Calcium-strontium mixed phosphate as novel injectable and radio-opaque hydraulic cement

Repair of a rat calvaria defect with injectable strontium (Sr)-doped polyphosphate dicalcium phosphate dehydrate (P-DCPD) ceramic bone grafts

The trace element strontium (Sr) enhances new bone formation. However, delivering Sr, like other materials, in a sustained manner from a ceramic bone graft substitute (BGS) is difficult. We developed a novel ceramic BGS, polyphosphate dicalcium phosphate dehydrate (P-DCPD), which delivers embedded drugs in a sustained pattern. This study assessed the in vitro and in vivo performance of Sr-doped P-DCPD. In vitro P-DCPD and 10%Sr-P-DCPD were nontoxic and eluents from 10%Sr-P-DCPD significantly enhanced osteoblastic MC3T3 cell differentiation. A sustained, zero-order Sr release was observed from 10%Sr-P-DCPD for up to 70 days. When using this BGS in a rat calvaria defect model, both P-DCPD and 10% Sr-P-DCPD were found to be biocompatible and biodegradable. Histologic data from decalcified and undecalcified tissue showed that 10%Sr-P-DCPD had more extensive new bone formation compared with P-DCPD 12-weeks after surgery and the 10%Sr-P-DCPD had more organized new bone and much less fibrous tissue at the defect margins. The new bone was formed on the surface of the degraded ceramic debris within the bone defect area. P-DCPD represented a promising drug-eluting BGS for repair of critical bone defects.

Rapid Fabrication of MgNH4PO4·H2O/SrHPO4 Porous Composite Scaffolds with Improved Radiopacity via 3D Printing Process

Although bone repair scaffolds are required to possess high radiopacity to be distinguished from natural bone tissues in clinical applications, the intrinsic radiopacity of them is usually insufficient. For improving the radiopacity, combining X-ray contrast agents with bone repair scaffolds is an effective method. In the present research, MgNH₄PO₄·H₂O/SrHPO₄ 3D porous composite scaffolds with improved radiopacity were fabricated via the 3D printing technique. Here, SrHPO₄ was firstly used as a radiopaque agent to improve the radiopacity of magnesium phosphate scaffolds. X-ray diffraction (XRD), scanning electron microscopy (SEM), and energy-dispersive spectroscopy (EDS) were used to characterize the phases, morphologies, and element compositions of the 3D porous composite scaffolds. The radiography image showed that greater SrHPO₄ contents corresponded to higher radiopacity. When the SrHPO₄ content reached 9.34%, the radiopacity of the composite scaffolds was equal to that of a 6.8 mm Al ladder. The porosity and in vitro degradation of the porous composite scaffolds were studied in detail. The results show that magnesium phosphate scaffolds with various Sr contents could sustainably degrade and release the Mg, Sr, and P elements during the experiment period of 28 days. In addition, the cytotoxicity on MC3T3-E1 osteoblast precursor cells was evaluated, and the results show that the porous composite scaffolds with a SrHPO₄ content of 9.34% possessed superior cytocompatibility compared to that of the pure MgNH₄PO₄·H₂O scaffolds when the extract concentration was 0.1 g/mL. Cell adhesion experiments showed that all of the scaffolds could support MC3T3-E1 cellular attachment well. This research indicates that MgNH₄PO₄·H₂O/SrHPO₄ porous composite scaffolds have potential applications in the bone repair fields.

A Novel Fast-Setting Strontium-Containing Hydroxyapatite Bone Cement With a Simple Binary Powder System

In recent years, strontium-substituted calcium phosphate bone cement (Sr-CPC) has attracted more and more attentions in the field of bone tissue repair due to its comprehensive advantages of both traditional CPC and Sr ions. In this study, a crucial Sr-containing α-Ca_{3 - x} Sr _x (PO₄)₂ salt has been synthesized using a simplified one-step method at lower synthesis temperature. A novel Sr-CPC has been developed based on the simple binary Sr-containing α-Ca_{3 - x} Sr _x (PO₄)₂/Ca₄(PO₄)₂O cement powder. The physicochemical properties and hydration mechanism of this Sr-CPC at various Sr contents were intensively investigated. The setting product of this Sr-CPC after a set for 72 h is a single-phase Sr-containing hydroxyapatite, and its compressive strength slightly decreased and its setting time extended with the increase of Sr content. The hydration process included the initial formation of the medium product CaHPO₄⋅2H₂O (30 min∼1 h), the following complete hydration of Ca₄(PO₄)₂O and the initially formed CaHPO₄⋅2H₂O (2∼6 h), and the final self-setting of α-Ca_{3 - x} Sr _x (PO₄)₂ (6 h∼). The compressive strength of Sr-CPC, which was closely related to the transformation rate of Sr-containing hydroxyapatite, tended to increase with the extension of hydration time. In addition, Sr-CPC possessed favorable cytocompatibility and the effect of Sr ions on cytocompatibility of Sr-CPC was not obvious at low Sr contents. The present study suggests α-Ca_{3 - x} Sr _x (PO₄)₂ is a kind of vital Sr-containing salt source which is useful to develop some novel Sr-containing biomaterials. In addition, the new Sr-containing cement system based on this simple binary α-Ca_{3 - x} Sr _x (PO₄)₂/Ca₄(PO₄)₂O cement powder displayed an attractive clinical application potential in orthopedics.

Applications of Metals for Bone Regeneration

The regeneration of bone tissue is the main purpose of most therapies in dental medicine. For bone regeneration, calcium phosphate (CaP)-based substitute materials based on natural (allo- and xenografts) and synthetic origins (alloplastic materials) are applied for guiding the regeneration processes. The optimal bone substitute has to act as a substrate for bone ingrowth into a defect, as well as resorb in the time frame needed for complete regeneration up to the condition of restitution ad integrum. In this context, the modes of action of CaP-based substitute materials have been frequently investigated, where it has been shown that such materials strongly influence regenerative processes such as osteoblast growth or differentiation and also osteoclastic resorption due to different physicochemical properties of the materials. However, the material characteristics needed for the required ratio between new bone tissue formation and material degradation has not been found, until now. The addition of different substances such as collagen or growth factors and also of different cell types has already been tested but did not allow for sufficient or prompt application. Moreover, metals or metal ions are used differently as a basis or as supplement for different materials in the field of bone regeneration. Moreover, it has already been shown that different metal ions are integral components of bone tissue, playing functional roles in the physiological cellular environment as well as in the course of bone healing. The present review focuses on frequently used metals as integral parts of materials designed for bone regeneration, with the aim to provide an overview of currently existing knowledge about the effects of metals in the field of bone regeneration.

Percutaneous Injection of Strontium Containing Hydroxyapatite versus Polymethacrylate Plus Short-Segment Pedicle Screw Fixation for Traumatic A2- and A3/AO-Type Fractures in Adults

Introduction

Polymethacrylate (PMMA) is commonly used in vertebroplasty and balloon kyphoplasty, but its use has been associated with complications. This study tests three hypotheses: (1) whether strontium hydroxyapatite (Sr-HA) is equivalent to PMMA for restoring thoracolumbar vertebral body fractures, (2) whether the incidence of PMMA leakage is similar to that of Sr-HA leakage, and (3) whether Sr-HAis is resorbed and substituted by new vertebral bone.

Materials and Methods

Two age- and sex-matched groups received short percutaneous pedicle screw fixation plus PEEK implant (Kiva, VCF Treatment System, Benvenue Medical, Santa Clara, CA, USA) filled with either Sr-HA (Group A) or PMMA (Group B) after A2- and A3/AO-type thoracolumbar vertebral body fractures. The Visual Analog Scale (VAS) score and imaging parameters, which included segmental kyphosis angle (SKA), vertebral body height ratios (VBHr), spinal canal encroachment (SCE), bone cement leakage, and Sr-HA resorption, were compared between the two groups.

Results

The average follow-up was 28 months. No differences in VAS scores between Groups A and B were observed at baseline. Baseline back pain in both groups improved significantly three months postoperatively. Anterior, middle, and posterior VBHr did not differ between the two groups at any time point. SKA was improved insignificantly in both groups. SCE decreased insignificantly in both groups on 12-month follow-up using computed tomography (CT). PMMA leakage was observed in one patient, while no Sr-HA paste leakages occurred. Sr-HA resorption and replacement with vertebral bone were observed, and no new fractures were observed.

Conclusions

As all hypotheses were confirmed, the authors recommend the use of Sr-HA instead of PMMA in traumatic spine fractures, although more patients and longer follow-up will be needed to strengthen these results. This trial is registered with NCT03431519.

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

In this study a premixed strontium-containing calcium phosphate bone cement for the application in osteoporotic bone defects has been developed and characterised regarding its material and in vitro properties as well as minimally invasive applicability in balloon kyphoplasty. Strontium was introduced into the cement by substitution of one precursor component, CaCO₃, with its strontium analogue, SrCO₃. Using a biocompatible oil phase as carrier liquid, a cement paste that only set upon contact with aqueous environment was obtained. Strontium modification resulted in an increased strength of set cements and radiographic contrast; and the cements released biologically relevant doses of Sr²⁺-ions that were shown to enhance osteoprogenitor cell proliferation and osteogenic differentiation. Finally, applicability of strontium-containing cement pastes in balloon kyphoplasty was demonstrated in a human cadaver spine procedure. The cement developed in this study may therefore be well suited for minimally invasive, osteoporosis-related bone defect treatment.

STATEMENT OF SIGNIFICANCE

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

Growth of strontium hydrogen phosphate/gelatin composites: a biomimetic approach

Our study has focused on the crystal growth of strontium phosphatesviagel growth method due to the bioactivity and biocompatibility of these materials with bone tissue.

Effects on growth and osteogenic differentiation of mesenchymal stem cells by the strontium-added sol-gel hydroxyapatite gel materials

In the present study, strontium-modified hydroxyapatite gels (Sr-HA) at different concentrations were prepared using sol-gel approach and their effect on human-bone-marrow-derived mesenchymal stem cells, were evaluated. The effect of Strontium on physico-chemical and morphological properties of hydroxyapatite gel were evaluated. Morphological analyses (SEM and TEM) demonstrate that an increasing in the amount of Sr ions doped into HA made the agglomerated particles smaller. The substitution of large Sr2+ for small Ca2+ lead to denser atomic packing of the system causing retardation of crystals growth. The biological results demonstrated that hydroxyapatite gel containing from 0 to 20 mol% of Sr presented no cytotoxicity and promote the expression of osteogenesis related genes including an early marker for osteogenic differentiation ALP; a non-collagen protein OPN and a late marker for osteogenic differentiation OCN. Finally, the Sr-HA gels could have a great potential application as filler in bone repair and regeneration and used in especially in the osteoporotic disease.

Strontium modified calcium phosphate cements – approaches towards targeted stimulation of bone turnover

Strontium modified calcium phosphate cements can target local bone turnover by stimulating osteoblast proliferation and differentiation (1) as well as bone mineralisation (2), reducing osteoclastogenesis (3) and resorption activity, increase osteoclast apoptosis (4) and affect osteoblast/osteoclast paracrine signalling (5).

Bone cements for percutaneous vertebroplasty and balloon kyphoplasty: Current status and future developments

Osteoporotic vertebral compression fractures (OVCFs) have gradually evolved into a serious health care problem globally. In order to reduce the morbidity of OVCF patients and improve their life quality, two minimally invasive surgery procedures, vertebroplasty (VP) and balloon kyphoplasty (BKP), have been developed. Both VP and BKP require the injection of bone cement into the vertebrae of patients to stabilize fractured vertebra. As such, bone cement as the filling material plays an essential role in the effectiveness of these treatments. In this review article, we summarize the bone cements that are currently available in the market and those still under development. Two major categories of bone cements, nondegradable acrylic bone cements (ABCs) and degradable calcium phosphate cements (CPCs), are introduced in detail. We also provide our perspectives on the future development of bone cements for VP and BKP.

The status of strontium in biological apatites: an XANES/EXAFS investigation

Osteoporosis represents a major public health problem through its association with fragility fractures. The public health burden of osteoporotic fractures will rise in future generations, due in part to an increase in life expectancy. Strontium-based drugs have been shown to increase bone mass in postmenopausal osteoporosis patients and to reduce fracture risk but the molecular mechanisms of the action of these Sr-based drugs are not totally elucidated. The local environment of Sr(2+) cations in biological apatites present in pathological and physiological calcifications in patients without such Sr-based drugs has been assessed. In this investigation, X-ray absorption spectra have been collected for 17 pathological and physiological calcifications. These experimental data have been combined with a set of numerical simulations using the ab initio FEFF9 X-ray spectroscopy program which takes into account possible distortion and Ca/Sr substitution in the environment of the Sr(2+) cations. For selected samples, Fourier transforms of the EXAFS modulations have been performed. The complete set of experimental data collected on 17 samples indicates that there is no relationship between the nature of the calcification (physiological and pathological) and the adsorption mode of Sr(2+) cations (simple adsorption or insertion). Such structural considerations have medical implications. Pathological and physiological calcifications correspond to two very different preparation procedures but are associated with the same localization of Sr(2+) versus apatite crystals. Based on this study, it seems that for supplementation of Sr at low concentration, Sr(2+) cations will be localized into the apatite network.

A novel strontium(II)-modified calcium phosphate bone cement stimulates human-bone-marrow-derived mesenchymal stem cell proliferation and osteogenic differentiation in vitro

In the present study, the in vitro effects of novel strontium-modified calcium phosphate bone cements (SrCPCs), prepared using two different approaches on human-bone-marrow-derived mesenchymal stem cells (hMSCs), were evaluated. Strontium ions, known to stimulate bone formation and therefore already used in systemic osteoporosis therapy, were incorporated into a hydroxyapatite-forming calcium phosphate bone cement via two simple approaches: incorporation of strontium carbonate crystals and substitution of Ca(2+) by Sr(2+) ions during cement setting. All modified cements released 0.03-0.07 mM Sr(2+) under in vitro conditions, concentrations that were shown not to impair the proliferation or osteogenic differentiation of hMSCs. Furthermore, strontium modification led to a reduced medium acidification and Ca(2+) depletion in comparison to the standard calcium phosphate cement. In indirect and direct cell culture experiments with the novel SrCPCs significantly enhanced cell proliferation and differentiation were observed. In conclusion, the SrCPCs described here could be beneficial for the local treatment of defects, especially in the osteoporotic bone.

Self-setting calcium orthophosphate formulations

In early 1980s, researchers discovered self-setting calcium orthophosphate cements, which are bioactive and biodegradable grafting bioceramics in the form of a powder and a liquid. After mixing, both phases form pastes, which set and harden forming either a non-stoichiometric calcium deficient hydroxyapatite or brushite. Since both of them are remarkably biocompartible, bioresorbable and osteoconductive, self-setting calcium orthophosphate formulations appear to be promising bioceramics for bone grafting. Furthermore, such formulations possess excellent molding capabilities, easy manipulation and nearly perfect adaptation to the complex shapes of bone defects, followed by gradual bioresorption and new bone formation. In addition, reinforced formulations have been introduced, which might be described as calcium orthophosphate concretes. The discovery of self-setting properties opened up a new era in the medical application of calcium orthophosphates and many commercial trademarks have been introduced as a result. Currently such formulations are widely used as synthetic bone grafts, with several advantages, such as pourability and injectability. Moreover, their low-temperature setting reactions and intrinsic porosity allow loading by drugs, biomolecules and even cells for tissue engineering purposes. In this review, an insight into the self-setting calcium orthophosphate formulations, as excellent bioceramics suitable for both dental and bone grafting applications, has been provided.

A novel and easy-to-prepare strontium(II) modified calcium phosphate bone cement with enhanced mechanical properties

The aim of this study was to evaluate two different approaches to obtaining strontium-modified calcium phosphate bone cements (SrCPCs) without elaborate synthesis of Sr-containing calcium phosphate species as cement precursors that could release biologically effective doses of Sr(2+) and thus could improve the healing of osteoporotic bone defects. Using strontium carbonate as a strontium(II) source, it was introduced into a hydroxyapatite-forming cement either by the addition of SrCO3 to an α-tricalcium phosphate-based cement precursor mixture (A-type) or by substitution of CaCO3 by SrCO3 during precursor composition (S-type). The cements, obtained after setting in a water-saturated atmosphere, contained up to 2.2at.% strontium in different distribution patterns as determined by time-of-flight secondary ion mass spectrometry and energy-dispersive X-ray spectroscopy. The setting time of CPC and A-type cements was in the range of 6.5-7.5min and increased for substitution-type cements (12.5-13.0min). Set cements had an open porosity between 26 and 42%. Compressive strength was found to increase from 29MPa up to 90% in substituted S-type cements (58MPa). SrCPC samples released between 0.45 and 1.53mgg(-1) Sr(2+) within 21days and showed increased radiopacity. Based on these findings, the SrCPC developed in this study could be beneficial for the treatment of defects of systemically impaired (e.g. osteoporotic) bone.

Silicon-stabilized α-tricalcium phosphate and its use in a calcium phosphate cement: characterization and cell response

α-Tricalcium phosphate (α-TCP) is widely used as a reactant in calcium phosphate cements. This work aims at doping α-TCP with silicon with a twofold objective. On the one hand, to study the effect of Si addition on the stability and reactivity of this polymorph. On the other, to develop Si-doped cements and to evaluate the effect of Si on their in vitro cell response. For this purpose a calcium-deficient hydroxyapatite was sintered at 1250°C with different amounts of silicon oxide. The high temperature polymorph α-TCP was stabilized by the presence of silicon, which inhibited reversion of the β→α transformation, whereas in the Si-free sample α-TCP completely reverted to the β-polymorph. However, the β-α transformation temperature was not affected by the presence of Si. Si-α-TCP and its Si-free counterpart were used as reactants for a calcium phosphate cement. While Si-α-TCP showed faster hydrolysis to calcium-deficient hydroxyapatite, upon complete reaction the crystalline phases, morphology and mechanical properties of both cements were similar. An in vitro cell culture study, in which osteoblast-like cells were exposed to the ions released by both materials, showed a delay in cell proliferation in both cases and stimulation of cell differentiation, more marked for the Si-containing cement. These results can be attributed to strong modification of the ionic concentrations in the culture medium by both materials. Ca-depletion from the medium was observed for both cements, whereas continuous Si release was detected for the Si-containing cement.

The influence of Sr and H3PO4 concentration on the hydration of SrCaHA bone cement

Sr-contained calcium hydroxyapatite (SrCaHA) cement is a potential biomaterial for in vivo bone repair and surgery fixation due to its excellent biodegradability, bioactivity, biocompatibility, easily shaping and self-hardening. We had ever reported the in vitro physiochemical properties, biocompatibility and in vivo degradability of the SrCaHA cement obtained by mixing a cement powder of Ca(4)(PO(4))(2)O/CaHPO(4)/SrHPO(4) and a cement liquid of diluted H(3)PO(4) aqueous solution. In the present study, we intensively studied the influences of both Sr content and H(3)PO(4) concentration in diluted phosphoric acid aqueous solution on the setting time, hydration heat-liberation behaviours, and real-time microstructure and phase evolutions of the SrCaHA cement. The results show that both PO(4)(3-) and H(+) ions in PA solution attended the hydration reaction as reactants, and thus the increase of the PA concentration not only promoted the dissolution of Ca(4)(PO(4))(2)O but also pushed the hydration progress of SrCaHA bone cement. Sr content exhibits a remarkable retardation role on the apatite transformation of the SrCaHA cement pastes which probably attributed to its higher degree of supersaturation for yielding apatite crystals and lower transformation rate when exposed to the Sr(2+)-containing hydration system. This present results contribute to a better understanding on the hydration mechanism of the new SrCaHA cement and help to the more precisely controlling of its hydration process.

Co-grinding significance for calcium carbonate-calcium phosphate mixed cement. Part I: effect of particle size and mixing on solid phase reactivity

In part I of this study we aim to evaluate and control the characteristics of the powders constituting the solid phase of a vaterite CaCO(3)-dicalcium phosphate dihydrate cement using a co-grinding process and to determine their impact on cement setting ability. An original methodology involving complementary analytical techniques was implemented to thoroughly investigate the grinding mechanism of separated or mixed reactive powders and the effects on solid phase reactivity. We showed that the association of both reactive powders during co-grinding improves the efficiency of this process in terms of the particle size decrease, thus making co-grinding adaptable to industrial development of the cement. For the first time the usefulness of horizontal attenuated total reflection Fourier transform infrared spectroscopy to follow the chemical setting reaction at 37°C in real time has been demonstrated. We point out the antagonist effects that co-grinding can have on cement setting: the setting time is halved; however, progress of the chemical reaction involving dissolution-reprecipitation is delayed by 30 min, probably due to the increased contact area between the reactive powders, limiting their hydration. More generally, we can take advantage of the co-grinding process to control powder mixing, size and reactivity and this original analytical methodology to better understand its effect on the phenomena involved during powder processing and cement setting, which is decisive for the development of multi-component cements.

Effects of strontium in modified biomaterials

Strontium (Sr) plays a special role in bone remodelling, being associated with both the stimulation of bone formation and a reduction in bone resorption. Thus, the modification of biomaterials by partial or full substitution by Sr is expected to increase both bioactivity and biocompatibility. However, such effects have to be studied individually. Although no phase transition was found in Sr-substituted hydroxyapatite (Sr-HA), Sr-containing calcium silicate (Sr-CS) or Sr-containing borosilicate (Sr-BS), their biological performance was substantially affected by changes in the physico-chemical properties and Sr content of the materials. Three distinct outcomes were found for the presence of Sr: (1) increased HA solubility; (2) no significant effect on the degradation rate of CS; (3) apparent inhibition of the otherwise rapid degradation of BS. In each case the released Sr affected osteoblast proliferation and alkaline phosphatase activity, with clear evidence that an optimum Sr dose exists. Such chemical and biological variations must be disentangled for the behaviour to be properly understood and materials design to be advanced.