Premixed Calcium Phosphate Cements Research Articles

Carvacrol-loaded premixed calcium phosphate bone cements with exceptional osteogenic and antibacterial properties to heal infected bone defects

The healing of infected bone fractures represents a significant clinical challenge in orthopedic surgery. Calcium phosphate cements (CPCs) are attractive materials, highly applicable in bone healing due to their satisfactory biological properties and chemical similarity to bone minerals. However, manual mixing is often required before localized application of conventional CPCs, increasing the risk of infection. Moreover, their antibacterial properties are often insufficient for treating infected fractures. In this study, antimicrobial two-paste premixed CPCs loaded with carvacrol were developed. The influence of the carvacrol on the setting properties and mechanical strength of the cement was studied. In vitro studies demonstrated the biocompatibility, osteogenic potential, and broad-spectrum antimicrobial efficacy of the premixed bone cements, including effectiveness against gram-positive, gram-negative, and drug-resistant bacteria. Notably, in vivo studies revealed exceptional antimicrobial and osteogenic properties of the carvacrol-loaded cements, confirming the promising potential of the premixed cements for the healing of infected bone defects.

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

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

Degradation in vitro and in vivo of β-TCP/MCPM-based premixed calcium phosphate cement

Premixed calcium phosphate cements (CPCs) have been developed to shorten the surgical time of conventional CPCs. However, there is lack of investigation on degradation behavior of premixed CPCs in vitro and in vivo. In this study, the premixed CPCs are prepared by mixing glycerol or polyethylene glycol (PEG) with the CPC power (β-tricalcium phosphate (β-TCP) and monocalcium phosphate monohydrate (MCPM)), and their degradation performances including the microstructure, chemical composition and mechanical properties are systematically evaluated both in vitro and in vivo (subcutaneous implantations in rabbits). When the premixed CPCs aged in PBS or FBS, results show weight loss of the specimens, decreased pH value and increased calcium ion concentration of aging media. Meanwhile, the setting products convert from dicalcium phosphate dihydrate (DCPD) to dicalcium phosphate anhydrous (DCPA), and no hydroxyapatite deposit. The specimen size and the molecular weight of non-aqueous solvent can modulate the setting product of premixed CPCs. For the larger specimens, DCPA is the main setting product, for the smaller ones, the composite contained DCPD and DCPA. With the decrease of the molecular weight of the non-aqueous solvent PEG, the setting product change from both DCPD and DCPA to DCPA due to the quicker exchange rate of PEG with water. After a period of subcutaneous implantation, the surface of the grafts obviously disintegrated with the formation of porous structures, but their internal morphology do not obviously change.

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

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

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

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

Calcium Phosphate Bone Cements Reinforced with Biodegradable Polymer Fibres for Drug Delivery

Conventional calcium phosphate bone cements are self setting water based pastes. Recently pre-mixed calcium phosphate bone cements have been proposed that have non-aqueous fluid as liquid phase of the paste. Such cements thus only start setting reaction in contact with body fluids. In this work the properties (cohesion, compressive strength, phase composition) of pre-mixed calcium phosphate cements based on α-tricalcium phosphate and calcium dihydrogen phosphate monohydrate are described. Properties of several cement compositions are examined and compared to properties of β-tricalcium phosphate and calcium dihydrogen phosphate monohydrate based cements. It was found that α-tricalcium phosphate and calcium dihydrogen phosphate monohydrate based cements have higher compressive strength (10 - 15 MPa) than corresponding β-tricalcium phosphate and calcium dihydrogen phosphate monohydrate based cements (10 - 6 MPa). Out of examined cement paste liquids (glycerol, polyethylene glycol and polypropylene glycol) cements using glycerol as the liquid phase had higher compressive strength and are more cohesive.

Fast Setting Pre-Mixed Calcium Phosphate Bone Cements Based on α-Tricalcium Phosphate

Conventional calcium phosphate bone cements are self setting water based pastes. Recently pre-mixed calcium phosphate bone cements have been proposed that have non-aqueous fluid as liquid phase of the paste. Such cements thus only start setting reaction in contact with body fluids. In this work the properties (cohesion, compressive strength, phase composition) of pre-mixed calcium phosphate cements based on α-tricalcium phosphate and calcium dihydrogen phosphate monohydrate are described. Properties of several cement compositions are examined and compared to properties of β-tricalcium phosphate and calcium dihydrogen phosphate monohydrate based cements. It was found that α-tricalcium phosphate and calcium dihydrogen phosphate monohydrate based cements have higher compressive strength (10 - 15 MPa) than corresponding β-tricalcium phosphate and calcium dihydrogen phosphate monohydrate based cements (10 - 6 MPa). Out of examined cement paste liquids (glycerol, polyethylene glycol and polypropylene glycol) cements using glycerol as the liquid phase had higher compressive strength and are more cohesive.

Influence of polymer addition on the mechanical properties of a premixed calcium phosphate cement

Premixed calcium phosphate cements can reduce handling complications that are associated with the mixing of cements in the operating room. However, to extend the clinical indication of ceramic cements their mechanical properties need to be further improved. The incorporation of a polymeric material with intrinsically high tensile properties could possibly assist in increasing the mechanical properties of calcium phosphate cement. In this study polymer microparticles made from poly(lactid-co-glycolide) plasticised with poly(ethylene glycol) 400 (PLGA/PEG microparticles) were added in amounts of up to 5 wt% to a premixed acidic calcium phosphate cement. The PLGA/PEG microparticles added undergo a shape transformation at 37 °C, which could give a better integration between polymer microparticles and ceramic cement compared with polymer microparticles lacking this property. The results showed that the incorporation of 1.25 wt% PLGA/PEG microparticles increased the compressive strength by approximately 20% up to 15.1 MPa while the diametral tensile strength was kept constant. The incorporation of PLGA/PEG microparticles increased the brushite to monetite ratio after setting compared with pure ceramic cements. In conclusion, small amounts of PLGA/PEG microparticles can be incorporated into premixed acidic calcium phosphate cement and increase their mechanical properties, which could lead to increased future applications.

Influence of particle size on hardening and handling of a premixed calcium phosphate cement

Premixed calcium phosphate cements (pCPC) have been developed to circumvent problems related to mixing and transfer of cements in the operating room. In addition, by using pCPC the short working times generally associated with conventional water-mixed cements are avoided. In this work, the influence of particle size on handling and hardening characteristics of a premixed monetite cement has been assessed. The cements were evaluated with respect to their injectability, setting time and compressive strength. It was found that cements with smaller particle sizes were more difficult to inject and had higher compressive strength. Regarding setting time, no clear trend could be discerned. The addition of granules made the cements easier to inject, but setting time was prolonged and lower strengths were obtained. The main findings of this work demonstrate that particle size can be used to control handling and physical properties of premixed cements and that previous knowledge from water-based CPC, regarding effects of particle size, is not directly applicable to premixed CPC.

Setting Mechanisms of an Acidic Premixed Calcium Phosphate Cement

Premixed calcium phosphate cements (pCPC), where glycerol is used instead of water as mixing liquid, present better handling characteristics than water-based cements. However, the setting mechanisms of pCPC have not been described thoroughly. The aim of this paper is to increase the understanding of the setting mechanism of pCPC. The investigated cement starts to set when glycerol is exchanged with water via diffusion of glycerol out to the surrounding body fluid and water into the material. To better understand the water-glycerol exchange a method was developed where the setting depth of the cement was measured over time. Thermo gravimetric analysis (TGA) was used to determine the liquid exchange rate during setting. To study the influence of temperature on the crystalline end product, pCPC and water-mixed calcium phosphate cement (wCPC) were set at different temperatures and analyzed with X-ray diffraction (XRD). The setting depth measurements showed that the set layer of the pCPC grew with a speed proportional to t0.51 at 37°C. TGA results furthermore showed that less than 10% of the glycerol remained after 16 hours. Setting of pCPC at different temperatures showed that mainly brushite was formed at 5°C, a mixture of brushite and monetite at 21°C and mainly monetite at 37°C. It furthermore showed that brushite was the main phase after setting of wCPC, but some monetite was present in these cements. The study presents a new method for evaluation of pCPC that increases the understanding of their setting mechanism. Furthermore, the XRD results indicate that storage at 5°C could improve the shelf life of acidic pCPC.

In Vivo Characteristics of Premixed Calcium Phosphate Cements When Implanted in Subcutaneous Tissues and Periodontal Bone Defects.

Previous studies showed that water-free, premixed calcium phosphate cements (Pre-CPCs) exhibited longer hardening times and lower strengths than conventional CPCs, but were stable in the package. The materials hardened only after being delivered to a wet environment and formed hydroxyapatite as the only product. Pre-CPCs also demonstrated good washout resistance and excellent biocompatibility when implanted in subcutaneous tissues in rats. The present study evaluated characteristics of Pre-CPCs when implanted in subcutaneous tissues (Study I) and used for repairing surgically created two-wall periodontal defects (Study II). Pre-CPC pastes were prepared by combining CPC powders that consisted of CPC-1: Ca4(PO4)2O and CaHPO4, CPC-2: α-Ca3(PO4)2 and CaCO3 or CPC-3: DCPA and Ca(OH)2 with a glycerol at powder-to-liquid mass ratios of 3.5, 2.5, and 2.5, respectively. In each cement mixture, the Ca to P molar ratio was 1.67. The glycerol contained Na2HPO4 (30 mass %) and hydroxypropyl methylcellulose (0.55 %) to accelerate cement hardening and improve washout resistance, respectively. In Study I, the test materials were implanted subcutaneously in rats. Four weeks after the operation, the animals were sacrificed and histopathological observations were performed. The results showed that all of the implanted materials exhibited very slight or negligible inflammatory reactions in tissues contacted with the implants. In Study II, the mandibular premolar teeth of mature beagle dogs were extracted. One month later, two-wall periodontal bone defects were surgically created adjacent to the teeth of the mandibular bone. The defects were filled with the Pre-CPC pastes and the flaps replaced in the preoperative position. The dogs were sacrificed at 1, 3 and 6 months after surgery and sections of filled defects resected. Results showed that one month after surgery, the implanted Pre-CPC-1 paste was partially replaced by bone and was converted to bone at 6 months. The pockets filled with Pre-CPC-2 were completely covered by newly formed bone in 1 month. The Pre-CPC-2 was partially replaced by trabecular bone in 1 month and was completely replaced by bone in 6 months. Examination of 1 month and 3 month samples indicated that Pre-CPC-2 resorbed and was replaced by bone more rapidly than Pre-CPC 1. Both Pre-CPC pastes were highly osteoconductive. When implanted in periodontal defects, Pre-CPC-2 was replaced by bone more rapidly than Pre-CPC-1.

Properties of Injectable Apatite-Forming Premixed Cements.

Previous studies reported premixed calcium phosphate cements (CPCs) that were stable in the package and form hydroxyapatite (HA) as the product after exposure to an aqueous environment. These cements had setting times of greater than 60 min, which are too long to be useful for some clinical applications. The present study investigated properties of fast-setting HA-forming premixed CPCs that initially consisted of two separate premixed pastes: (1) finely ground (1.0 μm in median size) dicalcium phosphate anhydrous (DCPA) mixed with an aqueous NaH2PO4 solution, 1.5 mol/L or 3.0 mol/L in concentration, and (2) tetracalcium phosphate consisting of combinations of particles of two different size distributions, 5 μm (TTCP5) and 17 μm (TTCP17) in median size, mixed with glycerin. Equal volume of Pastes 1 and 2 were injected with the use of atwo-barrel syringe fitted with a static mixer into sample molds. The molar Ca/P ratio of combined paste was approximately 1.5. Cements were characterized in terms of setting time (Gilmore needle), diametral tensile strength (DTS), and phase composition (powder x-ray diffraction, XRD). Setting times were found to range from (4.3 ± 0.6 to 68 ± 3) min (mean ± sd; n = 3), and 1-d and 7-d DTS values were from (0.89 ± 0.08 to 2.44 ± 0.16) MPa (mean ± sd; n = 5). Both the NaH2PO4 concentration and TTCP particle size distribution had significant (p < 0.01) effects on setting time and DTS. Powder XRD analysis showed that low crystallinity HA and unreacted DCPA were present in the 1-day specimens, and the extent of HA formation increased with increasing amount of TTCP5 in the TTCP paste. Conclusion: Injectable HA-forming premixed CPCs with setting times from 4 to 70 min can be prepared by using DCPA and TTCP as the ingredients. Compared to the conventional powder liquid cements, these premixed CPCs have the advantages of being easy to use and having a range of hardening times.

β-TCP/MCPM-based premixed calcium phosphate cements

Novel premixed calcium phosphate cements (CPCs) were prepared by combining cement liquids comprised of glycerol or polyethylene glycol with CPC powders that consisted of β-tricalcium phosphate (β-TCP) and monocalcium phosphate monohydrate (MCPM). Changing the powder to liquid mass ratio enabled the setting time to be regulated, and improved the compressive strength of the CPCs. Although some ratios of the new premixed CPCs had long setting times, these ranged from 12.4 to 27.8 min which is much shorter than the hour or more reported previously for a premixed CPC. The premixed CPCs had tolerable washout resistance before final setting, and the cements had strengths matching that of cancellous bone (5–10 MPa); their maximum compressive strength was up to 12 MPa. The inflammatory response around the premixed CPCs implanted in the subcutaneous tissue in rabbits was more prominent than that of apatite cement. These differences might be due to the much faster resorption rate of the premixed CPCs.

Premixed calcium phosphate cements: Synthesis, physical properties, and cell cytotoxicity

Objectives Calcium phosphate cement (CPC) is a promising material for dental, periodontal, and craniofacial repairs. However, its use requires on-site powder–liquid mixing that increases the surgical placement time and raises concerns of insufficient and inhomogeneous mixing. The objective of this study was to determine a formulation of premixed CPC (PCPC) with rapid setting, high strength, and good in vitro cell viability. Methods PCPCs were formulated from CPC powder + non-aqueous liquid + gelling agent + hardening accelerator. Five PCPCs were thus developed: PCPC-Tartaric, PCPC-Malonic, PCPC-Citric, PCPC-Glycolic, and PCPC-Malic. Formulations and controls were compared for setting time, diametral tensile strength, and osteoblast cell compatibility. Results Setting time (mean ± S.D.; n = 4) for PCPC-Tartaric was 8.2 ± 0.8 min, significantly less than the 61.7 ± 1.5 min for the Premixed Control developed previously ( p < 0.001). On 7th day immersion, the diametral tensile strength of PCPC-Tartaric reached 6.5 ± 0.8 MPa, higher than 4.5 ± 0.8 MPa of Premixed Control ( p = 0.036). Osteoblast cells displayed a polygonal morphology and attached to the nano-hydroxyapatite crystals in the PCPCs. All cements had similar live cell density values ( p = 0.126), indicating that the new PCPCs were as cell compatible as a non-premixed CPC control known to be biocompatible. Each of the new PCPCs had a cell viability that was not significantly different ( p > 0.1) from that of the non-premixed CPC control. Significance PCPCs will eliminate the powder–liquid mixing during surgery and may also improve the cement performance. The new PCPCs supported cell attachment and yielded a high cell density and viability. Their mechanical strengths approached the reported strengths of sintered porous hydroxyapatite implants and cancellous bone. These nano-crystalline hydroxyapatite cements may be useful in dental, periodontal, and craniofacial repairs.