Facile Surface Modification Method for Synergistically Enhancing the Biocompatibility and Bioactivity of Poly(ether ether ketone) That Induced Osteodifferentiation

Overcoming biological inertness: multifaceted strategies to optimize PEEK bioactivity for interdisciplinary clinical applications

Polyether ether ketone (PEEK), characterized by a comparable elastic modulus to human bone with high wear resistance, radiolucency, and biocompatibility, demonstrates considerable promise for clinical applications. However, due to the significant limitations in clinical applications caused by the biological inertness of PEEK, it should first be modified to meet clinical needs. Currently, the field of PEEK modifications is rapidly advancing, with a particular emphasis on enhancing its biological properties. Most of the previous reviews have separately discussed strategies like antibacterial, osteogenic, and angiogenic enhancements for PEEK. This review combines cross-domain insights to update and synthesize recent research on PEEK composites, focusing on advanced multi-component sustained release platforms that mimic postoperative biological processes. Such temporal alignment between material functionality and physiological healing phases demonstrates unprecedented potential for expanding PEEK's clinical versatility.

A pH-Responsive Polyetheretherketone Implant Modified with a Core-Shell Metal-Organic Framework to Promote Antibacterial and Osseointegration Abilities

Polyetheretherketone (PEEK) is considered to be a potential material for oral implants due to its elastic modulus being similar to that of human cortical bone. However, the poor antibacterial, anti-inflammatory, and osseointegration properties of bioinert PEEK have hindered its clinical application. Therefore, this study designed and constructed a pH-responsive PEEK implant with a bilayer core-shell zeolitic imidazolate framework-8 (ZIF-8) structure loaded on its surface, with an antimicrobial peptide (KR12) encapsulated in the outer shell and an osteogenic peptide (osteogenic growth peptide ) encapsulated in its inner core. In this study, the bilayer core-shell ZIF-8 structure was confirmed to have pH-responsive properties. In vitro studies proved that the implant could promote bone marrow mesenchymal stem cells' proliferation and differentiation and the M1 phenotype to M2 phenotype conversion of RAW 264.7 and could inhibit bacterial adhesion and proliferation. By constructing rats' distal femur with/without infection models, it was further demonstrated that the novel implant could effectively inhibit bacterial adhesion and growth, inhibit inflammation, and promote peri-implant osseointegration, which was more substantial when the local area was infected and the pH was lower than that of normal tissue. Collectively, the results suggest that this novel pH-responsive PEEK implant loaded with a bilayer core-shell ZIF-8 structure is a promising peptide delivery implant system, which is well suited for dental applications and offers a potential solution for the prevention of infection during the early phase after implantation.

A high-safety lithium-ion battery electrospun separator with Si3N4-assisted sulfonated poly(ether ether ketone) for regulating lithium flux

The uncontrolled lithium (Li) dendrite growth significantly impacts the safety performance of polymer separators. To mitigate this growth, this study introduces Si3N4 into sulfonated poly(ether Ether Ketone) (SPEEK) and prepares Si3N4/SPEEK composite separators via electrospinning. At the interface between the Si3N4/SPEEK separator and the Li anode, the Si nanowires that form impede Li dendrite growth, thereby enhancing the electrochemical performance of lithium-ion batteries (LIBs). The Li deposition test of the 10 % Si3N4/SPEEK separator can operate for 1000 h without short-circuiting. Additionally, the LiFePO4||Li cell with the 10 % Si3N4/SPEEK separator shows improved initial discharge capacity (157.8 mAh g-1 at 1C) and superior rate performance (125 mAh g-1 at 10C). Moreover, the nano-scale Si3N4 endows the separator with robust thermal and mechanical properties. The FLIR observations reveal that the 10 % Si3N4/SPEEK separator maintains uniform thermal distribution and structural integrity even at 300 °C, ensuring safe battery operation at high temperatures. The additional load of the 10 % Si3N4/SPEEK separator can reach 10.2 mN, which enhances the puncture resistance of the separator. This work provides a solid approach for the application of SPEEK as a high-safety and high-rate LIB separator.

A comprehensive review on the State of the Art in the research and development of poly-ether-ether-ketone (PEEK) biomaterial-based implants

Polyetheretherketone (PEEK) is a preferred high-performance polymer in the spine, orthopedic, and craniomaxillofacial implant industry. However, despite its commendable mechanical properties, its bioinert nature limits the implants from integrating with neighboring tissues, impacting the implant's long-term performance. To address this limitation, various kinds of surface functionalization techniques have been developed over the years. Noteworthy efforts have been made to incorporate bioactive fillers in the PEEK matrix to develop standalone bioactive composites. In personalized medicine, significant advances have been made in the 3D Printing of PEEK implants. 3D-printed PEEK implants are now being developed at Point-of-Care, significantly reducing manufacturing and logistic time. Given the recent clinical follow-up updates and advancements in PEEK-based implants, PEEK implants are witnessing an important phase in its history. Recognizing this vital phase, this paper aims to comprehensively review the advancements of PEEK implants over the past decade. The review starts with an overview of the clinical impact of varying PEEK implants, followed by PEEK's surface functionalization techniques and engineering of PEEK-based bioactive composites. Next, this review describes the advancements made in the 3D printing of PEEK implants and points out the essential considerations that should be considered when developing 3D-printed PEEK-based implants. Finally, the review ends with an estimated projection about the future of PEEK-based implants. Readers are expected to gain an all-encompassing and in-depth understanding of PEEK biomedical implants' past, present, and future, enabling researchers to advance the research and development of PEEK-based implants in the required direction. STATEMENT OF SIGNIFICANCE: PEEK is a preferred high-performance polymer in the implant industry, with notable benefits over metallic and ceramic implants, such as bone-matching stiffness and durability. Significant strides have been made in the last decade to make PEEK implants bioactive and utilize 3D Printing to develop patient-specific implants. Given the recent advancements in PEEK-based implants, this review aims to provide an all-encompassing and in-depth understanding of PEEK biomedical implants' past, present, and future. It will comprehensively discuss the know-how gained from the clinical follow-up, the strategies to address the limitations of PEEK implants, and the essential considerations in 3D Printing of PEEK implants. This review will enable researchers to advance the research and development of PEEK implants in the required direction.

A Surface-Mediated Biomimetic Porous Polyether-Ether-Ketone Scaffold for Regulating Immunity and Promoting Osteogenesis

The repair of critical-sized bone defects remains a major challenge for clinical orthopedic surgery. Here, we develop a surface biofunctionalized three-dimensional (3D) porous polyether-ether-ketone (PEEK) scaffold that can simultaneously promote osteogenesis and regulate macrophage polarization. The scaffold is created using polydopamine (PDA)-assisted immobilization of silk fibroin (SF) and the electrostatic self-assembly of nanocrystalline hydroxyapatite (nano-HA) on a 3D-printed porous PEEK scaffold. The SF/nano-HA functionalized surface provides a bone-like microenvironment for osteoblastic cells' adhesion, proliferation, mineralization and osteogenic differentiation. Moreover, the biofunctionalized surface can effectively drive macrophages polarization from the pro-inflammatory M1 phenotype to the anti-inflammatory M2 phenotype. Integrin β1-specific cell-matrix binding and the activation of Ca2+ receptor-mediated signaling pathway play critical roles in the regulation of macrophage polarization. Compared with the as-printed scaffold, the SF/nano-HA functionalized porous PEEK scaffold induces minimal inflammatory response, enhanced angiogenesis, and substantial new bone formation, resulting in improved osseointegration in vivo. This study not only develops a promising candidate for bone repair but also demonstrates a facile surface biofunctionalization strategy for orthopedic implants to improve osseointegration by stimulating osteogenesis and regulating immunity.

Characterization and biocompatibility of a bilayer PEEK-based scaffold for guiding bone regeneration

BACKGROUND

Polyetheretherketone (PEEK) is well known for its excellent physical-chemical properties and biosafety. The study aimed to open up a new method for clinical application of PEEK to reconstruct large-scale bone defects.

METHODS

A bilayer scaffold for bone regeneration was prepared by combining a sulfonated PEEK barrier framework (SPEEK) with a hydrogel layer loaded with aspirin (ASA) and nano-hydroxyapatite (nHAP) by the wet-bonding of Polydopamine (PDA).

RESULTS

The hydrogel was successfully adhered to the surface of SPEEK, resulting in significant changes including the introduction of bioactive groups, improved hydrophilicity, and altered surface morphology. Subsequent tests confirmed that the bilayer scaffold exhibited enhanced compression resistance and mechanical compatibility with bone compared to a single hydrogel scaffold. Additionally, the bilayer scaffold showed stable and reliable bonding properties, as well as excellent biosafety verified by cell proliferation and viability experiments using mouse embryo osteoblast precursor (MC3T3-E1) cells.

CONCLUSION

The bilayer bone regeneration scaffold prepared in this study showed promising potential in clinical application for bone regeneration.

Polydopamine-Based Biomaterials in Orthopedic Therapeutics: Properties, Applications, and Future Perspectives

Polydopamine is a versatile and modifiable polymer, known for its excellent biocompatibility and adhesiveness. It can also be engineered into a variety of nanoparticles and biomaterials for drug delivery, functional modification, making it an excellent choice to enhance the prevention and treatment of orthopedic diseases. Currently, the application of polydopamine biomaterials in orthopedic disease prevention and treatment is in its early stages, despite some initial achievements. This article aims to review these applications to encourage further development of polydopamine for orthopedic therapeutic needs. We detail the properties of polydopamine and its biomaterial types, highlighting its superior performance in functional modification on nanoparticles and materials. Additionally, we also explore the challenges and future prospects in developing optimal polydopamine biomaterials for clinical use in orthopedic disease prevention and treatment.

Peek@ZIF-8(CEL) as a Novel Bone Implant for Large Defect Repair and Enhanced Bone Healing via a Long-Term Stable Bioactive Releaser

The repair of large bone defects poses a significant challenge in orthopedics. Polyetheretherketone (PEEK) is a promising bone substitute, while it suffers a lack of bioactivity. Although several studies have been performed to further improve the bioactivities of PEEK by various surface modifications, PEEK offering long-term, multifaceted biofunctionalities remains still desired. In this study, we introduced metal-organic frameworks (MOFs), specifically ZIF-8 loaded with celecoxib (ZIF-8(CEL)), onto the PEEK surface through dopamine adhesion. The resulting PEEK@ZIF-8(CEL) aims to achieve long-term stable release of Zn ions and CEL for enhanced bone integration. Material characterization and biological experiments confirmed the successful integration of ZIF-8(CEL) onto PEEK and its positive biomedical effects, including creating a positive bone immunological environment and promoting bone growth. This study demonstrates the potential of PEEK@ZIF-8(CEL) as a novel repair material for large bone defects, offering a promising alternative in orthopedic applications.

Enhancing bioactivity and biocompatibility of polyetheretherketone (PEEK) for dental and maxillofacial implants: A novel sequential soaking process

Polyetheretherketone (PEEK) exhibits excellent biocompatibility, fatigue resistance, and an elastic modulus similar to bone, presenting broad application prospects in the field of dental and maxillofacial implants. However, the bioinertness of PEEK limits its applications. In this study, we developed a method to generate biocompatible and bioactive PEEK through a simple sequential soaking process, aimed at inducing bone differentiation and enhancing antibacterial properties. Initially, a three-dimensional (3D) porous network was introduced on the PEEK surface by soaking in concentrated sulfuric acid and water. Subsequently, the sulfonated PEEK surface was treated with oxygen plasma, followed by immersion in a dopamine solution to coat a polydopamine (PDA) layer. Finally, polydopamine phosphate ester-modified 3D porous PEEK was obtained through the reaction of phosphoryl chloride with surface phenolic hydroxyl groups. Systematic studies were conducted using scanning electron microscopy, X-ray photoelectron spectroscopy, water contact angle analysis, cell proliferation and adhesion, osteogenic gene expression detection, alkaline phosphatase staining, alizarin red staining, and bacterial culture. Overall, compared to unmodified PEEK, the modified PEEK significantly enhanced in vitro cell proliferation and adhesion, osteogenic differentiation, and antibacterial properties. The simple surface modification measures combined in this study may represent a promising technology and could facilitate the application of PEEK in dental and maxillofacial implants.

Application of 3D‑printed porous titanium interbody fusion cage vs. polyether ether ketone interbody fusion cage in anterior cervical discectomy and fusion: A systematic review and meta‑analysis update

The present study aimed to compare the differences between 3D-printed porous titanium and polyether ether ketone (PEEK) interbody fusion cages for anterior cervical discectomy and fusion (ACDF). Literature on the application of 3D-printed porous titanium and PEEK interbody fusion cages for ACDF was searched in the PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang and VIP databases. A total of 1,181 articles were retrieved and 12 were finally included. The Cochrane bias risk assessment criteria and Newcastle-Ottawa scale were used for quality evaluation and Review Manager 5.4 was used for data analysis. The 3D cage group was superior to the PEEK cage group in terms of operative time [mean difference (MD): -7.68; 95% confidence interval (CI): -11.08, -4.29; P<0.00001], intraoperative blood loss (MD: -6.17; 95%CI: -10.56, -1.78; P=0.006), hospitalization time (MD: -0.57; 95%CI: -0.86, -0.28: P=0.0001), postoperative complications [odds ratio (OR): 0.35; 95%CI: 0.15, 0.80; P=0.01], C2-7 Cobb angle (MD: 2.85; 95%CI: 1.45, 4.24; P<0.0001), intervertebral space height (MD: 1.20; 95%CI: 0.54, 1.87; P=0.0004), Japanese Orthopaedic Association Assessment of Treatment (MD: 0.69; 95%CI: 0.24, 1.15; P=0.003) and visual analogue scale score (MD: -0.43; 95%CI: -0.78, -0.07; P=0.02). The difference was statistically significant, while there was no significant difference between the two groups in terms of fusion rate (OR: 1.74; 95%CI: 0.71, 4.27; P=0.23). The use of 3D-printed porous titanium interbody fusion cage in ACDF has the advantages of short operation time, less bleeding loss, shorter hospitalization time and fewer postoperative complications. It can better maintain the cervical curvature and intervertebral height, relieve pain and accelerate postoperative functional recovery.

Multifunctional surface of the nano-morphic PEEK implant with enhanced angiogenic, osteogenic and antibacterial properties

Polyetheretherketone (PEEK) is a high-performance polymer suitable for use in biomedical coatings. The implants based on PEEK have been extensively studied in dental and orthopedic fields. However, their inherent inert surfaces and poor osteogenic properties limit their broader clinical applications. Thus, there is a pressing need to produce a multifunctional PEEK implant to address this issue. In response, we developed sulfonated PEEK (sPEEK)-Cobalt-parathyroid hormone (PTH) materials featuring multifunctional nanostructures. This involved loading cobalt (Co) ions and PTH (1-34) protein onto the PEEK implant to tackle this challenge. The findings revealed that the controlled release of Co2+ notably enhanced the vascular formation and the expression of angiogenic-related genes, and offered antimicrobial capabilities for sPEEK-Co-PTH materials. Additionally, the sPEEK-Co-PTH group exhibited improved cell compatibility and bone regeneration capacity in terms of cell activity, alkaline phosphatase (ALP) staining, matrix mineralization and osteogenic gene expression. It surpassed solely sulfonated and other functionalized sPEEK groups, demonstrating comparable efficacy even when compared to the titanium (Ti) group. Crucially, animal experiments also corroborated the significant enhancement of osteogenesis due to the dual loading of cobalt ions and PTH (1-34). This study demonstrated the potential of bioactive Co2+ and PTH (1-34) for bone replacement, optimizing the bone integration of PEEK implants in clinical applications.

Strategies to improve the performance of polyetheretherketone (PEEK) as orthopedic implants: from surface modification to addition of bioactive materials

Polyetheretherketone (PEEK), as a high-performance polymer, is widely used for bone defect repair due to its homogeneous modulus of elasticity of human bone, good biocompatibility, excellent chemical stability and projectability. However, the highly hydrophobic surface of PEEK is biologically inert, which makes it difficult for cells and proteins to attach, and is accompanied by the development of infections that ultimately lead to failure of PEEK implants. In order to further enhance the potential of PEEK as an orthopedic implant, researchers have explored modification methods such as surface modification by physical and chemical means and the addition of bioactive substances to PEEK-based materials to enhance the mechanical properties, osteogenic activity and antimicrobial properties of PEEK. However, these current modification methods still have obvious shortcomings in terms of cost, maneuverability, stability and cytotoxicity, which still need to be explored by researchers. This paper reviews some of the modification methods that have been used to improve the performance of PEEK over the last three years in anticipation of the need for researchers to design PEEK orthopedic implants that better meet clinical needs.

PRP coating on different modified surfaces promoting the osteointegration of polyetheretherketone implant

Introduction: Polyetheretherketone (PEEK) material implants have been applied more and more clinically recently. In order to increase the osteogenic activity of PEEK material, the microstructure change of the material surface and the construction of functional microcoatings have become a hot research topic. This study investigated the ability of PEEK surfaces modified by different methods to carry Platelet-rich plasma (PRP) and the osteogenic ability of different PEEK microstructures after carrying PRP in vivo/in vitro. Methods: In this study, PEEK surfaces were modified by sulfuric acid, gaseous sulfur trioxide and sandpaper. Next, PRP from SD rats was prepared and incubated on PEEK material with different surface microstructures. Lactate dehydrogenase test, scanning electron microscope and Elisa assay was used to evaluate adhesion efficiency of PRP. Then in vitro tests such as CCK-8, ALP staining, ARS staining and RT-qPCR et al were used to further evaluate osteogenesis ability of the PRP coating on PEEK surface. Finally, The tibia defects of SD rats were established, and the new bone was evaluated by Micro-CT, HE staining, and immunofluorescence staining. Results: The sandpaper-polished PEEK with the strongest PRP carrying capacity showed the best osteogenesis. Our study found that the modified PEEK surface with PRP coating has excellent osteogenic ability and provided the basis for the interface selection of PRP for the further application of PEEK materials. Discussion: Among the three PEEK modified surfaces, due to the most PRP carrying and the strongest osteogenic ability in vitro/vivo, the frosted surface was considered to be the most suitable surface for the preparation of PRP coating.

Current surface modification strategies to improve the binding efficiency of emerging biomaterial polyetheretherketone (PEEK) with bone and soft tissue: A literature review

PURPOSE

The aim of this study was to review the literature on current surface modification strategies used to improve the binding efficiency of an emerging biological material, polyetheretherketone (PEEK), with bone and soft tissues.

STUDY SELECTION

This review was based on articles retrieved from PubMed, Google Scholar, Web of Science, and ScienceDirect databases. The main keywords used during the search were "polyetheretherketone (PEEK)," "implant," "surface modification," "biomaterials," "bone," "osseointegration," and "soft tissue."

RESULTS

The suitability of PEEK surface modification strategies has been critically analyzed and summarized here. Many cell and in vivo experiments in small animals have shown that the use of advanced modification technologies with appropriate surface modification strategies can effectively improve the surface inertness of PEEK, thereby improving its binding efficiency with bone and soft tissues.

CONCLUSIONS

Surface modifications of PEEK have revealed new possibilities for implant treatment; however, most results are based on in vitro or short-term in vivo evaluations in small animals. To achieve a broad application of PEEK in the field of oral implantology, more in vivo experiments and long-term clinical evaluations are needed to investigate the effects of various surface modifications on the tissue integration ability of PEEK to develop an ideal implant material.

Strategies of immobilizing BMP-2 with 3D-printed scaffolds to improve osteogenesis

The management and definitive treatment of critical-size bone defects in severe trauma, tumor resection and congenital malformation are troublesome for orthopedic surgeons and patients worldwide without recognized good treatment strategies. Researchers and clinicians are working to develop new strategies to treat these problems. This review aims to summarize the techniques used by additive manufacturing scaffolds loaded with BMP-2 to promote osteogenesis and to analyze the current status and trends in relevant clinical translation. Optimize composite scaffold design to enhance bone regeneration through printing technology, material selection, structure design and loading methods of BMP-2 to advance the clinical therapeutic bone repair field.

Improvement of the Surface Properties of Polyether Ether Ketone via Arc Evaporation for Biomedical Applications

Polyether ether ketone is a bioinert polymer, that is of high interest in research and medicine as an alternative material for the replacement of bone implants made of metal. The biggest deficit of this polymer is its hydrophobic surface, which is rather unfavorable for cell adhesion and thus leads to slow osseointegration. In order to address this drawback, 3D-printed and polymer extruded polyether ether ketone disc samples that were surface-modified with titanium thin films of four different thicknesses via arc evaporation were investigated and compared with non-modified disc samples. Depending on the modification time, the thickness of the coatings ranged from 40 nm to 450 nm. The 3D-printing process does not affect the surface or bulk properties of polyether ether ketone. It turned out that the chemical composition of the coatings obtained did not depend on the type of substrate. Titanium coatings contain titanium oxide and have an amorphous structure. Microdroplets formed on the sample surfaces during treatment with an arc evaporator contain a rutile phase in their composition. Surface modification of the samples via arc evaporation resulted in an increase in the arithmetic mean roughness from 20 nm to 40 nm for the extruded samples and from 40 nm to 100 nm for the 3D-printed samples, with the mean height difference increasing from 100 nm to 250 nm and from 140 nm to 450 nm. Despite the fact that the hardness and reduced elastic modulus of the unmodified 3D-printed samples (0.33 GPa and 5.80 GPa) are higher than those of the unmodified extruded samples (0.22 GPa and 3.40 GPa), the surface properties of the samples after modification are approximately the same. The water contact angles of the polyether ether ketone sample surfaces decrease from 70° to 10° for the extruded samples and from 80° to 6° for the 3D-printed samples as the thickness of the titanium coating increases, making this type of coating promising for biomedical applications.

A dual-functional PEEK implant coating for anti-bacterial and accelerated osseointegration

Polyetheretherketone (PEEK) has been widely applied in biomedical engineering. However, the unsatisfactory bioactivity essentially limits the clinical application of PEEK. In this study, a simply immersing method was proposed to fabricate a dual-functional PEEK with antibacterial properties and enhanced bone integration. Firstly, the surface of PEEK was modified with a polydopamine (PDA) coating by incubating at dopamine solution. Afterward, the PEEK-PDA was modified with manganese (Mn) and silver (Ag) ions by the soaking method to fabricate the PEEK-PDA-Mn/Ag. The physicochemical capabilities of PEEK-PDA-Mn/Ag were further explored in the ions release, wettability, morphology, and element distributions. PEEK-PDA-Mn/Ag obviously accelerated the adhesion and distribution of MC3T3-E1 cells, indicating favorable biosafety in vitro. Meanwhile, the osteogenic properties of PEEK-PDA-Mn and PEEK-PDA-Mn/Ag were proved by the increased expression of osteogenic genes, alkaline phosphatase (ALP), and mineralization in vitro. Additionally, the wide antibacterial capabilities of PEEK-PDA-Mn/Ag were proved in both Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) in vitro. Furthermore, the PEEK-PDA-Mn/Ag was antibacterial with capability in enhancing osseointegration in vivo. Overall, the simply immersing method can modify the surface of PEEK, giving the bioactivity, biocompatibility, and antibacterial ability to the composited PEEK, which could be applied as an orthopedic implant in clinical.

Fabrication of bFGF/polydopamine-loaded PEEK implants for improving soft tissue integration by upregulating Wnt/β-catenin signaling

The difficulties associated with polyetheretherketone (PEEK) implants and soft tissue integration for craniomaxillofacial bone repair have led to a series of complications that limit the clinical benefits. In this study, 3D printed multi-stage microporous PEEK implants coated with bFGF via polydopamine were fabricated to enhance PEEK implant-soft tissue integration. Multistage microporous PEEK scaffolds prepared by sulfonation of concentrated sulfuric acid were coated with polydopamine, and then used as templates for electrophoretic deposition of bFGF bioactive factors. Achieving polydopamine and bFGF sustained release, the composite PEEK scaffolds possessed good mechanical properties, hydrophilicity, protein adhesion properties. The in vitro results indicated that bFGF/polydopamine-loaded PEEK exhibited good biocompatibility to rabbit embryonic fibroblasts (REF) by promoting cell proliferation, adhesion, and migration. Ribonucleic acid sequencing (RNA-seq) revealed that bFGF/polydopamine-loaded PEEK implants significantly upregulated the expression of genes and proteins associated with soft tissue integration and activated Wnt/β-catenin signaling in biological processes, but related expression of genes and proteins was significantly downregulated when the Wnt/β-catenin signaling was inhibited. Furthermore, in vivo bFGF/polydopamine-loaded PEEK implants exhibited excellent performance in improving the growth and adhesion of the surrounding soft tissue. In summary, bFGF/polydopamine-loaded PEEK implants possess soft tissue integration properties by activating the Wnt/β-catenin signaling, which have a potential translational clinical application in the future.

Porous surface with fusion peptides embedded in strontium titanate nanotubes elevates osteogenic and antibacterial activity of additively manufactured titanium alloy

It is still a big challenge in orthopedics to treat infected bone defects properly using medical metals. The use of three-dimensional (3D) scaffold materials that simultaneously mimic the skeletal hierarchy and induce sustainable osteogenic and antibacterial functions are a promising solution with an increasing appeal. In this study, we first designed a bifunctional fusion peptide (HHC36-RGD, HR) by linking antimicrobial peptide (HHC36) and arginine-glycine-aspartate (RGD) peptide via 6-aminohexanoic acid. Then the 3D scaffold was fabricated by additive manufacturing, and the strontium titanate nanotube structure (3D-STN) was constructed on its surface. Finally, the HR was anchored to the 3D-STN with the aid of polydopamine (PDA, P), forming the 3D-STN-P-HR scaffold. The results showed that the scaffold exhibited an ordered 3D porous structure, and that the surface was covered by a dense HHC36-RGD layer. Expectedly, the adsorption of PDA effectively slowed down the release of HR. Moreover, the functionalized scaffold had a significant inhibitory effect on Staphylococcus aureus and Escherichia coli, and its antibacterial rate could reach more than 95%. The results of in vitro cell culture experiments demonstrated that the 3D-STN-P-HR scaffold possessed excellent cytocompatibility and could promote the transcription of osteogenic differentiation-related genes and the expression of related proteins. In conclusion, the functionally modified 3D porous titanium alloy scaffold (3D-STN-P-HR) has a balanced antibacterial and osteogenic function, which bodes well for future potential in the customized functional reconstruction of complex-shaped infected bone defects.

Antibacterial properties of antimicrobial peptide HHC36 modified polyetheretherketone

Introduction

Polyetheretherketone (PEEK) is considered to be a new type of orthopedic implant material due to its mechanical properties and biocompatibility. It is becoming a replacement for titanium (Ti) due to its near-human-cortical transmission and modulus of elasticity. However, its clinical application is limited because of its biological inertia and susceptibility to bacterial infection during implantation. To solve this problem, there is an urgent need to improve the antibacterial properties of PEEK implants.

Methods

In this work, we fixed antimicrobial peptide HHC36 on the 3D porous structure of sulfonated PEEK (SPEEK) by a simple solvent evaporation method (HSPEEK), and carried out characterization tests. We evaluated the antibacterial properties and cytocompatibility of the samples in vitro. In addition, we evaluated the anti-infection property and biocompatibility of the samples in vivo by establishing a rat subcutaneous infection model.

Results

The characterization test results showed that HHC36 was successfully fixed on the surface of SPEEK and released slowly for 10 days. The results of antibacterial experiments in vitro showed that HSPEEK could reduce the survival rate of free bacteria, inhibit the growth of bacteria around the sample, and inhibit the formation of biofilm on the sample surface. The cytocompatibility test in vitro showed that the sample had no significant effect on the proliferation and viability of L929 cells and had no hemolytic activity on rabbit erythrocytes. In vivo experiments, HSPEEK can significantly reduce the bacterial survival rate on the sample surface and the inflammatory reaction in the soft tissue around the sample.

Discussion

We successfully loaded HHC36 onto the surface of SPEEK through a simple solvent evaporation method. The sample has excellent antibacterial properties and good cell compatibility, which can significantly reduce the bacterial survival rate and inflammatory reaction in vivo. The above results indicated that we successfully improved the antibacterial property of PEEK by a simple modification strategy, making it a promising material for anti-infection orthopedic implants.

Surface Treatments of PEEK for Osseointegration to Bone

Polymers, in general, and Poly (Ether-Ether-Ketone) (PEEK) have emerged as potential alternatives to conventional osseous implant biomaterials. Due to its distinct advantages over metallic implants, PEEK has been gaining increasing attention as a prime candidate for orthopaedic and dental implants. However, PEEK has a highly hydrophobic and bioinert surface that attenuates the differentiation and proliferation of osteoblasts and leads to implant failure. Several improvements have been made to the osseointegration potential of PEEK, which can be classified into three main categories: (1) surface functionalization with bioactive agents by physical or chemical means; (2) incorporation of bioactive materials either as surface coatings or as composites; and (3) construction of three-dimensionally porous structures on its surfaces. The physical treatments, such as plasma treatments of various elements, accelerated neutron beams, or conventional techniques like sandblasting and laser or ultraviolet radiation, change the micro-geometry of the implant surface. The chemical treatments change the surface composition of PEEK and should be titrated at the time of exposure. The implant surface can be incorporated with a bioactive material that should be selected following the desired use, loading condition, and antimicrobial load around the implant. For optimal results, a combination of the methods above is utilized to compensate for the limitations of individual methods. This review summarizes these methods and their combinations for optimizing the surface of PEEK for utilization as an implanted biomaterial.

3D bioprinting of human mesenchymal stem cells-laden hydrogels incorporating MXene for spontaneous osteodifferentiation

Contemporary advances in three-dimensional (3D) bioprinting technologies have enabled the fabrication of tailored live 3D tissue mimetics. Furthermore, the development of advanced bioink materials has been highlighted to accurately reproduce the composition of a native extracellular matrix and mimic the intrinsic properties of laden cells. Recent research has shown that MXene is one of promising nanobiomaterials with osteogenic activity for bone grafts and scaffolds due to its unique atomic structure of three titanium layers between two carbon layers. In this study, the MXene-incorporated gelatin methacryloyl (GelMA) and hyaluronic acid methacryloyl (HAMA) (i.e., GelMA/HAMA-MXene) bioinks were prepared to explore if they have the potential to enable the spontaneous osteodifferentiation of human mesenchymal stem cells (hMSCs) when the hMSCs-laden GelMA/HAMA-MXene bioinks were 3D printed. The physicochemical and rheological characteristics of the GelMA/HAMA-MXene hydrogels were proven to be unprecedentedly favorable supportive matrices suited for the growth and survival of hMSCs. Furthermore, hMSCs were shown to spontaneously differentiate into osteoblasts within GelMA-HAMA/MXene composites to provide favorable microenvironments for osteogenesis. Therefore, our results suggest that the remarkable biofunctional advantages of the MXene-incorporated GelMA/HAMA bioink can be utilized in a wide range of strategies for the development of effective scaffolds in bone tissue regeneration.

Coating of manganese functional polyetheretherketone implants for osseous interface integration

Polyetheretherketone (PEEK) has been used extensively in biomedical engineering and it is highly desirable for PEEK implant to possess the ability to promote cell growth and significant osteogenic properties and consequently stimulate bone regeneration. In this study, a manganese modified PEEK implant (PEEK-PDA-Mn) was fabricated via polydopamine chemical treatment. The results showed that manganese was successfully immobilized on PEEK surface, and the surface roughness and hydrophilicity significantly improved after surface modification. Cell experiments in vitro demonstrated that the PEEK-PDA-Mn possesses superior cytocompatibility in cell adhesion and spread. Moreover, the osteogenic properties of PEEK-PDA-Mn were proved by the increased expression of osteogenic genes, alkaline phosphatase (ALP), and mineralization in vitro. Further rat femoral condyle defect model was utilized to assess bone formation ability of different PEEK implants in vivo. The results revealed that the PEEK-PDA-Mn group promoted bone tissue regeneration in defect area. Taken together, the simple immersing method can modify the surface of PEEK, giving outstanding biocompatibility and enhanced bone tissue regeneration ability to the modified PEEK, which could be applied as an orthopedic implant in clinical.

Use of Piranha Solution as An Alternative Route to Promote Bioactivation of PEEK Surface with Low Functionalization Times

This study aimed to achieve bioactivity on the PEEK surface using piranha solution through a lower functionalization time. For this purpose, the functionalization occurred with piranha solution and 98% sulfuric acid in the proportions of 1:2, 1:1, and 2:1 at periods of 30, 60, and 90 s. The samples treated for longer times at higher concentrations registered the characteristic spectroscopy band associated with sulfonation. Additionally, both chemical treatments allowed the opening of the aromatic ring, increasing the number of functional groups available and making the surface more hydrophilic. The piranha solution treatments with higher concentrations and longer times promoted greater heterogeneity in the surface pores, which affected the roughness of untreated PEEK. Furthermore, the treatments induced calcium deposition on the surface during immersion in SBF fluid. In conclusion, the proposed chemical modifications using sulfuric acid SPEEK 90 and, especially, the piranha solution PEEK-PS 2:1-90, were demonstrated to be promising in promoting the rapid bioactivation of PEEK-based implants.

Biomimetic Strategy to Enhance Epithelial Cell Viability and Spreading on PEEK Implants

Polyetheretherketone (PEEK) is a biocompatible material widely used in spinal and craniofacial implants, with potential use in percutaneous implants. However, its inertness prevents it from forming a tight seal with the surrounding soft tissue, which can lead to infections and implant failure. Conversely, the surface chemistry of percutaneous organs (i.e., teeth) helps establish a strong interaction with the epithelial cells of the contacting soft tissues, and hence a tight seal, preventing infection. The seal is created by adsorption of basement membrane (BM) proteins, secreted by epithelial cells, onto the percutaneous organ surfaces. Here, we aim to create a tight seal between PEEK and epithelial tissues by mimicking the surface chemistry of teeth. Our hypothesis is that collagen I, the most abundant tooth protein, enables integration between the epithelial tissue and teeth by promoting adsorption of BM proteins. To test this, we immobilized collagen I via EDC/NHS coupling on a carboxylated PEEK surface modified using diazonium chemistry. We used titanium alloy (Ti-6Al-4V) for comparison, as titanium is the most widely used percutaneous biomaterial. Both collagen-modified PEEK and titanium showed a larger adsorption of key BM proteins (laminin, nidogen, and fibronectin) compared to controls. Keratinocyte epithelial cell viability on collagen-modified PEEK was twice that of control PEEK and ∼1.5 times that of control titanium after 3 days of cell seeding. Both keratinocytes and fibroblasts spread more on collagen-modified PEEK and titanium compared to controls. This work introduces a versatile and biomimetic surface modification technique that may enhance PEEK-epithelial tissue sealing with the potential of extending PEEK applications to percutaneous implants, making it competitive with titanium.

Strategies to improve bioactive and antibacterial properties of polyetheretherketone (PEEK) for use as orthopedic implants

Polyetheretherketone (PEEK) has gradually become the mainstream material for preparing orthopedic implants due to its similar elastic modulus to human bone, high strength, excellent wear resistance, radiolucency, and biocompatibility. Since the 1990s, PEEK has increasingly been used in orthopedics. Yet, the widespread application of PEEK is limited by its bio-inertness, hydrophobicity, and susceptibility to microbial infections. Further enhancing the osteogenic properties of PEEK-based implants remains a difficult task. This article reviews some modification methods of PEEK in the last five years, including surface modification of PEEK or incorporating materials into the PEEK matrix. For surface modification, PEEK can be modified by chemical treatment, physical treatment, or surface coating with bioactive substances. For PEEK composite material, adding bioactive filler into PEEK through the melting blending method or 3D printing technology can increase the biological activity of PEEK. In addition, some modification methods such as sulfonation treatment of PEEK or grafting antibacterial substances on PEEK can enhance the antibacterial performance of PEEK. These strategies aim to improve the bioactive and antibacterial properties of the modified PEEK. The researchers believe that these modifications could provide valuable guidance on the future design of PEEK orthopedic implants.

Strontium-modified porous polyetheretherketone with the triple function of osteogenesis, angiogenesis, and anti-inflammatory for bone grafting

Polyetheretherketone (PEEK) is a potential bone repair material because of its stable chemical and good mechanical properties. However, the biological inertness of PEEK limits its clinical application. Sr²⁺ has multi biological functions, including promoting bone formation and blood vessel regeneration and inhibiting inflammation. In this paper, PEEK was modified with Sr²⁺ with the purpose to construct PEEK bone graft material with triple functions of osteogenesis, angiogenesis, and anti-inflammatory. The results showed that Sr-modified PEEK could stably release Sr²⁺ for a long time in the PBS solution, and indeed could promote the proliferation and differentiation of osteoblasts, promote angiogenesis, and inhibit inflammation. Therefore, it is believed that this multifunctional PEEK with Sr²⁺ should show great promise for clinical applications in bone repair.

Systematic Review of Syndrome of the Trephined and Reconstructive Implications

Syndrome of the trephined (SoT) is a severe complication following decompressive craniectomy resulting in neurological decline which can progress to aphasia, catatonia, and even death. While cranioplasty can reverse neurological symptoms of SoT, awareness of SoT is poor outside of the neurosurgery community. The authors performed a systematic review of the literature on SoT with a focus on reconstructive implications. Search terms "syndrome of the trephined" and "sunken flap syndrome" were applied to PubMed to identify primary studies through October 2021. Full-text review yielded 11 articles discussing SoT and reconstructive techniques or implications with 56 patients undergoing cranial reconstruction. Average age of the patients was 41.8±9.5 years. Sixty-three percent of the patients were male. The most common indication for craniectomy was traumatic brain injury (43%), followed by tumor resection (23%), intracerebral hemorrhage (11%), and aneurysmal subarachnoid hemorrhage (2%). Patients most commonly suffered from motor deficits (52%), decreased wakefulness (30%), depression or anxiety (21%), speech deficits (16%), headache (16%), and cognitive difficulties (2%). Time until presentation of symptoms following decompression was 4.4±8.9 months. Patients typically underwent cranioplasty with polyetheretherketone (48%), titanium mesh (21%), split thickness calvarial bone (16%), full thickness calvarial bone (14%), or split thickness rib graft (4%). Eight percent of patients required free tissue transfer for soft tissue coverage. Traumatic Brain Injury (TBI) was a risk factor for development of SoT when adjusting for age and sex (odds ratio: 8.2, 95% confidence interval: 1.2-8.9). No difference significant difference was observed between length until initial improvement of neurological symptoms following autologous versus allograft reconstruction (P=0.47). SoT can be a neurologically devastating complication of decompressive craniectomy which can resolve following urgent cranioplasty. Familiarity with this syndrome and its reconstructive implications is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.

Application of biomolecules modification strategies on PEEK and its composites for osteogenesis and antibacterial properties

As orthopedic and dental implants, polyetheretherketone (PEEK) is expected to be a common substitute material of titanium (Ti) and its alloys due to its good biocompatibility, chemical stability, and elastic modulus close to that of bone tissue. It could avoid metal allergy and bone resorption caused by the stress shielding effect of Ti implants, widely studied in the medical field. However, the lack of biological activity is not conducive to the clinical application of PEEK implants. Therefore, the surface modification of PEEK has increasingly become one of the research hotspots. Researchers have explored various biomolecules modification methods to effectively enhance the osteogenic and antibacterial activities of PEEK and its composites. Therefore, this review mainly summarizes the recent research of PEEK modified by biomolecules and discusses the further research directions to promote the clinical transformation of PEEK implants.

Surface modification of polyetheretherketone (PEEK) to enhance osteointegration by grafting strontium Eucommia ulmoides polysaccharides

The complex bone regeneration microenvironment puts high demands on orthopedic implants. The implants are not only desired to satisfy the meeting of the biomechanical properties, but should also possess capabilities to promote osseointegration and bone immune regulation. PEEK is a promising polymeric material for bone implants due to its suitable mechanical properties that well match natural cortical bone tissue. However, its inert biological properties limit its application. As a newly-developed bioactive polysaccharides complex, strontium Eucommia ulmoides polysaccharides (EUP-Sr) has been proved to have capabilities including promoting osteogenesis and regulating bone immunity. In this study, in order to improve the bioactivities of PEEK, we introduce EUP-Sr to the PEEK surface via polydopamine-based coating and form a bioactive PEEK named DPEEK@EUP-Sr. The as-fabricated DPEEK@EUP-Sr was systematically investigated through scanning electron microscopy, X-ray photoelectron spectroscopy, water contact angle analysis to verify the successful introduction of EUP-Sr to PEEK, and in vitro biological experiments including cell proliferation and RT-PCR analysis suggested that the DPEEK@EUP-Sr can effectively promote the proliferation of preosteoblast MC3T3-E1, and exhibit significant anti-inflammation and osteogenesis effects, and so should be beneficial for osteointegration between bone and implants.

Bioinspired Surface Functionalization of Poly(ether ether ketone) for Enhancing Osteogenesis and Bacterial Resistance

In orthopedics, developing functionalized biomaterials to enhance osteogenesis and bacterial resistance is crucial. Although poly(ether ether ketone) (PEEK) is regarded as an important engineering plastic for biomedical material with excellent mechanical properties and biocompatibility, its biological inertness has greatly compromised its application in biomedical engineering. Inspired by the catecholamine chemistry of mussels, we propose a universal and versatile approach for enhancing the osteogenesis and antibacterial performances of PEEK based on surface functionalization of polydopamine-modified nanohydroxyapatite and lysozyme simultaneously. The characterizations of surface morphology and elemental composition revealed that the composite coating was successfully added to the PEEK surface. Additionally, the in vitro cell experiment and biomineralization assay indicated that the composite coating-modified PEEK was biocompatible with significantly improved bioactivity to promote osteogenesis and biomineralization compared with the untreated PEEK. Furthermore, the antibacterial test demonstrated that the composite coating had a strongly destructive effect on two bacteria (Staphylococcus aureus and Escherichia coli) with antibacterial ratios of 98.7% and 96.1%, respectively. In summary, the bioinspired method for surface functionalization can enhance the osteogenesis and bacterial resistance of biomedical materials, which may represent a potential approach for designing functionalized implants in orthopedics.

Modification of polyether ether ketone for the repairing of bone defects

Bone damage as a consequence of disease or trauma is a common global occurrence. For bone damage treatment-bone implant materials are necessary across three classifications of surgical intervention (i.e. fixation, repair, and replacement). Many types of bone implant materials have been developed to meet the requirements of bone repair. Among them, polyether ether ketone (PEEK) has been considered as one of the next generation of bone implant materials, owing to its advantages related to good biocompatibility, chemical stability, x-ray permeability, elastic modulus comparable to natural bone, as well as the ease of processing and modification. However, as PEEK is a naturally bioinert material, some modification is needed to improve its integration with adjacent bones after implantation. Therefore, it has become a very hot topic of biomaterials research and various strategies for the modification of PEEK including blending, 3D printing, coating, chemical modification and the introduction of bioactive and/or antibacterial substances have been proposed. In this systematic review, the recent advances in modification of PEEK and its application prospect as bone implants are summarized, and the remaining challenges are also discussed.

Surface Modification of Poly(ether ether ketone) by Simple Chemical Grafting of Strontium Chondroitin Sulfate to Improve its Anti-Inflammation, Angiogenesis, Osteogenic Properties

Besides inducing osteogenic differentiation, the surface modification of poly(ether ether ketone) (PEEK) is highly expected to improve its angiogenic activity and reduce the inflammatory response in the surrounding tissue. Herein, strontium chondroitin sulfate is first attempted to be introduced into the surface of sulfonated PEEK (SPEEK-CS@Sr) based on the Schiff base reaction between PEEK and ethylenediamine (EDA) and the amidation reaction between EDA and chondroitin sulfate (CS). The surface characteristics of SPEEK-CS@Sr implant are systematically investigated, and its biological properties in vitro and in vivo are also evaluated. The results show that the surface of SPEEK-CS@Sr implant exhibits a 3D microporous structure and good hydrophilicity, and can steadily release Sr ions. Importantly, the SPEEK-CS@Sr not only displays excellent biocompatibility, but also can remarkably promote cell adhesion and spread, improve osteogenic activity and angiogenic activity, and reduce the inflammatory response compared to the original PEEK. Therefore, this study presents the surface modification of PEEK material by simple chemical grafting of strontium chondroitin sulfate to improve its angiogenesis, anti-inflammation, and osteogenic properties, and the as-fabricated SPEEK-CS@Sr has the potential to serve as a promising orthopedic implant in bone tissue engineering.

Enhanced Antibacterial Ability and Bioactivity of Polyetherketoneketone Modified with LL-37

Polyetherketoneketone (PEKK) is considered to be a potential substitute material for metal bone implants because of its advantageous biocompatibility, chemical stability, and mechanical properties, but clinical application has been severely restricted due to PEKK's lack of antibacterial ability and biological activity. In this study, LL-37, a natural human antimicrobial peptide, was successfully modified on the PEKK surface with polydopamine as the intermediate layer and released continuously for more than 6 days. The results of the MTT assay, colony counts, and Live/Dead staining demonstrated that compared to unmodified PEKK, the LL-37-modified PEKK significantly inhibited the adhesion, vitality, and bacterial biofilm growth of Staphylococcus aureus and Escherichia coli in a concentration-dependent way. Furthermore, the LL-37-modified PEKK enhanced biocompatibility (cell adhesion and viability) and promoted osteogenic differentiation of human umbilical cord Wharton's jelly-derived mesenchymal stem cells. Our data suggested that LL-37-modified PEKK might be a promising material for use in orthopedic implants.

3D printed porous sulfonated polyetheretherketone scaffold for cartilage repair: Potential and limitation

Objective

The treatment of cartilage lesions has always been a difficult problem. Although cartilage tissue engineering provides alternative treatment options for cartilage lesions, biodegradable tissue engineering scaffolds have limitations.

Methods

In this study, we constructed a porous PEEK scaffold via 3D printing, surface-engineered with concentrated sulfuric acid for 15 s (SPK-15), 30 s (SPK-30), and 60 s (SPK-60). We systematically evaluated the physical and chemical characteristics and biofunctionalities of the scaffolds, and then evaluated the macrophage polarization modulating ability and anti-inflammatory effects of the sulfonated PEEK, and observed the cartilage-protective effect of SPK using a co-culture study. We further evaluated the repair effect of PEEK and SPK by implanting the prosthetic scaffold into a cartilage defect in a rabbit model.

Results

Compared to the PEEK, SPK-15 and SPK-60 scaffolds, SPK-30 has a good micro/nanostructure, appropriate biomechanical properties (compressive modulus, 43 ± 5 MPa; Shaw hardness, 20.6 ± 1.3 HD; close to native cartilage, 30 ± 8 MPa, 17.8 ± 0.8 HD), and superior biofunctionalities. Compared to PEEK, sulfonated PEEK can favor macrophage polarization to the M2 phenotype, which increases anti-inflammatory cytokine secretion. Furthermore, SPK can also prevent macrophage-induced cartilage degeneration. The in-vivo animal experiment demonstrates that SPK can favor new tissue ingrowth and integration, prevent peri-scaffold cartilage degeneration and patellar cartilage degeneration, inhibit inflammatory cytokine secretion, and promote cartilage function restoration.

Conclusion

The present study confirmed that the 3D printed porous sulfonated PEEK scaffold could promote cartilage functional repair, and suggests a new promising strategy for treating cartilage defects with a functional prosthesis that spontaneously inhibits nearby cartilage degeneration.

Translational potential of this article

In the present study, we propose a new cartilage repair strategy based on a porous, non-biodegradable polyetheretherketone (PEEK) scaffold, which may bring up a new treatment route for elderly patients with cartilage lesions in the future.

Icariin-loaded Sulfonated Polyetheretherketone with Osteogenesis Promotion and Osteoclastogenesis Inhibition Properties via Immunomodulation for Advanced Osseointegration

Preventing prosthesis loosening due to insufficient osseointegration is critical for patients with osteoporosis. Endowing implants with immunomodulatory function can effectively enhance osseointegration. In this work, we loaded icariin (ICA) onto...

Surface Bioactivation of Polyether Ether Ketone (PEEK) by Sulfuric Acid and Piranha Solution: Influence of the Modification Route in Capacity for Inducing Cell Growth

The aim of this study was to promote bioactivity of the PEEK surface using sulfuric acid and piranha solution. PEEK was functionalized by a sulfuric acid treatment for 90 s and by piranha solution for 60 and 90 s. Chemical modification of the PEEK surface was evaluated by infrared spectroscopy, contact angle analysis, cytotoxicity, cell adhesion and proliferation. The spectroscopy characteristic band associated with sulfonation was observed in all treated samples. PEEK with piranha solution 60 s showed an increase in the intensity of the bands, which was even more significant for the longer treatment (90 s). The introduction of the sulfonic acid functional group reduced the contact angle. In cytotoxicity assays, for all treatments, the number of viable cells was higher when compared to those of untreated PEEK. PEEK treated with sulfuric acid and piranha solution for 60 s were the treatments that showed the highest percentage of cell viability with no statistically significant differences between them. The modified surfaces had a greater capacity for inducing cell growth, indicative of effective cell adhesion and proliferation. The proposed chemical modifications are promising for the functionalization of PEEK-based implants, as they were effective in promoting bioactivation of the PEEK surface and in stimulating cell growth and proliferation.

Modification of polyetheretherketone implants: From enhancing bone integration to enabling multi-modal therapeutics

Polyetheretherketone (PEEK) is a popular thermoplastic material widely used in engineering applications due to its favorable mechanical properties and stability at high temperatures. With the first implantable grade PEEK being commercialized in 1990s, the use of PEEK has since grown exponentially in the biomedical field and has rapidly transformed a large section of the medical devices landscape. Nowadays, PEEK is a standard biomaterial used across a wide range of implant applications, however, its bioinertness remains a limitation for bone repair applications. The increasing demand for enhanced treatment efficacy/improved patient quality of life, calls for next-generation implants that can offer fast bone integration as well as other desirable therapeutic functions. As such, modification of PEEK implants has progressively shifted from offering desirable mechanical properties, enhancing bioactivity/fast osteointegration, to more recently, tackling post-surgery bacterial infection/biofilm formation, modulation of inflammation and management of bone cancers. Such progress is also accompanied by the evolution of the PEEK manufacturing technologies, to meet the ever increasing demand for more patient specific devices. However, no review has comprehensively covered the recently engaged application areas to date. This paper provides an up-to-date review on the development of PEEK-based biomedical devices in the past 10 years, with particularly focus on modifying PEEK for multi-modal therapeutics. The aim is to provide the peers with a timely update, which may guide and inspire the research and development of next generation PEEK-based healthcare products. STATEMENT OF SIGNIFICANCE: Significant progress has been made in PEEK processing and modification techniques in the past decades, which greatly contributed to its wide applications in the biomedical field. Despite the high volume of published literature on PEEK implant related research, there is a lack of review on its emerging applications in multi-modal therapeutics, which involve bone regeneration, anti-bacteria/anti-inflammation, and cancer inhibition, etc. This timely review covers the state-of-the-art in these exciting areas and provides the important guidance for next generation PEEK based biomedical device research and development.

Surface engineering of biomaterials in orthopedic and dental implants: Strategies to improve osteointegration, bacteriostatic and bactericidal activities

BACKGROUND

The success of biomedical implants in orthopedic and dental applications is usually limited due to insufficient bone-implant integration, and implant-related infections. Biointerfaces are critical in regulating their interactions and the desirable performance of biomaterials in biological environment. Surface engineering has been widely studied to realize better control of the interface interaction to further enhance the desired behavior of biomaterials.

PURPOSE AND SCOPE

This review aims to investigate surface coating strategies in hard tissue applications to address insufficient osteointegration and implant-related infection problems.

SUMMARY

We first focused on surface coatings to enhance the osteointegration and biocompatibility of implants by emphasizing calcium phosphate-related, nanoscale TiO₂ -related, bioactive tantalum-based and biomolecules incorporated coatings. Different coating strategies such as plasma spraying, biomimetic deposition, electrochemical anodization and LENS are discussed. We then discussed techniques to construct anti-adhesive and bactericidal surface while emphasizing multifunctional surface coating techniques that combine potential osteointegration and antibacterial activities. The effects of nanotopography via TiO₂ coatings on antibacterial performance are interesting and included. A smart bacteria-responsive titanium dioxide nanotubes coating is also attractive and elaborated.

CONCLUSION

Developing multifunctional surface coatings combining osteogenesis and antimicrobial activity is the current trend. Surface engineering methods are usually combined to obtain hierarchical multiscale surface structures with better biofunctionalization outcomes.

Strontium ranelate incorporated 3D porous sulfonated PEEK simulating MC3T3-E1 cell differentiation

Polyetheretherketone (PEEK) has been used as an implant material because it has similar mechanical properties to natural bone. However, inferior osseointegration and bioinertness hamper the clinical application of PEEK. In this study, the surfaces of sulfonated three-dimensional (3D) PEEK porous structures were loaded with different concentrations of strontium ranelate, a compound commonly used in the treatment or prevention of osteoporosis by promoting bone formation and inhibiting bone resorption. Field-emission scanning electron microscopy was used to characterize the topography of the structures, elemental carbon, oxygen and strontium contents were measured by X-ray photoelectron spectroscopy, and surface zeta potentials and water-contact angle were also measured. The results indicated that strontium ranelate was successfully loaded onto the 3D porous structures. In vitro cellular results showed that strontium ranelate-treated sulfonated PEEK (SP-SR) strengthened the adhesion of MC3T3-E1 cells. The activity of alkaline phosphatase, collagen secretion and extracellular matrix mineralization deposition of MC3T3-E1 cells were also improved on the surface of SP-SR. These results indicate that SP-SR could serve a new implant candidate for surgical treatment.

Conducting Polyetheretherketone Nanocomposites with an Electrophoretically Deposited Bioactive Coating for Bone Tissue Regeneration and Multimodal Therapeutic Applications

The use of polyetheretherketone (PEEK) has grown exponentially in the biomedical field in recent decades because of its outstanding biomechanical properties. However, its lack of bioactivity/osteointegration remains an unresolved issue toward its wide use in orthopedic applications. In this work, graphene nanosheets have been incorporated into PEEK to obtain multifunctional nanocomposites. Because of the formation of an electrical percolation network and the π-π* conjugation between graphene and PEEK, the resulting composites have achieved 12 orders of magnitude enhancement in their electrical conductivity and thereby enabled electrophoretic deposition of a bioactive/antibacterial coating consisting of stearyltrimethylammonium chloride-modified hydroxyapatite. The coated composite implant shows significant boosting of bone marrow mesenchymal stem cell proliferation in vitro. In addition, the strong photothermal conversion effect of the graphene nanofillers has enabled laser-induced heating of our nanocomposite implants, where the temperature of the implant can reach 45 °C in 150 s. The unique multifunctionality of the implant has also been demonstrated for photothermal applications such as enhancing bacterial eradication and tumor cell inhibition, as well as bone tissue regeneration in vivo. The results suggest the strong potential of our multifunctional implant in bone repair applications as well as multimodal therapy of challenging bone diseases such as osteosarcoma and osteomyelitis.

Preparation of Poly(ether-ether-ketone)/Nanohydroxyapatite Composites with Improved Mechanical Performance and Biointerfacial Affinity

Poly(ether-ether-ketone) (PEEK) displays promising potential in hard tissue repair and orthopedic surgery due to its adaptable mechanical performance, good chemical resistance, and bioinertness. However, the low biointerfacial affinity of pure PEEK implants and the decrease of mechanical strength after processing greatly limit their clinical applications. In this work, the influences on mechanical performance and biointerfacial affinity of the PEEK/nanohydroxyapatite (nHA) composites are systematically investigated. Results show that the mechanical performance of PEEK/nHA composites was improved by adjusting the nHA content. The maximum values of the tensile, compressive, bending, and impact strength of the composites were increased by approximately 16.2, 25, 54, and 21%, respectively, when compared with that of pure PEEK. Studies in vitro show that PEEK/nHA composites display good cytocompatibility and promote the biomimic formation of HA, adhesion, and proliferation of L929 cells on the surface. Studies in vivo demonstrate that, compared to the pure PEEK, PEEK/nHA composites exhibit higher biointerfacial affinity, including the adhesion and encapsulation of muscle tissues on the surface of the implants and the suppression of inflammatory reaction around the implants. Our findings could pave the way for extensive applications of PEEK/nHA composites in hard tissue repair, particularly orthopedic surgery.

Osteointegration of 3D-Printed Fully Porous Polyetheretherketone Scaffolds with Different Pore Sizes

Polyetheretherketone (PEEK) constitutes a preferred alternative material for orthopedic implants owing to its good mechanical properties and biocompatibility. However, the poor osseointegration property of PEEK implants has limited their clinical applications. To address this issue, in this study, we investigated the mechanical and biological properties of fully porous PEEK scaffolds with different pore sizes both in vitro and in vivo. PEEK scaffolds with designed pore sizes of 300, 450, and 600 μm and a porosity of 60% were manufactured via fused deposition modeling (FDM) to explore the optimum pore size. Smooth solid PEEK cylinders (PEEK-S) were used as the reference material. The mechanical, cytocompatibility, proliferative, and osteogenic properties of PEEK scaffolds were characterized in comparison to those of PEEK-S. In vivo dynamic contrast-enhanced magnetic resonance imaging, microcomputed tomography, and histological observation were performed after 4 and 12 weeks of implantation to evaluate the microvascular perfusion and bone formation afforded by the various PEEK implants using a New Zealand white rabbit model with distal femoral condyle defects. Results of in vitro testing supported the good biocompatibility of the porous PEEK scaffolds manufactured via FDM. In particular, the PEEK-450 scaffolds were most beneficial for cell adhesion, proliferation, and osteogenic differentiation. Results of in vivo analysis further indicated that PEEK-450 scaffolds exhibited preferential potential for bone ingrowth and vascular perfusion. Together, our findings support that porous PEEK implants designed with a suitable pore size and fabricated via three-dimensional printing constitute promising alternative biomaterials for bone grafting and tissue engineering applications with marked potential for clinical applications.

MXene-Based Hydrogels Endow Polyetheretherketone with Effective Osteogenicity and Combined Treatment of Osteosarcoma and Bacterial Infection

After an osteosarcoma resection, the risks of cancer recurrence, postoperative infection, and large bone loss still threaten patients' health. Conventional treatment relies on implanting orthopedic materials to fill bone defects after surgery, but it has no ability of destroying residual tumor cells and preventing bacterial invasion. To tackle this challenge, here, we develop a novel multifunctional implant (SP@MX/GelMA) that mainly consists of MXene nanosheets, gelatin methacrylate (GelMA) hydrogels, and bioinert sulfonated polyetheretherketone (SP) with the purpose of facilitating tumor cell death, combating pathogenic bacteria, and promoting osteogenicity. Because of the synergistic photothermal effects of MXene and polydopamine (pDA), osteosarcoma cells are effectively killed on the multifunctional coatings under 808 nm near-infrared (NIR) irradiation through thermal ablation. After loading tobramycin (TOB), the SP@MX-TOB/GelMA implants display robust antibacterial properties against Gram-negative/Gram-positive bacteria. More importantly, the multifunctional implants are demonstrated to have superior cytocompatibility and osteogenesis-promoting capability in terms of cell replication, spreading, alkaline phosphatase activity, calcium matrix mineralization, and in vivo osseointegration. Accordingly, such photothermally controlled multifunctional implants not only defeat osteosarcoma cells and bacteria but also intensify osteogenicity, which hold a greatly promising countermeasure for curing postoperative tissue lesion from an osteosarcoma excision.

Multifunctional Surface with Enhanced Angiogenesis for Improving Long-Term Osteogenic Fixation of Poly(ether ether ketone) Implants

Poly(ether ether ketone) (PEEK) is a biocompatible polymer, but the lack of angiogenesis makes the long-term osteogenic fixation of PEEK implants challenging, which has hampered their wider application in orthopedics. Herein, we develop a multifunctional micro-/nanostructured surface presenting hydroxyapatite (HA) nanoflowers and nickel hydroxide (Ni(OH)₂) nanoparticles on PEEK implants (sPEEK-Ni-HA) to tackle the problem. The results show that the reasonable release of Ni²⁺ from sPEEK-Ni-HA significantly facilitates the migration, tube formation, and angiogenic gene expression of human umbilical vein endothelial cells (HUVECs). In addition to angiogenesis, the sPEEK-Ni-HA displays enhanced cytocompatibility and osteogenicity in terms of cell proliferation, spreading, alkaline phosphatase activity, matrix mineralization, and osteogenesis-related gene secretion, exceeding pure and other multifunctional sPEEK samples. Importantly, in vivo evaluations employing a rabbit femoral condyle implantation model confirm that such dual decoration of Ni elements and HA nanoflowers boosts bone remodeling/osseointegration, which dramatically promotes the in vivo osteogenic fixation of implants. Therefore, this work not only sheds light on the significance of angiogenesis on the osteogenic fixation of an implant but also presents a facile strategy to empower bioinert PEEK with a well-orchestrated feature of angiogenesis and osteogenesis.

Co–Cr–Mo alloy binding peptide as molecular glue for constructing biomedical surfaces

The mechanical properties of Co–Cr–Mo (CCM) alloys are advantageous in various biomedical applications. However, because of their bioinert surface, CCM alloys exhibit poor endothelial cell attachment properties; thus, problems of biocompatibility remain. In this study, we aimed to improve the biocompatibility of the CCM alloy surface using solid-binding peptides. We selected peptides with high binding affinity for cast CCM alloy surfaces through in vitro evolution by the phage display method. The peptides were functionalized on the CCM alloy surfaces by simple immersion in the peptide solution. The peptide bound to both cast and 3D-printed CCMs with the same affinity. The peptides linked to the amino acid motif that promotes cell adhesion, and improved the attachment of endothelial cells on the 3D-printed CCM in serum and serum-free conditions. Hence, CCM-binding peptides are attractive tools for constructing a biofunctional surface on CCM-based biodevices.