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Although commonly used in orthopedic surgery, bone cements often face a high risk of post-operative infection. Developing bone cement with antibacterial capability is an effective path for eliminating implant-associated infections. Herein, the potential of silver ions (Ag + ) and silver nanoparticles (AgNPs) in modifying CPC for long-term antibacterial property was investigated. Ag + ions or AgNPs of various concentrations were incorporated in starch-modified calcium phosphate bone cement (CPB) to obtain Ag + -containing (Ag + @CPB) and AgNPs-containing (AgNP@CPB) bone cements. The results showed that all silver-containing CPBs had setting times of about 25-40 min, compressive strengths of greater than 22 MPa, high cytocompatibility but inhibitory effect on Staphylococcus aureus growth. After soaking for 1 week, the mechanical properties and the cytocompatibility of all cements revealed no significant changes, but only CPB with a relatively high content of Ag + (H-Ag + @CPB) maintained good antibacterial capability over the tested time period. In addition, all the cements showed high injectability and interdigitating capability in cancellous bone and demonstrated augmentation effect on the cannulated pedicle screws fixation in the Sawbones model. In summary, the sustainable antibacterial capability and enhanced biomechanical properties demonstrated that Ag + ions were more suitable for the fabrication of antibacterial CPC compared to AgNPs. Also, the H-Ag + @CPB, with good injectability, high cytocompatibility, good interdigitating and biomechanical property in cancellous bone, and sustainable antibacterial effects, bears great potential for the treatments of bone infections or implant-associated infections., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Calcium phosphate cement (CPC) modified with native and pregelatinized normal corn and waxy maize starches was studied. Effects of starch pregelatinization and starch type on the physicochemical properties of CPC were investigated. CPC modified with pregelatinized normal corn starch (CPB-PNC) or pregelatinized waxy maize starch (CPB-PW) was evaluated by two vertebral fracture surgical models in vitro. Both granular and pregelatinized starches significantly improved the setting times and injectability of CPC, but only the pregelatinized starches improved the anti-collapsibility and compressive strength of CPC significantly. CPB-PW, whose micro-structure was compact and uniform, showed the best physicochemical properties. Addition of starch did not inhibit the hydro-reaction of CPC. Unmodified CPC had very poor dispersibility and could not apply in the tests of the surgical models. Pregelatinized starch especially waxy maize starch improved the dispersibility of CPC and showed good dispersion area, volume, improved pull-out force and maximum torque in the Sawbones sponge model. Similarly, in the minimally invasive kyphoplasty model, CPB-PNC and CPB-PW could disperse in the osteoporotic sheep vertebrae and improve the compressive strength of the sheep vertebral body. In conclusion, starch pregelatinization and starch botanical source affect the physicochemical properties of CPC significantly. Bone cements modified by different starches also performed differently in surgical models for osteoporotic vertebral fracture. Pregelatinized waxy maize starch may be a better candidate for CPC modification comparing to the pregelatinized normal corn starch., (© 2021 Wiley Periodicals LLC.)

Background Context: Polymethylmethacrylate (PMMA) is the most commonly used filling material when performing percutaneous kyphoplasty (PKP) for the treatment of osteoporotic vertebral compression fractures. However, there are some inherent and unavoidable drawbacks with the clinical use of PMMA. PMMA bone cement tends to leak during injection, which can lead to injury of the spinal nerves and spinal cord. Moreover, the mechanical strength of PMMA-augmented vertebral bodies is extraordinary and this high level of mechanical strength might predispose to adjacent vertebral fractures. A novel biodegradable calcium phosphate-based nanocomposite (CPN) for PKP augmentation has recently been developed to potentially avoid these issues., Purpose: By comparison with PMMA, the leakage characteristics, biomechanical properties, and dispersion of CPN were evaluated when used for PKP., Study Design: Biomechanical evaluation and studies on the dispersion and anti-leakage properties of CPN and PMMA cements were performed and compared using cadaveric vertebral fracture model, sheep vertebral fracture model, and simulated rigid foam model., Methods: Sheep vertebral bodies were decalcified by ethylenediaminetetraacetic acid disodium salt (EDTA-Na 2 ) to simulate osteoporosis in vitro. After compression to create wedge-shaped fractures using a self-designed fracture creation tool, human cadaveric vertebrae and decalcified sheep vertebrae were augmented by PKP. In addition, three L5 vertebral bodies from human cadavers were used in a contrast vertebroplasty (VP) augmentation experiment. Occurrence of cement leakage was observed and compared between CPN and PMMA during the process of vertebral augmentation. Open-cell rigid foam model (Sawbones#1522-507) was used to create a simulated leakage model for the evaluation of the leakage characteristics of CPN and PMMA with different viscosities. The augmentation effects of CPN and PMMA were evaluated in human cadaveric and decalcified sheep vertebral models and then compared to the results from solid rigid foam model (Sawbones#1522-23). The dispersion abilities of CPN and PMMA were evaluated via three methods as follows. The dispersion volume and dispersion ratio were calculated by three-dimensional reconstruction using human vertebral body CT scans; the ratio of cement area to injection volume was calculated from three-dimensional sections of micro-CT scans of a sheep vertebra; and the micro-CT images of cement dispersion in open-cell rigid foam model (Sawbones#1522-507) were compared between CPN and PMMA. This study was funded by the National Natural Science Foundation of China (No. 81622032, 190,000 dollars and No. 51672184, 90,600 dollars), Principal Project of Natural Science Research of Jiangsu Higher Education Institutions (No. 17KJA180011, 22,000 dollars), and Jiangsu Innovation and Entrepreneurship Program (146,000 dollars)., Results: There was no significant difference in vertebral height between CPN and PMMA during PKP augmentation and both cements restored the vertebral height after augmentation. In PKP augmentation experiment, posterior wall cement leakage occurred in 75% of human vertebrae augmented with PMMA; however, no leakage occurred in human vertebrae augmented with CPN. Anterior leakage occurred in all vertebrae augmented by PMMA, while in only 75% of vertebra augmented by CPN. Furthermore, CPN and PMMA had completely different leakage patterns in the simulated rigid foam model whether administered at the same injection speed or under the same injection force, suggesting that CPN has anti-leakage characteristics. The augmentation in human cadaveric vertebrae was lower with CPN compared to PMMA (1,668±816 N vs. 2,212±813 N, p=.459, respectively), but this difference was not significant. The augmentation force in sheep vertebral bodies reached 1,393±433 N when augmented with PMMA, but 1,108±284 N when augmented with CPN. The dispersion of CPN was better, and the dispersion volume and ratio were greater, with CPN than with PMMA. Imaging of the open-cell rigid foam model showed completely different dispersion modes for CPN and PMMA. After injection, the PMMA cement formed a contracted clump in the open-cell rigid foam model. However, the CPN cement extended many antennae outward, appearing to spread to the surrounding area. The surface areas of the CPN cement blocks with different liquid-to-solid ratios were significantly larger than the surface area of the PMMA cement in the open-cell rigid foam model (p<.05)., Conclusions: CPN has anti-leakage properties, which might be related to its high viscosity and viscoplasticity. CPN had a slightly lower augmentation force than PMMA when used in cadaveric vertebrae, decalcified sheep vertebrae, and in the standard rigid foam model. However, CPN diffused more easily into cancellous bone than did PMMA and encapsulated bone tissue during the dispersion process. The excellent dispersion of CPN generated better interdigitation with cancellous bone, which may be why the augmentation effect of CPN is similar to that of PMMA., Clinical Significance: Biodegradable CPN is a potential alternative to PMMA cement in PKP surgery, in which CPN is likely to reduce the cement leakage during the surgery and avoid the post-surgery complications caused by excessive strengths and nondegradability of PMMA cement., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Poly(methyl methacrylate) (PMMA) cement is widely used for percutaneous kyphoplasty and vertebroplasty (PKP and PVP) but possesses formidable shortcomings due to non-degradability. Here, a biodegradable replacement is developed., Methods: Calcium phosphate cement (CPC) was redesigned by incorporating starch and BaSO 4 (new cement named as CPB). The biomechanical, biocompatibility, osseointegrative and handling properties of CPB were systematically evaluated in vitro and in vivo by the models of osteoporotic sheep vertebra, rat subcutaneous implantation and rat femoral defect., Results: CPB revealed appropriate injectability and setting ability for PKP and PVP. More importantly, its biomechanical strengths measured by in vitro and in vivo models were not less than that of PMMA, while its biodegradability and osseointegrative capacities were significantly enhanced compared to PMMA., Conclusions: CPB is injectable, biomechanically robust, biodegradable and osseointegrative, demonstrating revolutionary potential for the application in PKP and PVP.

Polymethyl methacrylate (PMMA)-augmented cannulated pedicle-screw fixation has been routinely performed for the surgical treatment of lumbar degenerative diseases. Despite its satisfactory clinical outcomes and prevalence, problems and complications associated with high-strength, stiff, and nondegradable PMMA have largely hindered the long-term efficacy and safety of pedicle-screw fixation in osteoporotic patients. To meet the unmet need for better bone cement for cannulated pedicle-screw fixation, a new injectable and biodegradable nanocomposite that was the first of its kind was designed and developed in the present study. The calcium phosphate-based nanocomposite (CPN) exhibited better anti-pullout ability and similar fluidity and dispersing ability compared to clinically used PMMA, and outperformed conventional calcium phosphate cement (CPC) in all types of mechanical properties, injectability, and biodegradability. In term of axial pullout strength, the CPN-augmented cannulated screw reached the highest force of ~120 N, which was higher than that of PMMA (~100 N) and CPC (~95 N). The compressive strength of the CPN (50 MPa) was three times that of CPC, and the injectability of the CPN reached 95%. In vivo tests on rat femur revealed explicit biodegradation of the CPN and subsequent bone ingrowth after 8 weeks. The promising results for the CPN clearly suggest its potential for replacing PMMA in the application of cannulated pedicle-screw fixation and its worth of further study and development for clinical uses., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Current injectable calcium phosphate bone cements (CPC) encounter the problems of low strength, high brittleness, and low cohesion in aqueous environment, which greatly hinder their clinical applications for loading-bearing bone substitution and minimally invasive orthopedic surgeries. Here, a strategy of using gelatinized starches to reinforce injectable CPC was investigated. Four types of starches, namely corn starch, crosslinked starch, cationic starch, and Ca-modified starch, were studied for their influence on CPC mechanical properties, injectability, setting times, anticollapsibility, and cytocompatibility. Gelatinized starch significantly improved compressive strength and modulus as well as strain energy density of CPC to different extents. Specifically, both corn starch and Ca-modified starch revealed sixfold and more than twofold increases in the compressive strength and modulus of CPC, respectively. The addition of gelatinized starches with proper contents increased the injectability and anticollapsibility of CPC. In addition, osteoblast proliferation tests on leaching solution of modified cements showed that gelatinized starches had no adverse effect on cell proliferation, and all cement samples resulted in better osteoblast proliferation compared to phosphate-buffered solution control. The mechanisms behind the reinforcing effect of different starches were preliminarily studied. Two possible mechanisms, reinforcement by the second phase of gelatinized starch and strong interlocking of apatite crystals, were proposed based on the results of starch zeta potential and viscosity, cement microstructure, and resultant mechanical properties. In conclusion, incorporating gelatinized starches could be an effective, facile, and bio-friendly strategy to reinforce injectable CPC and improve its mechanical stability, and thus, should be further studied and developed., (© 2015 Wiley Periodicals, Inc.)

Calcium phosphate cement (CPC) has potentials in orthopaedics and orthodontics but it has significant limitations such as low mechanical strength, low injectability and instability in body. Starches from five botanical sources were used as cohesion additives to prepare calcium phosphate bone cement (CPB) and the starch source showed significant impact on physicochemical properties of the CPBs. CPB modified by pregelatinised waxy maize starch (CPB-W) had the highest mechanical strength, longest setting time, and most compact structure compared with other CPBs. As the amylose content increased, the viscosity of starch modified cement paste increased, and the cured cement had lower density and mechanical strength. It appears that starch with a low amylose content significantly improves the surgical performance and mechanical strength of CPC. CPB-W also exhibited good cytocompatibility to MC3T3-E1 cells. Starch modified CPBs are considered as promising injectable bone cements for minimally invasive surgery applications like vertebroplasty and kyphoplasty. [ABSTRACT FROM AUTHOR]

Calcium phosphate cements (CPCs) with high bioactivity and bio-degradability have great potential for orthopaedic applications. However, handling performance and mechanical properties of current CPCs are not adequate for the applications in the minimally invasive surgery treating osteoporotic vertebral fracture like kyphoplasty. Here, the effects of reactant compositions, additions of seed crystals and setting liquids on the handling and mechanical properties of alpha-tricalcium phosphate (α-TCP)-based CPC were firstly studied. In order to further improve the injectability, anti-collapsibility and mechanical properties of CPC, natural bio-macromolecules including starch and poly (gamma-glutamic acid) were used as additive bio-macromolecules for enhancing such properties. Compared with pure CPC, the injectability, anti-collapsibility and compressive strength were significantly enhanced by incorporation of the bio-macromolecule additives. The results indicated starch- and poly (gamma-glutamic acid)-modified CPCs have a potential for the application of injectable bone cements for kyphoplasty and other treatments for load-bearing bones, and therefore are worth further study. [ABSTRACT FROM AUTHOR]