Personalized composite scaffolds for accelerated cell- and growth factor-free craniofacial bone regeneration

Approaches to regenerating bone often rely on integrating biomaterials and biological signals in the form of cells or cytokines. However, from a translational point of view, these approaches are challenging due to the sourcing and quality of the biologic, unpredictable immune responses, complex regulatory paths, and high costs. We describe a simple manufacturing process and a material-centric 3D-printed composite scaffold system (CSS) that offers distinct advantages for clinical translation. The CSS comprises a 3D-printed porous polydiolcitrate-hydroxyapatite composite elastomer infused with a polydiolcitrate-graphene oxide hydrogel composite. Using a micro-continuous liquid interface production 3D printer, we fabricate a precise porous ceramic scaffold with 60 wt% hydroxyapatite resembling natural bone. The resulting scaffold integrates with a thermoresponsive hydrogel composite in situ to fit the defect, which is expected to enhance surface contact with surrounding tissue and facilitate biointegration. The antioxidative properties of citrate polymers prevent long-term inflammatory responses. The CSS stimulates osteogenesis in vitro and in vivo. Within 4 weeks in a calvarial critical-sized bone defect model, the CSS accelerated ECM deposition (8-fold) and mineralized osteoid (69-fold) compared to the untreated. Through spatial transcriptomics, we demonstrated the comprehensive biological processes of CSS for prompt osseointegration. Our material-centric approach delivers impressive osteogenic properties and streamlined manufacturing advantages, potentially expediting clinical application for bone reconstruction surgeries.

Characterization and selection of a skull surrogate for the development of a biofidelic head model

This research paper explores the advancement of physical models simulating the human skull-brain complex, focusing on applications in simulating mild Traumatic Brain Injury (mTBI). Existing models, especially head forms, lack biofidelity in accurately representing the native structures of the skull, limiting the understanding of intracranial injury parameters beyond kinematic head accelerations. This study addresses this gap by investigating the use of additive manufacturing (AM) techniques to develop biofidelic skull surrogates. Materials such as Polylactic Acid (PLA), a bone-simulant PLA variant, and Hydroxyapatite-coated Poly(methyl methacrylate) (PMMA) were used to create models tested for their flexural modulus and strength. The trabecular bone regions were simulated by adjusting infill densities (30%, 50%, 80%) and print raster directions, optimizing manufacturing parameters for biofidelic performance. Among the tested materials, PLA and its bone-simulating variant printed at 80% infill density with a side (tangential) print orientation demonstrated the closest approximation to the mechanical properties of cranial bone, yielding a mean flexural modulus of 1337.2 MPa and a mean ultimate strength of 56.9 MPa. Statistical analyses showed that infill density significantly influenced the moduli and strength of the printed simulants. Digital Image Correlation (DIC) corroborated the comparable performance of the simulants, showing similar strain and displacement behaviors to native skull bone. Notably, the performance of the manufactured cortical and trabecular regions underscored their crucial role in achieving biofidelity, with the trabecular structure providing critical dampening effects when the native bone is loaded. This study establishes PLA, particularly its bone-simulant variant, as an optimal candidate for cranial bone simulants, offering significant potential for developing more accurate biofidelic head models in mTBI research.

Structure driven bio-responsive ability of injectable nanocomposite hydrogels for efficient bone regeneration

Injectable hydrogels are promising for treatment of bone defects in clinic owing to their minimally invasive procedure. Currently, there is limited emphasis on how to utilize injectable hydrogels to mobilize body's regenerative potential for enhancing bone regeneration. Herein, an injectable bone-mimicking hydrogel (BMH) scaffold assembled from nanocomposite microgel building blocks was developed, in which a highly interconnected microporous structure and an inorganic/organic (methacrylated hydroxyapatite and methacrylated gelatin) interweaved nano structure were well-designed. Compared with hydrogels lacking micro-nano structures or only showing microporous structure, the BMH scaffold enhanced the ingrowth of vessels and promoted the formation of dense cellular networks (including stem cells and M2 macrophages), across the entire scaffold at early stage after subcutaneous implantation. Moreover, the BMH scaffold could not only directly trigger osteogenic differentiation of the infiltrated stem cells, but also provided an instructive osteo-immune microenvironment by inducing macrophages into M2 phenotype. Mechanistically, our results reveal that the nano-rough structure of the BMH plays an essential role in inducing macrophage M2 polarization through activating mechanotransduction related RhoA/ROCK2 pathway. Overall, this work offers an injectable hydrogel with micro-nano structure driven bio-responsive abilities, highlighting harnessing body's inherent regenerative potential to realize bone regeneration.

Advances in implants and bone graft types for lumbar spinal fusion surgery

The increasing prevalence of spinal disorders worldwide necessitates advanced treatments, particularly interbody fusion for severe cases that are unresponsive to non-surgical interventions. This procedure, especially 360° lumbar interbody fusion, employs an interbody cage, pedicle screw-and-rod instrumentation, and autologous bone graft (ABG) to enhance spinal stability and promote fusion. Despite significant advancements, a persistent 10% incidence of non-union continues to result in compromised patient outcomes and escalated healthcare costs. Innovations in lumbar stabilisation seek to mimic the properties of natural bone, with evolving implant materials like titanium (Ti) and polyetheretherketone (PEEK) and their composites offering new prospects. Additionally, biomimetic cages featuring precisely engineered porosities and interconnectivity have gained traction, as they enhance osteogenic differentiation, support osteogenesis, and alleviate stress-shielding. However, the limitations of ABG, such as harvesting morbidities and limited fusion capacity, have spurred the exploration of sophisticated solutions involving advanced bone graft substitutes. Currently, demineralised bone matrix and ceramics are in clinical use, forming the basis for future investigations into novel bone graft substitutes. Bioglass, a promising newcomer, is under investigation despite its observed rapid absorption and the potential for foreign body reactions in preclinical studies. Its clinical applicability remains under scrutiny, with ongoing research addressing challenges related to burst release and appropriate dosing. Conversely, the well-documented favourable osteogenic potential of growth factors remains encouraging, with current efforts focused on modulating their release dynamics to minimise complications. In this evidence-based narrative review, we provide a comprehensive overview of the evolving landscape of non-degradable spinal implants and bone graft substitutes, emphasising their applications in lumbar spinal fusion surgery. We highlight the necessity for continued research to improve clinical outcomes and enhance patient well-being.

Recent advances of 3D-printing in spine surgery

Background

The emerging use of three-dimensional printing (3DP) offers improved surgical planning and personalized care. The use of 3DP technology in spinal surgery has several common applications, including models for preoperative planning, biomodels, surgical guides, implants, and teaching tools.

Methods

A literature review was conducted to examine the current use of 3DP technology in spinal surgery and identify the challenges and limitations associated with its adoption.

Results

The review reveals that while 3DP technology offers the benefits of enhanced stability, improved surgical outcomes, and the feasibility of patient-specific solutions in spinal surgeries, several challenges remain significant impediments to widespread adoption. The obvious expected limitation is the high cost associated with implementing and maintaining a 3DP facility and creating customized patient-specific implants. Technological limitations, including the variability between medical imaging and en vivo surgical anatomy, along with the reproduction of intricate high-fidelity anatomical detail, pose additional challenges. Finally, the lack of comprehensive clinical monitoring, inadequate sample sizes, and high-quality scientific evidence all limit our understanding of the full scope of 3DP's utility in spinal surgery and preclude widespread adoption and implementation.

Conclusion

Despite the obvious challenges and limitations, ongoing research and development efforts are expected to address these issues, improving the accessibility and efficacy of 3DP technology in spinal surgeries. With further advancements, 3DP technology has the potential to revolutionize spinal surgery by providing personalized implants and precise surgical planning, ultimately improving patient outcomes and surgical efficiency.

3D Melt-Extrusion Printing of Medium Chain Length Polyhydroxyalkanoates and Their Application as Antibiotic-Free Antibacterial Scaffolds for Bone Regeneration

In this work, we investigated, for the first time, the possibility of developing scaffolds for bone tissue engineering through three-dimensional (3D) melt-extrusion printing of medium chain length polyhydroxyalkanoate (mcl-PHA) (i.e., poly(3-hydroxyoctanoate-co-hydroxydecanoate-co-hydroxydodecanoate), P(3HO-co-3HD-co-3HDD)). The process parameters were successfully optimized to produce well-defined and reproducible 3D P(3HO-co-3HD-co-3HDD) scaffolds, showing high cell viability (100%) toward both undifferentiated and differentiated MC3T3-E1 cells. To introduce antibacterial features in the developed scaffolds, two strategies were investigated. For the first strategy, P(3HO-co-3HD-co-3HDD) was combined with PHAs containing thioester groups in their side chains (i.e., PHACOS), inherently antibacterial PHAs. The 3D blend scaffolds were able to induce a 70% reduction of Staphylococcus aureus 6538P cells by direct contact testing, confirming their antibacterial properties. Additionally, the scaffolds were able to support the growth of MC3T3-E1 cells, showing the potential for bone regeneration. For the second strategy, composite materials were produced by the combination of P(3HO-co-3HD-co-HDD) with a novel antibacterial hydroxyapatite doped with selenium and strontium ions (Se-Sr-HA). The composite material with 10 wt % Se-Sr-HA as a filler showed high antibacterial activity against both Gram-positive (S. aureus 6538P) and Gram-negative bacteria (Escherichia coli 8739), through a dual mechanism: by direct contact (inducing 80% reduction of both bacterial strains) and through the release of active ions (leading to a 54% bacterial cell count reduction for S. aureus 6538P and 30% for E. coli 8739 after 24 h). Moreover, the composite scaffolds showed high viability of MC3T3-E1 cells through both indirect and direct testing, showing promising results for their application in bone tissue engineering.

Application of Bioactive Materials for Osteogenic Function in Bone Tissue Engineering

Bone tissue defects present a major challenge in orthopedic surgery. Bone tissue engineering using multiple versatile bioactive materials is a potential strategy for bone-defect repair and regeneration. Due to their unique physicochemical and mechanical properties, biofunctional materials can enhance cellular adhesion, proliferation, and osteogenic differentiation, thereby supporting and stimulating the formation of new bone tissue. 3D bioprinting and physical stimuli-responsive strategies have been employed in various studies on bone regeneration for the fabrication of desired multifunctional biomaterials with integrated bone tissue repair and regeneration properties. In this review, biomaterials applied to bone tissue engineering, emerging 3D bioprinting techniques, and physical stimuli-responsive strategies for the rational manufacturing of novel biomaterials with bone therapeutic and regenerative functions are summarized. Furthermore, the impact of biomaterials on the osteogenic differentiation of stem cells and the potential pathways associated with biomaterial-induced osteogenesis are discussed.

Recent Advances in 3D Printing of Smart Scaffolds for Bone Tissue Engineering and Regeneration

The repair and functional reconstruction of bone defects resulting from severe trauma, surgical resection, degenerative disease, and congenital malformation pose significant clinical challenges. Bone tissue engineering (BTE) holds immense potential in treating these severe bone defects, without incurring prevalent complications associated with conventional autologous or allogeneic bone grafts. 3D printing technology enables control over architectural structures at multiple length scales and has been extensively employed to process biomimetic scaffolds for BTE. In contrast to inert and functional bone grafts, next-generation smart scaffolds possess a remarkable ability to mimic the dynamic nature of native extracellular matrix (ECM), thereby facilitating bone repair and regeneration. Additionally, they can generate tailored and controllable therapeutic effects, such as antibacterial or antitumor properties, in response to exogenous and/or endogenous stimuli. This review provides a comprehensive assessment of the progress of 3D-printed smart scaffolds for BTE applications. It begins with an introduction to bone physiology, followed by an overview of 3D printing technologies utilized for smart scaffolds. Notable advances in various stimuli-responsive strategies, therapeutic efficacy, and applications of 3D-printed smart scaffolds are discussed. Finally, the review highlights the existing challenges in the development and clinical implementation of smart scaffolds, as well as emerging technologies in this field.

3D-Printed Demineralized Bone Matrix-Based Conductive Scaffolds Combined with Electrical Stimulation for Bone Tissue Engineering Applications

Bone is remodeled through a dynamic process facilitated by biophysical cues that support cellular signaling. In healthy bone, signaling pathways are regulated by cells and the extracellular matrix and transmitted via electrical synapses. To this end, combining electrical stimulation (ES) with conductive scaffolding is a promising approach for repairing damaged bone tissue. Therefore, "smart" biomaterials that can provide multifunctionality and facilitate the transfer of electrical cues directly to cells have become increasingly more studied in bone tissue engineering. Herein, 3D-printed electrically conductive composite scaffolds consisting of demineralized bone matrix (DBM) and polycaprolactone (PCL), in combination with ES, for bone regeneration were evaluated for the first time. The conductive composite scaffolds were fabricated and characterized by evaluating mechanical, surface, and electrical properties. The DBM/PCL composites exhibited a higher compressive modulus (107.2 MPa) than that of pristine PCL (62.02 MPa), as well as improved surface properties (i.e., roughness). Scaffold electrical properties were also tuned, with sheet resistance values as low as 4.77 × 105 Ω/sq for our experimental coating of the highest dilution (i.e., 20%). Furthermore, the biocompatibility and osteogenic potential of the conductive composite scaffolds were tested using human mesenchymal stromal cells (hMSCs) both with and without exogenous ES (100 mV/mm for 5 min/day four times/week). In conjunction with ES, the osteogenic differentiation of hMSCs grown on conductive DBM/PCL composite scaffolds was significantly enhanced when compared to those cultured on PCL-only and nonconductive DBM/PCL control scaffolds, as determined through xylenol orange mineral staining and osteogenic protein analysis. Overall, these promising results suggest the potential of this approach for the development of biomimetic hybrid scaffolds for bone tissue engineering applications.

Fabrication of 3D-Printed Scaffolds with Multiscale Porosity

3D printing is a promising technique for producing bone implants, but there is still a need to adjust efficiency, facilitate production, and improve biocompatibility. Porous materials have a proven positive effect on the regeneration of bone tissue, but their production is associated with numerous limitations. In this work, we described a simple method of producing polymer or polymer-ceramic filaments for 3D-printing scaffolds by adding micrometer-scale porous structures on scaffold surfaces. Scaffolds included polycaprolactone (PCL) as the primary polymer, β-tricalcium phosphate (β-TCP) as the ceramic filler, and poly(ethylene glycol) (PEG) as a porogen. The pressurized filament extrusion gave flexible filaments composed of PCL, β-TCP, and PEG, which are ready to use in fused filament fabrication (FFF) 3D printers. Washing of 3D-printed scaffolds in ethanol solution removed PEG and revealed a microporous structure and ceramic particles on the scaffold's surfaces. Furthermore, 3D-printed materials exhibit good printing precision, no cytotoxic properties, and highly impact MG63 cell alignment. Although combining PCL, PEG, and β-TCP is quite popular, the presented method allows the production of porous scaffolds with a well-organized structure without advanced equipment, and the produced filaments can be used to 3D print scaffolds on a simple commercially available 3D printer.

Fabrication and characterization of sodium alginate-silicon nitride-PVA composite biomaterials with damping properties

Silicon nitride is utilized clinically as a bioceramic for spinal fusion cages, owing to its high strength, osteoconductivity, and antibacterial effects. Nevertheless, silicon nitride exhibits suboptimal damping properties, a critical factor in mitigating traumatic bone injuries and fractures. In fact, there is a scarcity of spinal implants that simultaneously demonstrate proficient damping performance and support osteogenesis. In our study, we fabricated a novel sodium alginate-silicon nitride/poly(vinyl alcohol) (SA-SiN/PVA) composite scaffold, enabling enhanced energy absorption and rapid elastic recovery under quasi-static and impact loading scenarios. Furthermore, the study demonstrated that the incorporation of physical and chemical cross-linking significantly improved stiffness and recoverable energy dissipation. Concerning the interaction between cells and materials, our findings suggest that the addition of silicon nitride stimulated osteogenic differentiation while inhibiting Staphylococcus aureus growth. Collectively, the amalgamation of ceramics and tough hydrogels facilitates the development of advanced composites for spinal implants, manifesting superior damping, osteogenic potential, and antibacterial properties. This approach holds broader implications for applications in bone tissue engineering.

A comprehensive bench-to-bed look into the application of gamma-sterilized 3D-printed polycaprolactone/hydroxyapatite implants for craniomaxillofacial defects, an in vitro, in vivo, and clinical study

This study investigates the safety and efficacy of 3D-printed polycaprolactone/hydroxyapatite (PCL/HA) scaffolds for patient-specific cranioplasty surgeries, employing liquid deposition modeling (LDM) technology. This research is pioneering as it explores the impact of gamma radiation on PCL/HA scaffolds and utilizes printing ink with the highest content of HA known in the composite. The mechanical, morphological, and macromolecular stability of the gamma-sterilized scaffolds were verified before implantation. Subsequent research involving animal subjects was conducted to explore the effects of sterilized implants. Eventually, three clinical cases were selected for the implantation studies as part of a phase 1 non-randomized open-label clinical trial. It was shown that a 25 kGy gamma-ray dose for sterilizing the printed implants did not alter the required geometrical precision of the printed implants. The implants exhibited well-distributed HA and strength comparable to cancellous bone. Gamma radiation reduced hydrophobicity and water uptake capacity without inducing pyrogenic or inflammatory responses. Personalized PCL/HA substitutes successfully treated various craniomaxillofacial defects, including trauma-induced facial asymmetry and congenital deformities. HA nanoparticles in the ink stimulated significant osteoconductive responses within three months of implantation. Moreover, the results revealed that while larger implants may exhibit a slower bone formation response in comparison to smaller implants, they generally had an acceptable rate and volume of bone formation. This clinical trial suggests the application of a sterilized PCL/HA composite for craniomaxillofacial surgery is safe and could be considered as a substitute for autologous bone.

Piezocatalytically-induced controllable mineralization scaffold with bone-like microenvironment to achieve endogenous bone regeneration

Orderly hierarchical structure with balanced mechanical, chemical, and electrical properties is the basis of the natural bone microenvironment. Inspired by nature, we developed a piezocatalytically-induced controlled mineralization strategy using piezoelectric polymer poly-L-lactic acid (PLLA) fibers with ordered micro-nano structures to prepare biomimetic tissue engineering scaffolds with a bone-like microenvironment (pcm-PLLA), in which PLLA-mediated piezoelectric catalysis promoted the in-situ polymerization of dopamine and subsequently regulated the controllable growth of hydroxyapatite crystals on the fiber surface. PLLA fibers, as analogs of mineralized collagen fibers, were arranged in an oriented manner, and ultimately formed a bone-like interconnected pore structure; in addition, they also provided bone-like piezoelectric properties. The uniformly sized HA nanocrystals formed by controlled mineralization provided a bone-like mechanical strength and chemical environment. The pcm-PLLA scaffold could rapidly recruit endogenous stem cells, and promote their osteogenic differentiation by activating cell membrane calcium channels and PI3K signaling pathways through ultrasound-responsive piezoelectric signals. In addition, the scaffold also provided a suitable microenvironment to promote macrophage M2 polarization and angiogenesis, thereby enhancing bone regeneration in skull defects of rats. The proposed piezocatalytically-induced controllable mineralization strategy provides a new idea for the development of tissue engineering scaffolds that can be implemented for multimodal physical stimulation therapy.

Three-Dimensional-Printed Composite Scaffolds Containing Poly-ε-Caprolactone and Strontium-Doped Hydroxyapatite for Osteoporotic Bone Restoration

A challenge in tissue engineering and the pharmaceutical sector is the development of controlled local release of drugs that raise issues when systemic administration is applied. Strontium is an example of an effective anti-osteoporotic agent, used in treating osteoporosis due to both anti-resorptive and anabolic mechanisms of action. Designing bone scaffolds with a higher capability of promoting bone regeneration is a topical research subject. In this study, we developed composite multi-layer three-dimensional (3D) scaffolds for bone tissue engineering based on nano-hydroxyapatite (HA), Sr-containing nano-hydroxyapatite (SrHA), and poly-ε-caprolactone (PCL) through the material extrusion fabrication technique. Previously obtained HA and SrHA with various Sr content were used for the composite material. The chemical, morphological, and biocompatibility properties of the 3D-printed scaffolds obtained using HA/SrHA and PCL were investigated. The 3D composite scaffolds showed good cytocompatibility and osteogenic potential, which is specifically recommended in applications when faster mineralization is needed, such as osteoporosis treatment.

Flexible biopolymer-assisted 3D printed bioceramics scaffold with high shape adaptability

Bioceramics are widely used in bone tissue engineering, yet the inherent high brittleness and low ductility of the ceramics lead to poor machinability, which restricts their clinical applications. Here, a flexible and processable 3D printed bioceramic scaffold with high ceramic content (66.7 %) and shape fidelity (volume shrinkage rate < 5 %) was developed by freeze-thaw cycles, which was assisted by polyvinyl alcohol (PVA) and silk fibroin (SF). The hydrogen bonding between PVA imparted printability to the ceramic ink and enabled the subsequent formation of flexible scaffolds, which can be twisted, bend and cut to match bone defects. After adding SF, the printability of the inks and hydrophilicity of the scaffolds were enhanced, owing to the interactions between PVA and SF. Further, combined with the formation of β-sheet in SF, the scaffolds exhibited superior mechanical strength and excellent thermal stability, and can fully recover at 35 % compressive strain, which was breaking through the brittleness bottleneck of conventional ceramic scaffolds. Moreover, in vitro experiments showed excellent mineralization ability, osteogenic and angiogenic activities of the scaffolds, demonstrating its potential in bone regeneration. This initial study offers a promising personalized material for bone repair that can be used rapidly during surgery.

Comparison between Two Different Synthesis Methods of Strontium-Doped Hydroxyapatite Designed for Osteoporotic Bone Restoration

Development of efficient controlled local release of drugs that prevent systemic side effects is a challenge for anti-osteoporotic treatments. Research for new bone-regeneration materials is of high importance. Strontium (Sr) is known as an anti-resorptive and anabolic agent useful in treating osteoporosis. In this study, we compared two different types of synthesis used for obtaining nano hydroxyapatite (HA) and Sr-containing nano hydroxyapatite (SrHA) for bone tissue engineering. Synthesis of HA and SrHA was performed using co-precipitation and hydrothermal methods. Regardless of the synthesis route for the SrHA, the intended content of Sr was 1, 5, 10, 20, and 30 molar %. The chemical, morphological, and biocompatibility properties of HA and SrHA were investigated. Based on our results, it was shown that HA and SrHA exhibited low cytotoxicity and demonstrated toxic behavior only at higher Sr concentrations.

Toughening 3D printed biomimetic hydroxyapatite scaffolds: Polycaprolactone-based self-hardening inks

The application of 3D printing to calcium phosphates has opened unprecedented possibilities for the fabrication of personalized bone grafts. However, their biocompatibility and bioactivity are counterbalanced by their high brittleness. In this work we aim at overcoming this problem by developing a self-hardening ink containing reactive ceramic particles in a polycaprolactone solution instead of the traditional approach that use hydrogels as binders. The presence of polycaprolactone preserved the printability of the ink and was compatible with the hydrolysis-based hardening process, despite the absence of water in the ink and its hydrophobicity. The microstructure evolved from a continuous polymeric phase with loose ceramic particles to a continuous network of hydroxyapatite nanocrystals intertwined with the polymer, in a configuration radically different from the polymer/ceramic composites obtained by fused deposition modelling. This resulted in the evolution from a ductile behavior, dominated by the polymer, to a stiffer behavior as the ceramic phase reacted. The polycaprolactone binder provides two highly relevant benefits compared to hydrogel-based inks. First, the handleability and elasticity of the as-printed scaffolds, together with the proven possibility of eliminating the solvent, opens the door to implanting the scaffolds freshly printed once lyophilized, while in a ductile state, and the hardening process to take place inside the body, as in the case of calcium phosphate cements. Second, even with a hydroxyapatite content of more than 92 wt.%, the flexural strength and toughness of the scaffolds after hardening are twice and five times those of the all-ceramic scaffolds obtained with the hydrogel-based inks, respectively. STATEMENT OF SIGNIFICANCE: Overcoming the brittleness of ceramic scaffolds would extend the applicability of synthetic bone grafts to high load-bearing situations. In this work we developed a 3D printing ink by replacing the conventional hydrogel binder with a water-free polycaprolactone solution. The presence of polycaprolactone not only enhanced significantly the strength and toughness of the scaffolds while keeping the proportion of bioactive ceramic phase larger than 90 wt.%, but it also conferred flexibility and manipulability to the as-printed scaffolds. Since they are able to harden upon contact with water under physiological conditions, this opens up the possibility of implanting them immediately after printing, while they are still in a ductile state, with clear advantages for fixation and press-fit in the bone defect.

Biomimetic short fiber reinforced 3-dimensional scaffold for bone tissue regeneration

Bone defects caused by diseases and trauma are considered serious clinical challenges. Autologous and allogeneic transplantations are the most widely used methods to mitigate bone defects. However, transplantation poses risks such as secondary trauma, immune rejection, and disease transmission to patients. Preparing a biologically active bone tissue engineering scaffold as a bone substitute can overcome this problem. In the current study, a PLGA/gelatin (Gel) short fiber-reinforced composite three-dimensional (3D) scaffold was fabricated by electrospinning for bone tissue defect repair. A hybrid scaffold adding inorganic materials hydrotalcite (CaAl-LDH) and osteogenic factors deferoxamine (DFO) based on PLGA and Gel composite filaments was prepared. The structure, swelling, drug release, and compressive resilience performance of the 3D scaffolds in a wet state were characterized and the osteogenic effect of the crosslinked scaffold (C-DLPG) was also investigated. The scaffold has shown the optimum physicochemical attributes which still has 380 kPa stress after a 60% compression cycle and sustainedly released the drug for about twenty days. Moreover, a promisingIn vivoosteogenic performance was noted with better tissue organization. At 8 weeks after implantation, the C-DLPG scaffold could fill the bone defect site, and the new bone area reached 19 mm2. The 3D microfiber scaffold, in this study, is expected to be a promising candidate for the treatment of bone defects in the future.

Advanced Synthetic Scaffolds Based on 1D Inorganic Micro-/Nanomaterials for Bone Regeneration

Inorganic nanoparticulate biomaterials, such as calcium phosphate and bioglass particles, with chemical compositions similar to that of the inorganic component of natural bone, and hence having excellent biocompatibility and bioactivity, are widely used for the fabrication of synthetic bone graft substitutes. Growing evidence suggests that structurally anisotropic, or 1D inorganic micro-/nanobiomaterials are superior to inorganic nanoparticulate biomaterials in the context of mechanical reinforcement and construction of self-supporting 3D network structures. Therefore, in the past decades, efforts have been devoted to developing advanced synthetic scaffolds for bone regeneration using 1D micro-/nanobiomaterials as building blocks. These scaffolds feature extraordinary physical and biological properties, such as enhanced mechanical properties, super elasticity, multiscale hierarchical architecture, extracellular matrix-like fibrous microstructure, and desirable biocompatibility and bioactivity, etc. In this review, an overview of recent progress in the development of advanced scaffolds for bone regeneration is provided based on 1D inorganic micro-/nanobiomaterials with a focus on their structural design, mechanical properties, and bioactivity. The promising perspectives for future research directions are also highlighted.

Evaluation of the Morphological Effects of Hydroxyapatite Nanoparticles on the Rheological Properties and Printability of Hydroxyapatite/Polycaprolactone Nanocomposite Inks and Final Scaffold Features

This study is focused on the importance of nanohydroxyapatite (nHA) particle morphology with the same particle size range on the rheological behavior of polycaprolactone (PCL) composite ink with nHA as a promising candidate for additive manufacturing technologies. Two different physiologic-like nHA morphologies, that is, plate and rod shape, with particles size less than 100 nm were used. nHA powders were well characterized and the printing inks were prepared by adding the different ratios of nHA powders to 50% w/v of PCL solution (nHA/PCL: 35/65, 45/55, 55/45, and 65/35 w/w%). Subsequently, the influence of nHA particle morphology and concentration on the printability and rheological properties of composite inks was investigated. HA nanopowder analysis revealed significant differences in their microstructural properties, which affected remarkably the composite ink printability in several ways. For instance, adding up to 65% w/w of plate-like nHA to the PCL solution was possible, while nanorod HA could not be added above 45% w/w. The printed constructs were successfully fabricated using the extrusion-based printing method and had a porous structure with interconnected pores. Total porosity and surface area increased with nHA content due to the improved fiber stability following deposition of material ink. Consequently, degradation rate and bioactivity increased, while compressive properties decreased. While nanorod HA particles had a more significant impact on the mechanical strength than plate-like morphology, the latter showed less crystalline order, which makes them more bioactive than nanorod HA. It is therefore important to note that the nHA microstructure broadly affects the printability of printing ink and should be considered according to the intended biomedical applications.

Pushing boundaries in 3D printing: Economic pressure filament extruder for producing polymeric and polymer-ceramic filaments for 3D printers

3D printing technology can deliver tailored, bioactive, and biodegradable bone implants. However, producing the new, experimental material for a 3D printer could be the first and one of the most challenging steps of the whole bone implant 3D printing process. Production of polymeric and polymer-ceramic filaments involves using costly filament extruders and significantly consuming expensive medical-grade materials. Commercial extruders frequently require a large amount of raw material for experimental purposes, even for small quantities of filament. In our publication, we propose a simple system for pressure filament extruding, which allows obtaining up to 1-meter-long filament suitable for fused filament fabrication-type 3D printers, requiring only 30 g of material to begin work. Our device is based on stainless steel pipes used as a container for material, a basic electric heating system with a proportional-integral-derivative controller, and a pressurised air source with an air pressure regulator. We tested our device on various mixes of polylactide and polycaprolactone with β-tricalcium phosphate and demonstrated the possibility of screening production and testing of new materials for 3D-printed bone implants.

Comparison of demineralized bone matrix with different cycling crushing times in posterolateral fusion model of athymic rats

Decalcified bone matrix (DBM) is a widely used alternative material for bone transplantation. In the DBM production process, an effective particle size and the highest utilization rate of raw materials can be achieved only through multiple high-speed circulating comminution. The rat posterolateral lumbar fusion model (PLF) is the most mature small animal model for the initial evaluation of the efficacy of graft materials for bone regeneration and spinal fusion. To evaluate the differences in the in vivo osteogenic effects of DBM pulverization through 1, 5, 9, and 14 high-speed cycles, sixty athymic rats were divided into six groups: single cycling crushing (CC1), 5 cycles of crushing (CC5), 9 cycles of crushing (CC9), 13 cycles of crushing (CC13), autogenous bone graft (ABG) and negative control (NC). Posterolateral lumbar fusion was performed. Six weeks after surgery, the bilateral lumbar fusion of athymic rats was evaluated through manual palpation, X-ray, micro-CT and histological sections. Rank data were tested by the rank-sum test, and nonparametric data were tested by the Kruskal‒Wallis H test. The manual palpation and X-ray results showed that the fusion rate did not significantly differ between the CC1, CC5, CC9, CC13 and ABG groups. However, cavities appeared in CC9 and CC13 on the micro-CT image. The bone mass (BV/TV) of CC1, CC5, CC9 and CC13 was better than that of the ABG group, while almost no osteogenesis was observed in the NC group. Histologically, there was no obvious difference between the four groups except that the CC9 group and CC13 group had more fibrous tissues in the new bone. In conclusion, DMB with different cycling crushing times has no obvious difference in fusion rate of PLF, but it is slightly better than the ABG group.

Synergistic Effect of Physical and Chemical Cross-Linkers Enhances Shape Fidelity and Mechanical Properties of 3D Printable Low-Modulus Polyesters

Three-dimensional (3D) printing is becoming increasingly prevalent in tissue engineering, driving the demand for low-modulus, high-performance, biodegradable, and biocompatible polymers. Extrusion-based direct-write (EDW) 3D printing enables printing and customization of low-modulus materials, ranging from cell-free printing to cell-laden bioinks that closely resemble natural tissue. While EDW holds promise, the requirement for soft materials with excellent printability and shape fidelity postprinting remains unmet. The development of new synthetic materials for 3D printing applications has been relatively slow, and only a small polymer library is available for tissue engineering applications. Furthermore, most of these polymers require high temperature (FDM) or additives and solvents (DLP/SLA) to enable printability. In this study, we present low-modulus 3D printable polyester inks that enable low-temperature printing without the need for solvents or additives. To maintain shape fidelity, we incorporate physical and chemical cross-linkers. These 3D printable polyester inks contain pendant amide groups as the physical cross-linker and coumarin pendant groups as the photochemical cross-linker. Molecular dynamics simulations further confirm the presence of physical interactions between different pendants, including hydrogen bonding and hydrophobic interactions. The combination of the two types of cross-linkers enhances the zero-shear viscosity and hence provides good printability and shape fidelity.

A 3D-Printed Assemblable Bespoke Scaffold as a Versatile Microcryogel Carrier for Site-Specific Regenerative Medicine

Advances in additive manufacturing have led to diverse patient-specific implant designs utilizing computed tomography, but this requires intensive work and financial implications. Here, Digital Light Processing is used to fabricate a hive-structured assemblable bespoke scaffold (HIVE). HIVE can be manually assembled in any shape/size with ease, so a surgeon can create a scaffold that will best fit a defect before implantation. Simultaneously, it can have site-specific treatments by working as a carrier filled with microcryogels (MC) incorporating different biological factors in different pockets of HIVE. After characterization, possible site-specific applications are investigated by utilizing HIVE as a versatile carrier with incorporated treatments such as growth factors (GF), bioceramic, or cells. HIVE as a GF-carrier shows a controlled release of bone morphogenetic protein/vascular endothelial growth factor (BMP/VEGF) and induced osteogenesis/angiogenesis from human mesenchymal stem cells (hMSC)/human umbilical vein endothelial cells (HUVECs). Furthermore, as a bioceramic-carrier, HIVE demonstrates enhanced mineralization and osteogenesis, and as a HUVEC carrier, it upregulates both osteogenic and angiogenic gene expression of hMSCs. HIVE with different combinations of MCs yields a distinct local effect and successful cell migration is confirmed within assembled HIVEs. Finally, an in vivo rat subcutaneous implantation demonstrates site-specific osteogenesis and angiogenesis.

Collagen-Coated Hyperelastic Bone Promotes Osteoblast Adhesion and Proliferation

Successfully reconstructing bone and restoring its dynamic function represents a significant challenge for medicine. Critical size defects (CSDs), resulting from trauma, tumor removal, or degenerative conditions, do not naturally heal and often require complex bone grafting. However, these grafts carry risks, such as tissue rejection, infections, and surgical site damage, necessitating the development of alternative treatments. Three-dimensional and four-dimensional printed synthetic biomaterials represent a viable alternative, as they carry low production costs and are highly reproducible. Hyperelastic bone (HB), a biocompatible synthetic polymer consisting of 90% hydroxyapatite and 10% poly(lactic-co-glycolic acid, PLGA), was examined for its potential to support cell adhesion, migration, and proliferation. Specifically, we seeded collagen-coated HB with MG-63 human osteosarcoma cells. Our analysis revealed robust cell adhesion and proliferation over 7 days in vitro, with cells forming uniform monolayers on the external surface of the scaffold. However, no cells were present on the core of the fibers. The cells expressed bone differentiation markers on days 3 and 5. By day 7, the scaffold began to degrade, developing microscopic fissures and fragmentation. In summary, collagen-coated HB scaffolds support cell adhesion and proliferation but exhibit reduced structural support after 7 days in culture. Nevertheless, the intricate 3D architecture holds promise for cellular migration, vascularization, and early osteogenesis.

Advances in the Development of Nano-Engineered Mechanically Robust Hydrogels for Minimally Invasive Treatment of Bone Defects

Injectable hydrogels were discovered as attractive materials for bone tissue engineering applications given their outstanding biocompatibility, high water content, and versatile fabrication platforms into materials with different physiochemical properties. However, traditional hydrogels suffer from weak mechanical strength, limiting their use in heavy load-bearing areas. Thus, the fabrication of mechanically robust injectable hydrogels that are suitable for load-bearing environments is of great interest. Successful material design for bone tissue engineering requires an understanding of the composition and structure of the material chosen, as well as the appropriate selection of biomimetic natural or synthetic materials. This review focuses on recent advancements in materials-design considerations and approaches to prepare mechanically robust injectable hydrogels for bone tissue engineering applications. We outline the materials-design approaches through a selection of materials and fabrication methods. Finally, we discuss unmet needs and current challenges in the development of ideal materials for bone tissue regeneration and highlight emerging strategies in the field.

Micro-porous PLGA/β-TCP/TPU scaffolds prepared by solvent-based 3D printing for bone tissue engineering purposes

The 3D printing process of fused deposition modelling is an attractive fabrication approach to create tissue-engineered bone substitutes to regenerate large mandibular bone defects, but often lacks desired surface porosity for enhanced protein adsorption and cell adhesion. Solvent-based printing leads to the spontaneous formation of micropores on the scaffold's surface upon solvent removal, without the need for further post processing. Our aim is to create and characterize porous scaffolds using a new formulation composed of mechanically stable poly(lactic-co-glycol acid) and osteoconductive β-tricalcium phosphate with and without the addition of elastic thermoplastic polyurethane prepared by solvent-based 3D-printing technique. Large-scale regenerative scaffolds can be 3D-printed with adequate fidelity and show porosity at multiple levels analysed via micro-computer tomography, scanning electron microscopy and N2 sorption. Superior mechanical properties compared to a commercially available calcium phosphate ink are demonstrated in compression and screw pull out tests. Biological assessments including cell activity assay and live-dead staining prove the scaffold's cytocompatibility. Osteoconductive properties are demonstrated by performing an osteogenic differentiation assay with primary human bone marrow mesenchymal stromal cells. We propose a versatile fabrication process to create porous 3D-printed scaffolds with adequate mechanical stability and osteoconductivity, both important characteristics for segmental mandibular bone reconstruction.

Advances and Prospects in Materials for Craniofacial Bone Reconstruction

The craniofacial region is composed of 23 bones, which provide crucial function in keeping the normal position of brain and eyeballs, aesthetics of the craniofacial complex, facial movements, and visual function. Given the complex geometry and architecture, craniofacial bone defects not only affect the normal craniofacial structure but also may result in severe craniofacial dysfunction. Therefore, the exploration of rapid, precise, and effective reconstruction of craniofacial bone defects is urgent. Recently, developments in advanced bone tissue engineering bring new hope for the ideal reconstruction of the craniofacial bone defects. This report, presenting a first-time comprehensive review of recent advances of biomaterials in craniofacial bone tissue engineering, overviews the modification of traditional biomaterials and development of advanced biomaterials applying to craniofacial reconstruction. Challenges and perspectives of biomaterial development in craniofacial fields are discussed in the end.

Recent Advances in Organ-on-Chips Integrated with Bioprinting Technologies for Drug Screening

Currently, the demand for more reliable drug screening devices has made scientists and researchers develop novel potential approaches to offer an alternative to animal studies. Organ-on-chips are newly emerged platforms for drug screening and disease metabolism investigation. These microfluidic devices attempt to recapitulate the physiological and biological properties of different organs and tissues using human-derived cells. Recently, the synergistic combination of additive manufacturing and microfluidics has shown a promising impact on improving a wide array of biological models. In this review, different methods are classified using bioprinting to achieve the relevant biomimetic models in organ-on-chips, boosting the efficiency of these devices to produce more reliable data for drug investigations. In addition to the tissue models, the influence of additive manufacturing on microfluidic chip fabrication is discussed, and their biomedical applications are reviewed.

Covalently Grafted Biomimetic Matrix Reconstructs the Regenerative Microenvironment of the Porous Gradient Polycaprolactone Scaffold to Accelerate Bone Remodeling

Integrating a biomimetic extracellular matrix to improve the microenvironment of 3D printing scaffolds is an emerging strategy for bone substitute design. Here, a "soft-hard" bone implant (BM-g-DPCL) consisting of a bioactive matrix chemically integrated on a polydopamine (PDA)-coated porous gradient scaffold by polyphenol groups is constructed. The PDA-coated "hard" scaffolds promoted Ca²⁺ chelation and mineral deposition; the "soft" bioactive matrix is beneficial to the migration, proliferation, and osteogenic differentiation of stem cells in vitro, accelerated endogenous stem cell recruitment, and initiated rapid angiogenesis in vivo. The results of the rabbit cranial defect model (Φ = 10 mm) confirmed that BM-g-DPCL promoted the integration between bone tissue and implant and induced the deposition of bone matrix. Proteomics confirmed that cytokine adhesion, biomineralization, rapid vascularization, and extracellular matrix formation are major factors that accelerate bone defect healing. This strategy of highly chemically bonded soft-hard components guided the construction of the bioactive regenerative scaffold.

Biomechanical Characteristics and Analysis Approaches of Bone and Bone Substitute Materials

Bone has a special structure that is both stiff and elastic, and the composition of bone confers it with an exceptional mechanical property. However, bone substitute materials that are made of the same hydroxyapatite (HA) and collagen do not offer the same mechanical properties. It is important for bionic bone preparation to understand the structure of bone and the mineralization process and factors. In this paper, the research on the mineralization of collagen is reviewed in terms of the mechanical properties in recent years. Firstly, the structure and mechanical properties of bone are analyzed, and the differences of bone in different parts are described. Then, different scaffolds for bone repair are suggested considering bone repair sites. Mineralized collagen seems to be a better option for new composite scaffolds. Last, the paper introduces the most common method to prepare mineralized collagen and summarizes the factors influencing collagen mineralization and methods to analyze its mechanical properties. In conclusion, mineralized collagen is thought to be an ideal bone substitute material because it promotes faster development. Among the factors that promote collagen mineralization, more attention should be given to the mechanical loading factors of bone.

Murine models of posterolateral spinal fusion: A systematic review

BACKGROUND

Rodent models are commonly used experimentally to assess treatment effectiveness in spinal fusion. Certain factors are associated with better fusion rates. The objectives of the present study were to report the protocols most frequently used, to evaluate factors known to positively influence fusion rate, and to identify new factors.

METHOD

A systematic literature search of PubMed and Web of Science found 139 experimental studies of posterolateral lumbar spinal fusion in rodent models. Data for level and location of fusion, animal strain, sex, weight and age, graft, decortication, fusion assessment and fusion and mortality rates were collected and analyzed.

RESULTS

The standard murine model for spinal fusion was male Sprague Dawley rats of 295g weight and 13 weeks' age, using decortication, with L4-L5 as fusion level. The last two criteria were associated with significantly better fusion rates. On manual palpation, the overall mean fusion rate in rats was 58% and the autograft mean fusion rate was 61%. Most studies evaluated fusion as a binary on manual palpation, and only a few used CT and histology. Average mortality was 3.03% in rats and 1.56% in mice.

CONCLUSIONS

These results suggest using a rat model, younger than 10 weeks and weighing more than 300 grams on the day of surgery, to optimize fusion rates, with decortication before grafting and fusing the L4-L5 level.

A simple and fast method for screening production of polymer-ceramic filaments for bone implant printing using commercial fused deposition modelling 3D printers

3D printing is a promising technique for obtaining bone implants. However, 3D printed bone implants, especially those printed using fused deposition modelling, are still in the experimental phase despite decades of work. Research on new materials faces numerous limitations, such as reagents' cost and machines' high prices to produce filaments for 3D printing polymer-ceramic composites for fused deposition modelling. This paper presents a simple, low-cost, and fast method of obtaining polymer-ceramic filaments using apparatus consisting of parts available in a hardware store. The method's versatility for producing the filaments was demonstrated on two different biodegradable polymers - polylactic acid and polycaprolactone - and different concentrations of calcium phosphate - β-tricalcium phosphate - in the composite, up to 50 % by weight. For screening purposes, numerous scaffolds were 3D printed from the obtained filaments on a commercial 3D printer. Structural, mechanical, and biological tests show that the 3D printed scaffolds are suitable for bone implants, as their structure, mechanical, and non-cytotoxic properties are evident. Moreover, the proposed method of composite forming is a simplification of the processes of manufacturing and researching 3D printed materials with potential applications in the regeneration of bone tissue.

A bioactive material with dual integrin-targeting ligands regulates specific endogenous cell adhesion and promotes vascularized bone regeneration in adult and fetal bone defects

Significant progress has been made in designing bone materials capable of directing endogenous cells to promote vascularized bone regeneration. However, current strategies lack regulation of the specific endogenous cell populations for vascularized bone regeneration, thus leading to adverse tissue formation and decreased regenerative efficiency. Here, we engineered a biomaterial to regulate endogenous cell adhesion and promote vascularized bone regeneration. The biomaterial works by presenting two synthetic ligands, LLP2A and LXW7, explicitly targeting integrins α4β1 and αvβ3, respectively, expressed on the surfaces of the cells related to bone formation and vascularization, such as mesenchymal stem cells (MSCs), osteoblasts, endothelial progenitor cells (EPCs), and endothelial cells (ECs). In vitro, the LLP2A/LXW7 modified biomaterial improved the adhesion of MSCs, osteoblasts, EPCs, and ECs via integrin α4β1 and αvβ3, respectively. In an adult rat calvarial bone defect model, the LLP2A/LXW7 modified biomaterial enhanced bone formation and vascularization by synergistically regulating endogenous cells with osteogenic and angiogenic potentials, such as DLX5⁺ cells, osteocalcin⁺ cells, CD34⁺/CD45^- cells and CD31⁺ cells. In a fetal sheep spinal bone defect model, the LLP2A/LXW7 modified biomaterial augmented bone formation and vascularization without any adverse effects. This innovative biomaterial offers an off-the-shelf, easy-to-use, and biologically safe product suitable for vascularized bone regeneration in both fetal and adult disease environments.

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Two integrin-binding ligands for constructing vascularized bone biomaterial.

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Extracellular matrix (ECM)-mimicking collagen-based biomaterial with specific integrin binding sites for cell adhesion.

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Biomaterial regulates adhesion of endogenous stem cells with osteogenic and angiogenic potentials.

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Biomaterial promotes vascularized bone formation in adult and fetal bone defects without safety issues.

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An easy-to-make and off-the-shelf biomaterial for treatment of clinical bone diseases.

Influence of porosity on osteogenesis, bone growth and osteointegration in trabecular tantalum scaffolds fabricated by additive manufacturing

Porous tantalum implants are a class of materials commonly used in clinical practice to repair bone defects. However, the cumbersome and problematic preparation procedure have limited their widespread application. Additive manufacturing has revolutionized the design and process of orthopedic implants, but the pore architecture feature of porous tantalum scaffolds prepared from additive materials for optimal osseointegration are unclear, particularly the influence of porosity. We prepared trabecular bone-mimicking tantalum scaffolds with three different porosities (60%, 70% and 80%) using the laser powder bed fusing technique to examine and compare the effects of adhesion, proliferation and osteogenic differentiation capacity of rat mesenchymal stem cells on the scaffolds in vitro. The in vivo bone ingrowth and osseointegration effects of each scaffold were analyzed in a rat femoral bone defect model. Three porous tantalum scaffolds were successfully prepared and characterized. In vitro studies showed that scaffolds with 70% and 80% porosity had a better ability to osteogenic proliferation and differentiation than scaffolds with 60% porosity. In vivo studies further confirmed that tantalum scaffolds with the 70% and 80% porosity had a better ability for bone ingrowh than the scaffold with 60% porosity. As for osseointegration, more bone was bound to the material in the scaffold with 70% porosity, suggesting that the 3D printed trabecular tantalum scaffold with 70% porosity could be the optimal choice for subsequent implant design, which we will further confirm in a large animal preclinical model for better clinical use.

Personalized 3D printed bone scaffolds: A review

3D printed bone scaffolds have the potential to replace autografts and allografts because of advantages such as unlimited supply and the ability to tailor the scaffolds' biochemical, biological and biophysical properties. Significant progress has been made over the past decade in additive manufacturing techniques to 3D print bone grafts, but challenges remain in the lack of manufacturing techniques that can recapitulate both mechanical and biological functions of native bones. The purpose of this review is to outline the recent progress and challenges of engineering an ideal synthetic bone scaffold and to provide suggestions for overcoming these challenges through bioinspiration, high-resolution 3D printing, and advanced modeling techniques. The article provides a short overview of the progress in developing the 3D printed scaffolds for the repair and regeneration of critical size bone defects. STATEMENT OF SIGNIFICANCE: Treatment of critical size bone defects is still a tremendous clinical challenge. To address this challenge, diverse sets of advanced manufacturing approaches and materials have been developed for bone tissue scaffolds. 3D printing has sparked much interest because it provides a close control over the scaffold's internal architecture and in turn its mechanical and biological properties. This article provides a critical overview of the relationships between material compositions, printing techniques, and properties of the scaffolds and discusses the current technical challenges facing their successful translation to the clinic. Bioinspiration, high-resolution printing, and advanced modeling techniques are discussed as future directions to address the current challenges.

Biomaterial-based 3D bioprinting strategy for orthopedic tissue engineering

The advent of three-dimensional (3D) bioprinting has enabled impressive progress in the development of 3D cellular constructs to mimic the structural and functional characteristics of natural tissues. Bioprinting has considerable translational potential in tissue engineering and regenerative medicine. This review highlights the rational design and biofabrication strategies of diverse 3D bioprinted tissue constructs for orthopedic tissue engineering applications. First, we elucidate the fundamentals of 3D bioprinting techniques and biomaterial inks and discuss the basic design principles of bioprinted tissue constructs. Next, we describe the rationale and key considerations in 3D bioprinting of tissues in many different aspects. Thereafter, we outline the recent advances in 3D bioprinting technology for orthopedic tissue engineering applications, along with detailed strategies of the engineering methods and materials used, and discuss the possibilities and limitations of different 3D bioprinted tissue products. Finally, we summarize the current challenges and future directions of 3D bioprinting technology in orthopedic tissue engineering and regenerative medicine. This review not only delineates the representative 3D bioprinting strategies and their tissue engineering applications, but also provides new insights for the clinical translation of 3D bioprinted tissues to aid in prompting the future development of orthopedic implants. STATEMENT OF SIGNIFICANCE: 3D bioprinting has driven major innovations in the field of tissue engineering and regenerative medicine; aiming to develop a functional viable tissue construct that provides an alternative regenerative therapy for musculoskeletal tissue regeneration. 3D bioprinting-based biofabrication strategies could open new clinical possibilities for creating equivalent tissue substitutes with the ability to customize them to meet patient demands. In this review, we summarize the significance and recent advances in 3D bioprinting technology and advanced bioinks. We highlight the rationale for biofabrication strategies using 3D bioprinting for orthopedic tissue engineering applications. Furthermore, we offer ample perspective and new insights into the current challenges and future direction of orthopedic bioprinting translation research.

Sex-based Difference in Response to Recombinant Human Bone Morphogenetic Protein-2 in a Rat Posterolateral Fusion Model

STUDY DESIGN

This was a preclinical study.

OBJECTIVE

Evaluate sex-dependent differences in the bone healing response to recombinant human bone morphogenetic protein-2 (rhBMP-2) in a rat posterolateral spinal fusion model.

SUMMARY OF BACKGROUND DATA

Minimal and conflicting data exist concerning potential sex-dependent differences in rhBMP-2-mediated bone regeneration in the context of spinal fusion.

MATERIALS AND METHODS

Forty-eight female and male Sprague-Dawley rats (N=24/group), underwent L4-L5 posterolateral fusion with bilateral placement of an absorbable collagen sponge, each loaded with 5 µg of bone morphogenetic protein-2 (10 µg/animal). At eight weeks postoperative, 10 specimens of each sex were tested in flexion-extension with quantification of range of motion and stiffness. The remaining specimens were evaluated for new bone growth and successful fusion via radiography, blinded manual palpation and microcomputed tomography (microCT). Laboratory microCT quantified bone microarchitecture, and synchrotron microCT examined bone microstructure at the 1 µm level.

RESULTS

Manual palpation scores differed significantly between sexes, with mean fusion scores of 2.4±0.4 in females versus 3.1±0.6 in males ( P <0.001). Biomechanical stiffness did not differ between sexes, but range of motion was significantly greater and more variable for females versus males (3.7±5.6° vs. 0.27±0.15°, P <0.005, respectively). Laboratory microCT showed significantly smaller volumes of fusion masses in females versus males (262±87 vs. 732±238 mm 3 , respectively, P <0.001) but significantly higher bone volume fraction (0.27±0.08 vs. 0.12±0.05, respectively, P <0.001). Mean trabecular thickness was not different, but trabecular number was significantly greater in females (3.1±0.5 vs. 1.5±0.4 mm -1 , respectively, P <0.001). Synchrotron microCT showed fine bone structures developing in both sexes at the eight-week time point.

CONCLUSIONS

This study demonstrates sex-dependent differences in bone regeneration induced by rhBMP-2. Further investigation is needed to uncover the extent of and mechanisms underlying these sex differences, particularly at different doses of rhBMP-2.

Crystal Growth of 3D Poly(ε-caprolactone) Based Bone Scaffolds and Its Effects on the Physical Properties and Cellular Interactions

Extrusion additive manufacturing is widely used to fabricate polymer-based 3D bone scaffolds. However, the insight views of crystal growths, scaffold features and eventually cell-scaffold interactions are still unknown. In this work, melt and solvent extrusion additive manufacturing techniques are used to produce scaffolds considering highly analogous printing conditions. Results show that the scaffolds produced by these two techniques present distinct physiochemical properties, with melt-printed scaffolds showing stronger mechanical properties and solvent-printed scaffolds showing rougher surface, higher degradation rate, and faster stress relaxation. These differences are attributed to the two different crystal growth kinetics, temperature-induced crystallization (TIC) and strain-induced crystallization (SIC), forming large/integrated spherulite-like and a small/fragmented lamella-like crystal regions respectively. The stiffer substrate of melt-printed scaffolds contributes to higher ratio of nuclear Yes-associated protein (YAP) allocation, favoring cell proliferation and differentiation. Faster relaxation and degradation of solvent-printed scaffolds result in dynamic surface, contributing to an early-stage faster osteogenesis differentiation.

3D-printed NIR-responsive shape memory polyurethane/magnesium scaffolds with tight-contact for robust bone regeneration

Patients with bone defects suffer from a high rate of disability and deformity. Poor contact of grafts with defective bones and insufficient osteogenic activities lead to increased loose risks and unsatisfied repair efficacy. Although self-expanding scaffolds were developed to enhance bone integration, the limitations on the high transition temperature and the unsatisfied bioactivity hindered greatly their clinical application. Herein, we report a near-infrared-responsive and tight-contacting scaffold that comprises of shape memory polyurethane (SMPU) as the thermal-responsive matrix and magnesium (Mg) as the photothermal and bioactive component, which fabricated by the low temperature rapid prototyping (LT-RP) 3D printing technology. As designed, due to synergistic effects of the components and the fabrication approach, the composite scaffold possesses a homogeneously porous structure, significantly improved mechanical properties and stable photothermal effects. The programmed scaffold can be heated to recover under near infrared irradiation in 60s. With 4 wt% Mg, the scaffold has the balanced shape fixity ratio of 93.6% and shape recovery ratio of 95.4%. The compressed composite scaffold could lift a 100 g weight under NIR light, which was more than 1700 times of its own weight. The results of the push-out tests and the finite element analysis (FEA) confirmed the tight-contacting ability of the SMPU/4 wt%Mg scaffold, which had a signficant enhancement compared to the scaffold without shape memory effects. Furthermore, The osteopromotive function of the scaffold has been demonstrated through a series of in vitro and in vivo studies. We envision this scaffold can be a clinically effective strategy for robust bone regeneration.

3D printed hydroxyapatite - Zn2+ functionalized starch composite bone grafts for orthopedic and dental applications

Hydroxyapatite (HA) - polymer composite based 3D printed bone grafts require extensive mechanical and biological property optimization for specific clinical needs. This fuels the need to develop innovative methods of optimization. Using an in-house extrusion-based 3D printer, we show the feasibility of fabricating hydroxyapatite- Zn2+ functionalized starch composites as artificial bone graft substitutes. The experimental procedure for this purpose is fortified with a univariate multi-objective optimization strategy to predict the best composition. The compressive strength of the grafts improves up to ~ 4 folds by parametric optimization and Zn2+ functionalization, without any post-processing. These grafts maintain mechanical integrity and strength during 6 weeks of dissolution study in simulated body fluid (SBF), while the non -functionalized starch-HA grafts fully degrade within a week. The Zn2+ functionalization results in up to ~ 79% antibacterial efficacy against S. aureus. Osteoblast cell viability increases ~ 1.6 folds on these graft surfaces on day 11. Our innovative methods of optimization are expected to reduce the experiment time, cost, and chance of human error in 3D printing. This study redefines the importance of understanding composition and process dependence for making a functionalized 3D printed bone graft for repairing low load-bearing defects such as craniomaxillofacial bone.

3D printing of inorganic-biopolymer composites for bone regeneration

In most cases, bone injuries heal without complications, however, there is an increasing number of instances where bone healing needs major clinical intervention. Available treatment options have severe drawbacks, such as donor site morbidity and limited availability for autografting. Bone graft substitutes containing growth factors would be a viable alternative, however they have been associated with dose-related safety concerns and lack control over spatial architecture to anatomically match bone defect sites. 3D printing offers a solution to produce patient specific bone graft substitutes that are customized to the patient bone defect with temporal control over the incorporated therapeutics to maximize their efficacy. Inspired by the natural constitution of bone tissue, composites made of inorganic phases, such as nanosilicate particles, calcium phosphate, and bioactive glasses, combined with biopolymer matrices have been investigated as building blocks for the biofabrication of bone constructs. Besides capturing elements of the bone physiological structure, these inorganic/organic composites can be designed for specific cohesivity, rheological and mechanical properties, while both inorganic and organic constituents contribute to the composite bioactivity. This review provides an overview of 3D printed composite biomaterial-inks for bone tissue engineering. Furthermore, key aspects in biomaterial-ink design, 3D printing techniques, and the building blocks for composite biomaterial-inks are summarized.

Tailorable 3DP Flexible Scaffolds with Porosification of Filaments Facilitate Cell Ingrowth and Biomineralized Deposition

Facilitating cell ingrowth and biomineralized deposition inside filaments of 3DP scaffolds are an ideal bone repair strategy. Here, 3D printed PLGA/HA scaffolds with hydroxyapatite content of 50% (P5H5) and 70% (P3H7) were prepared by optimizing 3D printing inks, which exhibited good tailorability and foldability to meet clinical maneuverability. The supercritical CO2 foaming technology further endowed the filaments of P5H5 with a richer interconnected pore structure (P5H5-C). The finite element and computational fluid dynamics simulation analysis indicated that the porosification could effectively reduce the stress concentration at the filament junction and improved the overall permeability of the scaffold. The results of in vitro experiments confirmed that P5H5-C promoted the adsorption of proteins on the surface and inside of filaments, accelerated the release of Ca and P ions, and significantly upregulated osteogenesis (Col I, ALP, and OPN)- and angiogenesis (VEGF)-related gene expression. Subcutaneous ectopic osteogenesis experiments in nude mice further verified that P5H5-C facilitated cell growth inside filaments and biomineralized deposition, as well as significantly upregulated the expression of osteogenesis- and angiogenesis-related genes (Col I, ALP, OCN, and VEGF) and protein secretion (ALP, RUNX2, and VEGF). The porosification of filaments by supercritical CO2 foaming provided a new strategy for accelerating osteogenesis of 3DP implants.

Effect of high content nanohydroxyapatite composite scaffolds prepared via melt extrusion additive manufacturing on the osteogenic differentiation of human mesenchymal stromal cells

The field of bone tissue engineering seeks to mimic the bone extracellular matrix composition, balancing the organic and inorganic components. In this regard, additive manufacturing (AM) of high content calcium phosphate (CaP)-polymer composites holds great promise towards the design of bioactive scaffolds. Yet, the biological performance of such scaffolds is still poorly characterized. In this study, melt extrusion AM (ME-AM) was used to fabricate poly(ethylene oxide terephthalate)/poly(butylene terephthalate) (PEOT/PBT)-nanohydroxyapatite (nHA) scaffolds with up to 45 wt% nHA, which presented significantly enhanced compressive mechanical properties, to evaluate their in vitro osteogenic potential as a function of nHA content. While osteogenic gene upregulation and matrix mineralization were observed on all scaffold types when cultured in osteogenic media, human mesenchymal stromal cells did not present an explicitly clear osteogenic phenotype, within the evaluated timeframe, in basic media cultures (i.e. without osteogenic factors). Yet, due to the adsorption of calcium and inorganic phosphate ions from cell culture media and simulated body fluid, the formation of a CaP layer was observed on PEOT/PBT-nHA 45 wt% scaffolds, which is hypothesized to account for their bone forming ability in the long term in vitro, and osteoconductivity in vivo.

Zinc curcumin complex on fluoride doped hydroxyapatite with enhanced biological properties for dental and orthopedic applications

Since antiquity, curcumin, from turmeric is utilized in traditional Indian medicine (Ayurveda) to treat bone disorders. However, the hydrophobic nature and poor absorption of curcumin limit its clinical applications. There is a need to develop a novel strategy that can significantly enhance curcumin's biological properties. The current work reports the utilization of Zn²⁺-curcumin complex from a fluoride doped hydroxyapatite matrix for osteosarcoma inhibition, osteoblast growth, and anti-bacterial properties. The interaction between Zn²⁺ and curcumin increases curcumin release by ~ 2.5 folds. The fabricated drug delivery system shows up to ~ 1.6 times enhancement in osteoblast cell viability. The presence of curcumin results in ~ 4 times more osteosarcoma inhibition compared to control. The antibacterial efficacy of this system is confirmed against Staphylococcus aureus, due to the presence of antibacterial fluoride, zinc, and curcumin. This multifunctional drug delivery system can be utilized for various bone-tissue engineering and dental applications.

Pearl-inspired graphene oxide-collagen microgel with multi-layer mineralization through microarray chips for bone defect repair

Biomineralization of natural polymers in simulated body fluid (SBF) can significantly improve its biocompatibility, osteoconductivity, and osteoinductivity because of the hydroxyapatite (HAp) deposition. Nevertheless, the superficial HAp crystal deposition hamper the deep inorganic ions exchange in porous microgels, thus gradually leading to a nonuniform regeneration effect. Inspired by the pearl forming process, this article uses the microarray chips to fabricate the multi-layer mineralized graphene oxide (GO)-collagen (Col)-hydroxyapatite (HAp) microgel, denoted as MMGCH. These fabricated MMGCH microgels exhibit porous structure and uniform HAp distribution. Furthermore, the suitable microenvironment offered by microgel promotes the time-dependent proliferation and osteogenic differentiation of stem cells, which resulted in upregulated osteogenesis-related genes and proteins, such as alkaline phosphatase, osteocalcin, and collagen-1. Finally, the MMGCH microgels possess favorable bone regeneration capacities both in cranial bone defects and mandibular bone defects via providing a suitable microenvironment for host-derived cells to form new bone tissues. This work presents a biomimetic means aiming to achieve full-thickness and uniform HAp deposition in hydrogel for bone defect repair.

Materials Used in Cranial Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

Cranioplasty is a common neurological procedure with complication rates ranging from 20% to 50%. It is hypothesized that the risks of various complications are impacted by which material is used for cranioplasty.

OBJECTIVE

To evaluate existing literature comparing rates of complications following cranioplasty using different materials including autologous bone, hydroxyapatite, methyl methacrylate (MMA), demineralized bone matrix, polyetheretherketone, titanium, or composite materials.

METHODS

PubMed/MEDLINE database was searched for relevant articles published between 2010 and 2020. After screening, 35 articles were included. Outcomes included infection, wound problems, poor cosmesis, overall complications, duration of surgery, and length of stay. For each outcome, a frequentist network meta-analysis was conducted to compare materials used.

RESULTS

The risk of infection was 1.62 times higher when MMA was used compared to autologous bone (RR 1.62, 95% CI 1.07 to 2.45). Length of stay following cranioplasty was on average 3.62 days shorter when titanium was used compared autologous bone (95% CI -6.26 to -0.98). The networks constructed for other outcomes demonstrated moderate to substantial between-study heterogeneity, wide confidence intervals, and no significant differences between materials.

CONCLUSIONS

The quality of existing literature on this topic is relatively poor, almost exclusively comprised of single-center retrospective studies. There is currently not strong enough evidence available to make comprehensive conclusions regarding the risk-profiles of various cranioplasty materials across multiple outcomes. Prospective randomized trials are necessary to confirm the significant results found in this analysis and to further elucidate the differential risks of various cranioplasty materials.

Evaluation of imaging setups for quantitative phase contrast nanoCT of mineralized biomaterials

X-ray nano-tomography with phase contrast (nanoCT) using synchrotron radiation is a powerful tool to non-destructively investigate 3D material properties at the nanoscale. In large bone lesions, such as severe bone fractures, bone cancer or other diseases, bone grafts substituting the lost bone might be necessary. Such grafts can be of biological origin or be composed of a synthetic bone substitute. The long-term functioning of artificial bone substitutes depends on many factors. Synchrotron nanoCT imaging has great potential to contribute to further the understanding of integration of implants into bone tissue by imaging the spatial interaction between bone tissue and implant, and by accessing the interface between implant material and bone tissue. With this aim, a methodology for evaluating the image quality is presented for in-line phase contrast nanoCT images of bone scaffold samples. A PMMA-embedded tricalcium phosphate scaffold was used with both a closed and an open porosity structure and bone ingrowths as a representative system of three known materials. Parameters such as spatial resolution and signal-to-noise ratio were extracted and used to explore and quantitatively compare the effects of implementation choices in the imaging setup, such as camera technology and imaging energy, on the resulting image quality. Increasing the X-ray energy from 17.5 keV to 29.6 keV leads to a notable improvement in image quality regardless of the camera technology used, with the two tested camera setups performing at a comparable level when the recorded intensity was kept constant.