Journal of Orthopaedic Translation (2016) 6, 42e49

Available online at www.sciencedirect.com

ScienceDirect

journalhomepage:http://ees.elsevier.com/jot

REVIEW ARTICLE

From the printer: Potential of

three-dimensional printing for
orthopaedic applications
a,b c a,b
Sze-Wing Mok , Razmara Nizak , Sai-Chuen Fu ,
a,b a,b c,d
Ki-Wai Kevin Ho , Ling Qin , Daniel B.F. Saris ,
a,b c,e,
Kai-Ming Chan , Jos Malda *

a Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong,
China
b Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
c Department of Orthopaedics, University Medical Centre Utrecht, Utrecht, The Netherlands
d MIRA Institute for Biomedical Technology and Technical Medicine, Department of Tissue
Regeneration, University of Twente, Enschede, The Netherlands
e Department of Equine Sciences, Utrecht University, Utrecht, The Netherlands

Received 27 January 2016; received in revised form 14 April 2016; accepted 18 April 2016
Available online 10 May 2016

KEYWORDS Summary Three-dimensional (3D) printers can create complex structures based on digital
3D printing; models. The combination of medical diagnostic imaging with 3D printing has great potential in
biofabrication; day-to-day clinics for patient-specific solutions and applications. In the musculoskeletal sys-
orthopaedics; tem, 3D printing is used to create custom-made implants, patient-specific instrumentation, and
regenerative to regenerate tissues, in particular bone and cartilage. The major limiting factors for bio-printing
medicine include the lack of printing techniques with optimal printing resolution and materials with ideal
mechanical strengths while maintaining cellular functionality. Before tissues from the printer
can be widely applied, further research and development on improving and opti-mising printing
techniques and biomaterials, and knowledge on the development of printed constructs into
living tissues, is essential for future clinical application of this technology.
2016 The Authors. Published by Elsevier (Singapore) Pte Ltd on behalf of Chinese Speaking
Orthopaedic Society. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author. Huispostnummer G05.228, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
E-mail address: J.Malda@umcutrecht.nl (J. Malda).

http://dx.doi.org/10.1016/j.jot.2016.04.003
2214-031X/ 2016 The Authors. Published by Elsevier (Singapore) Pte Ltd on behalf of Chinese Speaking Orthopaedic Society. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
3D printing for orthopaedic applications 43

Introduction

Over the past 30 years, there has been great advancement

in medical technologies. Three-dimensional (3D) printing, a
technique based on topography and photosculpture, was
originally developed in 1986 by Charles W. Hull to build
objects layer by layer based on digital drawings [1,2]. This
technique, also known as additive manufacturing, was
designed to shorten the design cycle of new products by
fabricating plastic prototypes (rapid prototyping). Different
kinds of materials, such as metals and ceramics, can be
used for the printing of 3D objects. By using digital blue-
prints and image data, 3D printing has been used in various
applications, such as manufacturing, the food industry,
education, and art. For example, using the front and side
view photographs of a person, customised prescription
glasses can be 3D printed to fit personal facial features [3].
In orthodontics, x-ray images and photographs of patients
teeth can be taken or scanned using a 3D scanner. These
digital images are used for treatment plans and printing
orthodontics braces to align teeth [4].
The ability to use medical image data for designing a
Figure 1 A schematic flow of creating three-dimensional (3D)
model has opened up new possibilities in the field of printed products.
medicine. Three-dimensional printing can be used for
patient-specific therapy, as it allows for the fabrication of
custom-made implants and medical devices. In parallel,
with the concept of personalised medicine, which refers to Imaging and data processing
patient-specific medication based on patients genetic
profile, 3D printing can be used for personalised treatment. Combining medical imaging and 3D printing opens up new
In the past few years, there has been an increase in the possibilities for patient-specific therapy, as it allows for the
number of publications describing the use of 3D printing customisation of prosthetics and implants and visual-isation
techniques in patient-specific treatments. Further research of complicated pathologies. The process of creating 3D
in tissue engineering and regenerative medicine focus on models from imaging data involves image acquisition, data
developing specific printers and materials to create 3D segmentation, and transformation into digital 3D models,
constructs with living cells, growth factors, and other followed by 3D printing and post processing [7]. The choice
biomaterials using 3D printing [5]. These constructs are of imaging technique is based on the intended application
envisioned to replace damaged or diseased tissues and and image resolution. The resolution of the resulting image
can also be used as a disease or toxicity model to study the is important, as images with poor resolu-tion will result in an
interaction between different cell types or for drug inaccurate and unfit model. In or-thopaedics, imaging
screening. This fabrication process, also known as bio- techniques such as x-ray imaging, computed tomography
fabrication, which involves the printing of living cells and (CT), and magnetic resonance im-aging (MRI) are
biomaterials, is defined as: the automated generation of commonly used. X-ray imaging and CT are often employed
biologically functional products with structural organisa-tion to diagnose bone fractures or muscle dis-orders, whereas
from living cells, bioactive molecules, biomaterials, cell MRI is used to detect soft tissue damage. Once the initial
aggregates such as microtissues, or hybrid cell-material imaging data has been acquired, further processing, which
constructs, through bioprinting or bioassembly and includes selecting and isolating the re-gion of interest using
subsequent tissue maturation processes [6]. It offers the open or proprietary software, and transforming segmented
possibility to build complex tissues by the deposition of data into volumetric data, will be carried out prior to printing.
various bio-inks, such that the form and content of a
construct can be tailored to the tissue to be repaired. In this
article, the current techniques and recent de-velopments of
3D printing, for orthopaedic applications in particular, is Printing techniques
presented.
In order to meet the intended applications of a scaffold or
implant, the architectural design of a construct at various
Current technologies levels, macro- (overall shape), micro- (tissue architecture)
and nano-scales (surface modification) is important [8]. The
The general workflow of creating a 3D printed product selection of a 3D printer depends highly on the materials of
consists of a number of subsequent steps: (1) imaging and interest and resolution of the products. Common printing
data processing; (2) selection of printing techniques; (3) techniques include fused deposition modelling (FDM), se-
selection of materials and bioactive components; and (4) lective laser sintering (SLS), and inkjet printing. FDM
printing/bioprinting of products (Figure 1). printers generally extrude materials that are heated at the
44 S.-W. Mok et al.

nozzle and harden gradually after extrusion. As the print temperature) to improve the porosity, mechanical strengths,
head moves, it builds objects in thin layers. This cycle of and biocompatibility of these constructs. Hydrogels, another
printing repeats until a solid 3D object forms. SLS uses a important class of biomaterials, are commonly used as cell
laser as an energy source and draws the shape of an object carriers in tissue engineering. Hydrogels are designed to
to sinter powdered material. A new layer of material ap-plies act as an artificial extracellular matrix and provide living
on top, and the process repeats until the part is completed. cells a 3D environment to grow. The combination of
Inkjet printing uses thermal, air pressure, electromagnetic, hydrogel with cells and/or growth factors functions as a bio-
or piezoelectric technology to dispense droplets of ink onto ink. The type of polymer, chemical composition, molecular
a substrate. By changing the applied temperature gradient, weight, and concentra-tion of hydrogel directly determines
pressure, pulse frequency, and ink viscosity, the droplet size the viscosity, speed of gelation, and mechanical strength of
can be modified for different applications. Based on the the scaffold.
versatility, precision and speed of the printers, and the The optimal printing fidelity (shape, complexity, and
availability of materials, these printing techniques have resolution of the construct) will be determined by the
been used to print objects for different applications. processing parameters, including the fabrication time and
nozzle gauge, which in turn, will affect the cell viability and
Materials function [5]. Therefore, materials should be carefully chosen
based on the intended application of the construct. Aspects,
such as the mechanical strength of the materials and
Each material for 3D printing has its specific mechanical
structural requirements of the constructs are essential, as
properties, processing methods, chemical properties, and
these vary among the diverse target tissues. The ulti-mate
cell-material interactions. Some of the commonly used
goal is to mimic the structure and mechanical prop-erties of
materials include metals, bioceramics, synthetic, and
the native/target tissue and develop the printed constructs
natural polymers (Figure 2). Metals and bioceramics are
into a functional tissue. However, the lack of printable and
mainly employed to create implants and for bone resto-
regulatory bodies approved materials, suit-able bio-inks,
ration. For implantation, titanium (Ti) and its alloys have
and lengthy production time limits the development of
been demonstrated to be biocompatible with good me-
bioprinting for clinical use. Therefore, the current
chanical properties [9]. Bioceramics, such as hydroxyapa-
development of materials for bioprinting aims to solve these
tite (HA), calcium phosphate, and bioglass, have been used
problems.
for bone regeneration, as they are osteogenic, porous,
maintain their shape, and promote cell proliferation on their
surfaces. However, these materials lack appropriate
mechanical strength for implantation in load-bearing sites Current applications in orthopaedics
[10,11]. Recently, scaffolds based on composite materials,
such as HA and tricalcium phosphate (TCP) [12e14], poly- Three-dimensional printing offers a range of possibilities for
caprolactone (PCL)-HA with carbon nanotubes [15], PCL- patient-specific therapy. In orthopaedics, 3D printing has
poly lactic-co-glycolic acid (PLGA) [16e19], and PLGA-TCP been applied in various aspects including designing and
[20e22] have been investigated as scaffold materials in printing customised equipment for surgery, printing im-
order to optimize the architecture, biocompatibility, and plants, and prostheses for support, and regenerating
sintering conditions (particle size and sintering musculoskeletal tissues including bone, cartilage, and soft
tissues such as tendon, ligament, and muscles.

Figure 2 Materials commonly used in three-dimensional (3D) printing and bioprinting.

3D printing for orthopaedic applications 45

Customised surgical assistive tools and implants reduced, and operations will be less dependent on the
experience of the physician.
Three-dimensional printing is a suitable technique to create In addition to surgical assistive tools, implants have also
patient-specific anatomical models, customised moulds, been printed for treating orthopaedic diseases. For
and surgical guides, as well as permanent implants. Some example, a 3D printed customised axial vertebral body has
of the many benefits of employing 3D printing are that it al- recently been implanted in the upper cervical spine of a
lows better surgical planning, creates customised patient- patient [25]. One case study has also employed 3D printing
specific implants, shortens surgical time, and hospital stay. to create a titanium calcaneal prosthesis for a patient who
It also reduces morbidity, yields better fitting of prosthesis, has chondrosarcoma in the heel [26]. These cases demon-
as well as better educates and enhances patients under- strate how 3D printed, patient-specific implants may bring
standing of surgical procedures. Many of the patient- individualised solutions to rare and complicated problems,
specific models, guides, and templates are routinely used where restoration of the specific anatomy of each patient
(Figure 3). For example, patient-specific 3D printed screw remains challenging.
guide template systems can benefit intraoperative pedicle
screw fixation, a standard procedure of spinal instrumen- Musculoskeletal tissues
tation, in the thoracic spine by improving the accuracy of
the surgical procedure, reducing the operating time and
Three-dimensional printing approaches that aim to solve
radiation exposure during the surgery [23]. Furthermore,
various musculoskeletal tissue diseases are currently under
patient-specific, disposable surgical saw guides/cutting-
development and are most frequently studied in vitro for
blocks can be printed for the use in total knee arthro-plasty.
bone and cartilage regeneration, and fewer for meniscus,
The use of imaging and planning software, the different cuts
tendon, ligament, and muscle regeneration. As 3D bio-
of the bone resections, and the size and position of the
printing has not reached the clinic yet, the following sec-
knee implant can be planned prior to sur-gery. Each patient- tions will describe and review the current trends in the
specific saw guide/cutting-block pro-vides guidance to application of 3D printing for musculoskeletal tissue
surgeons during surgery, and reduces the number of regeneration.
decisions he/she has to make during surgery. This can
minimize tissue loss and optimise the positioning of Bone regeneration
implants, and hence, lengthen the lifetime of the pros- Bone is a dynamic tissue, with the ability to self-regenerate
thetics [24]. With the use of patient-specific surgical as- and self-repair. However, cancer, trauma, infection, and
sistive tools, the risk of surgical errors and outliers can be congenital deformity can lead to massive bone defects or

Figure 3 (A) Patient-specific sawguides for total knee arthroplasty (Smith & Nephew, USA) and (B, C) custom-made titanium
acetabulum implant with screw planning (Materialise, Belgium).
46 S.-W. Mok et al.

loss that fails to heal. Transplantation of vascularised Cartilage regeneration

autologous bone grafts (autografts, allografts, and artificial Cartilage degeneration due to age or injuries is one of the
bone substitutes), which promotes bone healing through most common musculoskeletal problems. Articular carti-
osteogenesis, osteoinduction, and osteoconduction, have been lage, which lines all the articular joints in the body, pro-vides
used for this purpose [27]. However, some of the major a smooth, lubricated surface and mechanical support of
limitations of these grafts include donor site co-morbidity, joint movements [38]. The articular cartilage, a hyaline
rejection, poor graft incorporation, and trans-mission of disease cartilage, has a unique composition and is comprised of an
[28]. Therefore, tissue engineering, which uses scaffolds and extracellular matrix composed of water, collagen, pro-
combinations of cells, materials, and/or biologics to improve or teoglycans, noncollagenous proteins and glycoproteins, and
replace biological tissues, is an attractive strategy for bone highly specialized chondrocytes which contribute to four
regeneration. Some of the essential elements of an effective zones of cartilage, the superficial, middle, deep, and
bone scaffold include the use of biocompatible and bioactive calcified zone [38]. The articular cartilage is avascular, lacks
materials, and a porous 3D matrix that allows cell attachment, innervation and a lymphatic system, and is subjected to a
delivery of nutrients to cells and cell migration, and the ingrowth harsh biochemical environment in the intra-articular space.
of blood ves-sels. In addition, the scaffold must possess a With the absence of blood flow, the articular carti-lage has a
suitable me-chanical stability, flexibility and allow the transfer limited capacity for intrinsic healing and repair. Very often,
and diffusion of growth and differentiation factors [29]. For cell untreated cartilage injuries will progress to arthritis of the
viability and tissue maturation within a gel, covalent joint, which currently has no cure. Bio-printing can create
immobilisation of extracellular matrix (ECM) molecules or constructs, which mimics the archi-tecture of tissues to be
adhesive peptides can be used. For example, the presence of repaired, and provides a potential treatment modality for
a peptide such as arginineeglycineeaspartic acid significantly cartilage repair [39]. Besides, the size, depth, and strength
increases the amount of bone formation in an alginate scaffold. of the construct can be monitored closely. Before the
In addition, the delivery of multiple growth factors has also implantation of the tissue into the body, the bioprinted
been demonstrated to improve bone tissue formation in construct needs to grow in a controlled environment
alginate gels [30]. In addition, poly-ethlyene glycol (PEG) (bioreactor) into a functional tissue. The maturation will then
hydrogels have been used extensively as mechanically strong, take place in vivo and the construct/ tissue can integrate
cytocompatible matrices, which can maintain cell viability and into the host body/tissue. Another possibility would be to
promote ECM production [31e33]. Because 3D printing allows integrate the functions of the tissue directly into the printed
a precise control of the overall geometry and the internal construct. For example, one study has investigated the
porous structure of a scaffold, much of the current research on fabrication of cell-laden, heteroge-neous hydrogel
bone regenera-tive medicine utilises this versatile technique. constructs using 3D printing for the poten-tial use as
One recent publication studied the biocompatibility of 3D osteochondral grafts. Both osteogenic progenitors and
printed calcined boneebiphasic ceramic composite/PVA gel chondrocytes were encapsulated in different parts of the
both in vitro and in vivo. The scaffold showed good mechanical construct, and the study demon-strated that the anticipated
properties, and the rabbits bone marrow stromal cells grew, tissue type were formed [40]. A similar study attempted to
proliferated, and differentiated on the surface of the scaffold build osteochondral constructs using two different materials,
after adherence. In vivo experiments also demonstrated that PCL and alginate, and encapsulate with osteoblasts and
the bone scaffolds showed high biocompatibility [34]. One
chondrocytes. This study was able to create a dual cell-
study introduced osteoinductive compounds, silica (SiO2), and laden scaffold, with enhanced mechanical properties while
zinc oxide (ZnO), to b-TCP, a known osteoconductive material, maintaining the anatomical position and viability of cells
and were 3D printed to investigate their osteoinduction [41].
potential in vivo. The re-sults of this study showed that the The current development of bioprinting of cartilage tissue
combination of SiO2 and ZnO dopants in TCP maybe a viable constructs includes improving the mechanical strength of
alternative to introduce osteoinductive properties to calcium hydrogels by coupling with synthetic polymers, creating
phosphates (CaPs) [35]. Other novel approaches in bioprinting zone specific cartilage constructs and creating
combined human mesenchymal stem cells (hMSCs) and osteochondral plugs that include both the cartilage and
poly(ethylene) glycol dimethacrylate (PEGDMA) with bioactive bone compartments [42]. For example, PCL fibres and
glass and/or HA to form the homogeneous bone constructs in a chondrocytes suspended in a fibrinecollagen hydrogel have
layer-by-layer approach. Significantly higher total collagen been printed to create a cartilage construct. The study
produc-tion and alkaline phosphatase (ALP) activity in hMSCs demonstrated that the constructs formed cartilage-like
were observed within the printed scaffold. This higher collagen tissues both in vitro and in vivo, and with enhanced me-
production was also observed in previous studies, and the chanical properties [43]. To create zone specific cartilage,
presence of HA increased the ALP activity in hMSCs and multilayered constructs composed of various combinations
promoted osteogenesis [36,37]. Future research directions of polymers, including PEG, hyaluronic acid, chondroitin
include exploring and expanding the current group of bio- sulphate, and metalloprotease sensitive peptides were used
materials for bone regeneration, as well as studying the stability to encapsulate a single lineage of mesenchymal stem cells.
of the individually designed blocks, potentially with incorporated The study was able to create a single construct, which
prevascular networks for larger bone replacement without an comprised of all three zones of articular cartilage from one
external matrix for support. single stem cell lineage [44].
One of the obstacles of using the current biomaterials for
cartilage repair is that there is limited cell-material
interactions and often forms inferior tissues [45]. Besides,
3D printing for orthopaedic applications 47

the available synthetic or natural biomaterials are unable to skeletal muscle cells were seeded onto a scaffold, which
mimic the complexity of natural extracellular matrix and its was created by electrospinning. The results showed that the
intrinsic functions. Recently, decellularised ECM (dECM) orientation of the nanofibres can significantly affect the
has been printed to provide microenvironments that induce induction of muscle cell alignment and myotube formation,
the growth of cartilage tissue. This study demonstrated that and that the aligned composite nanofibre is promising for
dECM provides crucial signals for cells engraftment, future functional muscle tissue implantation [50]. Taking this
survival and its long-term function [45]. Therefore, in order one step further, researchers have also begun to investigate
to create constructs for optimal cartilage regeneration, the fabricating tissues as a functional, composite unit, for
mechanical strength, cell survival, and functionality are example a muscle-tendon unit and ligament-bone unit. One
equally important. study has specifically attempted to create a region-specific
scaffold, using two synthetic polymeric materials and two
Meniscus regeneration cell-laden hydrogel based bioinks, to mimic the mechanical
Meniscus in the knee is a fibrocartilaginous tissue, which and biological properties of muscles and tendons [51]. In
acts as a shock absorber to protect the articular cartilage addition, an in vivo study employed 3D printing to create a
during knee movements and stabilize the knee. Similar to ligament-bone composite scaffold with an aim to aid
articular cartilage, the meniscus has a heterogeneous ligament reconstruction surgeries. The ceramic bone
composition of connective tissue cells including the scaffold was created using 3D printed resin moulds, and the
fibroblast-like cells, fibrochondrocytes and chondrocyte-like ligament scaffold was created by weaving degummed silk
cells, and components such as collagen type I, II, and fibres. The study demonstrated that there was a significant
glycosaminoglycans [46]. The meniscus also has minimal difference in mechanical strengths, new bone formation in
blood flow; the central region is avascular and therefore, the bone scaffolds, as well as a gradual structural transition
fails to heal. The current surgical treatments for meniscal between the scaffolds and host bones. This signified that
injuries include total and partial meniscectomy, meniscal the ligament-bone composite scaffolds was able to facilitate
repair, and meniscal transplantation. Meniscus allografts the regeneration of tissues at the ligamentebone interface
have been demonstrated to provide short-term benefits in [52].
young patients, however, the durability and ability to reduce
the risk of progression of osteoarthritis of these allograft is
still unknown. Challenges and future directions in bioprinting
Tissue-engineering approaches have been investigated
for meniscus regeneration. Previous work on meniscus With the ability to further mimic the cellular and extracel-
regeneration aimed to mimic the structure, mechanical lular structure and components of a tissues and organs, 3D
properties, and improve the integration of meniscal scaf- printing possesses significant potential in regenerative
folds using various combinations of biomaterials and cells. medicine. However, there are challenges and limitations in
For example, scaffolds, made of polyurethane, showed every step of creating a biological construct, from printing
optimal mechanical properties with interconnective macro- techniques to materials and cell sources. Although
porosity to facilitate cell ingrowth and differentiation [47]. significant steps have been taken, further optimisation of
One study utilized a 3D printing technique, projection bioinks, fabrication time, and biological performance would
stereolithography, to simulate the structural architecture of be necessary in order to bring 3D bioprinting to the clinic.
meniscus, and the scaffold was seeded with human cells There is currently a limited range of biomaterials available
from the meniscus. This study demonstrated that cells were for bioprinting, as most publications are using very similar
able to grow with an organised cellular alignment and ma-terials [5]. Therefore, there is a need to investigate and
promote meniscus-like tissue formation [48]. In addition, develop a diverse selection of materials that are biocom-
one recent study was able to mimic the zone-specific ma- patible, mechanically supportive and can maintain cell
trix phenotypes of meniscus in 3D printed scaffolds incor- viability and functions for 3D (bio)printing. In addition,
porated with spatiotemporally delivered human connective similar to any organ or tissue transplantation, there is
tissue growth factor and transforming growth factoreb3. always a chance of rejection of bioprinted constructs by the
These implants were placed in sheep, and the regenerated host immune system. Autologous and allogenic (stem) cells
meniscus demonstrated the ability to restore the mechan- and induced pluripotent stem cells are alternative cell
ical integrity of the meniscus [49]. sources; however, research on their safety will need to be
further verified. Furthermore, the maturation of cells,
Tendon, ligament, and muscle regeneration vasculature and innervation are common challenges for the
In addition to bone, cartilage, and meniscus, the muscu- bioprinting of larger tissue constructs. Vascularisation is
loskeletal system is also made up of muscles and connective essential for the long-term viability of cells. A recent review
tissues including tendon and ligament, which are structur-ally has suggested using a bioreactor for vascularisation, as it
optimised to generate and transfer force, and facilitate can maintain the viability of a tissue construct while allowing
movements. Similar to bone and cartilage, tissue engi-neering further pro-cessing. For example, using bioreactor
using 3D printing techniques have been employed to mimic processing in combi-nation with factors that promote
and create functional muscles, tendons, and lig-aments. Large angiogenesis and innervation can maintain cell viability [53].
skeletal muscle tissue defects can be due to trauma, tumours, Three-dimensional printed constructs, such as other
and congenital conditions. The current treatment options are medical devices, are subjected to regulatory approval prior
limited by the availability of host tissues, as well as donor site to commercialisation. Currently, 3D printed devices are
morbidity. In one study, human subjected to the same regulations listed in Section 510(k) of
48 S.-W. Mok et al.

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improving surgical precision, for example, a 3D printed titanium and medical imaging: a review of the methods and applica-
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enhanced by coating scaffolds with either dipyridamole or
3D printed tissue, the organisation of the printed construct, BMP-2. J Biomed Mater Res B Appl Biomater 2015. http:
the environment for the optimal tissue matura-tion, and the //dx.doi.org/10.1002/jbm.b.33561.
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Conflicts of interest MH, Amaral M, et al. Three-dimensional printed PCL-
hydroxyapa-tite scaffolds filled with CNTs for bone cell growth
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The authors have no conflicts of interest relevant to this
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Foundation Limited (Hong Kong, China) and the Dutch Performance of different three-dimensional scaffolds for in
Arthritis Foundation (LLP-12; Amsterdam, The Netherlands) vivo endochondral bone generation. Eur Cell Mater 2014;27:
for funding. 350e64.
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