The effect of different antibiotic combinations in calcium sulfate cement on the growth of Cutibacterium acnes and Staphylococcus periprosthetic shoulder infection isolates

BACKGROUND

Periprosthetic joint infections (PJI) of the shoulder are a devastating complication of shoulder arthroplasty and are commonly caused by Staphylococcus and Cutibacterium acnes. Absorbable calcium sulfate (CS) beads are sometimes used for delivering antibiotics in PJI. This study evaluates the in vitro effect of different combinations of gentamicin, vancomycin, and ertapenem in beads made from CS cement on the growth of C acnes and coagulase-negative Staphylococcus (CNS) strains.

METHODS

Three strains of C acnes and 5 strains of CNS from clinically proven shoulder PJI were cultured and plated with CS beads containing combinations of vancomycin, gentamicin, and ertapenem. Plates with C acnes were incubated anaerobically while plates with Staphylococcus were incubated aerobically at 37 °C. Zones of inhibition were measured at intervals of 3 and 7 days using a modified Kirby Bauer technique, and beads were moved to plates containing freshly streaked bacteria every seventh day. This process was run in triplicate over the course of 56 days. Statistical analysis was conducted using SPSS v. 28 with repeated measures analysis of variance (ANOVA) and pairwise comparisons with Tukey correction.

RESULTS

In experiments with C acnes, beads containing ertapenem + vancomycin and vancomycin alone formed the largest zones of inhibition over time (P < .001). In experiments with Staphylococcus, beads containing vancomycin alone formed the largest zones of inhibition over time for all 5 strains (P < .001). Zones of inhibition were 1.4x larger for C acnes than for Staphylococcus with beads containing vancomycin alone. For both C acnes and Staphylococcus, beads containing ertapenem had the strongest initial effect, preventing all bacterial growth in C acnes and almost all growth for Staphylococcus during the first week but dropping substantially by the second week. Beads containing gentamicin alone consistently created smaller zones of inhibition than beads containing vancomycin alone, with vancomycin producing zones 5.3x larger than gentamicin in C acnes and 1.3x larger in Staphylococcus (P < .001).

DISCUSSION

These data suggest that for both C acnes and Staphylococcal species, CS beads impregnated with vancomycin were most effective at producing a robust antibiotic effect. Additionally, ertapenem may be a viable supplement in order to create a more potent initial antibiotic effect but is not as effective as vancomycin when used alone. Gentamicin alone was not effective in maintaining consistent and long-term antibiotic effects. These results indicate that amongst the antibiotics currently commercially available to be used with CS, vancomycin is consistently superior to gentamicin in the setting of C. acnes and CNS.

Fabrication and histological evaluation of a self-setting granular cement using calcium sulfate hemihydrate granules with different pore distribution

Granular type of bone substitutes is currently used in the field of dentistry to restore alveolar bone defects. However, the migration of the granules from the implantation site is still an unresolved issue. In this study, the feasibility to fabricate self-setting calcium sulfate hemihydrate (CSH) granules using different ranges of loading pressure: CSH(0), CSH(50), CSH(100), and CSH(150) was investigated with the hypothesis that CSH granules with reduced microporosity can inhibit the rapid dissolution rate of the calcium sulfate dihydrate (CSD) set blocks and induce bone regeneration. After 4 weeks of implantation, the granules were mostly replaced with new bone although no significant differences were observed. Nevertheless, the granules demonstrated the ability to set within the bone defect. It is therefore concluded that the setting ability of calcium sulfate can contribute to address the issue of migration of the granules and provide a useful guide for designing setting bone substitutes.

Trends in bioactivity: inducing and detecting mineralization of regenerative polymeric scaffolds

Due to limitations of biological and alloplastic grafts, regenerative engineering has emerged as a promising alternative to treat bone defects. Bioactive polymeric scaffolds are an integral part of such an approach. Bioactivity importantly induces hydroxyapatite mineralization that promotes osteoinductivity and osseointegration with surrounding bone tissue. Strategies to confer bioactivity to polymeric scaffolds utilize bioceramic fillers, coatings and surface treatments, and additives. These approaches can also favorably impact mechanical and degradation properties. A variety of fabrication methods are utilized to prepare scaffolds with requisite morphological features. The bioactivity of scaffolds may be evaluated with a broad set of techniques, including in vitro (acellular and cellular) and in vivo methods. Herein, we highlight contemporary and emerging approaches to prepare and assess scaffold bioactivity, as well as existing challenges.

Limitations and modifications in the clinical application of calcium sulfate

Calcium sulfate and calcium sulfate-based biomaterials have been widely used in non-load-bearing bone defects for hundreds of years due to their superior biocompatibility, biodegradability, and non-toxicity. However, lower compressive strength and rapid degradation rate are the main limitations in clinical applications. Excessive absorption causes a sharp increase in sulfate ion and calcium ion concentrations around the bone defect site, resulting in delayed wound healing and hypercalcemia. In addition, the space between calcium sulfate and the host bone, resulting from excessively rapid absorption, has adverse effects on bone healing or fusion techniques. This issue has been recognized and addressed. The lack of sufficient mechanical strength makes it challenging to use calcium sulfate and calcium sulfate-based biomaterials in load-bearing areas. To overcome these defects, the introduction of various inorganic additives, such as calcium carbonate, calcium phosphate, and calcium silicate, into calcium sulfate is an effective measure. Inorganic materials with different physical and chemical properties can greatly improve the properties of calcium sulfate composites. For example, the hydrolysis products of calcium carbonate are alkaline substances that can buffer the acidic environment caused by the degradation of calcium sulfate; calcium phosphate has poor degradation, which can effectively avoid the excessive absorption of calcium sulfate; and calcium silicate can promote the compressive strength and stimulate new bone formation. The purpose of this review is to review the poor properties of calcium sulfate and its complications in clinical application and to explore the effect of various inorganic additives on the physicochemical properties and biological properties of calcium sulfate.

Vancomycin Elution Kinetics of Four Antibiotic Carriers Used in Orthopaedic Surgery: In Vitro Study over 42 Days

This study aimed to analyse and compare the vancomycin elution kinetics of four biodegradable, osteoconductive antibiotic carriers used in clinical practice within a 42-day in vitro setting. Carriers A and D already contained vancomycin (1.1 g and 0.247 g), whereas carriers B and C were mixed with vancomycin according to the manufacturer's recommendations (B: 0.83 g and C: 0.305 g). At nine time points, 50% (4.5 mL) of the elution sample was removed and substituted with the same amount of PBS. Probes were analysed with a kinetic microparticle immunoassay. Time-dependent changes in vancomycin concentrations for each carrier and differences between carriers were analysed. Mean initial antibiotic levels were highest for carrier A (37.5 mg/mL) and lowest for carrier B (5.4 mg/mL). We observed time-dependent, strongly negative linear elution kinetics for carriers A (-0.835; p < 0.001), C (-0.793; p < 0.001), and D (-0.853; p < 0.001). Vancomycin concentrations increased from 48 h to 7 d and dropped thereafter in carriers C and D whilst constantly decreasing at any time point for carrier A. Carrier B showed a shallower decrease. Mean antibiotics levels at 42 d were 1.5 mg/mL, 2.6 mg/mL, 0.1 mg/mL, and 0.1 mg/mL for carriers A, B, C, and D. Differences in mean initial and final vancomycin concentrations for carrier A were significantly larger in comparison to C (p = 0.040). A carrier consisting of allogenic bone chips showed the highest vancomycin-to-carrier ratio and the largest elution over the study period. Whilst vancomycin concentrations were still measurable at 42 days for all carriers, carrier A provided a higher drug-to-carrier ratio and a more consistent antibiotic-releasing profile.

Elution profiles of metronidazole from calcium sulfate beads

BACKGROUND

Antibiotic beads are used to treat local bacterial infections by delivering high drug concentrations to infected tissue.

OBJECTIVES

This study examined the elution characteristics of metronidazole from metronidazole-calcium sulfate (MCa) and metronidazole-calcium-potassium sulfate (MCaK) beads over 20 days and the antibacterial efficacy of the beads after storage.

METHODS

The MCa and MCaK beads were prepared by mixing 250 mg of metronidazole and 10 g of calcium sulfate hemihydrate with water and a 3% potassium sulfate solution, respectively. The beads were placed in phosphate-buffered saline for the elution study. The metronidazole eluents were determined using high-performance liquid chromatography. The microstructures were examined by scanning electron microscopy (SEM), and the antimicrobial activity was evaluated by a microbioassay.

RESULTS

For the 20-day study, the total amount of metronidazole released was greater in the MCa beads than in the MCaK beads by 6.61 ± 0.48 mg (89.11% ± 3.04%) and 4.65 ± 0.36 mg (73.11% ± 4.38%), respectively. The amounts of eluted drugs from the MCa and MCaK beads were higher than the minimum inhibitory concentration at 0.5 µg/mL against anaerobic bacteria at both 20 days and 14 days. SEM showed that calcium crystals on the outer surface had dissolved after elution, and thinner calcium crystals were prominent in the MCaK beads. The MCa and MCaK beads exhibited antibacterial activity after setting, followed by storage at room temperature or 4°C for 21 days.

CONCLUSIONS

The MCa beads could release more drug than the MCaK beads, but all eluted metronidazole amounts were effective in controlling bacterial infections. Both metronidazole beads could be stored at ambient temperature or in a refrigerator.

Design and Manufacture of Bone Cements Based on Calcium Sulfate Hemihydrate and Mg, Sr-Doped Bioactive Glass

In the present study, a novel composite bone cement based on calcium sulfate hemihydrate (CSH) and Mg, Sr-containing bioactive glass (BG) as solid phase, and solution of chitosan as liquid phase were developed. The phase composition, morphology, setting time, injectability, viscosity, and cellular responses of the composites with various contents of BG (0, 10, 20, and 30 wt.%) were investigated. The pure calcium sulfate cement was set at approximately 180 min, whereas the setting time was drastically decreased to 6 min by replacing 30 wt.% glass powder for CSH in the cement solid phase. BG changed the microscopic morphology of the set cement and decreased the size and compaction of the precipitated gypsum phase. Replacing the CSH phase with BG increased injection force of the produced cement; however, all the cements were injected at a nearly constant force, lower than 20 N. The viscosity measurements in oscillatory mode determined the shear-thinning behavior of the pastes. Although the viscosity of the pastes increased with increasing BG content, it was influenced by the frequency extent. Pure calcium sulfate cement exhibited some transient cytotoxicity on human-derived bone mesenchymal stem cells and it was compensated by introducing BG phase. Moreover, BG improved the cell proliferation and mineralization of extracellular matrix as shown by calcein measurements. The results indicate the injectable composite cement comprising 70 wt.% CSH and 30 wt.% Mg, Sr-doped BG has better setting, mechanical and cellular behaviors and hence, is a potential candidate for bone repair, however more animal and human clinical evaluations are essential.

Efficacy and bone-contact biocompatibility of glass ionomer cement as a biomaterial for bone regeneration: A systematic review

Bone regeneration is a rapidly growing field that seeks to develop new biomaterials to regenerate bone defects. Conventional bone graft materials have limitations, such as limited availability, complication, and rejection. Glass ionomer cement (GIC) is a biomaterial with the potential for bone regeneration due to its bone-contact biocompatibility, ease of use, and cost-effectiveness. GIC is a two-component material that adheres to the bone and releases ions that promote bone growth and mineralization. A systematic literature search was conducted using PubMed-MEDLINE, Scopus, and Web of Science databases and registered in the PROSPERO database to determine the evidence regarding the efficacy and bone-contact biocompatibility of GIC as bone cement. Out of 3715 initial results, thirteen studies were included in the qualitative synthesis. Two tools were employed in evaluating the Risk of Bias (RoB): the QUIN tool for assessing in vitro studies and SYRCLE for in vivo. The results indicate that GIC has demonstrated the ability to adhere to bone and promote bone growth. Establishing a chemical bond occurs at the interface between the GIC and the mineral phase of bone. This interaction allows the GIC to exhibit osteoconductive properties and promote the growth of bone tissue. GIC's bone-contact biocompatibility, ease of preparation, and cost-effectiveness make it a promising alternative to conventional bone grafts. However, further research is required to fully evaluate the potential application of GIC in bone regeneration. The findings hold implications for advancing material development in identifying the optimal composition and fabrication of GIC as a bone repair material.

Effectiveness of an Antibiotic-impregnated Bioabsorbable Carrier for the Treatment of Chronic Intramedullary and Diffuse Osteomyelitis

Aim

The surgical management of chronic intramedullary osteomyelitis involves debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead-space management is often through antibiotic-impregnated bone cement. These depots of local antibiotics are variable in elution properties and need removal. We review our unit's experience using a bioabsorbable synthetic calcium sulphate to deliver gentamicin as an adjunct in the treatment of osteomyelitis involving the medullary canal.

Materials and methods

We retrospectively reviewed 34 patients with chronic osteomyelitis who were treated using this method in our institute. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology, and microbiology. The Cierny-Mader system was used to classify. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip/DASH scores) and a general health outcome questionnaire (SF36). The primary outcome measure was clinical recurrence of infection.

Results

There were 24 male and 10 female patients. The mean age at presentation was 47 years (20-67). Clinical, laboratory, radiological, and patient reported outcomes were obtained at a median follow-up of 2.5 years (1.4-6.6 years). The bones involved were the femur (14, 41%), tibia (16, 47%), radius (1, 3%), and humerus (3, 9%). There were 13 cases classified as Cierny-Mader stage IV (diffuse with intramedullary osteomyelitis) and 21 cases as Cierny-Mader stage I. The median Oxford Hip score was 38 (11 patients, range 9-48). The median AOFAS score was 78 (14 patients, range 23-100). The median IOWA knee score was 71 (25 patients, range 22-95). The median DASH score was 33 (2 patients, range 1.7-64.2). There were two recurrences. The treatment success to date is 94%.

Conclusion

In our series of patients, bioabsorbable carriers of antibiotics appear to be effective adjuncts to surgical treatment of osteomyelitis and were associated with high clinical success rates.

How to cite this article

Selvaratnam V, Roche A, Narayan B, et al. Effectiveness of an Antibiotic-impregnated Bioabsorbable Carrier for the Treatment of Chronic Intramedullary and Diffuse Osteomyelitis. Strategies Trauma Limb Reconstr 2023;18(3):148-154.

Hollow channels scaffold in bone regenerative: a review

Bone substitute materials have been extensively used for bone regeneration over the past 50 years. The development of novel materials, fabrication technologies and the incorporation and release of regenerative cytokines, growth factors, cells and antimicrobials has been driven by the rapid development in the field of additive manufacturing technology. There are still however, significant challenges that need addressing, including ways to better mediate the rapid vascularization of bone scaffolds to enhance subsequent regeneration and osteogenesis. Increasing construct porosity can accelerate the development of blood vessels in the scaffold, but doing so also weakens the constructs mechanical properties. A novel design for promoting rapid vascularization is to fabricate custom-made hollow channels as bone scaffolds. Summarized here are the current developments in hollow channels scaffold, including their biological attributes, physio-chemical properties, and effects on regeneration. An overview of recent developments in scaffold fabrication as they relate to hollow channel constructs and their structural features will be introduced with an emphasis on attributes that enhance new bone and vessel formation. Furthermore, the potential to enhance angiogenesis and osteogenesis by replicating the structure of real bone will be highlighted.

Fabrication and Characterisation of Calcium Sulphate Hemihydrate Enhanced with Zn- or B-Doped Hydroxyapatite Nanoparticles for Hard Tissue Restoration

A composite based on calcium sulphate hemihydrate enhanced with Zn- or B-doped hydroxyapatite nanoparticles was fabricated and evaluated for bone graft applications. The investigations of their structural and morphological properties were performed by X-ray diffraction (XRD), Fourier transform infrared (FTIR) spectroscopy, scanning electron microscopy (SEM), and energy dispersive X-ray (EDX) spectroscopy techniques. To study the bioactive properties of the obtained composites, soaking tests in simulated body fluid (SBF) were performed. The results showed that the addition of 2% Zn results in an increase of 2.27% in crystallinity, while the addition of boron causes an increase of 5.61% compared to the undoped HAp sample. The crystallite size was found to be 10.69 ± 1.59 nm for HAp@B, and in the case of HAp@Zn, the size reaches 16.63 ± 1.83 nm, compared to HAp, whose crystallite size value was 19.44 ± 3.13 nm. The mechanical resistance of the samples doped with zinc was the highest and decreased by about 6% after immersion in SBF. Mixing HAp nanoparticles with gypsum improved cell viability compared to HAp for all concentrations (except for 200 µg/mL). Cell density decreased with increasing nanoparticle concentration, compared to gypsum, where the cell density was not significantly affected. The degree of cellular differentiation of osteoblast-type cells was more accentuated in the case of samples treated with G+HAp@B nanoparticles compared to HAp@B. Cell viability in these samples decreased inversely proportionally to the concentration of administered nanoparticles. From the point of view of cell density, this confirmed the quantitative data.

Hypercalcemia Secondary to Antibiotic-Eluting Calcium Sulfate Beads

The use of calcium sulfate beads (CSBs) as a carrier for local delivery of antibiotics is increasingly reported for the treatment of localized infections. They are used most commonly in bone and joint infections, post-trauma infections, diabetes-related foot wounds, and vascular grafts. Hypercalcemia is rarely reported with CSB use but is an important safety concern, and patients at higher risk should be identified prospectively and followed carefully postoperatively. This case report details an 85-year-old male who developed severe, symptomatic postoperative hypercalcemia after antibiotic bead placement in the right knee. He presented with confusion, weakness, and lethargy, and was subsequently treated with fluids, calcitonin, and alendronate. The patient quickly returned to normal mental status, and calcium levels normalized, leading to discharge. The case report and review of the literature describe an incident of severe hypercalcemia attributed to the use of antibiotic-eluting CSBs and describe the risk factors and time course that may be expected.

Biomimetic, biodegradable and osteoinductive treated dentin matrix/α-calcium sulphate hemihydrate composite material for bone tissue engineering

It is still a huge challenge for bone regenerative biomaterial to balance its mechanical, biological and biodegradable properties. In the present study, a new composite material including treated dentin matrix (TDM) and α-calcium sulphate hemihydrate (α-CSH) was prepared. The optimal composition ratio between TDM and α-CSH was explored. The results indicate that both components were physically mixed and structurally stable. Its compressive strength reaches up to 5.027 ± 0.035 MPa for 50%TDM/α-CSH group, similar to human cancellous bone tissues. Biological experiments results show that TDM/α-CSH composite exhibits excellent biocompatibility and the expression of osteogenic related genes and proteins (ALP, RUNX2, OPN) is significantly increased. In vivo experiments suggest that the addition of TDM for each group (10%, 30%, 50%) effectively promotes cell proliferation and osteomalacia. In addition, 50% of the TDM/α-CSH combination displays optimal osteoconductivity. The novel TDM/α-CSH composite is a good candidate for certain applications in bone tissue engineering.

Hierarchical synchrotron diffraction and imaging study of the calcium sulfate hemihydrate-gypsum transformation

The mechanism of hydration of calcium sulfate hemihydrate (CaSO₄·0.5H₂O) to form gypsum (CaSO₄·2H₂O) was studied by combining scanning 3D X-ray diffraction (s3DXRD) and phase contrast tomography (PCT) to determine in situ the spatial and crystallographic relationship between these two phases. From s3DXRD measurements, the crystallographic structure, orientation and position of the crystalline grains in the sample during the hydration reaction were obtained, while the PCT reconstructions allowed visualization of the 3D shapes of the crystals during the reaction. This multi-scale study unfolds structural and morphological evidence of the dissolution-precipitation process of the gypsum plaster system, providing insights into the reactivity of specific crystallographic facets of the hemihydrate. In this work, epitaxial growth of gypsum crystals on the hemihydrate grains was not observed.

Injectable Self-Setting Ternary Calcium-Based Bone Cement Promotes Bone Repair

Bone defects, especially large ones, are clinically difficult to treat. The development of new bone repair materials exhibits broad application prospects in the clinical treatment of trauma. Bioceramics are considered to be one of the most promising biomaterials owing to their good biocompatibility and bone conductivity. In this study, a self-curing bone repair material having a controlled degradation rate was prepared by mixing calcium citrate, calcium hydrogen phosphate, and semi-hydrated calcium sulfate in varying proportions, and its properties were comprehensively evaluated. In vitro cell experiments and RNA sequencing showed that the composite cement activated PI3K/Akt and MAPK/Erk signaling pathways to promote osteogenesis by promoting the proliferation and osteoblastic differentiation of mesenchymal stem cells. In a rat model with femoral condyle defects, the composite bone cement showed excellent bone repair effect and promoted bone regeneration. The injectable properties of the composite cement further improved its practical applicability, and it can be applied in bone repair, especially in the repair of irregular bone defects, to achieve superior healing.

[Biological reconstruction of large bone defects : Masquelet technique and new procedures]

Extensive diaphyseal and metaphyseal bone defects continue to pose a major challenge for orthopedic trauma surgeons. Various treatment options have been described for the biological reconstruction of these defects. The most frequently used methods are bone segment transport, the Masquelet technique and 3D printed scaffolds. As far as the Masquelet technique is concerned, in the first stage spacers, such as polymethyl methacrylate (PMMA), calcium sulfate or polypropylene are inserted into the bone defects to induce a foreign body membrane. In the second stage the bone defect surrounded by the induced membrane is filled with autologous cancellous bone. The time interval between the first and second interventions is usually 4-8 weeks whereby the induced membranes do not lose their bioactivity even with a latency period longer than 8 weeks. Three-dimensional printed scaffolds are increasingly used but large clinical studies are lacking in order to show the exact role of this procedure in the reconstruction of bone defects.

Biodegradable Cements for Bone Regeneration

Bone cements such as polymethyl methacrylate and calcium phosphates have been widely used for the reconstruction of bone. Despite their remarkable clinical success, the low degradation rate of these materials hampers a broader clinical use. Matching the degradation rate of the materials with neo bone formation remains a challenge for bone-repairing materials. Moreover, questions such as the mechanism of degradation and how the composition of the materials contribute to the degradation property remain unanswered. Therefore, the review provides an overview of currently used biodegradable bone cements such as calcium phosphates (CaP), calcium sulfates and organic-inorganic composites. The possible degradation mechanism and clinical performance of the biodegradable cements are summarized. This paper reviews up-to-date research and applications of biodegradable cements, hoping to provide researchers in the field with inspirations and references.

An assessment of physical properties and the viability of osteoblast-like cells of cefazolin-impregnated calcium sulfate bone-void filler

Calcium sulfate, an injectable and biodegradable bone-void filler, is widely used in orthopedic surgery. Based on clinical experience, bone-defect substitutes can also serve as vehicles for the delivery of drugs, for example, antibiotics, to prevent or to treat infections such as osteomyelitis. However, antibiotic additions change the characteristics of calcium sulfate cement. Moreover, high-dose antibiotics may also be toxic to bony tissues. Accordingly, cefazolin at varying weight ratios was added to calcium sulfate samples and characterized in vitro. The results revealed that cefazolin changed the hydration reaction and prolonged the initial setting times of calcium sulfate bone cement. For the crystalline structure identification, X-ray diffractometer revealed that cefazolin additive resulted in the decrease of peak intensity corresponding to calcium sulfate dihydrate which implying incomplete phase conversion of calcium sulfate hemihydrate. In addition, scanning electron microscope inspection exhibited cefazolin changed the morphology and size of the crystals greatly. A relatively higher amount of cefazolin additive caused a faster degradation and a lower compressive strength of calcium sulfate compared with those of uploaded samples. Furthermore, the extract of cefazolin-impregnated calcium sulfate impaired cell viability, and caused the death of osteoblast-like cells. The results of this study revealed that the cefazolin additives prolonged setting time, impaired mechanical strength, accelerated degradation, and caused cytotoxicity of the calcium sulfate bone-void filler. The aforementioned concerns should be considered during intra-operative applications.

Optimization of an Injectable, Resorbable, Bioactive Cement Able to Release the Anti-Osteoclastogenic Biomolecule ICOS-Fc for the Treatment of Osteoporotic Vertebral Compression Fractures

Vertebral compression fractures are typical of osteoporosis and their treatment can require the injection of a cement through a minimally invasive procedure to restore vertebral body height. This study reports the development of an injectable calcium sulphate-based composite cement able to stimulate bone regeneration while inhibiting osteoclast bone resorption. To this aim, different types of strontium-containing mesoporous glass particles (Sr-MBG) were added to calcium sulphate powder to impart a pro-osteogenic effect, and the influence of their size and textural features on the cement properties was investigated. Anti-osteoclastogenic properties were conferred by incorporating into poly(lactic-co-glycolic)acid (PLGA) nanoparticles, a recombinant protein able to inhibit osteoclast activity (i.e., ICOS-Fc). Radiopaque zirconia nanoparticles (ZrO₂) were also added to the formulation to visualize the cement injection under fluoroscopy. The measured cement setting times were suitable for the clinical practice, and static mechanical testing determined a compressive strength of ca. 8 MPa, comparable to that of human vertebral bodies. In vitro release experiments indicated a sustained release of ICOS-Fc and Sr²⁺ ions up to 28 days. Overall, the developed cement is promising for the treatment of vertebral compression fractures and has the potential to stimulate bone regeneration while releasing a biomolecule able to limit bone resorption.

An injectable pH neutral bioactive glass-based bone cement with suitable bone regeneration ability

Background

As a class of promising bone augmentation materials, bone cements have attracted particular attention. Due to various limitations, the current bone cements are still imperfect. In this study, an injectable pH neutral bioactive bone cement (PSC/CSC) was developed by mixing phosphosilicate bioactive glass (PSC) and α-calcium sulfate hemihydrate (CSH), with the goal of optimizing bone defects repairs.

Methods

A range of compositions (PSC/CSC: 10P/90C, 30P/70C, 50P/50C) were developed and their physicochemical properties evaluated. Their bone regeneration ability was compared to those of two widely used bone cements as controls (calcium phosphate cement (CPC) and Genex®) in rabbit femoral condyle bone defect models for 4, 8 and 12 weeks. Based on physicochemical properties and in vivo bone regeneration ability, the PSC/CSC exhibited the best outcomes was selected. Then, in vitro, the effects of selected PSC/CSC, CPC and Genex® extracts on MC3T3-E1 cell proliferation, migration and osteogenesis as well as angiogenesis of HUVECs were examined.

Results

Based on physicochemical properties, the 30P/70C formula exhibited suitable operability and compressive strength (3.5 ± 0.3 MPa), which fulfilled the requirements for cancellous bone substitutes. In vivo, findings from micro-CT and histological analyses showed that the 30P/70C formula better promoted bone regeneration, compared to 10P/90C, 50P/50C, CPC and Genex®. Hence, 30P/70C was selected as the ideal PSC-based cement. In vitro, the 30P/70C extracts showed better promotion of cell viability, alkaline phosphatase (ALP) activity, calcium mineral deposition, mRNA and protein expression levels of osteogenesis in MC3T3-E1 cells, further supporting its superiority. Meanwhile, the 30P/70C extracts also showed better stimulation of HUVECs proliferation and angiogenesis.

Conclusion

The new composite cement, 30P/70C, is a favorable bioactive glass-based bone cement with suitable operability, compressive strength and bone regeneration ability.

The translational potential of this article

Clinically, treatment of large bone defects is still a major challenge for orthopaedic trauma. We showed that 30P/70C has the potential to be clinically used as an injectable cement for rapid bone repairs and reconstruction of critical sized bone defects.

Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis

Aim

In this study, we present a detailed surgical technique for treating chronic osteomyelitis (COM) of the intramedullary canal with injectable tobramycin and vancomycin-loaded calcium sulfate (CS).

Background

Chronic osteomyelitis of the long bones has been treated using antibiotic-impregnated polymethyl methacrylate (PMMA), which typically requires a second procedure for removal.

Technique

Removal of the infected intramedullary nail (if any), copious irrigation, canal reaming, and intramedullary canal injection of vancomycin- and tobramycin-loaded calcium sulfate as a single-stage procedure for the treatment of COM of long bones.

Conclusion

Intramedullary injection of vancomycin- and tobramycin-loaded CS can be used as a single-stage procedure for the treatment of long bone intramedullary COM. Further studies are necessary to compare the long-term outcomes of antibiotic-coated CS vs other antibiotic carriers for infection eradication.

Clinical significance

The authors have endeavored to explain the best surgical technique to eradicate long bones COM with injectable tobramycin and vancomycin-loaded CS.

How to cite this article

Elhessy AH, Rivera JC, Shu HT, et al. Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis. Strategies Trauma Limb Reconstr 2022;17(2):123–130.

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.

Bone defect treatment: does the type and properties of the spacer affect the induction of Masquelet membrane? Evidence today

PURPOSE

High clinical success rates have been reported with the Masquelet technique in the treatment of traumatic bone loss. An increasing number of studies suggest that various factors can influence the properties of induced membranes. Goal of this systematic review is to answer the following questions: (1) which are the ideal spacer properties (material, surface topography, antibiotic supplementation) to booster the quality and osteogenic potential of induced membranes? (2) what is the ideal time to perform the second-stage operation?

METHODS

A systematic search using the keywords "((Masquelet) OR (Induced Periosteum)) AND ((Spacer) OR (Time))" was performed in PubMed, Embase and Cochrane Library according to PRISMA guidelines. Studies published up to the 23rd of February 2022 were included and assessed independently by two reviewers.

RESULTS

Thirteen animal and 1 clinical studies were identified to address the above questions. Spacer materials used were PMMA, silicone, titanium, polypropylene, PVA, PCL and calcium sulfate. With the exception of PVA sponges, all solid materials could induce membranes. Low union rates have been reported with titanium and rough surfaced spacers. Scraping of the inner surface of the IM also increased bony union rates. In terms of the ideal timing to perform the second-stage evidence suggests that membranes older than 8 weeks continue to have regenerative capacities similar to younger ones.

CONCLUSION

Membranes induced by smooth PMMA spacers loaded with low concentrations of antibiotics showed powerful osteogenic properties. Other materials such as Polypropylene or Calcium sulfate can also be used with good results. Despite current recommendation to perform the second stage operation in 4-8 weeks, membranes older than 8 weeks seem to have similar regenerative capacities to younger ones.

Recent Advances in Production of Ecofriendly Polylactide (PLA)-Calcium Sulfate (Anhydrite II) Composites: From the Evidence of Filler Stability to the Effects of PLA Matrix and Filling on Key Properties

The melt-mixing of polylactide (PLA) with micro- and/or nanofillers is a key method used to obtain specific end-use characteristics and improvements of properties. So-called "insoluble" CaSO₄ (CS) β-anhydrite II (AII) is a mineral filler recently considered for the industry of polymer composites. First, the study proves that AII made from natural gypsum by a specifically thermal treatment is highly stable compared to other CS forms. Then, PLAs of different isomer purity and molecular weights (for injection molding (IM) and extrusion), have been used to produce "green" composites filled with 20-40 wt.% AII. The composites show good thermal and mechanical properties, accounting for the excellent filler dispersion and stability. The stiffness of composites increases with the amount of filler, whereas their tensile strength is found to be dependent on PLA molecular weights. Interestingly, the impact resistance is improved by adding 20% AII into all investigated PLAs. Due to advanced kinetics of crystallization ascribed to the effects of AII and use of a PLA grade of high L-lactic acid isomer purity, the composites show after IM an impressive degree of crystallinity (DC), i.e., as high as 50%, while their Vicat softening temperature is remarkably increased to 160 °C, which are thermal properties of great interest for applications requiring elevated rigidity and heat resistance.

Biomaterials for Interbody Fusion in Bone Tissue Engineering

In recent years, interbody fusion cages have played an important role in interbody fusion surgery for treating diseases like disc protrusion and spondylolisthesis. However, traditional cages cannot achieve satisfactory results due to their unreasonable design, poor material biocompatibility, and induced osteogenesis ability, limiting their application. There are currently 3 ways to improve the fusion effect, as follows. First, the interbody fusion cage is designed to facilitate bone ingrowth through the preliminary design. Second, choose interbody fusion cages made of different materials to meet the variable needs of interbody fusion. Finally, complete post-processing steps, such as coating the designed cage, to achieve a suitable osseointegration microstructure, and add other bioactive materials to achieve the most suitable biological microenvironment of bone tissue and improve the fusion effect. The focus of this review is on the design methods of interbody fusion cages, a comparison of the advantages and disadvantages of various materials, the influence of post-processing techniques and additional materials on interbody fusion, and the prospects for the future development of interbody fusion cages.

Treatment of long bone infection by a biodegradable bone cement releasing antibiotics in human

Repair of methicillin-resistant Staphylococcal (MRSA) chronic osteomyelitis and resulting bone defect is one of the major challenges in orthopaedics. Previous study has shown the effectiveness of antibiotic loaded biodegradable composite bone cement with in vitro tests and in the treatment of experimental osteomyelitis. The cement is composed of poly(lactide-co-glycolide) encapsulated antibiotic-biphasic calcium phosphate granule complex and additive antibiotic powder in gypsum binder. In this study, the cement was studied further to evaluate its in vitro biological properties (cytocompatibility, platelet activation), anti-infective, and bone regenerative potential in comparison to poly(methyl methacrylate) (PMMA) cement and parenteral therapy in 43 patients (age 5-57 years) with chronic MRSA osteomyelitis by analyzing the results of histopathology, radiographs, magnetic resonance imaging, scanning electron microscopy, and serum drug concentrations for 1 year. The composite cement showed superior cytocompatibility and coagulant activity compared to PMMA cement. Moreover, the results of different postoperative clinical and radiological examinations also proved the supremacy of composite cement over the other treatment modalities in terms of success rate, faster sepsis control and bone regeneration. Low serum antibiotic concentrations and normal serum calcium levels indicate that the calcium-rich composite cement is safe for application in human. Therefore, we conclude that the composite bone cement is a promising candidate for the treatment of chronic osteomyelitis.

Antibiotic-Impregnated Calcium Sulfate vs. Wound Irrigation-Suction to Treat Chronic Calcaneal Osteomyelitis

BACKGROUND

Chronic osteomyelitis of calcaneus is not rare but is very hard to treat. Irrigation-suction and antibiotic-impregnated calcium sulfate following debridement are commonly used in managing chronic osteomyelitis, but their effects have rarely been compared. We aimed to compare the effectiveness of antibiotic-impregnated calcium sulfate with irrigation-suction in the treatment of patients with chronic calcaneal osteomyelitis.

METHODS

From January 2011 to June 2018, adult patients at our institute with chronic osteomyelitis receiving treatment of either antibiotic-impregnated calcium sulfate (CS group) or irrigation-suction (IS group) following thorough debridement were screened and selected according to the inclusion and exclusion criteria. The clinical presentation, laboratory tests, complications, and the ultimate single-staged cure rate and recurrence were compared.

RESULTS

A total of 61 patients, including 41 in the CS group and 20 in the IS group, were included in our study. Of the patients, 85.4% in the CS group and 60.0% in the IS group (P = .006) were successfully cured in the single stage, respectively, without infection recurrence. Lower infection recurrence rates with shorter hospital stay were found in the CS group than the IS group. Inflammatory biomarkers after surgery with both treatments were slightly decreased and not significantly different from preoperative or between-groups postoperative. Exudate from incision was found primarily in the CS group.

CONCLUSION

This study demonstrates that both antibiotic-impregnated calcium sulfate and irrigation-suction after careful and thorough surgical debridement are generally effective in treating chronic calcaneal osteomyelitis. Antibiotic-impregnated calcium sulfate achieved a higher single-staged cure rate but was associated with an increased postoperative wound exudate.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Antibacterial ability and osteogenic activity of polyphenols-tailored calcium silicate bone cement

Calcium silicate-based cement (CSC) has attracted much interest because of its favourable osteogenic effect supporting its clinical use. Despite CSC has antibacterial activity, this activity still needs to be improved...

The effect of vanadium ferrite doping on the bioactivity of mesoporous bioactive glass-ceramics

Bioactive glasses are highly reactive surface materials synthesized by melting or sol–gel techniques. In this study, mesoporous bioactive glass-ceramics doped with different amounts of vanadium and iron ((60−(x + y)) SiO₂–36CaO–4P₂O₅–xV₂O₅–yFe₂O₃, x and y between 0, 5 and, 10 mole%) were synthesized using a sol–gel method. Then, their effects on particle morphology and the biomineralization process were examined in simulated body fluid (SBF). N2 adsorption isotherm analysis proved that the samples have a mesoporous structure. In addition, the Fourier-transform infrared spectroscopy (FTIR) spectra of the samples after soaking in SBF for various periods (7, 14, and 21 days) confirmed the presence of new chemical bonds related to the apatite phase, which is in accordance with scanning electron microscopy (SEM) observations. X-ray diffraction (XRD) patterns of the samples after SBF soaking showed that lower amounts of vanadium and iron were associated with the formation of a stable and more crystalline phase of hydroxyapatite. The MTT results showed that the cell viability of mesoporous bioactive glass containing 5% V₂O₅ remains more than 90% over 7 days, which indicates the biocompatibility of the samples. To conclude, further studies on these formulations are going to be carried out in future investigations for chemohyperthermia application.

Bioactive glasses are highly reactive surface materials synthesized by melting or sol–gel techniques.

Revisiting the Roles of Salinity, Temperature and Water Activity in Phase Selection during Calcium Sulfate Precipitation

Calcium sulfate is an important mineral present in a wide variety of natural and engineered environments. Three phases (gypsum, bassanite, and anhydrite), differing in their degree of hydration, can occur...

Synthetic Material for Bone, Periodontal, and Dental Tissue Regeneration: Where Are We Now, and Where Are We Heading Next?

Alloplasts are synthetic, inorganic, biocompatible bone substitutes that function as defect fillers to repair skeletal defects. The acceptance of these substitutes by host tissues is determined by the pore diameter and the porosity and inter-connectivity. This narrative review appraises recent developments, characterization, and biological performance of different synthetic materials for bone, periodontal, and dental tissue regeneration. They include calcium phosphate cements and their variants β-tricalcium phosphate (β-TCP) ceramics and biphasic calcium phosphates (hydroxyapatite (HA) and β-TCP ceramics), calcium sulfate, bioactive glasses and polymer-based bone substitutes which include variants of polycaprolactone. In summary, the search for synthetic bone substitutes remains elusive with calcium compounds providing the best synthetic substitute. The combination of calcium sulphate and β-TCP provides improved handling of the materials, dispensing with the need for a traditional membrane in guided bone regeneration. Evidence is supportive of improved angiogenesis at the recipient sites. One such product, (EthOss^® Regeneration, Silesden, UK) has won numerous awards internationally as a commercial success. Bioglasses and polymers, which have been used as medical devices, are still in the experimental stage for dental application. Polycaprolactone-TCP, one of the products in this category is currently undergoing further randomized clinical trials as a 3D socket preservation filler. These aforementioned products may have vast potential for substituting human/animal-based bone grafts.

Preparation and Characterization of Moldable Demineralized Bone Matrix/Calcium Sulfate Composite Bone Graft Materials

Demineralized bone matrix (DBM) is a decalcified allo/xenograft retaining collagen and noncollagenous proteins, which has been extensively used because of its osteoconductive and osteoinductive properties. Calcium sulfate (CaSO₄, CS) is a synthetic bone substitute used in bone healing with biocompatible, nontoxic, bioabsorbable, osteoconductive, and good mechanical characteristics. This study aims to prepare a DBM/CS composite bone graft material in a moldable putty form without compromising the peculiar properties of DBM and CS. For this purpose, firstly, porcine femur was defatted using chloroform/methanol and extracted by acid for demineralization, then freeze-dried and milled/sieved to obtain DBM powder. Secondly, the α-form and β-form of calcium sulfate hemihydrate (CaSO₄·0.5H₂O, CSH) were produced by heating gypsum (CaSO₄·2H₂O). The morphology and particle sizes of α- and β-CSH were obtained by SEM, and their chemical properties were confirmed by EDS, FTIR and XRD. Furthermore, the DBM-based graft was mixed with α- or β-CSH at a ratio of 9:1, and glycerol/4% HPMC was added as a carrier to produce a putty. DBM/CSH putty possesses a low washout rate, good mechanical strength and biocompatibility. In conclusion, we believe that the moldable DBM/CSH composite putty developed in this study could be a promising substitute for the currently available bone grafts, and might have practical application in the orthopedics field as a potential bone void filler.

Overall bone gaining after using calcium sulfate bone graft simultaneously to dental implantation

Objectives: this study was carried out to evaluate the gaining occurring in the bone gaining after the simultaneous grafting with calcium sulfate around dental implants. Materials and methods: 24 implantation sites in the anterior area of the maxilla were included in this study. Dental implants were inserted, bone grafting was done simultaneously and post evaluation of the overall bone gaining 6 months after the grafting process (T2 time) was done to study the changes. Results: Paired Samples T-Test revealed a significant difference between the three time points (before the implantation, the day after it, six months later) (P-value = 0.000) at the confidence level of 95%. Furthermore, two-way comparisons between the three follow-ups was done to determine where the difference was. The test showed that there is a significant difference (P-value < 0.05) between all time points. by doing two-way comparisons between the three follow-ups, it was shown that the significant difference (P-value < 0.05) was in each comparison. Conclusion: We conclude within the limits of this study that an adequate amount of bone gain was found 6 months after the bone grafting process.

Influence of mineral coatings on fibroblast behaviour: The importance of coating formulation and experimental design

Mineral coatings manipulate surface properties such as roughness, porosity, wettability and surface energy. Properties that are known to determine cell behaviour. Therefore, mineral coatings can potentially be used to manipulate cell fate. This paper studies mineral-cell interactions through coatings in a stacked cell culture platform. Minerals were chosen according to their influence on Human Dermal Fibroblasts (HDFs): calcium carbonate, calcium sulphates, and kaolin. Mineral coatings were formulated with the additives latex, sorbitol, polyvinyl alcohol (PVOH) and TEMPO-oxidised cellulose nanofibrils (CNF-T). The coatings were placed as a bottom or top of the device, for a direct or indirect interaction with HDFs, respectively. Cells were seeded, in various densities, to the bottom of the device; and cell density and confluency were monitored in time. Overall, results show that the coating interaction is influenced at first by the cell seeding density. Scarce cell seeding density limits adaptability to the new environment, while an abundant one encourages confluency in time. In between those densities, coating formulation plays the next major role. Calcium carbonate promoted HDFs growth the most as expected, but the response to the rest of minerals depended on the coating additive. CNF-T encouraged proliferation even for kaolin, a mineral with long-term toxicity to HDFs, while PVOH induced a detrimental effect on HDF growth regardless of the mineral. At last, the placement of the coated layer provided insights on the contact-dependency of each response. This study highlights the importance of the experimental design, including coating formulation, when investigating cellular response to biomaterials.

Construction of the Gypsum-Coated Scaffolds for In Situ Bone Regeneration

It is significant to use functional biomaterials to rationally engineer microenvironments for in situ bone regeneration in the field of bone tissue engineering. To this end, we constructed the gypsum-coated β-tricalcium phosphate (G-TCP) scaffolds by combing a three-dimensional printing technique and an epitaxial gypsum growth method. In vitro simulation experiments showed that the as-prepared scaffolds could establish a dynamic and weakly acidic microenvironment in a simulated body liquid, in which the pH and the calcium ion concentration always changed due to the gypsum degradation and growth of bone-like apatite nanoplates on the scaffold surfaces. The cell experiments confirmed that the microenvironment established by the G-TCP surfaces promoted rapid osteogenic differentiation and proliferation of bone marrow mesenchymal stem cells (BM-MSCs). In vivo experiments confirmed that the G-TCP scaffolds had high bioactivity in modulating in situ regeneration of bone, and the bioactivity of the G-TCP scaffolds was endowed by correct pore structures, degradation of gypsum, and growth of a bone-like apatite layer. The microenvironment established by the gypsum degradation could stimulate tissue inflammation and recruit white blood cells and BM-MSCs and thus accelerating native healing cascades of the bone defects via a bone growth/remodeling-absorption cycle process. Furthermore, in vivo experiments demonstrated that after the bone defects had healed completely, the as-prepared scaffolds also degraded completely within 24 weeks.

A Novel One-Pot Synthesis and Characterization of Silk Fibroin/α-Calcium Sulfate Hemihydrate for Bone Regeneration

This study aims to fabricate silk fibroin/calcium sulfate (SF/CS) composites by one-pot synthesis for bone regeneration applications. The SF was harvested from degummed silkworm cocoons, dissolved in a solvent system comprising of calcium chloride:ethanol:water (1:2:8), and then mixed with a stoichiometric amount of sodium sulfate to prepare various SF/CS composites. The crystal pattern, glass transition temperature, and chemical composition of SF/CS samples were analyzed by XRD, DSC, and FTIR, respectively. These characterizations revealed the successful synthesis of pure calcium sulfate dihydrate (CSD) and calcium sulfate hemihydrate (CSH) when it was combined with SF. The thermal analysis through DSC indicated molecular-level interaction between the SF and CS. The FTIR deconvolution spectra demonstrated an increment in the β-sheet content by increasing CS content in the composites. The investigation into the morphology of the composites using SEM revealed the formation of plate-like dihydrate in the pure CS sample, while rod-like structures of α-CSH surrounded by SF in the composites were observed. The compressive strength of the hydrated 10 and 20% SF-incorporated CSH composites portrayed more than a twofold enhancement (statistically significant) in comparison to that of the pure CS samples. Reduced compressive strength was observed upon further increasing the SF content, possibly due to SF agglomeration that restricted its uniform distribution. Therefore, the one-pot synthesized SF/CS composites demonstrated suitable chemical, thermal, and morphological properties. However, additional biological analysis of its potential use as bone substitutes is required.

A novel degradable tricalcium silicate/calcium polyphosphate/polyvinyl alcohol organic-inorganic composite cement for bone filling

In this study, tricalcium silicate (C₃S) calcium/polyphosphate/polyvinyl alcohol organic-inorganic self-setting composites were successfully designed. A variety of tests were conducted to characterize their self-setting properties, mechanical properties, degradation properties, and related biological properties. The composite bone cements showed a short setting time (5.5-37.5 min) with a 5:5-6:4 ratio of C₃S/CPP to maintain a stable compressive strength (28 MPa). In addition, PVA effectively reduced the brittleness of the inorganic phase. Degradation experiments confirmed the sustainable surface degradation of bone cement. A maximum degradation rate of 49% was reached within 56 days, and the structure remained intact without collapse. Culturing MC3T3 cells with bone cement extracts revealed that the composite bone cements had excellent biological properties in vitro. The original extract showed a proliferation promotion effect on cells, whereas most of the other original extracts of degradable bone cements were toxic to the cells. Meanwhile, extracellular matrix mineralization and alkaline phosphatase expression showed remarkable effects on cell differentiation. In addition, a good level of adhesion of cells to the surfaces of materials was observed. Taken together, these results indicate that C₃S/CPP/PVA composite bone cements have great potential in bone defect filling for fast curing.

Gastrocnemius muscle flap with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone graft for the phase I treatment of localized osteomyelitis after tibial plateau fracture surgery

Purpose

To investigate the clinical effect of gastrocnemius muscle flaps combined with vancomycin/gentamicin-calcium sulfate combined and autologous iliac bone graft in the phase I treatment of traumatic focal osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery.

Methods

From July 2009 to January 2018, 35 patients with localized osteomyelitis (Cierny-Mader type III) who met the inclusion criteria were followed up and treated. All patients were infected after undergoing internal fracture fixation surgery. Among them, 18 cases were plate-exposed, 14 cases were due to sinus tracts, two were due to skin necrosis, and one was bone-exposed. We treated patients with several measures. All cases were then followed up. The follow-up indicators included Hospital for Special Surgery knee scores (HSS), the time of laying drainage pipe, bone healing time, infection control rate, and the incidence of nonunion and other complications.

Results

All patients were followed up for 24–60 months. None of them underwent amputation. For repairing soft tissue defects, 17 cases were covered with a muscle flap using the medial head of gastrocnemius alone, 15 cases were treated with the lateral head of gastrocnemius muscle, and three cases were covered with the combination of the two heads. Compared to the preoperative score, we found that the average HSS improved at the 1-year and 2-year follow-up (54 vs. 86 vs. 87).

Conclusion

Using a gastrocnemius muscle flap combined with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone was an effective method for the phase I treatment of osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery. In the primary treatment of focal traumatic osteomyelitis, it can decrease the treatment time, number of surgeries, pain of patients, time of bone healing, postoperative exudation, and infection recurrence rate and increase the healing bone’s strength.

Dual role of tannic acid and pyrogallol incorporated in plaster of Paris: Morphology modification and release for antimicrobial properties

The design of bioactive plasters is of major interest for the amelioration of dental and bone cements. In this article, a one pot and environmentally friendly strategy based on the addition of a cheap polyphenol-tannic acid (TA) or the main phenolic constituent of TA, namely pyrogallol (PY)- able to interact with calcium sulfate is proposed. Tannic acid and pyrogallol not only modify the morphology of the obtained plaster+TA/PY composites but a part of it is released and provides strong-up to twenty fold- antibacterial effect against Staphylococcus aureus. It is shown that the higher antibacterial efficiency of PY is related to a greater release compared to TA even if in solution the antibacterial effect of PY is lower than that of TA when reported on the basis of the molar concentration in PY units.

Assessing the Bioactive Profile of Antifungal-Loaded Calcium Sulfate against Fungal Biofilms

Calcium sulfate (CS) has been used clinically as a bone- or void-filling biomaterial, and its resorptive properties have provided the prospect for its use as a release mechanism for local antibiotics to control biofilms. Here, we aimed to test CS beads loaded with three antifungal drugs against planktonic and sessile fungal species to assess whether these antifungal beads could be harnessed to provide consistent release of antifungals at biofilm-inhibitory doses. A panel of different fungal species (n = 15) were selected for planktonic broth microdilution testing with fluconazole (FLZ), amphotericin B (AMB), and caspofungin (CSP). After establishing planktonic inhibition, antifungal CS beads were introduced to fungal biofilms (n = 5) to assess biofilm formation and cell viability through a combination of standard quantitative and qualitative biofilm assays. Inoculation of a hydrogel substrate, packed with antifungal CS beads, was also used to assess diffusion through a semidry material, to mimic active infection in vivo In general, antifungals released from loaded CS beads were all effective at inhibiting the pathogenic fungi over 7 days within standard MIC ranges for these fungi. We observed a significant reduction of pregrown fungal biofilms across key fungal pathogens following treatment, with visually observable changes in cell morphology and biofilm coverage provided by scanning electron microscopy. Assessment of biofilm inhibition also revealed reductions in total and viable cells across all organisms tested. These data show that antifungal-loaded CS beads produce a sustained antimicrobial effect that inhibits and kills clinically relevant fungal species in vitro as planktonic and biofilm cells.

Review of calcium-sulphate-based ceramics and synthetic bone substitutes used for antibiotic delivery in PJI and osteomyelitis treatment

Infection in orthopaedic and trauma surgery remains a destructive complication with particularly challenging diagnosis and treatment due to bacterial antibiotic resistance and biofilm formation.

Along with surgical debridement and systemic antibiotics, an important type of adjuvant therapy is local antibiotic delivery, with the purpose of eliminating bacterial colonization and biofilm development.

Calcium sulphate, as a synthetic absorbable biomaterial used for local antibiotic delivery, has experienced an increasing popularity during the last decade, with multiple promoted advantages such as predictable antibiotic elution kinetics, complete and quick biodegradation, good biocompatibility, and limited associated complications.

A series of commercially available antibiotic-delivery systems based on calcium sulphate are under investigation and in clinical use, with different presentations, compositions, and application techniques.

The current article presents the main available calcium-sulphate-based products and the existing data about the clinical and preclinical research results, stemming from their implementation as local antibiotic carriers for surgical site and implant-associated infections treatment and prevention.

Cite this article: EFORT Open Rev 2021;6:297-304. DOI: 10.1302/2058-5241.6.200083

Injectable tricalcium phosphate/calcium sulfate granule enhances bone repair by reversible setting reaction

Towards repairing bone defects, calcium sulfate and calcium phosphate cement have been recognized as promising bone grafts. However, the current bone cements are generally lack of proper porosity for cell migration and new tissue formation. On the other hand, porous scaffold cannot be delivered by injection, which limits its use its clinical use. Herein, we develop a novel tricalcium phosphate/calcium sulfate granule to overcome the limitations of injectable cements and traditional scaffolds. The biocompatible granule underwent in situ self-setting to form scaffold with porous structure after injection. It contributes to calcium deposition and upregulation of osteogenic genes of mesenchymal stem cells in a time-dependent manner. Within three months, cavitary bone defects of distal rabbit femurs implanted the granules exhibited better bone formation than those with those implanted with autologous bone.

Formulation of a reactive oxygen producing calcium sulphate cement as an anti-bacterial hard tissue scaffold

Prophylactic antibiotic bone cements are extensively used in orthopaedics. However, the development of antimicrobial resistance to antibiotics, demonstrates a need to find alternative treatments. Herein, an antimicrobial honey (SurgihoneyRO-SHRO) has been successfully incorporated into a calcium sulphate (CS) based cement to produce a hard tissue scaffold with the ability to inhibit bacterial growth. Antimicrobial properties elicited from SHRO are predominantly owed to the water-initiated production of reactive oxygen species (ROS). As an alternative to initially loading CS cement with SHRO, in order to prevent premature activation, SHRO was added into the already developing cement matrix, locking available water into the CS crystal structure before SHRO addition. Promisingly, this methodology produced > 2.5 times (715.0 ± 147.3 μM/mL/g) more ROS over 24 h and exhibited a compressive strength (32.2 ± 5.8 MPa) comparable to trabecular bone after 3 weeks of immersion. In-vitro the SHRO loaded CS scaffolds were shown to inhibit growth of clinically relevant organisms, Staphylococcus aureus and Pseudomonas aeruginosa, with comparable potency to equivalent doses of gentamicin. Encouragingly, formulations did not inhibit wound healing or induce an inflammatory response from osteoblasts. Overall this study highlights the prophylactic potential of CS-SHRO cements as an alternative to traditional antibiotics.

Effect of Dehydrothermal Treatment on the Mechanical Properties and Biocompatibility of Plaster of Paris–CaCO3 Hydrogel Loaded With Cinnamaldehyde for Biomedical Purposes

CaCO3 hydrogel incorporation into Plaster of Paris (POP) formulations decreased the resorption rate of the POP after implantation in the body. Although an inflammatory process is required as part of wound healing, the accumulation and activation of inflammatory cells in the POP–hydrogel CaCO3 implant area needs to be controlled. Therefore, cinnamaldehyde, as an anti-inflammatory agent with a unique α, β-unsaturated aldehyde, was incorporated into the CaCO3 hydrogel. During the incorporation, both the lipophilic and hydrophilic sides of the cinnamaldehyde molecule can influence the physical and mechanical properties of the CaCO3 hydrogel, in which mechanical properties of a tissue engineering scaffold are important to fine tune cellular activity during implantation. On the other hand, as a 3-dimensional polymeric structure, crosslinking is needed for the CaCO3 hydrogel to stabilize and increase its molecular weight for better mechanical strength, and more resistance to heat, wear, and solvent attack. For that purpose, dehydrothermal treatment (DHT) was applied to the crosslink hydrogel system as a favorable crosslinking method to avoid the use of a chemical agent. In this study, 3 groups of hydrogels of CaCO3, namely DHT crosslinked, loaded with cinnamaldehyde, and loaded with cinnamaldehyde followed by DHT crosslinking were developed before being combined with POP in 50 wt%. To evaluate the effect of DHT to the final POP-cinnamaldehyde-loaded CaCO3 hydrogel properties and biocompatibility, scanning electron microscopy, contact angle, surface roughness, hardness, diametral tensile strength, and in vivo biocompatibility studies were conducted. It was observed that cinnamaldehyde with DHT treatment improved the POP–hydrogel CaCO3 properties and had good biocompatibility. Thus, POP-cinnamaldehyde-loaded CaCO3 hydrogel can be a promising bone substitute containing an anti-inflammatory agent.

Biphasic ceramic bone graft with biphasic degradation rates

In this study, the characteristics of a novel biphasic bone graft are reported. The bone graft is a physical mixture of calcium sulfate (CS) and hydroxyapatite (HA). This biphasic bone graft was prepared by sintering at 1100 °C. Since the degradation rate of CS is much faster than that of HA, the CS/HA biphasic bone graft exhibits two degradation rates. The degradation rate is rapid (~10 wt%/week) in the first stage and then slow (~1 wt%/week) in the second stage. The biphasic bone graft has been implanted into the distal femur of rat. Most the bone graft was degraded 13 weeks postoperatively. Instead, trabecular bone and vascular tissue are observed at the location of implant. The bone graft is unique for its burst of calcium ions at the start and its ability to remain stable throughout the degradation process. Its stable porous structure serves as an ideal scaffold for the formation of new bone as well as vascularization.

Biodegradable materials for bone defect repair

Compared with non-degradable materials, biodegradable biomaterials play an increasingly important role in the repairing of severe bone defects, and have attracted extensive attention from researchers. In the treatment of bone defects, scaffolds made of biodegradable materials can provide a crawling bridge for new bone tissue in the gap and a platform for cells and growth factors to play a physiological role, which will eventually be degraded and absorbed in the body and be replaced by the new bone tissue. Traditional biodegradable materials include polymers, ceramics and metals, which have been used in bone defect repairing for many years. Although these materials have more or fewer shortcomings, they are still the cornerstone of our development of a new generation of degradable materials. With the rapid development of modern science and technology, in the twenty-first century, more and more kinds of new biodegradable materials emerge in endlessly, such as new intelligent micro-nano materials and cell-based products. At the same time, there are many new fabrication technologies of improving biodegradable materials, such as modular fabrication, 3D and 4D printing, interface reinforcement and nanotechnology. This review will introduce various kinds of biodegradable materials commonly used in bone defect repairing, especially the newly emerging materials and their fabrication technology in recent years, and look forward to the future research direction, hoping to provide researchers in the field with some inspiration and reference.

Developing a biodegradable tricalcium silicate/glucono-delta-lactone/calcium sulfate dihydrate composite cement with high preliminary mechanical property for bone filling

Bone cements with the feature of easily shaping could ideally match the defect site and prevent the ingrowth of fibrous tissue. In this manuscript, a biodegradable tricalcium silicate (C₃S)/glucono-delta-lactone (GDL)/calcium sulfate dihydrate (CSD) organic-inorganic composite cement was fabricated with shorter setting time (less than 15 min) and high preliminary mechanical property (5.27 MPa in the first hour). Many methods were applied to study the physicochemical and biological properties of the cement in vitro. The weight loss in PBS can reach 58% after 12 weeks soaking indicating the better biodegradability. The excellent bioactivity in vitro was emerging after the cement was soaked in the simulated body fluid. The cell experiments showed that suitable concentration of the extract liquid of cement was conducive to the proliferation, differentiation and extracellular matrix calcification of the mouse bone marrow stromal cells. Briefly, the C₃S/GDL/CSD composite cement would have the bright capacity for bone filling.

"Hard" ceramics for "Soft" tissue engineering: Paradox or opportunity?

Tissue engineering provides great possibilities to manage tissue damages and injuries in modern medicine. The involvement of hard biocompatible materials in tissue engineering-based therapies for the healing of soft tissue defects has impressively increased over the last few years: in this regard, different types of bioceramics were developed, examined and applied either alone or in combination with polymers to produce composites. Bioactive glasses, carbon nanostructures, and hydroxyapatite nanoparticles are among the most widely-proposed hard materials for treating a broad range of soft tissue damages, from acute and chronic skin wounds to complex injuries of nervous and cardiopulmonary systems. Although being originally developed for use in contact with bone, these substances were also shown to offer excellent key features for repair and regeneration of wounds and "delicate" structures of the body, including improved cell proliferation and differentiation, enhanced angiogenesis, and antibacterial/anti-inflammatory activities. Furthermore, when embedded in a soft matrix, these hard materials can improve the mechanical properties of the implant. They could be applied in various forms and formulations such as fine powders, granules, and micro- or nanofibers. There are some pre-clinical trials in which bioceramics are being utilized for skin wounds; however, some crucial questions should still be addressed before the extensive and safe use of bioceramics in soft tissue healing. For example, defining optimal formulations, dosages, and administration routes remain to be fixed and summarized as standard guidelines in the clinic. This review paper aims at providing a comprehensive picture of the use and potential of bioceramics in treatment, reconstruction, and preservation of soft tissues (skin, cardiovascular and pulmonary systems, peripheral nervous system, gastrointestinal tract, skeletal muscles, and ophthalmic tissues) and critically discusses their pros and cons (e.g., the risk of calcification and ectopic bone formation as well as the local and systemic toxicity) in this regard. STATEMENT OF SIGNIFICANCE: Soft tissues form a big part of the human body and play vital roles in maintaining both structure and function of various organs; however, optimal repair and regeneration of injured soft tissues (e.g., skin, peripheral nerve) still remain a grand challenge in biomedicine. Although polymers were extensively applied to restore the lost or injured soft tissues, the use of bioceramics has the potential to provides new opportunities which are still partially unexplored or at the very beginning. This reviews summarizes the state of the art of bioceramics in this field, highlighting the latest evolutions and the new horizons that can be opened by their use in the context of soft tissue engineering. Existing results and future challenges are discussed in order to provide an up-to-date contribution that is useful to both experienced scientists and early-stage researchers of the biomaterials community.