Premixed rapid-setting calcium phosphate composites for bone repair

Multi-objective property optimisation of a phosphoserine-modified calcium phosphate cement for orthopaedic and dental applications using design of experiments methodology

Phosphoserine is a ubiquitous molecule found in numerous proteins and, when combined with alpha-tricalcium phosphate (α-TCP) powder, demonstrates the ability to generate an adhesive biomaterial capable of stabilising and repairing bone fractures. Design of Experiments (DoE) approach was able to optimise the composition of phosphoserine-modified calcium phosphate cement (PM-CPC) demonstrating that the liquid:powder ratio (LPR) and quantity of phosphoserine (wt%) significantly influenced the handling, mechanical, and adhesion properties. Subsequently, the DoE optimisation process identified the optimal PM-CPC formulation, exhibiting a compressive strength of 29.2 ± 4.9 MPa and bond/shear strength of 3.6 ± 0.9 MPa after a 24 h setting reaction. Moreover, the optimal PM-CPC composition necessitated a mixing time of 20 s and displayed an initial setting time between 3 and 4 min, thus enabling homogenous mixing and precise delivery within a surgical environment. Notably, the PM-CPC demonstrated a bone-to-bone bond strength of 1.05 ± 0.3 MPa under wet conditions, coupled with a slow degradation rate during the first five days. These findings highlight the ability of PM-CPC to effectively support and stabilise bone fragments during the initial stages of natural bone healing. The developed PM-CPC formulations fulfil the clinical requirements for working and setting times, static mechanical, degradation properties, and injectability, enabling surgeons to stabilise complex bone fractures. This innovative bioinspired adhesive represents a significant advancement in the treatment of challenging bone injuries, offering precise delivery within a surgical environment and the potential to enhance patient outcomes. STATEMENT OF SIGNIFICANCE: This manuscript presents a noteworthy contribution to the field of bone fracture healing and fixation by introducing a novel phosphoserine-modified calcium phosphate cement (PM-CPC) adhesive by incorporating phosphoserine and alpha-TCP. This study demonstrates the fabrication and extensive characterisation of this adhesive biomaterial that holds great promise for stabilising and repairing complex bone fractures. Design of Experiment (DoE) software was used to investigate the correlations between process, property, and structure of the adhesive, resulting in a cost-effective formulation with desirable physical and handling properties. The PM-CPC adhesive exhibited excellent adhesion and cohesion properties in wet-field conditions. This research offers significant potential for clinical translation and contributes to the ongoing advancements in bone tissue engineering.

The effect of supplementing the calcium phosphate cement containing poloxamer 407 on cellular activities

Calcium phosphate cement (CPC) is generally used for bone repair and augmentation. Poloxamers are tri-block copolymers that are used as surfactants but have applications in drug and antibiotic delivery. However, their biological effects on bone regeneration systems remain unelucidated. Here, we aimed to understand how supplementing the prototype CPC with poloxamer would impact cellular activity and its function as a bone-grafting material. A novel CPC, modified beta-tricalcium phosphate (mβ-TCP) powder, was developed through a planetary ball-milling process using a beta-tricalcium phosphate (β-TCP). The mβ-TCP dissolves rapidly and accelerates hydroxyapatite precipitation; successfully shortening the cement setting time and enhancing the strength. Furthermore, the addition of poloxamer 407 to mβ-TCP could reduce the risk of leakage from bone defects and improve fracture toughness while maintaining mechanical properties. In this study, the poloxamer addition effects (0.05 and 0.1 g/mL) on the cellular activities of MC3T3-E1 cells cultured in vitro were investigated. The cell viability of mβ-TCP containing poloxamer 407 was similar to that of mβ-TCP. All specimens showed effective cell attachment and healthy polygonal extension of the cytoplasm firmly attached to hydroxyapatite (HA) crystals. Therefore, even with the addition of poloxamer to mβ-TCP, it does not have a negative effect to osteoblast growth. These data demonstrated that the addition of poloxamer 407 to mβ-TCP might be considered a potential therapeutic application for the repair and regeneration of bone defects.

Ready-To-Use and Rapidly Biodegradable Magnesium Phosphate Bone Cement: In Vivo Evaluation in Sheep

In clinical practice, hydroxyapatite (HA) cements for bone defect treatment are frequently prepared by mixing a powder component and a liquid component shortly before implantation in the operation theater, which is time-consuming and error-prone. In addition, HA cements are only slightly resorbed, that is, cement residues can still be found in the bone years after implantation. Here, these challenges are addressed by a prefabricated magnesium phosphate cement paste based on glycerol, which is ready-to-use and can be directly applied during surgery. By using a trimodal particle size distribution (PSD), the paste is readily injectable and exhibits a compressive strength of 9-14 MPa after setting. Struvite (MgNH4 PO4 ·6H2 O), dittmarite (MgNH4 PO4 ·H2 O), farringtonite (Mg3 (PO4 )2 ), and newberyite (MgHPO4 ·3H2 O) are the mineral phases present in the set cement. The paste developed here features a promising degradation of 37% after four months in an ovine implantation model, with 25% of the implant area being newly formed bone. It is concluded that the novel prefabricated paste improves application during surgery, has a suitable degradation rate, and supports bone regeneration.

Novel Biocement/Honey Composites for Bone Regenerative Medicine

New biocements based on a powdered mixture of calcium phosphate/monetite (TTCPM) modified with the addition of honey were prepared by mixing the powder and honey liquid components at a non-cytotoxic concentration of honey (up to 10% (w/v)). The setting process of the cements was not affected by the addition of honey, and the setting time of ~4 min corresponded to the fast setting calcium phosphate cements (CPCs). The cement powder mixture was completely transformed into calcium-deficient nanohydroxyapatite after 24 h of hardening in a simulated body fluid, and the columnar growth of long, needle-like nanohydroxyapatite particles around the original calcium phosphate particles was observed in the honey cements. The compressive strength of the honey cements was reduced with the content of honey in the cement. Comparable antibacterial activities were found for the cements with honey solutions on Escherichia coli, but very low antibacterial activities were found for Staphylococcus aureus for all the cements. The enhanced antioxidant inhibitory activity of the composite extracts was verified. In vitro cytotoxicity testing verified the non-cytotoxic nature of the honey cement extracts, and the addition of honey promoted alkaline phosphatase activity, calcium deposit production, and the upregulation of osteogenic genes (osteopontin, osteocalcin, and osteonectin) by mesenchymal stem cells, demonstrating the positive synergistic effect of honey and CPCs on the bioactivity of cements that could be promising therapeutic candidates for the repair of bone defects.

Calcium Phosphate Cements Combined with Blood as a Promising Tool for the Treatment of Bone Marrow Lesions

The solid phase of a commercial calcium phosphate (Graftys^® HBS) was combined with ovine or human blood stabilized either with sodium citrate or sodium heparin. The presence of blood delayed the setting reaction of the cement by ca. 7-15 h, depending on the nature of the blood and blood stabilizer. This phenomenon was found to be directly related to the particle size of the HBS solid phase, since prolonged grinding of the latter resulted in a shortened setting time (10-30 min). Even though ca. 10 h were necessary for the HBS blood composite to harden, its cohesion right after injection was improved when compared to the HBS reference as well as its injectability. A fibrin-based material was gradually formed in the HBS blood composite to end-up, after ca. 100 h, with a dense 3D organic network present in the intergranular space, thus affecting the microstructure of the composite. Indeed, SEM analyses of polished cross-sections showed areas of low mineral density (over 10-20 µm) spread in the whole volume of the HBS blood composite. Most importantly, when the two cement formulations were injected in the tibial subchondral cancellous bone in a bone marrow lesion ovine model, quantitative SEM analyses showed a highly significant difference between the HBS reference versus its analogue combined with blood. After a 4-month implantation, histological analyses clearly showed that the HBS blood composite underwent high resorption (remaining cement: ca. 13.1 ± 7.3%) and new bone formation (newly formed bone: 41.8 ± 14.7%). This was in sharp contrast with the case of the HBS reference for which a low resorption rate was observed (remaining cement: 79.0 ± 6.9%; newly formed bone: 8.6 ± 4.8%). This study suggested that the particular microstructure, induced by the use of blood as the HBS liquid phase, favored quicker colonization of the implant and acceleration of its replacement by newly formed bone. For this reason, the HBS blood composite might be worth considering as a potentially suitable material for subchondroplasty.

Multifunctional Three-Dimensional Printed Copper Loaded Calcium Phosphate Scaffolds for Bone Regeneration

Bone regeneration using inorganic nanoparticles is a robust and safe approach. In this paper, copper nanoparticles (Cu NPs) loaded with calcium phosphate scaffolds were studied for their bone regeneration potential in vitro. The pneumatic extrusion method of 3D printing was employed to prepare calcium phosphate cement (CPC) and copper loaded CPC scaffolds with varying wt% of copper nanoparticles. A new aliphatic compound Kollisolv MCT 70 was used to ensure the uniform mixing of copper nanoparticles with CPC matrix. The printed scaffolds were studied for physico-chemical characterization for surface morphology, pore size, wettability, XRD, and FTIR. The copper ion release was studied in phosphate buffer saline at pH 7.4. The in vitro cell culture studies for the scaffolds were performed using human mesenchymal stem cells (hMSCs). The cell proliferation study in CPC-Cu scaffolds showed significant cell growth compared to CPC. The CPC-Cu scaffolds showed improved alkaline phosphatase activity and angiogenic potential compared to CPC. The CPC-Cu scaffolds showed significant concentration dependent antibacterial activity in Staphylococcus aureus. Overall, the CPC scaffolds loaded with 1 wt% Cu NPs showed improved activity compared to other CPC-Cu and CPC scaffolds. The results showed that copper has improved the osteogenic, angiogenic and antibacterial properties of CPC scaffolds, facilitating better bone regeneration in vitro.

Optimization of an Injectable, Resorbable, Bioactive Cement Able to Release the Anti-Osteoclastogenic Biomolecule ICOS-Fc for the Treatment of Osteoporotic Vertebral Compression Fractures

Vertebral compression fractures are typical of osteoporosis and their treatment can require the injection of a cement through a minimally invasive procedure to restore vertebral body height. This study reports the development of an injectable calcium sulphate-based composite cement able to stimulate bone regeneration while inhibiting osteoclast bone resorption. To this aim, different types of strontium-containing mesoporous glass particles (Sr-MBG) were added to calcium sulphate powder to impart a pro-osteogenic effect, and the influence of their size and textural features on the cement properties was investigated. Anti-osteoclastogenic properties were conferred by incorporating into poly(lactic-co-glycolic)acid (PLGA) nanoparticles, a recombinant protein able to inhibit osteoclast activity (i.e., ICOS-Fc). Radiopaque zirconia nanoparticles (ZrO₂) were also added to the formulation to visualize the cement injection under fluoroscopy. The measured cement setting times were suitable for the clinical practice, and static mechanical testing determined a compressive strength of ca. 8 MPa, comparable to that of human vertebral bodies. In vitro release experiments indicated a sustained release of ICOS-Fc and Sr²⁺ ions up to 28 days. Overall, the developed cement is promising for the treatment of vertebral compression fractures and has the potential to stimulate bone regeneration while releasing a biomolecule able to limit bone resorption.

The Influence of Nanosilica on Properties of Cement Based on Tetracalcium Phosphate/Monetite Mixture with Addition of Magnesium Pyrophoshate

The effect of nanosilica on the microstructure setting process of tetracalcium phosphate/nanomonetite calcium phosphate cement mixture (CPC) with the addition of 5 wt% of magnesium pyrophosphate (assigned as CT5MP) and osteogenic differentiation of mesenchymal stem cells cultured in cement extracts were studied. A more compact microstructure was observed in CT5MP cement with 0.5 wt% addition of nanosilica (CT5MP1Si) due to the synergistic effect of Mg₂P₂O₇ particles, which strengthened the cement matrix and nanosilica, which supported gradual growth and recrystallization of HAP particles to form compact agglomerates. The addition of 0.5 wt% of nanosilica to CT5MP cement caused an increase in CS from 18 to 24 MPa while the setting time increased almost twofold. It was verified that adding nanosilica to CPC cement, even in a low amount (0.5 and 1 wt% of nanosilica), positively affected the injectability of cement pastes and differentiation of cells with upregulation of osteogenic markers in cells cultured in cement extracts. Results revealed appropriate properties of these types of cement for filling bone defects.

Sudoku of porous, injectable calcium phosphate cements – Path to osteoinductivity

With the increase of global population, people's life expectancy is growing as well. Humans tend to live more active lifestyles and, therefore, trauma generated large defects become more common. Instances of tumour resection or pathological conditions and complex orthopaedic issues occur more frequently increasing necessity for bone substitutes. Composition of calcium phosphate cements (CPCs) is comparable to the chemical structure of bone minerals. Their ability to self-set and resorb in vivo secures a variety of potential applications in bone regeneration. Despite the years-long research and several products already reaching the market, finding the right properties for calcium phosphate cement to be osteoinductive and both injectable and suitable for clinical use is still a sudoku. This article is focused on injectable, porous CPCs, reviewing the latest developments on the path toward finding osteoinductive material, which is suitable for injection.

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Phase separation is an essential factor to be improved to obtain injectable material; several methods have been proposed.

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Osteoinductive bone substitutes – possible solution for bad mechanical performance of CPCs.

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Osteoinductivity of CPC could be attained even without the addition of different supplements.

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Less complex composition of CPC – potentially reduced price of the final product and wider availability on the market.

Characterization of Tetracalcium Phosphate/Monetite Biocement Modified by Magnesium Pyrophosphate

Magnesium pyrophosphate modified tetracalcium phosphate/monetite cement mixtures (MgTTCPM) were prepared by simple mechanical homogenization of compounds in a ball mill. The MgP₂O₇ was chosen due to the suitable setting properties of the final cements, in contrast to cements with the addition of amorphous (Ca, Mg) CO₃ or newberite, which significantly extended the setting time even in small amounts (corresponding ~to 1 wt% of Mg in final cements). The results showed the gradual dissolution of the same amount of Mg₂P₂O₇ phase, regardless of its content in the cement mixtures, and the refinement of formed HAP nanoparticles, which were joined into weakly and mutually bound spherical agglomerates. The compressive strength of composite cements was reduced to 14 MPa and the setting time was 5–10 min depending on the composition. Cytotoxicity of cements or their extracts was not detected and increased proliferative activity of mesenchymal stem cells with upregulation of osteopontin and osteonectin genes was verified in cells cultured for 7 and 15 days in cement extracts. The above facts, including insignificant changes in the pH of simulated body fluid solution and mechanical strength close to cancellous bone, indicate that MgTTCPM cement mixtures could be suitable biomaterials for use in the treatment of bone defects.

Engineering 3D Printed Scaffolds with Tunable Hydroxyapatite

Orthopedic and craniofacial surgical procedures require the reconstruction of bone defects caused by trauma, diseases, and tumor resection. Successful bone restoration entails the development and use of bone grafts with structural, functional, and biological features similar to native tissues. Herein, we developed three-dimensional (3D) printed fine-tuned hydroxyapatite (HA) biomimetic bone structures, which can be applied as grafts, by using calcium phosphate cement (CPC) bioink, which is composed of tetracalcium phosphate (TTCP), dicalcium phosphate anhydrous (DCPA), and a liquid [Polyvinyl butyral (PVB) dissolved in ethanol (EtOH)]. The ink was ejected through a high-resolution syringe nozzle (210 µm) at room temperature into three different concentrations (0.01, 0.1, and 0.5) mol/L of the aqueous sodium phosphate dibasic (Na₂HPO₄) bath that serves as a hardening accelerator for HA formation. Raman spectrometer, X-ray diffraction (XRD), and scanning electron microscopy (SEM) demonstrated the real-time HA formation in (0.01, 0.1, and 0.5) mol/L Na₂HPO₄ baths. Under those conditions_, HA was formed at different amounts, which tuned the scaffolds’ mechanical properties, porosity, and osteoclast activity. Overall, this method may pave the way to engineer 3D bone scaffolds with controlled HA composition and pre-defined properties, which will enhance graft-host integration in various anatomic locations.

Interfacial Compatibilization into PLA/Mg Composites for Improved In Vitro Bioactivity and Stem Cell Adhesion

The present work highlights the crucial role of the interfacial compatibilization on the design of polylactic acid (PLA)/Magnesium (Mg) composites for bone regeneration applications. In this regard, an amphiphilic poly(ethylene oxide-b-L,L-lactide) diblock copolymer with predefined composition was synthesised and used as a new interface to provide physical interactions between the metallic filler and the biopolymer matrix. This strategy allowed (i) overcoming the PLA/Mg interfacial adhesion weakness and (ii) modulating the composite hydrophilicity, bioactivity and biological behaviour. First, a full study of the influence of the copolymer incorporation on the morphological, wettability, thermal, thermo-mechanical and mechanical properties of PLA/Mg was investigated. Subsequently, the bioactivity was assessed during an in vitro degradation in simulated body fluid (SBF). Finally, biological studies with stem cells were carried out. The results showed an increase of the interfacial adhesion by the formation of a new interphase between the hydrophobic PLA matrix and the hydrophilic Mg filler. This interface stabilization was confirmed by a decrease in the damping factor (tanδ) following the copolymer addition. The latter also proves the beneficial effect of the composite hydrophilicity by selective surface localization of the hydrophilic PEO leading to a significant increase in the protein adsorption. Furthermore, hydroxyapatite was formed in bulk after 8 weeks of immersion in the SBF, suggesting that the bioactivity will be noticeably improved by the addition of the diblock copolymer. This ceramic could react as a natural bonding junction between the designed implant and the fractured bone during osteoregeneration. On the other hand, a slight decrease of the composite mechanical performances was noted.

Improved Anti-Washout Property of Calcium Sulfate/Tri-Calcium Phosphate Premixed Bone Substitute with Glycerin and Hydroxypropyl Methylcellulose

Calcium sulfate/calcium phosphate (CS-CP)-based bone substitutes have been developed in premixed putty for usage in clinical applications. However, it is difficult to completely stop the bleeding during an operation because premixed putty can come into contact with blood or body fluids leading to disintegration. Under certain conditions depending on particle size and morphology, collapsed (washed) particles can cause inflammation and delay bone healing. In this context, anti-washout premixed putty CS-CP was prepared by mixing glycerin with 1, 2, and 4 wt% of hydroxypropyl methylcellulose (HPMC), and the resultant anti-washout properties were evaluated. The results showed that more than 70% of the premixed putty without HPMC was disintegrated after being immersed into simulated body fluid (SBF) for 15 min. The results demonstrated that the more HPMC was contained in the premixed putty, the less disintegration occurred. We conclude that CS-CP pre-mixed putty with glycerin and HPMC is a potential bone substitute that has good anti-washout properties for clinical applications.

Strength and Biocompatibility of Heparin-Based Calcium Phosphate Cement Grafted with Ferulic Acid

The biomimetic synthesis of carbonated apatites by biomolecule-based templates is a promising way for broadening apatite applications in bone tissue regeneration. In this work, heparin was used as an organic template to prepare uniform carbonate-based apatite nanorods (CHA) and graft ferulic acid (F-CHA) for enhanced bone mineralization. Next, by combining calcium phosphate cement (CPC) with different F-CHA/CPC ratios, a new type of injectable bone cement combined with F-CHA bioactive apatite was developed (CPC + F-CHA). The physicochemical properties, biocompatibility, and mineralization potential of the CPC + F-CHA composites were determined in vitro. The experimental results confirmed the preparation of highly biocompatible CHA and the compatibility of F-CHA with CPC. Although CPC + F-CHA composites with F-CHA (2.5 wt%, 5 wt%, and 10 wt%) showed a significant reduction in compressive strength (CS), compositing CPC with 10 wt% F-CHA yielded a CS suitable for orthopedic repair (CS still larger than 30 MPa). Spectroscopic and phase analyses revealed that the phase of the hydrothermally synthesized CHA product was not modified by the heparin template. Injection and disintegration tests indicated that the CPC + F-CHA composites have good biocompatibility even at 10 wt% F-CHA. D1 osteoprogenitor cells were cultured with the composites for 7 days in vitro, and the CPC + 10%F-CHA group demonstrated significantly promoted cell mineralization compared with other groups. Given these results, the use of over 10% F-CHA in CPC composites should be avoided if the latter is to be applied to load-bearing areas. A stress-shielding device may also be recommended to stabilize these areas. These newly developed biocompatible CPC + F-CHA have great potential as osteoconductive bone fillers for bone tissue engineering.

A bone replacement-type calcium phosphate cement that becomes more porous in vivo by incorporating a degradable polymer

This study investigated whether mixing low viscosity alginic acid with calcium phosphate cement (CPC) causes interconnected porosity in the CPC and enhances bone replacement by improving the biological interactions. Furthermore, we hypothesized that low viscosity alginic acid would shorten the setting time of CPC and improve its strength. CPC samples were prepared with 0, 5, 10, and 20% low viscosity alginic acid. After immersion in acetate buffer, possible porosification in CPC was monitored in vitro using scanning electron microscopy (SEM), and the setting times and compressive strengths were measured. In vivo study was conducted by placing CPC in a hole created on the femur of New Zealand white rabbit. Microcomputed tomography and histological examination were performed 6 weeks after implantation. SEM images confirmed that alginic acid enhanced the porosity of CPC compared to the control, and the setting time and compressive strength also improved. When incorporating a maximum amount of alginic acid, the new bone mass was significantly higher than the control group (P = 0.0153). These biological responses are promising for the translation of these biomaterials and their commercialization for clinic applications.

Combination of biocompatible hydrogel precursors to apatitic calcium phosphate cements (CPCs): Influence of the in situ hydrogel reticulation on the CPC properties

In the field of bone regenerative medicine, injectable calcium phosphate cements (CPCs) are used for decades in clinics, as bone void fillers. Most often preformed polymers (e.g., hyaluronic acid, collagen, chitosan, cellulose ethers…) are introduced in the CPC formulation to make it injectable and improve its cohesion. Once the cement has hardened, the polymer is simply trapped in the CPC structure and no organic subnetwork is present. By contrast, in this work a CPC was combined with organic monomers that reticulated in situ so that a continuous biocompatible 3D polymeric subnetwork was formed in the CPC microstructure, resulting in a higher permeability of the CPC, which might allow to accelerate its in vivo degradation. Two options were investigated depending on whether the polymer was formed before the apatitic inorganic network or concomitantly. In the former case, conditions were found to reach a suitable rheology for easy injection of the composite. In addition, the in situ formed polymer was shown to strongly affect the size, density, and arrangement of the apatite crystals formed during the setting reaction, thereby offering an original route to modulate the microstructure and porosity of apatitic cements.

In vivo resorption of injectable apatitic calcium phosphate cements: Critical role of the intergranular microstructure

The in vivo resorption rate of two injectable apatitic calcium phosphate cements used in clinics (Graftys® HBS and NORIAN®) was compared, using a good laboratory practice (GLP) study based on an animal model of critical-sized bone defect. To rationalize the markedly different biological properties observed for both cements, key physical features were investigated, including permeability and water-accessible porosity, total porosity measured by mercury intrusion and gravimetry, and microstructure. Due to a different concept for creating porosity between the two cements investigated in this study, a markedly different microstructural arrangement of apatite crystals was observed in the intergranular space, which was found to significantly influence both the mechanical strength and in vivo degradation of the two calcium phosphate cements.

[Mechanical properties and effect on osteodifferentiation of induced pluripotent stem cells of chitosan/whisker/calcium phosphate cement composite biomaterial]

Objective

To investigate the mechanical properties of the novel compound calcium phosphate cement (CPC) biological material as well as the biological activity and osteogenesis effects of induced pluripotent stem cells (iPS) seeding on scaffold and compare their bone regeneration efficacy in cranial defects in rats.

Methods

Ac- cording to the different scaffold materials, the experiment was divided into 4 groups: pure CPC scaffold group (group A), CPC∶10% wt chitosan as 2∶1 ratio mixed scaffold group (group B), CPC∶10% wt chitosan∶whisker as 2∶1∶1 ratio mixed scaffold group (group C), and CPC∶10% wt chitosan∶whisker as 2∶1∶2 ratio mixed scaffold group (group D). Mechanical properties (bending strength, work-of-fracture, hardness, and modulus of elasticity) of each scaffold were detected. The scaffolds were cultured with fifth generation iPS-mesenchymal stem cells (MSCs), and the absorbance ( A) values of each group were detected at 1, 3, 7, and 14 days by cell counting kit 8 (CCK-8) method; the alkaline phosphatase (ALP) activity, Live/Dead fluorescence staining and quantitative detection, ALP, Runx2, collagen typeⅠ, osteocalcin (OC), and bone morphogenetic protein 2 (BMP-2) gene expressions by RT-PCR were detected at 1, 7, and 14 days; and the alizarin red staining were detected at 1, 7, 14, and 21 days. Twenty-four 3-month-old male Sprague Dawley rats were used to establish the 8 mm-long skull bone defect model, and were randomly divided into 4 groups ( n=6); 4 kinds of scaffold materials were implanted respectively. After 8 weeks, HE staining was used to observe the repair of bone defects and to detect the percentage of new bone volume and the density of neovascularization.

Results

The bending strength, work-of-fracture, hardness, and modulus of elasticity in groups B, C, and D were significantly higher than those in group A, and in groups C, D than in group B, and in group D than in group C ( P<0.05). CCK-8 assay showed that cell activity gradually increased with the increase of culture time, the A values in groups B, C, and D at 3, 7, 14 days were signifiantly higher than those in group A, and in groups C, D than in group B ( P<0.05), but no significant difference was found between groups C and D ( P>0.05). Live/Dead fluorescence staining showed that the proportion of living cells in groups B, C, and D at 7 and 14 days was significantly higher than that in group A ( P<0.05), and in groups C, D at 7 days than in group B ( P<0.05); but no significant difference was found between groups C and D ( P>0.05). RT-PCR showed that the relative expressions of genes in groups B, C, and D at 7 and 14 days were significantly higher than those in group A, and in groups C, D than in group B ( P<0.05); but no significant difference was found between groups C and D ( P>0.05). Alizarin red staining showed that the red calcium deposition on the surface of scaffolds gradually deepened and thickened with the prolongation of culture time; the A values in groups B, C, and D at 14 and 21 days were significantly higher than those in group A ( P<0.05), and in groups C and D than in group B ( P<0.05), but no significant difference was found between groups C and D ( P>0.05). In vivo repair experiments in animals showed that the new bone in each group was mainly filled with the space of scaffold material. Osteoblasts and neovascularization were surrounded by new bone tissue in the matrix, and osteoblasts were arranged on the new bone boundary. The new bone in groups B, C, and D increased significantly when compared with group A, and the new bone in groups C and D was significantly higher than that in group B. The percentage of new bone volume and the density of neovascularization in groups B, C, and D were significantly higher than those in group A, and in groups C and D than in group B ( P<0.05); but no significant difference was found between groups C and D ( P>0.05).

Conclusion

The mechanical properties of the new reinforced composite scaffold made from composite chitosan, whisker, and CPC are obviously better than that of pure CPC scaffold material, which can meet the mechanical properties of cortical bone and cancellous bone. iPS-MSCs is attaching and proliferating on the new reinforced composite scaffold material, and the repair effect of bone tissue is good. It can meet the biological and osteogenic activity requirements of the implant materials in the bone defect repair.

Incorporation of chitosan-alginate complex into injectable calcium phosphate cement system as a bone graft material

Calcium phosphate brushite type of cements have been used to replace bone graft materials because of their biocompatibility and other attractive features. Especially, injectability of cement allows easy handling of minimally invasive surgical techniques. New calcium phosphate cement (CPC) system, brushite based cement incorporated into polyelectrolyte complex, was developed in this study. Chitosan-alginate complex produced by an interaction between a cationic polymer (chitosan) and an anionic polymer (alginate) was loaded in the cement. This improved the functional properties and biocompatibility of the final cement. We optimized the liquid/solid (L/S) ratio of the cement components and investigated the compressive strength, setting time, pH change of CPC0 (with only citric acid) and CPC0.5, 1, and 1.5 (0.5, 1, and 1.5 v/v % chitosan-alginate complex in citric acid solution, respectively). The L/S ratio did not affect structural formation, while the addition of polymer complex showed new formation of macro-pores within CPC. However, a lower L/S ratio and higher amount of added polymer complex shortened the setting time and improved the compressive strength. The appropriate conditions for the injectable bone substitute were CPC1 with an L/S ratio of 0.45. To investigate the effect of the chitosan-alginate complex on CPC system in physiological conditions, CPC0 and CPC1 were implanted in a rabbit femoral head defect model for 1 and 3 months. Micro-computed tomography revealed improved bone formation in CPC1 compared to CPC0 3 months after implantation. Histological analysis revealed newly formed bone tissues around the peripheral sides of CPC0 and CPC1. The results indicate the potential value of the CPC system containing polymer complex as an injectable bone substitute. The study of the CPC-polymer complex system incorporating drugs or cells can be further developed into a controlled release system for faster bone regeneration.

Strontium-modified premixed calcium phosphate cements for the therapy of osteoporotic bone defects

In this study a premixed strontium-containing calcium phosphate bone cement for the application in osteoporotic bone defects has been developed and characterised regarding its material and in vitro properties as well as minimally invasive applicability in balloon kyphoplasty. Strontium was introduced into the cement by substitution of one precursor component, CaCO₃, with its strontium analogue, SrCO₃. Using a biocompatible oil phase as carrier liquid, a cement paste that only set upon contact with aqueous environment was obtained. Strontium modification resulted in an increased strength of set cements and radiographic contrast; and the cements released biologically relevant doses of Sr²⁺-ions that were shown to enhance osteoprogenitor cell proliferation and osteogenic differentiation. Finally, applicability of strontium-containing cement pastes in balloon kyphoplasty was demonstrated in a human cadaver spine procedure. The cement developed in this study may therefore be well suited for minimally invasive, osteoporosis-related bone defect treatment.

STATEMENT OF SIGNIFICANCE

Strontium-releasing calcium phosphate bone cements are promising materials for the clinical regeneration of osteoporosis-related bone defects since they have been shown to stimulate bone formation and at the same time limit osteoclastic bone resorption. Today clinical practice favours minimally invasive surgical techniques, e.g. for vertebral fracture treatment, posing special demands on such cements. We have therefore developed a premixed, strontium-releasing bone cement with enhanced mechanical properties and high radiographic visibility that releases biologically relevant strontium concentrations and thus stimulates cells of the osteogenic lineage. In a pilot experiment we also exemplify its excellent suitability for minimally invasive balloon kyphoplasty procedures.

Influence of gamma and electron beam sterilization on the stability of a premixed injectable calcium phosphate cement for trauma indications

Premixed calcium phosphate cements (CPC's) are becoming the material of choice for injectable cements as a result of their effective delivery to the target implantation site. For orthopaedic use, it is of vital importance that the attributes of these CPC's are not compromised by irradiation sterilization. Therefore, the aim of this study is to determine the influence of irradiation sterilization on a range of premixed CPC's, with an emphasis on improving product shelf life through the use of optimal packaging configurations and annealing steps. Electron spin resonance (ESR) confirmed the presence of free radicals in the inorganic phase of the CPC paste following irradiation. The inclusion of a 24-h annealing step was the only successful method in reducing the degree of free radical formation. Based on the results of injectability force testing, it was revealed that an annealing step greater than 24-h significantly altered the viscosity, however; at 24-h the key attributes of the CPC paste were minimally effected. Overall, it was established that vacuum packing the CPC paste, placing the contents into a foil pouch, gamma irradiating at the minimal dose required and using an annealing step of ≤ 24-h, has the potential to extend the shelf life of the cement.

Magnetic Field Effects on Bone Repair after Calcium Phosphate Cement Implants: Histometric and Biochemistry Evaluation

OBJECTIVE

This work evaluated histologic and biochemically the effect of magnetic field buried in bone repair after autogenous bone graft and calcium phosphate cement implants.

METHODOLOGY

Bone defects with 5,0 mm of diameter in the cranium of Wistar mice were used to analyse. These mice were submitted to different interventions: autogenous bone graft and calcium phosphate cement implants, both with and without magnetic stimulation. Longitudinal and transversal histometric and biochemistry analysis were made in times of 15, 30 and 60 post-operative days.

RESULTS

The histometric transversal analysis did not show significant differences in the bone repair between groups. Longitudinally, significant difference were found in the quantity of neoformed bone between the times 15 and 60 post-operative days in the autogenous bone graft group under magnetic stimulation. The alkaline phosphatase enzyme presented a higher activity in 30 post-operative days and the groups under magnetic stimulation presented reduced enzymatic activity in comparison to the other groups.

CONCLUSION

The permanent and static magnetic field promoted significant differences in the neoformed bone in the groups autogenous bone graft.

Regeneration of periapical lesions post-endodontic treatment and periapical surgeries in experimental animals utilizing thermo-responsive nano-β-tricalcium phosphate/chitosan hydrogel: a proof of concept

Using phosphate nanoparticles/polymeric hydrogels presents an interesting approach, especially concerning the reduced particle migration and enhanced biocompatibility. The current work aims to achieve a proof of concept for the development of a thermo-sensitive nano β-tricalcium phosphate (β-TCP)/chitosan (Cs)/glycerophosphate (Gl)/glyoxal (Gly) hydrogel to be applied in periapical surgeries post endodontic treatment. Physicochemical characterization using x-ray powder diffraction, Fourier transform infrared, TEM and SEM was performed. Bone formation efficiency of the achieved β-TCP/Cs/Gl/Gly hydrogel was followed. The composite gels were tested in vivo in dogs in comparison with the commercially available and surgically applied Klipdent-PL^® up to three months. Radiographic examinations were performed. Histological evaluations were achieved through histomorphological criteria being apical cementum surface, bone tissue resorption, apical PDL thickness, the intensity of inflammatory reaction and osseous repair. The cytotoxicity results proved the safety of the developed hydrogel. The thermo-sensitive hydrogel possessed comparable enhanced biocompatibility with anti-inflammatory activity. New bone formation was clearly enhanced in the infected teeth. Therefore, it can be directly applied in specific non-invasive dental surgeries.

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.

cmRNA/lipoplex encapsulation in PLGA microspheres enables transfection via calcium phosphate cement (CPC)/PLGA composites

In this study lipoplexes containing chemically modified messenger RNA (cmRNA) were incorporated into poly (lactic-co-glycolic acid) (PLGA) microspheres via water-in-oil-in-water (W/O/W) double emulsion solvent evaporation technique. The nanoparticle encapsulation by microparticle formation was optimized to achieve lipoplex release and maximum transfection efficiency in surrounding cells. It was possible to adjust characteristic features in surface topology and size of the PLGA-microspheres by varying the extent of lipoplex loading into the polymer matrix. The partial release of lipids and mRNA out of the microparticle system, their accumulation in cells and the production of encoded protein were visualized via fluorescence microscopy. These bioactive microspheres, containing cmRNA bearing lipoplexes, were developed for the incorporation of a therapeutic component into injectable calcium phosphate cements (CPC). Due to the incorporation of PLGA/lipoplex microspheres as a degradable entity, the porosity of the cement phase could additionally be adjusted. This approach of complex nanoparticle incorporation into polymer/cement composites represents a promising example for combining transcript therapy with biomechanical engineering.

Self-hardening and thermoresponsive alpha tricalcium phosphate/pluronic pastes

Although calcium phosphate cements (CPCs) are used for bone regeneration in a wide range of clinical applications, various physicochemical phenomena are known to hinder their potential use in minimally invasive surgery or in highly vascularized surgical sites, mainly because of their lack of injectability or their low washout resistance. The present work shows that the combination of CPCs with an inverse-thermoresponsive hydrogel is a good strategy for finely tuning the cohesive and rheological properties of CPCs to achieve clinical acceptable injectability to prevent phase separation during implantation and cohesion to avoid washout of the paste. The thermoresponsive CPC developed combines alpha-tricalcium phosphate with an aqueous solution of pluronic F127, which exhibits an inverse thermoresponsive behaviour, with a gelling transformation at around body temperature. These novel CPCs exhibited temperature-dependent properties. Addition of the polymer enhanced the injectability of the paste, even at a low liquid-to-powder ratio, and allowed the rheological properties of the cement to be tuned, with the injection force decreasing with the temperature of the paste. Moreover, the cohesion of the paste was also temperature-dependent and increased as the temperature of the host medium increased due to gelling induced in the paste. The thermoresponsive cement exhibited excellent cohesion and clinically acceptable setting times at 37°C, irrespective of the initial temperature of the paste. The addition of pluronic F127 slightly delayed the setting reaction in the early stages but did not hinder the full transformation to calcium-deficient hydroxyapatite. Moreover, the frozen storage of premixed thermoresponsive cement pastes was explored, the main physicochemical properties of the cements being maintained upon thawing, even after 18months of frozen storage. This avoids the need to mix the cement in the operating theatre and allows its use off-the-shelf. The reverse thermoresponsive cements studied herein open up new perspectives in the surgical field, where the sequential gelling/hardening of these novel cements could allow for a better and safer clinical application.

STATEMENT OF SIGNIFICANCE

Calcium phosphate cements are attractive bone substitutes due to their similarity to the bone mineral phase. Although they can be injectable, cohesion and stability of the paste are crucial in terms of performance and safety. A common strategy is the combination with hydrogels. However, this often results in a decrease of viscosity with increasing temperature, which can lead to extravasation and particle leakage from the bone defect. The preferred evolution would be the opposite: a low viscosity would enhance mixing and injection, and an instantaneous increase of viscosity after injection would ensure washout resistance to the blood flow. Here we develop for the first time a calcium phosphate cement exhibiting reverse thermoresponsive properties using a poloxamer featuring inverse thermal gelling.

Hydrogel fibers encapsulating human stem cells in an injectable calcium phosphate scaffold for bone tissue engineering

Human induced pluripotent stem cells (hiPSCs), human embryonic stem cells (hESCs) and human umbilical cord mesenchymal stem cells (hUCMSCs) are exciting cell sources for use in regenerative medicine. There have been no reports on long hydrogel fibers encapsulating stem cells inside an injectable calcium phosphate cement (CPC) scaffold for bone tissue engineering. The objectives of this study were: (1) to develop a novel injectable CPC construct containing hydrogel fibers encapsulating cells for bone engineering, and (2) to investigate and compare cell viability, proliferation and osteogenic differentiation of hiPSC-MSCs, hESC-MSCs and hUCMSCs in injectable CPC. The pastes encapsulating the stem cells were fully injectable under a small injection force, and the injection did not harm the cells, compared with non-injected cells (p  >  0.1). The mechanical properties of the stem cell-CPC construct were much better than those of previous injectable polymers and hydrogels for cell delivery. The hiPSC-MSCs, hESC-MSCs and hUCMSCs in hydrogel fibers in CPC had excellent proliferation and osteogenic differentiation. All three cell types yielded high alkaline phosphatase, runt-related transcription factor, collagen I and osteocalcin expression (mean  ±  SD; n  =  6). Cell-synthesized minerals increased substantially with time (p  <  0.05), with no significant difference among the three types of cells (p  >  0.1). Mineralization by hiPSC-MSCs, hESC-MSCs and hUCMSCs in CPC at 14 d was 13-fold that at 1 d. In conclusion, all three types of cells (hiPSC-MSCs, hESC-MSCs and hUCMSCs) in a CPC scaffold showed high potential for bone tissue engineering, and the novel injectable CPC construct with cell-encapsulating hydrogel fibers is promising for enhancing bone regeneration in dental, craniofacial and orthopedic applications.

Injectable calcium phosphate with hydrogel fibers encapsulating induced pluripotent, dental pulp and bone marrow stem cells for bone repair

Human induced pluripotent stem cell-derived mesenchymal stem cells (hiPSC-MSCs), dental pulp stem cells (hDPSCs) and bone marrow MSCs (hBMSCs) are exciting cell sources in regenerative medicine. However, there has been no report comparing hDPSCs, hBMSCs and hiPSC-MSCs for bone engineering in an injectable calcium phosphate cement (CPC) scaffold. The objectives of this study were to: (1) develop a novel injectable CPC containing hydrogel fibers encapsulating stem cells for bone engineering, and (2) compare cell viability, proliferation and osteogenic differentiation of hDPSCs, hiPSC-MSCs from bone marrow (BM-hiPSC-MSCs) and from foreskin (FS-hiPSC-MSCs), and hBMSCs in CPC for the first time. The results showed that the injection did not harm cell viability. The porosity of injectable CPC was 62%. All four types of cells proliferated and differentiated down the osteogenic lineage inside hydrogel fibers in CPC. hDPSCs, BM-hiPSC-MSCs, and hBMSCs exhibited high alkaline phosphatase, runt-related transcription factor, collagen I, and osteocalcin gene expressions. Cell-synthesized minerals increased with time (p<0.05), with no significant difference among hDPSCs, BM-hiPSC-MSCs and hBMSCs (p>0.1). Mineralization by hDPSCs, BM-hiPSC-MSCs, and hBMSCs inside CPC at 14d was 14-fold that at 1d. FS-hiPSC-MSCs were inferior in osteogenic differentiation compared to the other cells. In conclusion, hDPSCs, BM-hiPSC-MSCs and hBMSCs are similarly and highly promising for bone tissue engineering; however, FS-hiPSC-MSCs were relatively inferior in osteogenesis. The novel injectable CPC with cell-encapsulating hydrogel fibers may enhance bone regeneration in dental, craniofacial and orthopedic applications.

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.

Novel bone wax based on poly(ethylene glycol)-calcium phosphate cement mixtures

Classic bone wax is associated with drawbacks such as the risk of infection, inflammation and hindered osteogenesis. Here, we developed a novel self-setting bone wax on the basis of hydrophilic poly(ethylene glycol) (PEG) and hydroxyapatite (HA) forming calcium phosphate cement (CPC), to overcome the problems that are linked to the use of conventional beeswax systems. Amounts of up to 10 wt.% of pregelatinized starch were additionally supplemented as hemostatic agent. After exposure to a humid environment, the PEG phase dissolved and was exchanged by penetrating water that interacted with the HA precursor (tetracalcium phosphate (TTCP)/monetite) to form highly porous, nanocrystalline HA via a dissolution/precipitation reaction. Simultaneously, pregelatinized starch could gel and supply the bone wax with liquid sealing features. The novel bone wax formulation was found to be cohesive, malleable and after hardening under aqueous conditions, it had a mechanical performance (∼2.5 MPa compressive strength) that is comparable to that of cancellous bone. It withstood systolic blood pressure conditions for several days and showed antibacterial properties for almost one week, even though 60% of the incorporated drug vancomycin hydrochloride was already released after 8h of deposition by diffusion controlled processes.

STATEMENT OF SIGNIFICANCE

The study investigated the development of alternative bone waxes on the basis of a hydroxyapatite (HA) forming calcium phosphate cement (CPC) system. Conventional bone waxes are composed of non-biodegradable beeswax/vaseline mixtures that are often linked to infection, inflammation and hindered osteogenesis. We combined the usage of bioresorbable polymers, the supplementation with hemostatic agents and the incorporation of a mineral component to overcome those drawbacks. Self-setting CPC precursors (tetracalcium phosphate (TTCP), monetite) were embedded in a resorbable matrix of poly(ethylene glycol) (PEG) and supplemented with pregelatinized starch. This formulation was found to be malleable and cohesive underwater. While immersion in an aqueous environment, CPC precursors formed highly porous, nanocrystalline HA via dissolution/precipitation reaction as water penetrated the novel wax formulation and PEG molecules simultaneously dissolved. The bone wax further withstood blood pressure conditions. After hardening, mechanical performance was comparable to that of cancellous bone and we also successfully provided the bone wax with antibacterial properties. In our opinion, the described bone wax formulation outmatches conventional bone waxes, as it circumvents the detriments being associated with the term "bone wax". Our wax has a novel composition and would broaden the application of CPC and besides, the general interest in bone waxes will increase, as they were long considered as a "first-line treatment" to avoid.

Electrospun poly (3-hydroxybutyrate-co-3-hydroxyvalerate)/hydroxyapatite scaffold with unrestricted somatic stem cells for bone regeneration

The combination of scaffolds and cells can be useful in tissue reconstruction. In this study, nanofibrous poly (3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBV)/nanohydroxyapatite (nano-HAp) scaffolds, filled with unrestricted somatic stem cells (USSCs), were used for healing calvarial bone in rat model. The healing effects of these scaffolds, with and without stem cells, in bone regeneration were investigated by computed tomography (CT) analysis and pathology assays after 28 days of grafting. The results of CT analysis showed that bone regeneration on the scaffolds, and the amounts of regenerated new bone for polymer/nano-HAp scaffold with USSC, was significantly greater than the scaffold without cell and untreated control samples. Therefore, the combination of scaffold especially with USSC could be considered as a useful method for bone regeneration.

A review on carrier systems for bone morphogenetic protein-2

Bone morphogenetic protein-2 (BMP-2) has unique bone regeneration property. The powerful osteoinductive nature makes it considered as second line of therapy in nonunion bone defect. A large number of carriers and delivery systems made up of different materials have been investigated for controlled and sustained release of BMP-2. The delivery systems are in the form of hydrogel, microsphere, nanoparticles, and fibers. The carriers used for the delivery are made up of metals, ceramics, polymers, and composites. Implantation of these protein-loaded carrier leads to cell adhesion, degradation which eventually releases the drug/protein at site specific. But, problems like ectopic growth, lesser protein delivery, inactivation of the protein are reported in the available carrier systems. Therefore, it is need of an hour to modify the available carrier systems as well as explore other biomaterials with desired properties. In this review, all the reported carrier systems made of metals, ceramics, polymers, composites are evaluated in terms of their processing conditions, loading capacity and release pattern of BMP-2. Along with these biomaterials, the attempts of protein modification by adding some functional group to BMP-2 or extracting functional peptides from the protein to achieve the desired effect, is also evaluated. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 904-925, 2017.

Improvement of bioactivity, degradability, and cytocompatibility of biocement by addition of mesoporous magnesium silicate into sodium-magnesium phosphate cement

A novel mesoporous magnesium-based cement (MBC) was fabricated by using the mixed powders of magnesium oxide, sodium dihydrogen phosphate, and mesoporous magnesium silicate (m-MS). The results indicate that the setting time and water absorption of the MBC increased as a function of increasing m-MS content, while compressive strength decreased. In addition, the degradability of the MBC in a solution of Tris-HCl and the ability of apatite formation on the MBC were significantly improved with the increase in m-MS content. In cell culture experiments, the results show that the attachment, proliferation, and alkaline phosphatase activity of the MC3T3-E1 cells on the MBC were significantly enhanced with the increase of the content of m-MS. It can be suggested that the MBC with good cytocompatibility could promote the proliferation and differentiation of the MC3T3-E1 cells. In short, our findings indicate that the MBC containing m-MS had promising potential as a new biocement for bone regeneration and repair applications.

Calcium Orthophosphate-Containing Biocomposites and Hybrid Biomaterials for Biomedical Applications

The state-of-the-art on calcium orthophosphate (CaPO4)-containing biocomposites and hybrid biomaterials suitable for biomedical applications is presented. Since these types of biomaterials offer many significant and exciting possibilities for hard tissue regeneration, this subject belongs to a rapidly expanding area of biomedical research. Through the successful combinations of the desired properties of matrix materials with those of fillers (in such systems, CaPO4 might play either role), innovative bone graft biomaterials can be designed. Various types of CaPO4-based biocomposites and hybrid biomaterials those are either already in use or being investigated for biomedical applications are extensively discussed. Many different formulations in terms of the material constituents, fabrication technologies, structural and bioactive properties, as well as both in vitro and in vivo characteristics have been already proposed. Among the others, the nano-structurally controlled biocomposites, those containing nanodimensional compounds, biomimetically fabricated formulations with collagen, chitin and/or gelatin, as well as various functionally graded structures seem to be the most promising candidates for clinical applications. The specific advantages of using CaPO4-based biocomposites and hybrid biomaterials in the selected applications are highlighted. As the way from a laboratory to a hospital is a long one and the prospective biomedical candidates have to meet many different necessities, the critical issues and scientific challenges that require further research and development are also examined.

Effect of microstructure characteristics on tetracalcium phosphate-nanomonetite cement in vitro cytotoxicity

MC3T3E1 murine pre-osteoblastic cells were used to evaluate the cytotoxicity of tetracalcium phosphate (TTCP)-nanomonetite (DCPA) cement. The starting cement powder mixture was prepared by the in situ reaction between TTCP and a diluted solution of orthophosphoric acid in a planetary ball mill. The cements in the form of pressed cement powder mixture discs differ from each other by the method of pre-treatment and degree of the transformation of cement components in phosphate-buffered saline (PBS). For the evaluation of TTCP-DCPA cement to be non-cytotoxic, it was sufficient to apply the short-time soaking in PBS solution, regardless of whether the cement components were completely transformed or not. If the texture motif and hydroxyapatite particle morphology were properly developed during the initial stage of hardening, the cement cytotoxicity or osteoblast proliferation were insignificantly influenced by the soaking time or the texture stability during cell cultivation, but the lattice ordering enhanced cell proliferation. Results showed that the surface texture and the hydroxyapatite particle morphology are crucial for in vitro cement cytotoxicity evaluation.

Preformed chitosan cryogel-biphasic calcium phosphate: a potential injectable biocomposite for pathologic fracture

The increasing interest in chitosan-based biomaterials stems from its desirable physicochemical properties. Although calcium phosphates have been mixed with chitosan to form injectable scaffolds, its application for bone tissue engineering has been limited and is still being explored to improve its clinical translatability. We report a biocomposite comprised of preformed chitosan cryogel with dispersed biphasic calcium phosphate that can flow under moderate pressure allowing passage through a small gauge needle, while maintaining sufficient integrity and strength during injection for gel recovery. The formed samples were characterized by Fourier transform infrared spectroscopy, scanning electron microscopy, X-ray diffraction analysis and protein adsorption measurements. Composite with 1% w/v biphasic calcium phosphate (CSG1) resulted in a homogeneous and rigid final structure. Injectable composite cryogel CSG1 (2.5 ± 0.2 N, 23G needle) exhibited good protein adsorption and biocompatibility. Results of subcutaneous implantation in rats reveal relatively high presence of polymorphonuclear cells but with no fibrous encapsulation with the composites, allowing further infiltration of cells within the sample implants. The biocomposite system presents a less-invasive delivery of bone filling material for stabilizing pathologic fractures.

Fast setting and anti-washout injectable calcium–magnesium phosphate cement for minimally invasive treatment of bone defects

The fa-ICMPC exhibited potent anti-washout properties, fast setting, improved injectability, good biodegradability and osteoconductivity.

Calcium phosphate cement – gelatin powder composite testing in canine models: Clinical implications for treatment of bone defects

Previous studies have reported the excellent biocompatibility of calcium phosphate cement. However, calcium phosphate cement needs further improvement in order for it to promote bone replacement and eventual bone substitution, as it exhibits slow biodegradability and thus remains in the body over an extended period of time. In this study, we mixed calcium phosphate cement with gelatin powder in order to create a composite containing macropores with interconnectivity, and we then implanted it into canine femurs from the diaphysis to the distal metaphysis. Eight dogs were divided into the sham group, the control (C0) group with 100 wt% calcium phosphate cement, the C10 group with 90 wt% calcium phosphate cement and 10 wt% gelatin powder, and the C15 group with 85 wt% calcium phosphate cement and 15 wt% gelatin powder. Bone replaceability in C10 and C15 at 3 and 6 months was evaluated by radiography, micro-CT, histomorphometry, and mineral apposition rate. New bone formation was seen in C10 and C15 although that was not seen in C0 at six months. The mineral apposition rate was significantly higher in C15 than in C10 in both the diaphysis and metaphysis, and the composite was found to have excellent biodegradability and bone replaceability in canine subjects. As the composite is easily and rapidly prepared, it is likely to become a new bone substitute for use in clinical settings.

Injectable smart phase-transformation implants for highly efficient in vivo magnetic-hyperthermia regression of tumors

A minimally invasive, highly efficient and versatile strategy is proposed for localized tumor regression by developing a smart injectable liquid-solid phase-transformation organic-inorganic hybrid composite material, i.e., magnetic-Fe-powder-dispersed PLGA (Fe/PLGA) implants for magnetic hyperthermia therapy of cancer.

Inflammation-induced drug release by using a pH-responsive gas-generating hollow-microsphere system for the treatment of osteomyelitis

In the conventional treatment of osteomyelitis, the penetration of antibiotics into the infected bone is commonly poor. To ensure that the local antibiotic concentration is adequate, this work develops an injectable calcium phosphate (CP) cement in which is embedded pH-responsive hollow microspheres (HMs) that can control the release of a drug according to the local pH. The HMs are fabricated using a microfluidic device, with a shell of poly(D,L-lactic-co-glycolic acid) (PLGA) and an aqueous core that contains vancomycin (Van) and NaHCO3. At neutral pH, the CP/HM cement elutes a negligible concentration of the drug. In an acidic environment, the NaHCO3 that is encapsulated in the HMs reacts with the acid rapidly to generate CO2 bubbles, disrupting the PLGA shells and thereby releasing Van locally in excess of a therapeutic threshold. The feasibility of using this CP/HM cement to treat osteomyelitis is studied using a rabbit model. Analytical results reveal that the CP/HM cement provides highly effective local antibacterial activity. Histological examination further verifies the efficacy of the treatment by the CP/HM cement. The above findings suggest that the CP/HM cement is a highly efficient system for the local delivery of antibiotics in the treatment of osteomyelitis.

Bone tissue engineering via nanostructured calcium phosphate biomaterials and stem cells

Tissue engineering is promising to meet the increasing need for bone regeneration. Nanostructured calcium phosphate (CaP) biomaterials/scaffolds are of special interest as they share chemical/crystallographic similarities to inorganic components of bone. Three applications of nano-CaP are discussed in this review: nanostructured calcium phosphate cement (CPC); nano-CaP composites; and nano-CaP coatings. The interactions between stem cells and nano-CaP are highlighted, including cell attachment, orientation/morphology, differentiation and in vivo bone regeneration. Several trends can be seen: (i) nano-CaP biomaterials support stem cell attachment/proliferation and induce osteogenic differentiation, in some cases even without osteogenic supplements; (ii) the influence of nano-CaP surface patterns on cell alignment is not prominent due to non-uniform distribution of nano-crystals; (iii) nano-CaP can achieve better bone regeneration than conventional CaP biomaterials; (iv) combining stem cells with nano-CaP accelerates bone regeneration, the effect of which can be further enhanced by growth factors; and (v) cell microencapsulation in nano-CaP scaffolds is promising for bone tissue engineering. These understandings would help researchers to further uncover the underlying mechanisms and interactions in nano-CaP stem cell constructs in vitro and in vivo, tailor nano-CaP composite construct design and stem cell type selection to enhance cell function and bone regeneration, and translate laboratory findings to clinical treatments.

Structure, properties and animal study of a calcium phosphate/calcium sulfate composite cement

In-vitro and in-vivo studies have been conducted on an in-house-developed tetracalcium phosphate (TTCP)/dicalcium phosphate anhydrous (DCPA)/calcium sulfate hemihydrate (CSH)-derived composite cement. Unlike most commercial calcium-based cement pastes, the investigated cement paste can be directly injected into water and harden without dispersion. The viability value of cells incubated with a conditioned medium of cement extraction is >90% that of Al2O3 control and >80% that of blank medium. Histological examination reveals excellent bonding between host bone and cement without interposition of fibrous tissues. At 12 weeks-post implantation, significant remodeling activities are found and a new bone network is developed within the femoral defect. The 26-week samples show that the newly formed bone becomes more mature, while the interface between residual cement and the new bone appears less identifiable. Image analysis indicates that the resorption rate of the present cement is much higher than that of TTCP or TTCP/DCPA-derived cement under similar implantation conditions.

Ready-to-use injectable calcium phosphate bone cement paste as drug carrier

Current developments in calcium phosphate cement (CPC) technology concern the use of ready-to-use injectable cement pastes by dispersing the cement powder in a water-miscible solvent, such that, after injection into the physiological environment, setting of cements occurs by diffusion of water into the cement paste. It has also been demonstrated recently that the combination of a water-immiscible carrier liquid combined with suitable surfactants facilitates a discontinuous liquid exchange in CPC, enabling the cement setting reaction to take place. This paper reports on the use of these novel cement paste formulations as a controlled release system of antibiotics (gentamicin, vancomycin). Cement pastes were applied either as a one-component material, in which the solid drugs were physically dispersed, or as a two-component system, where the drugs were dissolved in an aqueous phase that was homogeneously mixed with the cement paste using a static mixing device during injection. Drug release profiles of both antibiotics from pre-mixed one- and two-component cements were characterized by an initial burst release of ∼7-28%, followed by a typical square root of time release kinetic for vancomycin. Gentamicin release rates also decreased during the first days of the release study, but after ∼1 week, the release rates were more or less constant over a period of several weeks. This anomalous release kinetic was attributed to participation of the sulfate counter ion in the cement setting reaction altering the drug solubility. The drug-loaded cement pastes showed high antimicrobial potency against Staphylococcus aureus in an agar diffusion test regime, while other cement properties such as mechanical performance or phase composition after setting were only marginally affected.