Novel 3D printable PEEK-HA-Mg2SiO4 composite material for spine implants: biocompatibility and imaging compatibility assessments.

PURPOSE: To develop a novel 3D printable polyether ether ketone (PEEK)-hydroxyapatite (HA)-magnesium orthosilicate (Mg2SiO4) composite material with enhanced properties for potential use in tumour, osteoporosis and other spinal conditions. We aim to evaluate biocompatibility and imaging compatibility of the material. METHODS: Materials were prepared in three different compositions, namely composite A: 75 weight % PEEK, 20 weight % HA, 5 weight % Mg2SiO4; composite B: 70 weight% PEEK, 25 weight % HA, 5 weight % Mg2SiO4; and composite C: 65 weight % PEEK, 30 weight % HA, 5 weight % Mg2SiO4. The materials were processed to obtain 3D printable filament. Biomechanical properties were analysed as per ASTM standards and biocompatibility of the novel material was evaluated using indirect and direct cell cytotoxicity tests. Cell viability of the novel material was compared to PEEK and PEEK-HA materials. The novel material was used to 3D print a standard spine cage. Furthermore, the CT and MR imaging compatibility of the novel material cage vs PEEK and PEEK-HA cages were evaluated using a phantom setup. RESULTS: Composite A resulted in optimal material processing to obtain a 3D printable filament, while composite B and C resulted in non-optimal processing. Composite A enhanced cell viability up to ~ 20% compared to PEEK and PEEK-HA materials. Composite A cage generated minimal/no artefacts on CT and MR imaging and the images were comparable to that of PEEK and PEEK-HA cages. CONCLUSION: Composite A demonstrated superior bioactivity vs PEEK and PEEK-HA materials and comparable imaging compatibility vs PEEK and PEEK-HA. Therefore, our material displays an excellent potential to manufacture spine implants with enhanced mechanical and bioactive property.

3D-Printed PCL/rGO Conductive Scaffolds for Peripheral Nerve Injury Repair.

The incidence of peripheral nerve injuries is on the rise and the current gold standard for treatment of such injuries is nerve autografting. Given the severe limitations of nerve autografts which include donor site morbidity and limited supply, neural guide conduits (NGCs) are considered as an effective alternative treatment. Conductivity is a desired property of an ideal NGC. Reduced graphene oxide (rGO) possesses several advantages in addition to its conductive nature such as high surface area to volume ratio due to its nanostructure and has been explored for its use in tissue engineering. However, most of the works reported are on traditional 2D culture with a layer of rGO coating, while the native tissue microenvironment is three-dimensional. In this study, PCL/rGO scaffolds are fabricated using electrohydrodynamic jet (EHD-jet) 3D printing method as a proof of concept study. Mechanical and material characterization of the printed PCL/rGO scaffolds and PCL scaffolds was done. The addition of rGO results in softer scaffolds which is favorable for neural differentiation. In vitro neural differentiation studies using PC12 cells were also performed. Cell proliferation was higher in the PCL/rGO scaffolds than the PCL scaffolds. Reverse transcription polymerase chain reaction and immunocytochemistry results reveal that PCL/rGO scaffolds support neural differentiation of PC12 cells.

Pluronic F127 blended polycaprolactone scaffolds via e-jetting for esophageal tissue engineering.

Several attempts have been made to fabricate esophageal tissue engineering scaffolds. However, most of these scaffolds possess randomly oriented fibres and uncontrollable pore sizes. In order to mimic the native esophageal tissue structure, electro-hydrodynamic jetting (e-jetting) was used in this study to fabricate scaffolds with aligned fibres and controlled pore size. A hydrophilic additive, Pluronic F127 (F127), was blended with polycaprolactone (PCL) to improve the wettability of the scaffolds and hence the cell adhesion. PCL/F127 composite scaffolds with different weight ratios (0-12%) were fabricated. The wettability, phase composition, and the mechanical properties of the fabricated scaffolds were investigated. The results show that the e-jetted scaffolds have controllable fibres orientated in two perpendicular directions, which are similar to the human esophagus structure and suitable pore size for cell infiltration. In addition, the scaffolds with 8% F127 exhibited better wettability (contact angle of 14°) and an ultimate tensile strength (1.2 MPa) that mimics the native esophageal tissue. Furthermore, primary human esophageal fibroblasts were seeded on the e-jetted scaffolds. PCL/F127 scaffolds showed enhanced cell proliferation and expression of the vascular endothelial growth factor (VEGF) compared to pristine PCL scaffolds (1.5- and 25.8- fold increase, respectively; P < 0.001). An in vitro wound model made using the PCL/F127 scaffolds showed better cell migration than the PCL scaffolds. In summary, the PCL/F127 e-jetted scaffolds offer a promising strategy for the esophagus tissue repair.

Mechanically-enhanced three-dimensional scaffold with anisotropic morphology for tendon regeneration.

Tissue engineering has showed promising results in restoring diseased tendon tissue functions. Herein, a hybrid three-dimensional (3D) porous scaffold comprising an outer portion rolled from an electrohydrodynamic jet printed poly(ɛ-caprolactone) (PCL) fiber mesh, and an inner portion fabricated from uniaxial stretching of a heat-sealed PCL tube, was developed for tendon tissue engineering (TE) application. The outer portion included three layers of micrometer-scale fibrous bundles (fiber diameter: ~25 µm), with an interconnected spacing and geometric anisotropy along the scaffold length. The inner portion showed orientated micro-ridges/grooves in a parallel direction to that of the outer portion. Owning to the addition of the inner portion, the as-fabricated scaffold exhibited comparable mechanical properties to those of the human patellar tendon in terms of Young's modulus (~227 MPa) and ultimate tensile stress (~50 MPa). Compared to the rolled electrospun fibers, human tenocytes cultured in the tendon scaffolds showed increased cellular metabolism. Furthermore, the 3D tendon scaffold resulted in up-regulated cell alignment, cell elongation and formation of collagen type I. These results demonstrated the potential of mechanically-enhanced 3D fibrous scaffold for applications in tendon TE, with desired cell alignment and functional differentiation.

A comparative investigation on the mechanical properties and cytotoxicity of Cubic, Octet, and TPMS gyroid structures fabricated by selective laser melting of stainless steel 316L.

Metallic lattice structures can be fabricated by selective laser melting (SLM) with purposefully designed pores and controlled pore sizes that can bio mimic the natural bone, providing adequate mechanical and biological support for the patients. Strut-based structures, like Cubic, Octet; and sheet-based structures, like triply periodic minimal surface (TPMS) gyroid, have been studied extensively in the past. However, it lacks enough comparative study on the mechanical properties and cytotoxicity among these structures. Therefore, Cubic, Octet, and TPMS gyroid of Stainless steel 316 L (SS316L) are designed, manufactured, and characterized at 40/50/60% relative densities in this study. Moreover, the flowability, density characteristics, and cytotoxicity of SS316L powder are validated to ascertain its suitability for 3D printing and implant application. Based on refining the Gibson-Ashby model, it is possible to predict or design the mechanical properties via adjusting the relative densities. The results indicate these structures demonstrated appropriate Young's modulus and outstanding biocompatibility.

A biomechanical evaluation on Cubic, Octet, and TPMS gyroid Ti6Al4V lattice structures fabricated by selective laser melting and the effects of their debris on human osteoblast-like cells.

Lattice structures are widely used in orthopedic implants due to their unique features, such as high strength-to-weight ratios and adjustable biomechanical properties. Based on the type of unit cell geometry, lattice structures may be classified into two types: strut-based structures and sheet-based structures. In this study, strut-based structures (Cubic & Octet) and sheet-based structure (triply periodic minimal surface (TPMS) gyroid) were investigated. The biomechanical properties of the three different Ti6Al4V lattice structures fabricated by selective laser melting (SLM) were investigated using room temperature compression testing. Scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDX) were used to check the 3D printing quality with regards to defects and quantitative compositional information of 3D printed parts. Experimental results indicated that TPMS gyroid has superior biomechanical properties when compared to Cubic and Octet. Also, TPMS gyroid was found to be less affected by the variations in relative density. The biocompatibility of Ti6Al4V lattice structures was validated through the cytotoxicity test with human osteoblast-like SAOS2 cells. The debris generated during the degradation process in the form of particles and ions is among the primary causes of implant failure over time. In this study, Ti6Al4V particles with spherical and irregular shapes having average particle sizes of 36.5 µm and 28.8 µm, respectively, were used to mimic the actual Ti6Al4V particles to understand their harmful effects better. Also, the effects and amount of Ti6Al4V ions released after immersion within the cell culture media were investigated using the indirect cytotoxicity test and ion release test.

Functions and applications of metallic and metallic oxide nanoparticles in orthopedic implants and scaffolds.

Bone defects and diseases are devastating, and can lead to severe functional deficits or even permanent disability. Nevertheless, orthopedic implants and scaffolds can facilitate the growth of incipient bone and help us to treat bone defects and diseases. Currently, a wide range of biomaterials with distinct biocompatibility, biodegradability, porosity, and mechanical strength is used in bone-related research. However, most orthopedic implants and scaffolds have certain limitations and diverse complications, such as limited corrosion resistance, low cell proliferation, and bacterial adhesion. With recent advancements in materials science and nanotechnology, metallic and metallic oxide nanoparticles have become the subject of significant interest as they offer an ample variety of options to resolve the existing problems in the orthopedic industry. More importantly, these nanoparticles possess unique physicochemical and mechanical properties not found in conventional materials, and can be incorporated into orthopedic implants and scaffolds to enhance their antimicrobial ability, bioactive molecular delivery, mechanical strength, osteointegration, and cell labeling and imaging. However, many metallic and metallic oxide nanoparticles can also be toxic to nearby cells and tissues. This review article will discuss the applications and functions of metallic and metallic oxide nanoparticles in orthopedic implants and bone tissue engineering.

Evolution of materials for implants in metastatic spine disease till date - Have we found an ideal material?

"Metastatic Spine Disease" (MSD) often requires surgical intervention and instrumentation with spinal implants. Ti6Al4V is widely used in metastatic spine tumor surgery (MSTS) and is the current implant material of choice due to improved biocompatibility, mechanical properties, and compatibility with imaging modalities compared to stainless steel. However, it is still not the ideal implant material due to the following issues. Ti6Al4V implants cause stress-shielding as their Young's modulus (110 gigapascal [GPa]) is higher than cortical bone (17-21 GPa). Ti6Al4V also generates artifacts on CT and MRI, which interfere with the process of postoperative radiotherapy (RT), including treatment planning and delivery. Similarly, charged particle therapy is hindered in the presence of Ti6Al4V. In addition, artifacts on CT and MRI may result in delayed recognition of tumor recurrence and postoperative complications. In comparison, polyether-ether-ketone (PEEK) is a promising alternative. PEEK has a low Young's modulus (3.6 GPa), which results in optimal load-sharing and produces minimal artifacts on imaging with less hinderance on postoperative RT. However, PEEK is bioinert and unable to provide sufficient stability in the immediate postoperative period. This issue may possibly be mitigated by combining PEEK with other materials to form composites or through surface modification, although further research is required in these areas. With the increasing incidence of MSD, it is an opportune time for the development of spinal implants that possess all the ideal material properties for use in MSTS. Our review will explore whether there is a current ideal implant material, available alternatives and whether these require further investigation.

Can Polyether Ether Ketone Dethrone Titanium as the Choice Implant Material for Metastatic Spine Tumor Surgery?

Instrumentation during metastatic spine tumor surgery (MSTS) provides stability to the spinal column in patients with pathologic fracture or iatrogenic instability produced while undergoing extensive decompression. Titanium is the current implant material of choice in MSTS. However, it hinders radiotherapy planning and generates artifacts, with magnetic resonance imaging and computed tomography scans used for postoperative evaluation of tumor recurrence and/or complications. The high modulus of elasticity of titanium (110 GPa) results in stress shielding, which may lead to construct failure at the bone-implant interface. Polyether ether ketone (PEEK), a thermoplastic polymer, is an emerging alternative to titanium for use in MSTS. The modulus of elasticity of PEEK (3.6 GPa) is close to that of cortical bone (17-21 GPa), resulting in minimal stress shielding. Its radiolucent and nonmetallic properties cause minimal interference with magnetic resonance imaging and computed tomography scans. PEEK also causes low-dose perturbation for radiotherapy planning. However, PEEK has reduced bioactivity with bone and lacks sufficient rigidity to be used as rods in MSTS. The reduced bioactivity of PEEK may be addressed by 1) surface modification (introducing porosity or bioactive coating with hydroxyapatite [HA] or titanium) and 2) forming composites with HA/titanium. The mechanical properties of PEEK may be improved by forming composites with HA or carbon fiber. Despite these modifications, all PEEK and PEEK-based implants are difficult to handle and contour intraoperatively. Our review provides a comprehensive overview of PEEK and modified PEEK implants, with a description of their properties and limitations, potentially serving as a basis for their future development and use in MSTS.

Taguchi's methods to optimize the properties and bioactivity of 3D printed polycaprolactone/mineral trioxide aggregate scaffold: Theoretical predictions and experimental validation.

Mineral trioxide aggregate (MTA) can provide bioactivity to poly-caprolactone (PCL), which is an inert polymer used to print scaffolds. However, testing all combinations of scaffold characteristics (e.g., composition, pore size, and distribution) to optimize properties of scaffolds is time-consuming and costly. The Taguchi's methods can identify characteristics that have major influences on the properties of complex designs, hence decreasing the number of combinations to be tested. The objective was to assess the potential of Taguchi's methods as a predictive tool for the optimization of bioactive scaffold printed using electro-hydro dynamic jetting. A three-level approach assessed the influence of PCL/MTA proportion, pore size, fiber dimension and number of layers in pH, degradation rate, porosity, yield strength, and Young's modulus. Data were analyzed using Tukey's honest significant difference test, analysis of mean and signal-to-noise ratio (S/N) test. Cytocompatibility and differentiation potential were assessed for 5 and 30 days using dental pulp stem cells and analyzed with one-way analysis of variance (proliferation) or Mann-Whitney (qPCR). The S/N ratio and analysis of mean showed that fiber diameter and composition were the most influential characteristics in all properties. The experimental data confirmed that the addition of MTA to PCL increased the pH and scaffold degradation. Only PCL and PCL with 4% MTA allowed cell proliferation. The latter increased the genetic expression of ALP, COL-1, OCN, and MSX-1. The theoretical predictions were confirmed by the experiments. The Taguchi's identified the inputs that can be disregarded to optimize 3D printed meshed bioactive scaffolds.

An effective dual-factor modified 3D-printed PCL scaffold for bone defect repair.

Numerous bioactive molecules produced in cells are involved in the process of bone formation. We consider that appropriate, simultaneous application of two types of bioactive molecules would accelerate the regeneration of tissues and organs. Therefore, we combined aspirin-loaded liposomes (Asp@Lipo) and bone forming peptide-1 (BFP-1) on three dimensional-printed polycaprolactone (PCL) scaffold and determined whether this system improved bone regeneration outcomes. in vitro experiments indicated that Asp@Lipo/BFP-1at a 3:7 ratio was the best option for enhancing the osteogenic efficiency of human mesenchymal stem cells (hMSCs). This was confirmed in an in vivo cranial defect animal model. In addition, RNA-Seq was applied for preliminarily exploration of the mechanism of action of this composite scaffold system, and the results suggested that it mainly improved bone regeneration via the PI3K/AKT signaling pathway. This approach will have potential for application in bone tissue engineering and regenerative medicine.

Fabrication of Ti + Mg composites by three-dimensional printing of porous Ti and subsequent pressureless infiltration of biodegradable Mg.

A semi-degradable Ti + Mg composite with superior compression and cytotoxicity properties have been successfully fabricated using ink jet 3D printing followed by capillary mediated pressureless infiltration technique targeting orthopaedic implant applications. The composite exhibited low modulus (~5.2 GPa) and high ultimate compressive strength (~418 MPa) properties matching that of the human cortical bone. Ti + Mg composites with stronger 3D interconnected open-porous Ti networks are possible to be fabricated via 3D printing. Corrosion rate of samples measured through immersion testing using 0.9%NaCl solution at 37 °C indicate almost negligible corrosion rate for porous Ti (~1.14 µm/year) and <1 mm/year for Ti + Mg composites for 5 days of immersion, respectively. The composite significantly increased the SAOS-2 osteoblastic bone cell proliferation rate when compared to the 3D printed porous Ti samples and the increase is attributed to the exogenous Mg2+ ions originating from the Ti + Mg samples. The cell viability results indicated absent to mild cytotoxicity. An attempt is made to discuss the key considerations for net-shape fabrication of Ti + Mg implants using ink jet 3D printing followed by infiltration approach.

Fabrication of three-dimensional porous scaffolds with controlled filament orientation and large pore size via an improved E-jetting technique.

Biodegradable polymeric scaffolds have been widely used in tissue engineering as a platform for cell proliferation and subsequent tissue regeneration. Conventional microextrusion methods for three-dimensional (3D) scaffold fabrication were limited by their low resolution. Electrospinning, a form of electrohydrodynamic (EHD) printing, is an attractive method due to its capability of fabricating high-resolution scaffolds at the nanometer/micrometer scale level. However, the scaffold was composed of randomly orientated filaments which could not guide the cells in a specific direction. Furthermore, the pores of the electrospun scaffold were small, thus preventing cell infiltration. In this study, an alternative EHD jet printing (E-jetting) technique has been developed and employed to fabricate 3D polycaprolactone (PCL) scaffolds with desired filament orientation and pore size. The effect of PCL solution concentration was evaluated. Results showed that solidified filaments were achieved at concentration >70% (w/v). Uniform filaments of diameter 20 µm were produced via the E-jetting technique, and X-ray diffraction and attenuated total reflectance Fourier transform infrared spectroscopic analyses revealed that there was no physicochemical changes toward PCL. Scaffold with a pore size of 450 µm and porosity level of 92%, was achieved. A preliminary in vitro study illustrated that live chondrocytes were attaching on the outer and inner surfaces of collagen-coated E-jetted PCL scaffolds. E-jetted scaffolds increased chondrocytes extracellular matrix secretion, and newly formed matrices from chondrocytes contributed significantly to the mechanical strength of the scaffolds. All these results suggested that E-jetting is an alternative scaffold fabrication technique, which has the capability to construct 3D scaffolds with aligned filaments and large pore sizes for tissue engineering applications.