The Cytocompatibility and Early Osteogenic Characteristics of an Injectable Calcium Phosphate Cement

Traumatic Fracture Treatment: Calcium Phosphate Bone Substitute Case-Control Study in Humerus, Radius, Tibia Fractures-Assessing Efficacy and Recovery Outcomes

To date, insufficient investigation has been carried out on the biocompatibility of synthetic bioactive bone substitute materials after traumatically induced bone fractures in clinical conditions. This study encompasses the safety, resorption, healing process, and complications of surgical treatment. Our current hypothesis posits that calcium phosphate-based bone substitutes could improve bone healing. In this retrospective case-control study, over 290 patients who underwent surgical treatment for acute fractures were examined. Bone defects were augmented with calcium phosphate-based bone substitute material (CP) in comparison to with empty defect treatment (ED) between 2011 and 2018. A novel scoring system for fracture healing was introduced to assess bone healing in up to six radiological follow-up examinations. Furthermore, demographic data, concomitant diseases, and complications were subjected to analysis. Data analysis disclosed significantly fewer postoperative complications in the CP group relative to the ED group (p < 0.001). The CP group revealed decreased risks of experiencing complications (p < 0.001), arthrosis (p = 0.01), and neurological diseases (p < 0.001). The fracture edge, the fracture gap, and the articular surface were definably enhanced. Osteosynthesis and general bone density demonstrated similarity (p > 0.05). Subgroup analysis focusing on patients aged 64 years and older revealed a diminished complication incidence within the CP group (p = 0.025). Notably, the application of CP bone substitute materials showed discernible benefits in geriatric patients, evident by decreased rates of pseudarthrosis (p = 0.059). Intermediate follow-up evaluations disclosed marked enhancements in fracture gap, edge, and articular surface conditions through the utilization of CP-based substitutes (p < 0.05). In conclusion, calcium phosphate-based bone substitute materials assert their clinical integrity by demonstrating safety in clinical applications. They substantiate an accelerated early osseous healing trajectory while concurrently decreasing the severity of complications within the bone substitute cohort. In vivo advantages were demonstrated for CP bone graft substitutes.

Incorporating the Antioxidant Fullerenol into Calcium Phosphate Bone Cements Increases Cellular Osteogenesis without Compromising Physical Cement Characteristics

Herein, fullerenol (Ful), a highly water-soluble derivative of C60 fullerene with demonstrated antioxidant activity, is incorporated into calcium phosphate cements (CPCs) to enhance their osteogenic ability. CPCs with added carboxymethyl cellulose/gelatin (CMC/Gel) are doped with biocompatible Ful particles at concentrations of 0.02, 0.04, and 0.1 wt v%-1 and evaluated for Ful-mediated mechanical performance, antioxidant activity, and in vitro cellular osteogenesis. CMC/gel cements with the highest Ful concentration decrease setting times due to increased hydrogen bonding from Ful's hydroxyl groups. In vitro studies of reactive oxygen species (ROS) scavenging with CMC/gel cements demonstrate potent antioxidant activity with Ful incorporation and cement scavenging capacity is highest for 0.02 and 0.04 wt v%-1 Ful. In vitro cytotoxicity studies reveal that 0.02 and 0.04 wt v%-1 Ful cements also protect cellular viability. Finally, increase of alkaline phosphatase (ALP) activity and expression of runt-related transcription factor 2 (Runx2) in MC3T3-E1 pre-osteoblast cells treated with low-dose Ful cements demonstrate Ful-mediated osteogenic differentiation. These results strongly indicate that the osteogenic abilities of Ful-loaded cements are correlated with their antioxidant activity levels. Overall, this study demonstrates exciting potential of Fullerenol as an antioxidant and proosteogenic additive for improving the performance of calcium phosphate cements in bone reconstruction procedures.

Biomaterials for stem cell engineering and biomanufacturing

Recent years have witnessed the expansion of tissue failures and diseases. The uprising of regenerative medicine converges the sight onto stem cell-biomaterial based therapy. Tissue engineering and regenerative medicine proposes the strategy of constructing spatially, mechanically, chemically and biologically designed biomaterials for stem cells to grow and differentiate. Therefore, this paper summarized the basic properties of embryonic stem cells (ESCs), induced pluripotent stem cells (iPSCs) and adult stem cells. The properties of frequently used biomaterials were also described in terms of natural and synthetic origins. Particularly, the combination of stem cells and biomaterials for tissue repair applications was reviewed in terms of nervous, cardiovascular, pancreatic, hematopoietic and musculoskeletal system. Finally, stem-cell-related biomanufacturing was envisioned and the novel biofabrication technologies were discussed, enlightening a promising route for the future advancement of large-scale stem cell-biomaterial based therapeutic manufacturing.

Honeycomb blocks composed of carbonate apatite, β-tricalcium phosphate, and hydroxyapatite for bone regeneration: effects of composition on biological responses

Synthetic scaffolds exhibiting bone repair ability equal to that of autogenous bone are required in the fields of orthopedics and dentistry. A suitable synthetic bone graft substitute should induce osteogenic differentiation of mesenchymal stem cells, osteogenesis, and angiogenesis. In this study, three types of honeycomb blocks (HCBs), composed of hydroxyapatite (HAp), β-tricalcium phosphate (TCP), and carbonate apatite (CO3Ap), were fabricated, and the effects of HCB composition on bone formation and maturation were investigated. The HC structure was selected to promote cell penetration and tissue ingrowth. HAp and β-TCP HCBs were fabricated by extrusion molding followed by sintering. The CO3Ap HCBs were fabricated by extrusion molding followed by sintering and dissolution-precipitation reactions. These HCBs had similar macroporous structures: all harbored uniformly distributed macropores (∼160 ​μm) that were regularly arrayed and penetrated the blocks unidirectionally. Moreover, the volumes of macropores were nearly equal (∼0.15 ​cm3/g). The compressive strengths of CO3Ap, HAp, and β-TCP HCBs were 22.8 ​± ​3.5, 34.2 ​± ​3.3, and 24.4 ​± ​2.4 ​MPa, respectively. Owing to the honeycomb-type macroporous structure, the compressive strengths of these HCBs were higher than those of commercial scaffolds with intricate three-dimensional or unidirectional macroporous structure. Notably, bone maturation was markedly faster in CO3Ap HCB grafting than in β-TCP and HAp HCB grafting, and the mature bone area percentages for CO3Ap HCBs at postsurgery weeks 4 and 12 were 14.3- and 4.3-fold higher and 7.5- and 1.4-fold higher than those for HAp and β-TCP HCBs, respectively. The differences in bone maturation and formation were probably caused by the disparity in concentrations of calcium ions surrounding the HCBs, which were dictated by the inherent material resorption behavior and mechanism; generally, CO3Ap is resorbed only by osteoclastic resorption, HAp is not resorbed, and β-TCP is rapidly dissolved even in the absence of osteoclasts. Besides the composition, the microporous structure of HC struts, inevitably generated during the formation of HCBs of various compositions, may contribute to the differences in bone maturation and formation.

Encapsulation of mesenchymal stem cells in chitosan/β-glycerophosphate hydrogel for seeding on a novel calcium phosphate cement scaffold

Due to its moldability, biocompatibility, osteoconductivity and resorbability, calcium phosphate cement (CPC) is a highly promising scaffold material for orthopedic applications. However, pH changes and ionic activity during the CPC setting reaction may adversely affect cells seeded directly on CPC. Moreover, a lack of macropores in CPC limits ingrowth of new bone. The objectives of this study were to prepare macroporous CPC scaffolds via porogen leaching, using mannitol crystals as the porogen and to evaluate the in vitro proliferation and osteogenic differentiation of mesenchymal stem cells (MSCs) encapsulated in chitosan/β-glycerophosphate (C/GP) hydrogel prior to exposure to the novel CPC scaffold. MSCs were found to be adhered to the surfaces of CPC macropores via scanning electron microscopy. The viability and osteogenic differentiation of MSCs in C/GP hydrogel with or without exposure to CPC constructs containing mannitol crystals indicated that coating with C/GP hydrogel protected the cells during cement mixing and setting. In conclusion, novel, macroporous CPC scaffolds were prepared, and our data indicate that a hydrogel encapsulation-based strategy can be used to protect cells during scaffold formation. Thus, the MSC-laden CPC scaffolds show promise for the delivery of stem cells to promote bone regeneration.

Addition of Wollastonite Fibers to Calcium Phosphate Cement Increases Cell Viability and Stimulates Differentiation of Osteoblast-Like Cells

Calcium phosphate cement (CPC) that is based on α-tricalcium phosphate (α-TCP) is considered desirable for bone tissue engineering because of its relatively rapid degradation properties. However, such cement is relatively weak, restricting its use to areas of low mechanical stress. Wollastonite fibers (WF) have been used to improve the mechanical strength of biomaterials. However, the biological properties of WF remain poorly understood. Here, we tested the response of osteoblast-like cells to being cultured on CPC reinforced with 5% of WF (CPC-WF). We found that both types of cement studied achieved an ion balance for calcium and phosphate after 3 days of immersion in culture medium and this allowed subsequent long-term cell culture. CPC-WF increased cell viability and stimulated cell differentiation, compared to nonreinforced CPC. We hypothesize that late silicon release by CPC-WF induces increased cell proliferation and differentiation. Based on our findings, we propose that CPC-WF is a promising material for bone tissue engineering applications.

Clinical experience with the artificial bone graft substitute Calcibon used following curettage of benign and low-grade malignant bone tumors

Artificial bone graft substitutes, such as Calcibon, are becoming increasingly interesting as they do not cause donor site morbidity which is an advantage compared to autologous bone grafts. The aim of this study was to evaluate the efficacy and potential complications associated with the use of Calcibon. Twenty-seven patients with benign and low-grade malignant bone tumors were treated with curettage and refilling of the bony cavity. Based on the radiological classification system of Neer, these lesions only comprised Grade I lesions, describing cysts that only require curettage and filling, but no additional treatment. At a mean follow up of six months we observed radiological consolidation without resorption of the bone graft substitute. These observations were also made at a mean follow-up of 13 and 32 months, respectively. According to the classification system of Goslings and Gouma we observed six surgical complications. Summing up, Calcibon seems to be a reliable bone graft substitute with low complication rates. However, delayed resorption should be expected. Calcibon seems to be an alternative to autologous bone grafts or allografts in adequate indications.

Preparation and characterization of calcium phosphate/pectin scaffolds for bone tissue engineering

A calcium phosphate cement (CPC) scaffold has been used to repair bone defects, but its low compressive strength and poor osteogenesis greatly hinder its clinical application.

A comparative morphometric analysis of biodegradable scaffolds as carriers for dental pulp and periosteal stem cells in a model of bone regeneration

Bone regeneration and bone fixation strategies in dentistry utilize scaffolds containing regenerating-competent cells as a replacement of the missing bone portions and gradually replaced by autologous tissues. Mesenchymal stem cells represent an ideal cell population for scaffold-based tissue engineering. Among them, dental pulp stem cells (DPSCs) and periosteal stem cells (PeSCs) have the potential to differentiate into a variety of cell types including osteocytes, suggesting that they can be used with this purpose. However, data on bone regeneration properties of these types of cells in scaffold-based tissue engineering are yet insufficient.In this study, we evaluated temporal dynamic bone regeneration (measured as a percentage of bone volume on the total area of the defect) induced by DPSCs or PeSCs when seeded with different scaffolds to fill critical calvarial defects in SCID Beige nude mice. Two commercially available scaffolds (granular deproteinized bovine bone with 10% porcine collagen and granular β;-tricalcium phosphate) and one not yet introduced on the market (a sponge of agarose and nanohydroxyapatite) were used. The results showed that tissue-engineered constructs did not significantly improve bone-induced regeneration process when compared with the effect of scaffolds alone. In addition, the data also showed that the regeneration induced by β;-tricalcium phosphate alone was higher after 8 weeks than that of scaffold seeded with the 2 stem cell lines. Altogether these findings suggest that further studies are needed to evaluate the potential of DPSCs and PeSCs in tissue construct and identify the appropriate conditions to generate bone tissue in critical-size defects.

Induced pluripotent stem cell-derived mesenchymal stem cell seeding on biofunctionalized calcium phosphate cements

Induced pluripotent stem cells (iPSCs) have great potential due to their proliferation and differentiation capability. The objectives of this study were to generate iPSC-derived mesenchymal stem cells (iPSC-MSCs), and investigate iPSC-MSC proliferati on and osteogenic differentiation on calcium phosphate cement (CPC) containing biofunctional agents for the first time. Human iPSCs were derived from marrow CD34+ cells which were reprogrammed by a single episomal vector. iPSCs were cultured to form embryoid bodies (EBs), and MSCs migrated out of EBs. Five biofunctional agents were incorporated into CPC: RGD (Arg-Gly-Asp) peptides, fibronectin (Fn), fibronectin-like engineered polymer protein (FEPP), extracellular matrix Geltrex, and platelet concentrate. iPSC-MSCs were seeded on five biofunctionalized CPCs: CPC-RGD, CPC-Fn, CPC-FEPP, CPC-Geltrex, and CPC-Platelets. iPSC-MSCs on biofunctional CPCs had enhanced proliferation, actin fiber expression, osteogenic differentiation and mineralization, compared to control. Cell proliferation was greatly increased on biofunctional CPCs. iPSC-MSCs underwent osteogenic differentiation with increased alkaline phosphatase, Runx2 and collagen-I expressions. Mineral synthesis by iPSC-MSCs on CPC-Platelets was 3-fold that of CPC control. In conclusion, iPSCs showed high potential for bone engineering. iPSC-MSCs on biofunctionalized CPCs had cell proliferation and bone mineralization that were much better than traditional CPC. iPSC-MSC-CPC constructs are promising to promote bone regeneration in craniofacial/orthopedic repairs.

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.

Micro-CT and PET analysis of bone regeneration induced by biodegradable scaffolds as carriers for dental pulp stem cells in a rat model of calvarial "critical size" defect: Preliminary data

Bone regeneration strategies in dentistry utilize biodegradable scaffolds seeded with stem cells able to induce bone formation. However, data on regeneration capacity of these tissue engineering constructs are still deficient. In this study micro-Computed tomography (micro-CT) and positron emission tomography (PET) analyses were used to investigate bone regeneration induced by two scaffolds [Granular deproteinized bovine bone (GDPB) and Beta-tricalcium phosphate (β-TCP)] used alone or in combination with dental pulp stem cells (DPSC) in a tissue engineered construct implanted in a rat critical calvarial defect. Bone mineral density (BMD) and standard uptake value (SUV) of tracer incorporation were measured after 2, 4, 8, and 12 weeks post-implant. The results showed that: (1) GDPB implants were mostly well positioned, as compared to ß-TCP; (2) GDPB induced higher BMD and SUV values within the cranial defect as compared to ß-TCP, either alone or in combination with stem cells; (3) addition of DPSC to the grafts did not significantly induce an increase in BMD and SUV values as compared to the scaffolds grafted alone, although a small tendency to increase was observed. Thus our study demonstrates that GDPB, when used to fill critical calvarial defects, induces a greater percentage of bone formation as compared to ß-TCP. Moreover, this study shows that addition of DPSC to pre-wetted scaffolds has the potential to ameliorate bone regeneration process, although the set of optimal conditions requires further investigation.

Injectable collagen/α-tricalcium phosphate cement: collagen-mineral phase interactions and cell response

A bone inspired material was obtained by incorporating collagen in the liquid phase of an α-tricalcium phosphate cement, either in solubilized or in fibrilized form. This material was able to set in situ, giving rise to a calcium deficient hydroxyapatite (CDHA)/collagen composite. The morphology and distribution of collagen in the composite was shown to be strongly affected by the collagen pre-treatment. The interactions between collagen and the inorganic phase were assessed by FTIR. A red shift of the amide I band was indicative of calcium chelation by the collagen carbonyl groups. The rate of CDHA formation was not affected when diluted collagen solutions (1 mg/ml) were used, whereas injectability improved. The presence of solubilized collagen, even in low amount (1 %), increased cell adhesion and proliferation on the composites. Still in the absence of osteogenic medium, significant ALP activity was detected both in the inorganic and the collagen-containing cements. The maximum ALP activity was advanced in the collagen-containing cement as compared to the inorganic cement.

Human embryonic stem cell-derived mesenchymal stem cell seeding on calcium phosphate cement-chitosan-RGD scaffold for bone repair

Calcium phosphate cement (CPC) has in situ-setting ability and excellent osteoconductivity. Human embryonic stem cells (hESCs) are exciting for regenerative medicine due to their strong proliferative ability and multilineage differentiation capability. However, there has been no report on hESC seeding with CPC. The objectives of this study were to obtain hESC-derived mesenchymal stem cells (hESCd-MSCs), and to investigate hESCd-MSC proliferation and osteogenic differentiation on novel CPC with chitosan immobilized with RGD (CPC-chitosan-RGD). RGD was covalently bonded with chitosan, which was then incorporated into CPC. The CPC-chitosan-RGD scaffold had higher strength and toughness than CPC-chitosan control without RGD (p<0.05). hESCs were cultured to form embryoid bodies (EBs), and the MSCs were then migrated out of the EBs. Flow cytometry indicated that the hESCd-MSCs expressed typical surface antigen profile of MSCs. hESCd-MSCs had good viability when seeded on CPC scaffolds. The percentage of live cells and the cell density were significantly higher on CPC-chitosan-RGD than CPC-chitosan control. Scanning electron microscope examination showed hESCd-MSCs with a healthy spreading morphology adherent to CPC. hESCd-MSCs expressed high levels of osteogenic markers, including alkaline phosphatase, osteocalcin, collagen I, and Runx2. The mineral synthesis by the hESCd-MSCs on the CPC-chitosan-RGD scaffold was twice that for CPC-chitosan control. In conclusion, hESCs were successfully seeded on CPC scaffolds for bone tissue engineering. The hESCd-MSCs had good viability and osteogenic differentiation on the novel CPC-chitosan-RGD scaffold. RGD incorporation improved the strength and toughness of CPC, and greatly enhanced the hESCd-MSC attachment, proliferation, and bone mineral synthesis. Therefore, the hESCd-MSC-seeded CPC-chitosan-RGD construct is promising to improve bone regeneration in orthopedic and craniofacial applications.

Biofunctionalized calcium phosphate cement to enhance the attachment and osteodifferentiation of stem cells released from fast-degradable alginate-fibrin microbeads

Stem cell-encapsulating microbeads could be mixed into a paste such as calcium phosphate cement (CPC), where the microbeads could protect the cells from the mixing and injection forces. After being placed, the microbeads could quickly degrade to release the cells throughout the scaffold, while creating macropores. The objectives of this study were to (1) construct alginate-fibrin microbeads encapsulating human umbilical cord mesenchymal stem cells (hUCMSCs) embedded in the surface of novel biofunctionalized CPC and (2) investigate microbead degradation, cell release, and osteodifferentiation on CPC. Hydrogel microbeads were fabricated that encapsulated hUCMSCs at 1×10(6) cells/mL. CPC was biofunctionalized with fibronectin (Fn) and Arg-Gly-Asp (RGD). Four scaffolds were tested: CPC control, CPC mixed with Fn, CPC mixed with RGD, and CPC grafted with RGD. The degradable microbeads released hUCMSCs at 7 days, which attached to CPC. Adding Fn or RGD to CPC greatly improved cell attachment. CPC grafted with RGD showed the fastest cell proliferation, with cell density being ninefold that on CPC control. The released hUCMSCs underwent osteodifferentiation. Alkaline phosphatase, osteocalcin, collagen 1, and runt-related transcription factor 2 (Runx2) gene expression increased by 10 to 30 fold at 7-21 days, compared with day 1. The released cells on CPC synthesized bone minerals, with the mineralization amount at 21 days being two orders of magnitude higher than that at 7 days. In conclusion, alginate-fibrin microbeads embedded in CPC surface were able to quickly release the hUCMSCs that attached to biofunctionalized CPC. Incorporating Fn and RGD into CPC greatly improved cell function, and CPC grafted with RGD had the fastest cell proliferation. The released cells on CPC differentiated into the osteogenic lineage and synthesized bone minerals. The new biofunctionalized CPC with hUCMSC-encapsulating microbeads is promising for bone regeneration applications.

Calcium phosphate cement with biofunctional agents and stem cell seeding for dental and craniofacial bone repair

OBJECTIVE

Calcium phosphate cement (CPC) can be injected to harden in situ and is promising for dental and craniofacial applications. However, human stem cell attachment to CPC is relatively poor. The objectives of this study were to incorporate biofunctional agents into CPC, and to investigate human umbilical cord mesenchymal stem cell (hUCMSC) seeding on biofunctionalized CPC for osteogenic differentiation for the first time.

METHODS

Five types of biofunctional agents were used: RGD (Arg-Gly-Asp) peptides, human fibronectin (Fn), fibronectin-like engineered polymer protein (FEPP), extracellular matrix Geltrex, and human platelet concentrate. Five biofunctionalized CPC scaffolds were fabricated: CPC-RGD, CPC-Fn, CPC-FEPP, CPC-Geltrex, and CPC-Platelets. The hUCMSC attachment, proliferation, osteogenic differentiation and mineral synthesis were measured.

RESULTS

The hUCMSCs on biofunctionalized CPCs had much better cell attachment, proliferation, actin fiber expression, osteogenic differentiation and mineral synthesis, compared to the traditional CPC control. Cell proliferation was increased by an order of magnitude via incorporation of biofunctional agents in CPC (p<0.05). Mineral synthesis on biofunctionalized CPCs was 3-5 folds of those of control (p<0.05). hUCMSCs differentiated with high alkaline phosphatase, Runx2, osteocalcin, and collagen I gene expressions. Mechanical properties of biofunctionalized CPC matched the reported strength and elastic modulus of cancellous bone.

SIGNIFICANCE

A new class of biofunctionalized CPCs was developed, including CPC-RGD, CPC-Fn, CPC-FEPP, CPC-Geltrex, and CPC-Platelets. hUCMSCs on biofunctionalized CPCs had cell density, cell proliferation, actin fiber density, and bone mineralization that were dramatically better than those on traditional CPC. Novel biofunctionalized CPC scaffolds with greatly enhanced human stem cell proliferation and differentiation are promising to facilitate bone regeneration in a wide range of dental, craniofacial and orthopedic applications.

Differential loading methods for BMP-2 within injectable calcium phosphate cement

Clinical application of calcium phosphate cement (CPC; with incorporated polymeric porogens) in an injectable form implicates that loading methods for growth factors are limited. In view of this, the current study evaluated the in vitro and in vivo release kinetics of bone morphogenetic protein-2 (BMP-2) loaded on poly(d,l-lactic-co-glycolic acid) (PLGA) microparticles (CPC/PLGA), BMP-2 incorporation into the liquid phase of CPC (CPC/liquid), and BMP-2 absorbed to the surface of preset, porous CPC (CPC/surface) as a control via an in vitro release experiment and in vivo using microSPECT imaging with (125)I-labeled BMP-2. In addition, the osteoinductive capacity of scaffolds generated via the different BMP-2 loading methods was assessed in a subcutaneous rat model. Additional controls consisted of porous CPC scaffolds (CPC/porous) and CPC/PLGA (CPC/control) without BMP-2 loading. The results revealed that it is feasible to load BMP-2 into CPC via adsorption to PLGA-microparticles or the liquid phase of CPC, which resulted in a similar release profile over the course of 28 days, despite distinct protein distribution patterns. Compared to CPC-scaffolds with surface-loaded BMP-2, these loading methods showed a similar release profile, except for a significantly decreased burst release. As such, the observed osteoinductive capacity for only CPC-scaffolds with surface-loaded BMP-2 is likely to be related to this difference in burst release. It remains unclear to what extent the differential BMP-2 loading methods for injectable CPC can affect the biological response in a bone environment.

Umbilical cord stem cells released from alginate-fibrin microbeads inside macroporous and biofunctionalized calcium phosphate cement for bone regeneration

The need for bone repair has increased as the population ages. The objectives of this study were to (1) develop a novel biofunctionalized and macroporous calcium phosphate cement (CPC) containing alginate-fibrin microbeads encapsulating human umbilical cord mesenchymal stem cells (hUCMSC) and, for the first time, (2) investigate hUCMSC proliferation and osteogenic differentiation inside the CPC. A macroporous CPC was developed using calcium phosphate powder, chitosan, and a gas-foaming porogen. Five types of CPC were fabricated: a CPC control, CPC+0.05% fibronectin (Fn), CPC+0.1% Fn, CPC+0.1% arginine-glycine-aspartate (RGD), and CPC+0.1% Fn+0.1% RGD. Alginate-fibrin microbeads containing 10(6) hUCMSC per ml were encapsulated in the CPC paste. After the CPC had set, the degradable microbeads released hUCMSC within it. The hUCMSC proliferated inside the CPC, with the cell density after 21 days being 4-fold that on day1. CPC+0.1% RGD had the highest cell density, which was 4-fold that of the CPC control. The released cells differentiated along the osteogenic lineage and synthesized bone mineral. The hUCMSC inside the CPC+0.1% RGD construct expressed the genes alkaline phosphatase, osteocalcin and collagen I, at twice the level of the CPC control. Mineral synthesis by hUCMSC inside the CPC+0.1% RGD construct was 2-fold that in the CPC control. RGD and Fn incorporation in the CPC did not compromise its strength, which matched the reported strength of cancellous bone. In conclusion, degradable microbeads released hUCMSC which proliferated, differentiated and synthesized minerals inside the macroporous CPC. The CPC with RGD greatly enhanced cell function. The novel biofunctionalized and macroporous CPC-microbead-hUCMSC construct is promising for bone tissue engineering applications.

Polymeric additives to enhance the functional properties of calcium phosphate cements

The vast majority of materials used in bone tissue engineering and regenerative medicine are based on calcium phosphates due to their similarity with the mineral phase of natural bone. Among them, calcium phosphate cements, which are composed of a powder and a liquid that are mixed to obtain a moldable paste, are widely used. These calcium phosphate cement pastes can be injected using minimally invasive surgery and adapt to the shape of the defect, resulting in an entangled network of calcium phosphate crystals. Adding an organic phase to the calcium phosphate cement formulation is a very powerful strategy to enhance some of the properties of these materials. Adding some water-soluble biocompatible polymers in the calcium phosphate cement liquid or powder phase improves physicochemical and mechanical properties, such as injectability, cohesion, and toughness. Moreover, adding specific polymers can enhance the biological response and the resorption rate of the material. The goal of this study is to overview the most relevant advances in this field, focusing on the different types of polymers that have been used to enhance specific calcium phosphate cement properties.

Novel soybean/gelatine-based bioactive and injectable hydroxyapatite foam: material properties and cell response

Despite their known osteoconductivity, clinical use of calcium phosphate cements is limited both by their relatively slow rate of resorption and by rheological properties incompatible with injectability. Bone in-growth and material resorption have been improved by the development of porous calcium phosphate cements. However, injectable formulations have so far only been obtained through the addition of relatively toxic surfactants. The present work describes the response of osteoblasts to a novel injectable foamed bone cement based on a composite formulation including the bioactive foaming agents soybean and gelatine. The foaming properties of both defatted soybean and gelatine gels were exploited to develop a self-hardening soy/gelatine/hydroxyapatite composite foam able to retain porosity upon injection. After setting, the foamed paste produced a calcium-deficient hydroxyapatite scaffold, showing good injectability and cohesion as well as interconnected porosity after injection. The intrinsic bioactivity of soybean and gelatine was shown to favour osteoblast adhesion and growth. These findings suggest that injectable, porous and bioactive calcium phosphate cements can be produced for bone regeneration through minimally invasive surgery.

Microstructure and biomechanical characteristics of bone substitutes for trauma and orthopaedic surgery

BACKGROUND

Many (artificial) bone substitute materials are currently available for use in orthopaedic trauma surgery. Objective data on their biological and biomechanical characteristics, which determine their clinical application, is mostly lacking. The aim of this study was to investigate structural and in vitro mechanical properties of nine bone substitute cements registered for use in orthopaedic trauma surgery in the Netherlands.

METHODS

Seven calcium phosphate cements (BoneSource®, Calcibon®, ChronOS®, Eurobone®, HydroSet™, Norian SRS®, and Ostim®), one calcium sulphate cement (MIIG® X3), and one bioactive glass cement (Cortoss®) were tested. Structural characteristics were measured by micro-CT scanning. Compression strength and stiffness were determined following unconfined compression tests.

RESULTS

Each bone substitute had unique characteristics. Mean total porosity ranged from 53% (Ostim®) to 0.5% (Norian SRS®). Mean pore size exceeded 100 μm only in Eurobone® and Cortoss® (162.2 ± 107.1 μm and 148.4 ± 70.6 μm, respectively). However, 230 μm pores were found in Calcibon®, Norian SRS®, HydroSet™, and MIIG® X3. Connectivity density ranged from 27/cm3 for HydroSet™ to 0.03/cm3 for Calcibon®. The ultimate compression strength was highest in Cortoss® (47.32 MPa) and lowest in Ostim® (0.24 MPa). Young's Modulus was highest in Calcibon® (790 MPa) and lowest in Ostim® (6 MPa).

CONCLUSIONS

The bone substitutes tested display a wide range in structural properties and compression strength, indicating that they will be suitable for different clinical indications. The data outlined here will help surgeons to select the most suitable products currently available for specific clinical indications.

Bone substitutes in the Netherlands - a systematic literature review

Autologous bone grafting is currently considered as the gold standard to restore bone defects. However, clinical benefit is not guaranteed and there is an associated 8-39% complication rate. This has resulted in the development of alternative (synthetic) bone substitutes. The aim of this systematic literature review was to provide a comprehensive overview of literature data of bone substitutes registered in the Netherlands for use in trauma and orthopedic surgery. Brand names of selected products were used as search terms in three available databases: Embase, PubMed and Cochrane. Manuscripts written in English, German or Dutch that reported on structural, biological or biomechanical properties of the pure product or on its use in trauma and orthopedic surgery were included. The primary search resulted in 475 manuscripts from PubMed, 653 from Embase and 10 from Cochrane. Of these, 218 met the final inclusion criteria. Of each product, structural, biological and biomechanical characteristics as well as their clinical indications in trauma and orthopedic surgery are provided. All included products possess osteoconductive properties but differ in resorption time and biomechanical properties. They have been used for a wide range of clinical applications; however, the overall level of clinical evidence is low. The requirements of an optimal bone substitute are related to the size and location of the defect. Calcium phosphate grafts have been used for most trauma and orthopedic surgery procedures. Calcium sulphates were mainly used to restore bone defects after tumour resection surgery but offer minimal structural support. Bioactive glass remains a potential alternative; however, its use has only been studied to a limited extent.

Umbilical cord stem cell seeding on fast-resorbable calcium phosphate bone cement

Tissue engineering offers immense promise for bone regeneration. Human umbilical cord mesenchymal stem cells (hUCMSCs) can be collected without invasive procedures required for bone marrow MSCs. The objective of this study was to investigate the physical properties and the differentiation capacity of hUCMSCs on calcium phosphate cement (CPC) scaffolds with improved dissolution/resorption rates. CPC consisted of tetracalcium phosphate and dicalcium phosphate anhydrous, with various tetracalcium phosphate/dicalcium phosphate anhydrous ratios. At 1/3 ratio, CPC had a dissolution rate 40% faster than CPC control at 1/1. The faster-resorbable CPC had strength and modulus similar to CPC control. Their strength and modulus exceeded the reported values for cancellous bone, and were much higher than those of hydrogels and injectable polymers for cell delivery. hUCMSCs attached to the nano-apatitic CPC and proliferated rapidly. hUCMSCs differentiated into the osteogenic lineage, with significant increases in alkaline phosphatase activity, osteocalcin, collagen I, and osterix gene expression. In conclusion, in this study we reported that hUCMSCs attaching to CPC with high dissolution/resorption rate showed excellent proliferation and osteogenic differentiation. hUCMSCs delivered via high-strength CPC have the potential to be an inexhaustible and low-cost alternative to the gold-standard human bone marrow mesenchymal stem cells. These results may broadly impact stem-cell-based tissue engineering.

Human bone marrow stem cell-encapsulating calcium phosphate scaffolds for bone repair

Due to its injectability and excellent osteoconductivity, calcium phosphate cement (CPC) is highly promising for orthopedic applications. However, a literature search revealed no report on human bone marrow mesenchymal stem cell (hBMSC) encapsulation in CPC for bone tissue engineering. The aim of this study was to encapsulate hBMSCs in alginate hydrogel beads and then incorporate them into CPC, CPC-chitosan and CPC-chitosan-fiber scaffolds. Chitosan and degradable fibers were used to mechanically reinforce the scaffolds. After 21 days, that the percentage of live cells and the cell density of hBMSCs inside CPC-based constructs matched those in alginate without CPC, indicating that the CPC setting reaction did not harm the hBMSCs. Alkaline phosphate activity increased by 8-fold after 14 days. Mineral staining, scanning electron microscopy and X-ray diffraction confirmed that apatitic mineral was deposited by the cells. The amount of hBMSC-synthesized mineral in CPC-chitosan-fiber matched that in CPC without chitosan and fibers. Hence, adding chitosan and fibers, which reinforced the CPC, did not compromise hBMSC osteodifferentiation and mineral synthesis. In conclusion, hBMSCs were encapsulated in CPC and CPC-chitosan-fiber scaffolds for the first time. The encapsulated cells remained viable, osteodifferentiated and synthesized bone minerals. These self-setting, hBMSC-encapsulating CPC-based constructs may be promising for bone tissue engineering applications.

Osteogenic differentiation and immune response of human bone-marrow-derived mesenchymal stem cells on injectable calcium-silicate-based bone grafts

Calcium silicate cement (CSC) is biocompatible and possesses in vitro bioactivity. The aim of this study was to improve the handling and enhance osteogenic and immune properties of CSC by the addition of adjuvants to modify the cement. Human bone-marrow-derived mesenchymal stem cells were used to study the osteogenic behavior and immune response of cells on hybrid cements with added gelatin (GLT) and chitosan oligosaccharides (COS), which are analogs of the extracellular matrix components collagen and glycosaminoglycan, respectively. The addition of COS to the liquid phase slightly prolonged the setting time of CSC, whereas GLT in the solid phase significantly (p < 0.05) extended the hydration reaction. However, the addition of GLT appreciably improved the injectability of CSC, compared to COS. Cell viability was higher on CSC-COS than on the CSC control or on CSC-GLT at all culture times. The hybrid bone cements elicited less immune response than the CSC control. Additionally, COS inhibited expression of inducible nitric oxide synthase and interleukin-1 and activated interleukin-10 more effectively than GLT. Osteocalcin production and bone sialoprotein production were higher, and more calcium was detected in human bone-marrow-derived mesenchymal stem cells cultured on a CSC-GLT-COS surface than on CSC, CSC-GLT, or CSC-COS. These synergistic improvements in injectability, immune response, and osteogenesis suggest that the combination of bioactive calcium silicate, GLT, and COS has potential for use in clinical applications.

N-acetyl cysteine improves affinity of beta-tricalcium phosphate granules for cultured osteoblast-like cells

Enhancement of bone substitute's biocompatibility may accelerate healing of surrounding bone. Although widely used as a biodegradable alloplastic bone substitute for alveolar bone augmentation, the osteocompatibility of beta-tricalcium phosphate (β-TCP) remains to be proven. The adverse cellular response to biomaterials is associated with oxidative stress. We hypothesized that commercially available β-TCP granules for clinical use, caused oxidative stress and was not optimal in osteocompatibility and that application of antioxidant amino acid derivative N-acetyl cysteine (NAC) would improve osteoblastic responses to the material. Only 20% of rat calvarial osteoblasts cultured on β-TCP granules remained viable at 24 h after seeding as opposed to 90% on polystyrene. Cell death on β-TCP granules was characterized by necrosis. However, the percentage of viable osteoblasts cultured on β-TCP granules showed a 100% increase with pre-treatment with NAC. NAC restored suppressed alkaline phosphatase activity on β-TCP granules at day 5. Intracellular ROS level on β-TCP granules was 16-fold greater than that on polystyrene, but decreased by half with pre-treatment with NAC. Cell death and intracellular ROS elevation were also induced in polystyrene culture under β-TCP granules even when the osteoblasts were not in direct contact with the β-TCP granules. NAC, however, prevented induction of cell death and elevation of intracellular ROS under β-TCP granules. These results indicate that commercially available β-TCP granules negatively affect cultured osteoblastic viability and function via oxidative stress and that NAC improves these negative responses to the material. This implies enhanced bone regeneration around biodegradable calcium phosphate-based bone substitute by NAC.

The performance of dental pulp stem cells on nanofibrous PCL/gelatin/nHA scaffolds

The aim of current study is to investigate the in vitro and in vivo behavior of dental pulp stem cells (DPSCs) seeded on electrospun poly(epsilon-caprolactone) (PCL)/gelatin scaffolds with or without the addition of nano-hydroxyapatite (nHA). For the in vitro evaluation, DNA content, alkaline phosphatase (ALP) activity and osteocalcin (OC) measurement showed that the scaffolds supported DPSC adhesion, proliferation, and odontoblastic differentiation. Moreover, the presence of nHA upregulated ALP activity and promoted OC expression. Real-time PCR data confirmed these results. SEM micrographs qualitatively confirmed the proliferation and mineralization characteristics of DPSCs on both scaffolds. Subsequently, both scaffolds seeded with DPSCs were subcutaneously implanted into immunocompromised nude mice. Scaffolds with nHA but without cells were implanted as control. Histological evaluation revealed that all implants were surrounded by a thin fibrous tissue capsule without any adverse effects. The cell/scaffold composites showed obvious in vivo hard tissue formation, but there was no sign of tissue ingrowth. Further, the combination of nHA in scaffolds did upregulate the expression of specific odontogenic genes. In conclusion, the incorporation of nHA in nanofibers indeed enhanced DPSCs differentiation towards an odontoblast-like phenotype in vitro and in vivo.

Calcium Orthophosphate Cements and Concretes

In early 1980s, researchers discovered self-setting calcium orthophosphate cements, which are a bioactive and biodegradable grafting material in the form of a powder and a liquid. Both phases form after mixing a viscous paste that after being implanted, sets and hardens within the body as either a non-stoichiometric calcium deficient hydroxyapatite (CDHA) or brushite, sometimes blended with unreacted particles and other phases. As both CDHA and brushite are remarkably biocompartible and bioresorbable (therefore, in vivo they can be replaced with newly forming bone), calcium orthophosphate cements represent a good correction technique for non-weight-bearing bone fractures or defects and appear to be very promising materials for bone grafting applications. Besides, these cements possess an excellent osteoconductivity, molding capabilities and easy manipulation. Furthermore, reinforced cement formulations are available, which in a certain sense might be described as calcium orthophosphate concretes. The concepts established by calcium orthophosphate cement pioneers in the early 1980s were used as a platform to initiate a new generation of bone substitute materials for commercialization. Since then, advances have been made in the composition, performance and manufacturing; several beneficial formulations have already been introduced as a result. Many other compositions are in experimental stages. In this review, an insight into calcium orthophosphate cements and concretes, as excellent biomaterials suitable for both dental and bone grafting application, has been provided.

Ceramic composites as matrices and scaffolds for drug delivery in tissue engineering

Ceramic composites and scaffolds are popular implant materials in the field of dentistry, orthopedics and plastic surgery. For bone tissue engineering especially CaP-ceramics or cements and bioactive glass are suitable implant materials due to their osteoconductive properties. In this review the applicability of these ceramics but also of ceramic/polymer composites for bone tissue engineering is discussed, and in particular their use as drug delivery systems. Overall, the high density and slow biodegradability of ceramics is not beneficial for tissue engineering purposes. To address these issues, macroporosity can be introduced often in combination with osteoinductive growth factors and cells. Ceramics are good carriers for drugs, in which release patterns are strongly dependent on the chemical consistency of the ceramic, type of drug and drug loading. Biodegradable polymers like polylactic acid, gelatin or chitosan are used as matrices for ceramic particles or as adjuvant to calcium phosphate cements. The use of these polymers can introduce a tailored biodegradation/drug release to the ceramic material.