Synthetic hydrogel composite

Abstract

Cellulose-reinforced hydrogels may include a cellulose nanofiber network and an interstitial hydrogel portion within interstitial regions of the cellulose nanofiber network, the interstitial hydrogel portion comprising polyvinyl alcohol (PVA), wherein the hydrogel component has a crystallinity of 20% or greater.

Claims

1. A method of forming an implant having a cellulose-reinforced hydrogel, comprising: attaching a cross-linked cellulose nanofiber network to a top bearing surface of the implant; infiltrating a hydrogel component within interstitial regions of the cross-linked cellulose nanofiber network to form the cellulose-reinforced hydrogel; and annealing the cellulose-reinforced hydrogel so that a crystalline content of the hydrogel component has a crystallinity of 20% or greater, wherein the cellulose-reinforced hydrogel comprises at least 20% by weight of water, wherein the cellulose-reinforced hydrogel has a tensile strength exceeding 40 MPa.

2. The method of claim 1, wherein the hydrogel component comprises polyvinyl alcohol (PVA).

3. The method of claim 1, wherein annealing the cellulose-reinforced hydrogel comprises heating the cellulose-reinforced hydrogel.

4. The method of claim 3, wherein the cellulose-reinforced hydrogel is heated to a temperature ranging from 90-140° C.

5. The method of claim 1, wherein annealing the cellulose-reinforced hydrogel comprises heating the cellulose-reinforced hydrogel to decrease a water content of the cellulose-reinforced hydrogel.

6. The method of claim 1, wherein annealing the cellulose-reinforced hydrogel comprises rehydrating the cellulose-reinforced hydrogel.

7. The method of claim 1, further comprising removing an excess of the hydrogel component from a surface of the cross-linked cellulose nanofiber network.

8. The method of claim 7, wherein the excess of the hydrogel component is removed by hand or by molding the cellulose-reinforced hydrogel.

9. The method of claim 1, wherein the cross-linked cellulose nanofiber network comprises bacterial cellulose (BC).

10. The method of claim 1, wherein attaching the cross-linked cellulose nanofiber network to the top bearing surface comprises clamping the cross-linked cellulose nanofiber around a periphery of the top bearing surface.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) A better understanding of the features and advantages of the methods and apparatuses described herein will be obtained by reference to the following detailed description that sets forth illustrative embodiments, and the accompanying drawings.

(2) FIG. 1A is an illustration of an exemplary process for attachment of a hydrogel to a porous base by a Nanofiber-Enhanced STicking (NEST) method. In this example, a nanofibrous sheet (e.g., bacterial cellulose) is attached to a surface (e.g., a porous base such as porous titanium) with an adhesive (e.g. α-TCP cement), after which the hydrogel components are infiltrated into the nanofibrous sheet.

(3) FIG. 1B shows an example of a hydrogel bonded to a titanium plug.

(4) FIG. 1C shows an SEM image of a surface of an exemplary freeze-dried bacterial cellulose sheet.

(5) FIGS. 2A-2D show various hydrogel samples before and after annealing and rehydration to illustrate the effects on the morphology of different hydrogel compositions.

(6) FIGS. 3A-3E are graphs illustrating effects of annealing on the mechanical properties of various hydrogel compositions: FIG. 3A illustrates a tensile stress-strain curve for PVA hydrogels annealed at different temperatures; FIG. 3B illustrates a compressive stress-strain curve for PVA hydrogels annealed at different temperatures; FIG. 3C illustrates tensile strength and moduli of PVA annealed at different temperatures; FIG. 3D illustrates compressive stress at 0.8 strain and moduli of PVA annealed at different temperatures; and FIG. 3E illustrates crystallinity and solid content weight fraction of PVA annealed at different temperatures.

(7) FIGS. 4A-4E are graphs illustrating effects of annealing on the mechanical properties of BC-PVA hydrogel. FIG. 4A illustrates a tensile stress-strain curve for BC-PVA hydrogels annealed at different temperatures; FIG. 4B illustrates a compressive stress-strain curve for BC-PVA hydrogels annealed at different temperatures; FIG. 4C illustrates tensile strength and moduli of BC-PVA annealed at different temperatures; FIG. 4D illustrates compressive stress at 0.8 strain and moduli of BC-PVA annealed at different temperatures; and FIG. 4E illustrates crystallinity and solid content weight fraction of BC-PVA annealed at different temperatures.

(8) FIGS. 5A and 5B are graphs illustrating effects of PAMPS on an annealed BC-PVA hydrogel: FIG. 5A illustrates tensile strength, tensile moduli and solid content weight fraction of BC-PVA-PAMPS hydrogels that were made with solutions containing different concentrations of the AMPS monomer, where BC-PVA samples were annealed before infiltration of AMPS; and FIG. 5B illustrates compressive strength and moduli of BC-PVA-PAMPS hydrogels.

(9) FIGS. 6A-6D illustrate various aspects of measuring wear and coefficient of friction (COF) of various hydrogel compositions and comparing such measurements against cartilage: FIG. 6A illustrates a schematic for how the wear and COF of hydrogels versus cartilage was measured; FIG. 6B illustrates Micro-CT cross-section images of the cartilage and hydrogel samples; FIG. 6C illustrates the wear depth of cartilage and hydrogel samples after 106 cycles under 1 MPa of pressure, a spin rate of 100 mm/s, and with FBS as the lubricant; and FIG. 6D illustrates the COF between cartilage and the hydrogels during the tests over 24 hours.

(10) FIGS. 7A-7C illustrate various aspects of measuring wear of various hydrogel compositions and comparing such measurements against cartilage: FIG. 7A illustrates a schematic for how the wear of cartilage versus hydrogels was measured; FIG. 7B illustrate Micro-CT cross-section images; and FIG. 7C illustrates the wear depth of cartilage and hydrogel samples after 106 cycles under 1 MPa of pressure, a spin rate of 100 mm/s, and with FBS as the lubricant.

(11) FIGS. 8A-8D illustrate various aspects of shear strength testing of various hydrogel composition and cartilage: FIG. 8A illustrates results for shear testing of pig cartilage and hydrogels secured to metal pins with adhesive and shape memory alloy clamps; FIG. 8B illustrates an image of an osteochondral plug extracted from a pig knee after testing to failure;

(12) FIG. 8C illustrates an image of a BC-PVA-PAMPS hydrogel (fabricated with a freeze-thaw process) after testing to failure; and FIG. 8D illustrates an image of a BC-PVA hydrogel (fabricated by annealing at 90° C. and rehydrated) after testing to failure.

(13) FIGS. 9A-9F show front and side views of an annealed BC-PVA hydrogel incorporated in an implant for partial knee resurfacing before and after undergoing mechanical stress.

(14) FIGS. 10A and 10B schematically illustrate examples of implants including a hydrogel attached (e.g., forming the surface) as described herein.

(15) FIG. 11 illustrates an exemplary method of forming and attaching a hydrogel surface.

(16) FIG. 12A is an image illustrating one example of a method of attaching a hydrogel to a metallic plug, including using a clamp (e.g., a shape memory alloy clamp).

(17) FIGS. 12B and 12C illustrate examples of a fixture that may be used for aligning forming the materials described herein (e.g., aligning the BC, including a rod, cut BC, and ring clamp) as described herein: FIG. 12B shows a perspective view of the fixture; and FIG. 12C shows a sectional view through the fixture.

(18) FIG. 12D is an image showing an exemplary sheet of bacterial cellulose (BC) cut (e.g., with legs or crenellations) for wrapping over the edge of a bearing surface (e.g., metal rod, head, etc.).

(19) FIG. 12E is diagram denoting the diameter D, length L, and width W dimensions of one example of a sheet.

(20) FIG. 13 is an example of one test fixture that may be used to test searing of cartilage off of bone and/or a hydrogel material off of a test rod.

(21) FIG. 14A shows an example of a process for attaching the BC-PVA-PAMPS hydrogel to a titanium implant for treatment of osteochondral defects. FIGS. 14B and 14C show repair of an implant.

(22) FIGS. 15A-15D show hydrogel samples before and after annealing and rehydration. All samples were annealed at 90° C. for 25 hours and rehydrated in PBS solution for 24 hours at 23° C. (A) A sample of BC without PVA. (B) A sample of BC that was annealed in a solution of 10 wt. % PVA. (C) A sample of 40 wt. % PVA. (D) A BC sample that was infiltrated with 40 wt. % PVA in a hydrothermal bomb for 24 hours at 120° C. before annealing and rehydration.

(23) FIG. 16A shows an FTIR spectra of BC-PVA, annealed BC-PVA and annealed PVA hydrogels. FIG. 16B shows a zoomed-in region highlighting the shift of the hydroxyl peak. FIG. 16A shows an increase in hydrogen bonding that occurs upon annealing.

(24) FIGS. 17A-17C show DSC thermograms for (A) freeze-thawed and annealed PVA hydrogels, (B) freeze-thawed and annealed BC-PVA hydrogels, and (C) annealed BC-PVA and annealed BC-PVA-PAMPS. The concentration of the AMPS solution used to make the BC-PVA-PAMPS was 10 wt. %.

(25) FIG. 18 show a DSC thermogram for an annealed BC-PVA hydrogel sample demonstrating how the peak was integrated.

DETAILED DESCRIPTION

(26) Described herein are hydrogel compositions for the long-term repair of cartilage. The hydrogels have a crystalline structure that impart tensile and compressive strengths to the hydrogels that equal or exceed that of cartilage. The hydrogels may be incorporated in a nanofiber network (e.g., cellulose) to increase wear properties and/or to facilitate attachment to an implant body. The hydrogels are found to withstand the high compressive and shear stresses associated movement of the knee joint, and are thus well-suited for implementation on knee implants. The hydrogels may be characterized by one or more attributes and properties, such as crystalline structure, tensile strength, compressive strength, water content, coefficient of friction (COF), and/or other attributes and properties.

(27) The methods of forming hydrogel implants described herein can be used to create hydrogel-coated orthopedic implants with surfaces that mimic or improve on the mechanical and/or tribological properties of cartilage. Previously methods of forming implants with hydrogels comprising a bacterial cellulose (BC) network infused with polyvinyl alcohol (PVA) and poly(2-acrylamido-2-methyl-1-propanesulfonic acid sodium salt (PAMPS), referred to as BC-PVA-PAMPS hydrogels, are described in International Patent Application No. PCT/US2021/040031, which is incorporated herein by reference in its entirety. In preparing the BC-PVA-PAMPS hydrogel, a freeze-thaw method is used to gel a PVA-water mixture after infiltration into the BC. This freeze-thaw gelation step was used to increase the strength of the PVA hydrogel, and to prevent dissolution of the PVA in a following PAMPS infiltration step. The increase in strength upon freezing and thawing the PVA is attributed to crystallization of the PVA chains and phase segregation.

(28) Methods described herein improve upon these previous methods by enhancing the mechanical properties of the reinforced hydrogels, thereby improving performance of the implant, even when subjected to high impact and shear forces. For example, the tensile and compressive strength of the reinforced hydrogel may be increased up to and beyond that of cartilage. The methods involve a mechanical strengthening process that increases the crystallinity and decreases the water content of PVA relative to the freeze-thaw process. The mechanical strengthening process may include drying, annealing, and/or rehydrating of the hydrogel. When implemented on a hydrogel, the crystalline structure within the hydrogel may be increased despite being interdigitated within the fibrous network. In addition, the hydrogel may be substantially bubble-free and crack-free after undergoing the crystal restructuring process.

(29) FIGS. 1A-1C illustrate an example of an apparatus in which a hydrogel has been bonded to an implant surface as described herein. The hydrogel may be coupled to the implant surface by first attaching a layer of nanofibrous material, such as cellulous (e.g., bacterial cellulous) to an implant base using an adhesive (e.g., cement). The nanofibrous material may be dry (e.g., before attaching to the implant base). The attaching surface of the implant base may be porous, for example, to enhance adhesion. The nanofibrous layer may then be infiltrated with a hydrogel component. In this way, the nanofibrous portion may be secured with an adhesive (e.g., cement) that can penetrate and secure the porous bacterial cellulose network to the surface and may create an interdigitating bond without the interference of water. Once the hydrogel component is infiltrated within the nanofibrous network, the reinforced hydrogel may be processed (e.g., annealed) to change the crystalline structure of the hydrogel component, thereby enhancing mechanical properties of the reinforced hydrogel.

(30) For example, in FIG. 1A, the nanofibrous portion is bacterial cellulose (BC) 101 that is applied to the prepared surface of the implant (shown in this example as a titanium base, having pores) 103. A cement (e.g., any appropriate medical or dental grade cement may be used) is applied, and secures the dry bacterial cellulose to the implant surface. Thereafter the hydrogel component may be infiltrated into the nanofibrous portion, resulting in the complete hydrogel 107 attached to the base 103 via the bacterial cellulose 101. The reinforced hydrogel 107 then undergoes a crystal restructuring process to enhance its mechanical properties.

(31) FIG. 1B shows an example of a titanium implant (e.g., plug) to which a cellulous-reinforced hydrogel has been attached, as described herein. In this example, the nanofibrous portion (e.g., BC) of the hydrogel is bonded via an adhesive to the porous surface of the implant, and the hydrogel is linked to the nanofibrous portion. Any appropriate adhesive (e.g., cement) may be used to adhere the nanofibrous portion of the hydrogel to the surface of the implant. In some variation the cement is α-tricalcium phosphate (α-TCP), a hydroxyapatite-forming cement that may be used for attachment of the hydrogel due to its biocompatibility, osteoconductivity, and shear strength, which may exceed that of cyanoacrylate. In some cases, α-TCP is combined with phosphoserine (PPS) to promote adhesion. In some cases, the hydroxyapatite is reinforced with stainless-steel powder (SSP) (e.g., with an average particle size of 150 μm) to hinder crack propagation. As will be described in greater detail below, in some examples an adhesive is not used, and the nanofibrous portion is secured to the bearing surface by a mechanical means (such as a clamp).

(32) As described herein, the nanofibrous portion (e.g., BC) may be treated to dried (e.g., freeze-dried) to increase adhesion to the nanofibers. FIG. 1C is a scanning electron microscope (SEM) image of the surface of an exemplary freeze-dried piece of BC, which shows that it consists of many nanoscale fibers that present a large surface area for attachment with an adhesive. In some examples, multiple freeze-thaw cycles are performed, which may increase tensile strength (once the hydrogel is infused therein) and/or increase the shear strength of the adhesion of the reinforced hydrogel to the implant base.

(33) As mentioned above, a previous approach to creating a cartilage-equivalent hydrogel involves infiltrating a bacterial cellulose (BC) nanofiber network with polyvinyl alcohol (PVA) and poly(2-acrylamido-2-methyl-1-propanesulfonic acid sodium salt) (PAMPS). This hydrogel exhibited a tensile strength of 22.6 MPa and a compression strength of 20 MPa. In comparison, the range of tensile and compression strengths reported for human cartilage are 8.1-40 MPa and 14-59 MPa, respectively. Thus, there is room to improve the strength of hydrogels to be at the higher end of the range of strengths reported for cartilage, or to exceed cartilage in strength, while having a similar modulus, coefficient of friction, and resistance to wear as cartilage. Given the higher tensile strength of annealed PVA relative to freeze-thawed PVA, tests were performed to determine whether changing from a freeze-thaw to annealing process can improve the mechanical strength of a BC-PVA-PAMPS hydrogel while retaining adequate control over the hydrogel shape and defect content. Given the tensile strength of a BC-PVA-PAMPS hydrogel (22.6 MPa), is already similar to the tensile strength of a PVA hydrogel made by annealing (20 MPa), it was not obvious that switching to the annealing process for a BC-reinforced hydrogel would yield further improvements in the mechanical strength. In addition, the presence of BC or PAMPS could potentially interfere with the crystallization of PVA that occurs during the annealing process, thereby hindering the improvement in mechanical strength that occurs as a result of crystallization. It was also not clear whether it would be possible to obtain high-quality, bubble-free, crack-free samples after annealing PVA reinforced with BC. Obtaining samples that are as free of defects as possible may be necessary to maximizing the mechanical strength of the hydrogel. Finally, it was unclear whether the lower water content of the annealed hydrogel might cause the COF and opposing surface wear to be too high.

(34) As demonstrated herein, reinforcement of annealed PVA with BC leads to a 3.2-fold improvement in the tensile strength (from 15.6 to 50.5 MPa) and a 1.7-fold increase in the compressive strength (from 56.7 to 95.4 MPa). The highly crystallized BC-PVA hydrogel that results from annealing is the first hydrogel with a tensile and compressive strength that exceeds that of cartilage. Reinforcement of the PVA with BC may essentially eliminate the deformation and bubbles that would otherwise occur during annealing. When tested against cartilage, annealed BC-PVA wore an opposing cartilage surface to the same extent as cartilage and was three times more resistant to wear than cartilage. The COF of BC-PVA against cartilage was equivalent to that of cartilage against cartilage. In contrast to results with freeze-thawed BC-PVA, addition of PAMPS to the annealed BC-PVA decreased the tensile strength of the hydrogel due to a loss of crystallized PVA and an increase in water content. The improved tensile strength of annealed BC-PVA enabled it to attach to a metal base with a shear strength 68% greater than the shear strength of cartilage on bone. The high strength, high wear resistance, and low COF of annealed BC-PVA make it an excellent material for replacing damaged cartilage.

(35) The tests and measurements performed and described herein on various hydrogel compositions demonstrate how certain hydrogel compositions that undergo one or more strengthening processes, such as an annealing process, may increase the strength of a hydrogel to the upper limits or exceeding that of cartilage while attaining other characteristics (e.g., coefficient of friction) similar to that of cartilage.

(36) One potential disadvantage of annealing a hydrogel is that the hydrogel may develop bubbles and cracks, especially as the sample thickness increases or water content increases. FIGS. 2A-2D show various hydrogel samples before and after annealing and rehydration to illustrate the effects on the morphology of different hydrogel compositions. In particular, these samples illustrate the effect of the hydrogel composition on the shape of the sample after drying, annealing and rehydration. All samples were annealed at 90° C. for 25 hours and rehydrated in phosphate-buffered saline (PBS) solution for 24 hours at 23° C. FIG. 2A shows a sample of BC (without PVA), demonstrating how the BC sample became wrinkled and folded at the edges after annealing and rehydration. FIG. 2B shows a sample of BC that was annealed in a solution of 10 wt % PVA. As shown, the BC annealed in 10 wt % PVA solution also demonstrating substantial deformation. A PVA layer formed on top of the BC after annealing contains a large number of bubbles and easily delaminates from the BC film. The bubbles may be the result of the evaporation of water. FIG. 2D shows a sample 40 wt % PVA before and after annealing, demonstrating that such hydrogel also formed a large number of bubbles and deformed during the annealing process.

(37) FIG. 2E shows a BC sample that was infiltrated with 40 wt % PVA in a hydrothermal bomb for 24 hours at 120° C. before annealing and rehydration. As shown, reinforcement of 40 wt % PVA with BC allowed the hydrogel to retain its shape with little to no deformation after annealing. This lack of deformation may be attributed to the higher solid content and tensile modulus of the BC-reinforced PVA. That is, the nanoscale network of the BC layer appears to suppress the formation of the large bubbles that are visible in the 40 wt % PVA sample (FIG. 2C). A comparison of FIG. 2B to FIG. 2D indicates that the approach of infiltrating a high concentration of PVA into BC in a hydrothermal bomb, followed by removal of excess PVA from the BC surface, results in a more uniform hydrogel than if a BC sample is placed in a more dilute PVA solution that is concentrated via drying. These results demonstrate that, unlike BC alone, PVA alone, or the combination of BC with a 10 wt % of PVA, the BC infiltrated with 40 wt % PVA could retain its shape and remain relatively free of bubbles and other defects after annealing.

(38) FIGS. 3A-3E illustrate the effects of annealing on the mechanical properties of various hydrogel compositions, where the effects of annealing on a PVA hydrogel were analyzed as a reference point. The PVA was fully hydrolyzed with a molecular weight of 145,000 g mol-1. A 40 wt. % PVA solution was dried at 90° C. for 24 hours, annealed at 90° C., 120° C. or 140° C., and then placed in a 0.15 M PBS solution for 24 hours for rehydration. PVA samples that underwent a freeze-thaw cycle were tested for comparison. FIGS. 3A and 3B show that annealing the hydrogel dramatically increased the tensile and compressive strength relative to samples that had undergone a freeze-thaw cycle. FIGS. 3C and 3D show that, relative to the freeze-thaw process, annealing increased the tensile strength by 60 times (from 0.26 to 15.6 MPa) and the compressive strength by 9 times (from 14.8 to 140.8 MPa). Increasing the annealing temperature from 90° C. to 140° C. led to an increase in the tensile strength and modulus. The increase in strength and modulus has been ascribed to the increase in the crystallinity and solid content of the hydrogel after annealing. FIG. 2E confirms that the crystallinity and solid content of the annealed PVA hydrogels are much greater than that of a freeze-thawed PVA hydrogel. For example, a PVA hydrogel made via the freeze-thaw process has an overall solid content of 0.09 and a PVA crystallinity of 0.21, whereas a PVA hydrogel made via annealing at 90° C. has an overall solid content of 0.42 and a PVA crystallinity of 0.58. The crystallites formed during annealing strengthens the otherwise amorphous PVA by acting as tough cross-links that redistribute applied stresses and hinder crack propagation. The crystallites also increase the solid content and strength of the hydrogel by reducing the amount of water taken up by the PVA when it is soaked in 0.15 M PBS after annealing.

(39) FIGS. 4A-4E illustrate the effect of annealing on a BC-PVA hydrogel. The same annealing process to PVA hydrogel described above with reference to FIGS. 3A-3E was applied to BC-PVA hydrogels. As with the PVA hydrogels, the BC-PVA hydrogels were dried at 90° C. for 24 hours, annealed at 90° C., 120° C. or 140° C., and then placed in a 0.15 M PBS solution for 24 hours for rehydration. FIGS. 4A and 4C show the tensile strength of the annealed BC-PVA hydrogels reached 50.4 MPa, an increase of 4.6 times relative to the BC-PVA that went through a freeze-thaw cycle, and an increase of 3.2 times relative to annealed PVA that was not reinforced with BC. FIGS. 4B and 4D show the compressive strength increased from 55.32 MPa to 95.35 MPa after annealing. Similar to the PVA hydrogel, this dramatic increase in strength can be attributed to the increase in crystallinity and solid content after annealing. FIG. 3E shows the crystallinity of the BC-PVA hydrogel increased from 0.07 after a freeze-thaw cycle to 0.4 after annealing. The solid weight fraction of the BC-PVA hydrogel increased from 0.11 after a freeze-thaw cycle to 0.53 after annealing. These results shows that PVA can still form crystallites within the nanofibrous BC network, and that these crystallites increase the solid content and strength of the hydrogel.

(40) FIGS. 5A and 5B illustrate the effect of PAMPS on an annealed BC-PVA hydrogel. As mentioned above, it was previously found that the incorporation of PAMPS into a BC-PVA hydrogel made with a freeze-thaw cycle resulted in an increase in the tensile and compressive strength of the hydrogel. Thus, PAMPS was incorporated into an annealed BC-PVA hydrogel to determine the effect of the addition of PAMPS. As shown in FIG. 5A, the addition of PAMPS into the annealed BC-PVA hydrogel led to a decrease in the solid content relative to BC-PVA alone, from 0.53 to 0.37. Differential scanning calorimetry (DSC) thermograms show that after the addition of 10 wt % PAMPS, the peak from melting crystalline PVA disappeared, indicating the addition of PAMPS destroys the PVA crystallites that form during the annealing process. The decrease in solid content and loss of crystallinity upon addition of PAMPS led to a decrease in the tensile strength (from 48.9 MPa to 20.8 MPa), tensile modulus (from 444.8 MPa to 150.5 MPa) and compressive strength (from 98.1 MPa to 56.0 MPa in FIG. 5B) of the hydrogel. The increase in water content of the hydrogel and loss of strength was likely due to the fact that PAMPS is a negatively charged polymer, and this negative charge results in an osmotic pressure that swells the hydrogel with water.

(41) FIGS. 6A-6D illustrate various aspects of measuring wear and coefficient of friction (COF) of various hydrogel compositions and comparing such measurements against cartilage. FIG. 6A is a schematic illustration of an example of how a wear test is performed. A pin-on-disc configuration described in Example 11 below for testing the wear of hydrogels in fetal bovine serum (FBS) was used. A porcine cartilage plug was rotated against the hydrogel surface 106 times under 1 MPa of pressure and at a speed of 319 rotations per minute (maximum linear velocity was 100 mm s.sup.−1). The wear resistance of a potential replacement for cartilage exceeds that of cartilage to ensure durability and minimize the generation of wear debris that could potentially cause an adverse biological reaction. The wear resistance of a BC-PVA-PAMPS hydrogel was previously shown to be equivalent to that of cartilage and to be superior to PVA or PVA-PAMPS when tested against a stainless-steel pin. These hydrogels were made by applying a freeze-thaw cycle to crystallize the PVA. FIGS. 6B-6D compare the wear resistance of PVA-based hydrogels (PVA, BC-PVA, and BC-PVA-PAMPS) that have been dried and annealed at 90° C. to that of porcine cartilage when tested against a porcine cartilage plug in FBS.

(42) FIG. 6B shows cross-sectional Micro-CT images of the hydrogels that were acquired in the center of the wear mark to measure the maximum wear depth. FIG. 6C compares the wear depth of the hydrogels and cartilage. The wear depth of the BC-PVA hydrogel with 0% AMPS was 70.1 μm. The addition of 20% AMPS decreased the mean wear depth to 65.9 μm, but the difference between the 0% and 20% AMPS samples was not statistically significant. This comparison illustrates that the negative charge and higher water content caused by incorporating PAMPS into an annealed BC-PVA hydrogel does not significantly improve the wear resistance. Both of these values were 3 times lower than the wear depth on the cartilage sample, which was 227.8 μm. The wear depth for annealed and rehydrated PVA was 301.0 μm, four times greater than either BC-PVA sample. These results indicate the presence of BC in the hydrogel can dramatically improve the wear resistance of an annealed PVA hydrogel to be superior to that of cartilage.

(43) The COF was recorded during the wear test, as shown in FIG. 6D. Cartilage maintained a constant COF of 0.020 during the test. The COF of BC-PVA decreased during the test from 0.040 to 0.021. The BC-PVA hydrogel with 20% AMPS had a similar COF as that without AMPS. In contrast, the COF of PVA increased dramatically during the test, from 0.033 to 0.135. Previous work has similarly demonstrated the COF of PVA against cartilage increases over time while the COF of cartilage against cartilage is constant. The increase in the COF for a PVA-Cartilage interface has been ascribed to transfer of damaged PVA to the cartilage surface, which, in turn, decreases the ability of the cartilage surface to maintain a lubricating water layer. The incorporation of BC into PVA clearly inhibits damage of the hydrogel, allowing it to maintain a low coefficient of friction similar to that cartilage during the wear test. The presence of AMPS in the hydrogel does not appear to be necessary for maintaining a low COF and high resistance to wear.

(44) The materials used for cartilage replacement on one side of the joint, i.e., on the femoral condyle, should not cause wear of cartilage on the opposing surface, i.e., the tibial plateau. Traditional orthopedic materials like cobalt-chrome and ultra-high molecular-weight polyethylene are known to damage an opposing cartilage surface to a greater extent than hydrogels due to the higher COF and hardness of traditional orthopedic materials. To assess the wear caused by BC-PVA and BC-PVA-PAMPS hydrogels on cartilage, hydrogel plugs were created for wear testing (see Example 7 below). The hydrogel plugs were pressed against cartilage samples (see FIG. 7A) with 1 MPa of pressure, and rotated 106 times at a speed of 319 rotations per minute (the maximum linear velocity at the circumference of the pin was 100 mm s.sup.−1).

(45) FIG. 7B shows cross-sectional Micro-CT images of the cartilage samples that were acquired in the center of the wear mark to measure the maximum wear depth. FIG. 7C compares the wear depth on cartilage caused by the hydrogels or cartilage. The wear caused by the BC-PVA on cartilage (247±16 μm) was not significantly different from the wear caused by cartilage on cartilage (228±12 μm). The addition of PAMPS into the BC-PVA reduced the wear on the opposing cartilage surface to 81±27 μm, significantly below the wear of cartilage on cartilage.

(46) FIGS. 8A-8D show various aspects of shear strength testing of various hydrogel composition and cartilage. It was hypothesized that increasing the tensile strength of the hydrogel should also increase the shear strength. In order to be used for a cartilage replacement material, a synthetic hydrogel should be secured into a defect site with the same shear strength as the junction between cartilage and bone. One way to accomplish this goal is to have hydrogels that directly attach to bone or cartilage with sufficient strength. Alternatively, the hydrogel can be attached to a metallic base, such as titanium, which has the ability to integrate with bone. As mentioned above, the ability to attach BC-PVA-PAMPS hydrogels to a metallic base with a shear strength equivalent to the cartilage-bone interface, as described in PCT/US2021/040031. Previous tests indicated the strength of hydrogel attachment was limited by the tensile force required to fracture the hydrogel that is curved over the edge of the metallic base. Thus, increasing the tensile strength of the hydrogel should in turn increase the shear strength with which the hydrogel is attached to a metallic base.

(47) The setup used for shear testing is described in Example 7 and 12 below. FIGS. 8A-8D show the results for shear testing a plug of porcine cartilage on bone extracted from a pig knee, testing of a BC-PVA-PAMPS hydrogel made with the previous freeze-thaw process, and testing a BC-PVA hydrogel annealed at 90° C. and then rehydrated. Both of the hydrogels are attached to stainless-steel rods with a combination of RelyX Ultimate cement and a shape memory alloy ring. The BC-PVA shear strength of 1.98 is significantly greater than that of porcine cartilage (p-value from one-way ANOVA is <0.05). The average value of the shear strength for BC-PVA is also 40% greater than that of BC-PVA-PAMPS, but the error in the measurements is such that the difference in these values is not statistically significant. Comparison of the sample after failure show that while pig cartilage was sheared completely off of the underlying bone, both BC-PVA-PAMPS (made with the freeze-thaw process) and BC-PVA (made by annealing at 90° C., followed by rehydration) were fractured on one side of the cylindrical sample but remained attached. These results show that the shear strength of attachment for the annealed BC-PVA is greater than that of pig cartilage.

(48) Described above are tensile strength, compression strength and shear strength of BC-reinforced hydrogels attached to a metal pin with a diameter of 5.2 mm. While this size is convenient for testing, such a diameter is too small to serve as an implant for partial knee resurfacing. In addition, the samples lacked the curvature necessary to mimic the natural curvature of the femoral condyle. FIGS. 9A-9F show application of an annealed BC-PVA hydrogel on an implant for partial knee resurfacing to demonstrate the ability of the hydrogel to attach to a metal base with a size and shape representative of an implant for partial knee resurfacing.

(49) FIGS. 9A and 9B show the implant prior to mechanical testing. The implant sample is 20 mm in diameter with a radius of curvature of 20 mm. An implant diameter of 20 mm is a typical size used for an osteochondral allograft, and a 20 mm radius of curvature is within the range of typical curvatures for the femoral condyle. The peak force on the knee during jogging has been measured to be 5551 N for a body weight of 100 kg. The tibiofemoral contact area has been measured to be 1500 mm.sup.2 at 3100 N. The peak stress on the contacted area of the knee during jogging is 3.7 MPa based on the assumption that the contact area will not increase at a higher force. FIGS. 9C and 9D show the implant after being subjected to a compression stress of 16 MPa, 4.3 times greater than the peak physiological force on the femoral condyle. After this test, there were no signs of fracture or damage on the surface of the hydrogel. This test indicates an implant created with the annealed BC-PVA hydrogel can withstand the compressive forces in the knee without fracture. Peak anterior shear forces in the knee for walking have been measured to be 30% of body weight, or 294 N for a 100 kg individual. This is the highest shear force measured in the knee for any investigated daily activity. The tibiofemoral contact area has been measured to be 1500 mm.sup.2 at 3100 N, which is approximately equivalent to the peak normal force during walking for an individual with a body weight of 100 kg. As the peak normal force coincides with the peak shear force, we can use this tibiofemoral contact area to calculate that the peak shear stress experienced by cartilage during walking is 0.2 MPa (294 N÷1 500 mm.sup.2). Shear testing on the implant indicated failure did not occur until a stress of 0.9 MPa was applied. Since the implant can withstand shear loads 4.5 times greater than that experienced by cartilage in the knee, this result shows the annealed BC-PVA hydrogel and method of attachment have sufficient strength for creation of an implant for partial knee resurfacing.

(50) An implant for partial knee resurfacing may be relatively large and may be curved to mimic the natural curvature of the femoral condyle. FIGS. 14A-14C shows images of an implant 20 mm in diameter with a radius of curvature of 20 mm. An implant diameter of 20 mm is a typical size used for an osteochondral allograft, and a 20 mm radius of curvature is within the range of typical curvatures for the femoral condyle. In this example, five pieces of BC were cut into shapes with 8 octagonal legs to enable the BC to fold over the edge of the implant. A 0.25-mm-thick coating of commercially pure titanium was applied to the stem of the implant and underneath the base with a plasma spray process in order to improve integration with bone. FIGS. 14B and 14C show an example of how such an implant would be used to resurface the knee. FIG. 14B shows an example of a cartilage defect. The surgeon would drill out a hole over the defect site that is complementary to the shape of the hydrogel-capped implant. The hydrogel-capped implant would then be pressed into the hole to replace the damaged cartilage.

(51) The methods and apparatuses described herein may be used to reinforce an annealed PVA hydrogel with BC to provide, for the first time, a hydrogel with a compression and tensile strength greater than cartilage. Annealing increased the tensile strength of BC-PVA by 5 times and the compressive strength by 1.8 times relative to a freeze-thaw process due to the greater crystallization and lower water content that was achieved by annealing. Reinforcement of PVA with BC lowered the wear of the hydrogel by 4 times relative to PVA alone, and 3 times relative to cartilage. The annealed BC-PVA hydrogel caused a minimal amount of opposing surface wear, similar to what was caused by cartilage on itself. Attachment of the BC to a metal plug via an adhesive and/or clamp, followed by infiltration and annealing of the PVA, enabled attachment of the BC-PVA hydrogel to a metal backing with a shear strength greater than the attachment of cartilage to bone. These advances in hydrogel strength and attachment enable the creation of an implant with a hydrogel surface and titanium backing that can enable durable resurfacing of damaged cartilage in an articulating joint.

(52) As used herein, an implant may have any appropriate structure for implanting into a body. In some (non-limiting) examples, the implants may have a shape that allows them to be implanted into bone, with a hydrogel attached to an outward-facing side. For example, FIGS. 10A and 10B illustrate examples of implants to which a hydrogel has been attached, as described herein. In FIG. 10A, the implant includes a base 1001 (e.g., a titanium base) having an elongate pin-shape that may be, for example, 2 mm×7 mm (tapering to about 1.5 mm at about 3 mm from the end). The base may include one or more channels, openings, passages, etc. for ingrowth of bone. The implant also includes a top portion 1005 that may be curved (e.g., with a single curvature or a double-curvature. For example, the surface may be curved with a radius of curvature of about 17 mm (single curvature) or about 19 mm×12 mm (double curvature). In FIG. 10A the top is approximately 7 mm in diameter 1007. The outer surface of the implant may be approximately 1 mm thick or thicker 1009 and may be about 70% porous, or greater. The hydrogel may be attached to the top surface. The hydrogel in this example is a triple-network hydrogel of BC-PVA-PAMPS and the BC is cemented to the porous top, while the PVA-PAMPS is impregnated into the BC. FIG. 10B shows a similar implant to that shown in FIG. 10A, in which a hydrogel is attached (e.g., via cementing the nanofibrous portion of the hydrogel to the porous surface of the implant, as shown. The implant in FIG. 10B is titanium.

(53) As mentioned above, any of these implant surfaces may include a porous structure. The porosity of the implant surface may be, e.g., between 10% porous and 90% porous, e.g., between 30% porous and 90% porous, between 55% porous and 95% porous, between 65% porous and 85% porous, etc.). The depth of the pores may also be varied. For example, the surface may be porous to a depth of between 0.1 mm and 5 mm, between 0.2 mm to 3 mm, between 0.5 mm to 2 mm (e.g., 0.2 mm or greater, 0.3 mm or greater, 0.5 mm or greater, 0.75 mm or greater, 1 mm or greater, 1.5 mm or greater, etc.).

(54) As mentioned, any appropriate nanofibrous network may be used, including, but not limited to nanofibrous bacterial cellulose. Other nanofibrous networks may include electrospun polymer nanofibers such as poly(vinyl alcohol) (PVA) nanofibers, aramid nanofibers (e.g., Aramid-PVA nanofibers), wet-spun silk protein nanofiber, chemically crosslinked cellulose nanofiber, or polycaprolactone fibers (e.g., 3D woven PCL fibers). In addition, any appropriate double network hydrogels may be used, including but not limited to PVA and PAMPS. For example, other hydrogel-forming polymers may include poly-(N,N′-dimethyl acrylamide) (PDMAAm), copolymers of 1-vinylimidazole and methacrylic acid, double-network hydrogels based on amphiphilic triblock copolymers, polyampholyte hydrogels, a PVA-tannic acid hydrogel, a poly(N-acryloyl) glycinamide hydrogel, polyacrylic acid-acrylamide-C18 hydrogel, Guanine-boric acid reinforced PDMAAm, polyelectrolyte hydrogels, a poly(acrylonitrile-co-1-vinylimidazole) hydrogel (e.g., a mineralized poly(acrylonitrile-co-1-vinylimidazole) hydrogel), a polyacrylic acid-Fe3+-chitosan hydrogel, a poly(methacrylic acid) gel, a Graphene oxide/Xonotlite reinforced polyacrylamide (PAAm) gel, a poly(stearyl methacrylate)-polyacrylic acid gel, an annealed PVA-polyacrylic acid hydrogel, supramolecular hydrogels from multiurea linkage segmented copolymers, polyacrylonitrile-PAAm hydrogel, a microsilica reinforced DMA gel, a Agar-polyhydroxyethylmethacrylate gel, a polyfacryloyloethyltrimethylammonium chloride hydrogel, a poly(3-(methacryloylamino)propyl-trimethylammonium chloride hydrogel, a poly(sodium p-styrenesulfonate) hydrogel, a polyethylene glycol diacrylate hydrogel, a polyethylene glycol hydrogel, or hydrogels composed of a combination of these polymers.

(55) The implants described herein may be formed of any appropriate material, including, but not limited to titanium and stainless steel. For example, a hydrogel may be attached as described herein to an implant surface (e.g., base, including a porous base) that is formed of a stainless steel alloy, other titanium alloys, Co—Cr alloys, tantalum, gold, niobium, bone, Al oxide, Zr oxide, hydroxyapatite, tricalcium phosphate, calcium sodium phosphosilicate (Bio glass), poly(methyl methacrylate), polyether ether ketone, polyethylene, polyamide, polyurethane, polytetrafluoroethylene, or other materials used for making implants.

(56) Any of the implants described herein may include a hydrogel having a surface that is substantial smooth and/or is shaped in a predetermined configuration, such as (but not limited to) concave, convex, saddle-shaped, etc. For example, any of these apparatuses (e.g., implants) may have a surface roughness that is less than 30 microns. In some cases, the surface may be formed smooth by molding. In some cases, the surface may be formed smooth by polishing or sanding. For example, once the additional hydrogel components have formed the network (e.g., the nanofibrous-reinforced network), the hydrogel coating may optionally be finished by polishing; in particular, the surface may be sanded to polish to a roughness of less than 30 microns. Polishing may be performed by sanding (e.g., using a fine grit sanding surface, such as a 600, 400, 320, etc. grit).

(57) FIG. 11 is a flowchart illustrating an exemplary method of making an apparatus as described herein. The surface to which the hydrogel is to be attached, e.g., an implant surface, may optionally be prepared 1101. For example, the surface may be made porous. In some examples, the porosity may be at least 0.5 mm deep (e.g., 1 mm deep or deeper). The porosity may be described as the percent porosity (e.g., between 10% and 90% porous, between 20% and 90%, greater than 30%, greater than 40%, greater than 50%, etc.).

(58) The nanofibrous portion may then be prepared for attachment to the surface 1103. For example, the nanofibrous portion dried (e.g., freeze dried). The nanofibrous portion may be applied dry or substantially dry, to the attachment surface 1105. The nanofibrous portion may then be secured to the surface 1107. In some variations an adhesive (e.g., cement) may be applied to the surface before the nanofibrous portion is applied and/or the adhesive may be applied onto the nanofibrous portion on the surface. In some variations the adhesive may be applied to the nanofibrous portion prior to attaching to the surface. In some examples an adhesive is not used at all.

(59) The adhesive, if used, may be applied to dry (e.g., for a predetermined time, e.g., 1 hour, 2 hours, 3 hours, 6 hours, 12 hours, 24 hours, etc.) at a drying temperature (e.g., room temperature, 30 degrees, etc.). Once dried, the nanofibrous portion that is cemented to the surface may optionally be rehydrated 1109, e.g., by the addition of an aqueous solution.

(60) The nanofibrous portion may then be infiltrated by the other components of the hydrogel, which become impregnated into the nanofibrous portion secured onto the surface 1111. The other components may include one or more polymer components capable of forming a hydrogel and that are crystallizable upon a subsequent annealing process. In some examples, the polymer components include polyvinyl alcohol (PVA). In some examples, the polymer component only includes PVA.

(61) Once the polymer hydrogel component is infused within the nanofibrous portion, a mechanical strengthening process may be implemented to strengthen the hydrogel. The mechanical strengthening process may include drying, annealing and rehydrating the hydrogel. Drying and/or annealing may include heating the hydrogel to a predetermined temperature (e.g., ranging from 90° C. to 140° C.), followed by rehydration (e.g., in PBS solution). The resulting hydrogel may have an increased crystalline structure. For example, the interstitial polymer hydrogel (e.g., PVA) may have a crystallinity of at least 20%. In some examples, the tensile strength of the resulting hydrogel is at least 40 MPa. In some examples, the compressive strength of the resulting hydrogel is at least 59 MPa. In addition, the hydrogel may have a water content of about 20 wt % or greater. Once the mechanical strengthening process is complete, the hydrogel surface may optionally be polished 1115.

(62) In some examples the apparatuses described herein may form part of a surgical implant for treating a defect, such as an osteochondral defect. For example, a surgical implant may include a surface that is covered in a hydrogel; this surface may act an interface between one or more other body regions, including hard tissues, such as bone and cartilage. Repair of a cartilage lesion with a hydrogel may benefit from long-term fixation of the hydrogel in the defect site. Attachment of a hydrogel to a base (substrate) that allows for integration with bone could enable long-term fixation of the hydrogel, but current methods of forming bonds to hydrogels have less than a tenth of the shear strength of the osteochondral junction. The apparatuses and methods described herein may include bonding a hydrogel to a surface (e.g., base) with a shear strength that is many times larger than has been previously achieved.

(63) FIGS. 12A-12C illustrate a brief overview of an example of how the hydrogel may be attached to a metal base (e.g., of the top bearing surface). In this example freeze-dried BC sheets were cut into octagonal shapes with 8 projections (e.g., “legs”) that can be bent over the edges of the implant, as shown in the example of FIG. 12D. This cut may remove excess BC that would otherwise be folded up on the sides of the cylinder. The pieces of cut BC were then placed into a fixture that facilitates centering and alignment of the ring clamp with the pieces of BC and the metal rod. The metal rod was pushed down through the fixture so that the ring pushed the pieces of BC onto the metal rod. This process of pushing the ring over the BC and onto the rod could also be done by hand. The use of an alignment features, such as shown in FIGS. 12B-12C may help consistently center the pieces during assembly. The sample may then be clamped, e.g., by heated in an oven at 90° C. to initiate clamping in a shape-memory alloy material preset as described herein (which starts at a temperature of 50° C.). The part was then heated in a hydrothermal bomb at 120° C. for 24 hours with PVA to infiltrate the polymer into the BC. The part was then dried, annealed, and rehydrated as described herein.

(64) The following are example methods for preparing and testing various hydrogel samples described herein.

Example 1: Fabrication of BC-PVA-PAMPS Hydrogel

(65) BC sheets were pressed to be 0.5 mm thick and placed into a hydrothermal reactor with a mixture of polyvinyl alcohol (PVA) (40 wt. %) and deionized water (60 wt. %). The hydrothermal reactor was sealed and heated at 120° C. for 24 hours to allow the PVA to diffuse into the voids of BC and form a BC-PVA hydrogel. The BC-PVA hydrogel was removed from the reactor when hot (e.g., greater than 85° C.). The residual PVA solution was removed by scrapping the surface of the BC-PVA samples with a metal spatula. The samples were frozen at −78° C. for 30 minutes and thawed at room temperature to physically crosslink the PVA network. The BC-PVA hydrogel was then soaked in a solution of 2-acrylamido-2-methylpropanesulfonic acid sodium salt (AMPS) (30 wt. %), N,N′-methylenediacrylamide (MBAA) (60 mM), 2-hydroxy-4′-(2-hydroxyethoxy)-2-methylpropiophenone (12959) (50 mM) and potassium persulfate (KPS) (0.5 mg mL-1) for 24 hours. The hydrogel was cured with an ultraviolet (UV) transilluminator for 15 minutes on each side, and further cured in an oven at 60° C. for 8 hours to ensure even and complete curing. The resulting BC-PVA-PAMPS hydrogel was stored in phosphate buffered saline (PBS) for at least 24 hours before further characterization.

Example 2: Fabrication of Annealed BC

(66) BC sheets were pressed to be 0.5 mm thick. The BC sheets were then placed into a 90° C. oven for 24 hours before being annealed at 90° C. for an additional hour. The resulting annealed BC was cut into the desired shape and stored in 0.15 M PBS for at least 24 hours.

Example 3: Fabrication of PVA Hydrogel

(67) To fabricate the PVA hydrogel, a slurry of PVA (40 wt. %) and DI water (60 wt. %) were mixed in a metal baking pan (diameter: 203.2 mm) and heated at 120° C. for 20 minutes in an autoclave sterilizer. To make annealed PVA hydrogel, the resulting hydrogel was dried in an oven at 90° C. for 24 hours before being annealed at 90° C., 120° C. or 140° C. for an additional hour. To make freeze-thawed PVA hydrogel, the autoclaved hydrogel was frozen at −80° C. for 30 minutes and thawed at 23° C. for 30 minutes. The resulting PVA hydrogel was cut into the desired shape and stored in 0.15 M PBS for at least 24 hours before tests.

Example 4: Fabrication of Annealed BC-40 wt. % PVA Hydrogel

(68) BC sheets were pressed to be 0.5 mm thick and placed into a hydrothermal reactor with a mixture of PVA (40 wt. %) and DI water (60 wt. %). The hydrothermal reactor was sealed and heated at 120° C. for 24 hours to allow the PVA to diffuse into the voids of BC and form a BC-PVA hydrogel. The BC-PVA hydrogel was removed from the reactor when hot (e.g., greater than 85° C.). Note the hydrothermal reactor was pressurized with hot steam and created a burn hazard, so personal protective equipment including lab coat, heat resistant gloves and full-coverage face shields should be used when opening the reactor. The residual PVA solution was removed by scrapping the surface of the BC-PVA samples with a metal spatula. The samples were dried in an oven at 90° C. for 24 hours before annealing at 90° C., 120° C. or 140° C. for an additional hour. The resulting annealed BC-PVA hydrogel was cut into a desired shape and stored in 0.15 M PBS for at least 24 hours before tests.

Example 5: Fabrication of Annealed BC-10 wt. % PVA Hydrogel

(69) BC sheets were pressed to be 0.5 mm thick and placed into a baking pan (15.6 cm×8.6 cm×4.2 cm). Approximately 30 mL of 10 wt. % PVA solution was added to the baking pan. The baking pan was placed in an oven at 90° C. for 24 hours and annealed at 90° C. for an additional hour. The resulting annealed BC-PVA hydrogel was cut into the desired shape and stored in 0.15 M PBS for at least 24 hours.

Example 6: Fabrication of Annealed BC-PVA-PAMPS Hydrogel

(70) BC sheets were pressed to be 0.5 mm thick and placed into a hydrothermal reactor with a mixture of PVA (40 wt. %) and DI water (60 wt. %). The hydrothermal reactor was sealed and heated at 120° C. for 24 hours to allow the PVA to diffuse into the voids of BC and form a BC-PVA hydrogel. The BC-PVA hydrogel was removed from the reactor when hot (>85° C.). Note the hydrothermal reactor was pressurized with hot steam and created a burn hazard, so personal protective equipment including a lab coat, heat resistant gloves and full-coverage face shields should be used when opening the reactor. The residual PVA solution was removed by scrapping the surface of the BC-PVA samples with a metal spatula. The samples were dried in an oven at 90° C. for 24 hours before being annealing at 90° C., 120° C. or 140° C. for an additional hour. The annealed BC-PVA hydrogel was then soaked in a solution of AMPS (30 wt. %), MBAA (60 mM), 12959 (50 mM) and KPS (0.5 mg mL-1) for 24 hours. The hydrogel was cured with a UV transilluminator (VWR International) for 15 minutes on each side, and further cured in an oven at 60° C. for 8 hours to ensure even and complete curing. The resulting annealed BC-PVA-PAMPS hydrogel was stored in PBS for at least 24 hours before further characterization.

Example 7: Fabrication of Hydrogel on the Stainless-Steel Pin

(71) Preparation of all hydrogel samples started with cutting the freeze-dried BC. The BC is cut in the shape of an octagon with diameter D and 8 legs which has leg length of L and widths of W=0.383 D (See FIGS. 2A-2D, for example). The sample was labeled as BC-D-L after cutting. The 8-piece star shape (BC-D-L) was generated by MATLAB and loaded into Adobe Illustrator. In Adobe Illustrator the stroke of the shape is changed to 0.0001 pt to ensure accurate cutting. The file is sent to the laser cutter (Epilog Fusion M2) by using the print function and the laser cutter was selected as the printer. The vector process is used, with 100% speed, 20% power and 100% frequency. For cutting the BC, a clean metal plate was placed on the bed of the laser cutter, and the freeze-dried BC was placed on onto the metal plate. Another metal plate was placed onto the edge of the BC to ensure the BC stays in place. The focus was adjusted, and the shape was cut by the machine. After cutting, the BC was collected and stored in a petri dish for future use.

(72) For preparing the shear test samples, six pieces of BC were adhered to the stainless-steel rod with one layer of cement and a clamp. An overview of the assembly method is shown in FIGS. 12A-12C and 13. A stainless-steel test rod was machined to have a top section with a diameter of 5.2 mm and a height of 2 mm, and a bottom section with a diameter of 6.75 mm and a height of 13 mm. Three pieces of BC-6.5-2.25 and 3 pieces of BC-6.5-2 were placed in an alignment fixture. As an optional step an adhesive (e.g., Scotchbond Universal Adhesive) may be applied to the layer of the BC in contact with the rod and the top surface of the rod. If used, the adhesive was allowed to set for 20 seconds before being blown by air for another 5 seconds. In one example, about 0.15 g of RelyX Ultimate Cement was then applied to the same surfaces coated with the Scotchbond Universal Adhesive. The rod was pressed into the BC layers and then into a shape memory alloy ring clamp. The cement was cured for 1 h. The sample was heated in an oven at 175° C. for 10 min to shrink the clamp. The sample was then soaked in DI water for 1 hour in a centrifuge tube before future use. The sample with BC on top then went through the specific hydrogel fabrication process.

(73) Compression test samples were fabricated using the stainless-steel rod and a clamp, but without cement. Wear test samples were fabricated with a stainless-steel rod 5.7 mm in diameter and 38 mm in height, 3 pieces of BC-6.5-2, and the shape memory alloy ring, but without cement.

Example 8: Monotonic Tensile and Compression Tests

(74) Monotonic tensile tests were carried out on an Instron 1321 (Instron, Norwood, Mass., USA) and a TestResources 830 (TestResources, Shakopee, Minn., USA) load frame at a rate of 0.25 mm s.sup.−1. The finished hydrogel was cut into an ASTM D638-14 Type V shape with a titanium hollow punch for testing (see FIG. 1 for examples). The dimensions of the samples were measured with a caliper before testing. The ultimate tensile strength (UTS) was the maximum stress measured before fracture in the case of the BC-PVA samples, or the maximum compressive stress at 80% strain for the PVA samples. The tensile modulus was taken as the slope of the stress-strain curve at a stress of 1 MPa for comparison with previous studies of human cartilage.

(75) The compressive properties of all samples were measured with an axial Torsion System (TestResources 830LE63). Cylindrical samples of PVA were cut out of films of hydrogel with a hollow steel punch with a diameter of 4 mm. BC-PVA samples were attached to a metal pin for compression testing in order to have a sample that was sufficiently thick. The dimensions of the samples were measured with a caliper before testing. The compressive properties were measured with a strain rate of 0.05 s.sup.−1. The ultimate compressive strength was taken as the maximum stress measured before fracture. The compressive modulus was derived as the slope of the stress-strain curve at a stress of 0.4 MPa for comparison with previous studies of human cartilage.

Example 9: Differential Scanning Calorimetry

(76) Differential scanning calorimetry (DSC) was performed on hydrogels to determine the crystallinity of the PVA. The tests were completed on a TA TGA550. In a typical experiment, a hydrogel sample of approximately 5 mg was placed in an aluminum pan under a nitrogen gas flow and heated at a rate of 10° C./min from 25° C. to 300° C. Typical thermograms for PVA, BC-PVA and BC-PVA-PAMPS hydrogels are shown in FIGS. 4A-4D.

(77) The calculation for how much of the PVA was crystallized, i.e., the degree of crystallinity, was adopted from Hassan et al.22 After the DSC thermogram was acquired, the area under the melting peak over the range 140-220° C. (as shown in FIGS. 5A and 5B) was integrated to obtain a value with units of J.Math.° C..Math.S−1.Math.g−1. This number was then divided by the heating rate (0.17° C..Math.S.sup.−1) to obtain ΔH (J.Math.g.sup.−1). The crystallinity of PVA was then calculated by dividing ΔH for the sample by the heat required for melting a 100% crystalline PVA sample, ΔH.sub.e=138.6 J/g, and the weight fraction of PVA in the sample, W.sub.PVA,

(78) ${\chi }_{PVA}=\frac{\Delta H}{W_{PVA}\times \Delta H_c}$

(79) where χ.sub.PVA is the crystallinity of the PVA.

Example 10: Measurement of Solid Weight Fraction

(80) The weight of approximately 1 g of hydrated hydrogel was measured before drying at 90° C. for 24 hours. The weight of the dehydrated sample was then measured. The weight after dehydration was divided by the weight before dehydration to determine the solid weight fraction of the hydrogel sample.

Example 11: Wear Testing

(81) The wear resistance of the hydrogels and porcine cartilage samples were determined with the pin-on-disk setup shown in FIGS. 6A-6D. The pin-on-disk method was used with an Anton Paar Rheometer (MR302) and a tribology accessory (SCF7). Cartilage samples were harvested from pig femurs with an osteochondral autograft transfer system (Arthrex). The femurs were purchased from a local grocery store and frozen at −78° C. before harvesting the samples. Hydrogel samples were polished with #600, #800, #1000, #1200, #1500, #2000, #2500 and #3000 sandpapers to make them smooth prior to testing. A hydrogel pin was fabricated by using the method described in Example 7 above. A disk of hydrogel or porcine cartilage with a diameter of 12.7 mm was adhered with cyanoacrylate glue (Gorilla Glue Company) to the sample holder. The testing parameters were as follows: 1,000,000 rotations; angular speed: 319 rounds per minute (maximum linear velocity: 100 mm s−1); normal force: 28.26N (pressure: 1 MPa). A pressure of 1 MPa was applied to each sample for 5 minutes before tests started. The tests were performed in FBS. FBS is often used during wear tests to mimic the lubrication provided by synovial fluid.

(82) After the wear test, the samples were rehydrated in FBS for 24 hours to allow the gels to recover from the applied pressure before the wear depth was measured with a High-Resolution X-ray Computed Tomography (Micro-CT) Scanner (Nikon XTH 225 ST). A 3D model of the reconstructed Micro-CT images was rendered with Avizo 9 Lite. To measure the wear depth, a slice of the 3D model was taken in the middle of the wear mark. The wear depths were measured from the images of the middle slices with ImageJ.

(83) For calculating the COF, we determined the total friction force (F) from the torque (T) and the radius of the pin in the pin-on-disk setup (R):

(84) $F=\frac{3T}{2R}$

(85) The COF can then be calculated by:

(86) $COF=\frac{F}{F_N}$

(87) Here F.sub.N is the normal force (28.26N). The linear velocity (ν) was calculated by:
ν=ωR

(88) where ω was the angular speed of the pin.

(89) The results described above are particularly and unexpectedly surprising, showing that annealed BC-PVA as described herein provide a material that maintains a low coefficient of friction (0.21) over 1 million or more cycles of wear that is similar to cartilage (0.2). In contrast, annealed PVA by itself has a COF that increases from 0.033 to 0.135 over the million cycles. It is particularly surprising that adding the BC to the PVA resulted in a long-term COF that is 6.5 times lower than PVA by itself. This lower COF enabled by BC is critical to preventing wear of an opposing cartilage surface. Along the same lines, it is surprising that adding BC to annealed PVA decreased the wear depth by more than three times relative to annealed PVA by itself. This greater wear resistance enabled by BC may also be critical for the long term durability of the implant.

Example 12: Shear Testing

(90) Shear testing was performed on an 830LE63 Axial Torsion Test Machine equipped with a 100 pound (lb) load cell. Each test was performed in a customized shear test fixture (see FIG. 13). For shearing of cartilage or hydrogel on metal samples, the sample was secured in a cylindrical hole in the left side of the fixture. The hole size was 6 mm for the pig plug and 7 mm for the hydrogel samples. Spacers were added underneath the samples to precisely align the shear plane to the cartilage-bone or hydrogel-metal interface. The right side of the fixture was machined to have a complementary half-cylinder that was used to push the hydrogel or cartilage off of their substrates. The diameter of the right half-cylinder matched that of the left side (either 6 or 7 mm). Rubber was placed between the sample and the right shear fixture to apply pressure during the shear test in order to minimize cleavage and peeling. A crosshead displacement rate of 2 mm min-1 was used for all the measurements.

(91) Supplemental Materials

(92) As mentioned, in some of these examples, Bacterial Cellulose (BC) was purchased from Gia Gia Nguyen Co. Ltd. Poly(vinyl alcohol) (PVA) (fully hydrolyzed, molecular weight: 145,000 g mol.sup.−1), N,N′-methylenediacrylamide (MBAA, 97.0%), 2-hydroxy-4′-(2-hydroxyethoxy)-2-methylpropiophenone (12959), potassium persulfate (KPS) and 2-acrylamido-2-methylpropanesulfonic acid sodium salt (AMPS, 50 wt. % solution in water) were purchased from Sigma Aldrich. Phosphate buffered saline (PBS) was purchased from VWR International. Fetal bovine serum (FBS, Canada origin, collected from cattle typically 12-24 months old) was purchased from Corning. Shape memory alloy ring clamps were purchased from Intrinsic Devices.

(93) In some examples, BC sheets were pressed to be 0.5 mm thick and placed into a hydrothermal reactor with a mixture of PVA (40 wt. %) and DI water (60 wt. %). The hydrothermal reactor was sealed and heated at 135° C. for 24 hours to allow the PVA to diffuse into the voids of BC and form a BC-PVA hydrogel. The BC-PVA hydrogel was removed from the reactor when hot (>85° C.). Note the hydrothermal reactor was pressurized with hot steam and is a burn hazard, so personal protective equipment including lab coat, heat resistant gloves and full-coverage face shields should be used when opening the reactor. The residual PVA solution was removed by scrapping the surface of the BC-PVA samples with a metal spatula. The samples were frozen at −78° C. for 30 minutes and thawed at room temperature to physically crosslink the PVA network. The BC-PVA hydrogel was then soaked in a solution of AMPS (30 wt. %), MBAA (60 mM), 12959 (50 mM) and KPS (0.5 mg mL-1) for 24 hours. The hydrogel was cured with a UV transilluminator (VWR International) for 15 minutes on each side, and further cured in an oven at 60° C. for 8 hours to ensure even and complete curing. The resulting BC-PVA-PAMPS hydrogel was stored in PBS for at least 24 hours before further characterization.

(94) As mentioned, BC sheets were pressed, e.g., to be about 0.5 mm thick. In some examples, the BC sheets were then placed into a 90° C. oven for 24 hours before being annealed at 90° C. for an additional hour. The resulting annealed BC was cut into the desired shape and stored in PBS (0.15 M) for at least 24 hours.

(95) Any appropriate method may be used to fabricate the PVA hydrogel. For example, to fabricate a PVA hydrogel, a slurry of PVA (40 wt. %) and DI water (60 wt. %) were mixed in a metal baking pan (diameter: 203.2 mm) and heated at 120° C. for 20 minutes in an autoclave sterilizer. To make annealed PVA hydrogel, the resulting hydrogel was dried in an oven at 90° C. for 24 hours before being annealed at 90° C., 120° C. or 140° C. for an additional hour. To make freeze-thawed PVA hydrogel, the autoclaved hydrogel was frozen at −80° C. for 30 minutes and thawed at 23° C. for 30 minutes. The resulting PVA hydrogel was cut into the desired shape and stored in PBS (0.15 M) for at least 24 hours before testing.

(96) Annealed BC-40 wt. % PVA Hydrogel may be fabricated in any appropriate manner. For example, BC sheets may be pressed to be 0.5 mm thick and placed into a hydrothermal reactor with a mixture of PVA (40 wt. %) and DI water (60 wt. %). The hydrothermal reactor was sealed and heated at 135° C. for 24 hours to allow the PVA to diffuse into the voids of BC and form a BC-PVA hydrogel. The BC-PVA hydrogel was removed from the reactor when hot (>85° C.). The residual PVA solution was removed by scrapping the surface of the BC-PVA samples with a metal spatula. The samples were dried in an oven at 90° C. for 24 hours before annealing at 90° C., 120° C. or 140° C. for an additional hour. The resulting annealed BC-PVA hydrogel was cut into a desired shape and stored in PBS (0.15 M) for at least 24 hours before tests.

(97) In some examples Annealed BC-10 wt. % PVA Hydrogel was fabricated by pressing BC sheets to be about 0.5 mm thick and placed into a baking pan (15.6 cm×8.6 cm×4.2 cm). Approximately 30 mL of 10 wt. % PVA solution was added to the baking pan. The baking pan was placed in an oven at 90° C. for 24 hours and annealed at 90° C. for an additional hour. The resulting annealed BC-PVA hydrogel was cut into the desired shape and stored in PBS (0.15 M) for at least 24 hours.

(98) Annealed BC-PVA-PAMPS Hydrogel was fabricated by pressing BC sheets to be about 0.5 mm thick and placed into a hydrothermal reactor with a mixture of PVA (40 wt. %) and DI water (60 wt. %). The hydrothermal reactor was sealed and heated at 120° C. for 24 hours to allow the PVA to diffuse into the voids of BC and form a BC-PVA hydrogel. The BC-PVA hydrogel was removed from the reactor when hot (>85° C.). Note the hydrothermal reactor was pressurized with hot steam and created a burn hazard, so personal protective equipment including a lab coat, heat resistant gloves and full-coverage face shields should be used when opening the reactor. The residual PVA solution was removed by scrapping the surface of the BC-PVA samples with a metal spatula. The samples were dried in an oven at 90° C. for 24 hours before being annealing at 90° C., 120° C. or 140° C. for an additional hour. The annealed BC-PVA hydrogel was then soaked in a solution of AMPS (30 wt. %), MBAA (60 mM), 12959 (50 mM) and KPS (0.5 mg mL-1) for 24 hours. The hydrogel was cured with a UV transilluminator (VWR International) for 15 minutes on each side, and further cured in an oven at 60° C. for 8 hours to ensure even and complete curing. The resulting annealed BC-PVA-PAMPS hydrogel was stored in PBS (0.15 M) for at least 24 hours before further characterization.

(99) Fabrication of Hydrogel on a Stainless-Steel Pin

(100) In some examples, Preparation of hydrogel samples on a stainless-steel pin started with cutting the freeze-dried BC. The BC was cut in the shape of an octagon with diameter D, 8 legs of length of L, and widths of W=0.383 D. The sample was labeled as BC-D-L after cutting. The 8-piece star shape (BC-D-L) was generated by MATLAB and loaded into Adobe Illustrator. In Adobe Illustrator the stroke of the shape was changed to 0.0001 pt to ensure accurate cutting. The file was sent to the laser cutter (Epilog Fusion M2) using the print function and the laser cutter was selected as the printer. The vector process was used, with 100% speed, 20% power and 100% Frequency. For cutting the BC, a clean metal plate was placed on the bed of the laser cutter, and the freeze-dried BC was placed onto the metal plate. Another metal plate was placed onto the edge of the BC to ensure the BC did not move. The focus was adjusted, and the shape was cut by the machine. After cutting, the BC was collected and stored in a petri dish for future use.

(101) For preparing the shear test samples, six pieces of BC were adhered to the stainless-steel rod with one layer of cement and a clamp. A stainless-steel test rod was machined to have a top section with a diameter of 5.2 mm and a height of 2 mm, and a bottom section with a diameter of 6.75 mm and a height of 13 mm. Three pieces of BC-6.5-2.25 and 3 pieces of BC-6.5-2 were placed in an alignment fixture. Scotchbond Universal Adhesive was applied to the layer of the BC in contact with the rod and the top surface of the rod. The adhesive was allowed to set for 20 seconds before being blown by air for another 5 seconds. About 0.15 g of RelyX Ultimate Cement was then applied to the same surfaces coated with the Scotchbond Universal Adhesive. The rod was pressed into the BC layers and then into a shape memory alloy ring clamp. The cement was cured for 1 h. The sample was heated in an oven at 175° C. for 10 min to shrink the clamp. The sample was then soaked in DI water for 1 hour in a centrifuge tube before future use. The sample with BC on top then went through the specific hydrogel fabrication process.

(102) Compression test samples were fabricated using the stainless-steel rod and a clamp, but without cement. Wear test samples were fabricated with a stainless-steel rod 5.7 mm in diameter and 38 mm in height, 3 pieces of BC-6.5-2, and the shape memory alloy ring, but without cement.

(103) Monotonic tensile tests were carried out on an Instron 1321 load frame (Instron, Norwood, Mass., USA) and a Test Resources 830LE63 Axial Torsion Test Machine (TestResources, Shakopee, Minn., USA) at a rate of 0.25 mm s.sup.−1. The finished hydrogel was cut into an ASTM D638-14 Type V shape with a titanium hollow punch for testing (see FIGS. 15A-15D, for examples). The dimensions of the samples were measured with a caliper before testing. The ultimate tensile strength (UTS) was the maximum stress measured before fracture in the case of the BC-PVA samples, or the maximum compressive stress at 80% strain for the PVA samples. The tensile modulus was taken as the slope of the stress-strain curve at a stress of 1 MPa for comparison with previous studies of human cartilage.

(104) The compressive properties of all samples were measured with a Test Resources 830LE63 Axial Torsion Test Machine. Cylindrical samples of PVA were cut out of films of hydrogel samples with a hollow steel punch with a diameter of 4 mm. BC-PVA samples were attached to a metal pin for compression testing in order to have a sample that was sufficiently thick. The dimensions of the samples were measured with a caliper before testing. The compressive properties were measured with a strain rate of 0.05 s.sup.−1. The compressive strength was taken stress at a strain of 0.8, or the stress at fracture if the material failed before a strain of 0.8. The compressive modulus was derived as the slope of the stress-strain curve at a stress of 0.4 MPa for comparison with previous studies of human cartilage.

(105) Differential scanning calorimetry (DSC) was performed on hydrogel samples to determine the crystallinity of the PVA. The tests were completed on a TA Instruments TGA550. In a typical test, a hydrogel sample of approximately 5 mg was placed in an aluminum pan and heated at a scanning rate of 10° C./min under a nitrogen gas flow from 25° C. to 300° C. Typical thermograms for PVA, BC-PVA and BC-PVA-PAMPS hydrogels are shown in FIGS. 17A-17C.

(106) The calculation for how much of the PVA was crystallized, i.e., the degree of crystallinity, was performed. After the DSC thermogram was acquired, the area under the melting peak over the range 140-220° C. (as shown in FIG. 18) was integrated to obtain a value with units of J.Math.° C..Math.S.sup.−1.Math.g.sup.−1. This number was then divided by the heating rate (0.17° C..Math.S.sup.−1) to obtain ΔH (J.Math.g.sup.−1). The crystallinity of PVA (X.sub.PVA), was then calculated by dividing ΔH for the sample by the heat required for melting a 100% crystalline PVA sample, (ΔHc=138.6 J/g) and the weight fraction of PVA in the sample, W.sub.PVA:

(107) ${\chi }_{PVA}=\frac{\Delta H}{W_{PVA}\times \Delta H_c}$

(108) The weight of approximately 1 g of hydrated hydrogel was measured before drying at 90° C. for 24 hours. The weight of the dehydrated sample was then measured. The weight after dehydration was divided by the weight before dehydration to determine the solid weight fraction of the hydrogel sample.

(109) Fourier Transform Infrared (FTIR) spectroscopy was performed on hydrogel samples to analyze changes in bonding after annealing. Hydrogel samples were cut into a 1 cm by 1 cm square before testing. The tests were completed on a Thermo Scientific Nicolet iS50 FT-IR. In a typical test, the sample was held under the detector with the number of scans set to 32, resolution set to 4 (0.482 cm.sup.−1) and format set to % transmittance. Typical FTIR spectra are shown in FIGS. 16A-16B.

(110) The wear resistance of the hydrogels and porcine cartilage samples were determined with the pin-on-disk setup. The pin-on-disk method was used with an Anton Paar Rheometer (MR302) and a tribology accessory (SCF7). Cartilage samples were harvested from pig femurs with an osteochondral autograft transfer system (Arthrex). The femurs were purchased from a local grocery store and frozen at −78° C. before harvesting the samples. Hydrogel samples were polished with #600, #800, #1000, #1200, #1500, #2000, #2500 and #3000 sandpapers to make them smooth prior to testing. A hydrogel pin was fabricated by using the method described in section 2.8. A disk of hydrogel or porcine cartilage with a diameter of 12.7 mm was adhered with cyanoacrylate glue (Gorilla Glue Company) to the sample holder. The testing parameters were as follows: 1,000,000 rotations; angular speed: 319 rounds per minute (maximum linear velocity: 100 mm s−1); normal force: 28.26N (pressure: 1 MPa). A pressure of 1 MPa was applied to each sample for 5 minutes before starting the test. The tests were performed in FBS. FBS is often used during wear tests to mimic the lubrication provided by synovial fluid.

(111) After the wear test, the samples were rehydrated in FBS for 24 hours to allow the gels to recover from the applied pressure before the wear depth was measured with a High-Resolution X-ray Computed Tomography (Micro-CT) Scanner (Nikon XTH 225 ST). A 3D model of the reconstructed Micro-CT images was rendered with Avizo 9 Lite. To measure the wear depth, a slice of the 3D model was taken in the middle of the wear mark. The wear depths were measured from the images of the middle slices with ImageJ.

(112) For calculating the COF, we determined the total friction force (F) from the torque (T) and the radius of the pin in the pin-on-disk setup (R):

(113) $F=\frac{3T}{2R}$

(114) The COF can then be calculated by:

(115) $COF=\frac{F}{F_N}$

(116) Here F.sub.N is the normal force (28.26N). The linear velocity (ν) was calculated by
ν=ωDR

(117) where ω was the angular speed of the pin.

(118) Shear testing was performed on a Test Resources 830LE63 Axial Torsion Test Machine equipped with a 100 lb. load cell. Each test was performed in a customized shear test fixture (see FIG. 13). For shearing of cartilage off bone or hydrogel off metal samples, the sample was secured in a cylindrical hole in the left side of the fixture. Spacers were added underneath the samples to precisely align the shear plane to the cartilage-bone or hydrogel-metal interface. The right side of the fixture was machined to have a complementary half-cylinder that was used to push the hydrogel or cartilage off of their substrates. A rubber spacer was placed between the sample and the right shear fixture to apply pressure during the shear test in order to minimize cleavage and peeling. A crosshead displacement rate of 2 mm min-1 was used for all the measurements.

(119) A human-sized osteochondral implant 20 mm in diameter was fabricated. The top surface of the implant had a radius of curvature of 20 mm to match the native curvature of the femoral condyle. This implant was fabricated with 5 BC layers. A 0.25-mm-thick coating of commercially pure titanium was applied to the stem of the implant and underneath the base with a plasma spray process in order to improve integration with bone.

(120) TABLE-US-00001 Tensile Tensile Compressive Compressive Strength Modulus Strength Modulus Composition (MPa) (MPa) (MPa) (MPa) Freeze-thawed BC-PVA 11.1 115.3 55.3 15.0 Annealed BC-PVA 50.5 503.9 98.1 9.57 Annealed BC-PVA- 22.1 179.0 60.4 16.5 PAMPS Annealed PVA 15.6 24.5 56.7 12.1 Freeze-thawed PVA 0.26 <0.14 14.8 2.41 Human cartilage 8.1-40 58-228 14-59 8.1-20.1 BC-PVA-PAMPS 22.6 227 23.0 15.2 CNC-BA-PAAm 16.5 232.4 31.1 65.4 BC-PAAm 40 114 5.1 10 Polyaramid nanofiber- 5 9.1 4 26.5 PVA BC-gelatin 3.8 21 5.3 2.9 PVA-Agarose 14.6 6.38 3.66 0.09 PVA-HA/HAAC 3.05 0.7 40.15 0.88 3D printed PCL 4.41 9.53 3 1.2 scaffold-PVA PVA-CS 4.02 2.07 18 1.5

(121) The table above shows mechanical properties of annealed BC-PVA, annealed BC-PVA-PAMPS, annealed PVA hydrogels, cartilage, and previously reported hydrogels. This table compares the properties of the anneal BC-PVA to freeze-thawed and other previous hydrogels showing a remarkable improvement in properties.

(122) Abbreviations used in this table: BC: bacterial cellulose; PVA: Poly(vinyl alcohol); PAMPS: poly(2-acrylamido-2-methyl-1-propanesulfonic acid sodium salt); PAAm: polyacrylamide; CNC: cellulose nanocrystal, PA: phenyl acrylate; HA: hydroxyapatite, HACC: 2-hydroxypropyltrimethyl ammonium chloride chitosan, PCL: polycaprolactone, CS: chitosan. For the sake of clarity, the references in this table were limited to publications that report all four metrics, i.e., strength and modulus in tension and compression, and had a tensile and compressive strength higher than 3 MPa.

(123) Any of the methods (including user interfaces) described herein may be implemented as software, hardware or firmware, and may be described as a non-transitory computer-readable storage medium storing a set of instructions capable of being executed by a processor (e.g., computer, tablet, smartphone, etc.), that when executed by the processor causes the processor to control perform any of the steps, including but not limited to: displaying, communicating with the user, analyzing, modifying parameters (including timing, frequency, intensity, etc.), determining, alerting, or the like.

(124) It should be appreciated that all combinations of the foregoing concepts and additional concepts discussed in greater detail below (provided such concepts are not mutually inconsistent) are contemplated as being part of the inventive subject matter disclosed herein and may be used to achieve the benefits described herein.

(125) When a feature or element is herein referred to as being “on” another feature or element, it can be directly on the other feature or element or intervening features and/or elements may also be present. In contrast, when a feature or element is referred to as being “directly on” another feature or element, there are no intervening features or elements present. It will also be understood that, when a feature or element is referred to as being “connected”, “attached” or “coupled” to another feature or element, it can be directly connected, attached or coupled to the other feature or element or intervening features or elements may be present. In contrast, when a feature or element is referred to as being “directly connected”, “directly attached” or “directly coupled” to another feature or element, there are no intervening features or elements present. Although described or shown with respect to one embodiment, the features and elements so described or shown can apply to other embodiments. It will also be appreciated by those of skill in the art that references to a structure or feature that is disposed “adjacent” another feature may have portions that overlap or underlie the adjacent feature.

(126) Terminology used herein is for the purpose of describing particular embodiments only and is not intended to be limiting of the invention. For example, as used herein, the singular forms “a”, “an” and “the” are intended to include the plural forms as well, unless the context clearly indicates otherwise. It will be further understood that the terms “comprises” and/or “comprising,” when used in this specification, specify the presence of stated features, steps, operations, elements, and/or components, but do not preclude the presence or addition of one or more other features, steps, operations, elements, components, and/or groups thereof. As used herein, the term “and/or” includes any and all combinations of one or more of the associated listed items and may be abbreviated as “/”.

(127) Spatially relative terms, such as “under”, “below”, “lower”, “over”, “upper” and the like, may be used herein for ease of description to describe one element or feature's relationship to another element(s) or feature(s) as illustrated in the figures. It will be understood that the spatially relative terms are intended to encompass different orientations of the device in use or operation in addition to the orientation depicted in the figures. For example, if a device in the figures is inverted, elements described as “under” or “beneath” other elements or features would then be oriented “over” the other elements or features. Thus, the exemplary term “under” can encompass both an orientation of over and under. The device may be otherwise oriented (rotated 90 degrees or at other orientations) and the spatially relative descriptors used herein interpreted accordingly. Similarly, the terms “upwardly”, “downwardly”, “vertical”, “horizontal” and the like are used herein for the purpose of explanation only unless specifically indicated otherwise.

(128) Although the terms “first” and “second” may be used herein to describe various features/elements (including steps), these features/elements should not be limited by these terms, unless the context indicates otherwise. These terms may be used to distinguish one feature/element from another feature/element. Thus, a first feature/element discussed below could be termed a second feature/element, and similarly, a second feature/element discussed below could be termed a first feature/element without departing from the teachings of the present invention.

(129) Throughout this specification and the claims which follow, unless the context requires otherwise, the word “comprise”, and variations such as “comprises” and “comprising” means various components can be co-jointly employed in the methods and articles (e.g., compositions and apparatuses including device and methods). For example, the term “comprising” will be understood to imply the inclusion of any stated elements or steps but not the exclusion of any other elements or steps.

(130) In general, any of the apparatuses and methods described herein should be understood to be inclusive, but all or a sub-set of the components and/or steps may alternatively be exclusive, and may be expressed as “consisting of” or alternatively “consisting essentially of” the various components, steps, sub-components or sub-steps.

(131) As used herein in the specification and claims, including as used in the examples and unless otherwise expressly specified, all numbers may be read as if prefaced by the word “about” or “approximately,” even if the term does not expressly appear. The phrase “about” or “approximately” may be used when describing magnitude and/or position to indicate that the value and/or position described is within a reasonable expected range of values and/or positions. For example, a numeric value may have a value that is +/−0.1% of the stated value (or range of values), +/−1% of the stated value (or range of values), +/−2% of the stated value (or range of values), +/−5% of the stated value (or range of values), +/−10% of the stated value (or range of values), etc. Any numerical values given herein should also be understood to include about or approximately that value, unless the context indicates otherwise. For example, if the value “10” is disclosed, then “about 10” is also disclosed. Any numerical range recited herein is intended to include all sub-ranges subsumed therein. It is also understood that when a value is disclosed that “less than or equal to” the value, “greater than or equal to the value” and possible ranges between values are also disclosed, as appropriately understood by the skilled artisan. For example, if the value “X” is disclosed the “less than or equal to X” as well as “greater than or equal to X” (e.g., where X is a numerical value) is also disclosed. It is also understood that the throughout the application, data is provided in a number of different formats, and that this data, represents endpoints and starting points, and ranges for any combination of the data points. For example, if a particular data point “10” and a particular data point “15” are disclosed, it is understood that greater than, greater than or equal to, less than, less than or equal to, and equal to 10 and 15 are considered disclosed as well as between 10 and 15. It is also understood that each unit between two particular units are also disclosed. For example, if 10 and 15 are disclosed, then 11, 12, 13, and 14 are also disclosed.

(132) Although various illustrative embodiments are described above, any of a number of changes may be made to various embodiments without departing from the scope of the invention as described by the claims. For example, the order in which various described method steps are performed may often be changed in alternative embodiments, and in other alternative embodiments one or more method steps may be skipped altogether. Optional features of various device and system embodiments may be included in some embodiments and not in others. Therefore, the foregoing description is provided primarily for exemplary purposes and should not be interpreted to limit the scope of the invention as it is set forth in the claims.

(133) The examples and illustrations included herein show, by way of illustration and not of limitation, specific embodiments in which the subject matter may be practiced. As mentioned, other embodiments may be utilized and derived there from, such that structural and logical substitutions and changes may be made without departing from the scope of this disclosure. Such embodiments of the inventive subject matter may be referred to herein individually or collectively by the term “invention” merely for convenience and without intending to voluntarily limit the scope of this application to any single invention or inventive concept, if more than one is, in fact, disclosed. Thus, although specific embodiments have been illustrated and described herein, any arrangement calculated to achieve the same purpose may be substituted for the specific embodiments shown. This disclosure is intended to cover any and all adaptations or variations of various embodiments. Combinations of the above embodiments, and other embodiments not specifically described herein, will be apparent to those of skill in the art upon reviewing the above description.