weight decreased gradually over the incubation time as a consequence of fiber erosion and fragmentation. Analogously, the tensile properties markedly decreased. Both spectroscopic and thermal analyses confirmed the gradual increase in the crystalline character of the fibers. The incubation buffers containing the soluble degradation products were subjected to cytotoxicity testing with human HEK293 cells and mouse neuroblastoma N2a cells. No detrimental effects on cell viability were observed, suggesting that the degradation products do not retain any toxic property. Finally, the mass spectrometry analysis of degradation products showed that the SF polypeptides recovered in the incubation buffers were representative of the aminoacidic sequence of the fibroin light chain and of the highly repetitive fibroin heavy chain, indicating that virtually the entire sequence of the fibroin protein constituent of SilkBridge was degraded.

Modulation of Neuronal Cell Affinity on PEDOT-PSS Nonwoven Silk Scaffolds for Neural Tissue Engineering

Peripheral nerve injury is a common consequence of trauma with low regenerative potential. Electroconductive scaffolds can provide appropriate cell growth microenvironments and synergistic cell guidance cues for nerve tissue engineering. In the present study, electrically conductive scaffolds were prepared by conjugating poly (3,4-ethylenedioxythiophene)-polystyrene sulfonate (PEDOT-PSS) or dimethyl sulfoxide (DMSO)-treated PEDOT-PSS on electrospun silk scaffolds. Conductance could be tuned by the coating concentration and was further boosted by DMSO treatment. Analogue NG108-15 neuronal cells were cultured on the scaffolds to evaluate neuronal cell growth, proliferation, and differentiation. Cellular viability was maintained on all scaffold groups while showing comparatively better metabolic activity and proliferation than neat silk. DMSO-treated PEDOT-PSS functionalized scaffolds partially outperformed their PEDOT-PSS counterparts. Differentiation assessments suggested that these PEDOT-PSS assembled silk scaffolds could support neurite sprouting, indicating that they show promise to be used as a future platform to restore electrochemical coupling at the site of injury and preserve normal nerve function.

Graphene oxide and electroactive reduced graphene oxide-based composite fibrous scaffolds for engineering excitable nerve tissue

This study systematically investigates the role of graphene oxide (GO) and reduced GO (rGO)/silk-based composite micro/nano-fibrous scaffolds in regulating neuronal cell behavior in vitro, given the limited comparative studies on the effects of graphene family materials on nerve regeneration. Fibrous scaffolds can mimic the architecture of the native extracellular matrix and are potential candidates for tissue engineering peripheral nerves. Silk/GO micro/nano-fibrous scaffolds were electrospun with GO loadings 1 to 10 wt.%, and optionally post-reduced in situ to explore a family of electrically conductive non-woven silk/rGO scaffolds. Conductivities up to 4 × 10^-5 S cm^-1 were recorded in the dry state, which increased up to 3 × 10^-4 S cm^-1 after hydration. Neuronoma NG108-15 cells adhered and were viable on all substrates. Enhanced metabolic activity and proliferation were observed on the GO-containing scaffolds, and these cell responses were further promoted for electroactive silk/rGO. Neurite extensions up to 100 μm were achieved by day 5, with maximum outgrowth up to ~250 μm on some of the conductive substrates. These electroactive composite fibrous scaffolds exhibit potential to enhance the neuronal cell response and could be versatile supportive substrates for neural tissue engineering applications.

Natural-Based Biomaterials for Peripheral Nerve Injury Repair

Peripheral nerve injury treatment is a relevant problem because of nerve lesion high incidence and because of unsatisfactory regeneration after severe injuries, thus resulting in a reduced patient's life quality. To repair severe nerve injuries characterized by substance loss and to improve the regeneration outcome at both motor and sensory level, different strategies have been investigated. Although autograft remains the gold standard technique, a growing number of research articles concerning nerve conduit use has been reported in the last years. Nerve conduits aim to overcome autograft disadvantages, but they must satisfy some requirements to be suitable for nerve repair. A universal ideal conduit does not exist, since conduit properties have to be evaluated case by case; nevertheless, because of their high biocompatibility and biodegradability, natural-based biomaterials have great potentiality to be used to produce nerve guides. Although they share many characteristics with synthetic biomaterials, natural-based biomaterials should also be preferable because of their extraction sources; indeed, these biomaterials are obtained from different renewable sources or food waste, thus reducing environmental impact and enhancing sustainability in comparison to synthetic ones. This review reports the strengths and weaknesses of natural-based biomaterials used for manufacturing peripheral nerve conduits, analyzing the interactions between natural-based biomaterials and biological environment. Particular attention was paid to the description of the preclinical outcome of nerve regeneration in injury repaired with the different natural-based conduits.

Preclinical Validation of SilkBridgeTM for Peripheral Nerve Regeneration

Silk fibroin (Bombyx mori) was used to manufacture a nerve conduit (SilkBridge^TM) characterized by a novel 3D architecture. The wall of the conduit consists of two electrospun layers (inner and outer) and one textile layer (middle), perfectly integrated at the structural and functional level. The manufacturing technology conferred high compression strength on the device, thus meeting clinical requirements for physiological and pathological compressive stresses. As demonstrated in a previous work, the silk material has proven to be able to provide a valid substrate for cells to grow on, differentiate and start the fundamental cellular regenerative activities in vitro and, in vivo, at the short time point of 2 weeks, to allow the starting of regenerative processes in terms of good integration with the surrounding tissues and colonization of the wall layers and of the lumen with several cell types. In the present study, a 10 mm long gap in the median nerve was repaired with 12 mm SilkBridge^TM conduit and evaluated at middle (4 weeks) and at longer time points (12 and 24 weeks). The SilkBridge^TM conduit led to a very good functional and morphological recovery of the median nerve, similar to that observed with the reference autograft nerve reconstruction procedure. Taken together, all these results demonstrated that SilkBridge^TM has an optimized balance of biomechanical and biological properties, which allowed proceeding with a first-in-human clinical study aimed at evaluating safety and effectiveness of using the device for the reconstruction of digital nerve defects in humans.

The progress of biomaterials in peripheral nerve repair and regeneration

Repair and regeneration of the injured peripheral nerve (PN) is a challenging issue in clinics. Although the regeneration outcome of large PN defects is currently unsatisfactory, recently, the study of PN repair has considerably progressed. In particular, biomaterials for repairing PNs, such as nerve guidance conduits and nerve repair membranes, have been well developed. Herein, we summarize the anatomy of the PN, the pathophysiological features of the nerve injury, and the repair process post injury. Then, we highlight the progress in the development of natural and synthetic biomaterials and summarize the applications, advantages, and disadvantages of these materials. These materials can be used as nerve repair membranes and nerve conduits in the field of PN repair. Finally, we discuss the challenges encountered and development strategies for PN repair in the future.