ECM-based Ca²⁺/_L-arginine/NO periosteum nourishes bone defect microenvironment, directs macrophage polarity, and accelerates osteogenesis and angiogenesis

The natural periosteum is responsible for supporting bone homeostasis and initiating repair, but is often damaged during bone fracture, causing acute inflammation and loss of a functioning substratum for induction of new bone formation. Here, we propose an ECM-based Ca²⁺/L-arginine/nitric oxide (NO) electrospun periosteum to reinitiate bone regeneration. The multifaceted action of NO could promote osteoblastic differentiation, angiogenesis and polarization of macrophages, while accelerating new bone formation, enhancing bone quality and reducing inflammation in a rat critical size calvarial defect model, acting as a mainspring that drives the rest of the PI3K-AKT pathway including the downstream action of VEGF, MAPK and mTOR signalling. The modulation of NO cycle by periosteum scaffold is envisioned to be highly efficient at supporting bone grafting surgeries, with simple and clean clinical translation and implications for anti-inflammatory healing.