Silver and copper addition enhances the antimicrobial activity of calcium hydroxide coatings on titanium.

Electrochemically assisted deposition of Ca(OH)2 (Portlandite) coatings on titanium surfaces has been proven as a promising method to provide the substrate with a most desirable combination of significant bacterial growth reduction on one hand and good biocompatibility on the other. Due to the rapid in vivo transformation of Ca(OH)2 to hydroxyapatite, the antimicrobial activity will be an ephemeral property of the coating when implanted into the human body. In this study, the ability to reduce bacterial growth of such portlandite coatings was significantly enhanced by an ionic modification with copper and silver ions. Antibacterial tests revealed a noticeably elevated reduction of bacterial growth, especially for copper and even at a relatively low copper content of about 0.3 wt.%. In addition, the cytocompatibility, a crucial prerequisite for potential in vivo biocompatibility, of the copper-modified coating was comparable to pure calcium hydroxide coatings.

Perfluorodecalin and bone regeneration.

Perfluorodecalin (PFD) is a chemically and biologically inert biomaterial and, as many perfluorocarbons, is also hydrophobic, radiopaque and has a high solute capacity for gases such as oxygen. In this article we have demonstrated, both in vitro and in vivo, that PFD may significantly enhance bone regeneration. Firstly, the potential benefit of PFD was demonstrated by prolonging the survival of bone marrow cells cultured in anaerobic conditions. These findings translated in vivo, where PFD incorporated into bone-marrow-loaded 3D-printed scaffolds substantially improved their capacity to regenerate bone. Secondly, in addition to biological applications, we have also shown that PFD improves the radiopacity of bone regeneration biomaterials, a key feature required for the visualisation of biomaterials during and after surgical implantation. Finally, we have shown how the extreme hydrophobicity of PFD enables the fabrication of highly cohesive self-setting injectable biomaterials for bone regeneration. In conclusion, perfluorocarbons would appear to be highly beneficial additives to a number of regenerative biomaterials, especially those for bone regeneration.

Dual setting α-tricalcium phosphate cements.

An extension of the application of calcium phosphate cements (CPC) to load-bearing defects, e.g. in vertebroplasty, would require less brittle cements with an increased fracture toughness. Here we report the modification of CPC made of alpha-tricalcium phosphate (α-TCP) with 2-hydroxyethylmethacrylate (HEMA), which is polymerised during setting to obtain a mechanically stable polymer-ceramic composite with interpenetrating organic and inorganic networks. The cement liquid was modified by the addition of 30-70 % HEMA and ammoniumpersulfate/tetramethylethylendiamine as initiator. Modification of α-TCP cement paste with HEMA decreased the setting time from 14 min to 3-8 min depending on the initiator concentration. The 4-point bending strength was increased from 9 MPa to more than 14 MPa when using 50 % HEMA, while the bending modulus decreased from 18 GPa to approx. 4 GPa. The addition of ≥50 % HEMA reduced the brittle fracture behaviour of the cements and resulted in an increase of the work of fracture by more than an order of magnitude. X-ray diffraction analyses revealed that the degree of transformation of α-TCP to calcium deficient hydroxyapatite was lower for polymer modified cements (82 % for polymer free cement and 55 % for 70 % HEMA) after 24 h setting, while the polymerisation of HEMA in the cement liquid was quantitative according to FT-IR spectroscopy. This work demonstrated the feasibility of producing fracture resistant dual-setting calcium phosphate cements by adding water soluble polymerisable monomers to the liquid cement phase, which may be suitable for an application in load-bearing bone defects.

Monetite, an important calcium phosphate compound-Its synthesis, properties and applications in orthopedics.

This review recognizes a unique calcium phosphate (CaP) phase known as monetite or dicalcium phosphate anhydrous (DCPA, CaHPO4), and presents an overview of its properties, processing, and applications in orthopedics. The motivation for the present effort is to highlight the state-of-the-art research and development of monetite and propel the research community to explore more of its potentials in orthopedics. After a brief introduction of monetite, we provide a summary of its various synthesis routes like dehydration, solvent-based, energy-assisted processes and also discuss the formation of different crystal structures with respect to the synthesis conditions. Subsequently, we discuss the material's noteworthy physico-chemical properties including the crystal structure, vibrational spectra, solubility, thermal decomposition, and conversion to other phases. Of note, we focus on the biological (in vitro and in vivo) properties of monetite, given its ever-increasing popularity as a biomaterial for medical implants. Appropriately, we discuss various orthopedic applications of monetite as bone cement, implant coatings, granules for defect fillers, and scaffolds. Many in vitro and in vivo studies confirmed the favorable osteointegration and osteoconduction properties of monetite products, along with a better balance between implant resorption and new bone formation as compared to other CaP phases. The review ends with translational aspects of monetite and presents thoughts about its possible future research directions. Further research may explore but not limited to improvements in mechanical strength of monetite-based scaffolds, using monetite particles as a therapeutic agent delivery, and tissue engineering strategies where monetite serves as the biomaterial. STATEMENT OF SIGNIFICANCE: This is the first review that focusses on the favorable potential of monetite for hard tissue repair and regeneration. The article accurately covers the "Synthesis-Structure-Property-Applications" correlations elaborating on monetite's diverse material properties. Special focus is put on the in vitro and in vivo properties of the material highlighting monetite as an orthopedic material-of-choice. The synthesis techniques are discussed which provide important information about the different fabrication routes for monetite. Most importantly, the review provides comprehensive knowledge about the diverse biomedical applications of monetite as granules, defect--specific scaffolds, bone cements and implant coatings. This review will help to highlight monetite's potential as an effective regenerative medicine and catalyze the continuing translation of this bioceramic from the laboratory to clinics.

Multifunctional calcium phosphate based coatings on titanium implants with integrated trace elements.

For decades, the main focus of titanium implants developed to restore bone functionality was on improved osseointegration. Additional antimicrobial properties have now become desirable, due to the risk that rising antibiotic resistance poses for implant-associated infections. To this end, the trace elements of copper and zinc were integrated into calcium phosphate based coatings by electrochemically assisted deposition. In addition to their antimicrobial activity, zinc is reported to attract bone progenitor cells through chemotaxis and thus increase osteogenic differentiation, and copper to stimulate angiogenesis. Quantities of up to 68.9 ± 0.1 µg cm- 2 of copper and 56.6 ± 0.4 µg cm- 2 of zinc were deposited; co-deposition of both ions did not influence the amount of zinc but slightly increased the amount of copper in the coatings. The release of deposited copper and zinc species was negligible in serum-free simulated body fluid. In protein-containing solutions, a burst release of up to 10 µg ml-1 was observed for copper, while zinc was released continuously for up to 14 days. The presence of zinc was beneficial for adhesion and growth of human mesenchymal stromal cells in a concentration-dependent manner, but cytotoxic effects were already visible for coatings with an intermediate copper content. However, co-deposited zinc could somewhat alleviate the adverse effects of copper. Antimicrobial tests with E. coli revealed a decrease in adherent bacteria on brushite without copper or zinc of 60%, but if the coating contained both ions there was almost no bacterial adhesion after 12 h. Coatings with high zinc content and intermediate copper content had the overall best multifunctional properties.

Carvable calcium phosphate bone substitute material.

This study investigated the use of partially set hydroxyapatite forming calcium phosphate cement as a carvable and mechanically stable bone substitute material. Hydroxyapatite-forming cements were made of either mechanically activated alpha-tricalcium phosphate or a mixture of tetracalcium phosphate and dicalcium phosphate anhydrous and setting was arrested up to 4 h post setting. The study showed that these partially set rigid samples of defined geometry could be carved into a desired shape when the degree of reaction was 30-40% and the relative porosity between 40 and 50%; samples are then expected to set completely after implantation in the presence of water or serum, having the same compressive strength as a continuously set calcium phosphate cement (up to 36 MPa). The development of compressive strength, phase composition, and crystallinity when varying production parameters of these partially "preset" bone substitute materials are presented for both cement systems.

Calcium phosphate bone cement/mesoporous bioactive glass composites for controlled growth factor delivery.

Calcium phosphate (CaP) bone cements are widely used for the treatment of bone defects and have been proposed to serve as a delivery platform for therapeutic drugs, proteins and growth factors into the defect region. However, they lack sufficient porosity to allow immediate bone ingrowth and thus foster rapid integration into the bone tissue. In this study we investigated a composite prepared from a hydroxyapatite forming bone cement and mesoporous bioactive glass (MBG) granules as a potential carrier for biologically active proteins. The mechanical properties of the composite were not compromised by up to 10 wt% MBG granule addition, which can be attributed to the strong interface between the cement matrix and MBG particles, however this modification induced a significant increase in porosity within 3 weeks ageing in an aqueous liquid. The release profiles of two proteins, lysozyme and the vascular endothelial growth factor (VEGF), could be controlled when they were loaded onto MBG granules that were subsequently embedded into the cement when compared to direct loading into the cement precursor. Both proteins were also demonstrated to maintain their biologic activity during embedding and release from the composite. These findings suggest the CaP bone cement/MBG composite developed in this study as a potential delivery platform for growth factors or other bioactive substances.

Effects of fibre reinforcement on the mechanical properties of brushite cement.

In this study the effect of structure and amount of polyglactin fibre incorporation into a brushite forming calcium phosphate cement system and the effect of mechanical compaction on the fibre modified system were investigated. In comparison the effect of resorbable polycaprolactone surface coating of cement specimens was investigated. The results showed that, apart from the mechanical properties of the reinforcing material, the structure of the incorporated fibres, regular or random, is crucial for the resulting flexural strength and modulus of elasticity. Fibre reinforcement could also be combined with mechanical compaction of the cement/fibre composite paste leading to a possible 7-fold increase in flexural strength or an almost 5-fold increase in modulus of elasticity. Reinforcement of the tensile surface of cement grafts may ultimately improve strength where required, especially in conjunction with bone fixation devices.

Real-time monitoring of the setting reaction of brushite-forming cement using isothermal differential scanning calorimetry.

The setting behavior of a brushite-forming cement (beta-tricalcium phosphate/mono calcium monophosphate) was investigated using an indentation technique (the Gillmore needles method) and isothermal differential scanning calorimetry (DSC). The two objectives of the study were to investigate whether DSC could be used to real-time monitor a fast-setting calcium phosphate cement (CPC) and to determine if it is possible to correlate DSC results directly with conventional setting-time measurements. Best-fit linear correlation analysis revealed that both the initial and final setting time (T(i) and T(f)) measured by indentation were strongly correlated to the maximum heat flow measured with DSC. It seems therefore possible to predict the setting times, usually achieved with user dependent indentation methods, of this specific fast setting CPC on the basis of objective DSC measurements. The drawbacks of DSC, however, are its overall complexity and expense and the fact that only exothermal reactions can be investigated in comparison to the Gillmore needles method, furthermore, it is not possible to monitor the complete reaction as the first 2 or 3 min are lost due to sample preparation and apparatus set up.

Electrochemically assisted deposition of strontium modified magnesium phosphate on titanium surfaces.

Electrochemically assisted deposition was utilized to produce ceramic coatings on the basis of magnesium ammonium phosphate (struvite) on corundum-blasted titanium surfaces. By the addition of defined concentrations of strontium nitrate to the coating electrolyte Sr(2+) ions were successfully incorporated into the struvite matrix. By variation of deposition parameters it was possible to fabricate coatings with different kinetics of Sr(2+) into physiological media, whereas the release of therapeutically relevant strontium doses could be sustained over several weeks. Morphological and crystallographic examinations of the immersed coatings revealed that the degradation of struvite and the release of Sr(2+) ions were accompanied by a transformation of the coating to a calcium phosphate based phase similar to low-crystalline hydroxyapatite. These findings showed that strontium doped struvite coatings may provide a promising degradable coating system for the local application of strontium or other biologically active metal ions in the implant-bone interface.

Real-time measurement of protein adsorption on electrophoretically deposited hydroxyapatite coatings and magnetron sputtered metallic films using the surface acoustic wave technique.

Surface acoustic wave (SAW) biosensors are highly sensitive for mass binding and are therefore used to detect protein-protein and protein-antibody interactions. Whilst the standard surface of the chips is a thin gold film, measurements on implant- or bone-like surfaces could significantly enhance the range of possible applications for this technique. The aim of this study was to establish methods to coat biosensor chips with Ti, TiN, and silver-doped TiN using physical vapor deposition as well as with hydroxyapatite by electrophoresis. To demonstrate that protein adsorption can be detected on these surfaces, binding experiments with fibronectin and fibronectin-specific antibodies have been performed with the coatings, which successfully proved the applicability of PVD and EPD for SAW biosensor functionalization.

Technological issues for the development of more efficient calcium phosphate bone cements: a critical assessment.

The first calcium phosphate cements (CPCs) were discovered in the 1980s. Two decades later, the interest for these materials is still rising. The goal of the present document is to review the most recent achievements in the field and to analyze future directions in research and development.

Correlating crystallinity and reactivity in an alpha-tricalcium phosphate.

In this study, the effect of how variant milling time affects material characteristics of alpha phase tricalcium phosphate powder (alpha-TCP) was studied. Two alpha-TCP batches were separated in small lots and milled for various times for up to 4 h. The resulting milled lots were characterized by measuring their crystallinity, particle size, specific surface area, thermal stability, and heat released during hydration. Mechanical treatment was seen to greatly increase the alpha-TCP X-ray amorphous fraction and heat release during hydration, almost independently of alpha-TCP particle size and specific surface area. Therefore, the results suggest that the formation and presence of an X-ray amorphous phase in the alpha-TCP powder greatly contribute to its reactivity. The exotherm of the powders increases from 103 to 238 kJ/mol after milling.

Modified PMMA cements for a hydrolysis resistant metal-polymer interface in orthopaedic applications.

Amongst the many factors influencing the long-term stability of cemented hip prostheses, the interface between the implant and bone cement is considered to be one of the most susceptible to failure. Osteolysis and loosening of the implant can occur by the interaction of mechanically and/or hydrolytically induced bond failure of the metal-cement interface. In this work, an improvement of the hydrolysis resistance of the titanium-bone cement interface was obtained by cement modification with a bifunctional coupling agent combined with a tribochemical TiO2-modification of the metal surface. Methacryloxypropyl-trimethoxysilane was added as coupling agent to the PMMA monomer in concentrations between 5 and 20 wt.% followed by the testing the shear bond strength of PMMA/titanium joints before and after ageing in physiological saline solution. It was found that the hydrolysis resistance of the metal-PMMA interface could be significantly improved by the modification of the cement. At the same time, the mechanical properties (compressive and bending strength) of the modified cement were not altered by the addition of the coupling agent. The advantage of the modification of the cement matrix is an easy clinical applicability of the procedure maintaining the processing and implantation techniques of the cement material.

Rheological enhancement of mechanically activated alpha-tricalcium phosphate cements.

Most biocements are two- or three-component acid-based systems with large differences in the component particle sizes, which occurs by virtue of the differing processing routes. This work aimed to improve injectability and strength of a single reactive component cement, that is, mechanically activated alpha-tricalcium phosphate (TCP)-based cement by adding 13-33 wt % of several fine-particle-sized (d(50) of 0.5-1.1 microm) fillers [dicalcium phosphate anhydrous (DCPA), titanium dioxide (TiO(2)), and calcium carbonate] to the monomodal alpha-TCP matrix (d(50) = 9.8 microm). A high zeta-potential was measured for all particles in trisodium citrate solution. The fraction of alpha-TCP cement "injected" through an 800-microm hypodermic needle was found to be only 35% at a powder-to-liquid ratio of 3.5 g/mL. In contrast, the use of fillers decreased cement viscosity to a point, where complete injectability could be obtained. Mechanistically, these additives disrupted alpha-TCP particle packing yet decreased the interparticle spacing by a factor of approximately 5.5 such that the electrostatic repulsion effect was enhanced. A strength improvement was found when DCPA and TiO(2) were used as fillers despite the lower degree of conversion of these cements. Compressive strengths of precompacted cement samples increased from 70 MPa for unfilled alpha-TCP cement to 140 (110) MPa for 23 wt % DCPA (or TiO(2)) fillers as a result of porosity reduction. Strength improvement for more clinically relevant uncompacted cements was achieved by higher powder-to-liquid ratio mixes for filled cements such that maximum strengths of 90 MPa were obtained for 23 wt % DCPA filler compared with 50 MPa for single-component alpha-TCP cement.

Cortical bone screw fixation in ionically modified apatite cements.

Hydroxyapatite cements are used in reconstruction of the face; usually in well-defined cavities where the cement can be stabilized without the need for internal fixation. A hydroxyapatite cement that could enable screw fixation and some loading therefore has considerable potential in maxillofacial reconstruction. It has been demonstrated recently that water demand of calcium phosphate cements can be reduced by ionically modifying the liquid component. This study investigated the capacity of an ionically modified precompacted apatite cement to retain self-tapping cortical bone screws. Screw pullout forces were determined in the direction of the screw long axis and perpendicular to it, using cortical bone and polymethylmethacrylate cement as a control. In bending pullout tests, measured forces to remove screws from ionically modified precompacted cement were insignificantly different from cortical bone. However, pullout forces of bone screws from hydroxyapatite cement decreased with aging time in vitro.

Ionic modification of calcium phosphate cement viscosity. Part II: hypodermic injection and strength improvement of brushite cement.

Brushite-forming calcium phosphate cements are of great interest as bone replacement materials because they are resorbable in physiological conditions. However, their short setting times, low mechanical strengths and limited injectability limit broad clinical application. In this study, we showed that a significant improvement of these properties of brushite cement could be achieved by the use of sodium citrate or citric acid as setting retardants, such that workable cement pastes with a powder to liquid ratio of up to 5 could be manufactured. The cement used in this study consisted of an equimolar powder mixture of beta-tricalcium phosphate and monocalcium phosphate hydrate The use of 500 mM-1M retardant solutions as liquid phase enabled initial setting times of 8-12 min. Wet compressive strength were found to be in the range between 12-18 MPa after immersion of uncompacted cement samples in serum for 24 h. A further strength improvement to 32 MPa was obtained by compaction of the cement paste during samples preparation. This is significant because high-temperature processes cannot be used to fabricate hydrated calcium phosphate materials. Cement pastes were injectable through a hypodermic needle at a powder to liquid ratio of 3.3 g/ml when a 1M citric acid was used as liquid phase, thus enabling precise controlled delivery to small defects.

Mechanical activation and cement formation of beta-tricalcium phosphate.

The reactivity of acid base cements forming hydroxyapatite (HA) such as, tetracalcium phosphate, and dicalcium phosphate anhydride or dicalcium phosphate dihydrate, is normally adjusted by altering the particle size and hence the specific surface area of the compounds. Amorphous calcium phosphates, prepared by precipitation from supersaturated solutions, can also react to form apatitic cements since they are thermodynamic unstable with respect to HA and have a setting reaction more independent of particle size. In this report we show for the first time that prolonged high-energy ball milling of beta-tricalcium phosphate (beta-TCP), led to mechanically induced phase transformation from the crystalline to the amorphous state. The process increased the thermodynamic solubility of the beta-TCP compared to the unmilled material by up to nine times and accelerated the normally slow reaction with water. By using a 2.5% Na(2)HPO(4) solution setting times were reduced to 5-16min rather than hours. X-ray diffraction analyses indicated that the amorphous fraction within the materials was responsible for the primary setting reaction and hardening of the cements, while the crystalline fraction remained unreacted and converted only slowly to HA. Mechanically activated beta-TCP cements were produced with compressive and diametral tensile strengths of up to 50 and 7MPa respectively. The effect of preparation and setting parameters on the physical and chemical properties of mechanically activated beta-TCP cement was investigated.

Surface properties of calcium phosphate particles for self setting bone cements.

Calcium phosphate cements (CPC), consist of multicomponent powder mixtures of calcium orthophosphates with grain sizes in the region of 1-20 microm. Due to the small particle sizes surface properties as the zeta potential and adsorption processes play a significant role during manufacturing and application. In the context of this work zeta potentials of different calcium phosphates, like dicalcium phosphate anhydride (DPCA) tetracalcium phosphate (TTCP) and hydroxyapatite were measured in various organic/aqueous media with different pH values. The results show a strong dependency of the zeta potential on the kind of suspension medium used associated with different milling properties. The addition of sodium phosphate leads to a pH value dependent stabilization of the particles in the liquid phase; the zeta potential of the surface increases from about -15 to -18 mV in water and from -35 to -45 mV in 0.05 mol/l sodium phosphate solution. Besides the interaction of particles with various antibiotics was determined on the basis of the zeta potential of the surface. The substances partly cause a tremendous change of the surface load. This is accompanied by a change of the rheological properties of the cement paste, the morphology of the hardened cement matrix and a significant deterioration of the application-relevant properties as setting time or mechanical strength.

Nanocrystalline tetracalcium phosphate cement.

Calcium hydroxide cements can lack long-term stability and achieve sustained release by matrix-controlled diffusion of hydroxyl ions. Tetracalcium phosphate (TTCP) hydrolyzes slowly to form calcium hydroxide and a thin insoluble apatite layer that prevents further reaction. In this study, mechanical amorphization was used to create a setting calcium-hydroxide-releasing cement from TTCP. The effect of high-energy ball milling of TTCP on the mechanical properties of the cement was investigated. X-ray diffraction data were used to determine the phase composition of the set cements. An accelerated in vitro test compared pH of water after prolonged boiling of nanocrystalline TTCP cements and a calcium salicylate material. As milling time increased, cement compressive strength and degree of conversion increased. Hydroxyl ion release from the cement was comparable with that from a calcium salicylate material. This new cement system offers the antimicrobial potential of calcium salicylate materials combined with the long-term stability of insoluble apatite cements.