4D printing for Biomedical Applications

4D (bio-)printing endows 3D printed (bio-)materials with multiple functionalities and dynamic properties. 4D printed materials have been recently used in biomedical engineering for the design and fabrication of biomedical devices, such as stents, occluders, micro-needles, smart 3D-cell engineered micro-environments, drug delivery systems, wound closures, and implantable medical devices. However, the success of 4D printing relies on the rational design of 4D printed objects, the selection of smart materials, and the availability of appropriate types of external (multi-)stimuli. Here, we first highlight the different types of smart materials, external stimuli, and design strategies used in 4D (bio-)printing. Then, we present a critical review of the biomedical applications of 4D printing and discuss the future directions of biomedical research in this exciting area, including In vivo tissue regeneration studies, the implementation of multiple materials with reversible shape memory behaviors, the creation of fast shape-transformation responses, the ability to operate at the microscale, untethered activation and control, and the application of (machine learning-based) modeling approaches to predict the structure-property and design-shape transformation relationships of 4D (bio)printed constructs. This article is protected by copyright. All rights reserved.

Multi-scale in silico and ex silico mechanics of 3D printed cochlear implants for local drug delivery

The currently available treatments for inner ear disorders often involve systemic drug administration, leading to suboptimal drug concentrations and side effects. Cochlear implants offer a potential solution by providing localized and sustained drug delivery to the cochlea. While the mechanical characterization of both the implants and their constituent material is crucial to ensure functional performance and structural integrity during implantation, this aspect has been mostly overlooked. This study proposes a novel methodology for the mechanical characterization of our recently developed cochlear implant design, namely, rectangular and cylindrical, fabricated using two-photon polymerization (2 PP) with a novel photosensitive resin (IP-Q™). We used in silico computational models and ex silico experiments to study the mechanics of our newly designed implants when subjected to torsion mimicking the foreseeable implantation procedure. Torsion testing on the actual-sized implants was not feasible due to their small size (0.6 × 0.6 × 2.4 mm³). Therefore, scaled-up rectangular cochlear implants (5 × 5 × 20 mm³, 10 × 10 × 40 mm³, and 20 × 20 × 80 mm³) were fabricated using stereolithography and subjected to torsion testing. Finite element analysis (FEA) accurately represented the linear behavior observed in the torsion experiments. We then used the validated Finite element analysis models to study the mechanical behavior of real-sized implants fabricated from the IP-Q resin. Mechanical characterization of both implant designs, with different inner porous structures (pore size: 20 μm and 60 μm) and a hollow version, revealed that the cylindrical implants exhibited approximately three times higher stiffness and mechanical strength as compared to the rectangular ones. The influence of the pore sizes on the mechanical behavior of these implant designs was found to be small. Based on these findings, the cylindrical design, regardless of the pore size, is recommended for further research and development efforts.

Bioinspired rational design of bi-material 3D printed soft-hard interfaces

Durable interfacing of hard and soft materials is a major design challenge caused by the ensuing stress concentrations. In nature, soft-hard interfaces exhibit remarkable mechanical performance, with failures rarely happening at the interface. Here, we mimic the strategies observed in nature to design efficient soft-hard interfaces. We base our geometrical designs on triply periodic minimal surfaces (i.e., Octo, Diamond, and Gyroid), collagen-like triple helices, and randomly distributed particles. A combination of computational simulations and experimental techniques, including uniaxial tensile and quad-lap shear tests, are used to characterize the mechanical performance of the interfaces. Our analyses suggest that smooth interdigitated connections, compliant gradient transitions, and either decreasing or constraining strain concentrations lead to simultaneously strong and tough interfaces. We generate additional interfaces where the abovementioned toughening mechanisms work synergistically to create soft-hard interfaces with strengths approaching the upper achievable limit and enhancing toughness values by 50%, as compared to the control group.

3D printed patient-specific fixation plates for the treatment of slipped capital femoral epiphysis: Topology optimization vs. conventional design

Orthopedic plates are commonly used after osteotomies for temporary fixation of bones. Patient-specific plates have recently emerged as a promising fixation device. However, it is unclear how various strategies used for the design of such plates perform in comparison with each other. Here, we compare the biomechanical performance of 3D printed patient-specific bone plates designed using conventional computer-aided design (CAD) techniques with those designed with the help of topology optimization (TO) algorithms, focusing on cases involving slipped capital femoral epiphysis (SCFE). We established a biomechanical testing protocol to experimentally assess the performance of the designed plates while measuring the full-field strain using digital image correlation. We also created an experimentally validated finite element model to analyze the performance of the plates under physiologically relevant loading conditions. The results indicated that the TO construct exhibited higher ultimate load and biomechanical performance as compared to the CAD construct, suggesting that TO is a viable approach for the design of such patient-specific bone plates. The TO plate also distributed stress more evenly over the screws, likely resulting in more durable constructs and improved anatomical conformity while reducing the risk of screw and plate failure during cyclic loading. Although differences existed between finite element analysis and experimental testing, this study demonstrated that finite element modelling can be used as a reliable method for evaluating and optimizing plates for SCFE patients. In addition to enhancing the mechanical performance of patient-specific fixation plates, the utilization of TO in plate design may also improve the surgical outcome and decrease the recovery time by reducing the plate and incision sizes.

Biomechanical evaluation of additively manufactured patient-specific mandibular cage implants designed with a semi-automated workflow: A cadaveric and retrospective case study

OBJECTIVE

Mandibular reconstruction using patient-specific cage implants is a promising alternative to the vascularized free flap reconstruction for nonirradiated patients with adequate soft tissues, or for patients whose clinical condition is not conducive to microsurgical reconstruction. This study aimed to assess the biomechanical performance of 3D printed patient-specific cage implants designed with a semi-automated workflow in a combined cadaveric and retrospective case series study.

METHODS

We designed cage implants for two human cadaveric mandibles using our previously developed design workflow. The biomechanical performance of the implants was assessed with the finite element analysis (FEA) and quasi-static biomechanical testing. Digital image correlation (DIC) was used to measure the full-field strains and validate the FE models by comparing the distribution of maximum principal strains within the bone. The retrospective study of a case series involved three patients, each of whom was treated with a cage implant of similar design. The biomechanical performance of these implants was evaluated using the experimentally validated FEA under the scenarios of both mandibular union and nonunion.

RESULTS

No implant or screw failure was observed prior to contralateral bone fracture during the quasi-static testing of both cadaveric mandibles. The FEA and DIC strain contour plots indicated a strong linear correlation (r = 0.92) and a low standard error (SE=29.32με), with computational models yielding higher strain values by a factor of 2.7. The overall stresses acting on the case series' implants stayed well below the yield strength of additively manufactured (AM) commercially pure titanium, when simulated under highly strenuous chewing conditions. Simulating a full union between the graft and remnant mandible yielded a substantial reduction (72.7±1.5%) in local peak stresses within the implants as compared to a non-bonded graft.

CONCLUSIONS

This study shows the suitability of the developed semi-automated workflow in designing patient-specific cage implants with satisfactory mechanical functioning under demanding chewing conditions. The proposed workflow can aid clinical engineers in creating reconstruction systems and streamlining pre-surgical planning. Nevertheless, more research is still needed to evaluate the osteogenic potential of bone graft insertions.

Physiomimetic biocompatibility evaluation of directly printed degradable porous iron implants using various cell types

Additively manufactured (AM) degradable porous metallic biomaterials offer unique opportunities for satisfying the design requirements of an ideal bone substitute. Among the currently available biodegradable metals, iron has the highest elastic modulus, meaning that it would benefit the most from porous design. Given the successful preclinical applications of such biomaterials for the treatment of cardiovascular diseases, the moderate compatibility of AM porous iron with osteoblast-like cells, reported in earlier studies, has been surprising. This may be because, as opposed to static in vitro conditions, the biodegradation products of iron in vivo are transported away and excreted. To better mimic the in situ situations of biodegradable biomaterials after implantation, we compared the biodegradation behavior and cytocompatibility of AM porous iron under static conditions to the conditions with dynamic in situ-like fluid flow perfusion in a bioreactor. Furthermore, the compatibility of these scaffolds with four different cell types was evaluated to better understand the implications of these implants for the complex process of natural wound healing. These included endothelial cells, L929 fibroblasts, RAW264.7 macrophage-like cells, and osteoblastic MG-63 cells. The biodegradation rate of the scaffolds was significantly increased in the perfusion bioreactor as compared to static immersion. Under either condition, the compatibility with L929 cells was the best. Moreover, the compatibility with all the cell types was much enhanced under physiomimetic dynamic flow conditions as compared to static biodegradation. Our study highlights the importance of physiomimetic culture conditions and cell type selection when evaluating the cytocompatibility of degradable biomaterials in vitro. STATEMENT OF SIGNIFICANCE: Additively manufactured (AM) degradable porous metals offer unique opportunities for the treatment of large bony defects. Despite the successful preclinical applications of biodegradable iron in the cardiovascular field, the moderate compatibility of AM porous iron with osteoblast-like cells was reported. To better mimic the in vivo condition, we compared the biodegradation behavior and cytocompatibility of AM porous iron under static condition to dynamic perfusion. Furthermore, the compatibility of these scaffolds with various cell types was evaluated to better simulate the process of natural wound healing. Our study suggests that AM porous iron holds great promise for orthopedic applications, while also highlighting the importance of physio-mimetic culture conditions and cell type selection when evaluating the cytocompatibility of degradable biomaterials in vitro.

Deformable titanium for acetabular revision surgery: a proof of concept

Custom-made triflange acetabular implants are increasingly used in complex revision surgery where supporting bone stock is diminished. In most cases these triflange cups induce stress-shielding. A new concept for the triflange is introduced that uses deformable porous titanium to redirect forces from the acetabular rim to the bone stock behind the implant and thereby reduces further stress-shielding. This concept is tested for deformability and primary stability.Three different designs of highly porous titanium cylinders were tested under compression to determine their mechanical properties. The most promising design was used to design five acetabular implants either by incorporating a deformable layer at the back of the implant or by adding a separate generic deformable mesh behind the implant. All implants were inserted into sawbones with acetabular defects followed by a cyclic compression test of 1800N for 1000 cycles.The design with a cell size of 4 mm and 0.2 mm strut thickness performed the best and was applied for the design of the acetabular implants. An immediate primary fixation was realized in all three implants with an incorporated deformable layer. One of the two implants with a separate deformable mesh needed fixation with screws. Cyclic tests revealed an average additional implant subsidence of 0.25 mm that occurred in the first 1000 cycles with minimal further subsidence thereafter.It is possible to realize primary implant fixation and stability in simulated large acetabular revision surgery using a deformable titanium layer behind the cup. Additional research is needed for further implementation of such implants in the clinic.

3D patellar shape is associated with radiological and clinical signs of patellofemoral osteoarthritis

OBJECTIVE

To examine the association between 3D patellar shape and 1) isolated magnetic resonance imaging (MRI)-based patellofemoral osteoarthritis (PFOA), 2) the morphological features of PFOA, and 3) the clinical symptoms of PFOA.

DESIGN

MRI data from 66 women with isolated MRI-based PFOA and 66 age- and BMI-matched healthy women were selected from a cohort study. The patellae were manually segmented from MRI scans and used to create a 3D statistical shape model (SSM) of the patella. Structural abnormalities were semi-standardized scored on MRI using MRI osteoarthritis knee score (MOAKS). Regression analyses were applied to determine the associations between the shape parameters retrieved from the SSM, group status, clinical symptoms, and structural abnormalities.

RESULTS

Four shape variants showed a statistically significant (<0.05) association with the group status. The mode responsible for most of the shape variations showed participants with PFOA possess a relatively thicker dorsal bump on the articular part of the patella, compared to patellae of control participants. Three of these variants showed an association with the presence of osteophytes and cartilage loss on the patella. Multiple associations were found between patellar shape and the clinical symptoms of PFOA.

CONCLUSIONS

Patellar shape is associated with the prevalence of MRI-based PFOA in women. Some shape variants were also associated with clinical symptoms. Interestingly, one particular shape variant associated with the presence of MRI-based PFOA was earlier shown to be associated with structural abnormalities associated with OA in a population aged under 40. This may suggest that patellar shape may be an early detectable risk factor for PFOA.

Extrusion-based 3D printing of biodegradable, osteogenic, paramagnetic, and porous FeMn-akermanite bone substitutes

The development of biodegradable Fe-based bone implants has rapidly progressed in recent years. Most of the challenges encountered in developing such implants have been tackled individually or in combination using additive manufacturing technologies. Yet not all the challenges have been overcome. Herein, we present porous FeMn-akermanite composite scaffolds fabricated by extrusion-based 3D printing to address the unmet clinical needs associated with Fe-based biomaterials for bone regeneration, including low biodegradation rate, MRI-incompatibility, mechanical properties, and limited bioactivity. In this research, we developed inks containing Fe, 35 wt% Mn, and 20 or 30 vol% akermanite powder mixtures. 3D printing was optimized together with the debinding and sintering steps to obtain scaffolds with interconnected porosity of 69%. The Fe-matrix in the composites contained the γ-FeMn phase as well as nesosilicate phases. The former made the composites paramagnetic and, thus, MRI-friendly. The in vitro biodegradation rates of the composites with 20 and 30 vol% akermanite were respectively 0.24 and 0.27 mm/y, falling within the ideal range of biodegradation rates for bone substitution. The yield strengths of the porous composites stayed within the range of the values of the trabecular bone, despite in vitro biodegradation for 28 d. All the composite scaffolds favored the adhesion, proliferation, and osteogenic differentiation of preosteoblasts, as revealed by Runx2 assay. Moreover, osteopontin was detected in the extracellular matrix of cells on the scaffolds. Altogether, these results demonstrate the remarkable potential of these composites in fulfilling the requirements of porous biodegradable bone substitutes, motivating future in vivo research. STATEMENT OF SIGNIFICANCE: We developed FeMn-akermanite composite scaffolds by taking advantage of the multi-material capacity of extrusion-based 3D printing. Our results demonstrated that the FeMn-akermanite scaffolds showed an exceptional performance in fulfilling all the requirements for bone substitution in vitro, i.e., a sufficient biodegradation rate, having mechanical properties in the range of trabecular bone even after 4 weeks biodegradation, paramagnetic, cytocompatible and most importantly osteogenic. Our results encourage further research on Fe-based bone implants in in vivo.

Osteoimmunomodulatory potential of 3D printed submicron patterns assessed in a direct co-culture model

Modulation of the immune response following the implantation of biomaterials can have beneficial effects on bone regeneration. This involves complex interactions between the inflammatory and osteogenic cells. Therefore, the study of cell-cell interactions using direct co-culture models integrated with biomaterials is of great interest. This research aimed to study the viability, morphology, and osteogenic activity of preosteoblasts (OBs) co-cultured with pro-inflammatory macrophages (M1s) on the 3D printed (non)patterned surfaces. OBs and M1s remained alive and proliferated actively for 14 days in the mixture of Dulbecco's Modified Eagle's Medium (DMEM) and alpha Minimum Essential Medium (α-MEM) (1:1), regardless of the cell ratio in the co-cultures. The spatial organization of the two types of cells changed with the time of culture from an initially uniform cell distribution to the formation of a thick layer of OBs covered by clusters of M1s. On day 7, the expression of PGE2 and TNF-α were upregulated in the co-culture relative to the mono-culture of OBs and M1s. The inflammation decreased differentiation and matrix mineralization of OBs after 28 days of culture. Interestingly, the incorporation of 3D printed submicron pillars into the direct co-culture model enhanced the differentiation of preosteoblasts, as shown by relatively higher RUNX2 expression, thereby revealing the osteoimmunomodulatory potential of such surface patterns.

Additive manufacturing of bioactive and biodegradable porous iron-akermanite composites for bone regeneration

Advanced additive manufacturing techniques have been recently used to tackle the two fundamental challenges of biodegradable Fe-based bone-substituting materials, namely low rate of biodegradation and insufficient bioactivity. While additively manufactured porous iron has been somewhat successful in addressing the first challenge, the limited bioactivity of these biomaterials hinder their progress towards clinical application. Herein, we used extrusion-based 3D printing for additive manufacturing of iron-matrix composites containing silicate-based bioceramic particles (akermanite), thereby addressing both of the abovementioned challenges. We developed inks that carried iron and 5, 10, 15, or 20 vol% of akermanite powder mixtures for the 3D printing process and optimized the debinding and sintering steps to produce geometrically-ordered iron-akermanite composites with an open porosity of 69-71%. The composite scaffolds preserved the designed geometry and the original α-Fe and akermanite phases. The in vitro biodegradation rates of the composites were improved as much as 2.6 times the biodegradation rate of geometrically identical pure iron. The yield strengths and elastic moduli of the scaffolds remained within the range of the mechanical properties of the cancellous bone, even after 28 days of biodegradation. The composite scaffolds (10-20 vol% akermanite) demonstrated improved MC3T3-E1 cell adhesion and higher levels of cell proliferation. The cellular secretion of collagen type-1 and the alkaline phosphatase activity on the composite scaffolds (10-20 vol% akermanite) were, respectively higher than and comparable to Ti6Al4V in osteogenic medium. Taken together, these results clearly show the potential of 3D printed porous iron-akermanite composites for further development as promising bone substitutes. STATEMENT OF SIGNIFICANCE: : Porous iron matrix composites containing akermanite particles were produced by means of multi-material additive manufacturing to address the two fundamental challenges associated with biodegradable iron-based biomaterials, namely very low rate of biodegradation and insufficient bioactivity. Our porous iron-akermanite composites exhibited enhanced biodegradability and superior bioactivity compared to porous monolithic iron scaffolds. The murine bone cells proliferated on the composite scaffolds, and secreted the collagen type-1 matrix that stimulated bony-like mineralization. The results show the exceptional potential of the developed porous iron-based composite scaffolds for application as bone substitutes.

Semi-automated digital workflow to design and evaluate patient-specific mandibular reconstruction implants

The reconstruction of large mandibular defects with optimal aesthetic and functional outcomes remains a major challenge for maxillofacial surgeons. The aim of this study was to design patient-specific mandibular reconstruction implants through a semi-automated digital workflow and to assess the effects of topology optimization on the biomechanical performance of the designed implants. By using the proposed workflow, a fully porous implant (LA-implant) and a topology-optimized implant (TO-implant) both made of Ti-6Al-4V ELI were designed and additively manufactured using selective laser melting. The mechanical performance of the implants was predicted by performing finite element analysis (FEA) and was experimentally assessed by conducting quasi-static and cyclic biomechanical tests. Digital image correlation (DIC) was used to validate the FE model by comparing the principal strains predicted by the FEM model with the measured distribution of the same type of strain. The numerical predictions were in good agreement with the DIC measurements and the predicted locations of specimen failure matched the actual ones. No statistically significant differences (p < 0.05) in the mean stiffness, mean ultimate load, or mean ultimate displacement were detected between the LA- and TO-implant groups. No implant failures were observed during quasi-static or cyclic testing under masticatory loads that were substantially higher (>1000 N) than the average maximum biting force of healthy individuals. Given its relatively lower weight (16.5%), higher porosity (17.4%), and much shorter design time (633.3%), the LA-implant is preferred for clinical application. This study clearly demonstrates the capability of the proposed workflow to develop patient-specific implants with high precision and superior mechanical performance, which will greatly facilitate cost- and time-effective pre-surgical planning and is expected to improve the surgical outcome.

Extrusion-based 3D printed magnesium scaffolds with multifunctional MgF2 and MgF2-CaP coatings

Additively manufactured (AM) biodegradable magnesium (Mg) scaffolds with precisely controlled and fully interconnected porous structures offer unprecedented potential as temporary bone substitutes and for bone regeneration in critical-sized bone defects. However, current attempts to apply AM techniques, mainly powder bed fusion AM, for the preparation of Mg scaffolds, have encountered some crucial difficulties related to safety in AM operations and severe oxidation during AM processes. To avoid these difficulties, extrusion-based 3D printing has been recently developed to prepare porous Mg scaffolds with highly interconnected structures. However, limited bioactivity and a too high rate of biodegradation remain the major challenges that need to be addressed. Here, we present a new generation of extrusion-based 3D printed porous Mg scaffolds that are coated with MgF₂ and MgF₂-CaP to improve their corrosion resistance and biocompatibility, thereby bringing the AM scaffolds closer to meeting the clinical requirements for bone substitutes. The mechanical properties, in vitro biodegradation behavior, electrochemical response, and biocompatibility of the 3D printed Mg scaffolds with a macroporosity of 55% and a strut density of 92% were evaluated. Furthermore, comparisons were made between the bare scaffolds and the scaffolds with coatings. The coating not only covered the struts but also infiltrated the struts through micropores, resulting in decreases in both macro- and micro-porosity. The bare Mg scaffolds exhibited poor corrosion resistance due to the highly interconnected porous structure, while the MgF₂-CaP coatings remarkably improved the corrosion resistance, lowering the biodegradation rate of the scaffolds down to 0.2 mm y^-1. The compressive mechanical properties of the bare and coated Mg scaffolds before and during in vitro immersion tests for up to 7 days were both in the range of the values reported for the trabecular bone. Moreover, direct culture of MC3T3-E1 preosteoblasts on the coated Mg scaffolds confirmed their good biocompatibility. Overall, this study clearly demonstrated the great potential of MgF₂-CaP coated porous Mg prepared by extrusion-based 3D printing for further development as a bone substitute.

3D printed submicron patterns orchestrate the response of macrophages

The surface topography of engineered extracellular matrices is one of the most important physical cues regulating the phenotypic polarization of macrophages. However, not much is known about the ways through which submicron (i.e., 100-1000 nm) topographies modulate the polarization of macrophages. In the context of bone tissue regeneration, it is well established that this range of topographies stimulates the osteogenic differentiation of stem cells. Since the immune response affects the bone tissue regeneration process, the immunomodulatory consequences of submicron patterns should be studied prior to their clinical application. Here, we 3D printed submicron pillars (using two-photon polymerization technique) with different heights and interspacings to perform the first ever systematic study of such effects. Among the studied patterns, the highest degree of elongation was observed for the cells cultured on those with the tallest and densest pillars. After 3 days of culture with inflammatory stimuli (LPS/IFN-γ), sparsely decorated surfaces inhibited the expression of the pro-inflammatory cellular marker CCR7 as compared to day 1 and to the other patterns. Furthermore, sufficiently tall pillars polarized the M1 macrophages towards a pro-healing (M2) phenotype, as suggested by the expression of CD206 within the first 3 days. As some of the studied patterns are known to be osteogenic, the osteoimmunomodulatory capacity of the patterns should be further studied to optimize their bone tissue regeneration performance.

The effects of plasma electrolytically oxidized layers containing Sr and Ca on the osteogenic behavior of selective laser melted Ti6Al4V porous implants

Surface biofunctionalization is frequently applied to enhance the functionality and longevity of orthopedic implants. Here, we investigated the osteogenic effects of additively manufactured porous Ti6Al4V implants whose surfaces were biofunctionalized using plasma electrolytic oxidation (PEO) in Ca/P-based electrolytes with or without strontium. Various levels of Sr and Ca were incorporated in the oxide layers by using different current densities and oxidation times. Increasing the current density and oxidation time resulted in thicker titanium oxide layers and enhanced the release of Ca²⁺ and Sr²⁺. Biofunctionalization with strontium resulted in enhanced pore density, a thinner TiO₂ layer, four-fold reduced release of Ca²⁺, and mainly anatase phases as compared to implants biofunctionalized in electrolytes containing solely Ca/P species under otherwise similar conditions. Different current densities and oxidation times significantly increased the osteogenic differentiation of MC3T3-E1 cells on implants biofunctionalized with strontium, when the PEO treatment was performed with a current density of 20 A/dm² for 5 and 10 min as well as for a current density of 40 A/dm² for 5 min. Therefore, addition of Sr in the PEO electrolyte and control of the PEO processing parameters represent a promising way to optimize the surface morphology and osteogenic activity of future porous AM implants.

Self-defending additively manufactured bone implants bearing silver and copper nanoparticles

Effective preventive measures against implant-associated infection (IAI) are desperately needed. Therefore, the development of self-defending implants with intrinsic antibacterial properties has gained significant momentum. Biomaterials biofunctionalized with silver (Ag) have resulted in effective antibacterial biomaterials, yet regularly induce cytotoxicity. In this study, the use of both Ag and copper (Cu) nanoparticles (NPs) on TiO2 surfaces was investigated to generate antibacterial and osteoconductive biomaterials. Hence, additively manufactured Ti-6Al-4V volume-porous implants were biofunctionalized with plasma electrolytic oxidation (PEO) through the incorporation of varying ratios of Ag and/or Cu NPs in the TiO2 layer covering the implant surface. For all experimental groups, the surface morphology, chemical composition, ion release profile, generation of reactive ion species, antibacterial activity against methicillin-resistant Staphylococcus aureus (MRSA) in vitro and ex vivo, as well as the response of pre-osteoblastic MC3T3-E1 cells in metabolic activity and differentiation assays were determined. PEO biofunctionalization resulted in rough and highly porous surfaces that released Ag and Cu ions for 28 days and generated hydroxyl as well as methyl radicals. A strong synergistic bactericidal behavior between Ag and Cu ions was detected, which allowed to decrease the concentration of Ag ions by 10-fold, while maintaining the same level of antibacterial activity. Antibacterial agar diffusion and quantitative assays indicated strong antibacterial activity in vitro for the implants containing Ag and Ag/Cu, while no antibacterial activity was observed for implants bearing only Cu NPs. Moreover, the biofunctionalized implants with ratios of up to 75% Ag and 25% Cu NP totally eradicated all bacteria in an ex vivo model using murine femora. Meanwhile, the biofunctionalized implants did not show any signs of cytotoxicity, while implants bearing only Cu NPs improved the metabolic activity after 7 and 11 days. The biomaterials developed here, therefore, exploit the synergistic behavior of Ag and Cu to simultaneously offer strong antibacterial behavior while fully mitigating the cytotoxicity of Ag against mammalian cells.

Additively manufactured functionally graded biodegradable porous zinc

Topological design provides additively manufactured (AM) biodegradable porous metallic biomaterials with a unique opportunity to adjust their biodegradation behavior and mechanical properties, thereby satisfying the requirements for ideal bone substitutes. However, no information is available yet concerning the effect of topological design on the performance of AM porous zinc (Zn) that outperforms Mg and Fe in biodegradation behavior. Here, we studied one functionally graded and two uniform AM porous Zn designs with diamond unit cell. Cylindrical specimens were fabricated from pure Zn powder by using a powder bed fusion technique, followed by a comprehensive study on their static and dynamic biodegradation behaviors, mechanical properties, permeability, and biocompatibility. Topological design, indeed, affected the biodegradation behavior of the specimens, as evidenced by 150% variations in biodegradation rate between the three different designs. After in vitro dynamic immersion for 28 days, the AM porous Zn had weight losses of 7-12%, relying on the topological design. The degradation rates satisfied the desired biodegradation time of 1-2 years for bone substitution. The mechanical properties of the biodegraded specimens of all the groups maintained within the range of those of cancellous bone. As opposed to the trends observed for other biodegradable porous metals, after 28 days of in vitro biodegradation, the yield strengths of the specimens of all the groups (σy = 7-14 MPa) increased consistently, as compared to those of the as-built specimens (σy = 4-11 MPa). Moreover, AM porous Zn showed excellent biocompatibility, given that the cellular activities in none of the groups differed from the Ti controls for up to 72 h. Using topological design of AM porous Zn for controlling its mechanical properties and degradation behavior is thus clearly promising, thereby rendering flexibility to the material to meet a variety of clinical requirements.

Solvent-cast 3D printing of magnesium scaffolds

Biodegradable porous magnesium (Mg) scaffolds are promising for application in the regeneration of critical-sized bone defects. Although additive manufacturing (AM) carries the promise of offering unique opportunities to fabricate porous Mg scaffolds, current attempts to apply the AM approach to fabricating Mg scaffolds have encountered some crucial issues, such as those related to safety in operation and to the difficulties in composition control. In this paper, we present a room-temperature extrusion-based AM method for the fabrication of topologically ordered porous Mg scaffolds. It is composed of three steps, namely (i) preparing a Mg powder loaded ink with desired rheological properties, (ii) solvent-cast 3D printing (SC-3DP) of the ink to form scaffolds with 0 °/ 90 °/ 0 ° layers, and (iii) debinding and sintering to remove the binder in the ink and then get Mg powder particles bonded by applying a liquid-phase sintering strategy. A rheological analysis of the prepared inks with 54, 58 and 62  vol% Mg powder loading was performed to reveal their viscoelastic properties. Thermal-gravimetric analysis (TGA), Fourier transform infrared spectroscopy (FTIR), carbon/sulfur analysis and scanning electron microscopy (SEM) indicated the possibilities of debinding and sintering at one single step for fabricating pure Mg scaffolds with high fidelity and densification. The resulting scaffolds with high porosity contained hierarchical and interconnected pores. This study, for the first time, demonstrated that the SC-3DP technique presents unprecedented possibilities to fabricate Mg-based porous scaffolds that have the potential to be used as a bone-substituting material. STATEMENT OF SIGNIFICANCE: Biodegradable porous magnesium scaffolds are promising for application in the regeneration of critical-sized bone defects. Although additive manufacturing (AM) carries the promise of offering unique opportunities to fabricate porous magnesium scaffolds, current attempts to apply the AM approach to fabricating magnesium scaffolds still have some crucial limitations. This study demonstrated that the solvent-cast 3D printing technique presents unprecedented possibilities to fabricate Mg-based porous scaffolds. The judicious chosen of formulated binder system allowed for the negligible binder residue after debinding and the short-time liquid-phase sintering strategy led to a great success in sintering pure magnesium scaffolds. The resulting scaffolds with hierarchical and interconnected pores have great potential to be used as a bone-substituting material.

Strain rate-dependent mechanical metamaterials

Mechanical metamaterials are usually designed to exhibit novel properties and functionalities that are rare or even unprecedented. What is common among most previous designs is the quasi-static nature of their mechanical behavior. Here, we introduce a previously unidentified class of strain rate-dependent mechanical metamaterials. The principal idea is to laterally attach two beams with very different levels of strain rate-dependencies to make them act as a single bi-beam. We use an analytical model and multiple computational models to explore the instability modes of such a bi-beam construct, demonstrating how different combinations of hyperelastic and viscoelastic properties of both beams, as well as purposefully introduced geometric imperfections, could be used to create robust and highly predictable strain rate-dependent behaviors of bi-beams. We then use the bi-beams to design and experimentally realize lattice structures with unique strain rate-dependent properties including switching between auxetic and conventional behaviors and negative viscoelasticity.

Multi-material additive manufacturing technologies for Ti-, Mg-, and Fe-based biomaterials for bone substitution

The growing interest in multi-functional metallic biomaterials for bone substitutes challenges the current additive manufacturing (AM, =3D printing) technologies. It is foreseeable that advances in multi-material AM for metallic biomaterials will not only allow for complex geometrical designs, but also improve their multi-functionalities by tuning the types or compositions of the underlying base materials, thereby presenting unprecedented opportunities for advanced orthopedic treatments. AM technologies are yet to be extensively explored for the fabrication of multi-functional metallic biomaterials, especially for bone substitutes. The aim of this review is to present the viable options of the state-of-the-art multi-material AM for Ti-, Mg-, and Fe-based biomaterials to be used as bone substitutes. The review starts with a brief review of bone tissue engineering, the design requirements, and fabrication technologies for metallic biomaterials to highlight the advantages of using AM over conventional fabrication methods. Five AM technologies suitable for metal 3D printing are compared against the requirements for multi-material AM. Of these AM technologies, extrusion-based multi-material AM is shown to have the greatest potential to meet the requirements for the fabrication of multi-functional metallic biomaterials. Finally, recent progress in the fabrication of Ti-, Mg-, and Fe-based biomaterials including the utilization of multi-material AM technologies is reviewed so as to identify the knowledge gaps and propose the directions of further research for the development of multi-material AM technologies that are applicable for the fabrication of multi-functional metallic biomaterials. STATEMENT OF SIGNIFICANCE: Addressing a critical bone defect requires the assistance of multi-functional porous metallic bone substitutes. As one of the most advanced fabrication technology in bone tissue engineering, additive manufacturing is challenged for its viability in multi-material fabrication of metallic biomaterials. This article reviews how the current metal additive manufacturing technologies have been and can be used for multi-material fabrication of Ti-, Mg-, and Fe-based bone substitutes. Progress on the Ti-, Mg-, and Fe-based biomaterials, including the utilization of multi-material additive manufacturing, are discussed to direct future research for advancing the multi-functional additively manufactured metallic bone biomaterials.

Immunomodulation of surface biofunctionalized 3D printed porous titanium implants

Additive manufacturing (AM) techniques have provided many opportunities for the rational design of porous metallic biomaterials with complex and precisely controlled topologies that give rise to unprecedented combinations of mechanical, physical, and biological properties. These favorable properties can be enhanced by surface biofunctionalization to enable full tissue regeneration and minimize the risk of implant-associated infections (IAIs). There is, however, an increasing need to investigate the immune responses triggered by surface biofunctionalized AM porous metals. Here, we studied the immunomodulatory effects of AM porous titanium (Ti-6Al-4V) printed using selective laser melting, and of two additional groups consisting of AM implants surface biofunctionalized using plasma electrolytic oxidation (PEO) with/without silver nanoparticles. The responses of human primary macrophages and human mesenchymal stromal cells (hMSCs) were studied in terms of cell viability, cell morphology and biomarkers of macrophage polarization. Non-treated AM porous titanium triggered a strong pro-inflammatory response in macrophages, albeit combined with signs of anti-inflammatory effects. The PEO treatment of AM porous titanium implants showed a higher potential to induce polarization towards a pro-repair macrophage phenotype. We detected no cytotoxicity against hMSCs in any of the groups. However, the incorporation of silver nanoparticles resulted in strong cytotoxicity against attached macrophages. The results of this study indicate the potential immunomodulatory effects of the AM porous titanium enhanced with PEO treatment, and point towards caution and further research when using silver nanoparticles for preventing IAIs.

Corrosion fatigue behavior of additively manufactured biodegradable porous zinc

Additively manufactured (AM) biodegradable porous zinc exhibits great potential as a promising bone-substituting biomaterial. However, there is no information whatsoever available regarding its corrosion fatigue behavior. In this study, we used direct metal printing to fabricate topologically ordered biodegradable porous zinc based on a diamond unit cell. We compared the compression-compression fatigue behavior of AM porous zinc in air and in revised simulated body fluid (r-SBF). The fatigue strength of AM porous zinc was high in air (i.e., 70% of its yield strength) and even higher in r-SBF (i.e., 80% of its yield strength). The high value of the relative fatigue strength in air could be attributed to the good ductility of pure zinc itself. The formation of corrosion products around the strut junctions might explain the higher fatigue strength of AM zinc in r-SBF. Furthermore, we compared the fatigue behavior of a uniform design of the AM porous zinc with a functionally graded design. The functionally graded structure exhibited higher relative fatigue strengths than the uniform structure. The inspection of the fatigue crack distribution revealed that the functionally graded design controlled the sequence of crack initiation, which occurred early in the thicker struts and moved towards the thinner struts over time. The theoretical fatigue life models suggest that optimizing the functionally graded structure could be used as an effective means to improve the fatigue life of AM porous zinc. In conclusion, the favorable fatigue behavior of AM porous zinc further highlights its potential as a promising bone-substituting biomaterial. STATEMENT OF SIGNIFICANCE: Additively manufactured (AM) biodegradable porous zinc exhibits great potential for the treatment of large bony defects. However, there is no information available regarding its corrosion fatigue behavior. Here, we compared the fatigue behavior of AM porous zinc in air and in revised simulated body fluid (r-SBF). The fatigue strength of AM porous Zn was even higher in r-SBF than in air, which were attributed to the formation of corrosion products. Furthermore, we found that the functionally graded structure controlled the sequence of crack initiation in differently sized struts and exhibited higher relative fatigue strengths than the uniform structure, suggesting that optimizing the functionally graded structure could be an effective means to improve the fatigue life of AM porous Zn.

3D Printing of Large Areas of Highly Ordered Submicron Patterns for Modulating Cell Behavior

Fabricating large areas of geometrically complex and precisely controlled topographies is required for the studies of cell behavior on patterned surfaces. Direct laser writing (DLW) is an advanced 3D-fabrication technique, which facilitates the manufacturing of structures within various scales (from a few hundred nanometers to millimeters). However, this method requires improvements in the accuracy and reproducibility of the submicron and nanoscale features that are printed over a large area. Here, we present a scheme to both improve the uniformity of the printed submicron patterns and decrease the printing time. The effects of various processing parameters (e.g., laser power and writing field) on the dimensions and uniformity of submicron pillars as well as on their Young's modulus and surface wettability were assessed. Decreasing the writing field to 33 × 33 μm2 significantly improved the uniformity of submicron pillars that were printed over an area of 4 mm2 in a single-step process. Preosteoblast cells (MC3T3-E1) were used to assess the cytocompatibility of the used material (IP-L780 resin) with a focus on cell morphology, cell proliferation, cytoskeletal organization, and the elastic modulus of the cells. The cells cultured for 2 days on the submicron pillars showed a polarized shape and a higher Young's modulus of the area corresponding to the nucleus relative to those cultured on flat surfaces. Taken together, the results of the current study clearly show that the submicron patterns created using DLW are both cytocompatible and could modulate the morphology and mechanical properties of cells. This work paves the way for direct printing of submicron features with controlled Young's moduli over large areas in a single-step process, which is necessary for systematically studying how such patterns modulate cellular functions.

Additively manufactured functionally graded biodegradable porous iron

Additively manufactured (AM) functionally graded porous metallic biomaterials offer unique opportunities to satisfy the contradictory design requirements of an ideal bone substitute. However, no functionally graded porous structures have ever been 3D-printed from biodegradable metals, even though biodegradability is crucial both for full tissue regeneration and for the prevention of implant-associated infections in the long term. Here, we present the first ever report on AM functionally graded biodegradable porous metallic biomaterials. We made use of a diamond unit cell for the topological design of four different types of porous structures including two functionally graded structures and two reference uniform structures. Specimens were then fabricated from pure iron powder using selective laser melting (SLM), followed by experimental and computational analyses of their permeability, dynamic biodegradation behavior, mechanical properties, and cytocompatibility. It was found that the topological design with functional gradients controlled the fluid flow, mass transport properties and biodegradation behavior of the AM porous iron specimens, as up to 4-fold variations in permeability and up to 3-fold variations in biodegradation rate were observed for the different experimental groups. After 4 weeks of in vitro biodegradation, the AM porous scaffolds lost 5-16% of their weight. This falls into the desired range of biodegradation rates for bone substitution and confirms our hypothesis that topological design could indeed accelerate the biodegradation of otherwise slowly degrading metals, like iron. Even after 4 weeks of biodegradation, the mechanical properties of the specimens (i.e., E = 0.5-2.1 GPa, σ_y = 8-48 MPa) remained within the range of the values reported for trabecular bone. Design-dependent cell viability did not differ from gold standard controls for up to 48 h. This study clearly shows the great potential of AM functionally graded porous iron as a bone substituting material. Moreover, we demonstrate that complex topological design permits the control of mechanical properties, degradation behavior of AM porous metallic biomaterials. STATEMENT OF SIGNIFICANCE: No functionally graded porous structures have ever been 3D-printed from biodegradable metals, even though biodegradability is crucial both for full tissue regeneration and for the prevention of implant-associated infections in the long term. Here, we present the first report on 3D-printed functionally graded biodegradable porous metallic biomaterials. Our results suggest that topological design in general, and functional gradients in particular can be used as an important tool for adjusting the biodegradation behavior of AM porous metallic biomaterials. The biodegradation rate and mass transport properties of AM porous iron can be increased while maintaining the bone-mimicking mechanical properties of these biomaterials. The observations reported here underline the importance of proper topological design in the development of AM porous biodegradable metals.

Crumpling of thin sheets as a basis for creating mechanical metamaterials

Crumpled thin sheets exhibit extraordinary characteristics such as a high strength combined with a low volume ratio. This review focuses on the physics of crumpled thin sheets, including the crumpling mechanics, crumpling methods, and the mechanical behavior of crumpled thin sheets. Most of the physical and mechanical properties of crumpled thin sheets change with the compaction ratio, which creates the opportunity to obtain the properties that are needed for a specific application simply by changing the compaction ratio. This also enables obtaining unusual combinations of material properties, which cannot be easily found in nature. Furthermore, crumpling starts from a flat surface, which could first be decorated with (nano-) patterns or functionalized through other surface treatment techniques, many of which are only applicable to flat surfaces. Ultimately, the crumpling of thin sheets could be used for creating disordered mechanical metamaterials, which are less sensitive to geometric imperfections compared to ordered designs of mechanical metamaterials that are based, for example, on origami or lattice structures.

Random formation of layers and ridges through the crumpling of a flat matter can form a robust mechanical metamaterial.

In-silico quest for bactericidal but non-cytotoxic nanopatterns

Nanopillar arrays that are bactericidal but not cytotoxic against the host cells could be used in implantable medical devices to prevent implant-associated infections. It is, however, unclear what heights, widths, interspacing, and shape should be used for the nanopillars to achieve the desired antibacterial effects while not hampering the integration of the device in the body. Here, we present an in-silico approach based on finite element modeling of the interactions between Staphylococcus aureus and nanopatterns on the one hand and osteoblasts and nanopatterns on the other hand to find the best design parameters. We found that while the height of the nanopillars seems to have little impact on the bactericidal behavior, shorter widths and larger interspacings substantially increase the bactericidal effects. The same combination of parameters could, however, also cause cytotoxicity. Our results suggest that a specific combination of height (120 nm), width (50 nm), and interspacing (300 nm) offers the bactericidal effects without cytotoxicity.

Additively manufactured biodegradable porous iron

Additively manufactured (AM) topologically ordered porous metallic biomaterials with the proper biodegradation profile offer a unique combination of properties ideal for bone regeneration. These include a fully interconnected porous structure, bone-mimicking mechanical properties, and the possibility of fully regenerating bony defects. Most of such biomaterials are, however, based on magnesium and, thus, degrade too fast. Here, we present the first report on topologically ordered porous iron made by Direct Metal Printing (DMP). The topological design was based on a repetitive diamond unit cell. We conducted a comprehensive study on the in vitro biodegradation behavior (up to 28 days), electrochemical performance, time-dependent mechanical properties, and biocompatibility of the scaffolds. The mechanical properties of AM porous iron (E = 1600-1800 MPa) were still within the range of the values reported for trabecular bone after 28 days of biodegradation. Electrochemical tests showed up to ≈12 times higher rates of biodegradation for AM porous iron as compared to that of cold-rolled (CR) iron, while only 3.1% of weight loss was measured after 4 weeks of immersion tests. The biodegradation mechanisms were found to be topology-dependent and different between the periphery and central parts of the scaffolds. While direct contact between MG-63 cells and scaffolds revealed substantial and almost instant cytotoxicity in static cell culture, as compared to Ti-6Al-4V, the cytocompatibility according to ISO 10993 was reasonable in in vitro assays for up to 72 h. This study shows how DMP could be used to increase the surface area and decrease the grain sizes of topologically ordered porous metallic biomaterials made from metals that are usually considered to degrade too slowly (e.g., iron), opening up many new opportunities for the development of biodegradable metallic biomaterials.

STATEMENT OF SIGNIFICANCE

Biodegradation in general and proper biodegradation profile in particular are perhaps the most important requirements that additively manufactured (AM) topologically ordered porous metallic biomaterials should offer in order to become the ideal biomaterial for bone regeneration. Currently, most biodegradable metallic biomaterials are based on magnesium, which degrade fast with gas generation. Here, we present the first report on topologically ordered porous iron made by Direct Metal Printing (DMP). We also conducted a comprehensive study on the biodegradation behavior, electrochemical performance, biocompatibility, and the time evolution of the mechanical properties of the implants. We show that these implants possess bone-mimicking mechanical properties, accelerated degradation rate, and reasonable cytocompatibility, opening up many new opportunities for the development of iron-based biodegradable materials.

Length-scale dependency of biomimetic hard-soft composites

Biomimetic composites are usually made by combining hard and soft phases using, for example, multi-material additive manufacturing (AM). Like other fabrication methods, AM techniques are limited by the resolution of the device, hence, setting a minimum length scale. The effects of this length scale on the performance of hard-soft composites are not well understood. Here, we studied how this length scale affects the fracture toughness behavior of single-edge notched specimens made using random, semi-random, and ordered arrangements of the hard and soft phases with five different ratios of hard to soft phases. Increase in the length scale (40 to 960 μm) was found to cause a four-fold drop in the fracture toughness. The effects of the length scale were also modulated by the arrangement and volumetric ratio of both phases. A decreased size of the crack tip plastic zone, a crack path going through the soft phase, and highly strained areas far from the crack tip were the main mechanisms explaining the drop of the fracture toughness with the length scale.

Fatigue and quasi-static mechanical behavior of bio-degradable porous biomaterials based on magnesium alloys

Magnesium and its alloys have the intrinsic capability of degrading over time in vivo without leaving toxic degradation products. They are therefore suitable for use as biodegradable scaffolds that are replaced by the regenerated tissues. One of the main concerns for such applications, particularly in load-bearing areas, is the sufficient mechanical integrity of the scaffold before sufficient volumes of de novo tissue is generated. In the majority of the previous studies on the effects of biodegradation on the mechanical properties of porous biomaterials, the change in the elastic modulus has been studied. In this study, variations in the static and fatigue mechanical behavior of porous structures made of two different Mg alloys (AZ63 and M2) over different dissolution times ( 6, 12, and 24 h) have been investigated. The results showed an increase in the mechanical properties obtained from stress-strain curve (elastic modulus, yield stress, plateau stress, and energy absorption) after 6-12 h and a sharp decrease after 24 h. The initial increase in the mechanical properties may be attributed to the accumulation of corrosion products in the pores of the porous structure before degradation has considerably proceeded. The effects of mineral deposition was more pronounced for the elastic modulus as compared to other mechanical properties. That may be due to insufficient integration of the deposited particles in the structure of the magnesium alloys. While the bonding of the parts being combined in a composite-like material is of great importance in determining its yield stress, the effects of bonding strength of both parts is much lower in determining the elastic modulus. The results of the current study also showed that the dissolution rates of the studied Mg alloys were too high for direct use in human body. © 2018 Authors Journal of Biomedical Materials Research Part A Published by Wiley Periodicals, Inc. J Biomed Mater Res Part A: 106A: 1798-1811, 2018.

Towards deployable meta-implants

Meta-biomaterials exhibit unprecedented or rare combinations of properties not usually found in nature. Such unusual mechanical, mass transport, and biological properties could be used to develop novel categories of orthopedic implants with superior performance, otherwise known as meta-implants. Here, we use bi-stable elements working on the basis of snap-through instability to design deployable meta-implants. Deployable meta-implants are compact in their retracted state, allowing them to be brought to the surgical site with minimum invasiveness. Once in place, they are deployed to take their full-size load-bearing shape. We designed five types of meta-implants by arranging bi-stable elements in such a way to obtain a radially-deployable structure, three types of auxetic structures, and an axially-deployable structure. The intermediate stable conditions (i.e. multi-stability features), deployment force, and stiffness of the meta-implants were found to be strongly dependent on the geometrical parameters of the bi-stable elements as well as on their arrangement.

Shape-matching soft mechanical metamaterials

Architectured materials with rationally designed geometries could be used to create mechanical metamaterials with unprecedented or rare properties and functionalities. Here, we introduce "shape-matching" metamaterials where the geometry of cellular structures comprising auxetic and conventional unit cells is designed so as to achieve a pre-defined shape upon deformation. We used computational models to forward-map the space of planar shapes to the space of geometrical designs. The validity of the underlying computational models was first demonstrated by comparing their predictions with experimental observations on specimens fabricated with indirect additive manufacturing. The forward-maps were then used to devise the geometry of cellular structures that approximate the arbitrary shapes described by random Fourier's series. Finally, we show that the presented metamaterials could match the contours of three real objects including a scapula model, a pumpkin, and a Delft Blue pottery piece. Shape-matching materials have potential applications in soft robotics and wearable (medical) devices.

Development and mechanical characterisation of self-compressed collagen gels

Collagen gels are considered a promising biomaterial for the manufacturing of tissue engineering scaffolds, however, their mechanical properties often need to be improved to enable them to provide enough mechanical support during the course of tissue regeneration process. In this paper, we present a simple self-compression technique for the improvement of the mechanical properties of collagen gels, identified by the fitting of bespoke biphasic finite element models. Radially-confined highly hydrated gels were allowed to self-compress for 18h, expelling fluid, and which were subsequently subjected to unconfined ramp-hold compression. Gels, initially of 0.2%, 0.3% and 0.4% (w/v) collagen and 13mm thickness, transformed to 2.9±0.2%, 3.2±0.3% and 3.6±0.1% (w/w) collagen and 0.45±0.06mm, 0.69±0.04mm and 0.99±0.07mm thickness. Young's moduli of the compressed gels did not increase with increasing collagen fibril density, whilst zero-strain hydraulic permeability significantly decreased from 51 to 21mm⁴/Ns. The work demonstrates that biphasic theory, applied to unconfined compression, is a highly appropriate paradigm to mechanically characterise concentrated collagen gels and that confined compression of highly hydrated gels should be further investigated to enhance gel mechanical performance.

Crumpling-based soft metamaterials: the effects of sheet pore size and porosity

Crumpled-based materials are relatively easy to fabricate and show robust mechanical properties for practical applications, including meta-biomaterials design aimed for improved tissue regeneration. For such requests, however, the structure needs to be porous. We introduce a crumpled holey thin sheet as a robust bio-metamaterial and measure the mechanical response of a crumpled holey thin Mylar sheet as a function of the hole size and hole area fraction. We also study the formation of patterns of crease lines and ridges. The area fraction largely dominated the crumpling mechanism. We also show, the crumpling exponents slightly increases with increasing the hole area fraction and the total perimeter of the holes. Finally, hole edges were found to limit and guide the propagation of crease lines and ridges.

Simultaneous Delivery of Multiple Antibacterial Agents from Additively Manufactured Porous Biomaterials to Fully Eradicate Planktonic and Adherent Staphylococcus aureus

Implant-associated infections are notoriously difficult to treat and may even result in amputation and death. The first few days after surgery are the most critical time to prevent those infections, preferably through full eradication of the micro-organisms entering the body perioperatively. That is particularly important for patients with a compromised immune system such as orthopedic oncology patients, as they are at higher risk for infection and complications. Full eradication of bacteria is, especially in a biofilm, extremely challenging due to the toxicity barrier that prevents delivery of high doses of antibacterial agents. This study aimed to use the potential synergistic effects of multiple antibacterial agents to prevent the use of toxic levels of these agents and achieve full eradication of planktonic and adherent bacteria. Silver ions and vancomycin were therefore simultaneously delivered from additively manufactured highly porous titanium implants with an extremely high surface area incorporating a bactericidal coating made from chitosan and gelatin applied by electrophoretic deposition (EPD). The presence of the chitosan/gelatin (Ch+Gel) coating, Ag, and vancomycin (Vanco) was confirmed by X-ray photoelectron spectroscopy (XPS) and Fourier transform infrared spectroscopy (FTIR). The release of vancomycin and silver ions continued for at least 21 days as measured by inductively coupled plasma (ICP) and UV-spectroscopy. Antibacterial behavior against Staphylococcus aureus, both planktonic and in biofilm, was evaluated for up to 21 days. The Ch+Gel coating showed some bactericidal behavior on its own, while the loaded hydrogels (Ch+Gel+Ag and Ch+Gel+Vanco) achieved full eradication of both planktonic and adherent bacteria without causing significant levels of toxicity. Combining silver and vancomycin improved the release profiles of both agents and revealed a synergistic behavior that further increased the bactericidal effects.

Additively Manufactured and Surface Biofunctionalized Porous Nitinol

Enhanced bone tissue regeneration and improved osseointegration are among the most important goals in design of multifunctional orthopedic biomaterials. In this study, we used additive manufacturing (selective laser melting) to develop multifunctional porous nitinol that combines superelasticity with a rationally designed microarchitecture and biofunctionalized surface. The rational design based on triply periodic minimal surfaces aimed to properly adjust the pore size, increase the surface area (thereby amplifying the effects of surface biofunctionalization), and resemble the curvature characteristics of trabecular bone. The surface of additively manufactured (AM) porous nitinol was biofunctionalized using polydopamine-immobilized rhBMP2 for better control of the release kinetics. The actual morphological properties of porous nitinol measured by microcomputed tomography (e.g., open/close porosity, and surface area) closely matched the design values. The superelasticity originated from the austenite phase formed in the nitinol porous structure at room temperature. Polydopamine and rhBMP2 signature peaks were confirmed by X-ray photoelectron spectroscopy and Fourier transform infrared spectroscopy tests. The release of rhBMP2 continued until 28 days. The early time and long-term release profiles were found to be adjustable independent of each other. In vitro cell culture showed improved cell attachment, cell proliferation, cell morphology (spreading, spindle-like shape), and cell coverage as well as elevated levels of ALP activity and increased calcium content for biofunctionalized surfaces as compared to as-manufactured specimens. The demonstrated functionalities of porous nitinol could be used as a basis for deployable orthopedic implants with rationally designed microarchitectures that maximize bone tissue regeneration performance by release of biomolecules with adjustable and well-controlled release profiles.

Auxetic mechanical metamaterials

We review the topology–property relationship and the spread of Young's modulus–Poisson's ratio duos in three main classes of auxetic metamaterials.

Effects of bone substitute architecture and surface properties on cell response, angiogenesis, and structure of new bone

This paper presents an overview of the effect of porous biomaterial architecture on seeding efficiency, cell response, angiogenesis, and bone formation.

Bone shape difference between control and osteochondral defect groups of the ankle joint

OBJECTIVE

The etiology of osteochondral defects (OCDs), for which the ankle (talocrural) joint is one of the common sites, is not yet fully understood. In this study, we hypothesized that bone shape plays a role in development of OCDs. Therefore, we quantitatively compared the morphology of the talus and the distal tibia between an OCD group and a control group.

METHODS

The shape variations of the talus and distal tibia were described separately by constructing two statistical shape models (SSMs) based on the segmentation of the bones from ankle computed tomography (CT) scans obtained from control (i.e., 35 CT scans) and OCD (i.e., 37 CT scans) groups. The first five modes of shape variation for the SSM corresponding to each bone were statistically compared between control and OCD groups using an analysis of variance (ANOVA) corrected with the Bonferroni for multiple comparisons.

RESULTS

The first five modes of variation in the SSMs respectively represented 49% and 40% of the total variance of talus and tibia. Less than 5% of the variance per mode was described by the higher modes. Mode 5 of the talus (P = 0.004) primarily describing changes in the vertical neck angle and Mode 1 of the tibia (P < 0.0001) representing variations at the medial malleolus, showed statistically significant difference between the control and OCD groups.

CONCLUSION

Shape differences exist between control and OCD groups. This indicates that a geometry modulated biomechanical behavior of the talocrural joint may be a risk factor for OCD.

Antibacterial Behavior of Additively Manufactured Porous Titanium with Nanotubular Surfaces Releasing Silver Ions

Additive manufacturing (3D printing) has enabled fabrication of geometrically complex and fully interconnected porous biomaterials with huge surface areas that could be used for biofunctionalization to achieve multifunctional biomaterials. Covering the huge surface area of such porous titanium with nanotubes has been already shown to result in improved bone regeneration performance and implant fixation. In this study, we loaded TiO2 nanotubes with silver antimicrobial agents to equip them with an additional biofunctionality, i.e., antimicrobial behavior. An optimized anodizing protocol was used to create nanotubes on the entire surface area of direct metal printed porous titanium scaffolds. The nanotubes were then loaded by soaking them in three different concentrations (i.e., 0.02, 0.1, and 0.5 M) of AgNO3 solution. The antimicrobial behavior and cell viability of the developed biomaterials were assessed. As far as the early time points (i.e., up to 1 day) are concerned, the biomaterials were found to be extremely effective in preventing biofilm formation and decreasing the number of planktonic bacteria particularly for the middle and high concentrations of silver ions. Interestingly, nanotubes not loaded with antimicrobial agents also showed significantly smaller numbers of adherent bacteria at day 1, which may be attributed to the bactericidal effect of high aspect ratio nanotopographies. The specimens with the highest concentrations of antimicrobial agents adversely affected cell viability at day 1, but this effect is expected to decrease or disappear in the following days as the rate of release of silver ions was observed to markedly decrease within the next few days. The antimicrobial effects of the biomaterials, particularly the ones with the middle and high concentrations of antimicrobial agents, continued until 2 weeks. The potency of the developed biomaterials in decreasing the number of planktonic bacteria and hindering the formation of biofilms make them promising candidates for combating peri-operative implant-associated infections.

Micro- and nano-mechanics of osteoarthritic cartilage: The effects of tonicity and disease severity

The present study aims to discover the contribution of glycosaminoglycans (GAGs) and collagen fibers to the mechanical properties of the osteoarthritic (OA) cartilage tissue. We used nanoindentation experiments to understand the mechanical behavior of mild and severe osteoarthritic cartilage at micro- and nano-scale at different swelling conditions. Contrast enhanced micro-computed tomography (EPIC-μCT) was used to confirm that mild OA specimens had significantly higher GAGs content compared to severe OA specimens. In micro-scale, the semi-equilibrium modulus of mild OA specimens significantly dropped after immersion in a hypertonic solution and at nano-scale, the histograms of the measured elastic modulus revealed three to four components. Comparing the peaks with those observed for healthy cartilage in a previous study indicated that the first and third peaks represent the mechanical properties of GAGs and the collagen network. The third peak shows considerably stiffer elastic modulus for mild OA samples as compared to the severe OA samples in isotonic conditions. Furthermore, this peak clearly dropped when the tonicity increased, indicating the loss of collagen (pre-) stress in the shrunk specimen. Our observations support the association of the third peak with the collagen network. However, our results did not provide any direct evidence to support the association of the first peak with GAGs. For severe OA specimens, the peak associated with the collagen network did not drop when the tonicity increased, indicating a change in the response of OA cartilage to hypertonicity, likely collagen damage, as the disease progresses to its latest stages.

Transport of Neutral Solute Across Articular Cartilage: The Role of Zonal Diffusivities

Transport of solutes through diffusion is an important metabolic mechanism for the avascular cartilage tissue. Three types of interconnected physical phenomena, namely mechanical, electrical, and chemical, are all involved in the physics of transport in cartilage. In this study, we use a carefully designed experimental-computational setup to separate the effects of mechanical and chemical factors from those of electrical charges. Axial diffusion of a neutral solute (Iodixanol) into cartilage was monitored using calibrated microcomputed tomography (micro-CT) images for up to 48 hr. A biphasic-solute computational model was fitted to the experimental data to determine the diffusion coefficients of cartilage. Cartilage was modeled either using one single diffusion coefficient (single-zone model) or using three diffusion coefficients corresponding to superficial, middle, and deep cartilage zones (multizone model). It was observed that the single-zone model cannot capture the entire concentration-time curve and under-predicts the near-equilibrium concentration values, whereas the multizone model could very well match the experimental data. The diffusion coefficient of the superficial zone was found to be at least one order of magnitude larger than that of the middle zone. Since neutral solutes were used, glycosaminoglycan (GAG) content cannot be the primary reason behind such large differences between the diffusion coefficients of the different cartilage zones. It is therefore concluded that other features of the different cartilage zones such as water content and the organization (orientation) of collagen fibers may be enough to cause large differences in diffusion coefficients through the cartilage thickness.

Full regeneration of segmental bone defects using porous titanium implants loaded with BMP-2 containing fibrin gels

Regeneration of load-bearing segmental bone defects is a major challenge in trauma and orthopaedic surgery. The ideal bone graft substitute is a biomaterial that provides immediate mechanical stability, while stimulating bone regeneration to completely bridge defects over a short period. Therefore, selective laser melted porous titanium, designed and fine-tuned to tolerate full load-bearing, was filled with a physiologically concentrated fibrin gel loaded with bone morphogenetic protein-2 (BMP-2). This biomaterial was used to graft critical-sized segmental femoral bone defects in rats. As a control, porous titanium implants were either left empty or filled with a fibrin gels without BMP-2. We evaluated bone regeneration, bone quality and mechanical strength of grafted femora using in vivo and ex vivo µCT scanning, histology, and torsion testing. This biomaterial completely regenerated and bridged the critical-sized bone defects within eight weeks. After twelve weeks, femora were anatomically re-shaped and revealed open medullary cavities. More importantly, new bone was formed throughout the entire porous titanium implants and grafted femora regained more than their innate mechanical stability: torsional strength exceeded twice their original strength. In conclusion, combining porous titanium implants with a physiologically concentrated fibrin gels loaded with BMP-2 improved bone regeneration in load-bearing segmental defects. This material combination now awaits its evaluation in larger animal models to show its suitability for grafting load-bearing defects in trauma and orthopaedic surgery.

Effects of anodizing parameters and heat treatment on nanotopographical features, bioactivity, and cell culture response of additively manufactured porous titanium

Anodizing could be used for bio-functionalization of the surfaces of titanium alloys. In this study, we use anodizing for creating nanotubes on the surface of porous titanium alloy bone substitutes manufactured using selective laser melting. Different sets of anodizing parameters (voltage: 10 or 20V anodizing time: 30min to 3h) are used for anodizing porous titanium structures that were later heat treated at 500°C. The nanotopographical features are examined using electron microscopy while the bioactivity of anodized surfaces is measured using immersion tests in the simulated body fluid (SBF). Moreover, the effects of anodizing and heat treatment on the performance of one representative anodized porous titanium structures are evaluated using in vitro cell culture assays using human periosteum-derived cells (hPDCs). It has been shown that while anodizing with different anodizing parameters results in very different nanotopographical features, i.e. nanotubes in the range of 20 to 55nm, anodized surfaces have limited apatite-forming ability regardless of the applied anodizing parameters. The results of in vitro cell culture show that both anodizing, and thus generation of regular nanotopographical feature, and heat treatment improve the cell culture response of porous titanium. In particular, cell proliferation measured using metabolic activity and DNA content was improved for anodized and heat treated as well as for anodized but not heat-treated specimens. Heat treatment additionally improved the cell attachment of porous titanium surfaces and upregulated expression of osteogenic markers. Anodized but not heat-treated specimens showed some limited signs of upregulated expression of osteogenic markers. In conclusion, while varying the anodizing parameters creates different nanotube structure, it does not improve apatite-forming ability of porous titanium. However, both anodizing and heat treatment at 500°C improve the cell culture response of porous titanium.

Mechanical factors explain development of cam-type deformity

OBJECTIVE

A cam-type deformity drastically increases the risk of hip osteoarthritis (OA). Since this type of skeletal anomaly is more prevalent among young active adults, it is hypothesized that the loading conditions experienced during certain types of vigorous physical activities stimulates formation of cam-type deformity. We further hypothesize that the growth plate shape modulates the influence of mechanical factors on the development of cam-type deformity.

DESIGN

We used finite element (FE) models of the proximal femur with an open growth plate to study whether mechanical factors could explain the development of cam-type deformity in adolescents. Four different loading conditions (representing different types of physical activities) and three different levels of growth plate extension towards the femoral neck were considered. Mechanical stimuli at the tissue level were calculated by means of the osteogenic index (OI) for all loading conditions and growth plate shape variations.

RESULTS

Loading conditions and growth plate shape influence the distribution of OI in hips with an open growth plate, thereby driving the development of cam-type deformity. In particular, specific types of loads experienced during physical activities and a larger growth plate extension towards the femoral neck increase the chance of cam-type deformity.

CONCLUSIONS

Specific loading patterns seem to stimulate the development of cam-type deformity by modifying the distribution of the mechanical stimulus. This is in line with recent clinical studies and reveals mechanobiological mechanisms that trigger the development of cam-type deformity. Avoiding these loading patterns during skeletal growth might be a potential preventative strategy for future hip OA.

Relationship between the shape and density distribution of the femur and its natural frequencies of vibration

It has been recently suggested that mechanical loads applied at frequencies close to the natural frequencies of bone could enhance bone apposition due to the resonance phenomenon. Other applications of bone modal analysis are also suggested. For the above-mentioned applications, it is important to understand how patient-specific bone shape and density distribution influence the natural frequencies of bones. We used finite element models to study the effects of bone shape and density distribution on the natural frequencies of the femur in free boundary conditions. A statistical shape and appearance model that describes shape and density distribution independently was created, based on a training set of 27 femora. The natural frequencies were then calculated for different shape modes varied around the mean shape while keeping the mean density distribution, for different appearance modes around the mean density distribution while keeping the mean bone shape, and for the 27 training femora. Single shape or appearance modes could cause up to 15% variations in the natural frequencies with certain modes having the greatest impact. For the actual femora, shape and density distribution changed the natural frequencies by up to 38%. First appearance mode that describes the general cortical bone thickness and trabecular bone density had one of the strongest impacts. The first appearance mode could therefore provide a sensitive measure of general bone health and disease progression. Since shape and density could cause large variations in the calculated natural frequencies, patient-specific FE models are needed for accurate estimation of bone natural frequencies.

Prediction of the elastic strain limit of tendons

The elastic strain limit (ESL) of tendons is the point where maximum elastic modulus is reached, after which micro-damage starts. Study of damage progression in tendons under repetitive (fatigue) loading requires a priori knowledge about ESL. In this study, we propose three different approaches for predicting ESL. First, one single value is assumed to represent the ESL of all tendon specimens. Second, different extrapolation curves are used for extrapolating the initial part of the stress-strain curve. Third, a method based on comparing the shape of the initial part of the stress-strain curve of specimens with a database of stress-strain curves is used. A large number of porcine tendon explants (97) were tested to examine the above-mentioned approaches. The variants of the third approach yielded significantly (p<0.05) smaller error values as compared to the other approaches. The mean absolute percentage error of the best-performing variant of the shape-based comparison was between 8.14±6.44% and 9.96±9.99% depending on the size of the initial part of the stress-strain curves. Interspecies generalizability of the best performing method was also studied by applying it for prediction of the ESL of horse tendons. The ESL of horse tendons was predicted with mean absolute percentage errors ranging between 10.53±7.6% and 19.16±14.31% depending on the size of the initial part of the stress-strain curves and the type of normalization. The results of this study suggest that both ESL and the shape of stress-strain curves may be highly different between different individuals and different anatomical locations.

Fatigue behavior of porous biomaterials manufactured using selective laser melting

Porous titanium alloys are considered promising bone-mimicking biomaterials. Additive manufacturing techniques such as selective laser melting allow for manufacturing of porous titanium structures with a precise design of micro-architecture. The mechanical properties of selective laser melted porous titanium alloys with different designs of micro-architecture have been already studied and are shown to be in the range of mechanical properties of bone. However, the fatigue behavior of this biomaterial is not yet well understood. We studied the fatigue behavior of porous structures made of Ti6Al4V ELI powder using selective laser melting. Four different porous structures were manufactured with porosities between 68 and 84% and the fatigue S-N curves of these four porous structures were determined. The three-stage mechanism of fatigue failure of these porous structures is described and studied in detail. It was found that the absolute S-N curves of these four porous structures are very different. In general, given the same absolute stress level, the fatigue life is much shorter for more porous structures. However, the normalized fatigue S-N curves of these four structures were found to be very similar. A power law was fitted to all data points of the normalized S-N curves. It is shown that the measured data points conform to the fitted power law very well, R(2)=0.94. This power law may therefore help in estimating the fatigue life of porous structures for which no fatigue test data is available. It is also observed that the normalized endurance limit of all tested porous structures (<0.2) is lower than that of corresponding solid material (c.a. 0.4).

Mass–spring–damper modelling of the human body to study running and hopping – an overview

Several mass–spring–damper models have been developed to study the response of the human body to the collision with the ground during hopping, trotting, or running. The mass, spring, and damper elements represent the masses, stiffness properties, and damping properties of hard and soft tissues. The masses that models are composed of are connected to each other via springs and dampers. The present paper reviews the various types of mass–spring–damper models including one-body and multi-body models. The models are further categorized as being either passive or active. In passive models, the mechanical properties (stiffness and damping) of soft tissues remain constant regardless of the type of footwear, ground stiffness, etc. In active models, the mechanical properties adapt to external loads. The governing equations of motion of all models as well as their parameters are presented. The specific ways that the models take account of the shoe–ground interactions are discussed as well. The methods used for determination of different modelling parameters are briefly surveyed. The advantages and disadvantages of the different types of mass–spring–damper models are also discussed. The paper concludes with a brief discussion of possible future research trends in the area of mass–spring–damper modelling.