Injectable calcium phosphate cement: effects of powder-to-liquid ratio and needle size

Injectable mineralized Sr-hydroxyapatite nanoparticles-loaded ɛ-polylysine-hyaluronic acid composite hydrogels for bone regeneration

In this study, multifunctional injectable mineralized antibacterial nanocomposite hydrogels were prepared by a homogenous distribution of high content of (up to 60 wt%) Sr-substituted hydroxyapatite (Sr-HAp) nanoparticles into covalently cross-linked ɛ-polylysine (ɛ-PL) and hyaluronic acid (HA) hydrogel network. The developed bone-targeted nanocomposite hydrogels were to synergistically combine the functional properties of bioactive Sr-HAp nanoparticles and antibacterial ɛ-PL-HA hydrogels for bone tissue regeneration. Viscoelasticity, injectability, structural parameters, degradation, antibacterial activity, and in vitro biocompatibility of the fabricated nanocomposite hydrogels were characterized. Physical performances of the ɛ-PL-HA hydrogels can be tailored by altering the mass ratio of Sr-HAp. The nanocomposite hydrogels revealed good stability against enzymatic degradation, which increased from 5 to 19 weeks with increasing the mass ratio of Sr-HAp from 40 % to 60 %. The loading of the Sr-HAp at relatively high mass ratios did not suppress the fast-acting and long-term antibacterial activity of the ɛ-PL-HA hydrogels against S. aureus and E. coli. The cell studies confirmed the cytocompatibility and pre-collagen I synthesis-promoting activity of the fabricated nanocomposite hydrogels.

Chitosan composite with mesenchymal stem cells: Properties, mechanism, and its application in bone regeneration

Bone defects resulting from trauma, illness or congenital abnormalities represent a significant challenge to global health. Conventional treatments such as autographs and allografts have limitations, leading to the exploration of bone tissue engineering (BTE) as an alternative approach. This review aims to provide a comprehensive analysis of bone regeneration mechanisms with a focus on the role of chitosan-based biomaterials and mesenchymal stem cells (MSCs) in BTE. In addition, the physiochemical and biological properties of chitosan, its potential for bone regeneration when combined with other materials and the mechanisms through which MSCs facilitate bone regeneration were investigated. In addition, different methods of scaffold development and the incorporation of MSCs into chitosan-based scaffolds were examined. Chitosan has remarkable biocompatibility, biodegradability and osteoconductivity, making it an attractive choice for BTE. Interactions between transcription factors such as Runx2 and Osterix and signaling pathways such as the BMP and Wnt pathways regulate the differentiation of MSCs and bone regeneration. Various forms of scaffolding, including porous and fibrous injections, have shown promise in BTE. The synergistic combination of chitosan and MSCs in BTE has significant potential for addressing bone defects and promoting bone regeneration, highlighting the promising future of clinical challenges posed by bone defects.

Enhanced injectability of aqueous β-tricalcium phosphate suspensions through PAA incorporation, gelling and preshearing

The major shortcoming of aqueous calcium phosphate suspensions used in biomedical applications is their unstable flow during delivery by mechanical means. In this study, microstructural changes and the resulting flow instabilities of aqueous β-TCP suspensions are demonstrated under both pressure-induced and drag-induced flow regimes and then remedied with the incorporation and subsequent gelling and preshearing of Carbopol 940, a biocompatible hydrogel. Mixing and dispersion of calcium phosphate particles into the hydrogel matrix was not efficient under simple agitation conditions. Swelling of the polymer chains was induced at approximately pH = 9.0 by water and particle intrusion within the opened-up coil structure due to deprotonation of the carboxylic acid groups by NaOH. As a result the composite material underwent a rapid viscoplastic transition into a doughy state which was not amenable to further processing without preshearing. Manual kneading converted the material into viscous state and enhanced the flow behavior significantly. Preshearing and probing the microstructure by mechanical spectrometer revealed multiple microstructural mechanisms responsible for the observed stable flow behavior, including improved dispersion of the particles, attrition of the polymeric network into microgel domains, enhanced adhesion and lubrication between the solid and liquid phase, crosslinking of the polymeric network. The net effect of these probable mechanisms was stiffening of the composite matrix, mobilization of solid particles and a marked enhancement in the stability of pressure-induced flow. The resistance of the material to liquid phase migration and its ability to undergo wall-slip and relax under stress were confirmed by simultaneous capillary rheometry and thermogravimetric analyses. The processing method enables improvements in the delivery of this composite material for injection and direct ink writing of scaffolds.

A Review of the Extruder System Design for Large-Scale Extrusion-Based 3D Concrete Printing

Extrusion-based 3D concrete printing (E3DCP) has been appreciated by academia and industry as the most plausible candidate for prospective concrete constructions. Considerable research efforts are dedicated to the material design to improve the extrudability of fresh concrete. However, at the time of writing this paper, there is still a lack of a review paper that highlights the significance of the mechanical design of the E3DCP system. This paper provides a comprehensive review of the mechanical design of the E3DCP extruder system in terms of the extruder system, positioning system and advanced fittings, and their effects on the extrudability are also discussed by relating to the extrusion driving forces and extrusion resistive forces which may include chamber wall shear force, shaping force, nozzle wall shear force, dead zone shear force and layer pressing force. Moreover, a classification framework of the E3DCP system as an extension of the DFC classification framework was proposed. The authors reckoned that such a classification framework could assist a more systematic E3DCP system design.

Fast self-curing α-tricalcium phosphate/β-dicalcium silicate composites beneficial for root canal sealing treatment

Objectives

α-tricalcium phosphate (α-TCP) and β-dicalcium silicate (β-C2S) have attracted much attention since these two types of self-curing Ca-phosphate and Ca-silicate are valuable biomaterials for bone defect or endodontic therapy. However, the injectable paste of their individual with high liquid/solid ratio is junior for root canal sealing due to very long self-setting time, low pH value and/or much volume shrinkage during paste-to-cement transformation.

Methods

Our studies evaluated the effect of biphasic ratio, liquid/solid ratio and pH condition of aqueous medium on setting time and mechanical strength of this biphasic composite cement, and also the hydroxyapatite re-mineralization potential and anti-microleakage level of the cements with different α-TCP/β-C2S ratio were explored in vitro. A control group free of paste filler was included in the extracted teeth model. Dentine re-mineralization and microleakage degree were observed by scanning electron microscopy and microCT reconstruction analysis.

Results

It indicated that the weak acidic solution with pH value of 6.0 may produce a significantly shorter initial setting time (from 90 min to less 20 min) and expected final setting time (<150 min) for the biphasic composite (2:1 or 1:2) in comparison with the pure β-C2S. Notably, the phasic composites exhibited limited microleakage and induced hydroxyapatite mineralization in the dentine tubules. These hydraulic pastes also produced strong alkaline feature and appreciable compressive resistance (12–18 MPa) after setting for a very short time stage. Moreover, a link between the addition of α-TCP leading to fast re-mineralization reaction was established.

Significance

Our findings suggest that the appreciable self-setting and physicochemical properties adaption to root canal sealability make α-TCP/β-C2S composites as preferential candidates for endodontic treatments.

Ball Milling Medium May Tune the Self-Curing Property and Root Canal Microleakage of β-Dicalcium Silicate-Based Cement

It is still a challenge to overcome the extended setting process of pure Ca-silicate as root canal fillers. We investigated the effects of attapulgite (a basic hydrous silicate of magnesium and aluminum) and ball-milling liquid medium on the self-curing properties of conventional β-dicalcium silicate (C2Si)-based cements. It was shown that a minor amount of attapulgite nanofibers (1–4%) had only a slight influence on setting time but caused a large increase in compressive resistance and structural stability. In particular, the ball milling media with different acetone/water ratios (3:0, 2:1, 1:2, 0:3) could directly influence the particle size distribution of C2Si powders, and the co-existence of liquid media (2:1 or 1:2) may be beneficial for shortening the setting time, enhancing early-stage compressive strength, and significantly improving the anti-microleakage ability of cement. Moreover, the composite cements also exhibited appreciable antibacterial efficacy in vitro. These findings demonstrated that the physicochemical properties of the Ca-silicate powders could be tuned by adding a minor amount of inorganic silicate nanofibers and a simple ball milling condition, and such a facile strategy is favorable for developing novel (pre-mixed) Ca silicate-based cements as root canal sealers.

Novel nanographene oxide-calcium phosphate cement inhibits Enterococcus faecalis biofilm and supports dental pulp stem cells

Background

Enterococcus faecalis (E. faecalis) is the most recovered species from the root canals after failed root canal treatment. Calcium phosphate bone cement (CPC) scaffold is promising for applications in endodontic treatment as a kind of root canal sealer. Graphene oxide (GO) has been extensively considered as a kind of promising nano-materials for antibacterial applications. In the present study, an injectable CPC-chitosan paste containing GO was developed for promising endodontic therapy. The antibacterial properties of this paste against E. faecalis biofilms as well as the support for human dental pulp stem cells (hDPSCs) were investigated.

Methods

CPC-chitosan composite with or without GO injectable scaffold was fabricated. The hDPSC growth and viability on scaffolds were investigated by live/dead assay. Antibacterial effects against E. faecalis biofilms were determined in clinical detin block samples.

Results

The antibacterial CPC-chitosan-GO disks had excellent hDPSC support with the percentages of live cells at around 90%. CPC-chitosan-GO also had greater antibacterial activity on E. faecalis than that of CPC-chitosan control using detin block models (p < 0.05).

Conclusions

The injectable CPC-chitosan-GO paste had strong effects on inhibition E. faecalis and hDPSC support, which could fill the void of adjusting paste to the defect and shaping in situ for promising endodontic therapy.

Bone Grafts and Substitutes in Dentistry: A Review of Current Trends and Developments

After tooth loss, bone resorption is irreversible, leaving the area without adequate bone volume for successful implant treatment. Bone grafting is the only solution to reverse dental bone loss and is a well-accepted procedure required in one in every four dental implants. Research and development in materials, design and fabrication technologies have expanded over the years to achieve successful and long-lasting dental implants for tooth substitution. This review will critically present the various dental bone graft and substitute materials that have been used to achieve a successful dental implant. The article also reviews the properties of dental bone grafts and various dental bone substitutes that have been studied or are currently available commercially. The various classifications of bone grafts and substitutes, including natural and synthetic materials, are critically presented, and available commercial products in each category are discussed. Different bone substitute materials, including metals, ceramics, polymers, or their combinations, and their chemical, physical, and biocompatibility properties are explored. Limitations of the available materials are presented, and areas which require further research and development are highlighted. Tissue engineering hybrid constructions with enhanced bone regeneration ability, such as cell-based or growth factor-based bone substitutes, are discussed as an emerging area of development.

Bone cement as a local chemotherapeutic drug delivery carrier in orthopedic oncology: A review

Metastatic bone lesions are common among patients with advanced cancers. While chemotherapy and radiotherapy may be prescribed immediately after diagnosis, the majority of severe metastatic bone lesions are treated by reconstructive surgery, which, in some cases, is followed by postoperative radiotherapy or chemotherapy. However, despite recent advancements in orthopedic surgery, patients undergoing reconstruction still have the risk of developing severe complications such as tumor recurrence and reconstruction failure. This has led to the introduction and evaluation of poly (methyl methacrylate) and inorganic bone cements as local carriers for chemotherapeutic drugs (usually, antineoplastic drugs (ANPDs)). The present work is a critical review of the literature on the potential use of these cements in orthopedic oncology. While several studies have demonstrated the benefits of providing high local drug concentrations while minimizing systemic side effects, only six studies have been conducted to assess the local toxic effect of these drug-loaded cements and they all reported negative effects on healthy bone structure. These findings do not close the door on chemotherapeutic bone cements; rather, they should assist in materials selection when designing future materials for the treatment of metastatic bone disease.

An antibacterial and injectable calcium phosphate scaffold delivering human periodontal ligament stem cells for bone tissue engineering

Osteomyelitis and post-operative infections are major problems in orthopedic, dental and craniofacial surgeries. It is highly desirable for a tissue engineering construct to kill bacteria, while simultaneously delivering stem cells and enhancing cell function and tissue regeneration. The objectives of this study were to: (1) develop a novel injectable calcium phosphate cement (CPC) scaffold containing antibiotic ornidazole (ORZ) while encapsulating human periodontal ligament stem cells (hPDLSCs), and (2) investigate the inhibition efficacy against Staphylococcus aureus (S. aureus) and the promotion of hPDLSC function for osteogenesis for the first time. ORZ was incorporated into a CPC-chitosan scaffold. hPDLSCs were encapsulated in alginate microbeads (denoted hPDLSCbeads). The ORZ-loaded CPCC+hPDLSCbeads scaffold was fully injectable, and had a flexural strength of 3.50 ± 0.92 MPa and an elastic modulus of 1.30 ± 0.45 GPa, matching those of natural cancellous bone. With 6 days of sustained ORZ release, the CPCC+10ORZ (10% ORZ) scaffold had strong antibacterial effects on S. aureus, with an inhibition zone of 12.47 ± 1.01 mm. No colonies were observed in the CPCC+10ORZ group from 3 to 7 days. ORZ-containing scaffolds were biocompatible with hPDLSCs. CPCC+10ORZ+hPDLSCbeads scaffold with osteogenic medium had 2.4-fold increase in alkaline phosphatase (ALP) activity and bone mineral synthesis by hPDLSCs, as compared to the control group (p < 0.05). In conclusion, the novel antibacterial construct with stem cell delivery had injectability, good strength, strong antibacterial effects and biocompatibility, supporting osteogenic differentiation and bone mineral synthesis of hPDLSCs. The injectable and mechanically-strong CPCC+10ORZ+hPDLSCbeads construct has great potential for treating bone infections and promoting bone regeneration.

Tough and injectable fiber reinforced calcium phosphate cement as an alternative to polymethylmethacrylate cement for vertebral augmentation: a biomechanical study

Vertebral compression fractures (VCFs) are a very common problem among the elderly, which ultimately result in severe pain and a drastically reduced quality of life. An effective treatment for VCFs is the minimally invasive augmentation of the damaged vertebrae through vertebroplasty and/or kyphoplasty. These surgical procedures treat the affected vertebrae by injection of poly(methyl methacrylate) cement (PMMA) into the vertebral body. However, clinical use of PMMA cement is associated with major drawbacks. Bioceramic cements such as injectable calcium phosphate cements (CPC) exhibit a superior osteocompatibility over PMMA cements, but are too brittle for load-bearing applications. Here, we evaluated the handling and mechanical properties of a recently developed CPC formulation containing both poly(vinyl alcohol) (PVA) fibers and carboxymethyl cellulose (CMC) as an alternative to PMMA cement for vertebro- and kyphoplasty. Our results demonstrate that the addition of CMC rendered fiber-reinforced CPC injectable without negatively affecting its mechanical properties. Further, an ex vivo mechanical analysis clearly showed that extravasation of PVA fiber-reinforced CPC with CMC into trabecular bone was limited as compared to PMMA. Finally, we observed that the ex vivo biomechanical performance of vertebrae treated with CMC and PVA fibers was similar to PMMA-treated vertebrae. The obtained data suggests that PVA fiber-reinforced CPCs with CMC possesses adequate handling, mechanical and structural characteristics for vertebro- and kyphoplasty procedures. These data pave the way for future preclinical studies on the feasibility of treating vertebral compression fractures using PVA fiber-reinforced CPC with CMC.

In-Situ Forming pH and Thermosensitive Injectable Hydrogels to Stimulate Angiogenesis: Potential Candidates for Fast Bone Regeneration Applications

Biomaterials that promote angiogenesis are required for repair and regeneration of bone. In-situ formed injectable hydrogels functionalised with bioactive agents, facilitating angiogenesis have high demand for bone regeneration. In this study, pH and thermosensitive hydrogels based on chitosan (CS) and hydroxyapatite (HA) composite materials loaded with heparin (Hep) were investigated for their pro-angiogenic potential. Hydrogel formulations with varying Hep concentrations were prepared by sol-gel technique for these homogeneous solutions were neutralised with sodium bicarbonate (NaHCO3) at 4 °C. Solutions (CS/HA/Hep) constituted hydrogels setting at 37 °C which was initiated from surface in 5-10 minutes. Hydrogels were characterised by performing injectability, gelation, rheology, morphology, chemical and biological analyses. Hydrogel solutions facilitated manual dropwise injection from 21 Gauge which is highly used for orthopaedic and dental administrations, and the maximum injection force measured through 19 G needle (17.191 ± 2.296N) was convenient for manual injections. Angiogenesis tests were performed by an ex-ovo chick chorioallantoic membrane (CAM) assay by applying injectable solutions on CAM, which produced in situ hydrogels. Hydrogels induced microvascularity in CAM assay this was confirmed by histology analyses. Hydrogels with lower concentration of Hep showed more efficiency in pro-angiogenic response. Thereof, novel injectable hydrogels inducing angiogenesis (CS/HA/Hep) are potential candidates for bone regeneration and drug delivery applications.

PMMA-Fe3O4 for internal mechanical support and magnetic thermal ablation of bone tumors

Background: Minimally invasive modalities are of great interest in the field of treating bone tumors. However, providing reliable mechanical support and fast killing of tumor cells to achieve rapid recovery of physical function is still challenging in clinical works.

Methods: A material with two functions, mechanical support and magnetic thermal ablation, was developed from Fe₃O₄ nanoparticles (NPs) distributed in a polymethylmethacrylate (PMMA) bone cement. The mechanical properties and efficiency of magnetic field-induced thermal ablation were systematically and successfully evaluated in vitro and ex vivo. CT images and pathological examination were successfully applied to evaluate therapeutic efficacy with a rabbit bone tumor model. Biosafety evaluation was performed with a rabbit in vivo, and a cytotoxicity test was performed in vitro.

Results: An NP content of 6% Fe₃O₄ (PMMA-6% Fe₃O₄, m_Fe: 0.01 g) gave the most suitable performance for in vivo study. At the 56-day follow-up after treatment, bone tumors were ablated without obvious side effects. The pathological examination and new bone formation in CT images clearly illustrate that the bone tumors were completely eliminated. Correspondingly, after treatment, the tendency of bone tumors toward metastasis significantly decreased. Moreover, with well-designed mechanical properties, PMMA-6%Fe₃O₄ implantation endowed tumor-bearing rabbit legs with excellent bio-mimic bone structure and internal support. Biosafety evaluation did not induce an increase or decrease in the immune response, and major functional parameters were all at normal levels.

Conclusion: We have presented a novel, highly efficient and minimally invasive approach for complete bone tumor regression and bone defect repair by magnetic thermal ablation based on PMMA containing Fe₃O₄ NPs; this approach shows excellent heating ability for rabbit VX2 tibial plateau tumor ablation upon exposure to an alternating magnetic field (AMF) and provides mechanical support for bone repair. The new and powerful dual-function implant is a promising minimally invasive agent for the treatment of bone tumors and has good clinical translation potential.

Evaluation of setting time and compressive strength of a new bone cement precursor powder containing Mg–Na–Ca

Taking the advantage of a novel magnesium phosphate precursor containing Na and Ca, the cementation rate of the cement, including only Mg/Mg–Na–Ca, was studied. Besides, two effective parameters, that is, calcination temperature, 650 °C and 800 °C, and powder-to-cement liquid ratio, 1 and 1.5 g/mL, were assessed. X-ray diffraction, scanning electron microscopy, ion chromatography, particle size analyser, Vicat needle and compression test were used to characterize the powders and obtained cements. The sample containing Mg–Na–Ca, calcined at 800 °C with powder-to-cement liquid ratio of 1.5, obtained the highest compressive strength, 20 MPa, but set fast. To control the kinetics of cementation, the powder containing Mg–Na–Ca calcined at 950 °C with powder-to-cement liquid ratio of 1.5 and 2 g/mL was assessed and the one with 2 g/mL set in 9 min possessing 22 MPa compressive strength was selected as optimal condition to be used as a candidate, injectable bone cement.

Encapsulation of mesenchymal stem cells in chitosan/β-glycerophosphate hydrogel for seeding on a novel calcium phosphate cement scaffold

Due to its moldability, biocompatibility, osteoconductivity and resorbability, calcium phosphate cement (CPC) is a highly promising scaffold material for orthopedic applications. However, pH changes and ionic activity during the CPC setting reaction may adversely affect cells seeded directly on CPC. Moreover, a lack of macropores in CPC limits ingrowth of new bone. The objectives of this study were to prepare macroporous CPC scaffolds via porogen leaching, using mannitol crystals as the porogen and to evaluate the in vitro proliferation and osteogenic differentiation of mesenchymal stem cells (MSCs) encapsulated in chitosan/β-glycerophosphate (C/GP) hydrogel prior to exposure to the novel CPC scaffold. MSCs were found to be adhered to the surfaces of CPC macropores via scanning electron microscopy. The viability and osteogenic differentiation of MSCs in C/GP hydrogel with or without exposure to CPC constructs containing mannitol crystals indicated that coating with C/GP hydrogel protected the cells during cement mixing and setting. In conclusion, novel, macroporous CPC scaffolds were prepared, and our data indicate that a hydrogel encapsulation-based strategy can be used to protect cells during scaffold formation. Thus, the MSC-laden CPC scaffolds show promise for the delivery of stem cells to promote bone regeneration.

Calcium phosphate cements for bone engineering and their biological properties

Calcium phosphate cements (CPCs) are frequently used to repair bone defects. Since their discovery in the 1980s, extensive research has been conducted to improve their properties, and emerging evidence supports their increased application in bone tissue engineering. Much effort has been made to enhance the biological performance of CPCs, including their biocompatibility, osteoconductivity, osteoinductivity, biodegradability, bioactivity, and interactions with cells. This review article focuses on the major recent developments in CPCs, including 3D printing, injectability, stem cell delivery, growth factor and drug delivery, and pre-vascularization of CPC scaffolds via co-culture and tri-culture techniques to enhance angiogenesis and osteogenesis.

Critical review: Injectability of calcium phosphate pastes and cements

Calcium phosphate cements (CPC) have seen clinical success in many dental and orthopaedic applications in recent years. The properties of CPC essential for clinical success are reviewed in this article, which includes properties of the set cement (e.g. bioresorbability, biocompatibility, porosity and mechanical properties) and unset cement (e.g. setting time, cohesion, flow properties and ease of delivery to the surgical site). Emphasis is on the delivery of calcium phosphate (CaP) pastes and CPC, in particular the occurrence of separation of the liquid and solid components of the pastes and cements during injection; and established methods to reduce this phase separation. In addition a review of phase separation mechanisms observed during the extrusion of other biphasic paste systems and the theoretical models used to describe these mechanisms are discussed.

STATEMENT OF SIGNIFICANCE

Occurrence of phase separation of calcium phosphate pastes and cements during injection limits their full exploitation as a bone substitute in minimally invasive surgical applications. Due to lack of theoretical understanding of the phase separation mechanism(s), optimisation of an injectable CPC that satisfies clinical requirements has proven difficult. However, phase separation of pastes during delivery has been the focus across several research fields. Therefore in addition to a review of methods to reduce phase separation of CPC and the associated constraints, a review of phase separation mechanisms observed during extrusion of other pastes and the theoretical models used to describe these mechanisms is presented. It is anticipated this review will benefit future attempts to develop injectable calcium phosphate based systems.

Bioactive calcium phosphate-based glasses and ceramics and their biomedical applications: A review

An overview of the formation of calcium phosphate under in vitro environment on the surface of a range of bioactive materials (e.g. from silicate, borate, and phosphate glasses, glass-ceramics, bioceramics to metals) based on recent literature is presented in this review. The mechanism of bone-like calcium phosphate (i.e. hydroxyapatite) formation and the test protocols that are either already in use or currently being investigated for the evaluation of the bioactivity of biomaterials are discussed. This review also highlights the effect of chemical composition and surface charge of materials, types of medium (e.g. simulated body fluid, phosphate-buffered saline and cell culture medium) and test parameters on their bioactivity performance. Finally, a brief summary of the biomedical applications of these newly formed calcium phosphate (either in the form of amorphous or apatite) is presented.

Self-Setting Calcium Phosphate Cements with Tunable Antibiotic Release Rates for Advanced Antimicrobial Applications

Osteomyelitis, an infectious disease predominantly tied to poor sanitary conditions in underdeveloped regions of the world, is in need of inexpensive, easily in situ synthesizable and administrable materials for its treatment. The results of this study stem from the attempt to create one such affordable and minimally invasive therapeutic platform in the form of a self-setting, injectable cement with a tunable drug release profile, composed of only nanoparticulate hydroxyapatite, the synthetic version of the bone mineral. Cements comprised two separately synthesized hydroxyapatite powders, one of which, HAP2, was precipitated abruptly, retaining the amorphous nature longer, and the other one of which, HAP1, was precipitated at a slower rate, more rapidly transitioning to the crystalline structure. Cements were made with four different weight ratios of the two hydroxyapatite components: 100/0, 85/15, 50/50, and 0/100 with respect to HAP1 and HAP2. Both the setting and the release rates measured on two different antibiotics, vancomycin and ciprofloxacin, were controlled using the weight ratio of the two hydroxyapatite components. Various inorganic powder properties were formerly used to control drug release, but here we demonstrate for the first time that the kinetics of the mechanism of formation of a solid compound can be controlled to produce tunable drug release profiles. Specifically, it was found that the longer the precursor calcium phosphate component of the cement retains the amorphous nature of the primary precipitate, the more active it was in terms of speeding up the diffusional release of the adsorbed drug. The setting rate was, in contrast, inversely proportional to the release rate and to the content of this active hydroxyapatite component, HAP2. The empirical release profiles were fitted to a set of equations that could be used to tune the release rate to the therapeutic occasion. All of the cements loaded with vancomycin or ciprofloxacin inhibited the growth of Gram-positive Staphylococcus aureus and Gram-negative Escherichia coli and Pseudomonas aeruginosa in both agar diffusion assays and broth dilution tests with intensities either comparable to the antibiotic per se, as in the case of ciprofloxacin, or even larger than the antibiotic alone, as in the case of vancomycin. Interestingly, even the pure cements exhibited an antibacterial effect ranging from moderate to strong, while demonstrating high levels of biocompatibility with osteoclastic RAW264.7 cells and only slightly affecting the viability of the osteoblastic MC3T3-E1 cells, in direct proportion with the amount of the more active hydroxyapatite component in the cements. This antibacterial effect was especially noticeable against Gram-negative bacteria, where the growth inhibition by the cements was comparable to or even stronger than that of the pure antibiotics. The antibiofilm assay against P. aeruginosa biofilms reiterated the antibiotic effectiveness of pure, antibiotic-free cements. That the carrier per se, composed of a nontoxic, easily prepared, bone mineral composite, can exhibit a strong antibacterial effect even in the absence of an antibiotic drug is an insight highly relevant in view of the rising resistance of an array of pathogens to traditional antibiotic therapies and the demands for the timely development of suitable alternatives.

Extent and mechanism of phase separation during the extrusion of calcium phosphate pastes

The aim of this study was to increase understanding of the mechanism and dominant drivers influencing phase separation during ram extrusion of calcium phosphate (CaP) paste for orthopaedic applications. The liquid content of extrudate was determined, and the flow of liquid and powder phases within the syringe barrel during extrusion were observed, subject to various extrusion parameters. Increasing the initial liquid-to-powder mass ratio, LPR, (0.4-0.45), plunger rate (5-20 mm/min), and tapering the barrel exit (45°-90°) significantly reduced the extent of phase separation. Phase separation values ranged from (6.22 ± 0.69 to 18.94 ± 0.69 %). However altering needle geometry had no significant effect on phase separation. From powder tracing and liquid content determination, static zones of powder and a non-uniform liquid distribution was observed within the barrel. Measurements of extrudate and paste LPR within the barrel indicated that extrudate LPR remained constant during extrusion, while LPR of paste within the barrel decreased steadily. These observations indicate the mechanism of phase separation was located within the syringe barrel. Therefore phase separation can be attributed to either; (1) the liquid being forced downstream by an increase in pore pressure as a result of powder consolidation due to the pressure exerted by the plunger or (2) the liquid being drawn from paste within the barrel, due to suction, driven by dilation of the solids matrix at the barrel exit. Differentiating between these two mechanisms is difficult; however results obtained suggest that suction is the dominant phase separation mechanism occurring during extrusion of CaP paste.

What's new in vertebral cementoplasty?

Vertebral cementoplasty is a well-known mini-invasive treatment to obtain pain relief in patients affected by vertebral porotic fractures, primary or secondary spine lesions and spine trauma through intrametameric cement injection. Two major categories of treatment are included within the term vertebral cementoplasty: the first is vertebroplasty in which a simple cement injection in the vertebral body is performed; the second is assisted technique in which a device is positioned inside the metamer before the cement injection to restore vertebral height and allow a better cement distribution, reducing the kyphotic deformity of the spine, trying to obtain an almost normal spine biomechanics. We will describe the most advanced techniques and indications of vertebral cementoplasty, having recently expanded the field of applications to not only patients with porotic fractures but also spine tumours and trauma.

Cross-linked chitosan improves the mechanical properties of calcium phosphate-chitosan cement

Calcium phosphate (CaP) cements are highly applicable and valuable materials for filling bone defects by minimally invasive procedures. The chitosan (CS) biopolymer is also considered as one of the promising biomaterial candidates in bone tissue engineering. In the present study, some key features of CaP-CS were significantly improved by developing a novel CaP-CS composite. For this purpose, CS was the first cross-linked with tripolyphosphate (TPP) and then mixed with CaP matrix. A group of CaP-CS samples without cross-linking was also prepared. Samples were fabricated and tested based on the known standards. Additionally, the effect of different powder (P) to liquid (L) ratios was also investigated. Both cross-linked and uncross-linked CaP-CS samples showed excellent washout resistance. The most significant effects were observed on Young's modulus and compressive strength in wet condition as well as surface hardness. In dry conditions, the Young's modulus of cross-linked samples was slightly improved. Based on the presented results, cross-linking does not have a significant effect on porosity. As expected, by increasing the P/L ratio of a sample, ductility and injectability were decreased. However, in the most cases, mechanical properties were enhanced. The results have shown that cross-linking can improve the mechanical properties of CaP-CS and hence it can be used for bone tissue engineering applications.

Injectability of calcium phosphate pastes: Effects of particle size and state of aggregation of β-tricalcium phosphate powders

The present study discloses a systematic study about the influence of some relevant experimental variables on injectability of calcium phosphate cements. Non-reactive and reactive pastes were prepared, based on tricalcium phosphate doped with 5 mol% (Sr-TCP) that was synthesised by co-precipitation. The varied experimental parameters included: (i) the heat treatment temperature within the range of 800-1100°C; (ii) different milling extents of calcined powders; (iii) the liquid-to-powder ratio (LPR); (iv) the use of powder blends with different particle sizes (PS) and particle size distributions (PSD); (v) the partial replacement of fine powders by large spherical dense granules prepared via freeze granulation method to simulate coarse individual particles. The aim was contributing to better understanding of the effects of PS, PSD, morphology and state of aggregation of the starting powders on injectability of pastes produced thereof. Powders heat treated at 800 and 1000°C with different morphologies but with similar apparent PSD curves obtained by milling/blending originated completely injectable reactive cement pastes at low LPR. This contrasted with non-reactive systems prepared thereof under the same conditions. Hypotheses were put forward to explain why the injectability results collected upon extruding non-reactive pastes cannot be directly transposed to reactive systems. The results obtained underline the interdependent roles of the different powder features and ionic strength in the liquid media on determining the flow and injectability behaviours.

Magnetic Hyperthermia Ablation of Tumors Using Injectable Fe₃O₄/Calcium Phosphate Cement

In this work, we have developed an injectable and biodegradable material using CPC containing Fe3O4 nanoparticles for minimally invasive and efficiently magnetic hyperthermia ablation of tumors. When exposed to an alternating magnetic field, the MCPC could quickly generate heat. The temperature of PBS and the excised bovine liver increased with the MCPC weight, iron content, and time. The ablated liver tissue volume for 0.36 g of 10% MCPC was 0.2 ± 0.03, 1.01 ± 0.07, and 1.96 ± 0.19 cm(3), respectively, at the time point of 60, 180, and 300 s. In our in vivo experiment, the MCPC could be directly injected into the center of the tumors under the guidance of ultrasound imaging. The formed MCPC was well-restricted within the tumor tissues without leakage, and the tumors were completely ablated by 0.36 g of 10% injectable MCPC after 180 s of induction heating.

Nanomaterials: the next step in injectable bone cements

Injectable bone cements (IBCs) are biocompatible materials that can be used as bone defect fillers in maxillofacial surgeries and in orthopedic fracture treatment in order to augment weakened bone due to osteoporosis. Current clinically available IBCs, such as polymethylmethacrylate and calcium phosphate cement, have certain advantages; however, they possess several drawbacks that prevent them from gaining universal acceptance. New gel-based injectable materials have also been developed, but these are too mechanically weak for load-bearing applications. Recent research has focused on improving various injectable materials using nanomaterials in order to render them suitable for bone tissue regeneration. This article outlines the requirements of IBCs, the advantages and limitations of currently available IBCs and the state-of-the-art developments that have demonstrated the effects of nanomaterials within injectable systems.

Development of an injectable bioactive bone filler cement with hydrogen orthophosphate incorporated calcium sulfate

Calcium sulfate cement (CSC) has emerged as a potential bone filler material mainly because of the possibility of incorporating therapeutic agents. Delivery of the cement through a needle or cannula will make it more useful in clinical applications. However, it was not possible to make CSC injectable because of the inherent lack of viscosity. The present work demonstrates the design development of a viscous and fully-injectable CSC by incorporating hydrogen orthophosphate ions, which does not hamper the biocompatibility of the material. The effect of addition of hydrogen orthophosphate on the rheological properties of the CSC paste was studied using a custom made capillary rheometer. The physicochemical changes associated with cement setting process were examined using X-ray diffraction and Fourier transform infrared spectroscopy and the thermal changes were measured through isothermal differential scanning calorimetry. Micromorphological features of different compositions were observed in environmental scanning electron microscopy and the presence of phosphate ions was identified with energy dispersive X-ray spectroscopic analysis and inductively coupled plasma-optical emission spectroscopy. The results indicated that HPO4 (2-) ions have profound effects on the rheological properties and setting of the CSC paste. Significant finding is that the HPO4 (2-) ions are getting substituted in the calcium sulfate dihydrate crystals during setting. The variations of setting time and compressive strength of the cement with the additive concentration were investigated. An optimum concentration of 2.5 % w/w gave a fully-injectable cement with clinically relevant setting time (below 20 min) and compressive strength (12 MPa). It was possible to inject the optimised cement paste from a syringe through an 18-gauge needle with thumb pressure. This cement will be useful both as bone filler and as a local drug delivery medium and it allows minimally invasive bone defect management.

A novel injectable, cohesive and toughened Si-HPMC (silanized-hydroxypropyl methylcellulose) composite calcium phosphate cement for bone substitution

This study reports on the incorporation of the self-setting polysaccharide derivative hydrogel (silanized-hydroxypropyl methylcellulose, Si-HPMC) into the formulation of calcium phosphate cements (CPCs) to develop a novel injectable material for bone substitution. The effects of Si-HPMC on the handling properties (injectability, cohesion and setting time) and mechanical properties (Young's modulus, fracture toughness, flexural and compressive strength) of CPCs were systematically studied. It was found that Si-HPMC could endow composite CPC pastes with an appealing rheological behavior at the early stage of setting, promoting its application in open bone cavities. Moreover, Si-HPMC gave the composite CPC good injectability and cohesion, and reduced the setting time. Si-HPMC increased the porosity of CPCs after hardening, especially the macroporosity as a result of entrapped air bubbles; however, it improved, rather than compromised, the mechanical properties of composite CPCs, which demonstrates a strong toughening and strengthening effect. In view of the above, the Si-HPMC composite CPC may be particularly promising as bone substitute material for clinic application.

Calcium phosphate cements for bone substitution: chemistry, handling and mechanical properties

Since their initial formulation in the 1980s, calcium phosphate cements (CPCs) have been increasingly used as bone substitutes. This article provides an overview on the chemistry, kinetics of setting and handling properties (setting time, cohesion and injectability) of CPCs for bone substitution, with a focus on their mechanical properties. Many processing parameters, such as particle size, composition of cement reactants and additives, can be adjusted to control the setting process of CPCs, concomitantly influencing their handling and mechanical performance. Moreover, this review shows that, although the mechanical strength of CPCs is generally low, it is not a critical issue for their application for bone repair--an observation not often realized by researchers and clinicians. CPCs with compressive strengths comparable to those of cortical bones can be produced through densification and/or homogenization of the cement matrix. The real limitation for CPCs appears to be their low fracture toughness and poor mechanical reliability (Weibull modulus), which have so far been only rarely studied.

In situ gelation of PEG-PLGA-PEG hydrogels containing high loading of hydroxyapatite: in vitro and in vivo characteristics

Thermosensitive hydrogels are renowned carriers that are used to deliver a variety of drugs with the aim of combating diseases. In this study, the injectability of thermosensitive hydrogels comprised of poly(ethylene glycol)-poly(lactic acid-co-glycolic acid)-poly(ethylene glycol) (PEG-PLGA-PEG, PELGE) and hydroxyapatite (HA) were examined for their ability to deliver bone morphological protein 2 (BMP-2). The physicochemical characteristics of PELGE, HA, and PELGE/HA hydrogel composites were investigated by (1)H NMR, GPC, FTIR, XRD, SEM, and TEM. The rheological properties, injectability, in vitro degradation, and in vivo biocompatibility were investigated. The hydrogel with a weight ratio of 4:6 of polymer to HA was found to be resistant to auto-catalyzed degradation of acidic monomers (LA, GA) for a period of 70 days owing to the presence of alkaline HA. Injectability was quantitatively determined by the ejected weight of the hydrogel composite at room temperature and was a close match to the weight amount predetermined by the syringe pump. The results not only revealed that the PELGE/HA hydrogel composite presented a minor tissue response in the subcutis of ICR mice at eight weeks, but they also indicated an acceptable tolerance of the hydrogel composite in animals. Thus, PELGE/HA hydrogel composite is expected to be a promising injectable orthopedic substitute because of its desirable thermosensitivity and injectability.

Effects of physical and chemical treatments on the molecular weight and degradation of alginate-hydroxyapatite composites

Degradation of alginate remains a critical issue to allow predictable biological performance upon implantation of alginate-based materials. Therefore, the objective of the current study is to compare the effects of γ-irradiation (dry state, 20-80 kGy), partial (1 and 4%) periodate oxidation (aqueous solution), and autoclaving (dry state) on the molecular weight of alginate, as well as the degradation behavior of alginate-based composites. The results show that γ-irradiation is by far the most destructive technique characterized by strongly reduced molecular weights and rapid loss of composite integrity upon soaking in simulated body fluid. Partial periodate oxidation is less destructive as characterized by more moderate decreases in molecular weight, but the production of hydrolytically labile bonds compromises the integrity of the resulting composites. Autoclaving is shown to be a powerful tool to reduce the molecular weight of alginate in a controllable and mild manner without compromising the integrity of the resulting alginate-hydroxyapatite composites, simply by increasing the number of repetitive autoclaving cycles.

Rational design and fabrication of a β-dicalcium silicate-based multifunctional cement with potential for root canal filling treatment

Gypsum-introduced, CaO-rich dicalcium silicate-based cements exhibit multifunctional physicochemical and biological properties and meet some challenging criteria in root canal therapy.

Direct and interactive influence of explanatory variables on properties of a calcium phosphate cement for vertebral body augmentation

We used the response surface methodology to investigate the direct and interactive effects of three explanatory variables on three properties of a calcium phosphate cement (CPC) for use in vertebroplasty (VP) and balloon kyphoplasty (BKP). The variables were poly(ethylene glycol) content of the cement liquid (PEG), powder-to-liquid ratio (PLR), and the amount of Na2HPO4 added to an aqueous solution of 4 wt/wt% poly(acrylic acid) (as the cement liquid) (SPC). The properties were injectability (I), final setting time (F), and 5-day compressive strength (UCS). We found that (1) there was an interactive effect between the variables on I and F but not on UCS; (2) the maximum I (98%) was obtained with PEG = 20 wt/wt% and PLR = 2 g mL(-1); (3) F = 15 min (the proposed optimum value for a CPC for use in VP and BKP) was obtained with PEG = 4 wt/wt% and PLR = 2.9 g mL(-1); and (4) the maximum UCS (39 MPa) was obtained with SPC = 0 and PLR = 3.5 g mL(-1).

Self-setting calcium orthophosphate formulations

In early 1980s, researchers discovered self-setting calcium orthophosphate cements, which are bioactive and biodegradable grafting bioceramics in the form of a powder and a liquid. After mixing, both phases form pastes, which set and harden forming either a non-stoichiometric calcium deficient hydroxyapatite or brushite. Since both of them are remarkably biocompartible, bioresorbable and osteoconductive, self-setting calcium orthophosphate formulations appear to be promising bioceramics for bone grafting. Furthermore, such formulations possess excellent molding capabilities, easy manipulation and nearly perfect adaptation to the complex shapes of bone defects, followed by gradual bioresorption and new bone formation. In addition, reinforced formulations have been introduced, which might be described as calcium orthophosphate concretes. The discovery of self-setting properties opened up a new era in the medical application of calcium orthophosphates and many commercial trademarks have been introduced as a result. Currently such formulations are widely used as synthetic bone grafts, with several advantages, such as pourability and injectability. Moreover, their low-temperature setting reactions and intrinsic porosity allow loading by drugs, biomolecules and even cells for tissue engineering purposes. In this review, an insight into the self-setting calcium orthophosphate formulations, as excellent bioceramics suitable for both dental and bone grafting applications, has been provided.

Premixed injectable calcium phosphate cement with excellent suspension stability

Premixed injectable calcium phosphate cement (p-ICPC) pastes have advantages over aqueous injectable calcium phosphate cement (a-ICPC) because p-ICPC remain stable during storage and harden only after placement into the defect. This paper focused on the suspension stability of p-ICPC paste by using fumed silica as a stabilizing agent and propylene glycol (PEG) as a continuous phase. Multiple light scanning techniques were first applied to evaluate the suspension stability. The results indicated that fumed silica effectively enhanced the suspension stability of p-ICPC pastes. The stabilizing effect of fumed silica results from the network structure formed in PEG because of its thixotropy. The p-ICPC could be eventually hydrated to form hydroxyapatite under aqueous circumstances by the unique replacement between water and PEG. p-ICPC (1) not only possesses proper thixotropy and compressive strength but has good injectability as well. p-ICPC (1) was cytocompatible and had no adverse effect on the attachment and proliferation of MG-63 cells in vitro. These observations may have applicability to the development of other nonaqueous injectable biomaterials for non-immediate filling and long-term storage.

Properties of injectable ready-to-use calcium phosphate cement based on water-immiscible liquid

Calcium phosphate cements (CPCs) are highly valuable materials for filling bone defects and bone augmentation by minimal invasive application via percutaneous injection. In the present study some key features were significantly improved by developing a novel injectable ready-to-use calcium phosphate cement based on water-immiscible carrier liquids. A combination of two surfactants was identified to facilitate the targeted discontinuous exchange of the liquid for water after contact with aqueous solutions, enabling the setting reaction to take place at distinct ratios of cement components to water. This prolonged the shelf life of the pre-mixed paste and enhanced reproducibility during application and setting reactions. The developed paste technology is applicable for different CPC formulations. Evaluations were performed for the formulation of an α-TCP-based CPC as a representative example for the preparation of injectable pastes with a powder-to-carrier liquid ratio of up to 85:15. We demonstrate that the resulting material retains the desirable properties of conventional CPC counterparts for fast setting, mechanical strength and biocompatibility, shows improved cohesion and will most probably show a similar degree of resorbability due to identical mineral structure of the set products.

Investigation of potential injectable polymeric biomaterials for bone regeneration

This article reviews the potential injectable polymeric biomaterial scaffolds currently being investigated for application in bone tissue regeneration. Two types of injectable biomaterial scaffolds are focused in this review, including injectable microspheres and injectable gels. The injectable microspheres section covers several polymeric materials, including poly(L-lactide-co-glycolide)-PLGA, poly(propylene fumarate), and chitosan. The injectable gel section covers alginate gels, hyaluronan hydrogels, poly(ethylene-glycol)-PEG hydrogels, and PEG-PLGA copolymer hydrogels. This review focuses on the effect of cellular behavior in vitro and in vivo in terms of material properties of polymers, such as biodegradation, biocompatibility, porosity, microsphere size, and cross-linking nature. Injectable polymeric biomaterials offer a major advantage for orthopedic applications by allowing the ability to use noninvasive or minimally invasive treatment methods. Therefore, combining injectable polymeric biomaterial scaffolds with cells have a significant potential to treat orthopedic bone defects, including spine fusion, and craniofacial and periodontal defects.

Effect of solid to liquid ratio on the physical properties of injectable nanohydroxyapatite

Injectable bone grafts based on nano hydroxyapatite, exhibiting a high cohesiveness were synthesized with three different solid to liquid (s/l) ratios. Effects of this ratio were studied on different structural and physical parameters of the injectable paste. Although crystallographic features remained insensitive to s/l ratio, we could observe the non linear correlations of zeta potential, cohesiveness, flowability and compressive strength of the injectable HA system as a function of s/l ratio.

Effectiveness of a bone substitute (CERAMENT™) as an alternative to PMMA in percutaneous vertebroplasty: 1-year follow-up on clinical outcome

PURPOSE

The aim of the study was to evaluate the efficacy of an injectable and partly absorbable calcium bone cement (CERAMENT™, Bone Support, Sweden) in the treatment of osteoporotic or traumatic vertebral fractures by percutaneous vertebroplasty.

METHODS

From March 2009 to October 2010 an open, prospective study in two centres was performed. 33 patients with symptomatic vertebral fractures were enrolled. Patients were included based on evaluation by X-ray, CT, and MRI. Clinical evaluation by Visual Analogue Scale (VAS, 0-10) and Oswestry Disability index test (ODI, 0-100 %) was performed before the operation as well as 1, 6 and 12 months after the procedure. Radiology assessment post-procedure was carried out by X-ray, CT, and MRI at 1, 6 and 12 months post-op. Intake of analgesic medications pre- and post-procedure was monitored.

RESULTS

66 vertebral bodies underwent percutaneous vertebroplasty. VAS score demonstrated a significant decrease from 8.61 (SD 19.8) pre-operatively to 2.48 (SD 2.36) at 1 month. The score was 2.76 (SD 2.68) at 6 months and 1.36 (SD 1.33) at the latest follow up. ODI score dropped significantly from 58.86 pre-op to 26.94 at 6 months and further down to 7.61 at 12 months. No re-fractures or adjacent level fractures were reported.

CONCLUSION

Data show that CERAMENT can be a substitute of PMMA in the treatment of osteoporotic and traumatic vertebral fractures, especially in young patients.

Injectability and mechanical properties of magnesium phosphate cements

Up to now magnesium phosphate cements are mainly being utilized in wastewater treatment due to their adsorptive properties. Recently they also have been shown to have a high potential as degradable biocements for application as replacement materials for bone defects. In comparison to degradable calcium phosphate cements they have the advantage of setting at neutral pH, which is favorable in biological environment. In this study two parameters of the cement composition, namely powder-to-liquid ratio (PLR) and citrate content, were varied in order to optimize the injectability properties of the cement paste and the mechanical properties of the reaction product. These properties were determined by means of testing setting time and temperature, paste viscosity, and injectability as well as phase composition and compressive strength of the set cements. Best results were obtained, when the cements were prepared with a PLR of 2.5 and a binder liquid consisting of an aqueous solution of 3 mol/l diammonium hydrogen phosphate and 0.5 mol/l diammonium citrate.

Elastin-like polypeptide based hydroxyapatite bionanocomposites

In nature, organic matrix macromolecules play a critical role in enhancing the mechanical properties of biomineralized composites such as bone and teeth. Designing artificial matrix analogues is promising but challenging because relatively little is known about how natural matrix components function. Therefore, in lieu of using natural components, we created biomimetic matrices using genetically engineered elastin-like polypeptides (ELPs) and then used them to construct mechanically robust ELP-hydroxyapatite (HAP) composites. ELPs were engineered with well-defined backbone charge distributions by periodic incorporation of negative, positive, or neutral side chains or with HAP-binding octaglutamic acid motifs at one or both protein termini. ELPs exhibited sequence-specific capacities to interact with ions, bind HAP, and disperse HAP nanoparticles. HAP-binding ELPs were incorporated into calcium phosphate cements, resulting in materials with improved mechanical strength, injectability, and antiwashout properties. The results demonstrate that rational design of genetically engineered polymers is a powerful system for determining sequence-property relationships and for improving the properties of organic-inorganic composites. Our approach may be used to further develop novel, multifunctional bone cements and expanded to the design of other advanced composites.