Controlled release of gentamicin from calcium phosphate—poly(lactic acid-co-glycolic acid) composite bone cement

Reinforcement of Calcium Phosphate Cement with Hybrid Silk Fibroin/Kappa-Carrageenan Nanofibers

Calcium phosphate cements (CPCs) offer a promising solution for treating bone defects due to their osteoconductive, injectable, biocompatible, and bone replacement properties. However, their brittle nature restricts their utilization to non-load-bearing applications. In this study, the impact of hybrid silk fibroin (SF) and kappa-carrageenan (k-CG) nanofibers as reinforcements in CPC was investigated. The CPC composite was fabricated by incorporating electrospun nanofibers in 1, 3, and 5% volume fractions. The morphology, mineralization, mechanical properties, setting time, injectability, cell adhesion, and mineralization of the CPC composites were analyzed. The results demonstrated that the addition of the nanofibers improved the CPC mixture, leading to an increase in compressive strength (14.8 ± 0.3 MPa compared to 8.1 ± 0.4 MPa of the unreinforced CPC). Similar improvements were seen in the bending strength and work fracture (WOF). The MC3T3-E1 cell culture experiments indicated that cells attached well to the surfaces of all cement samples and tended to join their adjacent cells. Additionally, the CPC composites showed higher cell mineralization after a culture period of 14 days, indicating that the SF/k-CG combination has potential for applications as a CPC reinforcement and bone cell regeneration promoter.

Injectable bone cement containing carboxymethyl cellulose microparticles as a silver delivery system able to reduce implant-associated infection risk

In the challenging quest for a solution to reduce the risk of implant-associated infections in bone substitution surgery, the use of silver ions is promising regarding its broad spectrum on planktonic, sessile as well as multiresistant bacteria. In view of controlling its delivery in situ at the desired dose, we investigated its encapsulation in carboxymethyl cellulose (CMC) microparticles by spray-drying and included the latter in the formulation of a self-setting calcium phosphate bone cement. We implemented an original step-by-step methodology starting from the in vitro study of the antibacterial properties and cytotoxicity of two silver salts of different solubility in aqueous medium and then in the cement to determine the range of silver loading able to confer anti-biofilm and non-cytotoxic properties to the biomaterial. A dose-dependent efficiency of silver was demonstrated on the main species involved in bone-implant infection (S. aureus and S. epidermidis). Loading silver in microspheres instead of loading it directly inside the cement permitted to avoid undesired silver-cement interactions during setting and led to a faster release of silver, i.e. to a higher dose released within the first days combining anti-biofilm activity and preserved cytocompatibility. In addition, a combined interest of the introduction of about 10% (w/w) silver-loaded CMC microspheres in the cement formulation was demonstrated leading to a fully injectable and highly porous (77%) cement, showing a compressive strength analogous to cancellous bone. This injectable silver-loaded biomimetic composite cement formulation constitutes a versatile bone substitute material with tunable drug delivery properties, able to fight against bone implant associated infection. STATEMENT OF SIGNIFICANCE: This study is based on two innovative scientific aspects regarding the literature: i) Choice of silver ions as antibacterial agent combined with their way of incorporation: Carboxymethylcellulose has never been tested into bone cement to control its drug loading and release properties. ii) Methodology to formulate an antibacterial and injectable bone cement: original and multidisciplinary step-by-step methodology to first define, through (micro)biological tests on two silver salts with different solubilities, the targeted range of silver dose to include in carboxymethylcellulose microspheres and, then optimization of silver-loaded microparticles processing to fulfill requirements (encapsulation efficiency and size). The obtained fully injectable composite controls the early delivery of active dose of silver (from 3 h and over 2 weeks) able to fight against bone implant-associated infections.

Fabrication of Radio-Opaque and Macroporous Injectable Calcium Phosphate Cement

The aim of this work was the development of injectable radio-opaque and macroporous calcium phosphate cement (CPC) to be used as a bone substitute for the treatment of pathologic vertebral fractures. A CPC was first rendered radio-opaque by the incorporation of zirconium dioxide (ZrO₂). In order to create macroporosity, poly lactic-co-glycolic acid (PLGA) microspheres around 100 μm were homogeneously incorporated into the CPC as observed by scanning electron microscopy. Physicochemical analyses by X-ray diffraction and Fourier transform infrared spectroscopy confirmed the brushite phase of the cement. The mechanical properties of the CPC/PLGA cement containing 30% PLGA (wt/wt) were characterized by a compressive strength of 2 MPa and a Young's modulus of 1 GPa. The CPC/PLGA exhibited initial and final setting times of 7 and 12 min, respectively. Although the incorporation of PLGA microspheres increased the force necessary to inject the cement and decreased the percentage of injected mass as a function of time, the CPC/PLGA appeared fully injectable at 4 min. Moreover, in comparison with CPC, CPC/PLGA showed a full degradation in 6 weeks (with 100% mass loss), and this was associated with an acidification of the medium containing the CPC/PLGA sample (pH of 3.5 after 6 weeks). A cell viability test validated CPC/PLGA biocompatibility, and in vivo analyses using a bone defect assay in the caudal vertebrae of Wistar rats showed the good opacity of the CPC through the tail and a significant increased degradation of the CPC/PLGA cement a month after implantation. In conclusion, this injectable CPC scaffold appears to be an interesting material for bone substitution.

Factors influencing the drug release from calcium phosphate cements

Thanks to their biocompatibility, biodegradability, injectability and self-setting properties, calcium phosphate cements (CPCs) have been the most economical and effective biomaterials of choice for use as bone void fillers. They have also been extensively used as drug delivery carriers owing to their ability to provide for a steady release of various organic molecules aiding the regeneration of defective bone, including primarily antibiotics and growth factors. This review provides a systematic compilation of studies that reported on the controlled release of drugs from CPCs in the last 25 years. The chemical, compositional and microstructural characteristics of these systems through which the control of the release rates and mechanisms could be achieved have been discussed. In doing so, the effects of (i) the chemistry of the matrix, (ii) porosity, (iii) additives, (iv) drug types, (v) drug concentrations, (vi) drug loading methods and (vii) release media have been distinguished and discussed individually. Kinetic specificities of in vivo release of drugs from CPCs have been reviewed, too. Understanding the kinetic and mechanistic correlations between the CPC properties and the drug release is a prerequisite for the design of bone void fillers with drug release profiles precisely tailored to the application area and the clinical picture. The goal of this review has been to shed light on these fundamental correlations.

Nano-hydroxyapatite as a delivery system: overview and advancements

Nano-hydroxyapatite is being investigated as vital components of implants and dental and tissue engineering devices. It is found as a bone replacement due to its non-toxicity and cytocompatibility with dental tissues and bone. The reality that nanocrystalline hydroxyapatite can be made of porous granules and scaffolds. Additionally, it has a massive loading potential indicating its use as a transporter for drugs or a regulated drug release mechanism in pharmaceutical research. This review aims to present existing nano-hydroxyapatite research developments as a drug carrier employed in bone tissue disorders locally and deliver poorly soluble drugs with reduced bioavailability. We have discussed the nano-hydroxyapatite role in the delivery of drugs (i.e. anti-resorptive, anti-cancer, and antibiotics), proteins, genetic material, and radionuclides.

Comparative efficacy of resorbable fiber wraps loaded with gentamicin sulfate or gallium maltolate in the treatment of osteomyelitis

The high incidence of osteomyelitis associated with critical-sized bone defects raises clinical challenges in fracture healing. Clinical use of antibiotic-loaded bone cement as an adjunct therapy is limited by incompatibility with many antimicrobials, sub-optimal release kinetics, and requirement of surgical removal. Furthermore, overuse of antibiotics can lead to bacterial modifications that increase efflux, decrease binding, or cause inactivation of the antibiotics. Herein, we compared the efficacy of gallium maltolate, a new metal-based antimicrobial, to gentamicin sulfate released from electrospun poly(lactic-co-glycolic) acid (PLGA) wraps in the treatment of osteomyelitis. In vitro evaluation demonstrated sustained release of each antimicrobial up to 14 days. A Kirby Bauer assay indicated that the gentamicin sulfate-loaded wrap inhibited the growth of osteomyelitis-derived isolates, comparable to the gentamicin sulfate powder control. In contrast, the gallium maltolate-loaded wrap did not inhibit bacteria growth. Subsequent microdilution assays indicated a lower than expected sensitivity of the osteomyelitis strain to the gallium maltolate with release concentrations below the threshold for bactericidal activity. A comparison of the selectivity indices indicated that gentamicin sulfate was less toxic and more efficacious than gallium maltolate. A pilot study in a contaminated femoral defect model confirmed that the sustained release of gentamicin sulfate from the electrospun wrap resulted in bacteria density reduction on the surrounding bone, muscle, and hardware below the threshold that impedes healing. Overall, these findings demonstrate the efficacy of a resorbable, antimicrobial wrap that can be used as an adjunct or stand-alone therapy for controlled release of antimicrobials in the treatment of osteomyelitis.

Sequential release of double drug (graded distribution) loaded gelatin microspheres/PMMA bone cement

Drugs are loaded into PMMA bone cement to reduce the risk of infection in freshly implanted prostheses or to promote the differentiation and growth of osteoblasts. However, the same method of loading of drugs in the bone cement cannot simultaneously achieve an effective antibacterial response and long-term treatment outcomes for osteoporosis based on a patient's clinical needs. In the present study, gentamicin sulfate (GS)/alendronate (ALN)-dual-loaded gelatin modified PMMA bone cement (GAPBC) was fabricated to provide rapid and continuous antibiotic release and long-term anti-osteoporotic therapy. Specifically, the gelatin microspheres were loaded with the drugs using separate methodologies, namely, ALN was loaded during fabrication of the gelatin microspheres after which GS was absorbed onto the gelatin from solution. The results demonstrate that sequential release of the GS and ALN was achieved, GS release playing a major role over the first 24 hours and ALN release dominant after 3 weeks of immersion in PBS, resulting from the graded distribution within the gelatin microspheres, and the final drug release ratio of GS (73.6%) and ALN (68.5%) from the modified bone cement was significantly higher than from PMMA bone cement. Therefore, GAPBC represents a potential drug carrier for future clinical applications.

Preparation of Protein-Peptide-Calcium Phosphate Composites for Controlled Protein Release

Protein-peptide-calcium phosphate composites were developed for achieving sustainable and controlled protein release. Bovine serum albumin (BSA) as a model acidic protein was efficiently encapsulated with basic polypeptides such as polylysine and polyarginine during the precipitation of calcium phosphate (CaP). The prepared composites were fully characterized in terms of their morphologies, crystallinities, and the porosity of their structures, and from these analyses, it was observed that there are no significant differences between the composites. Scanning transmission electron microscopy and energy dispersive X-ray spectroscopy analysis indicated a homogeneous distribution of nitrogen and sulfur, confirming the uniform distribution of BSA and polypeptide in the CaP composite. In vitro release studies demonstrated that the composite prepared with the peptides α-polylysine and polyarginine were suitable for the gradual release of the protein BSA, while those containing ε-polylysine and no peptide were unsuitable for protein release. Additionally, these composites showed high hemocompatibility for mouse red blood cells, and the osteoblast-like cell proliferation and spread in media with the composites prepared using BSA and α-polylysine showed similar tendencies to medium with no composite. From these results, protein-peptide-CaP composites are expected to be useful as highly biocompatible protein delivery agents.

Development of bone seeker-functionalised microspheres as a targeted local antibiotic delivery system for bone infections

Objective

Bone infections are challenging to treat because of limited capability of systemic antibiotics to accumulate at the bone site. To enhance therapeutic action, systemic treatments are commonly combined with local antibiotic-loaded materials. Nevertheless, available drug carriers have undesirable properties, including inappropriate antibiotic release profiles and nonbiodegradability. To alleviate such limitations, we aim to develop a drug delivery system (DDS) for local administration that can interact strongly with bone mineral, releasing antibiotics at the infected bone site.

Methods

Biodegradable polyesters (poly (ε-caprolactone) or poly (D,l-lactic acid)) were selected to fabricate antibiotic-loaded microspheres by oil in water emulsion. Antibiotic release and antimicrobial effects on Staphylococcus aureus were assessed by zone of inhibition measurements. Microsphere bone affinity was increased by functionalising the bisphosphonate drug alendronate to the microsphere surface using carbodiimide chemistry. Effect of bone targeting microspheres on bone homeostasis was tested by looking at the resorption potential of osteoclasts exposed to the developed microspheres.

Results

In vitro, the antibiotic release profile from the microspheres was shown to be dependent on the polymer used and the microsphere preparation method. Mineral binding assays revealed that microsphere surface modification with alendronate significantly enhanced interaction with bone-like materials. Additionally, alendronate functionalised microspheres did not differentially affect osteoclast mineral resorption in vitro, compared with nonfunctionalised microspheres.

Conclusion

We report the development and characterisation of a DDS which can release antibiotics in a sustained manner. Surface-grafted alendronate groups enhanced bone affinity of the microsphere construct, resulting in a bone targeting DDS.

The Translational Potential of this Article

The DDS presented can be loaded with hydrophobic antibiotics, representing a potential, versatile and biodegradable candidate to locally treat bone infection.

Fabrication of alginate modified brushite cement impregnated with antibiotic: Mechanical, thermal, and biological characterizations

Treatment of postsurgical infections, associated with orthopedic surgeries, has been a major concern for orthopedics. Several strategies including systematic and local administration of antibiotics have been proposed to this regard. The present work focused on fabricating alginate (Alg) modified brushite (Bru) cements, which could address osteogeneration and local antibiotic demands. To find the proper method of drug incorporation, Gentamicin sulfate (Gen) was loaded into the samples in the form of solution or powder. Several characterization tests including compression test, morphology, cytotoxicity, and cell adhesion assays were carried out to determine the proper concentration of Alg as a modifier of the Bru cement. The results indicated that addition of 1 wt% Alg led to superior mechanical and biological properties of the cement. Moreover, Alg addition changed the morphology of the cement from plate and needle-like structures to petal-like structure. Fourier transform infrared spectroscopy results confirmed the successful loading of Gen on the cements, specifically when Gen solution was used, and X-Ray Diffractometer result indicated that Gen caused a decrease in crystalline size. Furthermore, thermal analysis revealed that Gen-loaded sample had more stable structure as the transformation temperature slightly shifted to a higher one. The stability study confirmed the chemical stability and adequate mechanical performance of the cements within 1 month of soaking time. Finally, the addition of Alg has a positive impact on the release behavior at low concentration of Gen solution so that 20% decrease within 2 weeks of release experiment was remarkably detected.

Effect of Polymeric Microparticles Loaded With Catechin on the Physicochemical Properties of an Adhesive System

The objective of this study was to synthesize and characterize epigallocatechin-3-gallate (EGCG)-loaded/poly(D-L lactide-co-glycolide) acid (PLGA) microparticles, evaluate their effects on degree of conversion and release assay of adhesives, and subsequently to examine the resin-dentin bond strength of two EGCG formulations (free EGCG or loaded into PLGA microparticles) applied as a pretreatment or incorporated into an adhesive system. The formulations were prepared according to a PLGA:EGCG ratio of 16:1 using the spray-drying technique. The size and polydispersity index were determined by light scattering in aqueous dispersion. The degree of conversion (%DC) and release assay were assessed by Fourier transform infrared spectroscopy and ultraviolet-visible spectrophotometer, respectively. Subsequently, 45 third molars were divided into five groups (n=9) according to the different EGCG application modes and prepared for bond strength testing in a universal testing machine. Results demonstrated no statistically significant difference among the DC means after the PLGA microparticles were loaded with EGCG. For the release assay, the 1.0% PLGA/EGCG group presented better results after being elected for use in the bond strength test. The resin-dentin bond strengths of the experimental groups after 12 months of water storage were significantly higher than in the control group. EGCG could improve the durability of the resin-dentin bond over time and promote a new era for adhesive dentistry with the concept of controlled release.

Drug Delivery From Polymer-Based Nanopharmaceuticals-An Experimental Study Complemented by Simulations of Selected Diffusion Processes

The success of medical therapy depends on the correct amount and the appropriate delivery of the required drugs for treatment. By using biodegradable polymers a drug delivery over a time span of weeks or even months is made possible. This opens up a variety of strategies for better medication. The drug is embedded in a biodegradable polymer (the "carrier") and injected in a particular position of the human body. As a consequence of the interplay between the diffusion process and the degrading polymer the drug is released in a controlled manner. In this work we study the controlled release of medication experimentally by measuring the delivered amount of drug within a cylindrical shell over a long time interval into the body fluid. Moreover, a simple continuum model of the Fickean type is initially proposed and solved in closed-form. It is used for simulating some of the observed release processes for this type of carrier and takes the geometry of the drug container explicitly into account. By comparing the measurement data and the model predictions diffusion coefficients are obtained. It turns out that within this simple model the coefficients change over time. This contradicts the idea that diffusion coefficients are constants independent of the considered geometry. The model is therefore extended by taking an additional absorption term into account leading to a concentration dependent diffusion coefficient. This could now be used for further predictions of drug release in carriers of different shape. For a better understanding of the complex diffusion and degradation phenomena the underlying physics is discussed in detail and even more sophisticated models involving different degradation and mass transport phenomena are proposed for future work and study.

Low-intensity pulsed ultrasound enhances antibiotic release of gentamicin-loaded, self-setting calcium phosphate cement

Objective This study aimed to investigate the effect of low-intensity pulsed ultrasound on antibiotic release from gentamicin-loaded, self-setting calcium phosphate cement. Methods A gentamicin-loaded calcium phosphate cement cylinder was eluted in stimulated body fluid. Low-intensity pulsed ultrasound (46.5 kHz, 200 mW/cm²) was used to produce a sinusoidal wave in the experimental group. Non-gentamicin calcium phosphate cement was used in the control group. Results The transient concentration and cumulatively released percentage of gentamicin in the ultrasound group were higher than those in control group at every time point. The duration of gentamicin concentrations over the level of the minimum inhibitory concentration was significantly prolonged in the ultrasound group compared with the control group. Antibacterial efficacy of gentamicin in the ultrasound group was significantly better than that in the control group with the same concentration of gentamicin. Conclusion Low-intensity pulsed ultrasound enhances antibiotic release, providing sustained antibiotic release at high concentrations. This increases the antibacterial effect of gentamicin.

Silver nanoparticle deposited implants to treat osteomyelitis

In this study, electrolytically deposited strongly adherent silver nanoparticles on stainless-steel (SS) implants were used for in situ osteomyelitis treatment. Samples were heat treated to enhance adhesion of silver on 316 L SS. Ex vivo studies were performed to measure silver-release profiles from the 316 L SS screws inserted in equine cadaver bones. No change in the release profiles of silver ions were observed in vitro between the implanted screws and the control. In vivo studies were performed using osteomyelitic rabbit model with 3 mm diameter silver-deposited 316 L SS pins at two different doses of silver: high and low. Infection control ability of the pins for treating osteomyelitis in a rabbit model was measured using bacteriologic, radiographic, histological, and scanning electron microscopic studies. Silver-coated pins, especially high dose, offered a promising result to treat infection in animal osteomyelitis model without any toxicity to major organs. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1073-1083, 2018.

Effect of Low-Frequency Pulsed Ultrasound on Drug Delivery, Antibacterial Efficacy, and Bone Cement Degradation in Vancomycin-Loaded Calcium Phosphate Cement

Background

Calcium phosphate cement (CPC) has been applied as a biodegradable antibiotic carrier in osteomyelitis. However, the drug delivery, antibacterial efficacy, and degradation rate of CPC are insufficient and require further improvement in clinical application.

Material/Methods

Vancomycin-loaded CPC columns were prepared, and eluted in simulated body fluid. The drug delivery was assessed in the ultrasound group and control group by fluorescence polarization immunoassay. The antibacterial efficacy of vancomycin in the ultrasound group and control groups was investigated by standard plate count method. Low-frequency pulsed ultrasound (46.5 kHz, 900 mW/cm²) was used to produce a sinusoidal wave in the ultrasound groups. The percentage of residual weight was evaluated to assess the degradation of CPC.

Results

The concentration and cumulatively released percentage of vancomycin in the ultrasound group were higher than that in the control group at each time point (p<0.05). The duration of vancomycin concentration over the level of minimum inhibitory concentration was significantly prolonged in the ultrasound group (p<0.05). Antibacterial efficacy of vancomycin in the ultrasound group was significantly greater than that in the control group with same concentration of vancomycin (p<0.05). The percentage of residual weight in the ultrasound group was significantly less than that in the control group (p<0.05).

Conclusions

Low-frequency pulsed ultrasound can enhance vancomycin release, prolong the duration of vancomycin concentration at high levels, and accelerate the degradation rate of vancomycin-loaded CPC.

Biomaterial Strategies to Reduce Implant-Associated Infections

Although the prophylaxis in controlling sterility within the operating room environment has been greatly improved, implant-associated infection is still one of the most serious complications in implant surgeries due to the existence of immune depression in the peri-implant area. The antibacterial ability of materials themselves logically becomes an important factor in preventing implant-associated infections. With the understanding of the pathogenesis of implant-associated infections, many approaches have been developed through providing an anti-adhesive surface, delivering antibacterial agents to disrupt cell-cell communication and preventing bacteria aggregation or biofilm formation, or killing bacteria directly (lysing the cell membrane). In this article, we review the current strategies in improving the antibacterial ability of materials to prevent implant infection and further present promising tactics in materials design and applications.

Deterioration of the mechanical properties of calcium phosphate cements with Poly (γ-glutamic acid) and its strontium salt after in vitro degradation

The mechanical reliability of calcium phosphate cements has restricted their clinical application in load-bearing locations. Although their mechanical strength can be improved using a variety of strategies, their fatigue properties are still unclear, especially after degradation. The evolutions of uniaxial compressive properties and the fatigue behavior of calcium phosphate cements incorporating poly (γ-glutamic acid) and its strontium salt after different in vitro degradation times were investigated in the present study. Compressive strength decreased from the 61.2±5.4MPa of the original specimen, to 51.1±4.4, 42.2±3.8, 36.8±2.4 and 28.9±3.2MPa following degradation for one, two, three and four weeks, respectively. Fatigue life under same loading condition also decreased with increasing degradation time. The original specimens remained intact for one million cycles (run-out) under a maximum stress of 30MPa. After degradation for one to four weeks, the specimens were able to withstand maximum stress of 20, 15, 10 and 10MPa, respectively until run-out. Defect volume fraction within the specimens increased from 0.19±0.021% of the original specimen to 0.60±0.19%, 1.09±0.04%, 2.68±0.64% and 7.18±0.34% at degradation time of one, two, three and four weeks, respectively. Therefore, we can infer that the primary cause of the deterioration of the mechanical properties was an increasing in micro defects induced by degradation, which promoted crack initiation and propagation, accelerating the final mechanical failure of the bone cement. This study provided the data required for enhancing the mechanical reliability of the calcium phosphate cements after different degradation times, which will be significant for the modification of load-bearing biodegradable bone cements to match clinical application.

3D-Printed Bioactive Ca3SiO5 Bone Cement Scaffolds with Nano Surface Structure for Bone Regeneration

Silicate bioactive materials have been widely studied for bone regeneration because of their eminent physicochemical properties and outstanding osteogenic bioactivity, and different methods have been developed to prepare porous silicate bioactive ceramics scaffolds for bone-tissue engineering applications. Among all of these methods, the 3D-printing technique is obviously the most efficient way to control the porous structure. However, 3D-printed bioceramic porous scaffolds need high-temperature sintering, which will cause volume shrinkage and reduce the controllability of the pore structure accuracy. Unlike silicate bioceramic, bioactive silicate cements such as tricalcium silicate (Ca₃SiO₅ and C₃S) can be self-set in water to obtain high mechanical strength under mild conditions. Another advantage of using C₃S to prepare 3D scaffolds is the possibility of simultaneous drug loading. Herein, we, for the first time, demonstrated successful preparation of uniform 3D-printed C₃S bone cement scaffolds with controllable 3D structure at room temperature. The scaffolds were loaded with two model drugs and showed a loading location controllable drug-release profile. In addition, we developed a surface modification process to create controllable nanotopography on the surface of pore wall of the scaffolds, which showed activity to enhance rat bone-marrow stem cells (rBMSCs) attachment, spreading, and ALP activities. The in vivo experiments revealed that the 3D-printed C₃S bone cement scaffolds with nanoneedle-structured surfaces significantly improved bone regeneration, as compared to pure C₃S bone cement scaffolds, suggesting that 3D-printed C₃S bone cement scaffolds with controllable nanotopography surface are bioactive implantable biomaterials for bone repair.

Preparation of an antimicrobial surface by direct assembly of antimicrobial peptide with its surface binding activity

The designed antimicrobial peptide has surface binding activity onto titanium, gold, polymethyl methacrylate and hydroxyapatite substrates.

Magnesium Phosphate Cement Systems for Hard Tissue Applications: A Review

In the search for more ideal bone graft materials for clinical application, the investigation into ceramic bone cements or bone void filler is ongoing. Calcium phosphate-based materials have been widely explored and implemented for medical use in bone defect repair. Such materials are an excellent choice because the implant mimics the natural chemistry of mineralized bone matrix and in injectable cement form, can be implemented with relative ease. However, of the available calcium phosphate cements, none fully meet the ideal standard, displaying low strengths and acidic setting reactions or slow setting times, and are often very slow to resorb in vivo. The study of magnesium phosphates for bone cements is a relatively new field compared to traditional calcium phosphate bone cements. Although reports are more limited, preliminary studies have shown that magnesium phosphate cements (MPC) may be a strong alternative to calcium phosphates for certain applications. The goal of the present publication is to review the history and achievements of magnesium phosphate-based cements or bone void fillers to date, assess how these cements compare with calcium phosphate competitors and to analyze the future directions and outlook for the research, development, and clinical implementation of these cements.

Adding functionality with additive manufacturing: Fabrication of titanium-based antibiotic eluting implants

Additive manufacturing technologies have been utilised in healthcare to create patient-specific implants. This study demonstrates the potential to add new implant functionality by further exploiting the design flexibility of these technologies. Selective laser melting was used to manufacture titanium-based (Ti-6Al-4V) implants containing a reservoir. Pore channels, connecting the implant surface to the reservoir, were incorporated to facilitate antibiotic delivery. An injectable brushite, calcium phosphate cement, was formulated as a carrier vehicle for gentamicin. Incorporation of the antibiotic significantly (p=0.01) improved the compressive strength (5.8±0.7MPa) of the cement compared to non-antibiotic samples. The controlled release of gentamicin sulphate from the calcium phosphate cement injected into the implant reservoir was demonstrated in short term elution studies using ultraviolet-visible spectroscopy. Orientation of the implant pore channels were shown, using micro-computed tomography, to impact design reproducibility and the back-pressure generated during cement injection which ultimately altered porosity. The amount of antibiotic released from all implant designs over a 6hour period (<28% of the total amount) were found to exceed the minimum inhibitory concentrations of Staphylococcus aureus (16μg/mL) and Staphylococcus epidermidis (1μg/mL); two bacterial species commonly associated with periprosthetic infections. Antibacterial efficacy was confirmed against both bacterial cultures using an agar diffusion assay. Interestingly, pore channel orientation was shown to influence the directionality of inhibition zones. Promisingly, this work demonstrates the potential to additively manufacture a titanium-based antibiotic eluting implant, which is an attractive alternative to current treatment strategies of periprosthetic infections.

Local, Controlled Delivery of Local Anesthetics In Vivo from Polymer - Xerogel Composites

PURPOSE

Polymer-xerogel composite materials have been introduced to better optimize local anesthetics release kinetics for the pain management. In a previous study, it was shown that by adjusting various compositional and nano-structural properties of both inorganic xerogels and polymers, zero-order release kinetics over 7 days can be achieved in vitro. In this study, in vitro release properties are confirmed in vivo using a model that tests for actual functionality of the released local anesthetics.

METHODS

Composite materials made with tyrosine-polyethylene glycol(PEG)-derived poly(ether carbonate) copolymers and silica-based sol-gel (xerogel) were synthesized. The in vivo release from the composite controlled release materials was demonstrated by local anesthetics delivery in a rat incisional pain model.

RESULTS

The tactile allodynia resulting from incision was significantly attenuated in rats receiving drug-containing composites compared with the control and sham groups for the duration during which natural healing had not yet taken place. The concentration of drug (bupivacaine) in blood is dose dependent and maintained stable up to 120 h post-surgery, the longest time point measured.

CONCLUSIONS

These in vivo studies show that polymer-xerogel composite materials with controlled release properties represent a promising class of controlled release materials for pain management.

Antimicrobial delivery systems for local infection prophylaxis in orthopedic- and trauma surgery

Infectious complications occur in a minor but significant portion of the patients undergoing joint replacement surgery or fracture fixation, particularly those with severe open fractures, those undergoing revision arthroplasty or those at elevated risk because of poor health status. Once established, infections are difficult to eradicate, especially in the case of bacterial biofilm formation on implanted hardware. Local antibiotic carriers offer the prospect of controlled delivery of antibiotics directly in target tissues and implant, without inducing toxicity in non-target organs. Polymeric carriers have been developed to optimize the release and targeting of antibiotics. Passive polymeric carriers release antibiotics by diffusion and/or upon degradation, while active polymeric carriers release their antibiotics upon stimuli provided by bacterial pathogens. Additionally, some polymeric carriers gelate in-situ in response to physiological stimuli to form a depot for antibiotic release. As antibiotic resistance has become a major issue, also other anti-infectives such as silver and antimicrobial peptides have been incorporated in research. Currently, several antibiotic loaded biomaterials for local infection prophylaxis are available for use in the clinic. Here we review their advantages and limitations and provide an overview of new materials emerging that may overcome these limitations.

Effect of PLGA/lecithin hybrid microspheres and β-tricalcium phosphate granules on the physicochemical properties, in vitro degradation and biocompatibility of calcium phosphate cement

CPC with beta-TCP granules and PLGA/Lec microspheres reveals better degradability and cell affinity along with proper physicochemical properties.

Effect of hydroxyapatite-containing microspheres embedded into three-dimensional magnesium phosphate scaffolds on the controlled release of lysozyme and in vitro biodegradation

The functionality of porous three-dimensional (3D) magnesium phosphate (MgP) scaffold was investigated for the development of a novel protein delivery system and biomimetic bone tissue engineering scaffold. This enhancement can be achieved by incorporation of hydroxyapatite (HA)-containing polymeric microspheres (MSs) into a bulk MgP matrix, and a paste-extruding deposition (PED) system. In this work, the amount of MS and HA was precisely controlled when manufacturing MS-embedded MgP (MS/MgP) composite scaffolds. The main influence was researched in terms of in vitro lysozyme-release, in vitro biodegradation, mechanical properties, and in vitro calcification. The controlled release of lysozyme was indicated, while showing graded release patterns according to HA content. The composite scaffolds degraded gradually with MS content and degradation time. Due to the effect of HA inclusion, the higher HA-containing MS/MgP scaffolds could, not only delay the biodegradation process but also, compensate for the possible loss of mechanical properties. In this regard, it is reasonable to confirm the inverse relationship between biodegradation and corresponding compressive properties. In order to encourage bioactivity and osteoconductivity, the MS/MgP composite scaffolds were subjected to simulated body fluid treatment. Calcium deposition was, in turn, improved with increasing MS and HA content over time. This quantitative result was also proved using morphological and elemental analysis. In summary, a significant transformation of a monolithic MgP scaffold was directed toward a multifunctional bone tissue engineering scaffold equipped with controlled protein delivery, biodegradability, and bioactivity.

Phase and size separations occurring during the injection of model pastes composed of β-tricalcium phosphate powder, glass beads and aqueous solutions

Glass beads a few hundred micrometers in size were added to aqueous β-tricalcium phosphate pastes to simulate the effect of porogens and drug-loaded microspheres on the injectability of calcium phosphate cements and putties. The composition of the pastes was monitored during the injection process to assess the effect of glass bead content, glass bead size and paste composition on the paste injectability. The results revealed that the injection process led to both liquid and glass bead segregations: the liquid flowed faster than the glass beads, which themselves flowed faster than the β-tricalcium phosphate microparticles. In fact, even the particle size distribution of the glass beads was modified during injection. These results reveal that a good design of multiphasic injectable pastes is essential to prevent phase separation.

A controlled release of antibiotics from calcium phosphate-coated poly(lactic-co-glycolic acid) particles and their in vitro efficacy against Staphylococcus aureus biofilm

Ceramic-polymer hybrid particles, intended for osteomyelitis treatment, were fabricated by preparing poly(lactic-co-glycolic acid) particles through an emulsion solvent evaporation technique, followed by calcium phosphate (CaP) coating via a surface adsorption-nucleation method. The presence of CaP coating on the surface of the particles was confirmed by scanning electron microscopy, energy-dispersive X-ray spectroscopy, and X-ray photoelectron spectroscopy. Subsequently, two antibiotics for treating bone infection, nafcillin (hydrophilic) and levofloxacin (amphiphilic), were loaded into these hybrid particles and their in vitro drug release studies were investigated. The CaP coating was shown to reduce burst release, while providing sustained release of the antibiotics for up to 4 weeks. In vitro bacterial study against Staphylococcus aureus demonstrated the capability of these antibiotic-loaded hybrid particles to inhibit biofilm formation as well as deteriorate established biofilm, making this hybrid system a potential candidate for further investigation for osteomyelitis treatment.

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.

Effects of Caryota mitis profilin-loaded PLGA nanoparticles in a murine model of allergic asthma

Background

Pollen allergy is the most common allergic disease. However, tropical pollens, such as those of Palmae, have seldom been investigated compared with the specific immunotherapy studies done on hyperallergenic birch, olive, and ragweed pollens. Although poly(lactic-co-glycolic acid) (PLGA) has been extensively applied as a biodegradable polymer in medical devices, it has rarely been utilized as a vaccine adjuvant to prevent and treat allergic disease. In this study, we investigated the immunotherapeutic effects of recombinant Caryota mitis profilin (rCmP)-loaded PLGA nanoparticles and the underlying mechanisms involved.

Methods

A mouse model of allergenic asthma was established for specific immunotherapy using rCmP-loaded PLGA nanoparticles as the adjuvant. The model was evaluated by determining airway hyperresponsiveness and levels of serum-specific antibodies (IgE, IgG, and IgG2a) and cytokines, and observing histologic sections of lung tissue.

Results

The rCmP-loaded PLGA nanoparticles effectively inhibited generation of specific IgE and secretion of the Th2 cytokine interleukin-4, facilitated generation of specific IgG2a and secretion of the Th1 cytokine interferon-gamma, converted the Th2 response to Th1, and evidently alleviated allergic symptoms.

Conclusion

PLGA functions more appropriately as a specific immunotherapy adjuvant for allergen vaccines than does conventional Al(OH)₃ due to its superior efficacy, longer potency, and markedly fewer side effects. The rCmP-loaded PLGA nanoparticles developed herein offer a promising avenue for specific immunotherapy in allergic asthma.

Ex vivo human trabecular bone model for biocompatibility evaluation of calcium phosphate composites modified with spray dried biodegradable microspheres

Our aim was to study the suitability of the ex-vivo human trabecular bone bioreactor ZetOS to test the biocompatibility of calcium phosphate bone cement composites modified with spray dried, drug loaded microspheres. We hypothesized, that this bone bioreactor could be a promising alternative to in vivo assessment of biocompatibility in living human bone over a defined time period. Composites consisting of tetracycline loaded poly(lactic-co-glycolic acid) microspheres and calcium phosphate bone cement, were inserted into in vitro cultured human femora head trabecular bone and incubated over 30 days at 37°C in the incubation system. Different biocompatibility parameters, such as lactate dehydrogenase activity, alkaline phosphatase release and the expression of relevant cytokines, IL-1β, IL-6, and TNF-α, were measured in the incubation medium. No significant differences in alkaline phosphatase, osteocalcin, and lactate dehydrogenase activity were measured compared to control samples. Tetracycline was released from the microspheres, delivered and incorporated into newly formed bone. In this study we demonstrated that ex vivo biocompatibility testing using human trabecular bone in a bioreactor is a potential alternative to animal experiments since bone metabolism is still maintained in a physiological environment ex vivo.

Systematic approach to treat chronic osteomyelitis through localized drug delivery system: bench to bed side

Chronic osteomyelitis is a challenging setback to the orthopedic surgeons in deciding an optimal therapeutic strategy. Conversely, patients feel frustrated of the therapeutic outcomes and development of adverse drug effects, if any. Present investigation deals with extensive approach incorporating in vivo animal experimentation and human application to treat chronic osteomyelitis, using antibiotic loaded porous hydroxyapatite scaffolds. Micro- to macro-porous hydroxyapatite scaffolds impregnated with antibiotic ceftriaxone-sulbactam sodium (CFS) were fabricated and subsequently evaluated by in vivo animal model after developing osteomyelitis in rabbit tibia. Finally 10 nos. of human osteomyelitis patients involving long bone and mandible were studied for histopathology, radiology, pus culture, 3D CT etc. up to 8-18 months post-operatively. It was established up to animal trial stage that 50N50H samples [with 50-55% porosity, average pore size 110 μm, higher interconnectivity (10-100 μm), and moderately high drug adsorption efficiency (50%)] showed efficient drug release up to 42 days than parenteral group based on infection eradication and new bone formation. In vivo human bone showed gradual evidence of new bone formation and fracture union with organized callus without recurrence of infection even after 8 months. This may be a new, alternative, cost effective and ideal therapeutic strategy for chronic osteomyelitis treatment in human patients.

A new type of biphasic calcium phosphate cement as a gentamicin carrier for osteomyelitis

Osteomyelitis therapy is a long-term and inconvenient procedure for a patient. Antibiotic-loaded bone cements are both a complementary and alternative treatment option to intravenous antibiotic therapy for the treatment of osteomyelitis. In the current study, the biphasic calcium phosphate cement (CPC), called α-TCP/HAP (α-tricalcium phosphate/hydroxyapatite) biphasic cement, was prepared as an antibiotics carrier for osteomyelitis. The developed biphasic cement with a microstructure of α-TCP surrounding the HAP has a fast setting time which will fulfill the clinical demand. The X-ray diffraction and Fourier transform infrared spectrometry analyses showed the final phase to be HAP, the basic bone mineral, after setting for a period of time. Scanning electron microscopy revealed a porous structure with particle sizes of a few micrometers. The addition of gentamicin in α-TCP/HAP would delay the transition of α-TCP but would not change the final-phase HAP. The gentamicin-loaded α-TCP/HAP supplies high doses of the antibiotic during the initial 24 hours when they are soaked in phosphate buffer solution (PBS). Thereafter, a slower drug release is produced, supplying minimum inhibitory concentration until the end of the experiment (30 days). Studies of growth inhibition of Staphylococcus aureus and Pseudomonas aeruginosa in culture indicated that gentamicin released after 30 days from α-TCP/HAP biphasic cement retained antibacterial activity.