Polymethylmethacrylate Bone Cement Research Articles

Bioactive, Ion‐Releasing PMMA Bone Cement Filled with Functional Graphenic Materials

Graphene oxide and functionalized graphenic materials (FGMs) have promise as platforms for imparting programmable bioactivity to poly(methyl methacrylate) (PMMA)-based bone cement. To date, however, graphenic fillers have only been feasible in PMMA cements at extremely low loadings, limiting the bioactive effects. At higher loadings, graphenic fillers decrease cement strength by aggregating and interfering with curing process. Here, these challenges are addressed by combining bioactive FGM fillers with a custom cement formulation. These cements contain an order of magnitude more graphenic filler than previous reports. Even at 1 wt% FGM, these cements have compressive strengths of 78- 88 MPa, flexural strengths of 74-81 MPa, and flexural stiffnesses of 1.8-1.9 GPa, surpassing the ASTM requirements for bone cement and competing with traditional PMMA cement. Further, by utilizing designer FGMs with programmed bioactivity, these cements demonstrate controlled release of osteogenic calcium ions (releasing a total of 5 ± 2 µmol of Ca2+ per gram of cement over 28 d) and stimulate a 290% increase in expression of alkaline phosphatase in human mesenchymal stem cells in vitro. Also, design criteria are described to guide creation of future generations of bone cements that utilize FGMs as platforms to achieve dynamic biological activity.

Influence of Exogenous Variables on Intrusion Depth of PMMA Bone Cement: Revision of ISO 5833 Standard

Background: Poly (methyl methacrylate) (PMMA) bone cement is widely used to anchor total joint replacements to the contiguous bone. Among the clinically-relevant properties of this material is its intrusion depth (ID) because it indicates the potential for interdigitation of the curing cement into the interstices of the cancellous bone. ID is determined using procedures stipulated in ISO 5833. There is only one study in which ISO 5833 was examined critically, but only one exogenous variable was considered. Purpose: We carried out an extensive critical analysis of the ISO 5833 Standard with a view to making recommendations for revising it. Materials and Methods: 7 approved PMMA bone cement brands (covering low-, medium-, and high-viscosity brands) were used in two series of tests. In the first series, the influence of time at which ID was determined (relative to achievement of cement doughing time (DT)) was delineated. In the second series, the influence of three clinically-relevant variables on ID for each of these brands was determined and, then, response surface methodology was used to analyze the results. Results: ID results are given for both series of tests. Over the range of the variables used, the optimum IDs for a low-, medium-, and high-viscosity brand were computed to be 5.7 mm, 3.1 mm, and 2.4 mm, respectively. Conclusion: The findings allowed us to recommend that the following revisions be made to stipulations in ISO 5833 for determining ID: prior to running the ID test, store the cement unit at 1°C; 60 minutes after removing the cement unit from the storage medium, mix the cement powder and liquid, in a vacuum chamber, at 120 rpm; and determine ID 3 minutes after DT is achieved.

Mechanical and morphological characterization of PMMA/bone composites in human femoral heads

PMMA bone cement has gained an important place in a variety of orthopaedic applications in the femur. However, appropriate data on the mechanical properties of bone-cement composites from the human femur are lacking. Therefore, the goal of this study was to determine the morphological and quasi-static compressive properties of proximal femoral bone-cement composites. Thirty trabecular bone specimens were extracted from fifteen pairs of human femoral heads using specimen-specific cutting guides to ensure an accurate alignment with the main trabecular direction (MTD). One specimen from each pair was augmented with PMMA bone cement, while the other one was left untreated. Specimens were scanned with μCT to determine morphological parameters and tested in quasi-static compression until failure. We found that the long axis of the specimens was highly aligned with the MTD (mean error < 5°). A higher compressive modulus and ultimate strength were observed for the bone-cement composite specimens (E = 5.7 ± 0.4 GPa; σu = 77.9 ± 5.1 MPa) compared to the bone only specimens (E = 2.9 ± 0.7 GPa; σu = 19.0 ± 5.8 MPa). Furthermore, the composites had a higher modulus, but lower strength than cement itself (E = 5.0 ± 0.3 GPa; σu = 85.9 ± 2.7 MPa) and the composite modulus was significantly correlated with the bone volume fraction (BV/TV). These results are in contrast to previous findings on human vertebral bone, where the composite was more compliant than cement and no correlation was found between BV/TV and the composite modulus. Thus, properties of bone-cement composites cannot simply be applied across different anatomical sites; the site-specific differences in bone density and trabecular alignment should be taken into account. Collectively, the present results suggest that at low BV/TV, cement dominates the composite properties, while at high BV/TV, the contribution of bone becomes apparent, revealing a positive relationship between BV/TV and the on-axis modulus.

Effect of Calcium Acetate Content on Apatite-Forming Ability and Mechanical Property of PMMA Bone Cement Modified with Quaternary Ammonium.

Polymethyl methacrylate (PMMA)-based bone cement is a popular biomaterial used for fixation of artificial joints. A next-generation bone cement having bone-bonding ability, i.e., bioactivity and antibacterial property is desired. We previously revealed that PMMA cement added with 2-(tert-butylamino)ethyl methacrylate, γ-methacryloxypropyltrimethoxysilane and calcium acetate showed in vitro bioactivity and antibacterial activity. This cement contains calcium acetate at 20% of the powder component. Lower content of the calcium acetate is preferable, because the release of a lot of calcium salt may degrade mechanical properties in the body environment. In the present study, we investigate the effects of calcium acetate content on the setting property and mechanical strength of the cement and apatite formation in simulated body fluid (SBF). The setting time increased and the compressive strength decreased with an increase in calcium acetate content. Although the compressive strength decreased after immersion in SBF for 7 d, all the cements still satisfied the requirements of ISO5833. Apatite was formed in SBF within 7 d on the samples where the calcium acetate content was 5% or more. Therefore, it was found that PMMA cement having antibacterial properties and bioactivity can be obtained even if the amount of the calcium acetate is reduced to 5%.

Systematic Biomechanical Analysis of Prerequisites for Reliable Intraoperative Bonding of Polymethylmethacrylate Bone Cement in Preexisting Cement in Revision Arthroplasty.

Removal of a stable cement mantle may be invasive and time consuming and may result in unnecessary damage to bone and surrounding soft tissue. The goal of this study was to investigate the feasibility of the use of polymethylmethacrylate cement on preexisting cement as well as to explore the prerequisites for practical clinical use under standardized laboratory conditions. The strength of the cement-cement interface was evaluated with a 4-point bending to failure test, according to International Organization for Standardization 5833, as well as standardized shear strength, according to American Society for Testing and Materials D732. Various intraoperative cleaning agents were tested to remove simulated contamination with bone marrow. Contamination of the cement-cement interface with bone marrow decreases bending strength, modulus, and shear strength. Removal of the bone marrow with a degreasing agent significantly increases bending strength as well as bending modulus and can increase shear strength up to 9% compared with use of a nondegreasing agent. The cement-cement interface may reach up to 85% of bending strength, 92% of bending modulus, and comparable shear strength compared with a uniform cement block. Meticulous removal of fatty contaminant is important. Use of a degreasing agent further increases the stability of the cement-cement interface. With these precautions, it is safe to assume that the combined molecular and mechanical interlock is sufficient for most clinical applications and will not represent the weakest link in prosthetic revision. [Orthopedics. 2021;44(1):e55-e60.].

Does vacuum mixing affect diameter shrinkage of a PMMA cement mantle during in vitro cemented acetabulum implantation?

Radiolucent lines on immediate postoperative cemented acetabular component radiographs between the PMMA bone cement mantle and bone are an indicator of an increased risk of early loosening. The cause of these lines has yet to be identified. Thermal and chemical necrosis, fluid interposition and cement shrinkage have all been suggested in the literature. The aim of the study reported here was to take an engineering approach – eliminating confounding variables present during surgery – to quantify the size of the interstice created by cement shrinkage when a 50 mm diameter flanged acetabular cup is implanted in a model acetabulum with a 52 mm hemispherical bore under controlled conditions using vacuum and non-vacuum mixed cement. Irrespective of the mixing method used, a significant interstice was created between the bone cement and the mock acetabulum. When the cement was mixed under vacuum the interstice created between the mock acetabulum and the cement mantle was 0.60 mm ± 0.09 mm; when the cement was mixed under non-vacuum conditions the interstice created was 0.39 mm ± 0.15 mm. Possible explanations for radiolucent lines are discussed.

PROPERTIES OF THE HAND MIXED PMMA BASED CEMENT FOR BIOMEDICAL APPLICATIONS

This paper presents insights into the recent trends in development of PMMA bone cements considering their improvements for applications in clinical practice. Experimental investigation of hand mixed PMMA bone cement was realized, aiming to determine mechanical behavior of the material during nanoindentation. Standard multi-cycle indentation tests were applied, with maximum load of 15 N and immediate load relaxation down to 5 N, with sharp Vickers indenter. Indentation curves were obtained and analyzed as the function of the normal load vs penetration depth, for three different numbers of cycles (100, 200 and 300 cycles) and different indentation positions on the sample surface. Resulting indents were analyses from the aspect of the final material structure and its subsequent mechanical behavior. Agglomeration of PMMA beads was observed in the final hardened cement in some surface zones, thus indicating non-homogenous material structure. Changes in the number of cycles did not show significant influence on the mechanical response of the sample. However, sites with agglomerated PMMA beads showed significantly different indentation curves, thus indicating that hand-mixing of PMMA bone cement can produce non-homogenous final material structure.

NUMERICAL PREDICTION OF THE COMPONENT-RATIO-DEPENDENT COMPRESSIVE STRENGTH OF BONE CEMENT

Changes in the compression strength of the PMMA bone cement with a variable powder/liquid component mix ratio were investigated. The strength test data served to develop basic mathematical models and an artificial neural network was employed for strength predictions. The empirical and numerical results were compared to determine modelling errors and assess the effectiveness of the proposed methods and models. The advantages and disadvantages of mathematical modelling are discussed.

Preliminary application of CPC/PMMA composite bone cement in kyphoplasty for the elderly

From the perspective of clinical application to analyze the effectiveness and reliability of CPC/PMMA bone cement in percutaneous kyphoplasty (PKP) for the treatment of elderly patients with osteoporotic thoracolumbar fractures. A retrospective analysis was performed on 62 patients with osteoporotic compression fracture of single-vertebral thoracic or lumbar segment who underwent PKP surgery and had a bone density less than or equal to -3.0 SD from February 2016 to December 2016. Among them, 23 patients were in CPC/PMMA group, with an average age of (77.6±2.2) years old, 39 patients in PMMA group, with an average age of (77.1±1.1) years old. The indexes between two groups were compared, including the visual analogue scale (VAS), height ratio of anterior vertebra (AVHR), local Cobb angle, cement leakage, new adjacent vertebral fracture(NAVF). There were no significant difference in gender, age, follow-up time and preoperative VAS, AVHR, local Cobb angle between two groups (P>0.05), at the 1 day after operation, VAS, AVHR, local Cobb angle in all patients got obvious improvement (P<0.05), which was no significant difference at 1 day after operation and final follow-up (P>0.05). At the same time, there was no statistically significant difference in the incidence of new adjacent vertebral fracture and cement leakage (P>0.05). The pain in both groups continued to improve at follow up after operation (P<0.05), the local Cobb angle increased (P<0.05) and AVHR decreased slightly (P<0.05). However, the images of conventional methods (X-ray or CT) could not find signs about CPC degeneration and new bone ingrowth. CPC/PMMA composite bone cement is safe and reliablein PKP for treatment of elderly patients with osteoporotic thoracolumbar fractures, which can effectively relieve pain and maintain vertebral body stability. It has the same curative effect as PMMA bone cement. It was worthy to research more in future, although no direct evidences support the CPC/PMMA composite bone cement can reduce the incidence of adjacent vertebral fracture, CPC degeneration or new bone ingrowth.

Setting behaviour, mechanical properties and heat generation under alternate current magnetic fields of Fe3O4/TiO2/PMMA composite bone cement

AbstractPoly(methyl methacrylate) (PMMA) bone cement has excellent mechanical properties and is injectable; therefore, it is widely used as a filler for bone defects. To realize further effective treatment of bone defects, the design of PMMA cement containing magnetite (Fe3O4) and titania (TiO2), with good bone‐bonding properties and potential for application in magnetic hyperthermia treatment, is proposed. The ceramic content of the PMMA composite bone cements was varied from 20 mass% to 45 mass%. The setting behaviour, microstructure, compressive strength and heat generation under alternate current (AC) magnetic fields of the PMMA composite bone cements were evaluated. Determination of the setting temperature and time for the PMMA composite cements revealed that the maximum temperature during setting decreased with increasing Fe3O4 and TiO2 content while the setting time increased. The PMMA composite cements had dense microstructures regardless of the ceramic content. The nominal compressive strength for the samples ranged between 83 MPa and 94 MPa, which is sufficient for bone‐filling applications. Furthermore, the PMMA composite cement containing 25 mass% Fe3O4 generated heat under AC magnetic field, and its temperature reached 42.3°C after 10 min. Therefore, our findings contribute to the development of novel PMMA bone cements using functional ceramic components.

Hip Spacers with a Metal-on-Cement Articulation Did Not Show Significant Surface Alterations of the Metal Femoral Head in Two-Stage Revision for Periprosthetic Joint Infection.

Two-stage revision is considered the gold standard treatment for chronic periprosthetic joint infection (PJI). During the interim period, between explantation of the infected hip endoprosthesis and revision arthroplasty, individually formed articulating hip spacers made of polymethylmethacrylate (PMMA) bone cement can be used to provide better soft tissue preservation, local antibiotic release, and improved postoperative mobilization. If effective prevention from luxation is achieved, hip function and hence overall patient satisfaction is improved. Zirconium oxide particles inside conventional PMMA bone cement, however, are known to enhance third-body wear, which may cause alterations of the metal head in the articulating spacer and hence become a serious risk for the patient. Therefore, the aim of our study was to analyze whether the articular surface of cobalt-chrome (CoCr) femoral heads is significantly altered in the setting of a metal-on-cement articulation during the interim period of two-stage revision for PJI. We analyzed a consecutive series of 23 spacer cases and compared them with femoral heads from two series of conventional hip arthroplasty revisions with metal-on-polyethylene articulations and different time intervals in situ. To investigate metallic wear, the femoral heads were thoroughly examined, and their surface roughness was measured and analyzed. We found no significant differences between the two conventional hip arthroplasty groups, despite their very different times in situ. Furthermore, the individually different times in situ within the spacer group had no significant impact on surface roughness, either. Compared with the spacer group, the surface roughness of the metal femoral heads from both conventional hip arthroplasty groups were even higher. Within the spacer group, roughness parameters did not show significant differences regarding the five predefined locations on the metal head. We conclude that metal-on-cement articulations do not cause enhanced surface alterations of the metal femoral head and hence do not limit the application in articulating hip spacers in the setting of two-stage revision for PJI.

The stability of carbapenems before and after admixture to PMMA-cement used for replacement surgery caused by Gram-negative bacteria

BackgroundProsthetic joint infection (PJI) is a serious complication of orthopedic implant surgery. Treatment often includes the use of an antibiotic-loaded Polymethyl methacrylate (PMMA) bone cement spacer. Several antibiotics are commonly used for the preparation of these spacers, but due to the increasing number of infections with resistant Gram-negative bacteria, there is a need for the use of carbapenem antibiotics such as meropenem and imipenem as drugs of last resort. Unfortunately, the reaction heat generated during the preparation of the bone cement can be a major problem for the stability of these antibiotics. In the present study, the stability of meropenem and imipenem was tested before and after the admixture to PMMA bone cements.MethodsHigh-performance liquid chromatography with ion-pairing reversed-phase separation and spectrophotometric detection was used for analysis. Stability tests with meropenem and imipenem were performed with antibiotics in solution and solid form at different temperatures (37 °C, 45 °C, 60 °C, 90 °C) and times (30 min, 60 min, 120 min). To test the stability of both antibiotics in PMMA after exposure to the reaction heat during polymerization, three different bone cements were used to generate specimens that contained defined amounts of antibiotics. Reaction heat was measured. The form bodies were mechanically crushed and aliquots were dissolved in ethyl acetate. Samples were prepared for HPLC DAD analysis.ResultsMeropenem and imipenem showed the highest degradation levels after heat stressed in solution, with maximum levels of 75% and 95%, respectively. In solid form, degradation levels decreased dramatically for meropenem (5%) and imipenem (13%). Stability tests of both carbapenems in bone cement showed that they remained largely stable during PMMA polymerization, with retrieved amounts of about 70% in Palacos® R and Copal® G+V, and between 80 and 90% in Copal® spacem.ConclusionsIn contrast to the results of meropenem and imipenem in solution, both antibiotics remain stable in solid form and mostly stable in the cement after PMMA polymerization. The low degradation levels of both antibiotics after exposure to temperatures > 100 °C allow the conclusion that they can potentially be used for an application in PMMA cements.

Antibiotic Loaded Nano Rod Bone Cement for the Treatment of Osteomyelitis.

Polymethyl Methacrylate (PMMA) bone cement is the clinical gold standard biomaterial for local antibiotic therapy in osteomyelitis. However, it releases 50% of the antibiotic within the first three days. It generates excessive heat during polymerization and is non-biodegradable. It must be removed by another operation. The best-known alternative for PMMA is hydroxyapatite. The present patented work is focused on synthesizing the biodegradable hydroxyapatite in nano form for slow and sustained release of antibiotics and studying the release kinetics of antibiotics. Nano-hydroxyapatite was synthesized by co-precipitation method and characterized by particle size analyser, transmission electron microscopy, fourier transform infrared spectroscopy and energy dispersive X-Ray analysis. Antibiotic loaded nano-hydroxyapatite was prepared as 7 mm beads. The efficiency of drug-loaded nano-hydroxyapatite beads against osteomyelitic isolates was evaluated by well diffusion assay. Zero-order, first order, second order, Higuchi model, Korsmeyer-Peppas and Gompertz models were fit into the release kinetics of antibiotics from hydroxyapatite. Average size of nano-hydroxyapatite was 5 nm. The bactericidal activity exhibited by antibiotic- loaded micro-sized hydroxyapatite was therapeutic until 10 days only, whereas antibiotic-loaded nano-hydroxyapatite was therapeutic until 8 weeks. This confirms the burst release of antibiotics from micro-sized hydroxyapatite beads. In contrast, the release was slow and sustained up to 8 weeks from nano-hydroxyapatite. Korsmeyer-Peppas model fits into the release kinetics of antibiotics from nanohydroxyapatite. Nano-hydroxyapatite with a Ca/P ratio of 1.78 is suitable for the slow and sustained delivery of antibiotics for 8 weeks.

Canadian Spine SocietyPresentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spinePresentation CPSS2: The clinical significance of tether breakages in anterior vertebral body growth modulation: a 2-year postoperative analysisPresentation CPSS3: Anterior vertebral body growth modulation for idiopathic scoliosis: early, mid-term and late complicationsPresentation CPSS4: Ovine model of congenital chest wall and spine deformity with alterations of respiratory mechanics: follow-up from

Canadian Spine SocietyPresentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spinePresentation CPSS2: The clinical significance of tether breakages in anterior vertebral body growth modulation: a 2-year postoperative analysisPresentation CPSS3: Anterior vertebral body growth modulation for idiopathic scoliosis: early, mid-term and late complicationsPresentation CPSS4: Ovine model of congenital chest wall and spine deformity with alterations of respiratory mechanics: follow-up from

Vertebral body cemented stents combined with posterior stabilization in the surgical treatment of metastatic spinal cord compression of the thoracolumbar spine.

Background: Extensile interventions to provide anterior spinal column support in metastatic spinal cord compression (MSCC) surgery incur added morbidity in this surgically frail group of patients. We present our preliminary results of posterior spinal decompression and stabilization coupled with vertebral body cemented stents for anterior column support in MSCC.Methods: Fourteen patients underwent posterior spinal decompression and pedicle screw construct along with vertebral body stenting (VBS) technique for reconstruction and augmentation of the vertebral body. The primary in all except one was solid organ malignancy and 10 patients (71%) were treatment naïve. The mean revised Tokuhashi score was 10.7 ± 2.7 and the mean spinal instability neoplastic score was 9.6 ± 1.9. All vertebral body lesions were purely lytic and were associated with a cortical defect in the posterior wall.Results: A mean 5.3 ± 2.7 ml low-viscosity polymethyl methacrylate bone cement was injected within the stent at each compression level. No cement extrusion posteriorly was noted in any case from intraoperative fluoroscopy or postoperative radiographs. Five patients died at a mean 6.8 months (range 1–15 months), while the remaining patients have a mean survival of 18 months. Neither further revision surgical intervention nor any neurological deterioration was noted in any patient, who all continued to be ambulatory. The mean postoperative Core Outcome Measures Index score for 11 patients was 4.03 (standard deviation 3.11, 95% confidence interval (1.93–6.12).Conclusion: In lytic vertebral body lesions with posterior wall erosions, cemented VBS technique adds to the surgical armamentarium in MSCC surgery showing promising early results without added complications.

Setting behavior, apatite-forming ability, mechanical strength of polymethylmethacrylate bone cement through bioactivity modification of phosphate functional groups combined with Ca2+ ions

Bioactivity modification helps polymethylmethacrylate (PMMA) bone cement to reinforce its interfacial adhesion to bone tissues through the chemical bonding of apatite. Since Si-OH groups combined with Ca2+ ions have succeeded in inducing apatite formation, more combinations of functional groups and active ions are being explored. In this study, Bis[2-(methacryloyloxy)ethyl] phosphate (B2meP) containing phosphate (=PO4H) groups and Ca(CH3COO)2 supplying Ca2+ ion were adopted to investigate the feasibility of equipping PMMA bone cement with apatite-forming ability in vitro, more effects under designed contents on setting behavior, injectability, contact angle, cytotoxicity and mechanical strength were also investigated. Results showed B2meP copolymerized with MMA and became one section of PMMA chains, surface = PO4H groups and released Ca2+ ions pushed spherical apatite individuals nucleating and agglomerating into layer horizontally, Increasing B2meP content lowered the contact angle and the peak temperature, enhanced the cell viability of MC3T3-E1, but prolonged apatite forming period. Injectability rate performed a similar trend to setting time. Lower adding content and deposited apatite layer contributed to reduce the strength loss in soaking. Taking biological performance and other properties into balance, cement added with B2meP of 10 wt% in MMA and Ca(CH3COO)2 of 20 wt% in PMMA performed better.

Release behavior, mechanical properties, and antibacterial activity of ciprofloxacin-loaded acrylic bone cement: a mechanistic study

Objective To evaluate the effect of ciprofloxacin concentration and cement geometry on release, mechanical, and antibacterial properties of PMMA bone cement. Significance: Cements are used in different geometries and drug concentrations. These can affect cement strength, drug release behavior, and its antibacterial activity. Methods Antibiotic-loaded bone cement (ALBC) containing 2.5, 5.0, and 10.0 wt% ciprofloxacin were prepared as slab, rectangular prism and short cylinder. Drug release and compression strength of the cements were investigated for 28 days at 37 °C. The ALBC efficacies against prevalent bone infection bacteria, S. aureus, E. coli, and P. aeruginosa, were investigated. Drug determination was by HPLC. Results A two-stage behavior of fast release through dissolution/diffusion (stage A; <96 h) and 2–5 times slower Fickian diffusion (stage B; 96–672 h) was observed. Significant differences for release rate were observed among different geometries in the order of cylinder > prism > slab, in correlation with systems’ thickness, indicating lower drug depletion in thicker systems. Release rates were proportional to concentration for 2.5 and 5% systems. At 10.0% loading, however, apparently interconnected channels and higher porosity reduced the diffusional resistance and provided higher release rates than what expected from concentration increment. Growth of Gram-negative bacteria and S. aureus was inhibited at the lowest dose of drug over 1 and 48 h, respectively. ALBCs with 5.0 and 10.0% ciprofloxacin showed decrease of compression strength to below ISO standard. Conclusions Different properties of acrylic cements are affected by geometry and drug concentration and should be considered for optimized drug therapy.

Intracardial PMMA bone cement embolism after kyphoplasty-an unusual cause for sudden chest pain, hemothorax and hemopericardium.

Intracardial PMMA bone cement embolism after kyphoplasty-an unusual cause for sudden chest pain, hemothorax and hemopericardium.

Antibiotic Refilling, Antimicrobial Activity, and Mechanical Strength of PMMA Bone Cement Composites Critically Depend on the Processing Technique.

Antibiotic-laden poly(methyl methacrylate) (PMMA) bone cement is used in a variety of applications including temporary spacers for load-bearing arthroplasties and non-load bearing orthopedic revision procedures and antibiotic beads to treat infections. Depending upon the surgical preparation technique, properties of PMMA can widely vary. The primary objective of this work was to perform an in-depth structure-function analysis regarding how processing of PMMA impacted material and structural properties (i.e., porosity) and downstream functional properties (i.e., drug refilling and strength). PMMA with cyclodextrin (CD) microparticles was generated via hand- or vacuum-mixing and characterized for material and structural properties including porosity and internal morphology and functional properties of drug refilling, compressive strength, and antimicrobial activity. CD microparticles were incorporated into PMMA to enable functional refilling properties and to determine new information on drug distribution and distance or depth of PMMA which the refilled drug was able to penetrate. Vacuum-mixing of PMMA resulted in improved mechanical strength and allowed for incorporation of greater amounts of CD microparticles but less homogeneity relative to hand-mixing. Refilling studies showed shallow penetration of the drug into PMMA samples without CD. However, PMMA with CD microparticles showed increased depth of drug penetration, indicating that the drug could be delivered deeper within the device, resulting in more drug being available for delivery and more opportunity for later antibiotic refilling on a patient-specific basis. Knowledge of structure-function relationships can assist and provide valuable information in design and optimization of PMMA-CD for specific load-bearing or non-load-bearing applications.

Porous metal wedge augments to address glenoid retroversion in anatomic shoulder arthroplasty: midterm update

Wedge-shaped porous metal augments were used to address bone deficiency in shoulder arthroplasty as part of a hybrid combination of high-density polyethylene, polymethyl methacrylatebone cement, and porous metal implant. This article presents an ongoing review of the use of the generically designed augments in the shoulder to address glenoid retroversion as part of anatomic total shoulder arthroplasty (aTSA). Seventy-five shoulders in 66 patients (23 women and 43 men, aged 42-85 years) with Walch grade B2 or C glenoids underwent porous metal glenoid augment (PMGA) insertion as part of aTSA. Patients underwent preoperative 3-dimensional (3D) templating; based on that planning, patients received either a 15° or 30° PMGA wedge (secured by screws to the native glenoid) to correct excessive glenoid retroversion before a standard glenoid component was implanted using bone cement. Neither patient-specific guides nor navigation were used. Intraoperative glenoid alignment was assessed using a reusable guide that referenced the anterior scapular neck. Patients were prospectively assessed using shoulder functional assessments (Oxford Shoulder Score [OSS], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analogscale [VAS] pain scores, and forward elevation [FE]) preoperatively; at 3, 6, and 12 months postoperation; and yearly thereafter, with similar radiologic surveillance. Of the total consecutive series, 49 shoulders had a follow-up of greater than 24 months, with a median follow-up of 48 months (range: 24-87 months). For this cohort, median outcome scores improved for OSS (21 to 44), ASES (24 to 92), VAS (7 to 0), and FE (90° to 140°) from preoperative outcomes to the most recent review, respectively. Four patients died, but no others were lost to follow-up. Apart from 1 infection at 18 months postoperatively and 1 minor peg perforation, there were no complications, hardware failures, implant displacements, significant lucency, or posterior resubluxations. Radiographs showed good incorporation of the wedge augment, with correction of glenoid retroversion from median 22° (13° to 46°) to 4° (17° to anteversion 16°). All but 4 glenoids were corrected to within the target range (less than 10° retroversion), and only 2 glenoid components were implanted outside 15° of neutral glenoid version. The porous metal wedge-shaped augments effectively addressed posterior glenoid deficiency as part of aTSA for rotator cuff intact osteoarthritis, producing satisfactory clinical outcomes with no signs of impending future failure.