Highly permeable polylactide-caprolactone nerve guides enhance peripheral nerve regeneration through long gaps

Beyond the limiting gap length: peripheral nerve regeneration through implantable nerve guidance conduits

Peripheral nerve damage results in the loss of sensorimotor and autonomic functions, which is a significant burden to patients. Furthermore, nerve injuries greater than the limiting gap length require surgical repair. Although autografts are the preferred clinical choice, their usage is impeded by their limited availability, dimensional mismatch, and the sacrifice of another functional donor nerve. Accordingly, nerve guidance conduits, which are tubular scaffolds engineered to provide a biomimetic environment for nerve regeneration, have emerged as alternatives to autografts. Consequently, a few nerve guidance conduits have received clinical approval for the repair of short-mid nerve gaps but failed to regenerate limiting gap damage, which represents the bottleneck of this technology. Thus, it is still necessary to optimize the morphology and constituent materials of conduits. This review summarizes the recent advances in nerve conduit technology. Several manufacturing techniques and conduit designs are discussed, with emphasis on the structural improvement of simple hollow tubes, additive manufacturing techniques, and decellularized grafts. The main objective of this review is to provide a critical overview of nerve guidance conduit technology to support regeneration in long nerve defects, promote future developments, and speed up its clinical translation as a reliable alternative to autografts.

Osteoregenerative Potential of 3D-Printed Poly ε-Caprolactone Tissue Scaffolds In Vitro Using Minimally Manipulative Expansion of Primary Human Bone Marrow Stem Cells

The repair of orthopedic and maxillofacial defects in modern medicine currently relies heavily on the use of autograft, allograft, void fillers, or other structural material composites. This study examines the in vitro osteo regenerative potential of polycaprolactone (PCL) tissue scaffolding, fabricated via a three-dimensional (3D) additive manufacturing technology, i.e., a pneumatic micro extrusion (PME) process. The objectives of this study were: (i) To examine the innate osteoinductive and osteoconductive potential of 3D-printed PCL tissue scaffolding and (ii) To perform a direct in vitro comparison of 3D-printed PCL scaffolding with allograft Allowash® cancellous bone cubes with regards to cell-scaffold interactions and biocompatibility with three primary human bone marrow (hBM) stem cell lines. This study specifically examined cell survival, cell integration, intra-scaffold cell proliferation, and differentiation of progenitor cells to investigate the potential of 3D-printed PCL scaffolds as an alternative to allograft bone material for the repair of orthopedic injuries. We found that mechanically robust PCL bone scaffolds can be fabricated via the PME process and the resulting material did not elicit detectable cytotoxicity. When the widely used osteogenic model SAOS-2 was cultured in PCL extract medium, no detectable effect was observed on cell viability or proliferation with multiple test groups showing viability ranges of 92.2% to 100% relative to a control group with a standard deviation of ±10%. In addition, we found that the honeycomb infill pattern of the 3D-printed PCL scaffold allowed for superior mesenchymal stem-cell integration, proliferation, and biomass increase. When healthy and active primary hBM cell lines, having documented in vitro growth rates with doubling times of 23.9, 24.67, and 30.94 h, were cultured directly into 3D-printed PCL scaffolds, impressive biomass increase values were observed. It was found that the PCL scaffolding material allowed for biomass increase values of 17.17%, 17.14%, and 18.18%, compared to values of 4.29% for allograph material cultured under identical parameters. It was also found that the honeycomb scaffold infill pattern was superior to the cubic and rectangular matrix structures, and provided a superior microenvironment for osteogenic and hematopoietic progenitor cell activity and auto-differentiation of primary hBM stem cells. Histological and immunohistochemical studies performed in this work confirmed the regenerative potential of PCL matrices in the orthopedic setting by displaying the integration, self-organization, and auto-differentiation of hBM progenitor cells within the matrix. Differentiation products including mineralization, self-organizing "proto-osteon" structures, and in vitro erythropoiesis were observed in conjunction with the documented expression of expected bone marrow differentiative markers including CD-99 (>70%), CD-71 (>60%), and CD-61 (>5%). All of the studies were conducted without the addition of any exogenous chemical or hormonal stimulation and exclusively utilized the abiotic and inert material polycaprolactone; setting this work apart from the vast majority of contemporary investigations into synthetic bone scaffold fabrication In summary, this study demonstrates the unique clinical potential of 3D-printed PCL scaffolds for stem cell expansion and incorporation into advanced microstructures created via PME manufacturing to generate a physiologically inert temporary bony defect graft with significant autograft features for enhanced end-stage healing.

Recent Advances in Polymeric Drug Delivery Systems for Peripheral Nerve Regeneration

When a traumatic event causes complete denervation, muscle functional recovery is highly compromised. A possible solution to this issue is the implantation of a biodegradable polymeric tubular scaffold, providing a biomimetic environment to support the nerve regeneration process. However, in the case of consistent peripheral nerve damage, the regeneration capabilities are poor. Hence, a crucial challenge in this field is the development of biodegradable micro- nanostructured polymeric carriers for controlled and sustained release of molecules to enhance nerve regeneration. The aim of these systems is to favor the cellular processes that support nerve regeneration to increase the functional recovery outcome. Drug delivery systems (DDSs) are interesting solutions in the nerve regeneration framework, due to the possibility of specifically targeting the active principle within the site of interest, maximizing its therapeutical efficacy. The scope of this review is to highlight the recent advances regarding the study of biodegradable polymeric DDS for nerve regeneration and to discuss their potential to enhance regenerative performance in those clinical scenarios characterized by severe nerve damage.

Experimental study on the efficacy of a hybrid artificial nerve: The hot dog method

INTRODUCTION

We hypothesized that hybrid artificial nerves might overcome the limitations of a nerve conduit by isolating nerve fascicles from autologous nerves. Nerve sacrifice during harvest, a drawback of conventional autologous nerve transplantation, may be reduced by the hot dog method. The hot dog method (based on the morphology of hybrid artificial nerves) adds nerve conduits to autologous nerve fascicles.

METHODS

Forty-eight rats with a 10-mm sciatic nerve defect were divided into six groups (n = 8 per group) according to the neural reconstruction method: autologous nerve transplantation, the hot dog method, nerve conduit, nerve fascicle transplantation, sham control, and nerve fascicle isolation were classified as Groups I, II, III, IV, V, and VI, respectively. The sciatic nerve function was assessed in these groups, a histological evaluation was performed, and statistical analyses were conducted based on these data.

RESULTS

Group III (nerve conduit) and Group IV (nerve fascicle transplantation) showed the lowest functional and axonal regenerative effects, followed by Group II (hot dog method) and Group I (autologous nerve transplantation). Group VI (nerve fascicle isolation) tended to achieve better recovery in motor function and axonal regeneration than Group I (autologous nerve transplantation).

CONCLUSIONS

The hot dog method is simple, safe, and easy to execute. This method can serve as a new neural reconstruction method that uses artificial nerves.

Natural-Based Biomaterials for Peripheral Nerve Injury Repair

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

High Throughput Manufacturing of Bio-Resorbable Micro-Porous Scaffolds Made of Poly(L-lactide-co-ε-caprolactone) by Micro-Extrusion for Soft Tissue Engineering Applications

Porous scaffolds made of elastomeric materials are of great interest for soft tissue engineering. Poly(L-lactide-co-ε-caprolactone) (PLCL) is a bio-resorbable elastomeric copolymer with tailorable properties, which make this material an appropriate candidate to be used as scaffold for vascular, tendon, and nerve healing applications. Here, extrusion was applied to produce porous scaffolds of PLCL, using NaCl particles as a leachable agent. The effects of the particle proportion and size on leaching performance, dimensional stability, mechanical properties, and ageing of the scaffolds were analyzed. The efficiency of the particle leaching and scaffold swelling when wet were observed to be dependent on the porogenerator proportion, while the secant moduli and ultimate tensile strengths were dependent on the pore size. Porosity, swelling, and mechanical properties of the extruded scaffolds were tailorable, varying with the proportion and size of porogenerator particles and showed similar values to human soft tissues like nerves and veins (E = 7-15 MPa, σu = 7 MPa). Up to 300-mm length micro-porous PLCL tube with 400-µm thickness wall was extruded, proving extrusion as a high-throughput manufacturing process to produce tubular elastomeric bio-resorbable porous scaffolds of unrestricted length with tunable mechanical properties.

Peripheral Nerve Conduit: Materials and Structures

Peripheral nerve injuries (PNIs) are the most common injury types to affect the nervous system. Restoration of nerve function after PNI is a challenging medical issue. Extended gaps in transected peripheral nerves are only repaired using autologous nerve grafting. This technique, however, in which nerve tissue is harvested from a donor site and grafted onto a recipient site in the same body, has many limitations and disadvantages. Recent studies have revealed artificial nerve conduits as a promising alternative technique to substitute autologous nerves. This Review summarizes different types of artificial nerve grafts used to repair peripheral nerve injuries. These include synthetic and natural polymers with biological factors. Then, desirable properties of nerve guides are discussed based on their functionality and effectiveness. In the final part of this Review, fabrication methods and commercially available nerve guides are described.

A Comparison Between Two Collagen Nerve Conduits and Nerve Autograft: A Rat Model of Motor Nerve Regeneration

PURPOSE

To compare recovery in a rat model of sciatic nerve injury using a novel polyglycolic acid (PGA) conduit, which contains collagen fibers within the tube, as compared with both a hollow collagen conduit and nerve autograft. We hypothesize that a conduit with a scaffold will provide improved nerve regeneration over hollow conduits and demonstrate no significant differences when compared with autograft.

METHODS

A total of 72 Sprague-Dawley rats were randomized into 3 experimental groups, in which a unilateral 10-mm sciatic defect was repaired using either nerve autograft, a hollow collagen conduit, or a PGA collagen-filled conduit. Outcomes were measured at 12 and 16 weeks after surgery, and included bilateral tibialis anterior muscle weight, voltage and force maximal contractility, assessment of ankle contracture, and nerve histology.

RESULTS

In all groups, outcomes improved between 12 and 16 weeks. On average, the autograft group outperformed both conduit groups, and the hollow conduit demonstrated improved outcomes when compared with the PGA collagen-filled conduit. Differences in contractile force, however, were significant only at 12 weeks (autograft > hollow collagen conduit > PGA collagen-filled conduit). At 16 weeks, contractile force demonstrated no significant difference but corroborated the same absolute results (autograft > hollow collagen conduit > PGA collagen-filled conduit).

CONCLUSIONS

Nerve repair using autograft provided superior motor nerve recovery over the 2 conduits for a 10-mm nerve gap in a murine acute transection injury model. The hollow collagen conduit demonstrated superior results when compared with the PGA collagen-filled conduit.

CLINICAL RELEVANCE

The use of a hollow collagen conduit provides superior motor nerve recovery as compared with a PGA collagen-filled conduit.

Synthetic bioresorbable poly-α-hydroxyesters as peripheral nerve guidance conduits; a review of material properties, design strategies and their efficacy to date

Implantable tubular devices known as nerve guidance conduits (NGCs) have drawn considerable interest as an alternative to autografting in the repair of peripheral nerve injuries.

Nanofiber-Based Multi-Tubular Conduits with a Honeycomb Structure for Potential Application in Peripheral Nerve Repair

Peripheral nerve injury is a large-scale problem and it is a great challenge to repair the long lesion in a thick nerve. The design of a multi-tubular conduit with a honeycomb structure by mimicking the anatomy of a peripheral nerve for the potential repair of large defects in thick nerves has been reported. A bilayer mat of electrospun nanofibers is rolled up to form a single tube, with the inner and outer layers comprised aligned and random nanofibers, respectively. Seven such tubes are then assembled into a hexagonal array and encased within the lumen of a larger tube to form the multi-tubular conduit. By introducing an adhesive to the regions between the tubes, the conduit is robust enough for handling during surgery. The seeded bone marrow stem cells (BMSCs) are able to proliferate in all the tubes with even circumferential and longitudinal distributions. Under chemical induction, the BMSCs are transdifferentiated into Schwann-like cells in all the tubes. While the cellular version holds great promise for peripheral nerve repair, the multi-tubular conduit can also be used to investigate the fundamental aspects involved in the development of peripheral nervous system and migration of cells.

Evaluation of two collagen conduits and autograft in rabbit sciatic nerve regeneration with quantitative magnetic resonance DTI, electrophysiology, and histology

Background

We compared different surgical techniques for nerve regeneration in a rabbit sciatic nerve gap model using magnetic resonance diffusion tensor imaging (DTI), electrophysiology, limb function, and histology.

Methods

A total of 24 male New Zealand white rabbits were randomized into three groups: autograft (n = 8), hollow conduit (n = 8), and collagen-filled conduit (n = 8). A 10-mm segment of the rabbit proximal sciatic nerve was cut, and autograft or collagen conduit was used to bridge the gap. DTI on a 3-T system was performed preoperatively and 13 weeks after surgery using the contralateral, nonoperated nerve as a control.

Results

Overall, autograft performed better compared with both conduit groups. Differences in axonal diameter were significant (autograft > hollow conduit > collagen-filled conduit) at 13 weeks (autograft vs. hollow conduit, p = 0.001, and hollow conduit vs. collagen-filled conduit, p < 0.001). Significant group differences were found for axial diffusivity but not for any of the other DTI metrics (autograft > hollow conduit > collagen-filled conduit) (autograft vs. hollow conduit, p = 0.001 and hollow conduit vs. collagen-filled conduit, p = 0.021). As compared with hollow conduit (autograft > collagen-filled conduit > hollow conduit), collagen-filled conduit animals demonstrated a nonsignificant increased maximum tetanic force.

Conclusions

Autograft-treated rabbits demonstrated improved sciatic nerve regeneration compared with collagen-filled and hollow conduits as assessed by histologic, functional, and DTI parameters at 13 weeks.

Fibrin/Schwann Cell Matrix in Poly-Epsilon-Caprolactone Conduits Enhances Guided Nerve Regeneration

The goal of this study was to investigate if a three dimensional matrix, loaded homogeneously with Schwann cells and the neurotrophic factor LIF (leukemia inhibitory factor), enhances regeneration in a biodegradable nerve guidance channel as compared to non-structured cell suspensions. Therefore a 10 mm nerve gap in the buccal branch of the rat's facial nerve was bridged with tubular PCL (poly-epsilon-caprolactone) conduits filled with no matrix, Schwann cells, the three dimensional fibrin/Schwann cell matrix or the fibrin/Schwann cell matrix added with LIF. Four weeks after the nerve defects were bridged histological and morphometric analyses of the implants were performed. In conclusion, the three dimensional fibrin/Schwann cells matrix enhanced the quantity and the quality of peripheral nerve regeneration through PCL conduits. The application of LIF prevented hyperneurotization. Therefore, tissue engineered fibrin/Schwann cells matrices are new invented biocompatible and biodegradable devices for enhancing peripheral nerve regeneration as compared to non-structured cell suspensions without neurotrophic factors.

PEOT/PBT Guides Enhance Nerve Regeneration in Long Gap Defects

Development of new nerve guides is required for replacing autologous nerve grafts for the repair of long gap defects after nerve injury. A nerve guide comprised only of electrospun fibers able to bridge a critical (15 mm) nerve gap in a rat animal model is reported for the first time. The nerve conduits are made of poly(ethylene oxide terephthalate) and poly(butylene terephthalate) (PEOT/PBT), a biocompatible copolymer composed of alternating amorphous, hydrophilic poly(ethylene oxide terephthalate), and crystalline, hydrophobic poly(butylene terephthalate) segments. These guides show suitable mechanical properties, high porosity, and fibers aligned in the longitudinal axis of the guide. In vitro studies show that both neurites and Schwann cells exhibit growth alignment with PA fibers. In vivo studies reveal that, after rat sciatic nerve transection and repair with PEOT/PBT guides, axons grow occupying a larger area compared to silicone tubes. Moreover, after repair of limiting (10 mm) and critical (15 mm) nerve gaps, PEOT/PBT guides significantly increase the percentage of regenerated nerves, the number of regenerated myelinated axons, and improve motor, sensory, and autonomic reinnervation in both gaps. This nerve conduit design combines the properties of PEOT/PBT with electrospun structure, demonstrating that nerve regeneration through long gaps can be achieved through the design of instructive biomaterial constructs.

Preparation of Surface-Engineered Elastin/Lamin Nerve Guide Tubes of Poly(Lactic Acid)/Poly(Ethylene Vinyl Acetate)

In this study, a spray coating technique was used to prepare poly(lactic acid) (PLA) tubes. To improve the flexibility of these devices, an elastomeric polymer, poly(ethylene vinyl acetate) (PEVAc), was added to the PLA. The PLA/PEVAc tubes were further surface modified with elastin and laminin via carbodiimide and glutaraldehyde treatment. This study evaluated the surface graft matrix components (elastin and laminin) on PLA/PEVAc tubes as a method for regenerating biointeractive materials for nerve growth and tissue engineering.

Bio-safe processing of polylactic-co-caprolactone and polylactic acid blends to fabricate fibrous porous scaffolds for in vitro mesenchymal stem cells adhesion and proliferation

In this study, the design and fabrication of porous scaffolds, made of blends of polylactic-co-caprolactone (PLC) and polylactic acid (PLA) polymers, for tissue engineering applications is reported. The scaffolds are prepared by means of a bio-safe thermally induced phase separation (TIPS) approach with or without the addition of NaCl particles used as particulate porogen. The scaffolds are characterized to assess their crystalline structure, morphology and mechanical properties, and the texture of the pores and the pore size distribution. Moreover, in vitro human mesenchymal stem cells (hMSCs) culture tests have been carried out to demonstrate the biocompatibility of the scaffolds. The results of this study demonstrate that all of the scaffold materials processed by means of TIPS process are semi-crystalline. Furthermore, the blend composition affected polymer crystallization and, in turn, the nano and macro-structural properties of the scaffolds. Indeed, neat PLC and neat PLA crystallize into globular and randomly arranged sub micro-size scale fibrous conformations, respectively. Concomitantly, the addition of NaCl particles during the fabrication route allows for the creation of an interconnected network of large pores inside the primary structure while resulted in a significant decrease of scaffolds mechanical response. Finally, the results of cell culture tests demonstrate that both the micro and macro-structure of the scaffold affect the in vitro hMSCs adhesion and proliferation.

Integration of drug, protein, and gene delivery systems with regenerative medicine

Regenerative medicine has the potential to drastically change the field of health care from reactive to preventative and restorative. Exciting advances in stem cell biology and cellular reprogramming have fueled the progress of this field. Biochemical cues in the form of small molecule drugs, growth factors, zinc finger protein transcription factors and nucleases, transcription activator-like effector nucleases, monoclonal antibodies, plasmid DNA, aptamers, or RNA interference agents can play an important role to influence stem cell differentiation and the outcome of tissue regeneration. Many of these biochemical factors are fragile and must act intracellularly at the molecular level. They require an effective delivery system, which can take the form of a scaffold (e.g., hydrogels and electrospun fibers), carrier (viral and nonviral), nano- and microparticle, or genetically modified cell. In this review, we will discuss the history and current technologies of drug, protein, and gene delivery in the context of regenerative medicine. Next, we will present case examples of how delivery technologies are being applied to promote angiogenesis in nonhealing wounds or prevent angiogenesis in age related macular degeneration. Finally, we will conclude with a brief discussion of the regulatory pathway from bench to bedside for the clinical translation of these novel therapeutics.

Comparison of nerve, vessel, and cartilage grafts in promoting peripheral nerve regeneration

Peripheral nerve injury primarily occurs due to trauma as well as factors such as tumors, inflammatory diseases, congenital deformities, infections, and surgical interventions. The surgical procedure to be performed as treatment depends on the etiology, type of injury, and the anatomic region. The goal of treatment is to minimize loss of function due to motor and sensory nerve loss at the distal part of the injury. Regardless of the cause of the injury, the abnormal nerve regeneration due to incomplete nerve regeneration, optimal treatment of peripheral nerve injuries should provide adequate coaptation of proximal and distal sides without tension, preserving the neurotrophic factors within the repair line. The gold standard for the treatment of nerve defects is the autograft; however, due to denervation of the donor site, scarring, and neuroma formation, many studies have aimed to develop simpler methods, better functional results, and less morbidity. In this study, a defect 1 cm in length was created on the sciatic nerve of rats. The rats were treated with the following procedures: group 1, autograft; group 2, allogeneic aorta graft; group 3, diced cartilage graft in allogeneic aorta graft; and group 4, tubularized cartilage graft in allogeneic aorta graft. Group 5 was the control group. The effects of cartilage tissue in nerve regeneration were evaluated by functional and histomorphological methods.Group 1, for which the repair was performed with an autograft, was evaluated to be the most similar to the control group. There was not a statistically significant difference in myelination and Schwann cell rates between group 2, in which an allogeneic aorta graft was used, and group 3, in which diced cartilage in an allogeneic aorta graft was used. In group 4, myelination and Schwann cell formation were observed; however, they were scattered and irregular, likely due to increased fibrosis.In all of the groups, nerve regeneration at various rates was observed both functionally and histomorphologically. This study demonstrates that cartilage tissue has promoting effects in nerve regeneration.

Nerve conduits for peripheral nerve surgery

Autologous nerve grafts are the current criterion standard for repair of peripheral nerve injuries when the transected nerve ends are not amenable to primary end-to-end tensionless neurorrhaphy. However, donor-site morbidities such as neuroma formation and permanent loss of function have led to tremendous interest in developing an alternative to this technique. Artificial nerve conduits have therefore emerged as an alternative to autologous nerve grafting for the repair of short peripheral nerve defects of less than 30 mm; however, they do not yet surpass autologous nerve grafts clinically. A thorough understanding of the complex biological reactions that take place during peripheral nerve regeneration will allow researchers to develop a nerve conduit with physical and biological properties similar to those of an autologous nerve graft that supports regeneration over long nerve gaps and in large-diameter nerves. In this article, the authors assess the currently available nerve conduits, summarize research in the field of developing these conduits, and establish areas within this field in which further research would prove most beneficial.

Nerve repair: toward a sutureless approach

Peripheral nerve repair for complete section injuries employ reconstructive techniques that invariably require sutures in their application. Sutures are unable to seal the nerve, thus incapable of preventing leakage of important intraneural fluids from the regenerating nerve. Furthermore, sutures are technically demanding to apply for direct repairs and often induce detrimental scarring that impedes healing and functional recovery. To overcome these limitations, biocompatible and biodegradable glues have been used to seal and repair peripheral nerves. Although creating a sufficient seal, they can lack flexibility and present infection risks or cytotoxicity. Other adhesive biomaterials have recently emerged into practice that are usually based on proteins such as albumin and collagen or polysaccharides like chitosan. These adhesives form their union to nerve tissue by either photothermal (tissue welding) or photochemical (tissue bonding) activation with laser light. These biomaterial adhesives offer significant advantages over sutures, such as their capacity to unite and seal the epineurium, ease of application, reduced invasiveness and add the potential for drug delivery in situ to facilitate regeneration. This paper reviews a number of different peripheral nerve repair (or reconstructive) techniques currently used clinically and in experimental procedures for nerve injuries with or without tissue deficit.

Hierarchically structured nerve guidance channels based on poly-3-hydroxybutyrate enhance oriented axonal outgrowth

Traumatic peripheral nerve lesions can cause local anesthesia, paralysis and loss of autonomic control. Reconstruction using engineered nerve guidance conduits (NGCs) is rarely successful due to the sub-optimal characteristics of the conduits. To address the demands of clinical practice, we developed a hierarchically structured NGC from slowly resorbing poly(3-hydroxybutyric acid) (P3HB). The NGC consists of a permeable single-lumen tube and melt-spun fibrillar lumen fillers. Permeable tubes were constructed from P3HB/poly(ɛ-caprolactone) (PCL) blends or poly(3-hydroxybutyric acid-co-4-hydroxybutyric acid) (P(3HB-co-4HB)). Polyvinylpyrrolidone was used as a porogen in solvent-free thermoplastic processing, followed by selective polymer leaching. All tested material compositions showed hydrolytic degradation after 16weeks in phosphate buffered saline, whereas P3HB/PCL tubes maintained mechanical strength compared to (P(3HB-co-4HB)). The porous scaffolds allowed diffusion of large molecules (∼70kDa). In vitro studies demonstrated that mouse fibroblasts survived and proliferated inside closed porous tubes. An in vitro model of axonal regeneration using dorsal root ganglia and sympathetic cervical ganglia demonstrated that the NGCs successfully supported neuron survival and neurite outgrowth. The introduction of fibrillar lumen fillers promoted oriented neurite growth and coating with extracellular matrix proteins further increased ganglia attachment and cell migration. In this study we show that P3HB-based NGCs scaffolds have potential in long gap peripheral nerve repair strategies.

Recent advances in nerve tissue engineering

Nerve injury secondary to trauma, neurological disease or tumor excision presents a challenge for surgical reconstruction. Current practice for nerve repair involves autologous nerve transplantation, which is associated with significant donor-site morbidity and other complications. Previously artificial nerve conduits made from polycaprolactone, polyglycolic acid and collagen were approved by the FDA (USA) for nerve repair. More recently, there have been significant advances in nerve conduit design that better address the requirements of nerve regrowth. Innovations in materials science, nanotechnology, and biology open the way for the synthesis of new generation nerve repair conduits that address issues currently faced in nerve repair and regeneration. This review discusses recent innovations in this area, including the use of nanotechnology to improve the design of nerve conduits and to enhance nerve regeneration.

Scaffolds from block polyurethanes based on poly(ɛ-caprolactone) (PCL) and poly(ethylene glycol) (PEG) for peripheral nerve regeneration

Nerve guide scaffolds from block polyurethanes without any additional growth factors or protein were prepared using a particle leaching method. The scaffolds of block polyurethanes (abbreviated as PUCL-ran-EG) based on poly(ɛ-caprolactone) (PCL-diol) and poly(ethylene glycol) (PEG) possess highly surface-area porous for cell attachment, and can provide biochemical and topographic cues to enhance tissue regeneration. The nerve guide scaffolds have pore size 1-5 μm and porosity 88%. Mechanical tests showed that the polyurethane nerve guide scaffolds have maximum loads of 4.98 ± 0.35 N and maximum stresses of 6.372 ± 0.5 MPa. The histocompatibility efficacy of these nerve guide scaffolds was tested in a rat model for peripheral nerve injury treatment. Four types of guides including PUCL-ran-EG scaffolds, autograft, PCL scaffolds and silicone tubes were compared in the rat model. After 14 weeks, bridging of a 10 mm defect gap by the regenerated nerve was observed in all rats. The nerve regeneration was systematically characterized by sciatic function index (SFI), histological assessment including HE staining, immunohistochemistry, ammonia silver staining, Masson's trichrome staining and TEM observation. Results revealed that polyurethane nerve guide scaffolds exhibit much better regeneration behavior than PCL, silicone tube groups and comparable to autograft. Electrophysiological recovery was also seen in 36%, 76%, and 87% of rats in the PCL, PUCL-ran-EG, and autograft groups respectively, whilst 29.8% was observed in the silicone tube groups. Biodegradation in vitro and in vivo show proper degradation of the PUCL-ran-EG nerve guide scaffolds. This study has demonstrated that without further modification, plain PUCL-ran-EG nerve guide scaffolds can help peripheral nerve regeneration excellently.

A biodegradable, sustained-released, prednisolone acetate microfilm drug delivery system effectively prolongs corneal allograft survival in the rat keratoplasty model

Frequent and long-term use of topical corticosteroids after corneal transplantation is necessary to prevent graft rejection. However, it relies heavily on patient compliance, and sustained therapeutic drug levels are often not achieved with administration of topical eye drops. A biodegradable drug delivery system with a controlled and sustained drug release may circumvent these limitations. In this study, we investigated the efficacy of a prednisolone acetate (PA)-loaded poly (d,l-lactide-co-ε-caprolactone) (PLC) microfilm drug delivery system on promoting the survival of allogeneic grafts after penetrating keratoplasty (PK) using a rat model. The drug release profiles of the microfilms were characterized (group 1). Subsequently, forty-eight PK were performed in four experimental groups: syngeneic control grafts (group 2), allogeneic control grafts (group 3), allogeneic grafts with subconjunctivally-implanted PA microfilm (group 4), and allogeneic grafts with PA eye drops (group 5; n = 12 in each). PA-loaded microfilm achieved a sustained and steady release at a rate of 0.006-0.009 mg/day, with a consistent aqueous drug concentration of 207-209 ng/ml. The mean survival days was >28 days in group 2, 9.9±0.8 days in group 3, 26.8±2.7 days in group 4, and 26.4±3.4 days in group 5 (P = 0.023 and P = 0.027 compared with group 3). Statistically significant decrease in CD4+, CD163+, CD 25+, and CD54+ cell infiltration was observed in group 4 and group 5 compared with group 3 (P<0.001). There was no significant difference in the mean survival and immunohistochemical analysis between group 4 and group 5. These results showed that sustained PA-loaded microfilm effectively prolongs corneal allograft survival. It is as effective as conventional PA eye drops, providing a promising clinically applicable alternative for patients undergoing corneal transplantation.

Assessment of in vivo behavior of polymer tube nerve grafts simultaneously with the peripheral nerve regeneration process using scanning electron microscopy technique

In this study, scanning electron microscopy (SEM) has been applied for instantaneous assessment of processes occurring at the site of regenerating nerve. The technique proved to be especially useful when an artificial implant should have been observed but have not yet been extensively investigated before for assessment of nerve tissue. For in vivo studies, evaluation of implant's morphology and its neuroregenerative properties is of great importance when new prototype is developed. However, the usually applied histological techniques require separate and differently prepared samples, and therefore, the results are never a 100% comparable. In our research, we found SEM as a technique providing detailed data both on an implant behavior and the nerve regeneration process inside the implant. Observations were carried out during 12-week period on rat sciatic nerve injury model reconstructed with nerve autografts and different tube nerve grafts. Samples were analyzed with haematoxylin-eosin (HE), immunocytochemical staining for neurofillament and S-100 protein, SEM, TEM, and the results were compared. SEM studies enabled to obtain characteristic pictures of the regeneration process similarly to TEM and histological studies. Schwann cell transformation and communication as well as axonal outgrowth were identified, newly created and matured axons could be recognized. Concurrent analysis of biomaterial changes in the implant (degradation, collapsing of the tube wall, migration of alginate gel) was possible. This study provides the groundwork for further use of the described technique in the nerve regeneration studies.

Effects of Hot-drawing and Annealing on the Morphology and Mechanical Properties of Biodegradable Polyester Monofilament Fibers

Co/terpolymers of L-lactide (LL), ∊-caprolactone (CL) and glycolide (G) are biodegradable in the human body and, as such, have considerable potential for use in biomedical applications such as absorbable surgical sutures, nerve guides, bone fixation devices and drug delivery systems. This study focuses its attention on their potential as monofilament fibers for absorbable suture applications. Random co/terpolymers with different compositions of LL, CL and G were synthesized via bulk ring-opening polymerization. The polymers obtained were melt spun at slow speeds into ice-cooled water to produce as-spun monofilament fibers with as little molecular orientation and crystallinity as possible. Combinations of off-line hot-drawing and annealing steps under controlled conditions of draw rate, draw ratio, temperature and time were then employed in order to develop the fiber's oriented semi-crystalline morphology. The mechanical properties of the fibers were tested after each processing step and compared. The tensile test results showed that the tensile strength was strongly dependent on the draw ratio. A high draw ratio was obtained by multiple off-line hot-drawings with intermediate annealing. The first hot-drawing step dramatically enhanced the mechanical properties relative to those of the weak, highly extensible as-spun fiber. Subsequent annealing at a suitable temperature and for an appropriate length of time increased fiber flexibility as a result of molecular relaxation. Additional hot-drawing steps, again under precise temperature-time conditions, increased the total draw ratio and further enhanced the fiber's mechanical strength.

Hybrid conducting polymer-hydrogel conduits for axonal growth and neural tissue engineering

Successfully and efficiently bridging peripheral nerve gaps without the use of autografts is a substantial clinical advance for peripheral nerve reconstructions. Novel templating methods for the fabrication of conductive hydrogel guidance channels for axonal regeneration are designed and developed. PEDOT is electrodeposited inside the lumen to create fully coated-PEDOT agarose conduits and partially coated-PEDOT agarose conduits.

Influence of cross-linking degree of a biodegradable genipin-cross-linked gelatin guide on peripheral nerve regeneration

We evaluated peripheral nerve regeneration using biodegradable genipin-cross-linked gelatin nerve conduits (GGCs) with three different cross-linking degrees, 24, 36 and 51%. Biocompatibility and biodegradability of the GGC and its efficiency as a guidance channel were examined based on the repair process of a 10-mm gap in the rat sciatic nerve. From this pilot study we concluded that GGCs with a mean cross-linking degree of 36% can ensure nerve regeneration with a more mature structure, as demonstrated by better developed epineural and perineural organisation and axonal development, as well as better-recovered electrophysiology with a relatively positive sciatic functional index and a shorter latency of the muscle action potential curve. Regenerated nerves in the GGCs with mean cross-linking degrees of 24 and 51% were less favourable, due to irritation caused by degradation material and compression by the remaining tube walls, respectively.

Precision microchannel scaffolds for central and peripheral nervous system repair

In previous studies, we demonstrated the ability to linearly guide axonal regeneration using scaffolds comprised of precision microchannels 2 mm in length. In this work, we report our efforts to augment the manufacturing process to achieve clinically relevant scaffold dimensions in the centimeter-scale range. By selective etching of multi-component fiber bundles, agarose hydrogel scaffolds with highly ordered, close-packed arrays of microchannels, ranging from 172 to 320 μm, were fabricated with overall dimensions approaching clinically relevant length scales. Cross-sectional analyses determined that the maximum microchannel volume per unit volume of scaffold approached 80%, which is nearly twice that compared to our previously reported study. Statistical analyses at various points along the length of the microchannels also show a significant degree of linearity along the entire length of the scaffold. Two types of multi-component fiber bundle templates were evaluated; polystyrene and poly(methyl methacrylate). The scaffolds consisting of 2 cm long microchannels were fabricated with the poly(methyl methacrylate) fiber-cores exhibited a higher degree of linearity compared to those fabricated using polystyrene fibers. It is believed that the materials process developed in this study is useful for fabricating high aspect ratio microchannels in biocompatible materials with a wide range of geometries for guiding nerve regeneration.

Composition-property relationships for an experimental composite nerve guidance conduit: evaluating cytotoxicity and initial tensile strength

The objective of this work was to examine the main (individual), combined (interaction) and second-order (quadratic) effects of: (i) poly(D,L-lactide-co-glycolide) (PLGA), (ii) F127, and (iii) a zinc-silicate based bioactive glass, on the cytotoxicity and ultimate tensile strength of an experimental nerve guidance conduit (NGC). The experimental plan was carried out according to a Box-Behnken design matrix. The effects of each compositional factor were quantified using response surface methodology (RSM) techniques. Linear and quadratic polynomial equations were developed to examine cytotoxicity (after incubation at 3, 7 and 28 days) and initial ultimate tensile strength (UTS(0)). Multiple regression analyses showed that the developed models yielded a good prediction for each response examined. It was observed that the beneficial effects of PLGA and bioactive glass on controlling cytotoxicity appeared greater than that of F127. Furthermore, the experimental conduits (with the exception of CNGC-I and CNGC-K) generally showed superior cytocompatibility when compared with the comparable literature for the clinically used nerve guidance conduit Neurolac(®). In this investigation, optimal compositions for cell viability were obtained for the following composition: PLGA = 18.89 wt%/F127 = 0.52 wt%/glass = 12.71 wt%. The optimization of composition with respect to ultimate tensile strength was also established (desired UTS(0) being based on the properties of the control device Neurolac(®) whose UTS is c.20 MPa). The desired UTS(0) of ≤ 20 MPa was found for the composition: PLGA = 18.63 wt%/F127 = 0.77 wt%/glass = 5.54 wt%. A UTS(0) ≤ 30 MPa was recorded for the composition: PLGA = 18.34 wt%/F127 = 0.62 wt%/glass = 9.83 wt%, such tensile strengths are comparable to, reported values for Neurolac(®). Examination of the composition-property relationships with respect to combining cell viability and UTS(0) indicated preferred compositions in the range 17.97-19.90 wt% PLGA, 0.16-1.13 wt% F127 and between 5.54 and ≤ 20 wt% glass. This research demonstrates the value of a design of experiments approach for the design of novel nerve guidance conduits, and shows that the materials examined may have potential for the repair of peripheral nerve discontinuities.

Regeneration and repair of peripheral nerves with different biomaterials: review

Peripheral nerve injury may cause gaps between the nerve stumps. Axonal proliferation in nerve conduits is limited to 10-15 mm. Most of the supportive research has been done on rat or mouse models which are different from humans. Herein we review autografts and biomaterials which are commonly used for nerve gap repair and their respective outcomes. Nerve autografting has been the first choice for repairing peripheral nerve gaps. However, it has been demonstrated experimentally that tissue engineered tubes can also permit lead to effective nerve repair over gaps longer than 4 cm repair that was previously thought to be restorable by means of nerve graft only. All of the discoveries in the nerve armamentarium are making their way into the clinic, where they are, showing great potential for improving both the extent and rate of functional recovery compared with alternative nerve guides.

In vitro and in vivo testing of novel ultrathin PCL and PCL/PLA blend films as peripheral nerve conduit

In an attempt to obviate the drawbacks of nerve autograft, ultrathin microporous biodegradable PCL and PCL/PLA films were tested for their compatibility with motor neuron-like NG108-15 cells and primary Schwann cells. Data obtained from MTS colorimetric and DNA fluorimetric assays showed that both cell lines readily attached and proliferated on these materials. Images taken using scanning electron microscope and fluorescence microscope confirmed these observations. Enhanced cell-surface interaction was achieved by pretreating the films in NaOH solution. Importantly, NG108-15 cells could be induced into differentiated phenotype with long, un-branched neurites growing across the surface of the materials. The bipolar spindle-shaped phenotype of Schwann cells was also retained on these scaffolds. Positive immunochemical staining using antibodies against neurofilament for NG108-15 cells and S100 for Schwann cells indicated the expression of these marker proteins. In a small-scaled pilot testing, the performance of PCL conduits in bridging up a 10 mm gap in rat sciatic nerve model was assessed. Immunohistochemical staining showed that regenerated nerve tissue and penetrated Schwann cells have the potential to span the whole length of the conduit in 2 weeks.

Construction of tissue engineered nerve grafts and their application in peripheral nerve regeneration

Surgical repair of severe peripheral nerve injuries represents not only a pressing medical need, but also a great clinical challenge. Autologous nerve grafting remains a golden standard for bridging an extended gap in transected nerves. The formidable limitations related to this approach, however, have evoked the development of tissue engineered nerve grafts as a promising alternative to autologous nerve grafts. A tissue engineered nerve graft is typically constructed through a combination of a neural scaffold and a variety of cellular and molecular components. The initial and basic structure of the neural scaffold that serves to provide mechanical guidance and optimal environment for nerve regeneration was a single hollow nerve guidance conduit. Later there have been several improvements to the basic structure, especially introduction of physical fillers into the lumen of a hollow nerve guidance conduit. Up to now, a diverse array of biomaterials, either of natural or of synthetic origin, together with well-defined fabrication techniques, has been employed to prepare neural scaffolds with different structures and properties. Meanwhile different types of support cells and/or growth factors have been incorporated into the neural scaffold, producing unique biochemical effects on nerve regeneration and function restoration. This review attempts to summarize different nerve grafts used for peripheral nerve repair, to highlight various basic components of tissue engineered nerve grafts in terms of their structures, features, and nerve regeneration-promoting actions, and finally to discuss current clinical applications and future perspectives of tissue engineered nerve grafts.

Electrical stimulation of nerve cells using conductive nanofibrous scaffolds for nerve tissue engineering

Fabrication of scaffolds with suitable chemical, mechanical, and electrical properties is critical for the success of nerve tissue engineering. Electrical stimulation was directly applied to electrospun conductive nanofibrous scaffolds to enhance the nerve regeneration process. In the present study, electrospun conductive nanofibers were prepared by mixing 10 and 15 wt% doped polyaniline (PANI) with poly (epsilon-caprolactone)/gelatin (PG) (70:30) solution (PANI/PG) by electrospinning. The fiber diameter, pore size, hydrophilicity, tensile properties, conductivity, Fourier transform infrared (FTIR), and X-ray photoelectron spectroscopy spectra of nanofibers were determined, and the in vitro biodegradability of the different nanofibrous scaffolds was also evaluated. Nanofibrous scaffolds containing 15% PANI was found to exhibit the most balanced properties to meet all the required specifications for electrical stimulation for its enhanced conductivity and is used for in vitro culture and electrical stimulation of nerve stem cells. 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) assay and scanning electron microscopy results showed that conductive nanofibrous scaffolds are suitable substrates for the attachment and proliferation of nerve stem cells. Electrical stimulation through conductive nanofibrous PANI/PG scaffolds showed enhanced cell proliferation and neurite outgrowth compared to the PANI/PG scaffolds that were not subjected to electrical stimulation.

Collagen nerve conduits promote enhanced axonal regeneration, schwann cell association, and neovascularization compared to silicone conduits

Peripheral nerve regeneration within guidance conduits involves a critical association between regenerating axons, Schwann cells (SCs), and neovascularization. However, it is currently unknown if there is a greater association between these factors in nonpermeable versus semipermeable nerve guide conduits. We therefore examined this collaboration in both silicone- and collagen-based nerve conduits in both 5- and 10-mm-injury gaps in rat sciatic nerves. Results indicate that collagen conduits promoted enhanced axonal and SC regeneration and association when compared to silicone conduits in the shorter 5-mm-gap model. In addition, collagen tubes displayed enhanced neovascularization over silicone conduits, suggesting that these three factors are intimately related in successful peripheral nerve regeneration. At later time points (1- and 2-month analysis) in a 10-mm-gap model, collagen tubes displayed enhanced axonal regeneration, myelination, and vascularization when compared to silicone-based conduits. Results from these studies suggest that regenerating cables within collagen-based conduits are revascularized earlier and more completely, which in turn enhances peripheral nerve regeneration through these nerve guides as compared to silicone conduits.

Biocompatibility of Different Nerve Tubes

Bridging nerve gaps with suitable grafts is a major clinical problem. The autologous nerve graft is considered to be the gold standard, providing the best functional results; however, donor site morbidity is still a major disadvantage. Various attempts have been made to overcome the problems of autologous nerve grafts with artificial nerve tubes, which are “ready-to-use” in almost every situation. A wide range of materials have been used in animal models but only few have been applied to date clinically, where biocompatibility is an inevitable prerequisite. This review gives an idea about artificial nerve tubes with special focus on their biocompatibility in animals and humans.

Diffusion of soluble factors through degradable polymer nerve guides: Controlling manufacturing parameters

Nerve guides are cylindrical conduits of either biologically based or synthetic materials that are used to bridge nerve defects. While it is well known that a critical aspect of nerve regeneration is the delivery of oxygen and nutrients to the surviving nerve tissue, several guide parameters that determine the permeability of nerve guides to nutrients are often overlooked. We have reproducibly manufactured poly(caprolactone) (PCL) nerve guides of tailored porosity percentage, wall thickness and pore diameter through a dip-coating/salt-leaching technique. In this study, these three parameters were varied to measure the response of glucose and lysozyme diffusion through the guide wall. In addition, nerve guide permeability following protein fouling studies was examined. Based on the results from this study, it was determined that at high porosity percentages (80%), decreasing the pore diameter (10-38microm) was a measurable method of decreasing the lysozyme permeability of PCL nerve guides while not creating a loss of glucose permeability. PCL fouling studies were used to fine-tune the desirable nerve guide wall thickness. Results indicated that nerve guides 0.6mm thick decreased the loss of lysozyme to almost 10% without significantly diminishing glucose (nutrient) permeability. These results will be utilized to optimize nerve guide parameters for future in vivo applications.