Evaluation of an injectable bone substitute (betaTCP/hydroxyapatite/hydroxy-propyl-methyl-cellulose) in severely osteopenic and aged rats

Development of Injectable Calcium Sulfate and Self-Setting Calcium Phosphate Composite Bone Graft Materials for Minimally Invasive Surgery

The demand of bone grafting is increasing as the population ages worldwide. Although bone graft materials have been extensively developed over the decades, only a few injectable bone grafts are clinically available and none of them can be extruded from 18G needles. To overcome the existing treatment limitations, the aim of this study is to develop ideal injectable implants from biomaterials for minimally invasive surgery. An injectable composite bone graft containing calcium sulfate hemihydrate, tetracalcium phosphate, and anhydrous calcium hydrogen phosphate (CSH/CaP paste) was prepared with different CSH/CaP ratios and different concentrations of additives. The setting time, injectability, mechanical properties, and biocompatibility were evaluated. The developed injectable CSH/CaP paste (CSH/CaP 1:1 supplemented with 6% citric acid and 2% HPMC) presented good handling properties, great biocompatibility, and adequate mechanical strength. Furthermore, the paste was demonstrated to be extruded from a syringe equipped with 18G needles and exerted a great potential for minimally invasive surgery. The developed injectable implants with tissue repairing potentials will provide an ideal therapeutic strategy for minimally invasive surgery to apply in the treatment of maxillofacial defects, certain indications in the spine, inferior turbinate for empty nose syndrome (ENS), or reconstructive rhinoplasty.

Microarchitecture of titanium cylinders obtained by additive manufacturing does not influence osseointegration in the sheep

Large bone defects are a challenge for orthopedic surgery. Natural (bone grafts) and synthetic biomaterials have been proposed but several problems arise such as biomechanical resistance or viral/bacterial safety. The use of metallic foams could be a solution to improve mechanical resistance and promote osseointegration of large porous metal devices. Titanium cylinders have been prepared by additive manufacturing (3D printing/rapid prototyping) with a geometric or trabecular microarchitecture. They were implanted in the femoral condyles of aged ewes; the animals were left in stabling for 90 and 270 days. A double calcein labeling was done before sacrifice; bones were analyzed by histomorphometry. Neither bone volume, bone/titanium interface nor mineralization rate were influenced by the cylinder's microarchitecture; the morphometric parameters did not significantly increase over time. Bone anchoring occurred on the margins of the cylinders and some trabeculae extended in the core of the cylinders but the amount of bone inside the cylinders remained low. The rigid titanium cylinders preserved bone cells from strains in the core of the cylinders. Additive manufacturing is an interesting tool to prepare 3D metallic scaffolds, but microarchitecture does not seem as crucial as expected and anchoring seems limited to the first millimeters of the graft.

Osteoporotic Goat Spine Implantation Study Using a Synthetic, Resorbable Ca/P/S-Based Bone Substitute

One primary purpose of the present study is to clarify whether the highly porous, resorbable Ca/P/S-based bone substitute used in this study would still induce an osteoporotic bone when implanted into the osteoporotic vertebral defects of ovariectomized (OVX) goats, or the newly-grown bone would expectantly be rather healthy bone. The bone substitute material used for the study is a synthetic, 100% inorganic, highly porous and fast-resorbable Ca/P/S-based material (Ezechbone^® Granule CBS-400). The results show that the OVX procedure along with a low calcium diet and breeding away from light can successfully induce osteoporosis in the present female experimental goats. The histological examination reveals a newly-formed trabecular bone network within the surgically-created defect of the CBS-400-implanted (OVX_IP) goat. This new trabecular bone network in the OVX_IP goat appears much denser than the OVX goat and comparable to the healthy control goat. Histomorphometry show that, among all the experimental goats, the OVX_IP goat has the highest trabecular thickness and lowest trabecular bone packet prevalence. The differences in trabecular plate separation, trabecular number and trabecular bone tissue area ratio between the OVX_IP goat and the control goat are not significant, indicating that the trabecular bone architecture of the OVX_IP goat has substantially recovered to the normal level in about 6 months after implantation without signs of osteoporosis-related delay in the bone maturing process. The quick and nicely recovered trabecular architecture parameters observed in the OVX_IP goat indicate that the present Ca/P/S-based bone substitute material has a high potential to treat osteoporotic fractures.

Hyaluronic Acid Stimulates Osseointegration of β-TCP in Young and Old Ewes

Cross-linked hyaluronic acid (HyAR) increases the local concentration of growth factors. We compared β-TCP osseointegration in old and young ewes with/without HyAR addition. A blind tunnel was drilled on the medial femoral condyle of each knee in nine young and nine old ewes and was filled with β-TCP, β-TCP + HyAR or left unfilled. Double labeling with calcein allowed histodynamic analysis. Ewes were sacrificed at 84 days and the knees were harvested. MicroCT provided histomorphometric parameters: trabecular bone volume, residual volume of biomaterial. Histodynamic parameters were: mineralization rate, mineralized surfaces, bone formation rate. A non-parametric ANOVA and post hoc test analyzed differences between subgroups. Osseointegration of β-TCP was similar in the aged/young grafted groups. Trabecular bone volume was significantly increased versus ungrafted animals (p < 0.001). There were no significant difference for bone volume, residual volume of biomaterial and histodynamic parameters when a single parameter was considered but additional effects of β-TCP and HyAR were evidenced by 3D analysis. Addition of HyAR to ß-TCP does not significantly increase bone volume but tends to increase histodynamic parameters. However, considering the reduction of osteoblastic activity in aged animals, β-TCP, and HyAR boosts osteoblastic activity. HyAR leads to an equivalent response between young and old animals.

Biofunctionalization with a TGFβ-1 Inhibitor Peptide in the Osseointegration of Synthetic Bone Grafts: An In Vivo Study in Beagle Dogs

Objectives: The aim of this research was to determine the osseointegration of two presentations of biphasic calcium phosphate (BCP) biomaterial—one untreated and another submitted to biofunctionalization with a TGF-β1 inhibitor peptide, P144, on dental alveolus. Materials and Methods: A synthetic bone graft was used, namely, (i) Maxresorb^® (Botiss Klockner) (n = 12), and (ii) Maxresorb^® (Botiss Klockner) biofunctionalized with P144 peptide (n = 12). Both bone grafts were implanted in the two hemimandibles of six beagle dogs in the same surgical time, immediately after tooth extraction. Two dogs were sacrificed 2, 4, and 8 weeks post implant insertion, respectively. The samples were submitted to histomorphometrical and histological analyses. For each sample, we quantified the new bone growth and the new bone formed around the biomaterial’s granules. After optical microscopic histological evaluation, selected samples were studied using backscattered scanning electron microscopy (BS-SEM). Results: The biofunctionalization of the biomaterial’s granules maintains a stable membranous bone formation throughout the experiment timeline, benefitting from the constant presence of vascular structures in the alveolar space, in a more active manner that in the control samples. Better results in the experimental groups were proven both by quantitative and qualitative analysis. Conclusions: Synthetic bone graft biofunctionalization results in slightly better quantitative parameters of the implant’s osseointegration. The qualitative histological and ultramicroscopic analysis shows that biofunctionalization may shorten the healing period of dental biomaterials.

Decreased intramuscular calcium hydroxyapatite implant resorption in a murine model of osteoporosis

OBJECTIVE

Calcium hydroxyapatite (CaHA) is a common material for vocal fold injection augmentation. Durability is variable, and factors involved in implant longevity are not understood. Animal models of osteoporosis show decreased bone density and increased mineral liberation, suggesting CaHA retention may be altered in these conditions.

STUDY DESIGN

Prospective murine investigation.

METHODS

Fourteen skeletally mature, 10-month-old female Sprague-Dewley rats were treated by one of three interventions: oophorectomy, laparotomy without oophorectomy (sham), or monthly risedronate injection (90 μg/kg, subcutaneous). CaHA was implanted into the right lateral thigh muscle in all animals at the time of procedure or first risedronate injection. After 17 weeks, all rats were sacrificed, and the residual CaHA isolated from excised lateral thigh muscle through incubation in a 900 °C calcinator for 9 hours.

RESULTS

Mean CaHA mass remaining in the oophorectomy group was 65.9 (standard deviation ± 16.1) mg, compared to 44.4 ± 10.0 mg CaHA in the risedronate group and 48.6 ± 7.5 mg in the sham group. One-way analysis of variance found a statistically significant difference between the oophorectomy and risedronate groups but not between the sham and other groups, F(2,11) = 4.404, P = 0.039.

CONCLUSION

Persistent estrogen deficiency in a murine model of osteoporosis demonstrated decreased rate of CaHA resorption. This suggests that hormone alterations associated with osteoporosis may alter the longevity of CaHA implant resorption through an uncertain mechanism.

LEVEL OF EVIDENCE

NA. Laryngoscope, 2576-2580, 2018.

Beta-tricalcium phosphate for orthopedic reconstructions as an alternative to autogenous bone graft

Autogenous bone graft (autograft) remains the gold standard in the treatment of many orthopedic problems. However, graft harvest can lead to perioperative morbidity and increased cost. We tested the hypothesis that an osteoconductive matrix, beta-tricalcium phosphate (β-TCP), would be a safe and effective alternative to autograft alone. Beta-tricalcium phosphate (β-TCP) is considered as one of the most promising biomaterials for bone reconstruction. This study analyzes the outcomes of patients who received β-TCP as bone substitutes in orthopedic surgery.

METHODS

A total of 50 patients were enrolled in a controlled, non-inferiority clinical trial to compare the safety and efficacy of β-TCP (25 patients) with those of autograft (25 patients) in indications requiring usually autograft. These 50 patients were categorized according to the etiology and morphology of the 54 bone defects resulting from elective surgical procedures, such as 34 open-wedge high tibial osteotomies, and 20 osteonecrosis treatments with core decompression. Radiographic (healing process with or without integration of β-TCP), clinical (no other surgical procedure), functional outcomes and safety (with or without complications) were assessed through fifty-two weeks postoperatively.

RESULTS

With regard to the primary endpoint (radiographic evolution), the fusion rate of the 34 open-wedge osteotomies was 100% (17 among 17) for patients in the group with β-TCP compared with 94% (16 among 17) for patients in the autograft group. For the 20 cavitary defects (osteonecrosis), the radiographic union rates, as determined by the presence of osseous bridging, were 100% for patients in the group with β-TCP and 100% for those in the autograft group. Clinically at one year, all quality-of-life and functional outcome data supported non-inferiority of β-TCP compared with autograft, and patients in the β-TCP group were found to have less pain and an improved safety profile.

CONCLUSIONS

Treatment with β-TCP resulted in comparable fusion rates, less pain and fewer side effects as compared with treatment with autograft. This study established clinical parameters where the β-TCP alone can successfully support the osteogenic process.

Osteogenic efficacy of strontium hydroxyapatite micro-granules in osteoporotic rat model

Excessive demineralization in osteoporotic bones impairs its self-regeneration potential following a defect/fracture and is of great concern among the aged population. In this context, implants with inherent osteogenic ability loaded with therapeutic ions like Strontium (Sr²⁺) may bring forth promising outcomes. Micro-granular Strontium incorporated Hydroxyapatite scaffolds have been synthesized and in vivo osteogenic efficacy was evaluated in a long-term osteoporosis-induced aged (LOA) rat model. Micro-granules with improved surface area are anticipated to resorb faster and together with the inherent bioactive properties of Hydroxyapatite with the leaching of Strontium ions from the scaffold, osteoporotic bone healing may be promoted. Long-term osteoporosis-induced aged rat model was chosen to extrapolate the results to clinical osteoporotic condition in the aged. Micro-granular 10% Strontium incorporated Hydroxyapatite synthesized by wet precipitation method exhibited increased in vitro dissolution rate and inductively coupled plasma studies confirmed Strontium ion release of 0.01 mM, proving its therapeutic potential for osteoporotic applications. Wistar rats were induced to long-term osteoporosis-induced aged model by ovariectomy along with a prolonged induction period of 10 months. Thereafter, osteogenic efficacy of Strontium incorporated Hydroxyapatite micro-granules was evaluated in femoral bone defects in the long-term osteoporosis-induced aged model. Post eight weeks of implantation in vivo regeneration efficacy ratio was highest in the Strontium incorporated Hydroxyapatite implanted group (0.92 ± 0.04) compared to sham and Hydroxyapatite implanted group. Micro CT evaluation further substantiated the improved osteointegration of Strontium incorporated Hydroxyapatite implants from the density histograms. Thus, the therapeutical potential of micro-granular Strontium incorporated Hydroxyapatite scaffolds becomes relevant, especially as bone void fillers in osteoporotic cases of tumor resection or trauma.

Novel biomimetic thermosensitive β-tricalcium phosphate/chitosan-based hydrogels for bone tissue engineering

Among the less invasive surgical procedures for tissue engineering application, injectable in situ gelling systems have gained great attention. In this contest, this article is aimed to realize thermosensitive chitosan-based hydrogels, crosslinked with β-glycerophosphate and reinforced via physical interactions with β-tricalcium phosphate. The kinetics of sol-gel transition and the composite hydrogel properties were investigated by rheological analysis. The hydrogels were also characterized by Fourier transform infrared study, X-ray diffraction, scanning electron microscopy, transmission electron microscopy analysis, and thermal and biological studies. The hydrogels exhibit a gel-phase transition at body temperature, and a three-dimensional network with typical rheological properties of a strong gel. The presence of the inorganic phase, made up of nanocrystals, provides a structure with chemico-physical composition that mimics natural bone tissue, favoring cellular activity. These findings suggest the potential of the materials as promising candidates for hard tissue regeneration.

Loss of bone strength is dependent on skeletal site in disuse osteoporosis in rats

Intramuscular injection with botulinum toxin A (BTX) leads to a transient paralysis of the muscles, resulting in a rapid loss of muscle mass and function as well as rapid bone loss (disuse osteoporosis). The purpose of this study was to investigate the temporal development and the site specificity of BTX-induced immobilization on bone strength at five skeletal sites. Three-month-old rats (n = 108) were randomized into nine groups: one served as baseline, while four were injected with BTX and four with saline in the right hind-limb musculature. Animals were killed after 1, 2, 3, or 4 weeks. BTX-induced a significant loss of rectus femoris muscle mass (-61%) and muscle cell cross-sectional area (-59%) as well as bone strength at the femoral neck (-31%), femoral diaphysis (-6%), distal femoral metaphysis (-17%), proximal tibial metaphysis (-31%), and tibial diaphysis (-13%) after 4 weeks. Muscle atrophy occurred in parallel with the bone loss at the femoral neck and proximal tibia, whereas it occurred earlier than the bone loss at the other skeletal sites. At the proximal tibial metaphysis BTX significantly decreased BV/TV (-10%), trabecular thickness (-13%), and bone formation (MS/BS -25%, BFR/BS -50%) and increased osteoclast covered surfaces (+97%) after 4 weeks. In conclusion, BTX-induced a time-dependent loss of bone strength. Moreover, the loss of bone strength differed significantly at the five tested skeletal sites.

Fabrication of calcium phosphate-calcium sulfate injectable bone substitute using hydroxy-propyl-methyl-cellulose and citric acid

In this study, an injectable bone substitute (IBS) consisting of citric acid, chitosan, and hydroxyl propyl methyl cellulose (HPMC) as the liquid phase and tetra calcium phosphate (TTCP), dicalcium phosphate dihydrate (DCPD) and calcium sulfate dehydrate (CSD, CaSO4 x 2H2O) powders as the solid phase, were fabricated. Two groups were classified based on the percent of citric acid in the liquid phase (20, 40 wt%). In each groups, the HPMC percentage was 0, 2, and 4 wt%. An increase in compressive strength due to changes in morphology was confirmed by scanning electron microscopy images. A good conversion rate of HAp at 20% citric acid was observed in the XRD profiles. In addition, HPMC was not obviously affected by apatite formation. However, both HPMC and citric acid increased the compressive strength of IBS. The maximum compressive strength for IBS was with 40% citric acid and 4% HPMC after 14 days of incubation in 100% humidity at 37 degrees C.

Sinus lift augmentation and beta-TCP: a microCT and histologic analysis on human bone biopsies

Sinus lift elevation is an interesting method to restore bone mass at the maxilla in edentulated patients. We have investigated the histological effects of beta tricalcium phosphate (beta-TCP) combined with autograft bone for sinus lift elevation. A series of 14 patients who were candidate for dental implantation were grafted with beta-TCP granules and morcellized autograft bone harvested at the chin. beta-TCP was characterized by scanning electron microscopy and optical profilometry. Before implant placement, a small bone biopsy (2mm in diameter) was done. The amount of residual material and newly formed bone were determined by microcomputed tomography. Histological analysis was done on undecalcified sections stained by Goldner's trichrome and osteoclast identification (TRAcP). beta-TCP served as a template for bone apposition by osteoblasts onto the granules' surface. The material was simultaneously resorbed by TRAcP positive osteoclasts and macrophages. Fragments of the material remained buried in bone trabeculae as long as 12 months post-graft but the formed bone onto the granules surface had a lamellar texture. beta-TCP combined with autograft bone appears a suitable biomaterial for sinus lift augmentation before the placement of bone implants. The material favors the apposition of lamellar bone by osteoblasts and is simultaneous resorbed by two types of cells.

Hydroxyapatite particles maintain peri-implant bone mantle during osseointegration in osteoporotic bone

In osteoporotic bones, resorption exceeds formation during the remodelling phase of bone turnover. As a consequence, decreased bone volume and bone contact result in the peri-implant region. This may subsequently lead to loss of fixation. In this study we investigated whether the presence of nonresorbable, osteoconductive hydroxyapatite (HA) particles could help maintain a denser and more functional peri-implant bone structure. Titanium screws were implanted into the proximal tibial metaphysis of four months old, ovariectomized Wistar rats (n=60). In the right tibia, the drill hole was first filled with HA particles, while the left tibia served as a control without HA particles. Histological analysis demonstrated that during the remodelling phase the amount of newly formed bone was significantly higher on the HA over the control side. Micro-CT analysis corroborated the significant changes over time as well as differences in peri-implant bone volume density between treatment and control group. Mechanical tests demonstrated that the pull-out force was greater with HA particles. These results indicate that HA particles are able to induce and maintain for a longer time a denser peri-implant bone mantle in osteoporotic bone, which may have important implications in the prevention of implant migration and cut-outs.

Calcium Orthophosphates in Nature, Biology and Medicine

The present overview is intended to point the readers’ attention to the important subject of calcium orthophosphates. These materials are of the special significance because they represent the inorganic part of major normal (bones, teeth and dear antlers) and pathological (i.e. those appearing due to various diseases) calcified tissues of mammals. Due to a great chemical similarity with the biological calcified tissues, many calcium orthophosphates possess remarkable biocompatibility and bioactivity. Materials scientists use this property extensively to construct artificial bone grafts that are either entirely made of or only surface-coated with the biologically relevant calcium ortho-phosphates. For example, self-setting hydraulic cements made of calcium orthophosphates are helpful in bone repair, while titanium substitutes covered by a surface layer of calcium orthophosphates are used for hip joint endoprostheses and as tooth substitutes. Porous scaffolds made of calcium orthophosphates are very promising tools for tissue engineering applications. In addition, technical grade calcium orthophosphates are very popular mineral fertilizers. Thus ere calcium orthophosphates are of great significance for humankind and, in this paper, an overview on the current knowledge on this subject is provided.

Orchidectomy models of osteoporosis

Long considered a disease of post-menopausal women, osteoporosis is increasingly being recognized among the growing population of elderly men. Androgen deficiency may be associated with an increase of bone resorption in elderly men and so, with remodeling imbalance and fracture risk. It is firmly established that androgen withdrawal induced by orchidectomy (ORX) results in decreased bone mass in animal models especially in rodents. The mature rat is the model of choice. Skeletal effects of ORX in rats have been studied at the tissular and cellular level. It induces a decrease of BMD and BV/TV with microarchitecture alterations due to an increased bone remodeling. The present chapter focuses on the ORX surgery in rats and mice.

Histomorphometric assessment of bone formation in sinus augmentation utilizing a combination of autogenous and hydroxyapatite/biphasic tricalcium phosphate graft materials: at 6 and 9 months in humans

OBJECTIVE

The aim of this study was to examine the efficacy of a new biphasic hydroxyapatite/tricalcium phosphate (HA/TCP) bone substitute in combination with particulate autogenous bone in sinus floor augmentation procedures.

MATERIAL AND METHODS

A simultaneous or a two-stage sinus augmentation and implant placement were conducted in 28 patients. A mixture of HA/TCP and autogenous bone chips in a 1 : 1 ratio was used as the grafting biomaterial. Cylindrical specimen bone retrieval was performed in all patients except one. Specimens were harvested either at 6 (n=14) or 9 (n=13) months post-augmentation. For histologic and histomorphometric evaluations, the non-decalcified tissue processing (Donath's technique) was performed.

RESULTS

Newly formed bone around the grafted particles was found in all samples. The encircling, highly cellular bone followed the outline of the grafted particles in direct contact. Both woven and lamellar types of bone were observed. Morphometrically, the total mean bone area fraction of all sections was 34.8+/-10.3%, increasing from 28.6+/-7.8% at 6 months to 41.6+/-8.3% at 9 months (P<0.001). Mean particle area fraction average was 25.5+/-11.6% and 23.5+/-9.3% at 6 and 9 months, respectively, with a total mean of 24.5+/-10.4%. The increase in bone area fraction was not significantly correlated to the decrease of the grafted particles area fraction.

CONCLUSIONS

The biphasic HA/TCP showed biocompatible and osteoconductive properties. This alloplast as a composite with autogenous bone chips promotes newly formed bone, which increases in its fraction along an extended healing period.

Multiphasic Biomaterials: A Concept for Bone Substitutes Developed in the "Pays de la Loire"

This paper reports on the research into multiphase bone substitutes carried out by laboratories from the ‘Pays de la Loire’ region in France. This collaborative research was funded by both the French Government and the Regional Council in the period 2000-2007. Calcium phosphate bioceramics, polymers and combinations have been developed as bone substitutes for various maxillofacial and orthopaedic applications. These bone substitutes should support and regenerate bone tissue and resorb after implantation. In the bone tissue engineering area, they have been combined with autologous bone marrow cells or bioactive factors. The bone substitutes were tested in various animal models mimicking clinical situations or under pathological conditions (osteoporosis). In order to complete our research, the multiphase materials were also evaluated in clinical trials.

A novel methodology for imaging new bone formation around bioceramic bone substitutes

In this study, Frost's bulk-staining in combination with confocal laser scanning microscopy (CLSM) was used to image and characterize ground sections of undecalcified rat bone tissue with in situ bioceramic implants. This was addressed by bulk staining specimens in alcohol-soluble basic fuchsin dye. The ground sections were imaged using CLSM in the confocal fluorescence mode. Confocal images revealed that the newly formed bone could be clearly distinguished from bone marrow and cortical bone, as well as from the implant material.

Disuse and orchidectomy have additional effects on bone loss in the aged male rat

INTRODUCTION

A severely osteopenic rat model was obtained by combining orchidectomy (ORX) and disuse (due to local paralysis induced by botulinum toxin [BTX] in the quadriceps muscle).

METHODS

Forty-two aged male rats (5-6 months old) were randomized into three groups: 18 were SHAM operated; 6 were ORX; and 18 were ORX and BTX injected in the right hindlimb. One, two, and three months after surgery, bone mass (BV/TV) and microarchitectural parameters (Tb.Th, Tb.N, Tb.Sp, Tb.Pf, and structure model index [SMI]) were measured by microcomputed tomography (microCT) on the primary and secondary spongiosa of the femur. Osteoid parameters (OS/BS, O.Th), the number of osteoclasts (Nb.Oc), and the mineral apposition rate (Ct.MAR, Cn.MAR) were measured by histology. The serum tartrate-resistant acid phosphatase (TRAcP) 5b activity was measured by immunoassay.

RESULTS

ORX induced a decrease of BV/TV, Tb.N and an increase of Tb.Sp, Tb.Pf, and SMI on both primary and secondary spongiosa. ORX and BTX had cumulative effects on bone loss, since differences were maximized on the right femur. The decrease in BV/TV reached -65%. Osteoid parameters and mineral apposition rate increased during the time course of the study. A peak of serum TRAcP was found at 7 days post-ORX. TRAcP levels reached the highest values in the ORX-BTX groups and the effect lasted longer than in the group with ORX alone. The association of ORX-BTX induced a greater bone resorption, due to the removal of complete trabeculae, compared to ORX alone.

CONCLUSION

This model induced a severe and rapid bone loss and can be used to explore pharmacological- and biomaterial-based countermeasures.