Acrylic Bone Cement Research Articles

In Vitro and In Vivo Characterization of Premixed PMMA-CaP Composite Bone Cements.

Acrylic bone cements, although successful in the field of orthopedics, suffer from a lack of bioactivity, not truly integrating with surrounding bone. Bioactive fixation is expected to enhance cement performance because of the natural interlocking and bonding with bone, which can improve the augmentative potential of the material in applications such as vertebroplasty (VP). In a recent study, two composite cements (PMMA-hydroxyapatite and PMMA-brushite) showed promising results demonstrating no deterioration in rheological and mechanical properties after CaP filler addition. In this study, the dynamic properties of the cements were investigated in vitro and in vivo. The hypothesis was that these composite cements will provide osseointegration around the implanted cement and increase new bone formation, thus decreasing the risk of bone structural failure. The effects of CaP elution were thus analyzed in vitro using these cements. Mass-loss, pore formation, and mechanical changes were tracked after cement immersion in Hank's salt solution. PMMA-brushite was the only cement with a significant mass loss; however it showed low bulk porosity. Surface porosity increases were observed in both composite cements. Mechanical properties were maintained after cement immersion. In vitro culture studies tested preosteoblast cell viability and differentiation on the cement surface. Cell viability was demonstrated with MTT assay and confirmed on the cement surface. ALP assays showed no inhibition of osteoblast differentiation on the cement surface. In vivo experiments were performed using a rat tibiae model to demonstrate bone ingrowth around the implanted cements. Critical size defects were created and then filled with the cements. The animal studies showed no loss in mechanical strength after implantation and increased bone ingrowth around the composite cements. In summary, the composite cements provided bioactivity without sacrificing mechanical strength.

The tension-shear fracture behavior of polymeric bone cement modified with hydroxyapatite nano-particles

Polymethylmethacrylate (PMMA)-based bone cement is a well-known polymer in the medicine, especially orthopedic. However it has some drawbacks like lack of enough biocompatibility and poor mechanical properties. These problems can be addressed by incorporation of nano-materials. Hydroxyapatite has been proved to enhance biocompatibility of acrylic bone cements. This bioceramic can affect the mechanical properties of polymeric cements as well. In this study, a number of fracture tests were carried out to investigate the influence of nano-hydroxyapatite (HA) on the fracture behavior of acrylic bone cement under combined tension-shear (mixed mode) loading conditions. Semi-circular specimens were prepared by incorporating different amounts of HA powder into the cement matrix. It was found that adding up to 10wt% HA into the cement causes an increase in the fracture toughness of PMMA/HA nano-composite in all modes. However, pure cement exhibited the greatest fracture resistance among all samples. Moreover, the comparison between the experimental and theoretical results showed that the generalized maximum tangential stress criterion could estimate the experimental data satisfactorily.

Acrylic Bone Cements: New Insight and Future Perspective

The history of acrylic bone cement comprise a long period of time, Sir John Charnley being considered the founder of modern artificial joint replacement, as he started to develop the cementing in the late 1950s. Acrylic bone cements (ACB) are polymer-ceramic composites based on polymethyl metacrylate (PMMA), widely used in orthopaedics as suture materials and fixation devices. The main features of these materials are: 1) biocompatibility and ability to support new bone growth (osteoconductive) and 2) bioactivity (ability to form a calcium phosphate layer on its surface). The main function of the cement is to serve as interfacial phase between the high modulus metallic implant and the bone, thereby assisting to transfer and distribute loads. During years of follow up, cemented prosthesis with acrylic bone cements (ABC) demonstrated a good primary fixation and load distribution between implant and bone, along with the advantage of fast recovery of the patient. However, several problems are still persisting, as the orthopedic acrylic bone cements have to meet several medical requirements, such as low values of maximum cure temperature in order to avoid thermal necrosis of the bone tissue during the setting time, appropriate setting time (so that cement does not cure too fast or too slowly) and high values of compressive strength in order to withstand the compressive loads involved by normal daily activities. Generally, the improvement mechanical properties can be realized in three directions: 1) by searching alternative material to PMMA acrylic bone cements; 2) chemical modification of PMMA; and 3) the reinforcement of PMMA by adding different bioactive particles, antimicrobials, vitamins. The aim of this rewiew is to explore the development of bone cements in the last decade, to highlight the role of bone cement additives with respect to mechanical properties and limitations of polymethylmethacrylate in orthopaedic surgery. The behavior of antibiotic-loaded bone cement is discussed, compared with other alternative additives including nanofillers, together with areas of research that are now open to explore new insights and applications of this well known biomaterial.

Efficacy of Adjunctive Antibiotic-Loaded Acrylic Bone Cement for Deep Surgical Site Infection Prophylaxis after Primary Cemented Hip and Knee Arthroplasties

The efficacy of antibiotic-loaded acrylic bone cements (ALBC) for prophylaxis of deep surgical site infections (deep SSIs) after primary cemented joint replacement surgery remains controversial. Therefore, the purpose of this study was to examine the issue, with respect to three types of arthroplasty, namely, total knee arthroplasty (TKA), total hip arthroplasty (THA), and bipolar hip arthroplasty (BHA).

Development of advanced biantibiotic loaded bone cement spacers for arthroplasty associated infections

The incidence increase of infections in patients with hip or knee implants with resistant pathogens (mainly some S. coagulase-negative and gram positive bacteria) demands advanced antibiotic loaded formulations. In this paper, we report the design of new biantibiotic acrylic bone cements for in situ delivery. They include a last generation antibiotic (daptomycin or linezolid) in combination with vancomycin and are performed based on a novel modification of the Palacos R® acrylic bone cement, which is based on two components, a liquid (methyl methacrylate) and a solid (polymeric phase). Hence, the solid component of the experimental formulations include 45wt% of microparticles of poly(D,L-lactic-co-glycolic) acid, 55wt% of poly(methyl methacrylate) beads and supplements (10wt-% each) of antibiotics. These formulations provide a selective and excellent control of the local release of antibiotics during a long time period (up to 2 months), avoiding systemic dissemination. The antimicrobial activity of the advanced spacers tested against S. aureus shows that single doses would be enough for the control of the infection. In vitro biocompatibility of cements on human osteoblasts is ensured. This paper is mainly focused on the preparation and characterization of cements and the studies of elution kinetics and bactericidal effects. Developed formulations are proposed as spacers for the treatment of infected arthroplasties, but also, they could be applied in other antibiotic devices to treat relevant bone-related infection diseases.

Pigment epithelium derived factor (PEDF) prevents methyl methacrylate monomer-induced cytotoxicity in H9c2 cells

Acrylic bone cements are currently the most frequently and extensively used materials in orthopedic implant treatment. However, adverse effects have been described of acrylic bone cement on the cardiovascular system. In the present study, we examined the cytotoxicity of bone cement ingredient methyl methacrylate (MMA) to cardiomyocytes and the potential detoxifying effect of pigment epithelium-derived factor (PEDF) in H9c2 cells. We found that high concentration of MMA (>120 mmol/L) led to necrotic cell death in H9c2 cells. However, MMA at low concentrations (30-90 mmol/L) caused apoptosis. Pretreatment of PEDF prevented MMA-induced cytotoxicity. In addition, PEDF enhanced total superoxide dismutase activities, and decreased MMA-induced production of malonaldehyde. Furthermore, MMA-induced downregulation of Akt activity was suppressed by PEDF. PEDF also increased the levels of peroxisome proliferator activated receptor gamma (PPAR g) and lysophosphatidic acids (LPA) through PEDF receptor. These results indicated that PEDF inhibited MMA-induced cytotoxicity through attenuating oxidative stress, activating the phosphatidylinositol 3-kinase (PI3K)/Akt pathway and/or PEDF receptor-LPA-PPAR g pathways in H9c2 cells. PEDF may be explored as a candidate therapeutic agent for alleviating bone cement implantation syndrome during orthopedic surgery.

Antibiotic Elution from Hip and Knee Acrylic Bone Cement Spacers: A Systematic Review.

Knowledge about the elution from antibiotic-loaded cement spacers is an indispensable premise for guarantee of clinical success. A systematic literature search was performed through PubMed. Search terms were “antibiotic elution” and “antibiotic release” in combination with “spacer,” “hip spacer,” and “knee spacer,” respectively. A total of 11 studies could be identified. Seven studies reported on the release of antibiotics after spacer implantation, three studies at spacer removal, and one study on both time points. Seven studies reported on hip spacers, one study on knee spacers, and three studies on both. In eight studies, custom-made spacers have been implanted and in three prefabricated ones. In the majority of the studies, the cement has been loaded with an antibiotic combination, mostly consisting of aminoglycoside (either gentamicin or tobramycin) and vancomycin. Measured concentrations exceeded the minimal inhibitory concentration of the particular pathogen organisms in each case. However, large discrepancies were observed with regard to the height of the antibiotic concentration depending on the antibiotic combination and the antibiotic ratio used. Current literature data indicate a sufficient elution of antibiotics after spacer implantation and at spacer removal, respectively. Future studies are required to optimize the local antibiotic therapy at the site of spacer implantation.

Optimization of Methyl Methacrylate Inductively Coupled Plasma Surface Modification of ZrO2 Particles used in Acrylic Bone Cement Formulations

ABSTRACTA response surface methodology was used to optimize the relationships between the time and power of a methyl methacrylate plasma surface modification process for ZrO2 particles in bone cement formulations. Time and power were varied during the plasma process, and their effect on the mechanical properties of the bone cement was studied. All mechanical properties were improved in all bone cement formulations prepared with modified ZrO2 particles in comparison to those of bone cement formulated with ZrO2 particles without plasma treatment.

Acrylic bone cement and starch: Botanical variety impact on curing parameters and degradability

Acrylic bone cements are a conventional solution to heal bone defects. Starch is often added to the cement to improve its degradability and resorbability. The most used botanical variety is corn starch; few studies or applications deal with other varieties. This study focuses on classical formulations based on 2-hydroxyethylmethacrylate but incorporating different starches: waxy maize, corn, amylo maize, wheat, pea or potato, with or without enzyme (α-amylase).A thermocouple is used to determine the curing parameters: setting time and maximal temperature. The water uptake depends on the cement immersion time in a biological fluid and it is studied through sample mass variation analysis. The weight loss is determined after immersion (function of the time) and drying.Starch botanical variety and enzyme presence do not impact curing parameters and water uptake but strongly influence degradability. Water uptake involves advantageous swelling in situ filling the defect. This study shows that starch accessibility by the enzyme explains this impact. Grain spatial configuration, specific surface area and starch distribution in cement give a complementary explanation of the well-known influence of the ratio amylopectin/amylose. Acrylic cements incorporating starch can be classified according to their degradability.

Acrylic bone cements modified with poly(ethylene glycol)‐based biocompatible phase‐change materials

ABSTRACTThe high polymerization temperature of acrylic bone cements used in hip replacement implantation may cause thermal necrosis of surrounding tissues. In order to reduce the polymerization temperature, acrylic bone cement has been modified with a biocompatible polymeric phase‐change material (PCM) based on poly(ethylene glycol) (PEG) of different molecular weights and stabilized with potato starch. Structural and morphological studies were performed, and the thermal and mechanical properties were investigated. The incorporation of PEG‐based PCM led to a decrease in the polymerization temperature of bone cement from 70 °C for unmodified cement to 58 °C for modified cement. Modified cement materials were stable in incubation tests, although acoustic analysis data revealed a decrease in propagation speed after incubation, which indicates formation of material defects (pores, cracks, voids, etc.) due to water activity. However, in the regeneration process, these defects can be filled by freshly grown bone tissue leading to better incorporation of bone cement replacements into tissue. © 2016 Wiley Periodicals, Inc. J. Appl. Polym. Sci. 2016, 133, 43898.

Characterization of the quasi-static and viscoelastic properties of orthopaedic bone cement at the macro and nanoscale.

Acrylic bone cement is often used in total joint replacement procedures to anchor an orthopaedic implant to bone. Bone cement is a viscoelastic material that exhibits creep and stress relaxation properties, which have been previously characterized using a variety of techniques such as flexural testing. Nanoindentation has become a popular method to characterize polymer mechanical properties at the nanoscale due to the technique's high sensitivity and the small sample volume required for testing. The purpose of the present work therefore was to determine the mechanical properties of bone cement using traditional macroscale techniques and compare the results to those obtained from nanoindentation. To this end, the quasi-static and viscoelastic properties of two commercially available cements, Palacos and Simplex, were assessed using a combination of three-point bending and nanoindentation. Quasi-static properties obtained from nanoindentation tended to be higher relative to three-point bending. The general displacement and creep compliance trends were similar for the two methods. These findings suggest that nanoindentation is an attractive characterization technique for bone cement, due to the small sample volumes required for testing. This may prove particularly useful in testing failed/retrieved cement samples from patients where material availability is typically limited. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1461-1468, 2017.

Modification of acrylic bone cements by poly(ethylene glycol) with different molecular weight

The high polymerization temperature of acrylic bone cements can cause arthroplasty failure because of the thermal necrosis of surrounding bone tissue. To reduce this undesired effect we have developed novel acrylic bone cement composites containing a phase change material (PCM). As PCM poly(ethylene glycol) (PEG) of different molecular weight was applied and the effect of its incorporation on curing parameters, mechanical and morphological properties of acrylic bone cement was investigated. A significant decrease in maximum temperature from 65.8°C to 47.4°C and slight increase of setting time were observed. PEG introduction also contributed to the thermal stability of acrylic bone cement increase. SEM investigation of modified bone cement confirmed that the microstructure does not alter considerably because of PEG content. It was found that both PEG addition and incubation test contribute to an inconsiderable decrease in mechanical strength of bone cement. However, the mechanical strength increase can be caused by the fresh bone tissue incorporation into the pores appearing in bone cement. Copyright © 2016 John Wiley & Sons, Ltd.

Damage accumulation studied by acoustic emission in bone cement prepared with core–shell nanoparticles under fatigue

Analysis of acoustic emission signals generated during the fatigue testing of core–shell nanoparticles filled acrylic bone cements is reported. Core–shell nanoparticles composed of a poly(butyl acrylate) rubbery core and a poly(methyl methacrylate-co-styrene) (P(MMA-co-St)) outer glassy shell with varying compositions (20/80, 30/70, 40/60, and 50/50) were incorporated into the solid phase of bone cement at 10 wt%. Acoustic emission data revealed that the damage accumulation process was discontinuous for all bone cement formulations, being less pronounced in formulations with higher fatigue resistance (20/80 and 30/70) which emitted a higher number of events before the final fracture. The capability of both 20/80 and 30/70 core–shell nanoparticles to hinder the microcracks or crazes propagation was attributed to their poor interfacial adhesion with the matrix in comparison with formulations with 40/60 and 50/50 core–shell nanoparticles. Based on the acoustic emission data and SEM micrographs, a crack propagation scheme for bone cements containing core–shell nanoparticles was proposed. In this regard, core–shell nanoparticles had a double role on the bone cement as reported for other systems; firstly, the nanoparticles promoted nucleation sites for crazes or microcracks, and secondly, they could also hinder the propagation of these defects, acting as a barrier to their growth. Crack propagation mechanism consisted mainly in crazing ahead of the cracks tip as well as the coalescence of these cracks which were responsible of the acoustic emission detected.

Acrylic bone cement in total joint arthroplasty: A review.

Acrylic bone cement has a variety of applications in orthopedic surgery. Primary uses in total arthroplasties are limited to prostheses fixation and antibiotic delivery. With the large number of total joint arthroplasties expected to continue to rise, understanding the role bone cement plays in the success of total joint arthroplasty can have a significant impact on daily practice. The literature is inconclusive on whether cemented or cementless fixation technique is superior, and choice of fixation type is mainly determined by surgeon preference and experience. Surgeons should understand that if poor techniques exist, short-term outcomes of the replaced joint may be at risk. Statement of clinical significance: This article attempts to clarify some points of bone cement use through a review of the mechanical properties related to bone cement, a comparison to alternative materials, influence of additives, and the effects on surgical outcomes. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:737-744, 2016.

Mechanical and thermal behaviour of an acrylic bone cement modified with a triblock copolymer.

The basic formulation of an acrylic bone cement has been modified by the addition of a block copolymer, Nanostrength(®) (NS), in order to augment the mechanical properties and particularly the fracture toughness of the bone cement. Two grades of NS at different levels of loading, between 1 and 10 wt.%, have been used. Mechanical tests were conducted to study the behaviour of the modified cements; specific tests measured the bend, compression and fracture toughness properties. The failure mode of the fracture test specimens was analysed using scanning electron microscopy (SEM). The effect of NS addition on the thermal properties was also determined, and the polymerisation reaction using differential scanning calorimetry. It was observed that the addition of NS produced an improvement in the fracture toughness and ductility of the cement, which could have a positive contribution by reducing the premature fracture of the cement mantle. The residual monomer content was reduced when the NS was added. However this also produced an increase in the maximum temperature and the heat delivered during the polymerisation of the cement.

Combination of modified mixing technique and low frequency ultrasound to control the elution profile of vancomycin-loaded acrylic bone cement.

ObjectivesThe objective of this study was to determine if combining variations in mixing technique of antibiotic-impregnated polymethylmethacrylate (PMMA) cement with low frequency ultrasound (LFUS) improves antibiotic elution during the initial high phase (Phase I) and subsequent low phase (Phase II) while not diminishing mechanical strength.MethodsThree batches of vancomycin-loaded PMMA were prepared with different mixing techniques: a standard technique; a delayed technique; and a control without antibiotic. Daily elution samples were analysed using flow injection analysis (FIA). Beginning in Phase II, samples from each mix group were selected randomly to undergo either five, 15, 45, or 0 minutes of LFUS treatment. Elution amounts between LFUS treatments were analysed. Following Phase II, compression testing was done to quantify strength. A-priori t-tests and univariate ANOVAs were used to compare elution and mechanical test results between the two mix groups and the control group.ResultsThe delayed technique showed a significant increase in elution on day one compared with the standard mix technique (p < 0.001). The transition point from Phase I to Phase II occurred on day ten. LFUS treatments significantly increased elution amounts for all groups above control. Delayed technique resulted in significantly higher elution amounts for the five-minute- (p = 0.004) and 45-minute- (p < 0.001) duration groups compared with standard technique. Additionally, the correlations between LFUS duration and total elution amount for both mix techniques were significant (p = 0.03). Both antibiotic-impregnated groups exhibited a significant decrease in offset yield stress compared with the control group (p < 0.001), however, their lower 95% confidence intervals were all above the 70 MPa limit defined by International Standards Organization (ISO) 5833-2 reference standard for acrylic bone cement.ConclusionThe combination of a delayed mix technique with LFUS treatments provides a reasonable means for increasing both short- and long-term antibiotic elution without affecting mechanical strength.Cite this article: Dr. T. McIff. Combination of modified mixing technique and low frequency ultrasound to control the elution profile of vancomycin-loaded acrylic bone cement. Bone Joint Res 2016;5:26–32. DOI: 10.1302/2046-3758.52.2000412

Comparison of a quasi-dynamic and a static extraction method for the cytotoxic evaluation of acrylic bone cements

In this study, two different extraction approaches were compared in order to evaluate the cytotoxicity of 7 different acrylic bone cements, mainly developed for spinal applications, to osteoblastic cells. Firstly, a static extraction was carried out continuously over 24h, a method widely used in literature. Secondly, a quasi-dynamic extraction method that allowed the investigation of time-dependent cytotoxic effects of curing acrylic bone cements to cells was introduced. In both cases the extraction of the cements was started at a very early stage of the polymerization process to simulate the conditions during clinical application. Data obtained by the quasi-dynamic extraction method suggest that the cytotoxicity of the setting materials mainly originates from the release of toxic components during the first hour of the polymerization reaction. It was also shown that a static extraction over 24h generally represents this initial stage of the curing process. Furthermore, compared to the static extraction, time-dependent cytotoxicity profiles could be detected using the quasi-dynamic extraction method. Specifically, a modification of commercial Osteopal®V with castor oil as a plasticizer as well as a customized cement formulation showed clear differences in cytotoxic behavior compared to the other materials during the setting process. In addition, it was observed that unreacted monomer released from the castor oil modified cement was not the main component affecting the toxicity of the material extracts. The quasi-dynamic extraction method is a useful tool to get deeper insight into the cytotoxic potential of curing acrylic bone cements under relevant biological conditions, allowing systematic optimization of materials under development.

Controlled delivery of antibiotics from silica nanocarriers for acrylic bone cement applications

Controlled delivery of antibiotics from silica nanocarriers for acrylic bone cement applications

The effect of oligo(trimethylene carbonate) addition on the stiffness of acrylic bone cement.

With the increasing elderly population an increase in the number of bony fractures associated to age-related diseases such as osteoporosis also follows. The relatively high stiffness of the acrylic bone cements used in these patients has been suggested to give raise to a suboptimal load distribution surrounding the cement in vivo, and hence contribute to clinical complications, such as additional fractures. The aim of this study was to develop a low-modulus bone cement, based on currently used, commercially available poly(methyl methacrylate) (PMMA) cements for vertebroplasty. To this end, acrylate end-functionalized oligo(trimethylene carbonate) (oTMC) was incorporated into the cements, and the resulting compressive mechanical properties were evaluated, as well as the cytotoxic and handling properties of selected formulations. Sixteen wt%oTMC was needed in the vertebroplastic cement Osteopal V to achieve an elastic modulus of 1063 MPa (SD 74), which gave a corresponding compressive strength of 46.1 MPa (SD 1.9). Cement extracts taken at 1 and 12 hours gave a reduced MG-63 cell viability in most cases, while extracts taken at 24 hours had no significant effect on cell behavior. The modification also gave an increase in setting time, from 14.7 min (SD 1.7) to 18.0 min (SD 0.9), and a decrease in maximum polymerization temperature, from 41.5°C (SD 3.4) to 30.7°C (SD 1.4). While further evaluation of other relevant properties, such as injectability and in vivo biocompatibility, remains to be done, the results presented herein are promising in terms of approaching clinically applicable bone cements with a lower stiffness.

The feasibility of producing patient-specific acrylic cranioplasty implants with a low-cost 3D printer.

OBJECT Commercially available, preformed patient-specific cranioplasty implants are anatomically accurate but costly. Acrylic bone cement is a commonly used alternative. However, the manual shaping of the bone cement is difficult and may not lead to a satisfactory implant in some cases. The object of this study was to determine the feasibility of fabricating molds using a commercial low-cost 3D printer for the purpose of producing patient-specific acrylic cranioplasty implants. METHODS Using data from a high-resolution brain CT scan of a patient with a calvarial defect posthemicraniectomy, a skull phantom and a mold were generated with computer software and fabricated with the 3D printer using the fused deposition modeling method. The mold was used as a template to shape the acrylic implant, which was formed via a polymerization reaction. The resulting implant was fitted to the skull phantom and the cranial index of symmetry was determined. RESULTS The skull phantom and mold were successfully fabricated with the 3D printer. The application of acrylic bone cement to the mold was simple and straightforward. The resulting implant did not require further adjustment or drilling prior to being fitted to the skull phantom. The cranial index of symmetry was 96.2% (the cranial index of symmetry is 100% for a perfectly symmetrical skull). CONCLUSIONS This study showed that it is feasible to produce patient-specific acrylic cranioplasty implants with a low-cost 3D printer. Further studies are required to determine applicability in the clinical setting. This promising technique has the potential to bring personalized medicine to more patients around the world.