3D bioprinting for musculoskeletal applications

Recent trends in bioartificial muscle engineering and their applications in cultured meat, biorobotic systems and biohybrid implants

Recent advances in tissue engineering and biofabrication technology have yielded a plethora of biological tissues. Among these, engineering of bioartificial muscle stands out for its exceptional versatility and its wide range of applications. From the food industry to the technology sector and medicine, the development of this tissue has the potential to affect many different industries at once. However, to date, the biofabrication of cultured meat, biorobotic systems, and bioartificial muscle implants are still considered in isolation by individual peer groups. To establish common ground and share advances, this review outlines application-specific requirements for muscle tissue generation and provides a comprehensive overview of commonly used biofabrication strategies and current application trends. By solving the individual challenges and merging various expertise, synergetic leaps of innovation that inspire each other can be expected in all three industries in the future.

Extrusion 3D (Bio)Printing of Alginate-Gelatin-Based Composite Scaffolds for Skeletal Muscle Tissue Engineering

Volumetric muscle loss (VML), which involves the loss of a substantial portion of muscle tissue, is one of the most serious acute skeletal muscle injuries in the military and civilian communities. The injured area in VML may be so severely affected that the body loses its innate capacity to regenerate new functional muscles. State-of-the-art biofabrication methods such as bioprinting provide the ability to develop cell-laden scaffolds that could significantly expedite tissue regeneration. Bioprinted cell-laden scaffolds can mimic the extracellular matrix and provide a bioactive environment wherein cells can spread, proliferate, and differentiate, leading to new skeletal muscle tissue regeneration at the defect site. In this study, we engineered alginate−gelatin composite inks that could be used as bioinks. Then, we used the inks in an extrusion printing method to develop design-specific scaffolds for potential VML treatment. Alginate concentration was varied between 4−12% w/v, while the gelatin concentration was maintained at 6% w/v. Rheological analysis indicated that the alginate−gelatin inks containing 12% w/v alginate and 6% w/v gelatin were most suitable for developing high-resolution scaffolds with good structural fidelity. The printing pressure and speed appeared to influence the printing accuracy of the resulting scaffolds significantly. All the hydrogel inks exhibited shear thinning properties and acceptable viscosities, though 8−12% w/v alginate inks displayed properties ideal for printing and cell proliferation. Alginate content, crosslinking concentration, and duration played significant roles (p < 0.05) in influencing the scaffolds’ stiffness. Alginate scaffolds (12% w/v) crosslinked with 300, 400, or 500 mM calcium chloride (CaCl2) for 15 min yielded stiffness values in the range of 45−50 kPa, i.e., similar to skeletal muscle. The ionic strength of the crosslinking concentration and the alginate content significantly (p < 0.05) affected the swelling and degradation behavior of the scaffolds. Higher crosslinking concentration and alginate loading enhanced the swelling capacity and decreased the degradation kinetics of the printed scaffolds. Optimal CaCl2 crosslinking concentration (500 mM) and alginate content (12% w/v) led to high swelling (70%) and low degradation rates (28%) of the scaffolds. Overall, the results indicate that 12% w/v alginate and 6% w/v gelatin hydrogel inks are suitable as bioinks, and the printed scaffolds hold good potential for treating skeletal muscle defects such as VML.

Piezoelectric nanocomposite bioink and ultrasound stimulation modulate early skeletal myogenesis

Despite the significant progress in bioprinting for skeletal muscle tissue engineering, new stimuli-responsive bioinks to boost the myogenesis process are highly desirable. In this work, we developed a printable alginate/Pluronic-based bioink including piezoelectric barium titanate nanoparticles (nominal diameter: ∼60 nm) for the 3D bioprinting of muscle cell-laden hydrogels. The aim was to investigate the effects of the combination of piezoelectric nanoparticles with ultrasound stimulation on early myogenic differentiation of the printed structures. After the characterization of nanoparticles and bioinks, viability tests were carried out to investigate three nanoparticle concentrations (100, 250, and 500 μg mL^-1) within the printed structures. An excellent cytocompatibility was confirmed for nanoparticle concentrations up to 250 μg mL^-1. TEM imaging demonstrated the internalization of BTNPs in intracellular vesicles. The combination of piezoelectric nanoparticles and ultrasound stimulation upregulated the expression of MYOD1, MYOG, and MYH2 and enhanced cell aggregation, which is a crucial step for myoblast fusion, and the presence of MYOG in the nuclei. These results suggest that the direct piezoelectric effect induced by ultrasound on the internalized piezoelectric nanoparticles boosts myogenesis in its early phases.

Biofabrication Strategies for Musculoskeletal Disorders: Evolution towards Clinical Applications

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

Tissue-Specific Decellularized Extracellular Matrix Bioinks for Musculoskeletal Tissue Regeneration and Modeling Using 3D Bioprinting Technology

The musculoskeletal system is a vital body system that protects internal organs, supports locomotion, and maintains homeostatic function. Unfortunately, musculoskeletal disorders are the leading cause of disability worldwide. Although implant surgeries using autografts, allografts, and xenografts have been conducted, several adverse effects, including donor site morbidity and immunoreaction, exist. To overcome these limitations, various biomedical engineering approaches have been proposed based on an understanding of the complexity of human musculoskeletal tissue. In this review, the leading edge of musculoskeletal tissue engineering using 3D bioprinting technology and musculoskeletal tissue-derived decellularized extracellular matrix bioink is described. In particular, studies on in vivo regeneration and in vitro modeling of musculoskeletal tissue have been focused on. Lastly, the current breakthroughs, limitations, and future perspectives are described.

Review of Low-Cost 3D Bioprinters: State of the Market and Observed Future Trends

Three-dimensional (3D) bioprinting has become mainstream for precise and repeatable high-throughput fabrication of complex cell cultures and tissue constructs in drug testing and regenerative medicine, food products, dental and medical implants, biosensors, and so forth. Due to this tremendous growth in demand, an overwhelming amount of hardware manufacturers have recently flooded the market with different types of low-cost bioprinter models-a price segment that is most affordable to typical-sized laboratories. These machines range in sophistication, type of the underlying printing technology, and possible add-ons/features, which makes the selection process rather daunting (especially for a nonexpert customer). Yet, the review articles available in the literature mostly focus on the technical aspects of the printer technologies under development, as opposed to explaining the differences in what is already on the market. In contrast, this paper provides a snapshot of the fast-evolving low-cost bioprinter niche, as well as reputation profiles (relevant to delivery time, part quality, adherence to specifications, warranty, maintenance, etc.) of the companies selling these machines. Specifically, models spanning three dominant technologies-microextrusion, droplet-based/inkjet, and light-based/crosslinking-are reviewed. Additionally, representative examples of high-end competitors (including up-and-coming microfluidics-based bioprinters) are discussed to highlight their major differences and advantages relative to the low-cost models. Finally, forecasts are made based on the trends observed during this survey, as to the anticipated trickling down of the high-end technologies to the low-cost printers. Overall, this paper provides insight for guiding buyers on a limited budget toward making informed purchasing decisions in this fast-paced market.

Review of Bioprinting in Regenerative Medicine: Naturally Derived Bioinks and Stem Cells

Regenerative medicine offers the potential to repair or substitute defective tissues by constructing active tissues to address the scarcity and demands for transplantation. The method of forming 3D constructs made up of biomaterials, cells, and biomolecules is called bioprinting. Bioprinting of stem cells provides the ability to reliably recreate tissues, organs, and microenvironments to be used in regenerative medicine. 3D bioprinting is a technique that uses several biomaterials and cells to tailor a structure with clinically relevant geometries and sizes. This technique's promise is demonstrated by 3D bioprinted tissues, including skin, bone, cartilage, and cardiovascular, corneal, hepatic, and adipose tissues. Several bioprinting methods have been combined with stem cells to effectively produce tissue models, including adult stem cells, embryonic stem cells (ESCs), induced pluripotent stem cells (iPSCs), and differentiation techniques. In this review, technological challenges of printed stem cells using prevalent naturally derived bioinks (e.g., carbohydrate polymers and protein-based polymers, peptides, and decellularized extracellular matrix), recent advancements, leading companies, and clinical trials in the field of 3D bioprinting are delineated.

The effect of three-dimensional (3D) printing on quantitative and qualitative outcomes in paediatric orthopaedic osteotomies: a systematic review

Three-dimensional (3D) printing technology is increasingly being utilized in various surgical specialities. In paediatric orthopaedics it has been applied in the pre-operative and intra-operative stages, allowing complex deformities to be replicated and patient-specific instrumentation to be used. This systematic review analyses the literature on the effect of 3D printing on paediatric orthopaedic osteotomy outcomes.A systematic review of several databases was conducted according to PRISMA guidelines. Studies evaluating the use of 3D printing technology in orthopaedic osteotomy procedures in children (aged ≤ 16 years) were included. Spinal and bone tumour surgery were excluded. Data extracted included demographics, disease pathology, target bone, type of technology, imaging modality used, qualitative/quantitative outcomes and follow-up. Articles were further categorized as either 'pre-operative' or 'intra-operative' applications of the technology.Twenty-two articles fitting the inclusion criteria were included. The reported studies included 212 patients. There were five articles of level of evidence 3 and 17 level 4.A large variety of outcomes were reported with the most commonly used being operating time, fluoroscopic exposure and intra-operative blood loss.A significant difference in operative time, fluoroscopic exposure, blood loss and angular correction was found in the 'intra-operative' application group. No significant difference was found in the 'pre-operative' category.Despite a relatively low evidence base pool of studies, our aggregate data demonstrate a benefit of 3D printing technology in various deformity correction applications, especially when used in the 'intra-operative' setting. Further research including paediatric-specific core outcomes is required to determine the potential benefit of this novel addition. Cite this article: EFORT Open Rev 2021;6:130-138. DOI: 10.1302/2058-5241.6.200092.

3D Printing Decellularized Extracellular Matrix to Design Biomimetic Scaffolds for Skeletal Muscle Tissue Engineering

Functional engineered muscles are still a critical clinical issue to be addressed, although different strategies have been considered so far for the treatment of severe muscular injuries. Indeed, the regenerative capacity of skeletal muscle (SM) results inadequate for large-scale defects, and currently, SM reconstruction remains a complex and unsolved task. For this aim, tissue engineered muscles should provide a proper biomimetic extracellular matrix (ECM) alternative, characterized by an aligned/microtopographical structure and a myogenic microenvironment, in order to promote muscle regeneration. As a consequence, both materials and fabrication techniques play a key role to plan an effective therapeutic approach. Tissue-specific decellularized ECM (dECM) seems to be one of the most promising material to support muscle regeneration and repair. 3D printing technologies, on the other side, enable the fabrication of scaffolds with a fine and detailed microarchitecture and patient-specific implants with high structural complexity. To identify innovative biomimetic solutions to develop engineered muscular constructs for the treatment of SM loss, the more recent (last 5 years) reports focused on SM dECM-based scaffolds and 3D printing technologies for SM regeneration are herein reviewed. Possible design inputs for 3D printed SM dECM-based scaffolds for muscular regeneration are also suggested.

Information-Driven Design as a Potential Approach for 3D Printing of Skeletal Muscle Biomimetic Scaffolds

Severe muscle injuries are a real clinical issue that still needs to be successfully addressed. Tissue engineering can represent a potential approach for this aim, but effective healing solutions have not been developed yet. In this regard, novel experimental protocols tailored to a biomimetic approach can thus be defined by properly systematizing the findings acquired so far in the biomaterials and scaffold manufacturing fields. In order to plan a more comprehensive strategy, the extracellular matrix (ECM), with its properties stimulating neomyogenesis and vascularization, should be considered as a valuable biomaterial to be used to fabricate the tissue-specific three-dimensional structure of interest. The skeletal muscle decellularized ECM can be processed and printed, e.g., by means of stereolithography, to prepare bioactive and biomimetic 3D scaffolds, including both biochemical and topographical features specifically oriented to skeletal muscle regenerative applications. This paper aims to focus on the skeletal muscle tissue engineering sector, suggesting a possible approach to develop instructive scaffolds for a guided healing process.

Cutting-edge progress and challenges in stimuli responsive hydrogel microenvironment for success in tissue engineering today

The field of tissue engineering has numerous potential for modified therapeutic results and has been inspired by enhancements in bioengineering at the recent decades. The techniques of regenerating tissues and assembling functional paradigms that are responsible for repairing, maintaining, and revitalizing lost organs and tissues have affected the entire spectrum of health care studies. Strategies to combine bioactive molecules, biocompatible materials and cells are important for progressing the renewal of damaged tissues. Hydrogels have been utilized as one of the most popular cell substrate/carrier in tissue engineering since previous decades, respect to their potential to retain a 3D structure, to protect the embedded cells, and to mimic the native ECM. The hydrophilic nature of hydrogels can provide an ideal milieu for cell viability and structure, which simulate the native tissues. Hydrogel systems have been applied as a favorable matrix for growth factor delivery and cell immobilization. This study reviews a brief explanation of the structure, characters, applications, fabrication methods, and future outlooks of stimuli responsive hydrogels in tissue engineering and, in particular, 3D bioprinting.

3D printed oxidized alginate-gelatin bioink provides guidance for C2C12 muscle precursor cell orientation and differentiation via shear stress during bioprinting

Biofabrication can be a tool to three-dimensionally (3D) print muscle cells embedded inside hydrogel biomaterials, ultimately aiming to mimic the complexity of the native muscle tissue and to create in-vitro muscle analogues for advanced repair therapies and drug testing. However, to 3D print muscle analogues of high cell alignment and synchronous contraction, the effect of biofabrication process parameters on myoblast growth has to be understood. A suitable biomaterial matrix is required to provide 3D printability as well as matrix degradation to create space for cell proliferation, matrix remodelling capacity, and cell differentiation. We demonstrate that by the proper selection of nozzle size and extrusion pressure, the shear stress during extrusion-bioprinting of mouse myoblast cells (C2C12) can achieve cell orientation when using oxidized alginate-gelatin (ADA-GEL) hydrogel bionk. The cells grow in the direction of printing, migrate to the hydrogel surface over time, and differentiate into ordered myotube segments in areas of high cell density. Together, our results show that ADA-GEL hydrogel can be a simple and cost-efficient biodegradable bioink that allows the successful 3D bioprinting and cultivation of C2C12 cells in-vitro to study muscle engineering.

3D Bioprinting and Its Application to Military Medicine

Introduction

Traditionally, tissue engineering techniques have largely focused on 2D cell culture models—monolayers of immortalized or primary cells growing on tissue culture plastic. Although these techniques have proven useful in research, they often lack physiological validity, because of the absence of fundamental tissue properties, such as multicellular organization, specialized extracellular matrix structures, and molecular or force gradients essential to proper physiological function. More recent advances in 3D cell culture methods have facilitated the development of more complex physiological models and tissue constructs; however, these often rely on self-organization of cells (bottom-up design), and the range of tissue construct size and complexity generated by these methods remains relatively limited. By borrowing from advances in the additive manufacturing field, 3D bioprinting techniques are enabling top-down design and fabrication of cellular constructs with controlled sizing, spacing, and chemical functionality. The high degree of control over engineered tissue architecture, previously unavailable to researchers, enables the generation of more complex, physiologically relevant 3D tissue constructs. Three main 3D bioprinting techniques are reviewed—extrusion, droplet-based, and laser-assisted bioprinting techniques are among the more robust 3D bioprinting techniques, each with its own strengths and weaknesses. High complexity tissue constructs created through 3D bioprinting are opening up new avenues in tissue engineering, regenerative medicine, and physiological model systems for researchers in the military medicine community.

Materials and Methods

Recent primary literature and reviews were selected to provide a broad overview of the field of 3D bioprinting and illustrate techniques and examples of 3D bioprinting relevant to military medicine. References were selected to illustrate specific examples of advances and potential military medicine applications in the 3D bioprinting field, rather than to serve as a comprehensive review.

Results

Three classes of 3D bioprinting techniques were reviewed: extrusion, droplet-based, and laser-assisted bioprinting. Advantages, disadvantages, important considerations, and constraints of each technique were discussed. Examples from the primary literature were given to illustrate the techniques. Relevant applications of 3D bioprinting to military medicine, namely tissue engineering/regenerative medicine and new models of physiological systems, are discussed in the context of advancing military medicine.

Conclusions

3D bioprinting is a rapidly evolving field that provides researchers the ability to build tissue constructs that are more complex and physiologically relevant than traditional 2D culture methods. Advances in bioprinting techniques, bioink formulation, and cell culture methods are being translated into new paradigms in tissue engineering and physiological system modeling, advancing the state of the art, and increasing construct availability to the military medicine research community.

Three-Dimensional Extrusion Printing of Porous Scaffolds Using Storable Ceramic Inks

In this study, we describe the additive manufacturing of porous three-dimensionally (3D) printed ceramic scaffolds prepared with hydroxyapatite (HA), β-tricalcium phosphate (β-TCP), or the combination of both with an extrusion-based process. The scaffolds were printed using a novel ceramic-based ink with reproducible printability and storability properties. After sintering at 1200°C, the scaffolds were characterized in terms of structure, mechanical properties, and dissolution in aqueous medium. Microcomputed tomography and scanning electron microscopy analyses revealed that the structure of the scaffolds, and more specifically, pore size, porosity, and isotropic dimensions were not significantly affected by the sintering process, resulting in scaffolds that closely replicate the original dimensions of the 3D model design. The mechanical properties of the sintered scaffolds were in the range of human trabecular bone for all compositions. All ceramic bioinks showed consistent printability over a span of 14 days, demonstrating the short-term storability of the formulations. Finally, the mass loss did not vary among the evaluated compositions over a period of 28 days except in the case of β-TCP scaffolds, in which the structural integrity was significantly affected after 28 days of incubation in phosphate-buffered saline. In conclusion, this study demonstrates the development of storable ceramic inks for the 3D printing of scaffolds of HA, β-TCP, and mixtures thereof with high fidelity and low shrinkage following sintering that could potentially be used for bone tissue engineering in load-bearing applications.

Biodegradable polymer nanocomposites for ligament/tendon tissue engineering

Ligaments and tendons are fibrous tissues with poor vascularity and limited regeneration capacity. Currently, a ligament/tendon injury often require a surgical procedure using auto- or allografts that present some limitations. These inadequacies combined with the significant economic and health impact have prompted the development of tissue engineering approaches. Several natural and synthetic biodegradable polymers as well as composites, blends and hybrids based on such materials have been used to produce tendon and ligament scaffolds. Given the complex structure of native tissues, the production of fiber-based scaffolds has been the preferred option for tendon/ligament tissue engineering. Electrospinning and several textile methods such as twisting, braiding and knitting have been used to produce these scaffolds. This review focuses on the developments achieved in the preparation of tendon/ligament scaffolds based on different biodegradable polymers. Several examples are overviewed and their processing methodologies, as well as their biological and mechanical performances, are discussed.

Development of mussel-inspired 3D-printed poly (lactic acid) scaffold grafted with bone morphogenetic protein-2 for stimulating osteogenesis

3D printing is a versatile technique widely applied in tissue engineering due to its ability to manufacture large quantities of scaffolds or constructs with various desired architectures. In this study, we demonstrated that poly (lactic acid) (PLA) scaffolds fabricated via fused deposition not only retained the original interconnected microporous architectures, the scaffolds also exhibited lower lactic acid dissolution as compared to the freeze-PLA scaffold. The 3D-printed scaffolds were then grafted with human bone morphogenetic protein-2 (BMP-2) via the actions of polydopamine (PDA) coatings. The loading and release rate of BMP-2 were monitored for a period of 35 days. Cellular behaviors and osteogenic activities of co-cultured human mesenchymal stem cells (hMSCs) were assessed to determine for efficacies of scaffolds. In addition, we demonstrated that our fabricated scaffolds were homogenously coated with PDA and well grafted with BMP-2 (219.1 ± 20.4 ng) when treated with 250 ng/mL of BMP-2 and 741.4 ± 127.3 ng when treated with 1000 ng/mL of BMP-2. This grafting enables BMP-2 to be released in a sustained profile. From the osteogenic assay, it was shown that the ALP activity and osteocalcin of hMSCs cultured on BMP-2/PDA/PLA were significantly higher when compared with PLA and PDA/PLA scaffolds. The methodology of PDA coating employed in this study can be used as a simple model to immobilize multiple growth factors onto different 3D-printed scaffold substrates. Therefore, there is potential for generation of scaffolds with different unique modifications with different capabilities in regulating physiochemical and biological properties for future applications in bone tissue engineering.

3D Bioprinting in Skeletal Muscle Tissue Engineering

Skeletal muscle tissue engineering (SMTE) aims at repairing defective skeletal muscles. Until now, numerous developments are made in SMTE; however, it is still challenging to recapitulate the complexity of muscles with current methods of fabrication. Here, after a brief description of the anatomy of skeletal muscle and a short state-of-the-art on developments made in SMTE with "conventional methods," the use of 3D bioprinting as a new tool for SMTE is in focus. The current bioprinting methods are discussed, and an overview of the bioink formulations and properties used in 3D bioprinting is provided. Finally, different advances made in SMTE by 3D bioprinting are highlighted, and future needs and a short perspective are provided.

Advances in three-dimensional bioprinting of bone: Progress and challenges

Several attempts have been made to engineer a viable three-dimensional (3D) bone tissue equivalent using conventional tissue engineering strategies, but with limited clinical success. Using 3D bioprinting technology, scientists have developed functional prototypes of clinically relevant and mechanically robust bone with a functional bone marrow. Although the field is in its infancy, it has shown immense potential in the field of bone tissue engineering by re-establishing the 3D dynamic micro-environment of the native bone. Inspite of their in vitro success, maintaining the viability and differentiation potential of such cell-laden constructs overtime, and their subsequent preclinical testing in terms of stability, mechanical loading, immune responses, and osseointegrative potential still needs to be explored. Progress is slow due to several challenges such as but not limited to the choice of ink used for cell encapsulation, optimal cell source, bioprinting method suitable for replicating the heterogeneous tissues and organs, and so on. Here, we summarize the recent advancements in bioprinting of bone, their limitations, challenges, and strategies for future improvisations. The generated knowledge will provide deep insights on our current understanding of the cellular interactions with the hydrogel matrices and help to unravel new methodologies for facilitating precisely regulated stem cell behaviour.

Arylboronate esters mediated self-healable and biocompatible dynamic G-quadruplex hydrogels as promising 3D-bioinks

Extrudable G-quadruplex hydrogels were prepared at physiological pH. Gels with suitable mechanical properties were explored as 3D-bioinks. The 3D printing process is driven by injectability and the highly thixotropic and self-healable nature of the gel. High cell viability and homogeneous cell distribution within the gel make it a promising material as a 3D bioink.