3D printed bioceramics for dual antibiotic delivery to treat implant-associated bone infection

Cutibacterium acnes invades submicron osteocyte lacuno-canalicular networks following implant-associated osteomyelitis

Cutibacterium acnes, part of normal skin flora, is increasingly recognized as an opportunistic pathogen capable of causing chronic prosthetic joint infections (PJI) associated with total hip and knee arthroplasty. However, there is a paucity of literature examining the pathogenesis of C. acnes during PJI. To study this, we developed an implant-associated osteomyelitis murine model in which 8-10-week-old C57BL6 mice were subjected to transtibial implantation of titanium or stainless-steel L-shaped pins contaminated with C. acnes. Postsurgery, mice were killed on Days 14 and 28 for terminal assessments of (1) bacterial load in bone, implant, and internal organs (heart, spleen, kidney, and liver), (2) bone osteolysis (micro-CT), (3) abscess formation (histology), and (4) systematic electron microscopy (EM). In vitro scanning EM (SEM) confirmed that C. acnes can form biofilms on stainless-steel and titanium implants. In mice, C. acnes could persist for 28 days in the tibia. Also, we observed C. acnes dissemination to internal organs. C. acnes chronic osteomyelitis revealed markedly reduced bone osteolysis and abscess formation compared to Staphylococcus aureus infections. Importantly, transmission EM (TEM) investigation revealed the presence of C. acnes within canaliculi, demonstrating that C. acnes can invade the osteocyte lacuno-canalicular networks (OLCN) within bone. Our preliminary pilot study, for the first time, revealed that the OLCN in bone can be a reservoir for C. acnes and potentially provides a novel mechanism of why C. acnes chronic implant-associated bone infections are difficult to treat.

Drug delivery strategies through 3D-printed calcium phosphate

3D printing has revolutionized bone tissue engineering (BTE) by enabling the fabrication of patient- or defect-specific scaffolds to enhance bone regeneration. The superior biocompatibility, customizable bioactivity, and biodegradability have enabled calcium phosphate (CaP) to gain significance as a bone graft material. 3D-printed (3DP) CaP scaffolds allow precise drug delivery due to their porous structure, adaptable structure-property relationship, dynamic chemistry, and controlled dissolution. The effectiveness of conventional scaffold-based drug delivery is hampered by initial burst release and drug loss. This review summarizes different multifunctional drug delivery approaches explored in controlling drug release, including polymer coatings, formulation integration, microporous scaffold design, chemical crosslinking, and direct extrusion printing for BTE applications. The review also outlines perspectives and future challenges in drug delivery research, paving the way for next-generation bone repair methodologies.

Artificial Intelligence-Based 3D Printing Strategies for Bone Scaffold Fabrication and Its Application in Preclinical and Clinical Investigations

3D printing has become increasingly popular in the field of bone tissue engineering. However, the mechanical properties, biocompatibility, and porosity of the 3D printed bone scaffolds are major requirements for tissue regeneration and implantation as well. Designing the scaffold architecture in accordance with the need to create better mechanical and biological stimuli is necessary to achieve unique scaffold properties. To accomplish this, different 3D designing strategies can be utilized with the help of the scaffold design library and artificial intelligence (AI). The implementation of AI to assist the 3D printing process can enable it to predict, adapt, and control the parameters on its own, which lowers the risk of errors. This Review emphasizes 3D design and fabrication of bone scaffold using different materials and the use of AI-aided 3D printing strategies. Also, the adaption of AI to 3D printing helps to develop patient-specific scaffolds based on different requirements, thus providing feedback and adequate data for reproducibility, which can be improvised in the future. These printed scaffolds can also serve as an alternative to preclinical animal test models to cut costs and prevent immunological interference.

Rising role of 3D-printing in delivery of therapeutics for infectious disease

Modern drug delivery to tackle infectious disease has drawn close to personalizing medicine for specific patient populations. Challenges include antibiotic-resistant infections, healthcare associated infections, and customizing treatments for local patient populations. Recently, 3D-printing has become a facilitator for the development of personalized pharmaceutic drug delivery systems. With a variety of manufacturing techniques, 3D-printing offers advantages in drug delivery development for controlled, fine-tuned release and platforms for different routes of administration. This review summarizes 3D-printing techniques in pharmaceutics and drug delivery focusing on treating infectious diseases, and discusses the influence of 3D-printing design considerations on drug delivery platforms targeting these diseases. Additionally, applications of 3D-printing in infectious diseases are summarized, with the goal to provide insight into how future delivery innovations may benefit from 3D-printing to address the global challenges in infectious disease.

A Nanoporous 3D-Printed Scaffold for Local Antibiotic Delivery

Limitations of bone defect reconstruction include poor bone healing and osteointegration with acrylic cements, lack of strength with bone putty/paste, and poor osteointegration. Tissue engineering aims to bridge these gaps through the use of bioactive implants. However, there is often a risk of infection and biofilm formation associated with orthopedic implants, which may develop anti-microbial resistance. To promote bone repair while also locally delivering therapeutics, 3D-printed implants serve as a suitable alternative. Soft, nanoporous 3D-printed filaments made from a thermoplastic polyurethane and polyvinyl alcohol blend, LAY-FOMM and LAY-FELT, have shown promise for drug delivery and orthopedic applications. Here, we compare 3D printability and sustained antibiotic release kinetics from two types of commercial 3D-printed porous filaments suitable for bone tissue engineering applications. We found that both LAY-FOMM and LAY-FELT could be consistently printed into scaffolds for drug delivery. Further, the materials could sustainably release Tetracycline over 3 days, independent of material type and infill geometry. The drug-loaded materials did not show any cytotoxicity when cultured with primary human fibroblasts. We conclude that both LAY-FOMM and LAY-FELT 3D-printed scaffolds are suitable devices for local antibiotic delivery applications, and they may have potential applications to prophylactically reduce infections in orthopedic reconstruction surgery.

Fabrication of injectable antibiotic-loaded apatitic bone cements with prolonged drug delivery for treating post-surgery infections

Antibiotic-loaded bioactive bone substitutes are widely used for treating various orthopedic diseases and prophylactically to avoid post implantation infection. Calcium deficient hydroxyapatite (also known as apatitic bone cement) is a potential bioactive bone substitute in orthopedics due to its chemical composition similar to that of natural bone minerals. In this study, fabrication of mannitol (a solid porogen) incorporated injectable synthetic (Syn) and eggshell derived (ESD) apatitic bone cements loaded with antibiotics (gentamicin/meropenem/ rifampicin/vancomycin) was investigated. The release kinetics of the antibiotics were studied by fitting them with different kinetic models. All the antibiotics-loaded apatitic bone cements set within clinically accepted setting time (20 ± 2 min) and with good injectability (>70%). The antibiotics released from these bone cements were found to be controlled and sustained throughout the study time. Weibull and Gompertz (applies in least initial burst and sustain drug release rate models) were the best models to predict the release behavior. They cements had acceptable compressive strength (6-10 MPa; in the range of trabecular bone) and were biodegradable (21%-27% within 12 weeks of incubation) in vitro in simulated body fluids at physiological conditions. These bone cements showed excellent antibacterial activity from day 1 onwards and no bacterial colony was found from day 3 onwards. The viability of MG63 cells in vitro after 72 h was significantly higher after 24 h (i.e., ~110%). The cells were well attached and spread over the surface of the cements with extended morphology. The ESD antibiotic-loaded apatitic bone cements showed better injectability, degradation and cytocompatibility compared when compared to Syn antibiotic-loaded apatitic bone cements. Thus, we believe that the ESD antibiotic-loaded apatitic bone cements are suitable as potential injectable bone substitutes to avoid post-operative implant associated and other acute or chronic bone infections.

Rapid Prototyping Technologies: 3D Printing Applied in Medicine

Three-dimensional printing technology has been used for more than three decades in many industries, including the automotive and aerospace industries. So far, the use of this technology in medicine has been limited only to 3D printing of anatomical models for educational and training purposes, which is due to the insufficient functional properties of the materials used in the process. Only recent advances in the development of innovative materials have resulted in the flourishing of the use of 3D printing in medicine and pharmacy. Currently, additive manufacturing technology is widely used in clinical fields. Rapid development can be observed in the design of implants and prostheses, the creation of biomedical models tailored to the needs of the patient and the bioprinting of tissues and living scaffolds for regenerative medicine. The purpose of this review is to characterize the most popular 3D printing techniques.

Engineering 3D-Printed Advanced Healthcare Materials for Periprosthetic Joint Infections

The use of additive manufacturing or 3D printing in biomedicine has experienced fast growth in the last few years, becoming a promising tool in pharmaceutical development and manufacturing, especially in parenteral formulations and implantable drug delivery systems (IDDSs). Periprosthetic joint infections (PJIs) are a common complication in arthroplasties, with a prevalence of over 4%. There is still no treatment that fully covers the need for preventing and treating biofilm formation. However, 3D printing plays a major role in the development of novel therapies for PJIs. This review will provide a deep understanding of the different approaches based on 3D-printing techniques for the current management and prophylaxis of PJIs. The two main strategies are focused on IDDSs that are loaded or coated with antimicrobials, commonly in combination with bone regeneration agents and 3D-printed orthopedic implants with modified surfaces and antimicrobial properties. The wide variety of printing methods and materials have allowed for the manufacture of IDDSs that are perfectly adjusted to patients' physiognomy, with different drug release profiles, geometries, and inner and outer architectures, and are fully individualized, targeting specific pathogens. Although these novel treatments are demonstrating promising results, in vivo studies and clinical trials are required for their translation from the bench to the market.

3D Printed Materials for Combating Antimicrobial Resistance

Three-dimensional (3D) printing is a rapidly growing technology with a significant capacity for translational applications in both biology and medicine. 3D-printed living and non-living materials are being widely tested as a potential replacement for conventional solutions for testing and combating antimicrobial resistance (AMR). The precise control of cells and their microenvironment, while simulating the complexity and dynamics of an in vivo environment, provides an excellent opportunity to advance the modeling and treatment of challenging infections and other health conditions. 3D-printing models the complicated niches of microbes and host-pathogen interactions, and most importantly, how microbes develop resistance to antibiotics. In addition, 3D-printed materials can be applied to testing and delivering antibiotics. Here, we provide an overview of 3D printed materials and biosystems and their biomedical applications, focusing on ever increasing AMR. Recent applications of 3D printing to alleviate the impact of AMR, including developed bioprinted systems, targeted bacterial infections, and tested antibiotics are presented.

Review of Physical, Mechanical, and Biological Characteristics of 3D-Printed Bioceramic Scaffolds for Bone Tissue Engineering Applications

This review focuses on the advancements in additive manufacturing techniques that are utilized for fabricating bioceramic scaffolds and their characterizations leading to bone tissue regeneration. Bioscaffolds are made by mimicking the human bone structure, material composition, and properties. Calcium phosphate apatite materials are the most commonly used scaffold materials as they closely resemble live bone in their inorganic composition. The functionally graded scaffolds are fabricated by utilizing the right choice of the 3D printing method and material combinations to achieve the requirement of the bioscaffold. To tailor the physical, mechanical, and biological properties of the scaffold, certain materials are reinforced, doped, or coated to incorporate the functionality. The biomechanical loading conditions that involve flexion, torsion, and tension exerted on the implanted scaffold are discussed. The finite element analysis (FEA) technique is used to investigate the mechanical property of the scaffold before fabrication. This helps in reducing the actual number of samples used for testing. The FEA simulated results and the experimental result are compared. This review also highlights some of the challenges associated while processing the scaffold such as shrinkage, mechanical instability, cytotoxicity, and printability. In the end, the new materials that are evolved for tissue engineering applications are compiled and discussed.

Current therapeutic interventions combating biofilm-related infections in orthopaedics : a systematic review of in vivo animal studies

Aims

Biofilm-related infection is a major complication that occurs in orthopaedic surgery. Various treatments are available but efficacy to eradicate infections varies significantly. A systematic review was performed to evaluate therapeutic interventions combating biofilm-related infections on in vivo animal models.

Methods

Literature research was performed on PubMed and Embase databases. Keywords used for search criteria were “bone AND biofilm”. Information on the species of the animal model, bacterial strain, evaluation of biofilm and bone infection, complications, key findings on observations, prevention, and treatment of biofilm were extracted.

Results

A total of 43 studies were included. Animal models used included fracture-related infections (ten studies), periprosthetic joint infections (five studies), spinal infections (three studies), other implant-associated infections, and osteomyelitis. The most common bacteria were Staphylococcus species. Biofilm was most often observed with scanning electron microscopy. The natural history of biofilm revealed that the process of bacteria attachment, proliferation, maturation, and dispersal would take 14 days. For systemic mono-antibiotic therapy, only two of six studies using vancomycin reported significant biofilm reduction, and none reported eradication. Ten studies showed that combined systemic and topical antibiotics are needed to achieve higher biofilm reduction or eradication, and the effect is decreased with delayed treatment. Overall, 13 studies showed promising therapeutic potential with surface coating and antibiotic loading techniques.

Conclusion

Combined topical and systemic application of antimicrobial agents effectively reduces biofilm at early stages. Future studies with sustained release of antimicrobial and biofilm-dispersing agents tailored to specific pathogens are warranted to achieve biofilm eradication.

Cite this article: Bone Joint Res 2022;11(10):700–714.

Customised 3D printed multi-drug systems: An effective and efficient approach to polypharmacy

INTRODUCTION

Combination therapies continue to improve therapeutic outcomes as currently achieved by polypharmacy. Since the introduction of the polypill, there has been a significant improvement in adherence and patient outcomes. However, the mass production of polypills presents a number of technical, formulation, and clinical challenges. The current one-size-fits-all approach ignores the unique clinical demands of patients, necessitating the adoption of a more versatile tool. That will be the novel, but not so novel, 3D printing.

AREAS COVERED

: The present review investigates this promising paradigm shift from one medication for all, to customised medicines, providing an overview of the current state of 3D-printed multi-active pharmaceutical forms, techniques applied and printing materials. Details on cost implications, as well as potential limitations and challenges are also elaborated.

EXPERT OPINION

: 3D printing of multi-active systems, is not only beneficial but also essential. With growing interest in this field, a shift in manufacturing, prescribing, and administration patterns is at this point, unavoidable. Addressing limitations and challenges, as well as data presentation on clinical trial results, will aid in the acceleration of this technology's implementation. However, it is clear that 3D printing is not the end of it, as evidenced by the emerging 4D printing technology.

3D printing of bioactive materials for drug delivery applications

INTRODUCTION

Three-dimensional (3D) printing, also known as additive manufacturing (AM), is a modern technique/technology, which makes it possible to construct 3D objects from computer-aided design (CAD) digital models. This technology can be used in the progress of drug delivery systems, where porosity has played important role in attaining an acceptable level of biocompatibility and biodegradability with improved therapeutic effects. 3D printing may also provide the user possibility to control the dosage of each ingredient in order to a specific purpose, and makes it probable to improve the formulation of drug delivery systems.

AREAS COVERED

This article covers the 3D printing technologies, bioactive materials including natural and synthetic polymers as well as some ceramics and minerals and their roles in drug delivery systems.

EXPERT OPINION

This technology is feasible to fabricate drug products by incorporating multiple drugs in different parts in such a mode that these drugs can release from the section at a predetermined rate. Furthermore, this 3D printing technology has the possible to transform personalized therapy to various age-groups by design flexibility and precise dosing. In recent years, the potential use of this technology can be realized in a clinical situation where patients will acquire individualized medicine as per their require.

Role of Animal Models to Advance Research of Bacterial Osteomyelitis

Osteomyelitis is an inflammatory bone disease typically caused by infectious microorganisms, often bacteria, which causes progressive bone destruction and loss. The most common bacteria associated with chronic osteomyelitis is Staphylococcus aureus. The incidence of osteomyelitis in the United States is estimated to be upwards of 50,000 cases annually and places a significant burden upon the healthcare system. There are three general categories of osteomyelitis: hematogenous; secondary to spread from a contiguous focus of infection, often from trauma or implanted medical devices and materials; and secondary to vascular disease, often a result of diabetic foot ulcers. Independent of the route of infection, osteomyelitis is often challenging to diagnose and treat, and the effect on the patient's quality of life is significant. Therapy for osteomyelitis varies based on category and clinical variables in each case. Therapeutic strategies are typically reliant upon protracted antimicrobial therapy and surgical interventions. Therapy is most successful when intensive and initiated early, although infection may recur months to years later. Also, treatment is accompanied by risks such as systemic toxicity, selection for antimicrobial drug resistance from prolonged antimicrobial use, and loss of form or function of the affected area due to radical surgical debridement or implant removal. The challenges of diagnosis and successful treatment, as well as the negative impacts on patient's quality of life, exemplify the need for improved strategies to combat bacterial osteomyelitis. There are many in vitro and in vivo investigations aimed toward better understanding of the pathophysiology of bacterial osteomyelitis, as well as improved diagnostic and therapeutic strategies. Here, we review the role of animal models utilized for the study of bacterial osteomyelitis and their critically important role in understanding and improving the management of bacterial osteomyelitis.

Using scaffolds as drug delivery systems to treat bone tumor

Surgery is the principal strategy to treat osteosarcoma and other types of bone tumors, but it causes bone defects that cannot be healed spontaneously. After surgery, patients still need to receive radiotherapy and/or chemotherapy to prevent tumor recurrence and metastasis, which leads to systemic side effects. Bone scaffolds exhibit the potentials to load cargos (drugs or growth factors) and act as drug delivery systems (DDSs) in the osteosarcoma postoperative treatment. This review introduces current types of bone scaffolds and highlights representative works using scaffolds as DDSs to treat osteosarcomas. Challenges and perspectives in the scaffold-based DDSs are also discussed. This review may provide references to develop effective and safe strategies for osteosarcoma postoperative treatment.

Recent Advances in the Evaluation of Antimicrobial Materials for Resolution of Orthopedic Implant-Associated Infections In Vivo

While orthopedic implant-associated infections are rare, revision surgeries resulting from infections incur considerable healthcare costs and represent a substantial research area clinically, in academia, and in industry. In recent years, there have been numerous advances in the development of antimicrobial strategies for the prevention and treatment of orthopedic implant-associated infections which offer promise to improve the limitations of existing delivery systems through local and controlled release of antimicrobial agents. Prior to translation to in vivo orthopedic implant-associated infection models, the properties (e.g., degradation, antimicrobial activity, biocompatibility) of the antimicrobial materials can be evaluated in subcutaneous implant in vivo models. The antimicrobial materials are then incorporated into in vivo implant models to evaluate the efficacy of using the material to prevent or treat implant-associated infections. Recent technological advances such as 3D-printing, bacterial genomic sequencing, and real-time in vivo imaging of infection and inflammation have contributed to the development of preclinical implant-associated infection models that more effectively recapitulate the clinical presentation of infections and improve the evaluation of antimicrobial materials. This Review highlights the advantages and limitations of antimicrobial materials used in conjunction with orthopedic implants for the prevention and treatment of orthopedic implant-associated infections and discusses how these materials are evaluated in preclinical in vivo models. This analysis serves as a resource for biomaterial researchers in the selection of an appropriate orthopedic implant-associated infection preclinical model to evaluate novel antimicrobial materials.

Ink-jet 3D printing as a strategy for developing bespoke non-eluting biofilm resistant medical devices

Chronic infection as a result of bacterial biofilm formation on implanted medical devices is a major global healthcare problem requiring new biocompatible, biofilm-resistant materials. Here we demonstrate how bespoke devices can be manufactured through ink-jet-based 3D printing using bacterial biofilm inhibiting formulations without the need for eluting antibiotics or coatings. Candidate monomers were formulated and their processability and reliability demonstrated. Formulations for in vivo evaluation of the 3D printed structures were selected on the basis of their in vitro bacterial biofilm inhibitory properties and lack of mammalian cell cytotoxicity. In vivo in a mouse implant infection model, Pseudomonas aeruginosa biofilm formation on poly-TCDMDA was reduced by ~99% when compared with medical grade silicone. Whole mouse bioluminescence imaging and tissue immunohistochemistry revealed the ability of the printed device to modulate host immune responses as well as preventing biofilm formation on the device and infection of the surrounding tissues. Since 3D printing can be used to manufacture devices for both prototyping and clinical use, the versatility of ink-jet based 3D-printing to create personalised functional medical devices is demonstrated by the biofilm resistance of both a finger joint prosthetic and a prostatic stent printed in poly-TCDMDA towards P. aeruginosa and Staphylococcus aureus.

Recent advances in the local antibiotics delivery systems for management of osteomyelitis

Chronic osteomyelitis is a challenging disease due to its serious rates of mortality and morbidity while the currently available treatment strategies are suboptimal. In contrast to the adopted systemic treatment approaches after surgical debridement in chronic osteomyelitis, local drug delivery systems are receiving great attention in the recent decades. Local drug delivery systems using special carriers have the pros of enhancing the feasibility of penetration of antimicrobial agents to bone tissues, providing sustained release and localized concentrations of the antimicrobial agents in the infected area while avoiding the systemic side effects and toxicity. Most important, the incorporation of osteoinductive and osteoconductive materials in these systems assists bones proliferation and differentiation, hence the generation of new bone materials is enhanced. Some of these systems can also provide mechanical support for the long bones during the healing process. Most important, if the local systems are designed to be injectable to the affected site and biodegradable, they will reduce the level of invasion required for implantation and can win the patients’ compliance and reduce the healing period. They will also allow multiple injections during the course of therapy to guard against the side effect of the long-term systemic therapy. The current review presents different available approaches for delivering antimicrobial agents for the treatment of osteomyelitis focusing on the recent advances in researches for local delivery of antibiotics.

HIGHLIGHTS

Chronic osteomyelitis is a challenging disease due to its serious mortality and morbidity rates and limited effective treatment options.

Local drug delivery systems are receiving great attention in the recent decades.

Osteoinductive and osteoconductive materials in the local systems assists bones proliferation and differentiation

Local systems can be designed to provide mechanical support for the long bones during the healing process.

Designing the local system to be injectable to the affected site and biodegradable will reduces the level of invasion and win the patients’ compliance.

Exploiting Generative Design for 3D Printing of Bacterial Biofilm Resistant Composite Devices

As the understanding of disease grows, so does the opportunity for personalization of therapies targeted to the needs of the individual. To bring about a step change in the personalization of medical devices it is shown that multi-material inkjet-based 3D printing can meet this demand by combining functional materials, voxelated manufacturing, and algorithmic design. In this paper composite structures designed with both controlled deformation and reduced biofilm formation are manufactured using two formulations that are deposited selectively and separately. The bacterial biofilm coverage of the resulting composites is reduced by up to 75% compared to commonly used silicone rubbers, without the need for incorporating bioactives. Meanwhile, the composites can be tuned to meet user defined mechanical performance with ±10% deviation. Device manufacture is coupled to finite element modelling and a genetic algorithm that takes the user-specified mechanical deformation and computes the distribution of materials needed to meet this under given load constraints through a generative design process. Manufactured products are assessed against the mechanical and bacterial cell-instructive specifications and illustrate how multifunctional personalization can be achieved using generative design driven multi-material inkjet based 3D printing.

3D-Printing of Drug-Eluting Implants: An Overview of the Current Developments Described in the Literature

The usage of 3D-printing for drug-eluting implants combines the advantages of a targeted local drug therapy over longer periods of time at the precise location of the disease with a manufacturing technique that easily allows modifications of the implant shape to comply with the individual needs of each patient. Research until now has been focused on several aspects of this topic such as 3D-printing with different materials or printing techniques to achieve implants with different shapes, mechanical properties or release profiles. This review is intended to provide an overview of the developments currently described in the literature. The topic is very multifaceted and several of the investigated aspects are not related to just one type of application. Consequently, this overview deals with the topic of 3D-printed drug-eluting implants in the application fields of stents and catheters, gynecological devices, devices for bone treatment and surgical screws, antitumoral devices and surgical meshes, as well as other devices with either simple or complex geometry. Overall, the current findings highlight the great potential of the manufacturing of drug-eluting implants via 3D-printing technology for advanced individualized medicine despite remaining challenges such as the regulatory approval of individualized implants.

Recent Advances in 3D Printing for Parenteral Applications

3D printing has emerged as an advanced manufacturing technology in the field of pharmaceutical sciences. Despite much focus on enteral applications, there has been a lack of research focused on potential benefits of 3D printing for parenteral applications such as wound dressings, biomedical devices, and regenerative medicines. 3D printing technologies, including fused deposition modeling, vat polymerization, and powder bed printing, allow for rapid prototyping of personalized medications, capable of producing dosage forms with flexible dimensions based on patient anatomy as well as dosage form properties such as porosity. Considerations such as printing properties and material selection play a key role in determining overall printability of the constructs. These parameters also impact drug release kinetics, and mechanical properties of final printed constructs, which play a role in modulating immune response upon insertion in the body. Despite challenges in sterilization of printed constructs, additional post-printing processing procedures, and lack of regulatory guidance, 3D printing will continue to evolve to meet the needs of developing effective, personalized medicines for parenteral applications.

Regional gene therapy for bone healing using a 3D printed scaffold in a rat femoral defect model

At the present time there are no consistently satisfactory treatment options for some challenging bone loss scenarios. We have previously reported on the properties of a novel 3D-printed hydroxyapatite-composite material in a pilot study, which demonstrated osteoconductive properties but was not tested in a rigorous, clinically relevant model. We therefore utilized a rat critical-sized femoral defect model with a scaffold designed to match the dimensions of the bone defect. The scaffolds were implanted in the bone defect after being loaded with cultured rat bone marrow cells (rBMC) transduced with a lentiviral vector carrying the cDNA for BMP-2. This experimental group was compared against 3 negative and positive control groups. The experimental group and positive control group loaded with rhBMP-2 demonstrated statistically equivalent radiographic and histologic healing of the defect site (p > 0.9), and significantly superior to all three negative control groups (p < 0.01). However, the healed defects remained biomechanically inferior to the unoperated, contralateral femurs (p < 0.01). When combined with osteoinductive signals, the scaffolds facilitate new bone formation in the defect. However, the scaffold alone was not sufficient to promote adequate healing, suggesting that it is not substantially osteoinductive as currently structured. The combination of gene therapy with 3D-printed scaffolds is quite promising, but additional work is required to optimize scaffold geometry, cell dosage and delivery.

A Hyaluronic Acid Hydrogel Loaded with Gentamicin and Vancomycin Successfully Eradicates Chronic Methicillin-Resistant Staphylococcus aureus Orthopedic Infection in a Sheep Model

Implantable orthopedic devices have had an enormously positive impact on human health; however, despite best practice, patients are prone to developing orthopedic device-related infections (ODRI) that have high treatment failure rates. One barrier to the development of improved treatment options is the lack of an animal model that may serve as a robust preclinical assessment of efficacy. We present a clinically relevant large animal model of chronic methicillin-resistant Staphylococcus aureus (MRSA) ODRI that persists despite current clinical practice in medical and surgical treatment at rates equivalent to clinical observations. Furthermore, we showed that an injectable, thermoresponsive, hyaluronic acid-based hydrogel loaded with gentamicin and vancomycin outperforms current clinical practice treatment in this model, eliminating bacteria from all animals. These results confirm that local antibiotic delivery with an injectable hydrogel can dramatically increase treatment success rates beyond current clinical practice, with efficacy proven in a robust animal model.

Imminent antimicrobial bioink deploying cellulose, alginate, EPS and synthetic polymers for 3D bioprinting of tissue constructs

3D printing, one of its kinds has been a recent technological trend to fabricate complex and patterned biomaterial with controlled precision. With the conventional kick-start of printing metals and plastics, advancements in printing viable cells, polysaccharides or microbes themselves have been achieved. The additive antimicrobial properties in bioinks sourced from organic and inorganic materials have profound implications in tissue engineering. Cellulose, alginate, exopolysaccharides, ceramics and synthetic polymers are integrated as a viable component in inks and used for bio-printing. To date, bacterial infection and immunogenicity pose a potential health risk during a tissue implant or bone substitution. In order to mitigate microbial infection, antimicrobial bioinks with significant antimicrobial potential have been the much sought after strategies. This approach could be an effective frontline defense against microbial interference in tissue engineering and biomedical applications. An overview on the antimicrobial potential of polysaccharides as bioinks for 3D bioprinting has been critically reviewed.

Single-stage revision of MRSA orthopedic device-related infection in sheep with an antibiotic-loaded hydrogel

Local antimicrobial therapy is an integral aspect of treating orthopedic device-related infection (ODRI), which is conventionally administered via polymethyl-methacrylate (PMMA) bone cement. PMMA, however, is limited by a suboptimal antibiotic release profile and a lack of biodegradability. In this study, we compare the efficacy of PMMA versus an antibiotic-loaded hydrogel in a single-stage revision for chronic methicillin-resistant Staphylococcus aureus (MRSA) ODRI in sheep. Antibiofilm activity of the antibiotic combination (gentamicin and vancomycin) was determined in vitro. Swiss alpine sheep underwent a single-stage revision of a tibial intramedullary nail with MRSA infection. Local gentamicin and vancomycin therapy was delivered via hydrogel or PMMA (n = 5 per group), in conjunction with systemic antibiotic therapy. In vivo observations included: local antibiotic tissue concentration, renal and liver function tests, and quantitative microbiology on tissues and hardware post-mortem. There was a nonsignificant reduction in biofilm with an increasing antibiotic concentration in vitro (p = 0.12), confirming the antibiotic tolerance of the MRSA biofilm. In the in vivo study, four out of five sheep from each treatment group were culture-negative. Antibiotic delivery via hydrogel resulted in 10-100 times greater local concentrations for the first 2-3 days compared with PMMA and were comparable thereafter. Systemic concentrations of gentamicin were minimal or undetectable in both groups, while renal and liver function tests were within normal limits. This study shows that a single-stage revision with hydrogel or PMMA is equally effective, although the hydrogel offers certain practical benefits over PMMA, which make it an attractive proposition for clinical use.

New developments in anti-biofilm intervention towards effective management of orthopedic device related infections (ODRI's)

Orthopedic device related infections (ODRI's) represent a difficult to treat situation owing to their biofilm based nature. Biofilm infections once established are difficult to eradicate even with an aggressive treatment regimen due to their recalcitrance towards antibiotics and immune attack. The involvement of antibiotic resistant pathogens as the etiological agent further worsens the overall clinical picture, pressing on the need to look into alternative treatment strategies. The present review highlightes the microbiological challenges associated with treatment of ODRI's due to biofilm formation on the implant surface. Further, it details the newer anti-infective modalities that work either by preventing biofilm formation and/or through effective disruption of the mature biofilms formed on the medical implant. The study, therefore aims to provide a comprehensive insight into the newer anti-biofilm interventions (non-antibiotic approaches) and a better understanding of their mechanism of action essential for improved management of orthopedic implant infections.

Recent Developments of Biomaterials for Additive Manufacturing of Bone Scaffolds

Recent years have witnessed surging demand for bone repair/regeneration implants due to the increasing number of bone defects caused by trauma, cancer, infection, and arthritis worldwide. In addition to bone autografts and allografts, biomaterial substitutes have been widely used in clinical practice. Personalized implants with precise and personalized control of shape, porosity, composition, surface chemistry, and mechanical properties will greatly facilitate the regeneration of bone tissue and satiate the clinical needs. Additive manufacturing (AM) techniques, also known as 3D printing, are drawing fast growing attention in the fabrication of implants or scaffolding materials due to their capability of manufacturing complex and irregularly shaped scaffolds in repairing bone defects in clinical practice. This review aims to provide a comprehensive overview of recent progress in the development of materials and techniques used in the additive manufacturing of bone scaffolds. In addition, clinical application, pre-clinical trials and future prospects of AM based bone implants are also summarized and discussed.

An Antibiotic-Releasing Bone Void Filling (ABVF) Putty for the Treatment of Osteomyelitis

The number of total joint replacements (TJR) is on the rise with a corresponding increase in the number of infected TJR, which necessitates revision surgeries. Current treatments with either non-biodegradable, antibiotic-releasing polymethylmethacrylate (PMMA) based bone cement, or systemic antibiotic after surgical debridement do not provide effective treatment due to fluctuating antibiotic levels at the site of infection. Here, we report a biodegradable, easy-to-use "press-fitting" antibiotic-releasing bone void filling (ABVF) putty that not only provides efficient antibiotic release kinetics at the site of infection but also allows efficient osseointegration. The ABVF formulation was prepared using poly (D,L-lactide-co-glycolide) (PLGA), polyethylene glycol (PEG), and polycaprolactone (PCL) as the polymer matrix, antibiotic vancomycin, and osseointegrating synthetic bone PRO OSTEON for bone-growth support. ABVF was homogenous, had a porous structure, was moldable, and showed putty-like mechanical properties. The ABVF putty released vancomycin for 6 weeks at therapeutic level. Furthermore, the released vancomycin showed in vitro antibacterial activity against Staphylococcus aureus for 6 weeks. Vancomycin was not toxic to osteoblasts. Finally, ABVF was biodegradable in vivo and showed an effective infection control with the treatment group showing significantly higher bone growth (p < 0.001) compared to the control group. The potential of infection treatment and osseointegration makes the ABVF putty a promising treatment option for osteomyelitis after TJR.

Modulating antibiotic release from reservoirs in 3D-printed orthopedic devices to treat periprosthetic joint infection

Periprosthetic joint infection is a costly debilitating affliction following total joint arthroplasty. Despite a relatively low incidence rate, periprosthetic joint infection is an increasing problem due to a substantial increase in arthroplasty surgeries over time. The current treatment is replacing the primary implant with a temporary bone cement spacer that releases antibiotics over time. However, the spacer is mechanically weak with an ineffective antibiotic release. Alternatively, three-dimensional (3D)-printed reservoirs in high-strength devices have the potential to release antibiotics long term in a controlled manner. In this study, 3D-printed reservoirs were loaded with calcium sulfate embedded with gentamicin. In vitro antibiotic release is tuned by varying reservoir parameters, such as channel length, diameter, and quantity. In addition, a straightforward computational model effectively predicts antibiotic release curves to rapidly design devices with a preferred release profile. Overall, this study highlights a novel approach to potentially develop high-strength joint implants with the long-term effective release of antibiotics to treat the periprosthetic joint infection.

Chitosan-based drug delivery systems: From synthesis strategy to osteomyelitis treatment - A review

Osteomyelitis is a complex disease in orthopedics mainly caused by bacterial pathogens invading bone or bone marrow. The treatment of osteomyelitis is highly difficult and it is a major challenge in orthopedic surgery. The long-term systemic use of antibiotics may lead to antibiotic resistance and has limited effects on eradicating local biofilms. Localized antibiotic delivery after surgical debridement can overcome the problem of antibiotic resistance and reduce systemic toxicity. Chitosan, a special cationic polysaccharide, is a product extracted from the deacetylation of chitin. It has numerous advantages, such as nontoxicity, biocompatibility, and biodegradability. Recently, chitosan has attracted significant attention in bacterial inhibition and drug delivery. Because chitosan contains many functional bioactive groups conducive to chemical reaction and modification, some chitosan-based biomaterials have been applied as the local antibiotic delivery systems in the treatment of osteomyelitis. This review aims to introduce recent advances in the biomedical applications of chitosan-based drug delivery systems in osteomyelitis treatment and to highlight the perspectives for further studies.

Drug Delivery Applications of Three-Dimensional Printed (3DP) Mesoporous Scaffolds

Mesoporous materials are structures characterized by a well-ordered large pore system with uniform porous dimensions ranging between 2 and 50 nm. Typical samples are zeolite, carbon molecular sieves, porous metal oxides, organic and inorganic porous hybrid and pillared materials, silica clathrate and clathrate hydrates compounds. Improvement in biochemistry and materials science led to the design and implementation of different types of porous materials ranging from rigid to soft two-dimensional (2D) and three-dimensional (3D) skeletons. The present review focuses on the use of three-dimensional printed (3DP) mesoporous scaffolds suitable for a wide range of drug delivery applications, due to their intrinsic high surface area and high pore volume. In the first part, the importance of the porosity of materials employed for drug delivery application was discussed focusing on mesoporous materials. At the end of the introduction, hard and soft templating synthesis for the realization of ordered 2D/3D mesostructured porous materials were described. In the second part, 3DP fabrication techniques, including fused deposition modelling, material jetting as inkjet printing, electron beam melting, selective laser sintering, stereolithography and digital light processing, electrospinning, and two-photon polymerization were described. In the last section, through recent bibliographic research, a wide number of 3D printed mesoporous materials, for in vitro and in vivo drug delivery applications, most of which relate to bone cells and tissues, were presented and summarized in a table in which all the technical and bibliographical details were reported. This review highlights, to a very cross-sectional audience, how the interdisciplinarity of certain branches of knowledge, as those of materials science and nano-microfabrication are, represent a growing valuable aid in the advanced forum for the science and technology of pharmaceutics and biopharmaceutics.

Selective laser sintering 3D printing - an overview of the technology and pharmaceutical applications

Food and Drug Administration (FDA) has approved a drug product (Spritam®) and many medical devices manufactured by three-dimensional printing (3DP) processes for human use. There is immense potential to print personalized medicines using 3DP. Many 3DP methods have been reported in the literature for pharmaceutical applications. However, selective laser sintering (SLS) printing has remained least explored for pharmaceutical applications. There are many advantages and challenges in adopting a SLS method for fabrication of personalized medicines. Solvent-free nature, availability of FDA approved thermoplastic polymer/excipients (currently used in hot melt-extrusion process), minimal/no post-processing step, etc. are some of the advantages of the SLS printing process. Major challenges of the technology are requirement of at least one thermoplastic component in the formulation and thermal stability of drug and excipients. This review provides an overview of the SLS printing method, excipient requirements, process monitoring, quality defects, regulatory aspects, and potential pharmaceutical applications.

Development of a heat labile antibiotic eluting 3D printed scaffold for the treatment of osteomyelitis

In general, osteomyelitis is treated with antibiotics, and in severe cases, the inflammatory bone tissue is removed and substituted with poly (methyl methacrylate) (PMMA) beads containing antibiotics. However, this treatment necessitates re-surgery to remove the inserted PMMA beads. Moreover, rifampicin, a primary heat-sensitive antibiotic used for osteomyelitis, is deemed unsuitable in this strategy. Three-dimensional (3D) printing technology has gained popularity, as it facilitates the production of a patient-customized implantable structure using various biodegradable biomaterials as well as controlling printing temperature. Therefore, in this study, we developed a rifampicin-loaded 3D scaffold for the treatment of osteomyelitis using 3D printing and polycaprolactone (PCL), a biodegradable polymer that can be printed at low temperatures. We successfully fabricated rifampicin-loaded PCL 3D scaffolds connected with all pores using computer-aided design and manufacturing (CAD/CAM) and printed them at a temperature of 60 °C to prevent the loss of the antibacterial activity of rifampicin. The growth inhibitory activity against Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus), the representative causative organisms of osteomyelitis, was confirmed. In addition, we optimized the rifampicin-loading capacity that causes no damage to the normal bone tissues in 3D scaffold with toxicity evaluation using human osteoblasts. The rifampicin-releasing 3D scaffold developed herein opens new possibilities of the patient-customized treatment of osteomyelitis.

Sustainable release of vancomycin from micro-arc oxidised 3D-printed porous Ti6Al4V for treating methicillin-resistant Staphylococcus aureus bone infection and enhancing osteogenesis in a rabbit tibia osteomyelitis model

Elimination of infection and enhancement of osteogenesis by orthopaedic implants are two critical factors in the treatment of complex bone infections. A prolonged and expensive procedure requiring two surgical steps and a 6-8-week period of joint immobilisation is utilised as a primary treatment for revision arthroplasty of an infected prosthesis, greatly affecting long-term patient care for the ageing population. Here, we evaluated the effects of vancomycin-loaded in micro-arc oxidised (MAO) three-dimensional (3D) printed porous Ti6Al4V scaffolds on osteogenesis. This system showed a high loading capacity and sustained vancomycin release kinetics, as demonstrated using high-performance liquid chromatography. In vivo, 0.1 mL of 10⁸ colony forming units (CFU) methicillin-resistant Staphylococcus aureus was injected into the tibias of rabbits to induce severe osteomyelitis. Physical, haematological, radiographic, microbiological, and histopathological analyses were performed to evaluate the effects of treatment. Rabbits with vancomycin-loaded in MAO scaffolds showed the inhibition of bone infection and enhancement of osteogenesis, resulting in better outcomes than in the other groups. Overall, these findings demonstrated the potential of this 3D printed porous Ti6Al4V, with good osteogenesis and sustained vancomycin release properties, for application in the treatment of complex bone infections.

Use of silver-based additives for the development of antibacterial functionality in Laser Sintered polyamide 12 parts

Infectious diseases (exacerbated by antimicrobial resistance) cause death, loss of quality of life and economic burden globally. Materials with inherent antimicrobial properties offer the potential to reduce the spread of infection through transfer via surfaces or solutions, or to directly reduce microbial numbers in a host if used as implants. Additive Manufacturing (AM) techniques offer shorter supply chains, faster delivery, mass customisation and reduced unit costs, as well as highly complicated part geometries which are potentially harder to clean and sterilise. Here, we present a new approach to introducing antibacterial properties into AM, using Laser Sintering, by combining antimicrobial and base polymer powders prior to processing. We demonstrate that the mechanical properties of the resultant composite parts are similar to standard polymer parts and reveal the mode of the antibacterial activity. We show that antibacterial activity is modulated by the presence of obstructing compounds in different experimental media, which will inform appropriate use cases. We show that the material is not toxic to mammalian cells. This material could be quickly used for commercial products, and our approach could be adopted more generally to add new functionality to Laser Sintered parts.

3D Printing Technology in Drug Delivery: Recent Progress and Application

BACKGROUND

3D printing technology is a new chapter in pharmaceutical manufacturing and has gained vast interest in the recent past as it offers significant advantages over traditional pharmaceutical processes. Advances in technologies can lead to the design of suitable 3D printing device capable of producing formulations with intended drug release.

METHODS

This review summarizes the applications of 3D printing technology in various drug delivery systems. The applications are well arranged in different sections like uses in personalized drug dosing, complex drugrelease profiles, personalized topical treatment devices, novel dosage forms and drug delivery devices and 3D printed polypills.

RESULTS

This niche technology seems to be a transformative tool with more flexibility in pharmaceutical manufacturing. Typically, 3D printing is a layer-by-layer process having the ability to fabricate 3D formulations by depositing the product components by digital control. This additive manufacturing process can provide tailored and individualized dosing for treatment of patients different backgrounds with varied customs and metabolism pattern. In addition, this printing technology has the capacity for dispensing low volumes with accuracy along with accurate spatial control for customized drug delivery. After the FDA approval of first 3D printed tablet Spritam, the 3D printing technology is extensively explored in the arena of drug delivery.

CONCLUSION

There is enormous scope for this promising technology in designing various delivery systems and provides customized patient-compatible formulations with polypills. The future of this technology will rely on its prospective to provide 3D printing systems capable of manufacturing personalized doses. In nutshell, the 3D approach is likely to revolutionize drug delivery systems to a new level, though need time to evolve.

Extended Release Combination Antibiotic Therapy from a Bone Void Filling Putty for Treatment of Osteomyelitis

In spite of advances in Total Joint Replacements (TJR), infection remains a major concern and a primary causative factor for revision surgery. Current clinical standards treat these osteomyelitis infections with antibiotic-laden poly(methyl methacrylate) (PMMA)-based cement, which has several disadvantages, including inadequate local drug release kinetics, antibiotic leaching for a prolonged period and additional surgical interventions to remove it, etc. Moreover, not all antibiotics (e.g., rifampicin, a potent antibiofilm antibiotic) are compatible with PMMA. For this reason, treatment of TJR-associated infections and related complications remains a significant concern. The objective of this study was to develop a polymer-controlled dual antibiotic-releasing bone void filler (ABVF) with an underlying osseointegrating substrate to treat TJR implant-associated biofilm infections. An ABVF putty was designed to provide sustained vancomycin and rifampicin antibiotic release for 6 weeks while concurrently providing an osseointegrating support for regrowth of lost bone. The reported ABVF showed efficient antibacterial and antibiofilm activity both in vitro and in a rat infection model where the ABVF both showed complete bacterial elimination and supported bone growth. Furthermore, in an in vivo k-wire-based biofilm infection model, the ABVF putty was also able to eliminate the biofilm infection while supporting osseointegration. The retrieved k-wire implants were also free from biofilm and bacterial burden. The ABVF putty delivering combination antibiotics demonstrated that it can be a viable treatment option for implant-related osteomyelitis and may lead to retention of the hardware while enabling single-stage surgery.

Self-fluorescent antibiotic MoOx-hydroxyapatite: a nano-theranostic platform for bone infection therapies

Nowadays, the repair of large-size bone defects represents a huge medical challenge. A line of attack is the construction of advanced biomaterials having multifunctional properties. In this work, we show the creation of biocompatible MoOx-hydroxyapatite nanoparticles (nano-HA/MoOx) that simultaneously exhibit self-activated fluorescence and antibiotic skills. Along this text, we demonstrate that the insertion of molybdenum, an essential trace element, into the non-stoichiometric calcium deficient hydroxyapatite lattice generates intrinsic electronic point defects that exacerbate its epifluorescence blue emission and provokes new red emissions, preserving, always, its bioactivity. Furthermore, these point defects, acting as electron acceptors, stimulate the materials' biological redox status and promote the death of pathogen microorganisms after their direct contact. A putative mechanism, by which bacteria lose electrons from their metabolic circuit that alter the function of their cytoplasmic membrane and potentially die, agrees with our results. Our findings highlight the importance of tuning the electronic communications between biomaterial interfaces and biological units, and support the use of self-fluorescent MoOx-hydroxyapatite nanoparticles as fundamental building blocks for new real-time imaging platforms against bone infection.

Application of Micro-Scale 3D Printing in Pharmaceutics

3D printing, as one of the most rapidly-evolving fabrication technologies, has released a cascade of innovation in the last two decades. In the pharmaceutical field, the integration of 3D printing technology has offered unique advantages, especially at the micro-scale. When printed at a micro-scale, materials and devices can provide nuanced solutions to controlled release, minimally invasive delivery, high-precision targeting, biomimetic models for drug discovery and development, and future opportunities for personalized medicine. This review aims to cover the recent advances in this area. First, the 3D printing techniques are introduced with respect to the technical parameters and features that are uniquely related to each stage of pharmaceutical development. Then specific micro-sized pharmaceutical applications of 3D printing are summarized and grouped according to the provided benefits. Both advantages and challenges are discussed for each application. We believe that these technologies provide compelling future solutions for modern medicine, while challenges remain for scale-up and regulatory approval.

Fabrication Strategies of Scaffolds for Delivering Active Ingredients for Tissue Engineering

Designing scaffolds with optimum properties is an essential factor for tissue engineering success. They can be seeded with isolated cells or loaded with drugs to stimulate the body ability to repair or regenerate the injured tissues by acting as centers for new tissue formation. Recently, scaffolds gained a significant interest as principal candidates for tissue engineering due to overcoming the autograft or allograft's associated problems. The advancement of the tissue engineering field relies mainly on the introduction of new biomaterials for scaffolds' fabrication. This review presents and criticizes different scaffolds' fabrication techniques with particular emphasis on the fibrous, injectable in situ forming, foam, 3D freeze-dried, 3D printed, and 4D scaffolds. This article highlights on scaffolds' composition which would be beneficial for developing scaffolds that could potentially help to meet the demand for both drug delivery and tissue regeneration.

Antibiotics in 3D-printed implants, instruments and materials: benefits, challenges and future directions

3D printing is an additive manufacturing technology, which permits innovative approaches for incorporating antibiotics into 3D printed constructs. Antibiotic-incorporating applications in medicine have included medical implants, prostheses, along with procedural and surgical instruments. 3D-printed antibiotic-impregnated devices offer the advantages of increased surface area for drug distribution, sequential layers of antibiotics produced through layer-by-layer fabrication, and the ability to rapidly fabricate constructs based on patient-specific anatomies. To date, fused deposition modeling has been the main 3D printing method used to incorporate antibiotics, although inkjet and stereolithography techniques have also been described. This review offers a state-of-the-art summary of studies that incorporate antibiotics into 3D-printed constructs and summarizes the rationale, challenges, and future directions for the potential use of this technology in patient care.

Three-dimensional printing for drug delivery devices: a state-of-the-art survey

Over the last several decades, 3D printing technology, which encompasses many different fabrication techniques, had emerged as a promising tool in many fields of production, including the pharmaceutical industry. Specifically, 3D printing may be advantageous for drug delivery systems, systems aiming to improve the pharmacokinetics of drugs. These advantages include the ease of designing complex shapes, printing of drugs on demand, tailoring dosage to the specific needs of the patient and enhancing the bioavailability of drugs. This paper reviews the most recent advancements in this field, presenting both the abilities and limitations of several promising 3D printing methods.

3D printed dual macro-, microscale porous network as a tissue engineering scaffold with drug delivering function

Tissue engineering macroporous scaffolds are important for regeneration of large volume defects resulting from diseases such as breast or bone cancers. Another important part of the treatment of these conditions is adjuvant drug therapy to prevent disease recurrence or surgical site infection. In this study, we developed a new type of macroporous scaffolds that have drug loading and release functionality to use in these scenarios. 3D printing allows for building macroporous scaffolds with deterministically designed complex architectures for tissue engineering yet they often have low surface areas thus limiting their drug loading capability. In this proof-of-concept study, we aimed to introduce microscale porosity into macroporous scaffolds to allow for efficient yet simple soak-loading of various clinical drugs and control their release. Manufacturing of scaffolds having both macroporosity and microscale porosity remains a difficult task. Here, we combined porogen leaching and 3D printing to achieve this goal. Porogen microparticles were mixed with medical grade polycaprolactone and extruded into scaffolds having macropores of 0.7 mm in size. After leaching, intra-strut microscale pores were realized with pore size of 20-70 μm and a total microscale porosity of nearly 40%. Doxorubicin (DOX), paclitaxel (PTX) and cefazolin (CEF) were chosen as model drugs of different charges and solubilities to soak-load the scaffolds and achieved loading efficiency of over 80%. The microscale porosity was found to significantly reduce the burst release allowing the microporous scaffolds to release drugs up to 200, 500 and 150 h for DOX, PTX and CEF, respectively. Finally, cell assays were used and confirmed the bioactivities and dose response of the drug-loaded scaffolds. Together, the findings from this proof-of-concept study demonstrate a new type of scaffolds with dual micro-, macro-porosity for tissue engineering applications with intrinsic capability for efficient loading and sustained release of drugs to prevent post-surgery complications.

Antimicrobial Polymers for Additive Manufacturing

Three-dimensional (3D) printing technologies can be widely used for producing detailed geometries based on individual and particular demands. Some applications are related to the production of personalized devices, implants (orthopedic and dental), drug dosage forms (antibacterial, immunosuppressive, anti-inflammatory, etc.), or 3D implants that contain active pharmaceutical treatments, which favor cellular proliferation and tissue regeneration. This review is focused on the generation of 3D printed polymer-based objects that present antibacterial properties. Two main different alternatives of obtaining these 3D printed objects are fully described, which employ different polymer sources. The first one uses natural polymers that, in some cases, already exhibit intrinsic antibacterial capacities. The second alternative involves the use of synthetic polymers, and thus takes advantage of polymers with antimicrobial functional groups, as well as alternative strategies based on the modification of the surface of polymers or the elaboration of composite materials through adding certain antibacterial agents or incorporating different drugs into the polymeric matrix.

Calcium Phosphate Spacers for the Local Delivery of Sitafloxacin and Rifampin to Treat Orthopedic Infections: Efficacy and Proof of Concept in a Mouse Model of Single-Stage Revision of Device-Associated Osteomyelitis

Osteomyelitis is a chronic bone infection that is often treated with adjuvant antibiotic-impregnated poly(methyl methacrylate) (PMMA) cement spacers in multi-staged revisions. However, failure rates remain substantial due to recurrence of infection, which is attributed to the poor performance of the PMMA cement as a drug release device. Hence, the objective of this study was to design and evaluate a bioresorbable calcium phosphate scaffold (CaPS) for sustained antimicrobial drug release and investigate its efficacy in a murine model of femoral implant-associated osteomyelitis. Incorporating rifampin and sitafloxacin, which are effective against bacterial phenotypes responsible for bacterial persistence, into 3D-printed CaPS coated with poly(lactic co-glycolic) acid, achieved controlled release for up to two weeks. Implantation into the murine infection model resulted in decreased bacterial colonization rates at 3- and 10-weeks post-revision for the 3D printed CaPS in comparison to gentamicin-laden PMMA. Furthermore, a significant increase in bone formation was observed for 3D printed CaPS incorporated with rifampin at 3 and 10 weeks. The results of this study demonstrate that osteoconductive 3D printed CaPS incorporated with antimicrobials demonstrate more efficacious bacterial colonization outcomes and bone growth in a single-stage revision in comparison to gentamicin-laden PMMA requiring a two-stage revision.