Addition of sodium hyaluronate and the effect on performance of the injectable calcium phosphate cement

Hyaluronic-Acid-Based Organic-Inorganic Composites for Biomedical Applications

Applications of natural hyaluronic acid (HYH) for the fabrication of organic-inorganic composites for biomedical applications are described. Such composites combine unique functional properties of HYH with functional properties of hydroxyapatite, various bioceramics, bioglass, biocements, metal nanoparticles, and quantum dots. Functional properties of advanced composite gels, scaffold materials, cements, particles, films, and coatings are described. Benefiting from the synergy of properties of HYH and inorganic components, advanced composites provide a platform for the development of new drug delivery materials. Many advanced properties of composites are attributed to the ability of HYH to promote biomineralization. Properties of HYH are a key factor for the development of colloidal and electrochemical methods for the fabrication of films and protective coatings for surface modification of biomedical implants and the development of advanced biosensors. Overcoming limitations of traditional materials, HYH is used as a biocompatible capping, dispersing, and structure-directing agent for the synthesis of functional inorganic materials and composites. Gel-forming properties of HYH enable a facile and straightforward approach to the fabrication of antimicrobial materials in different forms. Of particular interest are applications of HYH for the fabrication of biosensors. This review summarizes manufacturing strategies and mechanisms and outlines future trends in the development of functional biocomposites.

Temporal response of an injectable calcium phosphate material in a critical size defect

BACKGROUND

Calcium phosphate-based bone graft substitutes are used to facilitate healing in bony defects caused by trauma or created during surgery. Here, we present an injectable calcium phosphate-based bone void filler that has been purposefully formulated with hyaluronic acid to offer a longer working time for ease of injection into bony defects that are difficult to access during minimally invasive surgery.

METHODS

The bone substitute material deliverability and physical properties were characterized, and in vivo response was evaluated in a critical size distal femur defect in skeletally mature rabbits to 26 weeks. The interface with the host bone, implant degradation, and resorption were assessed with time.

RESULTS

The calcium phosphate bone substitute material could be injected as a paste within the working time window of 7-18 min, and then self-cured at body temperature within 10 min. The material reached a maximum ultimate compressive strength of 8.20 ± 0.95 MPa, similar to trabecular bone. The material was found to be biocompatible and osteoconductive in vivo out to 26 weeks, with new bone formation and normal bone architecture observed at 6 weeks, as demonstrated by histological evaluation, microcomputed tomography, and radiographic evaluation.

CONCLUSIONS

These findings show that the material properties and performance are well suited for minimally invasive percutaneous delivery applications.

The application of hyaluronic acid in bone regeneration

Hyaluronic acid (HA) exists naturally as an important component of the extracellular matrix (ECM) in the human body. In recent decades, HA has been widely used in bone regeneration, and is currently a popular topic, particularly in the craniofacial and dental fields. From maxilla augmentation to craniofacial bone trauma, there is now a large demand for bone regenerative therapy. Serving as a cell-seeding scaffold or a carrier for bioactive components, hyaluronic acid-incorporated scaffolds and carriers in bone regeneration can be fabricated into either rigid or colloidal forms. Since the type of material used is a critical factor in the biological properties of a scaffold, HA derivatives or HA-incorporated composite scaffolds have shown excellent potential for improving osteogenesis and mineralization. Furthermore, in order to better enhance osteogenesis, local delivery carriers based on hyaluronic acid derivatives, rather than specifically serving as scaffolds, can be established by loading different osteoinductive or osteogenetic components and acquiring different release patterns. Such osteoinductive carriers immobilized on implant surfaces are also effective in improving osseointegration. Thus, as such a competent biomaterial, hyaluronic acid should be considered a promising tool in bone regeneration.

A ready-to-use acidic, brushite-forming calcium phosphate cement

Premixed calcium phosphate cements have been developed to simplify the usage of traditional calcium phosphate cements and reduce the influence of the setting reaction on the delivery process. However, difficulties in achieving a good cohesion, adequate shelf life and sufficient mechanical properties have so far impeded their use in clinical applications, especially for the more degradable acidic calcium phosphate cements. In this study, a brushite cement was developed from a series of ready-to-use calcium phosphate pastes. The brushite cement paste was formed via mixing of a monocalcium phosphate monohydrate (MCPM) paste and a β-tricalcium phosphate (β-TCP) paste with good injectability and adequate shelf life. The MCPM paste was based on a water-immiscible liquid with two surfactants and the β-TCP paste on a sodium hyaluronate aqueous solution. The effect of citric acid as a retardant was assessed. Formulations with suitable amounts of citric acid showed good cohesion and mechanical performance with potential for future clinical applications. STATEMENT OF SIGNIFICANCE: Acidic calcium phosphate cements have attracted extensive attention as bone substitute materials due to their ability to resorb faster than basic calcium phosphate cements in vivo. However, traditionally, short working times and low mechanical strength have limited their clinical application. Premixed cements could simplify the clinical use as well as improve property reproducibility, but short shelf lives, low cohesion and low mechanical properties have restricted the development. In this study, an injectable ready-to-use two-phase system consisting of an MCPM paste and a β-TCP paste was developed based on acidic cement. It shows good cohesion, compressive strength and adequate shelf life, which has the potential to be used in a dual chamber system for simplified and fast filling of bone defects in a minimally invasive manner. This will reduce surgery time, decrease the risk of contamination and ensure repeatable results.

Influence of polymeric additives on the cohesion and mechanical properties of calcium phosphate cements

To expand the clinical applicability of calcium phosphate cements (CPCs) to load-bearing anatomical sites, the mechanical and setting properties of CPCs need to be improved. Specifically, organic additives need to be developed that can overcome the disintegration and brittleness of CPCs. Hence, we compared two conventional polymeric additives (i.e. carboxylmethylcellulose (CMC) and hyaluronan (HA)) with a novel organic additive that was designed to bind to calcium phosphate, i.e. hyaluronan-bisphosphonate (HABP). The unmodified cement used in this study consisted of a powder phase of α-tricalcium phosphate (α-TCP) and liquid phase of 4% NaH2PO4·2H2O, while the modified cements were fabricated by adding 0.75 or 1.5 wt% of the polymeric additive to the cement. The cohesion of α-TCP was improved considerably by the addition of CMC and HABP. None of the additives improved the compression and bending strength of the cements, but the addition of 0.75% HABP resulted into a significantly increased cement toughness as compared to the other experimental groups. The stimulatory effects of HABP on the cohesion and toughness of the cements is hypothesized to derive from the strong affinity between the polymer-grafted bisphosphonate ligands and the calcium ions in the cement matrix.

Injectable Bioactive Glass/Polysaccharide Polymers Nanocomposites for Bone Substitution

nanobioactive glasses are biocompatible and osteoconductive materials which can be mixed with solution of biocompatible polymers to make nanobiocomposite paste for hard and even soft tissue treatment. In this study, bioactive glass based on CaO-SiO2-P2O5 system was produced via sol-gel technique and mixed with a solution phase. The solution phase was a 1:1 mixture of 3% hyaluronic acid solution and 3% sodium alginate solution in v/v. Rheological behaviors of the paste in rotation and oscillation modes were measured. For surface reactivity measurements, the paste was immersed in simulated body fluid (SBF) for different intervals and then characterized by SEM. The paste exhibited a superior injectability even from syringes with too narrow tips. It was a thixotropic fluid with shear thinning behavior. The results of surface reactivity revealed precipitation of apatite phase on the paste surfaces meanwhile an appropriate structural stability was observed against disintegration (anti-washout behavior). It seems that this biocomposite paste is an appropriate alternative for injectable bone substitute materials.

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.

A novel injectable borate bioactive glass cement for local delivery of vancomycin to cure osteomyelitis and regenerate bone

Osteomyelitis (bone infection) is often difficult to cure. The commonly-used treatment of surgical debridement to remove the infected bone combined with prolonged systemic and local antibiotic treatment has limitations. In the present study, an injectable borate bioactive glass cement was developed as a carrier for the antibiotic vancomycin, characterized in vitro, and evaluated for its capacity to cure osteomyelitis in a rabbit tibial model. The cement (initial setting time = 5.8 ± 0.6 min; compressive strength = 25.6 ± 0.3 MPa) released vancomycin over ~25 days in phosphate-buffered saline, during which time the borate glass converted to hydroxyapatite (HA). When implanted in rabbit tibial defects infected with methicillin-resistant Staphylococcus aureus (MRSA)-induced osteomyelitis, the vancomycin-loaded cement converted to HA and supported new bone formation in the defects within 8 weeks. Osteomyelitis was cured in 87 % of the defects implanted with the vancomycin-loaded borate glass cement, compared to 71 % for the defects implanted with vancomycin-loaded calcium sulfate cement. The injectable borate bioactive glass cement developed in this study is a promising treatment for curing osteomyelitis and for regenerating bone in the defects following cure of the infection.

Incorporation of salmon calcitonin-loaded poly(lactide-co-glycolide) (PLGA) microspheres into calcium phosphate bone cement and the biocompatibility evaluation in vitro

Slow tissue ingrowth is the major drawback for the use of calcium phosphate cements; to address the issue, salmon calcitonin–loaded biodegradable poly(lactide- co-glycolide) microspheres were incorporated into calcium phosphate cement in this study. The effects of poly(lactide- co-glycolide) weight ratio on the mechanical strength, self-setting properties, and salmon calcitonin release ability of calcium phosphate cement were systematically investigated. The in vitro degradation behavior and the cumulative mass loss (%) of the composite during incubation in phosphate-buffered saline were studied. The release of salmon calcitonin was sustained for at least 35 days, and the release rate can be tailored by adjusting the ratio of PLGA. The scanning electron microscopic images of the composites after incubation for 48 days indicated that the poly(lactide- co-glycolide) degraded completely and formed a porous structure in the calcium phosphate cement. An in vitro cell culture of the calcium phosphate cement/salmon calcitonin–poly(lactide- co-glycolide) cement provided more biocompatible than calcium phosphate cement. This composite possesses the basic performance for clinical needs, and it has potential use for treating osteoporosis and accelerating bone repair.

Polymeric additives to enhance the functional properties of calcium phosphate cements

The vast majority of materials used in bone tissue engineering and regenerative medicine are based on calcium phosphates due to their similarity with the mineral phase of natural bone. Among them, calcium phosphate cements, which are composed of a powder and a liquid that are mixed to obtain a moldable paste, are widely used. These calcium phosphate cement pastes can be injected using minimally invasive surgery and adapt to the shape of the defect, resulting in an entangled network of calcium phosphate crystals. Adding an organic phase to the calcium phosphate cement formulation is a very powerful strategy to enhance some of the properties of these materials. Adding some water-soluble biocompatible polymers in the calcium phosphate cement liquid or powder phase improves physicochemical and mechanical properties, such as injectability, cohesion, and toughness. Moreover, adding specific polymers can enhance the biological response and the resorption rate of the material. The goal of this study is to overview the most relevant advances in this field, focusing on the different types of polymers that have been used to enhance specific calcium phosphate cement properties.

Anti-washout carboxymethyl chitosan modified tricalcium silicate bone cement: preparation, mechanical properties and in vitro bioactivity

Anti-washout CaF(2) stabilized C(3)S (F-C(3)S) bone cement was prepared by adding water-soluble carboxymethyl chitosan (CMCS) to the hydration liquid. The setting time, compressive strength and in vitro bioactivity of the CMCS modified F-C(3)S (CMCS-C(3)S) pastes were evaluated. The results indicate that CMCS-C(3)S pastes could be stable in the shaking simulated body fluid (SBF) after immediately mixed. The addition of CMCS significantly enhances the cohesion of particles, at the same time restrains the penetration of liquid, and thus endows the anti-washout ability. The setting times of the pastes increase with the increase of CMCS concentrations in the hydration liquid. Besides, the compressive strengths of CMCS-C(3)S pastes after setting for 1-28 days are lower than that of the pure F-C(3)S paste, but the sufficient strengths would be suitable for the clinical applications. The crystalline apatite deposited on the paste surface is retarded from 1 to 2 days for the addition of CMCS, but the quantities of deposited apatite are same after soaking in SBF for 3 days. As the result that pure C(3)S paste has shorter setting times than pure F-C(3)S paste, CMCS modified pure C(3)S pastes would have better anti-washout ability. Our study provides a convenient way to use C(3)S bone cement with excellent anti-washout ability when the pastes are exposed to biological fluids. The novel anti-washout CMCS-C(3)S bone cement with suitable setting times, sufficient strengths and in vitro bioactivity would have good prospects for medical application.