Vertebroplasty by use of a strontium-containing bioactive bone cement

Surface functionalized bioceramics coated on metallic implants for biomedical and anticorrosion performance - a review

In modern days, the usage of trauma fixation devices has significantly increased due to sports injury, age-related issues, accidents, and revision surgery purposes. Numerous materials such as stainless steel, titanium, Co-Cr alloy, polymers, and ceramics have been used to replace the missing or defective parts of the human body. After implantation, body fluids (Na⁺, K⁺, and Cl^-), protein, and blood cells interact with the surface of metallic implants, which favours the release of ions from the metallic surface to surrounding body tissues, leading to a hypersensitive reaction. Body pH, temperature, and interaction of immune cells also cause metal ion leaching and lose host cell interaction and effective mineralization for better durability. Moreover, microbial invasion is another important crisis, which produces extracellular compounds onto the biomaterial surface through which it escapes from the antimicrobial agents. To enhance the performance of materials by improving mechanical, corrosion resistance, antimicrobial, and biocompatibility properties, surface modification is a prerequisite method in which chemical vapour deposition (CVD), physical vapour deposition (PVD), sol-gel method, and electrochemical deposition are generally involved. The properties of bioceramics such as chemical inertness, bioactivity, biocompatibility, and corrosion protection make them most suitable for the surface functionalization of metallic implants. To the best of our knowledge, very limited literature is available to discuss the interaction of body proteins, pH, and temperature onto bioceramic coatings. Hence, the present review focuses on the corrosion behaviour of different ceramic composite coating materials with different conditions. This review initially briefs the properties and surface chemistry of metal implants and the need for surface modifications by different deposition techniques. Further, mechanical, cytotoxicity, antimicrobial property, and electrochemical behaviour of ceramics and metal nitride coatings are discussed. Finally, future perspectives of coatings are outlined for biomedical applications.

The Influence of Strontium on Bone Tissue Metabolism and Its Application in Osteoporosis Treatment

Osteoporosis is a chronic disease characterized by low bone mass caused by increased bone turnover and impaired bone microarchitecture. In treatment, we use antiresorptive or anabolic drugs, which usually have a unidirectional effect, i.e., they inhibit the activity of osteoclasts or stimulate the effect of osteoblasts. Strontium ranelate is an anti-osteoporosis drug with a unique mechanism of action (used primarily in postmenopausal women). Unlike other medicines, it has a multidirectional effect on bone tissue, intensifying osteoblastogenesis while inhibiting osteoclastogenesis. It turns out that this effect is demonstrated by strontium ions, an element showing physical and chemical similarity to calcium, the basic element that builds the mineral fraction of bone. As a result, strontium acts through the calcium-sensing receptor (CaSR) receptor in bone tissue cells. In recent years, there has been a significant increase in interest in the introduction of strontium ions in place of calcium ions in ceramics used as bone replacement materials for the treatment of bone fractures and defects caused by osteoporosis. The aim of this study was to summarize current knowledge about the role of strontium in the treatment of osteoporosis, its effects (in various forms), and the ways in which it is administered.

Osteogenic effect of polymethyl methacrylate bone cement with surface modification of lactoferrin

Polymethyl methacrylate (PMMA) bone cement is a commonly used filling material in orthopedic surgery. Its good and stable performances make it the most widely used in all kinds of bone cement. With the advancement of the application and research of PMMA bone cement by surgeons, its disadvantages such as non-degradation and non-bioactivity are gradually exposed. In recent years, the biological functions of lactoferrin (LF) have been gradually explored, especially its role in promoting osteogenesis. In this study, LF was modified on the surface of solidified PMMA bone cement (LF/PMMA bone cement) by physical/chemical mixed modification and verified by cytological experiments in vitro. In vitro studies have implicated that PMMA bone cement modified with LF can improve the attachment, expansion, proliferation, extracellular matrix secretion and osteogenic differentiation of mouse preosteoblasts (MC3T3-E1) cells, indicating biocompatibility. This experiment provides a novel insight for improving the biological activity of PMMA bone cement and lays a foundation for broadening the clinical application of PMMA bone cement.

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.

A review of the latest insights into the mechanism of action of strontium in bone

Interest in strontium (Sr) has persisted over the last three decades due to its unique mechanism of action: it simultaneously promotes osteoblast function and inhibits osteoclast function. While this mechanism of action is strongly supported by in vitro studies and small animal trials, recent large-scale clinical trials have demonstrated that orally administered strontium ranelate (SrRan) may have no anabolic effect on bone formation in humans. Yet, there is a strong correlation between Sr accumulation in bone and reduced fracture risk in post-menopausal women, suggesting Sr acts via a purely physiochemical mechanism to enhance bone strength. Conversely, the local administration of Sr with the use of modified biomaterials has been shown to enhance bone growth, osseointegration and bone healing at the bone-implant interface, to a greater degree than Sr-free materials. This review summarizes current knowledge of the main cellular and physiochemical mechanisms that underly Sr's effect in bone, which center around Sr's similarity to calcium (Ca). We will also summarize the main controversies in Sr research which cast doubt on the 'dual-acting mechanism'. Lastly, we will explore the effects of Sr-modified bone-implant materials both in vitro and in vivo, examining whether Sr may act via an alternate mechanism when administered locally.

Multiple and Promising Applications of Strontium (Sr)-Containing Bioactive Glasses in Bone Tissue Engineering

Improving and accelerating bone repair still are partially unmet needs in bone regenerative therapies. In this regard, strontium (Sr)-containing bioactive glasses (BGs) are highly-promising materials to tackle this challenge. The positive impacts of Sr on the osteogenesis makes it routinely used in the form of strontium ranelate (SR) in the clinical setting, especially for patients suffering from osteoporosis. Therefore, a large number of silicate-, borate-, and phosphate-based BGs doped with Sr and produced in different shapes have been developed and characterized, in order to be used in the most advanced therapeutic strategies designed for the management of bone defects and injuries. Although the influence of Sr incorporation in the glass is debated regarding the obtained physicochemical and mechanical properties, the biological improvements have been found to be substantial both in vitro and in vivo. In the present study, we provide a comprehensive overview of Sr-containing glasses along with the current state of their clinical use. For this purpose, different types of Sr-doped BG systems are described, including composites, coatings and porous scaffolds, and their applications are discussed in the light of existing experimental data along with the significant challenges ahead.

Augmentation of a Locking Plate System Using Bioactive Bone Cement-Experiment in a Proximal Humeral Fracture Model

Introduction:

The purpose of this study was to test whether local filling of a novel strontium-containing hydroxyapatite (Sr-HA) bone cement can augment the fixation of a locking plate system in a cadaveric proximal humeral facture model.

Materials and Methods:

Twelve pairs of formalin-treated cadaveric humeri were used. One side in each pair was for cemented group, while the other side was for the control group. The bone mineral density (BMD) of the samples was tested. A 3-part facture model was created and then reduced and fixed by a locking plate system. In the cemented group, the most proximal 4 screw holes were filled with 0.5 mL bone cement. In the control group, the screw holes were not filled by cement. Locking screws were inserted in a standard manner before the cement hardened. X-ray was taken before all the specimens being subjected to mechanical study, in which 6 pairs were used for axial loading (varus bending) test, while other 6 pairs were used for axial rotational test.

Results:

There is no difference in BMD between the cemented side and the control side. The X-ray shows that the implant is in position. Cement filling was noted in the most proximal 4 screws in the cemented group. Better mechanical outcome was seen in the cemented groups, in terms of less maximal displacement per cycle and higher failure point and stiffness in varus bending test. However, no difference was found between the cemented group and the control group in the axial rotation test.

Discussion:

In similarity with the previous studies, our results showed better mechanical results in the cemented group. However, due to the limitations (e.g. sample size, fracture model, testing protocol, etc), we still cannot directly extrapolate current mechanical results to clinical practice at the present moment. Furthermore, it is still unknown whether better primary outcome may lead to better long-term results, even though the local release of strontium may enhance the local bone formation.

Conclusion:

The local filling of Sr-HA bone cement augments the fixation of the locking plate system in current proximal humeral fracture model.

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.

The Feasibility and Functional Performance of Ternary Borate-Filled Hydrophilic Bone Cements: Targeting Therapeutic Release Thresholds for Strontium

We examine the feasibility and functionality of hydrophilic modifications to a borate glass reinforced resin composite; with the objective of meeting and maintaining therapeutic thresholds for Sr release over time, as a potential method of incorporating antiosteoporotic therapy into a vertebroplasty material. Fifteen composites were formulated with the hydrophilic agent hydroxyl ethyl methacrylate (HEMA, 15, 22.5, 30, 37.5 or 45 wt% of resin phase) and filled with a borate glass (55, 60 or 65 wt% of total cement) with known Sr release characteristics. Cements were examined with respect to degree of cure, water sorption, Sr release, and biaxial flexural strength over 60 days of incubation in phosphate buffered saline. While water sorption and glass degradation increased with increasing HEMA content, Sr release peaked with the 30% HEMA compositions, scanning electron microscope (SEM) imaging confirmed the surface precipitation of a Sr phosphate compound. Biaxial flexural strengths ranged between 16 and 44 MPa, decreasing with increased HEMA content. Degree of cure increased with HEMA content (42 to 81%), while no significant effect was seen on setting times (209 to 263 s). High HEMA content may provide a method of increasing monomer conversion without effect on setting reaction, providing sustained mechanical strength over 60 days.

Controlled release of strontium through neutralization reaction within a methoxy(polyethylene glycol)-polyester hydrogel

BACKGROUND

The aim of this study was to develop a minimally invasive hydrogel system that can release strontium ions, an element that has been shown to increase osteoblast proliferation and prohibit bone resorption, in a controlled manner.

METHODS

SrCO3 was selected as the salt of choice due to potential acid neutralization reaction between SrCO3 and degradation by-products of methoxy(polyethylene glycol)-co-poly(lactic-co-glycolic acid) (mPEG-PLGA): namely, lactic acid and glycolic acid. SrCO3 was incorporated into mPEG-PLGA hydrogel, and the system was assessed for gelation properties, drug release and biocompatibility.

RESULTS

SrCO3 incorporation at hydrogel to SrCO3 ratios of 5:1, 3:1 and 1:1 (wt%) did not compromise the thermosensitivity of mPEG-PLGA hydrogels. Furthermore, incorporation of SrCO3 at 1:1 ratio prevented copolymer self-catalysis and decreased hydrogel weight loss from 85% to 61% in vitro after 30 days. During the 30-day time frame, zero-order strontium release was observed and was correlated to hydrogel degradation and acidity. The addition of SrCO3 also improved in vivo hydrogel biocompatibility, due to moderation of acidic microenvironment and amelioration of inflammatory response.

CONCLUSIONS

These results showed that the described system is suitable for the extended release of strontium and exhibits potential for localized treatment for osteoporosis or as a bone void filler.

Enzymatic Dissolution of Biocomposite Solids Consisting of Phosphopeptides to Form Supramolecular Hydrogels

Enzyme-catalyzed dephosphorylation is essential for biomineralization and bone metabolism. Here we report the exploration of using enzymatic reaction to transform biocomposites of phosphopeptides and calcium (or strontium) ions to supramolecular hydrogels as a mimic of enzymatic dissolution of biominerals. (31) P NMR shows that strong affinity between the phosphopeptides and alkaline metal ions (e.g., Ca(2+) or Sr(2+) ) induces the formation of biocomposites as precipitates. Electron microscopy reveals that the enzymatic reaction regulates the morphological transition from particles to nanofibers. Rheology confirms the formation of a rigid hydrogel. As the first example of enzyme-instructed dissolution of a solid to form supramolecular nanofibers/hydrogels, this work provides an approach to generate soft materials with desired properties, expands the application of supramolecular hydrogelators, and offers insights to control the demineralization of calcified soft tissues.

Evaluation of injectable strontium-containing borate bioactive glass cement with enhanced osteogenic capacity in a critical-sized rabbit femoral condyle defect model

The development of a new generation of injectable bone cements that are bioactive and have enhanced osteogenic capacity for rapid osseointegration is receiving considerable interest. In this study, a novel injectable cement (designated Sr-BBG) composed of strontium-doped borate bioactive glass particles and a chitosan-based bonding phase was prepared and evaluated in vitro and in vivo. The bioactive glass provided the benefits of bioactivity, conversion to hydroxyapatite, and the ability to stimulate osteogenesis, while the chitosan provided a cohesive biocompatible and biodegradable bonding phase. The Sr-BBG cement showed the ability to set in situ (initial setting time = 11.6 ± 1.2 min) and a compressive strength of 19 ± 1 MPa. The Sr-BBG cement enhanced the proliferation and osteogenic differentiation of human bone marrow-derived mesenchymal stem cells in vitro when compared to a similar cement (BBG) composed of chitosan-bonded borate bioactive glass particles without Sr. Microcomputed tomography and histology of critical-sized rabbit femoral condyle defects implanted with the cements showed the osteogenic capacity of the Sr-BBG cement. New bone was observed at different distances from the Sr-BBG implants within eight weeks. The bone-implant contact index was significantly higher for the Sr-BBG implant than it was for the BBG implant. Together, the results indicate that this Sr-BBG cement is a promising implant for healing irregularly shaped bone defects using minimally invasive surgery.

In vitro and in vivo studies on biodegradable CaMgZnSrYb high-entropy bulk metallic glass

In order to enhance the corrosion resistance of the Ca65Mg15Zn20 bulk metallic glass, which has too fast a degradation rate for biomedical applications, we fabricated the Ca20Mg20Zn20Sr20Yb20 high-entropy bulk metallic glass because of the unique properties of high-entropy alloys. Our results showed that the mechanical properties and corrosion behavior were enhanced. The in vitro tests showed that the Ca20Mg20Zn20Sr20Yb20 high-entropy bulk metallic glass could stimulate the proliferation and differentiation of cultured osteoblasts. The in vivo animal tests showed that the Ca20Mg20Zn20Sr20Yb20 high-entropy bulk metallic glass did not show any obvious degradation after 4 weeks of implantation, and they can promote osteogenesis and new bone formation after 2 weeks of implantation. The improved mechanical properties and corrosion behavior can be attributed to the different chemical composition as well as the formation of a unique high-entropy atomic structure with a maximum degree of disorder.

Current status of percutaneous vertebroplasty and percutaneous kyphoplasty--a review

Percutaneous vertebroplasty (PV) and kyphoplasty (PK) are the 2vertebral augmentation procedures that have emerged as minimally invasive surgical options to treat painful vertebral compression fractures (VCF) during the last 2 decades. VCF may either be osteoporotic or tumor-associated. Two hundred million women are affected by osteoporosis globally. Vertebral fracture may result in acute pain around the fracture site, loss of vertebral height due to vertebral collapse, spinal instability, and kyphotic deformity. The main goal of the PV and PK procedures is to give immediate pain relief to patients and restore the vertebral height lost due to fracture. In percutaneous vertebroplasty, bone cement is injected through a minimal incision into the fractured site. Kyphoplasty involves insertion of a balloon into the fractured site, followed by inflation-deflation to create a cavity into which the filler material is injected, and the balloon is taken out prior to cement injection. This literature review presents a qualitative overview on the current status of vertebral augmentation procedures,especially PV and PK, and compares the efficacy and safety of these 2 procedures. The review consists of a brief history of the development of these 2 techniques, a discussion on the current research on the bone cement, clinical outcome of the 2 procedures, and it also sheds light on ongoing and future research to maximize the efficacy and safety of vertebral augmentation procedures.

Traumatic burst fracture with spinal channel involvement augmentation with bioactive strontium-hydroxyapatite cement

In November 2011 a 75-year-old man was admitted to our emergency department with a low back pain caused by a traumatic L1 vertebral collapse with backward projection of posterior wall superior third. The indication for neurosurgical instrumentation was placed, although he refused the treatment. Hence he was treated conservatively without a significant improvement up to January 2012 when, still refusing surgery, he accepted to undergo percutaneous vertebroplasty with a novel bioactive injectable strontium-hydroxyapatite cement. Vertebroplasty was performed without complications. A CT scan, performed the day after the procedure, ruled out extravertebral cement leakage. Pain improvement was significant (preprocedure VAS 10, one-week VAS 4) with a gradual decrease up to three months when it stabilized at 2. CT examination after 1 year showed a good cement osseointegration with osteophytic spurs bridging the superior endplate of the level involved to the inferior one of the level above. The new bone ingrowing property of the strontium-hydroxyapatite containing cement permits to extend the treatment indication also to unstable collapses in which the risk of pseudoarthrosis is very high. In this reported case we evaluated the potential role of percutaneous vertebroplasty in traumatic burst fracture with spinal channel involvement.

Use of a strontium-enriched calcium phosphate cement in accelerating the healing of soft-tissue tendon graft within the bone tunnel in a rabbit model of anterior cruciate ligament reconstruction

We investigated whether strontium-enriched calcium phosphate cement (Sr-CPC)-treated soft-tissue tendon graft results in accelerated healing within the bone tunnel in reconstruction of the anterior cruciate ligament (ACL). A total of 30 single-bundle ACL reconstructions using tendo Achillis allograft were performed in 15 rabbits. The graft on the tested limb was treated with Sr-CPC, whereas that on the contralateral limb was untreated and served as a control. At timepoints three, six, nine, 12 and 24 weeks after surgery, three animals were killed for histological examination. At six weeks, the graft–bone interface in the control group was filled in with fibrovascular tissue. However, the gap in the Sr-CPC group had already been completely filled in with new bone, and there was evidence of the early formation of Sharpey fibres. At 24 weeks, remodelling into a normal ACL–bone-like insertion was found in the Sr-CPC group. Coating of Sr-CPC on soft tissue tendon allograft leads to accelerated graft healing within the bone tunnel in a rabbit model of ACL reconstruction using Achilles tendon allograft.

Cite this article: Bone Joint J 2013;95-B:923–8.

Strontium enhances osseointegration of calcium phosphate cement: a histomorphometric pilot study in ovariectomized rats

BACKGROUND

Calcium phosphate cements are used frequently in orthopedic and dental surgeries. Strontium-containing drugs serve as systemic osteoblast-activating medication in various clinical settings promoting mechanical stability of the osteoporotic bone.

METHODS

Strontium-containing calcium phosphate cement (SPC) and calcium phosphate cement (CPC) were compared regarding their local and systemic effects on bone tissue in a standard animal model for osteoporotic bone. A bone defect was created in the distal femoral metaphysis of 60 ovariectomized Sprague-Dawley rats. CPC and SPC were used to fill the defects in 30 rats in each group. Local effects were assessed by histomorphometry at the implant site. Systemic effects were assessed by bone mineral density (BMD) measurements at the contralateral femur and the spine.

RESULTS

Faster osseointegration and more new bone formation were found for SPC as compared to CPC implant sites. SPC implants exhibited more cracks than CPC implants, allowing more bone formation within the implant. Contralateral femur BMD and spine BMD did not differ significantly between the groups.

CONCLUSIONS

The addition of strontium to calcium phosphate stimulates bone formation in and around the implant. Systemic release of strontium from the SPC implants did not lead to sufficiently high serum strontium levels to induce significant systemic effects on bone mass in this rat model.

Physicochemical properties and cellular responses of strontium-doped gypsum biomaterials

This paper describes some physical, structural, and biological properties of gypsum bioceramics doped with various amounts of strontium ions (0.19-2.23 wt%) and compares these properties with those of a pure gypsum as control. Strontium-doped gypsum (gypsum:Sr) was obtained by mixing calcium sulfate hemihydrate powder and solutions of strontium nitrate followed by washing the specimens with distilled water to remove residual salts. Gypsum was the only phase found in the composition of both pure and gypsum:Sr, meanwhile a shift into lower diffraction angles was observed in the X-ray diffraction patterns of doped specimens. Microstructure of all gypsum specimens consisted of many rod-like small crystals entangled to each other with more elongation and higher thickness in the case of gypsum:Sr. The Sr-doped sample exhibited higher compressive strength and lower solubility than pure gypsum. A continuous release of strontium ions was observed from the gypsum:Sr during soaking it in simulated body fluid for 14 days. Compared to pure gypsum, the osteoblasts cultured on strontium-doped samples showed better proliferation rate and higher alkaline phosphatase activity, depending on Sr concentration. These observations can predict better in vivo behavior of strontium-doped gypsum compared to pure one.

Gentamicin-loaded strontium-containing hydroxyapatite bioactive bone cement--an efficient bioactive antibiotic drug delivery system

Modified strontium-containing hydroxyapatite (Sr-HA) bone cement was loaded with gentamicin sulfate to generate an efficient bioactive antibiotic drug delivery system for treatment of bone defects. Gentamicin release and its antibacterial property were determined by fluorometric method and inhibition of Staphylococcus aureus (S. aureus) growth. Gentamicin was released from Sr-HA bone cement during the entire period of study and reached around 38% (w/w) cumulatively after 30 days. Antibacterial activity of the gentamicin loaded in the cements is clearly confirmed by the growth inhibition of S. aureus. The results of the amount and duration of gentamicin release suggest a better drug delivery efficiency in Sr-HA bone cement over polymethylmethacrylate bone cement. Bioactivity of the gentamicin-loaded Sr-HA bone cement was confirmed with the formation of apatite layer with 1.836 ± 0.037 μm thick on day 1 and 5.177 ± 1.355 μm thick on day 7 after immersion in simulated body fluid. Compressive strengths of the gentamicin-loaded Sr-HA cement reached 132.60 ± 10.08 MPa, with a slight decrease from the unloaded groups by 4-9%. Bending moduli of Sr-HA cements with and without gentamicin were 1.782 ± 0.072 GPa and 1.681 ± 0.208 GPa, respectively. On the contrary, unloaded Sr-HA cement obtained slightly larger bending strength of 35.48 ± 2.63 MPa comparing with 33.00 ± 1.65 MPa for loaded cement. No statistical difference was found on the bending strengths and modulus of gentamicin-loaded and -unloaded Sr-HA cements. Sr-HA bone cement loaded with gentamicin was proven to be an efficient drug delivery system with uncompromised mechanical properties and bioactivity.

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.

Vertebroplasty with self-locking hexagonal metal implants shows comparable primary and secondary stiffness to PMMA cement augmentation techniques in a biomechanical vertebral compression fracture model

With the growing incidence of vertebral compression fractures in elderly patients having a fair overall health condition, minimal-invasive treatment techniques are getting in focus of surgical therapy. Cement augmentation is widely performed and its complications and mechanical limitations are well described. Implants avoiding the side effects of cement augmentation while reaching the same level of stability would be desirable. The primary and secondary stability of a new augmentation method with self-locking hexagonal metal implants were investigated and compared with the performance of established augmentation options. 18 fresh-frozen human spinal specimens (Th12-L2/L3-L5) were tested with pure moments of 7.5 Nm in a six-degree-of-freedom spine simulator to investigate primary and secondary stability of three augmentation techniques: (1) vertebroplasty, (2) PMMA filled cavity and (3) hexagonal metal implants. An increasing three-step cyclic loading model was included. Elastic displacement and height loss under loading did not show significant differences between the three test groups. Investigation of primary and secondary stability evenly demonstrated comparable results for all techniques indicating an insufficiency to stabilise the fracture with higher load cycles. The newly introduced method for augmentation with the metal implant Spine Pearls achieved comparable results to bone cement based techniques in a biomechanical in vitro study. Midterm and longterm reduction preservation and ingrowth of the implants have to be proven in further studies.

Adjacent vertebral body fracture following vertebroplasty with polymethylmethacrylate or calcium phosphate cement: biomechanical evaluation of the cadaveric spine

STUDY DESIGN

A biomechanical study using human cadaveric thoracolumbar spinal columns.

OBJECTIVE

To compare the effect of treatment by vertebroplasty (VP) with polymethylmethacrylate cement and VP with calcium phosphate cement on the creation of adjacent vertebral body fracture following VP.

SUMMARY OF BACKGROUND DATA

Adjacent vertebral body fractures have been reported as a complication following VP.

METHODS

Twenty-four spinal columns (T10-L2) from human cadavers were subjected to dual energy radiograph absorptiometry to assess bone mineral density. They were divided into the P group and C group, and experimental vertebral compression fractures were created at T12 vertebrae. T12 vertebrae were augmented with polymethylmethacrylate and calcium phosphate cement in the P group and C group, respectively. Each spinal column was compressed until a new fracture occurred at any vertebra, and the location of newly fractured vertebra and failure load was investigated.

RESULTS

There was no significant difference in bone mineral density at each level within each group. In the P group, a new fracture occurred at T10 in 2 specimens, T11 in 8, and L1 in 2. In the C group, it occurred at T10 in 1 specimen, T11 in 2, L1 in 1, and T12 (treated vertebra) in 8. The failure loads of the spinal column were 1774.8+/-672.3 N and 1501.2+/-556.5 N in the P group and C group, respectively. There was no significant difference in the failure load of the spinal column between each group.

CONCLUSION

New vertebral fractures occurred at the vertebra adjacent to augmented vertebrae in the P group and in the augmented vertebrae in the C group. The difference in the fractured site may be because of the difference in strength between the 2 bone filler materials. Therefore, the strength of bone filler materials is considered a risk factor in developing adjacent vertebral body fractures after VP.

Characteristics and mechanical properties of acrylolpamidronate-treated strontium containing bioactive bone cement

The aim of the present study was to determine the influence of surface treatment on the mechanical properties of strontium-containing hydroxyapatite (Sr-HA) bioactive bone cement. Previously we developed an injectable bioactive cement (SrHAC) system composed of Sr-HA powders and bisphenol A diglycidylether dimethacrylate (Bis-GMA). In this study, the Sr-HA powder was subjected to surface treatment using acrylolpamidronate, a bisphosphonate derivative, which has a polymerizable group, to improve the interface between inorganic filler and organic matrix by binding Sr-HA and copolymerizing into the matrix. After surface treatment, the compression strength, bending strength, and stiffness of the resulting composites were defined by using a material testing machine (MTS) according to ISO 5833. The fracture surface of the bone cement specimen was observed with a scanning electron microscope. Invitro cytotoxicity of surface-treated SrHAC was also studied using a tetrazolium-based cell viability assay (MTS/pms) on human osteoblast-like cells, the SaOS-2 cell line. Cells were seeded at a density of 10(4)/mL and allowed to grow in an incubator for 48 h at 37 degrees C. Results indicated that after surface treatment, the compression strength and stiffness significantly improved by 22.68 and 14.51%, respectively. The bending strength and stiffness of the bioactive bone cement also showed 19.06 and 8.91% improvements via three-point bending test. The fracture surface micromorphology after compression and bending revealed that the bonding between the resin to surface-treated filler considerably improved. The cell viability indicated that the treated particles were nontoxic and did not inhibit cell growth. This study demonstrated a new surface chemistry route to enhance the covalent bonds between inorganic fillers and polymer matrix for improving the mechanical properties of bone cement. This method not only improves the overall mechanical performance but also increases osteoblastic activity.

Influence of strontia on various properties of surgical simplex P acrylic bone cement and experimental variants

The fact that the composition of acrylic bone cement, as used in cemented primary arthroplasties, is not optimal has been highlighted in the literature. For example: (i) deleterious effects of the radiopacifier (BaSO(4) or ZrO(2) particles in the powder) have been reported; (ii) there is an indication that pre-polymerized poly(methylmethacrylate) (PMMA) beads in the powder may be dispensed with; and (iii) there is a strong consensus that the accelerator commonly used, N,N-dimethyl-p-toluidine (DMPT), is toxic and has many other undesirable properties. At the same time, the effectiveness of drugs that contain a strontium compound in treating the effects of osteoporosis has been explained in terms of the role of strontium in bone formation and resorption. This indicates that strontium compounds may also have desirable effects on osseointegration of arthroplasties. The present study is a detailed evaluation of 24 acrylic bone cement formulations comprising different relative amounts of BaSO(4), strontia (as an alternative radiopacifier), pre-polymerized PMMA beads and DMPT. A large number of properties of the curing and cured cement were determined, including setting time, polymerization rate, fracture toughness and fatigue life. The focus was on the radiopacifier, with the finding being that many properties of formulations that contained strontia were about the same or better than those for cements that contained BaSO(4). Thus, further developmental work on strontia-containing acrylic bone cements is justified, with a view to making them candidates for use in cemented primary arthroplasties.

Vertebral augmentation with a novel Vessel-X bone void filling container system and bioactive bone cement

STUDY DESIGN

Evaluation of a novel, leakage-free vertebroplastic instrumentation by fresh cadaveric studies.

OBJECTIVES

To compare Vessel-X, a novel percutaneous bone void filling container system, with conventional kyphoplasty in restoring strength, stiffness, and height in experimentally induced vertebral compressive fractures and morphologically determine the cement distribution.

SUMMARY OF BACKGROUND DATA

Clinically, both vertebroplasty and kyphoplasty perform well in reinforcement and pain relief. One of the shortcomings, however, is the risk of cement leakage. Vessel-X is a novel bone expander and bone void filler combined instrumentation for vertebral augmentation requiring evaluation.

METHODS

A total of 28 fresh-frozen vertebral specimens were randomly assigned to 4 groups for testing: unipedicular kyphoplasty, bipedicular kyphoplasty, unipedicular Vessel-X, and bipedicular Vessel-X. Compressive fractures were experimentally created on each vertebra after determining the bone mineral density. Kyphoplasty and Vessel-X were performed using bioactive bone cement (SrHAC) under C-arm fluoroscopy and compared by compression testing to measure the effects of augmentation. Morphologic observations were also performed to determine the cement distribution and vertebral height restoration.

RESULTS

There was no significant difference in bone mineral density, initial strength, and stiffness in any of the groups. Furthermore, no significant difference was observed in total cement volume in intragroup comparison within the unipedicular or bipedicular groups. Vessel-X bone filler container could expand well and contain most of the cement. The height restoration ranged from 88.5% to 96.4% in all groups. The augmented strength with unipedicular and bipedicular injections reached 3651.57 N and 4833.73 N, respectively. Stiffness with bipedicular injection was significantly higher than that of unipedicular injection.

CONCLUSION

Vessel-X was comparable to kyphoplasty in restoring the mechanical properties and height of the fractured vertebrae. Interestingly, Vessel-X instrumentation showed considerably less cement leakage and better cement placement in the vertebral body. Therefore, it could be a leakage controllable technique in percutaneous vertebral augmentation.