Advances in Porous Scaffold Design for Bone and Cartilage Tissue Engineering and Regeneration

Effect of Storage Time and Temperature on the Bioactivity of a Chitosan-Derived Epigenetic Modulation Scaffold

The appropriate storage protocol is one of the main limitations of translating tissue engineering technology to commercialized clinical applications. Recently, the development of a chitosan-derived composite scaffold incorporated with bioactive molecules has been reported as an excellent material to repair a critical size bony defect in mice calvaria. This study aims to determine the storage time and appropriate storage temperature of Chitosan/Biphasic Calcium Phosphate/Trichostatin A composite scaffold (CS/BCP/TSA scaffold) in vitro. The mechanical properties and in vitro bioactivity of trichostatin A (TSA) released from CS/BCP/TSA scaffolds in different storage times and temperatures were evaluated. Different storage times (0, 14, and 28 days) and temperatures (−18, 4, and 25 °C) did not affect the porosity, compressive strength, shape memory, and amount of TSA released. However, scaffolds stored at 25 °C and 4 °C were found to lose their bioactivity after 3- and 7-day storage periods, respectively. Thus, the CS/BCP/TSA scaffold should be stored in freezing conditions to preserve the long-term stability of TSA.

Development of chitosan-polygalacturonic acid polyelectrolyte complex fibrous scaffolds using the hydrothermal treatment for bone tissue engineering

An ideal bone regeneration scaffold system needs to meet the high compressive properties of the bone. The stiffness of the scaffold extracellular matrix determines the cell's fate via cell adhesion migration and differentiation in-vitro and in-vivo. This study aims to investigate the effect of hydrothermal treatment on polyelectrolyte complex (PEC) fibrous biomaterials and its effect on scaffold morphology, cell viability, and function in-vitro. FTIR analysis revealed the ability of the thermal treatment to set the interaction of HAp with polymeric PEC fibers. FESEM analysis showed that with an increase in temperature, the interconnectivity and pore size increased (control-82.38 ± 12.92 μm; at 120°C-335.48 ± 85.10 μm). Mechanical tests showed that the scaffolds heated at 90°C showed the highest stiffness in both dry and wet states (dry state: 1.82 ± 0.07 MPa, wet state: 122 ± 1.78 kPa). Additionally, the hydrothermal treatment also improved the aqueous stability as well as swelling capacity. According to the experimental findings, hydrothermal treatment is a useful technique for crosslinker-free gelation with improved mechanical strength and nanofibrous structure. Furthermore, the cell adhesion, proliferation, and osteogenic differentiation of the MG63 cells on the hydrogel scaffolds in-vitro were evaluated by MTT assay, confocal imaging, alkaline phosphatase assay, and collagen estimation. The in-vitro study showed that scaffolds fabricated at 90°C promoted better MG63 cell attachment, proliferation, and differentiation. These results suggest the potential use of hydrothermal treated chitosan-polygalacturonic acid (PgA) fibrous scaffolds in bone tissue engineering.

Chitosan/Xanthan/Hydroxyapatite-graphene oxide porous scaffold associated with mesenchymal stem cells for dentin-pulp complex regeneration

The aim of this paper was to synthesize and characterize polymeric scaffolds of Chitosan/Xanthan/Hydroxyapatite-Graphene Oxide nanocomposite associated with mesenchymal stem cells for regenerative dentistry application. The chitosan-xanthan gum (CX) complex was associated with Hydroxyapatite-Graphene Oxide (HA-GO) nanocomposite with different Graphene Oxides (GO) concentration (0.5 wt%; 1.0 wt%; 1.5 wt%). The scaffolds characterizations were performed by X-ray diffraction (XRD), Fourier Transform Infrared Spectroscopy (FTIR), Raman spectroscopy, thermogravimetric analysis (TGA), scanning electron microscopy (SEM) and contact angle. The mechanical properties were assessed by compressive strength. The in vitro bioactivity and the in vitro cytotoxicity test (MTT test) were analyzed as well. The data was submitted to the Normality and Homogeneity tests. In vitro Indirect Cytotoxicity assay data was statistically analyzed by ANOVA two-way, followed by Tukey's test (α = 0.05). Compressive strength and contact angle data were statistically analyzed by one-way ANOVA, followed by Tukey's test (α = 0.05). XRD showed the presence of Hydroxyapatite (HA) peaks in the structures CXHA, CXHAGO 0.5%,1.0% and 1.5%. FT-IR showed amino and carboxylic bands characteristic of CX. Raman spectroscopy analysis evidenced a high quality of the GO. In the TGA it was observed the mass loss associated with the CX degradation by depolymerization. SEM analysis showed pores in the scaffolds, in addition to HA incorporated and adhered to the polymer. Contact angle test showed that scaffolds have a hydrophilic characteristic, with the CX group the highest contact angle and CXHA the lowest (p < 0.05). 1.0 wt% GO significantly increased the compressive strength compared to other compositions. In the bioactivity test, the apatite crystals precipitation on the scaffold surface was observed. MTT test showed high cell viability in CXHAGO 1.0% and CXHAGO 1.5% scaffold. CXHAGO scaffolds are promising for regenerative dentistry application because they have morphological characteristics, mechanical and biological properties favorable for the regeneration process.

Biocompatibility and osteointegration capability of β-TCP manufactured by stereolithography 3D printing: In vitro study

Beta-tricalcium phosphate (β-TCP) bioceramics have an inorganic composition similar to the human bone. While conventional methods can only produce ceramic scaffolds with poor controllability, the advancement of 3D-printing, especially stereolithography, made it possible to manufacture controllable, highly precise, micropore ceramic scaffolds. In this study, the stereolithography was applied to produce β-TCP bioceramics, while ZrO₂, Al₂O₃, Ti6Al4V, and polyetheretherketone (PEEK) were used as controls. Phase analysis, water contact angle tests, and Micro-CT were applied to evaluate the surface properties and scaffold. Hemolytic toxicity, cell proliferation, and morphological assessment were performed to evaluate the biocompatibility. Alkaline phosphatase (ALP) level, mineralization, and qRT-PCR were measured to evaluate the osteointegration. During the manufacturing of β-TCP, no evident impurity substance and hemolytic toxicity was found. Cells on β-TCP had good morphologies, and their proliferation capability was similar to Ti6Al4V, which was higher than the other materials. Cells on β-TCP had higher ALP levels than PEEK. The degree of mineralization was significantly higher on β-TCP. The expression of osteogenesis-related genes on β-TCP was similar to Ti6Al4V and higher than the other materials. In this study, the β-TCP produced by stereolithography had no toxicity, high accuracy, and excellent osteointegration capability, thus resulting as a good choice for bone implants.

Review on Porous Scaffolds Generation Process: A Tissue Engineering Approach

Porous scaffolds have been widely explored for tissue regeneration and engineering in vitro three-dimensional models. In this review, a comprehensive literature analysis is conducted to identify the steps involved in their generation. The advantages and disadvantages of the available techniques are discussed, highlighting the importance of considering pore geometrical parameters such as curvature and size, and summarizing the requirements to generate the porous scaffold according to the desired application. This paper considers the available design tools, mathematical models, materials, fabrication techniques, cell seeding methodologies, assessment methods, and the status of pore scaffolds in clinical applications. This review compiles the relevant research in the field in the past years. The trends, challenges, and future research directions are discussed in the search for the generation of a porous scaffold with improved mechanical and biological properties that can be reproducible, viable for long-term studies, and closer to being used in the clinical field.

Progress of Microfluidic Hydrogel-Based Scaffolds and Organ-on-Chips for the Cartilage Tissue Engineering

Cartilage degeneration is among the fundamental reasons behind disability and pain across the globe. Numerous approaches have been employed to treat cartilage diseases. Nevertheless, none have shown acceptable outcomes in the long run. In this regard, the convergence of tissue engineering and microfabrication principles can allow developing more advanced microfluidic technologies, thus offering attractive alternatives to current treatments and traditional constructs used in tissue engineering applications. Herein, the current developments involving microfluidic hydrogel-based scaffolds, promising structures for cartilage regeneration, ranging from hydrogels with microfluidic channels to hydrogels prepared by the microfluidic devices, that enable therapeutic delivery of cells, drugs, and growth factors, as well as cartilage-related organ-on-chips are reviewed. Thereafter, cartilage anatomy and types of damages, and present treatment options are briefly overviewed. Various hydrogels are introduced, and the advantages of microfluidic hydrogel-based scaffolds over traditional hydrogels are thoroughly discussed. Furthermore, available technologies for fabricating microfluidic hydrogel-based scaffolds and microfluidic chips are presented. The preclinical and clinical applications of microfluidic hydrogel-based scaffolds in cartilage regeneration and the development of cartilage-related microfluidic chips over time are further explained. The current developments, recent key challenges, and attractive prospects that should be considered so as to develop microfluidic systems in cartilage repair are highlighted.

Nanofiber scaffolds based on extracellular matrix for articular cartilage engineering: A perspective

Articular cartilage has a low self-repair capacity due to the lack of vessels and nerves. In recent times, nanofiber scaffolds have been widely used for this purpose. The optimum nanofiber scaffold should stimulate new tissue's growth and mimic the articular cartilage nature. Furthermore, the characteristics of the scaffold should match those of the cellular matrix components of the native tissue to best merge with the target tissue. Therefore, selective modification of prefabricated scaffolds based on the structure of the repaired tissues is commonly conducted to promote restoring the tissue. A thorough analysis is required to find out the architectural features of scaffolds that are essential to make the treatment successful. The current review aims to target this challenge. The article highlights different optimization approaches of nanofibrous scaffolds for improved cartilage tissue engineering. In this context, the influence of the architecture of nanoscaffolds on performance is discussed in detail. Finally, based on the gathered information, a future outlook is provided to catalyze development in this promising field.

Fabrication of initial trabecular bone-inspired three-dimensional structure with cell membrane nano fragments

The extracellular matrix of trabecular bone has a large surface exposed to the bone marrow and plays important roles such as hematopoietic stem cell niche formation and maintenance. In vitro reproduction of trabecular bone microenvironment would be valuable not only for developing a functional scaffold for bone marrow tissue engineering but also for understanding its biological functions. Herein, we analyzed and reproduced the initial stages of trabecular bone formation in mouse femur epiphysis. We identified that the trabecular bone formation progressed through the following steps: (i) partial rupture of hypertrophic chondrocytes; (ii) calcospherite formation on cell membrane nano fragments (CNFs) derived from the ruptured cells; and (iii) calcospherite growth and fusion to form the initial three-dimensional (3D) structure of trabecular bones. For reproducing the initial trabecular bone formation in vitro, we collected CNFs from cultured cells and used as nucleation sites for biomimetic calcospherite formation. Strikingly, almost the same 3D structure of the initial trabecular bone could be obtained in vitro by using additional CNFs as a binder to fuse biomimetic calcospherites.

Novel Approaches and Biomaterials for Bone Tissue Engineering: A Focus on Silk Fibroin

Bone tissue engineering (BTE) represents a multidisciplinary research field involving many aspects of biology, engineering, material science, clinical medicine and genetics to create biological substitutes to promote bone regeneration. The definition of the most appropriate biomaterials and structures for BTE is still a challenge for researchers, aiming at simultaneously combining different features such as tissue generation properties, biocompatibility, porosity and mechanical strength. In this scenario, among the biomaterials for BTE, silk fibroin represents a valuable option for the development of functional devices because of its unique biological properties and the multiple chances of processing. This review article aims at providing the reader with a general overview of the most recent progresses in bone tissue engineering in terms of approaches and materials with a special focus on silk fibroin and the related mechanisms involved in bone regeneration, and presenting interesting results obtained by different research groups, which assessed the great potential of this protein for bone tissue engineering.

A new hydrogel with fluorapatite nanoparticles for osteogenic differentiation of human adipose-derived stem cells in tissue engineering field

Since scaffolds are engineered to support functional tissue formation, their design and materials play an essential role in medical fields by providing different mechanical function. The aim of this study was to investigate the synthesis and structural characterization of collagen-gelatin (COL-GEL) composite scaffolds containing fluorapatite (FA) nanoparticles as well as evaluation of the osteogenic differentiation of human adipose-derived stem cells (hADSCs). First, the composite scaffolds were evaluated using Fourier transform infrared spectroscopy, scanning electron microscopy, and X-ray diffraction. The cytotoxicity of scaffolds and various concentrations of FA nanoparticles was studied through MTT assay and acridine orange/ethidium bromide staining. Next, the differentiated hADSCs were analyzed using Alizarin red and von Kossa staining, calcium content assay, alkaline phosphatase (ALP) activity, real-time RT-PCR, and immunocytochemical analyses. According to the characterization analyses, the composite scaffolds were properly integrated. The results also illustrated that COL-GEL composite scaffolds in the presence of FA nanoparticles not only showed no cytotoxicity but also increased ALP activity and calcium deposition as well as the expression of osteogenic genes, including Runx2, Col-I, ALP, and osteocalcin and the synthesis of proteins such as osteocalcin and osteopontin in vitro. The obtained data were confirmed by Alizarin red and von Kossa staining. These results are very promising for further tissue engineering experiments, in which FA nanoparticle incorporation into COL-GEL composite scaffolds is a novel approach that improves the surface COL-GEL composite scaffolds for tissue engineering application in vitro.

Characterization of a cotton-wool like composite bone graft material

Bone graft materials are applied in patients to augment bone defects and enable the insertion of an implant in its ideal position. However, the currently available augmentation materials do not meet the requirements of being completely resorbed and replaced by new bone within 3 to 6 months. A novel electrospun cotton-wool like material (Bonewool^®, Zurich Biomaterials LLC, Zurich, Switzerland) consisting of biodegradable poly(lactic-co-glycolic) acid (PLGA) fibers with incorporated amorphous ß-tricalcium phosphate (ß-TCP) nanoparticles has been compared to a frequently used bovine derived hydroxyapatite (Bio-Oss^®, Geistlich Pharma, Wolhusen, Switzerland) in vitro. The material composition was determined and the degradation behavior (calcium release and pH in different solutions) as well as bioactivity has been measured. Degradation behavior of PLGA/ß-TCP was generally more progressive than for Bio-Oss^®, indicating that this material is potentially completely resorbable. Graphical abstract.

Metallic Scaffold with Micron-Scale Geometrical Cues Promotes Osteogenesis and Angiogenesis via the ROCK/Myosin/YAP Pathway

The advent of precision manufacturing has enabled the creation of pores in metallic scaffolds with feature size in the range of single microns. In orthopedic implants, pore geometries at the micron scale could regulate bone formation by stimulating osteogenic differentiation and the coupling of osteogenesis and angiogenesis. However, the biological response to pore geometry at the cellular level is not clear. As cells are sensitive to curvature of the pore boundary, this study aimed to investigate osteogenesis in high- vs low-curvature environments by utilizing computer numerical control laser cutting to generate triangular and circular precision manufactured micropores (PMpores). We fabricated PMpores on 100 μm-thick stainless-steel discs. Triangular PMpores had a 30° vertex angle and a 300 μm base, and circular PMpores had a 300 μm diameter. We found triangular PMpores significantly enhanced the elastic modulus, proliferation, migration, and osteogenic differentiation of MC3T3-E1 preosteoblasts through Yes-associated protein (YAP) nuclear translocation. Inhibition of Rho-associated kinase (ROCK) and Myosin II abolished YAP translocation in all pore types and controls. Inhibition of YAP transcriptional activity reduced the proliferation, pore closure, collagen secretion, alkaline phosphatase (ALP), and Alizarin Red staining in MC3T3-E1 cultures. In C166 vascular endothelial cells, PMpores increased the VEGFA mRNA expression even without an angiogenic differentiation medium and induced tubule formation and maintenance. In terms of osteogenesis-angiogenesis coupling, a conditioned medium from MC3T3-E1 cells in PMpores promoted the expression of angiogenic genes in C166 cells. A coculture with MC3T3-E1 induced tubule formation and maintenance in C166 cells and tubule alignment along the edges of pores. Together, curvature cues in micropores are important stimuli to regulate osteogenic differentiation and osteogenesis-angiogenesis coupling. This study uncovered key mechanotransduction signaling components activated by curvature differences in a metallic scaffold and contributed to the understanding of the interaction between orthopedic implants and cells.

Fabrication Methods of Electroactive Scaffold-Based Conducting Polymers for Tissue Engineering Application: A Review

Conductive scaffolds, defined as scaffold systems capable of carrying electric current, have been extensively researched for tissue engineering applications. Conducting polymers (CPs) as components of conductive scaffolds was introduced to improve morphology or cell attachment, conductivity, tissue growth, and healing rate, all of which are beneficial for cardiac, muscle, nerve, and bone tissue management. Conductive scaffolds have become an alternative for tissue replacement, and repair, as well as to compensate for the global organ shortage for transplantation. Previous researchers have presented a wide range of fabrication methods for conductive scaffolds. This review highlights the most recent advances in developing conductive scaffolds, with the aim to trigger more theoretical and experimental work to address the challenges and prospects of these new fabrication techniques in medical sciences.

Organic acid cross-linked 3D printed cellulose nanocomposite bioscaffolds with controlled porosity, mechanical strength, and biocompatibility

Herein, we fabricated chemically cross-linked polysaccharide-based three-dimensional (3D) porous scaffolds using an ink composed of nanofibrillated cellulose, carboxymethyl cellulose, and citric acid (CA), featuring strong shear thinning behavior and adequate printability. Scaffolds were produced by combining direct-ink-writing 3D printing, freeze-drying, and dehydrothermal heat-assisted cross-linking techniques. The last step induces a reaction of CA. Degree of cross-linking was controlled by varying the CA concentration (2.5–10.0 wt.%) to tune the structure, swelling, degradation, and surface properties (pores: 100-450 μm, porosity: 86%) of the scaffolds in the dry and hydrated states. Compressive strength, elastic modulus, and shape recovery of the cross-linked scaffolds increased significantly with increasing cross-linker concentration. Cross-linked scaffolds promoted clustered cell adhesion and showed no cytotoxic effects as determined by the viability assay and live/dead staining with human osteoblast cells. The proposed method can be extended to all polysaccharide-based materials to develop cell-friendly scaffolds suitable for tissue engineering applications.

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Chemically cross-linked polysaccharide-based 3D porous scaffolds were fabricated

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Physicochemical and mechanical properties increased with cross-linker concentration

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Lower cross-linker concentration led to higher porosity and interconnected pores

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Scaffolds promoted clustered cell adhesion and showed no cytotoxic effects

Poly (L-Lactic Acid) Cell-Laden Scaffolds Applied on Swine Model of Tracheal Fistula

INTRODUCTION

Tracheal fistula (TF) treatments may involve temporary orthosis and further ablative procedures, which can lead to infection. Thus, TF requires other therapy alternatives development. The hypothesis of this work was to demonstrate the feasibility of a tissue-engineered alternative for small TF in a preclinical model. Also, its association with suture filaments enriched with adipose tissue-derived mesenchymal stromal stem cells (AT-MSCs) was assessed to determine whether it could optimize the regenerative process.

METHODS

Poly (L-Lactic acid) (PLLA) membranes were manufactured by electrospinning and had morphology analyzed by scanning electron microscopy. AT-MSCs were cultured in these scaffolds and in vitro assays were performed (cytotoxicity, cellular adhesion, and viability). Subsequently, these cellular constructs were implanted in an animal small TF model. The association with suture filaments containing attached AT-MSCs was present in one animal group. After 30 d, animals were sacrificed and regenerative potential was evaluated, mainly related to the extracellular matrix remodeling, by performing histopathological (Hematoxylin-Eosin and trichrome Masson) and immunohistochemistry (Collagen I/II/III, matrix metalloproteinases-2, matrix metalloproteinases-9, vascular endothelial growth factor, and interleukin-10) analyses.

RESULTS

PLLA membranes presented porous fibers, randomly oriented. In vitro assays results showed that AT-MSCs attached were viable and maintained an active metabolism. Swine implanted with AT-MSCs attached to membranes and suture filaments showed aligned collagen fibers and a better regenerative progress in 30 d.

CONCLUSIONS

PLLA membranes with AT-MSCs attached were useful to the extracellular matrix restoration and have a high potential for small TF treatment. Also, their association with suture filaments enriched with AT-MSCs was advantageous.

De novo dual functional 3D scaffold using computational simulation with controlled drug release

A novel and facile synthesis is made of cotton-like three-dimensional (3D) fibrous scaffold containing spatiotemporally defined patterns of simvastatin (SIM) optimized for angiogenesis-coupled osteogenesis. Herein, we demonstrate the 3D fiber deposition mechanism in detail during the electrospinning process via computer simulation. The 3D fibrous scaffolds were functionalized with hydroxyapatite nanoparticles (HA - NPs) to induce the biomineralization process mimicking the natural apatite layer. The morphology, physiochemical properties, biomimetic mineralization, and drug release of the as-fabricated 3D fibrous scaffolds of simvastatin-loaded poly (ɛ-caprolactone) poly (glycerol-sebacate) hydroxyapatite nanoparticles (3D - PGHS) were investigated. The effects of simvastatin on the osteogenic differentiation of human mesenchymal stem cells (hMSCs) and angiogenesis in human umbilical vein endothelial cells (HUVECs) were assessed. The results showed that the 3D - PGHS both enhanced the expression of osteogenic markers including ALP, RUNX2, and COLA1 in hMSCs, and promoted the migration and tube formation of HUVECs. This finding demonstrates the potential of 3D scaffold-loaded SIM as a putative point-of-care therapy for tightly controlled tissue regeneration.

Biomimetic sponge using duck's feet derived collagen and hydroxyapatite to promote bone regeneration

Collagen, a natural biomaterial derived from animal tissues, has attracted the attention of biomedical material researchers because of its excellent cell affinity and low rejection in vivo. In this study, collagen was extracted using livestock by-product flippers, and an experiment was performed to assess its application as a scaffold for bone tissue implantation. For this purpose, we fabricated 2%, and 3% duck's feet derived collagen (DC) sponges. We then compared them to hydroxyapatite (HAp)-coated DC sponges, and measured the porosity and pore size using scanning electron microscopy (SEM) to analyze the physical properties and morphology of DC and DC/HAp sponges. 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay were carried out to measure the proliferation of bone marrow stem cells (BMSCs) in DC and DC/HAp sponges. An alkaline phosphatase activity assay confirmed the osteogenic differentiation ability of BMSCs. Polymerase chain reaction (PCR) was performed to confirm the BMSC-specific genetic marker. The osteogenic potential was confirmed by the bone formation in an in vivo environment on the scaffold by histological and immunohistochemical analysis. Overall, this study shows that DC/HAp sponges have biocompatibility and good physical properties. Additionally, DC/HAp sponges show potential use as bone graft materials for tissue engineering applications.

Mechanical and Biocompatibility Properties of Sintered Titanium Powder for Mimetic 3D-Printed Bone Scaffolds

A composite comprising Ti and NaCl powders was sintered similar to a three-dimensional (3D)-printed patient-customized artificial bone scaffold. Additionally, a proper microstructure of the mimetic scaffold and the optimum processing parameters for its development were analyzed. The mechanical properties of the metal-based porous-structured framework used as an artificial bone scaffold were an optimum replacement for the human bone. Thus, it was confirmed that patient-customized scaffolds could be manufactured via 3D printing. The 3D-printed mimetic specimens were fabricated by a powder-sintering method using Ti for the metal parts, NaCl as the pore former, and polylactic acid as the biodegradable binder. Scanning electron microscopy (SEM) images showed that pores were formed homogeneously, while X-ray computed tomography confirmed that open pores were generated. The porosity and pore size distribution were measured using a mercury porosimeter, while the flexural strength and flexural elastic modulus were calculated using the three-point bending test. Based on these measurements, a pore-former content of 15 vol % optimized the density and flexural strength to 2.52 g cm^-2 and 283 MPa, respectively, similar to those of the actual iliac bone. According to the 3D-printing production method, a selective laser-sintering process was applied for the fabrication of the mimetic specimen, and it was determined that the microstructure and properties similar to those of previous metal specimens could be achieved in the as-prepared specimen. Additionally, a decellularized extracellular matrix (dECM) was used to coat the surfaces and interiors of the specimens for evaluating their biocompatibilities. SEM image analysis indicated that the adipose-derived stem cells grew evenly inside the pores of the coated specimens, as compared with the bulky Ti specimens without the dECM coating. The doubling time at 65% was measured at 72, 75, and 83 h for specimens with pore-former contents of 5, 10, and 15 vol %, respectively. The doubling time without the pore former was 116 h. As compared with the specimens without the pore former (73 h), 15% of the dECM-coated specimens showed a doubling time of 64%, measured at 47 h.

Graphene-Oxide-Enriched Biomaterials: A Focus on Osteo and Chondroinductive Properties and Immunomodulation

Due to its exceptional physical properties, such as high electronic conductivity, good thermal stability, excellent mechanical strength, and chemical versatility, graphene has sparked a lot of interest in the scientific community for various applications. It has therefore been employed as an antibacterial agent, in photothermal therapy (PTT) and biosensors, in gene delivery systems, and in tissue engineering for regenerative purposes. Since it was first discovered in 1947, different graphene derivatives have been synthetized from pristine graphene. The most adaptable derivate is graphene oxide (GO). Owing to different functional groups, the amphiphilic structure of GO can interact with cells and exogenous or endogenous growth/differentiation factors, allowing cell adhesion, growth, and differentiation. When GO is used as a coating for scaffolds and nanomaterials, it has been found to enhance bone, chondrogenic, cardiac, neuronal, and skin regeneration. This review focuses on the applications of graphene-based materials, in particular GO, as a coating for scaffolds in bone and chondrogenic tissue engineering and summarizes the most recent findings. Moreover, novel developments on the immunomodulatory properties of GO are reported.

Biochemical Aspects of Scaffolds for Cartilage Tissue Engineering; from Basic Science to Regenerative Medicine

Chondral defects are frequent and important causes of pain and disability. Cartilage has limited self-repair and regeneration capacity. The ideal approach for articular cartilage defects is the regeneration of hyaline cartilage with sustainable symptom-free constructs. Tissue engineering provides new strategies for the regeneration of functional cartilage tissue through optimized scaffolds with architectural, mechanical, and biochemical properties similar to the native cartilage tissue. In this review, the basic science of cartilage structure, interactions between proteins, stem cells, as well as biomaterials, scaffold characteristics and fabrication methods, as well as current and potential therapies in regenerative medicine will be discussed mostly from a biochemical point of view. Furthermore, the recent trends in scaffold-based therapies and supplementary factors in cartilage tissue engineering will be considered.

Chitosan and Collagen-Based Materials Enriched with Curcumin (Curcuma longa): Rheological and Morphological Characterization

In this study, chitosan and collagen (Ch: Col)-based materials containing curcumin (Cur) as a bioactive compound were developed for wound-healing purposes. The effects of incorporating curcumin and increasing its concentration on both the rheological properties of the formed solutions and the morphological and thermal properties of the three-dimensional scaffolds obtained from them were evaluated. Rheology showed that the presence of curcumin resulted in solutions with a solid-like behavior (G’ > G″), higher collagen denaturation temperatures, and higher viscosities, favoring their use as biomaterials for wound healing. A greater cross-linking effect was observed at higher curcumin concentrations, possibly between the amino groups from both polymers and the hydroxyl and keto groups from the polyphenol. Such cross-linking was responsible for the delay in the onset of degradation of the scaffolds by 5 °C, as revealed by thermogravimetric analysis. Moreover, the pore diameter distribution profile of the scaffolds changed with increasing curcumin concentration; a greater number of pores with diameters between 40 and 60 µm was observed for the scaffold with the highest curcumin content (50 mg), which would be the most suitable for the proposed application. Thus, the materials developed in this study are presented as promising biomaterials for their biological evaluation in tissue regeneration.

Scaffold-Based Tissue Engineering Strategies for Osteochondral Repair

Over centuries, several advances have been made in osteochondral (OC) tissue engineering to regenerate more biomimetic tissue. As an essential component of tissue engineering, scaffolds provide structural and functional support for cell growth and differentiation. Numerous scaffold types, such as porous, hydrogel, fibrous, microsphere, metal, composite and decellularized matrix, have been reported and evaluated for OC tissue regeneration in vitro and in vivo, with respective advantages and disadvantages. Unfortunately, due to the inherent complexity of organizational structure and the objective limitations of manufacturing technologies and biomaterials, we have not yet achieved stable and satisfactory effects of OC defects repair. In this review, we summarize the complicated gradients of natural OC tissue and then discuss various osteochondral tissue engineering strategies, focusing on scaffold design with abundant cell resources, material types, fabrication techniques and functional properties.

Oxidized bacterial cellulose reinforced nanocomposite scaffolds for bone repair

Bone tissue engineering has been widely used in promoting the repair and regeneration of bone defects. Tissue-engineered bone scaffolds can simulate the extracellular matrix environment and induce the proliferation and differentiation of osteoblasts. The first issues to be considered when constructing bone repair scaffolds include biocompatibility, stress resistance, degradability and stability. Here, a low-cost manufacturing introduces a new bone repair composite scaffold (CS/OBC/nHAP). The scaffolds were composed of only natural derived components, including nano hydroxyapatite (nHAP) formed by in-situ crystallization of Ca²⁺/PO₄^2- solution and evenly dispersed in oxidized bacterial cellulose (OBC) and chitosan (CS) scaffolds. The experimental results showed that compared with CS/nHAP scaffold, CS/OBC/nHAP scaffold has significantly improve mechanical properties and water retention performance, and has a more stable degradation rate. Cell experiments showed that the CS/OBC/nHAP scaffold has good biocompatibility and significantly promote the proliferation of MC3T3-E1 cells. The rat skull defect model further proves that the CS/OBC/nHAP scaffold could induce the formation of bone tissue. Meanwhile, H&E staining experiment show that the CS/OBC/nHAP scaffold has good stability in vivo and could better promote the formation of bone tissue.

A review on 3D printing in tissue engineering applications

In tissue engineering, 3D printing is an important tool that uses biocompatible materials, cells, and supporting components to fabricate complex 3D printed constructs. This review focuses on the cytocompatibility characteristics of 3D printed constructs, made from different synthetic and natural materials. From the overview of this article, inkjet and extrusion-based 3D printing are widely used methods for fabricating 3D printed scaffolds for tissue engineering. This review highlights that scaffold prepared by both inkjet and extrusion-based 3D printing techniques showed significant impact on cell adherence, proliferation, and differentiation as evidenced by in vitro and in vivo studies. 3D printed constructs with growth factors (FGF-2, TGF-β1, or FGF-2/TGF-β1) enhance extracellular matrix (ECM), collagen I content, and high glycosaminoglycan (GAG) content for cell growth and bone formation. Similarly, the utilization of 3D printing in other tissue engineering applications cannot be belittled. In conclusion, it would be interesting to combine different 3D printing techniques to fabricate future 3D printed constructs for several tissue engineering applications.

Digital Light Processing Based Bioprinting with Composable Gradients

Recapitulation of complex tissues signifies a remarkable challenge and, to date, only a few approaches have emerged that can efficiently reconstruct necessary gradients in 3D constructs. This is true even though mimicry of these gradients is of great importance to establish the functionality of engineered tissues and devices. Here, a composable-gradient Digital Light Processing (DLP)-based (bio)printing system is developed, utilizing the unprecedented integration of a microfluidic mixer for the generation of either continual or discrete gradients of desired (bio)inks in real time. Notably, the precisely controlled gradients are composable on-the-fly by facilely by adjusting the (bio)ink flow ratios. In addition, this setup is designed in such a way that (bio)ink waste is minimized when exchanging the gradient (bio)inks, further enhancing this time- and (bio)ink-saving strategy. Various planar and 3D structures exhibiting continual gradients of materials, of cell densities, of growth factor concentrations, of hydrogel stiffness, and of porosities in horizontal and/or vertical direction, are exemplified. The composable fabrication of multifunctional gradients strongly supports the potential of the unique bioprinting system in numerous biomedical applications.

Additive manufacturing of cartilage-mimetic scaffolds as off-the-shelf implants for joint regeneration

Biomimetic scaffolds that provide a tissue-specific environment to cells are particularly promising for tissue engineering and regenerative medicine applications. The goal of this study was to integrate emerging additive manufacturing and biomaterial design strategies to produce articular cartilage (AC) mimetic scaffolds that could be used as 'off-the-shelf' implants for joint regeneration. To this end alginate sulfate, a sulfated glycosaminoglycan (sGAG) mimic, was used to functionalize porous alginate-based scaffolds and to support the sustained release of transforming growth factor-β3 (TGF-β3). Covalent crosslinking dramatically improved the elasticity of the alginate/alginate sulfate scaffolds, while scaffold architecture could be tailored using a directional freezing technique. Introducing such an anisotropic architecture was found to promote mesenchymal stem cell (MSC) infiltration into the scaffold and to direct the orientation of the deposited extracellular matrix, leading to the development of cartilage tissue with a biomimetic zonal architecture. In vitro experiments also demonstrated the capacity of the sulfated scaffolds to both enhance chondrogenesis of MSCs and to control the release of TGF-β3, leading to the development of a tissue rich in sGAG and type II collagen. The scaffolds were further reinforced with a 3D printed PLCL framework, leading to composite implants that were more elastic than those reinforced with PCL, and which better mimicked the bulk mechanical properties of native cartilage tissue. The ability of this composite scaffold to support chondrogenesis was then confirmed within a dynamic culture system. Altogether, these findings demonstrate the potential of such biomimetic scaffolds as putative 'single-stage' or 'off-the-shelf' strategies for articular cartilage regeneration.

The effect of modifying the nanostructure of gelatin fiber scaffolds on early angiogenesisin vitroandin vivo

Early angiogenesis is one of the key challenges in tissue regeneration. Crosslinking mode and fiber diameter are critical factors to affect the adhesion and proliferation of cells. However, whether and how these two factors affect early angiogenesis remain largely unknown. To address the issue, the optimal crosslinking mode and fiber diameter of gelatin fiber membrane for early angiogenesisin vivoandin vitrowere explored in this work. Compared with the post crosslinked gelatin fiber membrane with the same fiber diameter, the 700 nm diameterin situcrosslinked gelatin fiber membrane was found to have smaller roughness (230.67 ± 19 nm) and stronger hydrophilicity (54.77° ± 1.2°), which were suitable for cell growth and adhesion. Moreover, thein situcrosslinked gelatin fiber membrane with a fiber diameter of 1000 nm had significant advantages in early angiogenesis over the two with fiber diameters of 500 and 700 nm by up-regulating the expression of Ang1, VEGF, and integrin-β1. Our findings indicated that thein situcrosslinked gelatin fiber membrane with a diameter of 1000 nm might solve the problem of insufficient blood supply in the early stage of soft tissue regeneration and has broad clinical application prospects in promoting tissue regeneration.

Evaluation of the effects of starch on polyhydroxybutyrate electrospun scaffolds for bone tissue engineering applications

Efficient design for bone tissue engineering requires an understanding of the appropriate selection of biomimetic natural or synthetic materials and scalable fabrication technologies. In this research, poly (3-hydroxybutyrate) (PHB) and starch (5-15 wt%) as biological macromolecules were used to fabricate novel biomimetic scaffolds by electrospinning method. SEM results of electrospun scaffolds revealed bead-free nanofibers and three-dimensional homogenous structures with highly interconnected pores. Results of FTIR and Raman demonstrated that there were hydrogen bonds between the two polymers. The tensile strength of scaffolds was significantly improved by adding starch up to 10 wt%, from 3.05 to 15.54 MPa. In vitro degradation and hydrophilicity of the scaffolds were improved with the presence of starch. The viability and proliferation of MG-63 cells and alkaline phosphatase (ALP) activity were remarkably increased in the PHB-starch scaffolds compared to the PHB and control samples. The mineralization and calcium deposition of MG-63 cells were confirmed by alizarin red staining. It is concluded that PHB/starch electrospun scaffold could be a good candidate for bone tissue engineering applications.

Advanced Hydrogels for Cartilage Tissue Engineering: Recent Progress and Future Directions

Cartilage is a tension- and load-bearing tissue and has a limited capacity for intrinsic self-healing. While microfracture and arthroplasty are the conventional methods for cartilage repair, these methods are unable to completely heal the damaged tissue. The need to overcome the restrictions of these therapies for cartilage regeneration has expanded the field of cartilage tissue engineering (CTE), in which novel engineering and biological approaches are introduced to accelerate the development of new biomimetic cartilage to replace the injured tissue. Until now, a wide range of hydrogels and cell sources have been employed for CTE to either recapitulate microenvironmental cues during a new tissue growth or to compel the recovery of cartilaginous structures via manipulating biochemical and biomechanical properties of the original tissue. Towards modifying current cartilage treatments, advanced hydrogels have been designed and synthesized in recent years to improve network crosslinking and self-recovery of implanted scaffolds after damage in vivo. This review focused on the recent advances in CTE, especially self-healing hydrogels. The article firstly presents the cartilage tissue, its defects, and treatments. Subsequently, introduces CTE and summarizes the polymeric hydrogels and their advances. Furthermore, characterizations, the advantages, and disadvantages of advanced hydrogels such as multi-materials, IPNs, nanomaterials, and supramolecular are discussed. Afterward, the self-healing hydrogels in CTE, mechanisms, and the physical and chemical methods for the synthesis of such hydrogels for improving the reformation of CTE are introduced. The article then briefly describes the fabrication methods in CTE. Finally, this review presents a conclusion of prevalent challenges and future outlooks for self-healing hydrogels in CTE applications.

Enhancement of Bone-Forming Ability on Beta-Tricalcium Phosphate by Modulating Cellular Senescence Mechanisms Using Senolytics

Various stresses latently induce cellular senescence that occasionally deteriorates the functioning of surrounding tissues. Nevertheless, little is known about the appearance and function of senescent cells, caused by the implantation of beta-tricalcium phosphate (β-TCP)—used widely in dentistry and orthopedics for treating bone diseases. In this study, two varying sizes of β-TCP granules (<300 μm and 300–500 μm) were implanted, and using histological and immunofluorescent staining, appearances of senescent-like cells in critical-sized bone defects in the calvaria of Sprague Dawley rats were evaluated. Parallelly, bone formation in defects was investigated with or without the oral administration of senolytics (a cocktail of dasatinib and quercetin). A week after the implantation, the number of senescence-associated beta-galactosidase, p21-, p19-, and tartrate-resistant acid phosphatase-positive cells increased and then decreased upon administrating senolytics. This administration of senolytics also attenuated 4-hydroxy-2-nonenal staining, representing reactive oxygen species. Combining senolytic administration with β-TCP implantation significantly enhanced the bone formation in defects as revealed by micro-computed tomography analysis and hematoxylin-eosin staining. This study demonstrates that β-TCP granules latently induce senescent-like cells, and senolytic administration may improve the bone-forming ability of β-TCP by inhibiting senescence-associated mechanisms.

Dual crosslinked pullulan-gelatin cryogel scaffold for chondrocyte-mediated cartilage repair: synthesis, characterization andin vitroevaluation

Cryogels, a subset of hydrogels, have recently drawn attention for cartilage tissue engineering due to its inherent microporous architecture and good mechanical properties. In this study a dual crosslinked pullulan-gelatin cryogel (PDAG) scaffold was synthesized by crosslinking gelatin with oxidized pullulan by Schiff's base reaction followed by cryogelation. Chondrocytes seeded within the PDAG scaffolds and cultured for 21 din vitrodemonstrated enhanced cell proliferation, enhanced production of cartilage-specific extracellular matrix and up-regulated sulfated glycosaminoglycan without altering the articular chondrocyte phenotype. Quantitative reverse transcription-polymerase chain reaction-based gene expression studies, immunofluorescence, and histological studies demonstrated that the PDAG scaffold significantly enhanced the expression of chondrogenic marker genes such as type II collagen, aggrecan, and SOX9. Taken together, these results demonstrated that PDAG scaffold prepared by sequential Schiff's base reaction and cryogelation would be a promising cell-responsive scaffold for cartilage tissue engineering applications.

Fabrication and maturation of integrated biphasic anatomic mesenchymal stromal cell-laden composite scaffolds for osteochondral repair and joint resurfacing

Articular cartilage injury can lead to joint-wide erosion and the early onset of osteoarthritis. To address this, we recently developed a rapid fabrication method to produce patient-specific engineered cartilage tissues to replace an entire articular surface. Here, we extended that work by coupling a mesenchymal stromal cell-laden hydrogel (methacrylated hyaluronic acid) with the porous polycaprolactone (PCL) bone integrating phase and assessed the composition and mechanical performance of these constructs over time. To improve initial construct stability, PCL/hydrogel interface parameters were first optimized by varying PCL pretreatment (with sodium hydroxide before ethanol) before hydrogel infusion. Next, cylindrical osteochondral constructs were formed and cultured in media containing transforming growth factor β3 for up to 8 weeks, with constructs evaluated for viability, histological features, and biochemical content. Mechanical properties were also assessed in axial compression and via an interface shear strength assay. Results showed that the fabrication process was compatible with cell viability, and that construct biochemical content and mechanical properties increased with time. Interestingly, compressive properties peaked at 5 weeks, while interfacial shear properties continued to improve beyond this time point. Finally, these fabrication methods were combined with a custom mold developed from limb-specific computed tomography imaging data to create an anatomic implantable cell-seeded biologic joint surface, which showedmaturation similar to the osteochondral cylinders. Future work will apply these advances in large animal models of critically sized osteochondral defects to study repair and whole joint resurfacing.

An advanced method to design graded cylindrical scaffolds with versatile effective cross-sectional mechanical properties

The selection of the most-suited bone scaffold for a given clinical application is challenging, and has motivated numerous studies. They are mostly based on the characterization of cellular structures, generated from the three-dimensional repetition of a unit cell. However, the interest of circular graded bone scaffolds has been emphasized since they facilitate nutrient transport from the periphery to the core of the scaffold. In the present contribution, we present an advanced and versatile method to design graded circular porous 2D structures based on the conformal mapping of unit cells. We propose a method to generate 3D porous scaffolds by a multilayer repetition of the circular cross-section, resulting in tunable anisotropy depending on the clinical application. We then analyze the link between the porosities of the obtained structures and their effective elastic mechanical cross-sectional properties, making use of a novel and computationally efficient method allowing exhaustive parametric studies. The comparison of various conformal transformations and unit cell designs emphasizes the extent of mechanical properties and porosities that may be reached for a given constitutive material, including non-standard mechanical properties that open large perspectives towards the development of self-fitting scaffolds.

Development of a Two-Layer Porous Scaffold Based on Porcine Nasal Septal Cartilage for Orthopedics

The aim of the study was to design a construct based on a nasal septal cartilage plate providing required cell differentiation in different layers to replace a deep osteochondral defect and develop an algorithm of chemical and physical effect sequence to create non-immunogenic two-layer porous structure with requisite elasto-mechanical properties.

A 3D printed Ga containing scaffold with both anti-infection and bone homeostasis-regulating properties for the treatment of infected bone defects

Large bone defects face a high risk of infection, which can also lead to bone homeostasis disorders. This seriously hinders the bone healing process; therefore, the help of a dual-functional scaffold that has both anti-infection and bone-homeostasis-regulating capacities is needed in the treatment of infected bone defects. In this study, a 3D printed dual-functional scaffold composed of poly-ε-caprolactone (PCL), mesoporous bioactive glasses (MBG), and gallium (Ga) was produced. In vitro experiments demonstrated the excellent antibacterial ability of the PCL/MBG/Ga scaffold against methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli (E. coli). The scaffold also significantly inhibited osteoclastic activity and promoted osteogenic differentiation. Furthermore, a rabbit model with an infected bone defect in the radius was used to evaluate the in vivo bone healing capability of PCL/MBG/Ga. The results demonstrate that the PCL/MBG/Ga scaffold can significantly accelerate bone healing and prevent bone resorption, suggesting its potential for application in repairing infected bone defects.

Boosting cell proliferation in three-dimensional polyacrylates/nanohydroxyapatite scaffolds synthesized by deep eutectic solvent-based emulsion templating

Among three-dimensional (3D) scaffold fabrication methods, porous polymers templated using high internal phase emulsions (HIPEs) have emerged as an attractive method due to the facile generation of interconnected porosity through a variety of synthetic routes. These include a bottom-up approach to selectively incorporate nanomaterials onto the inner walls in a nonaqueous environment. In this work, novel nonaqueous HIPEs made of different (meth)acrylate monomers and a deep eutectic solvent (DES) were formulated with nonfunctionalized nanohydroxyapatite (NHA), which also played the role of cosurfactant. Free radical polymerization of HIPEs yielded free-standing nanocomposites with 3D interconnected macroporosity and nonfunctionalized NHA selectively decorating the scaffolds' inner surface. The influence of different polymer functionalities, acrylate or methacrylate, their alkyl tail length, and the presence of NHA on MC3T3-E1 preosteoblast cell proliferation in vitro, reactive oxygen species (ROS) production and alkaline phosphatase (ALP) activity were evaluated. All materials presented promising biocompatibility, non-hemolytic activity, negligible inflammatory response along to remarkably enhanced cell proliferation (e.g., up to 160-fold cell proliferation increase compared with polystyrene plate) in vitro, which open the path for the development of scaffolds in regenerative medicine. It is noteworthy that polyHIPEs studied here were obtained using a green synthetic protocol where nonfunctionalized nanoparticles can be selectively incorporated into a scaffolds' inner walls. This versatile technique allows for the simple construction of 3D bioactive nanocomposite scaffolds with varied compositions for cell culture.

Biofabrication Strategies for Musculoskeletal Disorders: Evolution towards Clinical Applications

Biofabrication has emerged as an attractive strategy to personalise medical care and provide new treatments for common organ damage or diseases. While it has made impactful headway in e.g., skin grafting, drug testing and cancer research purposes, its application to treat musculoskeletal tissue disorders in a clinical setting remains scarce. Albeit with several in vitro breakthroughs over the past decade, standard musculoskeletal treatments are still limited to palliative care or surgical interventions with limited long-term effects and biological functionality. To better understand this lack of translation, it is important to study connections between basic science challenges and developments with translational hurdles and evolving frameworks for this fully disruptive technology that is biofabrication. This review paper thus looks closely at the processing stage of biofabrication, specifically at the bioinks suitable for musculoskeletal tissue fabrication and their trends of usage. This includes underlying composite bioink strategies to address the shortfalls of sole biomaterials. We also review recent advances made to overcome long-standing challenges in the field of biofabrication, namely bioprinting of low-viscosity bioinks, controlled delivery of growth factors, and the fabrication of spatially graded biological and structural scaffolds to help biofabricate more clinically relevant constructs. We further explore the clinical application of biofabricated musculoskeletal structures, regulatory pathways, and challenges for clinical translation, while identifying the opportunities that currently lie closest to clinical translation. In this article, we consider the next era of biofabrication and the overarching challenges that need to be addressed to reach clinical relevance.

3D printed gelatin-genipin scaffolds for temporomandibular joint cartilage regeneration

Gelatin has emerged as a biocompatible polymer with high printability in scaffold-based tissue engineering. The aim of the current study was to investigate the potential of genipin-crosslinked 3D printed gelatin scaffolds for temporomandibular joint (TMJ) cartilage regeneration. Crosslinking with genipin increased the stability and mechanical properties, without any cytotoxic effects. Chondrogenic differentiation of human bone marrow-derived mesenchymal stem cells (hBMSC) on the scaffolds were compared to cell pellets and spheres. Although hBMSC seeded scaffolds showed a lower expression of chondrogenesis-related genes compared to cell pellets and spheres, they demonstrated a significantly reduced expression of collagen (COL) 10, suggesting a decreased hypertrophic tendency. After 21 days, staining with Alcian blue and immunofluorescence for SOX9 and COL1 confirmed the chondrogenic differentiation of hBMSC on genipin-crosslinked gelatin scaffolds. In summary, 3D printed gelatin-genipin scaffolds supported the viability, attachment and chondrogenic differentiation of hBMSC, thus, demonstrating potential for TMJ cartilage regeneration applications.

Platelet-Rich Plasma for Bone Fracture Treatment: A Systematic Review of Current Evidence in Preclinical and Clinical Studies

Background: Recently, there is an increasing interest in the therapeutic potential of platelet-rich plasma (PRP) for bone fracture treatment. Nevertheless, the effect of PRP for bone fracture treatment remains controversial and is still a matter of discussion. Therefore, we performed a systematic review to evaluate the efficacy and safety of PRP injection for treatment of bone fracture. Methods: The main bibliographic databases, including Medline, PubMed, Embase, Web of Science, and the Cochrane library, were comprehensively searched for studies focusing on the application of platelet-rich plasma (PRP) on bone fracture treatment. All relevant articles were screened for eligibility and subdivided into the preclinical and clinical studies. Data were extracted and presented systematically. Results: Finally, twenty-six in vitro preclinical studies (basic studies), nine in vivo preclinical studies (animal studies), and nine clinical studies, met the selection criteria, and were included in the present systematic review. Preclinical studies showed an overall positive effect of PRP on osteoblast-like cells in vitro and bone healing in animal models. The most used treatment for bone fracture in animal and clinical studies is fixation surgery combined with PRP injection. The clinical studies reported PRP shortened bony healing duration, and had no positive effect on improving the healing rate of closed fractures. However, the results of functional outcomes are controversial. Additionally, compared with control group, PRP would not increase the rate of postoperative wound infection. Conclusion: The present systematic review confirmed the continuing interests of PRP as an additional treatment for bone fracture. Preclinical studies highlighted the potential value of PRP as promising therapy for bone fracture. However, the preclinical evidence did not translate into a similar result in the clinical studies. In addition, types of fractures and procedures of PRP preparation are heterogeneous in enrolled studies, which might result in controversial results. Meanwhile, characteristics of PRP, such as platelet concentration, the numbers of leukocytes, still need to be determined and further research is required.