Brushite cement additives inhibit attachment to cell culture beads

Biological and mechanical performance of calcium phosphate cements modified with phytic acid

Calcium phosphate cements, primarily brushite cements, require the addition of setting retarders to ensure adequate processing time and processability. So far, citric acid has been the primary setting retarder used in this context. Due to the poor biocompatibility, it is crucial to explore alternative options for better processing. In recent years, the setting retarder phytic acid (IP6) has been increasingly investigated. This study investigates the biological behaviour of calcium phosphate cements with varying concentrations of IP6, in addition to their physical properties. Therefore cytocompatibility in vitro testing was performed using osteoblastic (MG-63) and osteoclastic (RAW 264.7 differentiated with RANKL) cells. We could demonstrate that the physical properties like the compressive strength of specimens formed with IP6 (brushite_IP6_5 = 11.2 MPa) were improved compared to the reference (brushite = 9.8 MPa). In osteoblast and osteoclast assays, IP6 exhibited significantly better cytocompatibility in terms of cell activity and cell number for brushite cements up to 11 times compared to the brushite reference. In contrast, the calcium-deficient hydroxyapatite (CDHA) cements produced similar results for IP6 (CDHA_IP6_0.25 = 27.0 MPa) when compared to their reference (CDHA = 21.2 MPa). Interestingly, lower doses of IP6 were found to be more effective than higher doses with up to 3 times higher. Additionally, IP6 significantly increased degradation in both passive and active resorption. For these reasons, IP6 is emerging as a strong new competitor to established setting retarders such as citric acid. These cements have potential applications in bone augmentation, the stabilisation of non-load bearing fractures (craniofacial), or the cementation of metal implants.

Biological and Mechanical Performance of Dual-Setting Brushite-Silica Gel Cements

Bone defects resulting from trauma, diseases, or surgical procedures pose significant challenges in the field of oral and maxillofacial surgery. The development of effective bone substitute materials that promote bone healing and regeneration is crucial for successful clinical outcomes. Calcium phosphate cements (CPCs) have emerged as promising candidates for bone replacement due to their biocompatibility, bioactivity, and ability to integrate with host tissues. However, there is a continuous demand for further improvements in the mechanical properties, biodegradability, and bioactivity of these materials. Dual setting of cements is one way to improve the performance of CPCs. Therefore, silicate matrices can be incorporated in these cements. Silicate-based materials have shown great potential in various biomedical applications, including tissue engineering and drug delivery systems. In the context of bone regeneration, silicate matrices offer unique advantages such as improved mechanical stability, controlled release of bioactive ions, and enhanced cellular responses. Comprehensive assessments of both the material properties and biological responses of our samples were conducted. Cytocompatibility was assessed through in vitro testing using osteoblastic (MG-63) and osteoclastic (RAW 264.7) cell lines. Cell activity on the surfaces was quantified, and scanning electron microscopy (SEM) was employed to capture images of the RAW cells. In our study, incorporation of tetraethyl orthosilicate (TEOS) in dual-curing cements significantly enhanced physical properties, attributed to increased crosslinking density and reduced pore size. Higher alkoxysilyl group concentration improved biocompatibility by facilitating greater crosslinking. Additionally, our findings suggest citrate's potential as an alternative retarder due to its positive interaction with the silicate matrix, offering insights for future dental material research. This paper aims to provide an overview of the importance of silicate matrices as modifiers for calcium phosphate cements, focusing on their impact on the mechanical properties, setting behaviour, and biocompatibility of the resulting composites.

Experimental Drillable Magnesium Phosphate Cement Is a Promising Alternative to Conventional Bone Cements

Clinically used mineral bone cements lack high strength values, absorbability and drillability. Therefore, magnesium phosphate cements have recently received increasing attention as they unify a high mechanical performance with presumed degradation in vivo. To obtain a drillable cement formulation, farringtonite (Mg₃(PO₄)₂) and magnesium oxide (MgO) were modified with the setting retardant phytic acid (C₆H₁₈O₂₄P₆). In a pre-testing series, 13 different compositions of magnesium phosphate cements were analyzed concentrating on the clinical demands for application. Of these 13 composites, two cement formulations with different phytic acid content (22.5 wt% and 25 wt%) were identified to meet clinical demands. Both formulations were evaluated in terms of setting time, injectability, compressive strength, screw pullout tests and biomechanical tests in a clinically relevant fracture model. The cements were used as bone filler of a metaphyseal bone defect alone, and in combination with screws drilled through the cement. Both formulations achieved a setting time of 5 min 30 s and an injectability of 100%. Compressive strength was shown to be ~12–13 MPa and the overall displacement of the reduced fracture was <2 mm with and without screws. Maximum load until reduced fracture failure was ~2600 N for the cements only and ~3800 N for the combination with screws. Two new compositions of magnesium phosphate cements revealed high strength in clinically relevant biomechanical test set-ups and add clinically desired characteristics to its strength such as injectability and drillability.

Biological and mechanical performance and degradation characteristics of calcium phosphate cements in large animals and humans

Calcium phosphate cements (CPCs) have been used to treat bone defects and support bone regeneration because of their good biocompatibility and osteointegrative behavior. Since their introduction in the 1980s, remarkable clinical success has been achieved with these biomaterials, because they offer the unique feature of being moldable and even injectable into implant sites, where they harden through a low-temperature setting reaction. However, despite decades of research efforts, two major limitations concerning their biological and mechanical performance hamper a broader clinical use. Firstly, achieving a degradation rate that is well adjusted to the dynamics of bone formation remains a challenging issue. While apatite-forming CPCs frequently remain for years at the implant site without major signs of degradation, brushite-forming CPCs are considered to degrade to a greater extent. However, the latter tend to convert into lower soluble phases under physiological conditions, which makes their degradation behavior rather unpredictable. Secondly, CPCs exhibit insufficient mechanical properties for load bearing applications because of their inherent brittleness. This review places an emphasis on these limitations and provides an overview of studies that have investigated the biological and biomechanical performance as well as the degradation characteristics of different CPCs after implantation into trabecular bone. We reviewed studies performed in large animals, because they mimic human bone physiology more closely in terms of bone metabolism and mechanical loading conditions compared with small laboratory animals. We compared the results of these studies with clinical trials that have dealt with the degradation behavior of CPCs after vertebroplasty and kyphoplasty.

Setting Mechanism of a CDHA Forming α-TCP Cement Modified with Sodium Phytate for Improved Injectability

A calcium deficient hydroxyapatite (CDHA) forming cement with a bimodal grain size distribution, composed of α-TCP and fine grained CDHA at a weight ratio of 9:1, was modified by the addition of sodium phytate (IP6) in variable amounts ranging from 0.25 to 2 wt.%, related to the powder content. The injectability of the cement paste was drastically increased by the IP6 addition, independent of the amount of added IP6. Additionally, the cement paste viscosity during the first minutes decreased. These effects could be clearly related to a slightly more negative zeta potential. Furthermore, IP6 was shown to strongly retard the setting reaction, as can be seen both in the calorimetry and X-ray diffraction measurements. In addition, octacalcium phosphate (OCP) was identified as a further setting product. All measurements were performed at 23 °C and 37 °C to assess the effect of temperature on the setting reaction for both clinical handling by the surgeon and the final hardening in the bone defect.

Physical, mechanical and in vitro evaluation of a novel cement based on akermantite and dicalcium phosphate dihydrate phase

Magnesium containing calcium silicates have recently shown that they are promising materials for various biomedical application with potential use in the form of bulk ceramic, composite scaffold or coatings on metallic substrates. A novel akermanite (AK; Ca₂MgSi₂O₇)/dicalcium phosphate dihydrate (DCPD, CaHPO₄. H₂O) cement mixture was tested in this work in order to produce an alternative AK/DCPD biocement for orthopedic applications. For comparison, we have prepared two cements mixed with 2.5 wt% NaH₂PO₄ solution (labeled as NaH₂PO₄ cement) and with the solution composed of organic 2.5 wt% citric acid a 2.5 wt% trisodium citrate (citrate cement) respectively. The results demonstrated only a partial dissolution of AK, regardless of the type of liquid used. On the other hand, the DCPD was completely hydrolyzed much faster in the citrate cement. The final hydration product was an amorhous quarternary phase of CaO-MgO-SiO₂-P₂O₅ composition with the remaining unreacted akermanite embeded in the cement matrix. The highest early compressive strength was observed in the citrate cement (33 MPa), but much lower value was measured in NaH₂PO₄ cement (7 MPa) after 1 d setting. Different cell responses have been observed when the cells were cultured on the surfaces of cement substrates. While the NaH₂PO₄ cement demonstrated high proliferation activity of osteoblast, the citrate cement showed strong cytotoxic cell response, probably as a result of higher concentration of citrates on the cement surface, which can negatively affect the attachment and proliferation of osteoblastic cells.

Effect of Baghdadite Substitution on the Physicochemical Properties of Brushite Cements

Brushite cements have been clinically used for irregular bone defect filling applications, and various strategies have been previously reported to modify and improve their physicochemical properties such as strength and injectability. However, strategies to address other limitations of brushite cements such as low radiopacity or acidity without negatively impacting mechanical strength have not yet been reported. In this study, we report the effect of substituting the beta-tricalcium phosphate reactant in brushite cement with baghdadite (Ca₃ZrSi₂O₉), a bioactive zirconium-doped calcium silicate ceramic, at various concentrations (0, 5, 10, 20, 30, 50, and 100 wt%) on the properties of the final brushite cement product. X-ray diffraction profiles indicate the dissolution of baghdadite during the cement reaction, without affecting the crystal structure of the precipitated brushite. EDX analysis shows that calcium is homogeneously distributed within the cement matrix, while zirconium and silicon form cluster-like aggregates with sizes ranging from few microns to more than 50 µm. X-ray images and µ-CT analysis indicate enhanced radiopacity with increased incorporation of baghdadite into brushite cement, with nearly a doubling of the aluminium equivalent thickness at 50 wt% baghdadite substitution. At the same time, compressive strength of brushite cement increased from 12.9 ± 3.1 MPa to 21.1 ± 4.1 MPa with 10 wt% baghdadite substitution. Culture medium conditioned with powdered brushite cement approached closer to physiological pH values when the cement is incorporated with increasing amounts of baghdadite (pH = 6.47 for pure brushite, pH = 7.02 for brushite with 20 wt% baghdadite substitution). Baghdadite substitution also influenced the ionic content in the culture medium, and subsequently affected the proliferative activity of primary human osteoblasts in vitro. This study indicates that baghdadite is a beneficial additive to enhance the radiopacity, mechanical performance and cytocompatibility of brushite cements.

Preparation of brushite cements with improved properties by adding graphene oxide

Background: Brushite (dicalcium phosphate dihydrate, DCPD) cement as a promising bioactive material for bone tissue engineering is widely used to treat defects. However, relatively poor mechanical properties of brushite cement limit its application in loadbearing conditions. The aim of this study is to investigate the effect of graphene oxide (GO) addition to the physical-mechanical-biological properties of brushite cement. Methods: The brushite types of cement were prepared by mixing β-tricalcium phosphate [β-TCP, Ca3 (PO4)2] and monocalcium phosphate monohydrate [MCPM, Ca(H2PO4)2. H2O]. GO was introduced at 0, 0.5, 2, and 5 wt.% with the liquid. MG63 cells were cultured on the GO/CPC surfaces to observe various cellular activities and hydroxyapatite (HA) mineralization. Results: Based on our results, GO/CPC composites exhibit improvement in compressive strength compared to pure CPC. New Ca-deficient apatite layer was deposited on the composite surface after immersing immersion in SBF for 7 and 14 days. Field emission scanning electron microscope (FESEM) images indicated that pure and GO incorporated brushite cement facilitates cell adhesion. CPC/GO was slightly toxic to cells such that high concentrations of GO decreased the cell viability. Besides, alkaline phosphatase (ALP) activity of cells was improved compared with the pure CPC. Conclusion: Our results highlight the role of graphene oxide that may have great potential in enabling the utility of graphene-based materials in various biomedical applications.

Short-time pre-washing of brushite-forming calcium phosphate cement improves its in vitro cytocompatibility

A pre-washing protocol was developed for resorbable, brushite-forming calcium phosphate cements (CPCs) to avoid harmful in vitro effects on cells. CPC discs (JectOS+, Kasios; self-developed CPC) were pre-washed with repeated changes of phosphate-buffered saline (PBS; 24h total). Unwashed or PBS-pre-washed discs were incubated in culture medium (5% fetal calf serum; up to 10days) and then tested for their influence on pH/calcium/phosphate levels in H₂O extracts. Effects on pH/calcium/phosphate levels in culture supernatants, and morphology, adherence, number, and viability of ATDC5 cells and adipose-tissue derived stem cells were analyzed in co-culture. Pre-washing did not alter CPC surface morphology or Ca/P ratio (scanning electron microscopy; energy-dispersive X-ray spectroscopy). However, acidic pH of unwashed JectOS+ and self-developed CPC (5.82; 5.11), and high concentrations of Ca (2.17; 2.40mM) and PO₄ (38.15; 49.28mM) in H₂O extracts were significantly counteracted by PBS-pre-washing (pH: 7.92; 7.92; Ca: 0.64; 1.11mM; PO₄: 5.39-5.97mM). Also, PBS-pre-washing led to physiological pH (approx. 7.5) and PO₄ levels (max. 5mM), and sub-medium Ca levels (0.5-1mM) in supernatants and normalized cell morphology, adherence, number, and viability. This CPC pre-washing protocol improves in vitro co-culture conditions without influencing its structure or chemical composition.

Phytic acid as alternative setting retarder enhanced biological performance of dicalcium phosphate cement in vitro

Dicalcium phosphate cement preparation requires the addition of setting retarders to meet clinical requirements regarding handling time and processability. Previous studies have focused on the influence of different setting modifiers on material properties such as mechanical performance or injectability, while ignoring their influence on biological cement properties as they are used in low concentrations in the cement pastes and the occurrence of most compounds in human tissues. Here, analyses of both material and biological behavior were carried out on samples with common setting retardants (citric acid, sodium pyrophosphate, sulfuric acid) and novel (phytic acid). Cytocompatibility was evaluated by in vitro tests with osteoblastic (hFOB 1.19) and osteoclastic (RAW 264.7) cells. We found cytocompatibility was better for sodium pyrophosphate and phytic acid with a three-fold cell metabolic activity by WST-1 test, whereas samples set with citric acid showed reduced cell number as well as cell activity. The compressive strength (CS) of cements formed with phytic acid (CS = 13 MPa) were nearly equal to those formed with citric acid (CS = 15 MPa) and approximately threefold higher than for other setting retardants. Due to a proven cytocompatibility and high mechanical strength, phytic acid seems to be a candidate replacement setting retardant for dicalcium phosphate cements.

Visualising phase change in a brushite-based calcium phosphate ceramic

The resorption of brushite-based bone cements has been shown to be highly unpredictable, with strong dependence on a number of conditions. One of the major factors is phase transformation, with change to more stable phases such as hydroxyapatite affecting the rate of resorption. Despite its importance, the analysis of phase transformation has been largely undertaken using methods that only detect crystalline composition and give no information on the spatial distribution of the phases. In this study confocal Raman microscopy was used to map cross-sections of brushite cylinders aged in Phosphate Buffered Saline, Foetal Bovine Serum, Dulbecco's - Minimum Essential Medium (with and without serum). Image maps showed the importance of ageing medium on the phase composition throughout the ceramic structure. When aged without serum, there was dissolution of the brushite phase concomitant to the deposition of octacalcium phosphate (OCP) around the periphery of the sample. The deposition of OCP was detectable within five days and reduced the rate of brushite dissolution from the material. The use of serum, even at a concentration of 10vol% prevented phase transformation. This paper demonstrates the value of confocal Raman microscopy in monitoring phase change in biocements; it also demonstrates the problems with assessing material degradation in non-serum containing media.

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.

Dual-setting brushite-silica gel cements

The current study describes a dual-mechanism-setting cement that combines a brushite-forming cement paste with a second inorganic silica-based precursor. Materials were obtained by pre-hydrolyzing tetraethyl orthosilicate (TEOS) under acidic conditions following the addition of a calcium phosphate cement (CPC) powder mixed of β-tricalcium phosphate and monocalcium phosphate. Cement setting occurred by a dissolution-precipitation process, while changes in pH during setting simultaneously initiated the condensation reaction of the hydrolyzed TEOS. This resulted in an interpenetrating phase composite material in which the macropores of the CPC were infiltrated by the microporous silica gel, leading to a higher density and a compressive strength ∼5-10 times higher than the CPC reference. This also altered the release of vancomycin as a model drug, whereby in contrast to the quantitative release from the CPC reference, 25% of the immobilized drug remained in the composite matrix. By varying the TEOS content in the composite, the cement phase composition could be controlled to form either brushite, anhydrous monetite or a biphasic mixture of both. The composites with the highest silicate content showed a cell proliferation similar to a hydroxyapatite reference with a significantly higher activity per cell. Surprisingly, the biological response did not seem to be attributed to the released silicate ions, but to the release of phosphate and the adsorption of magnesium ions from the cell culture medium.

Control of in vivo mineral bone cement degradation

The current study aimed to prevent the formation of hydroxyapatite reprecipitates in brushite-forming biocements by minimizing the availability of free Ca(2+) ions in the cement matrix. This was achieved by both maximizing the degree of cement setting to avoid unreacted, calcium-rich cement raw materials which can deliver Ca(2+) directly to the cement matrix after dissolution, and by a reduction in porosity to reduce Ca(2+) diffusion into the set cement matrix. In addition, a biocement based on the formation of the magnesium phosphate mineral struvite (MgNH4PO4·6H2O) was tested, which should prevent the formation of low-solubility hydroxyapatite reprecipitates due to the high magnesium content. Different porosity levels were fabricated by altering the powder-to-liquid ratio at which the cements were mixed and the materials were implanted into mechanically unloaded femoral defects in sheep for up to 10 months. While the higher-porosity brushite cement quantitatively transformed into crystalline octacalcium phosphate after 10 months, slowing down cement resorption, a lower-porosity brushite cement modification was found to be chemically stable with the absence of reprecipitate formation and minor cement resorption from the implant surface. In contrast, struvite-forming cements were much more degradable due to the absence of mineral reprecipitates and a nearly quantitative cement degradation was found after 10 months of implantation.