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Decades of research in orthopaedics has culminated in the quest for formidable yet resorbable biomaterials using bioactive materials. Brushite cements most salient features embrace high biocompatibility, bioresorbability, osteoconductivity, self-setting characteristics, handling, and injectability properties. Such type of materials is also effectively applied as drug delivery systems. However, brushite cements possess limited mechanical strength and fast setting times. By means of incorporating bioactive ions, which are incredibly promising in directing cell fate when incorporated within biomaterials, it can yield biomaterials with superior mechanical properties. Therefore, it is a key to develop fine-tuned regenerative medicine therapeutics. A comprehensive overview of the current accomplishments of ion-doped brushite cements for bone tissue repair and regeneration is provided herein. The role of ionic substitution on the cements physicochemical properties, such as structural, setting time, hydration products, injectability, mechanical behaviour and ion release is discussed. Cell-material interactions, osteogenesis, angiogenesis, and antibacterial activity of the ion-doped cements, as well as its potential use as drug delivery carriers are also presented. Ion-doped brushite cements have unbolted a new era in orthopaedics with high clinical interest to restore bone defects and facilitate the healing process, owing its outstanding bioresorbability and osteoconductive/osteoinductive features. Ion incorporation expands their application by increasing the osteogenic and neovascularization potential of the materials, as well as their mechanical performance. Recent accomplishments of brushite cements incorporating bioactive ions are overviewed. Focus was placed on the role of ions on the physicochemical and biological properties of the biomaterials, namely their structure, setting time, injectability and handling, mechanical behaviour, ion release and in vivo osteogenesis, angiogenesis and vascularization. Antibacterial activity of the cements and their potential use for delivery of drugs are also highlighted herein. Image, graphical abstract [ABSTRACT FROM AUTHOR]

Graphical abstract Abstract Premixed calcium phosphate cements have been developed to simplify the usage of traditional calcium phosphate cements and reduce the influence of the setting reaction on the delivery process. However, difficulties in achieving a good cohesion, adequate shelf life and sufficient mechanical properties have so far impeded their use in clinical applications, especially for the more degradable acidic calcium phosphate cements. In this study, a brushite cement was developed from a series of ready-to-use calcium phosphate pastes. The brushite cement paste was formed via mixing of a monocalcium phosphate monohydrate (MCPM) paste and a β-tricalcium phosphate (β-TCP) paste with good injectability and adequate shelf life. The MCPM paste was based on a water-immiscible liquid with two surfactants and the β-TCP paste on a sodium hyaluronate aqueous solution. The effect of citric acid as a retardant was assessed. Formulations with suitable amounts of citric acid showed good cohesion and mechanical performance with potential for future clinical applications. Statement of Significance Acidic calcium phosphate cements have attracted extensive attention as bone substitute materials due to their ability to resorb faster than basic calcium phosphate cements in vivo. However, traditionally, short working times and low mechanical strength have limited their clinical application. Premixed cements could simplify the clinical use as well as improve property reproducibility, but short shelf lives, low cohesion and low mechanical properties have restricted the development. In this study, an injectable ready-to-use two-phase system consisting of an MCPM paste and a β-TCP paste was developed based on acidic cement. It shows good cohesion, compressive strength and adequate shelf life, which has the potential to be used in a dual chamber system for simplified and fast filling of bone defects in a minimally invasive manner. This will reduce surgery time, decrease the risk of contamination and ensure repeatable results. [ABSTRACT FROM AUTHOR]

Graphical abstract Abstract With respect to the composition of natural bone, we established a degradable dual setting system of different poly(ethylene glycol) (PEG)-based hydrogels combined with a brushite cement. The idea was to reinforce the inorganic calcium phosphate mineral phase with an organic, polymeric phase to alter the cement's properties towards ductility and elasticity. Extremely flexible samples were produced via this dual setting approach with a fully reversible elasticity of the samples containing high molecular weight PEG-based hydrogel precursors. Using the decalcifying agent EDTA, the whole inorganic phase was dissolved due to Ca2+-complexation and dimensionally stable hydrogels were obtained, indicating a homogenous polymeric phase within the composites. This was also confirmed by SEM-analysis, where no discontinuities or agglomerations of the phase were observed. Additional XRD-measurements proved a significant influence of the coherent polymeric matrix on the conversion from β-TCP/MCPA to brushite with a decrease in signal intensity. The results confirmed a parallelly running process of setting reaction and gelation without an inhibition of the conversion to brushite and the formation of interpenetrating networks of hydrogel and cement. The strengths of this newly developed dual setting system are based on the material degradability as well as flexibility, which can be a promising tool for bone regeneration applications in non-load bearing craniomaxillofacial defects. Statement of Significance Brushite based calcium phosphate cements (CPCs) are known as bone replacement materials, which degrade in vivo and are replaced by native bone. However, the pure inorganic material shows a brittle fracture behavior. Here, the addition of a polymeric phase can influence the mechanical properties to create more ductile and flexible materials. This polymeric phase should ideally form during cement setting by a polymerization reaction to achieve high polymer loads without altering cement viscosity and it should be degradable in vivo similar to the cement itself. Therefore, we developed a dual setting system based on simultaneous cement setting of brushite and lactide modified poly(ethylene glycol) dimethacrylate (PEG-PLLA-DMA)-based hydrogel. It was evident that the gels form a continuous phase within the cement after radical polymerization with a strong reduction of cement brittleness. [ABSTRACT FROM AUTHOR]

Remodeling of calcium phosphate bone cements is a crucial prerequisite for their application in the treatment of large bone defects. In the present study trivalent chromium ions were incorporated into a brushite forming calcium phosphate cement in two concentrations (10 and 50 mmol/mol β-tricalcium phosphate) and implanted into a femoral defect in rats for 3 and 6 month, non-modified brushite was used as reference. Based on our previous in vitro findings indicating both an enhanced osteoclastic activity and cytocompatibility towards osteoprogenitor cells we hypothesized a higher in vivo remodeling rate of the Cr 3+ doped cements compared to the reference. A significantly enhanced degradation of the modified cements was evidenced by micro computed tomography, X-ray and histological examinations. Furthermore the formation of new bone tissue after 6 month of implantation was significantly increased from 29% to 46% during remodeling of cements, doped with the higher Cr 3+ amount. Time of flight secondary ion mass spectrometry (ToF-SIMS) of histological sections was applied to investigate the release of Cr 3+ ions from the cement after implantation and to image their distribution in the implant region and the surrounding bone tissue. The relatively weak incorporation of chromium into the newly formed bone tissue is in agreement to the low chromium concentrations which were released from the cements in vitro. The faster degradation of the Cr 3+ doped cements was also verified by ToF-SIMS. The positive effect of Cr 3+ doping on both degradation and new bone formation is discussed as a synergistic effect of Cr 3+ bioactivity on osteoclastic resorption on one hand and improvement of cytocompatibility and solubility by structural changes in the calcium phosphate matrix on the other hand. Statement of Significance While biologically active metal ions like strontium, magnesium and zinc are increasingly applied for the modification of ceramic bone graft materials, the present study is the first report on the incorporation of low doses of trivalent chromium ions into a calcium phosphate based biomaterial and testing of its performance in bone defect regeneration in vivo. Chromium(III)-doped calcium phosphate bone cements show improved cytocompatibility and both degradation rate and new bone formation in vivo are significantly increased compared to the reference cement. This important discovery might be the starting point for the application of trivalent chromium salts for the modification of bone graft materials to increase their remodelling rate. [ABSTRACT FROM AUTHOR]

Dicalcium phosphate cements (brushite and monetite) are resorbable biomaterials with osteoconductive potential for bone repair and regeneration that have yet to gain widespread commercial use. Brushite can be converted to monetite by heat treatments additionally resulting in various changes in the physico-chemical properties. However, since conversion is most commonly performed using autoclave sterilisation (wet heating), it is uncertain whether the properties observed for monetite as a result of heating brushite under dry conditions affect resorption and bone formation favourably. This study was designed to produce monetite grafts of differing physical form by autoclaving and dry heating (under vacuum) to be compared with brushite biomaterials in an orthotopic pre-clinical implantation model in rabbit for 12 weeks. It was observed that monetite grafts had higher porosity and specific surface area than their brushite precursors. The autoclaved monetite grafts had compressive strength reduced by 50% when compared with their brushite precursors. However, the dry heat converted monetite grafts had compressive strength comparable with brushite. Results from in vivo experiments revealed that both types of monetite graft materials resorbed faster than brushite and more bone formation was achieved. There was no significant difference in the amount of bone formed between the two types of monetite grafts. The implanted brushite grafts underwent phase transformation to form hydroxyapatite, which ultimately limited bioresorption. However, this was not observed in both types of monetite grafts. In summary, both autoclaving and dry heating the preset brushite cement grafts resulted in monetite biomaterials which were more resorbable with potential to be investigated and optimized for orthopaedic and maxillofacial bone repair and regeneration applications. Statement of Significance We present in this original research article a comparison between dicalcium phosphate cement based grafts (brushite and 2 types of monetite grafts prepared by wet and dry thermal processing) with regards to resorption and bone formation in vivo after orthotopic implantation in rabbit condylar femural region. To the best of our knowledge this is the first in vivo study that reports a comparison resorption and bone formation using brushite and two types of monetite biomaterials. Also, we have included in the manuscript a summary of all the in vivo studies performed on brushite and monetite biomaterials to date. This includes cement composition, physical properties (porosity and surface area), implantation and histomorphometrical details such as animal species, site of implantation, observation period, percentage bone tissue formation and residual graft material. In addition, we calculated the percentage resorption of graft materials based upon various implantation sites and included that into the discussion section. The results of this original research provides greater understanding of the resorption processes of dicalcium phosphate based grafts, allowing preparation of bone substitute materials with more predictable resorption profiles in future. [ABSTRACT FROM AUTHOR]

There are two types of DCP: dihydrated (brushite) and anhydrous (monetite). After implantation, brushite converts to hydroxyapatite (HA) which resorbs very slowly. This conversion is not observed after implantation of monetite cements and result in a greater of resorption. The precise mechanisms of resorption and degradation however of these ceramics remain uncertain. This study was designed to investigate the effect of: porosity, surface area and hydration on in vitro degradation and in vivo resorption of DCP. Brushite and two types of monetite cement based grafts (produced by wet and dry thermal conversion) were aged in phosphate buffered saline (PBS) and bovine serum solutions in vitro and were implanted subcutaneously in rats. Here we show that for high relative porosity grafts (50–65%), solubility and surface area does not play a significant role towards in vitro mass loss with disintegration and fragmentation being the main factors dictating mass loss. For grafts having lower relative porosity (35–45%), solubility plays a more crucial role in mass loss during in vitro ageing and in vivo resorption. Also, serum inhibited dissolution and the formation of HA in brushite cements. However, when aged in PBS, brushite undergoes phase conversion to a mixture of octacalcium phosphate (OCP) and HA. This phase conversion was not observed for monetite upon ageing (in both serum and PBS) or in subcutaneous implantation. This study provides greater understanding of the degradation and resorption process of DCP based grafts, allowing us to prepare bone replacement materials with more predictable resorption profiles. [ABSTRACT FROM AUTHOR]

The current study describes a dual-mechanism-setting cement that combines a brushite-forming cement paste with a second inorganic silica-based precursor. Materials were obtained by pre-hydrolyzing tetraethyl orthosilicate (TEOS) under acidic conditions following the addition of a calcium phosphate cement (CPC) powder mixed of β-tricalcium phosphate and monocalcium phosphate. Cement setting occurred by a dissolution–precipitation process, while changes in pH during setting simultaneously initiated the condensation reaction of the hydrolyzed TEOS. This resulted in an interpenetrating phase composite material in which the macropores of the CPC were infiltrated by the microporous silica gel, leading to a higher density and a compressive strength ∼5–10 times higher than the CPC reference. This also altered the release of vancomycin as a model drug, whereby in contrast to the quantitative release from the CPC reference, 25% of the immobilized drug remained in the composite matrix. By varying the TEOS content in the composite, the cement phase composition could be controlled to form either brushite, anhydrous monetite or a biphasic mixture of both. The composites with the highest silicate content showed a cell proliferation similar to a hydroxyapatite reference with a significantly higher activity per cell. Surprisingly, the biological response did not seem to be attributed to the released silicate ions, but to the release of phosphate and the adsorption of magnesium ions from the cell culture medium. [ABSTRACT FROM AUTHOR]

Abstract: The current study aimed to prevent the formation of hydroxyapatite reprecipitates in brushite-forming biocements by minimizing the availability of free Ca2+ ions in the cement matrix. This was achieved by both maximizing the degree of cement setting to avoid unreacted, calcium-rich cement raw materials which can deliver Ca2+ directly to the cement matrix after dissolution, and by a reduction in porosity to reduce Ca2+ diffusion into the set cement matrix. In addition, a biocement based on the formation of the magnesium phosphate mineral struvite (MgNH4PO4·6H2O) was tested, which should prevent the formation of low-solubility hydroxyapatite reprecipitates due to the high magnesium content. Different porosity levels were fabricated by altering the powder-to-liquid ratio at which the cements were mixed and the materials were implanted into mechanically unloaded femoral defects in sheep for up to 10months. While the higher-porosity brushite cement quantitatively transformed into crystalline octacalcium phosphate after 10months, slowing down cement resorption, a lower-porosity brushite cement modification was found to be chemically stable with the absence of reprecipitate formation and minor cement resorption from the implant surface. In contrast, struvite-forming cements were much more degradable due to the absence of mineral reprecipitates and a nearly quantitative cement degradation was found after 10months of implantation. [Copyright &y& Elsevier]

Abstract: Dicalcium phosphate dihydrate (brushite) is an osteoconductive biomaterial with great potential as a bioresorbable cement for bone regeneration. Preset brushite cement can be dehydrated into dicalcium phosphate anhydrous (monetite) bioceramics by autoclaving. This heat treatment results in changes in the physical characteristics of the material, improving in vivo bioresorption. This property is a great advantage in bone regeneration; however, it is not known how autoclaving brushite preset cement might improve its capacity to regenerate bone. This study was designed to compare brushite bioceramics with monetite bioceramics in terms of physical characteristics in vitro, and in vivo performance upon bone implantation. In this study we observed that monetite bioceramics prepared by autoclaving preset brushite cements had higher porosity, interconnected porosity and specific surface area than their brushite precursors. In vitro cell culture experiments revealed that bone marrow cells expressed higher levels of osteogenic genes Runx2, Opn, and Alp when the cells were cultured on monetite ceramics rather than on brushite ones. In vivo experiments revealed that monetite bioceramics resorbed faster than brushite ones and were more infiltrated with newly formed bone. In summary, autoclaving preset brushite cements results in a material with improved properties for bone regeneration procedures. [Copyright &y& Elsevier]

Abstract: Material-related effects of a brushite and a PLGA controlled release system loaded with two distinct doses of bone morphogenetic protein-2 (BMP-2) (3.5 and 17.5μg), pre-encapsulated in poly(lactic-co-glycolic acid) (PLGA), were investigated in an intramedullary femur defect model in rabbits. The systems were characterized in vitro and in vivo over 12weeks in terms of morphology, release kinetics, porosity, molecular weight, and composition using scanning electron microscopy, mercury porosimetry, radioactivity counting, X-ray diffractometry, differential scanning calorimetry, and gel permeation chromatography. During the experimental period the investigated systems underwent significant changes in vitro as well as in vivo. It should be stressed that the two in vitro release patterns were similar, however in vivo parallel profiles were observed with a higher burst effect for BMP-2 in the PLGA system. The PLGA system degraded and disintegrated significantly faster than the brushite system, which suffered slowly progressing external erosion and, additionally, material resorption by osteoclasts in vivo. The consequences of this were reflected in the degree of bone regeneration. Although a sustained delivery of BMP-2 was achieved with both systems, the brushite construct, independent of the loaded growth factor dose, failed to consistently induce defect repair, a result attributed to its slow resorption rate. In contrast, the PLGA system resulted in complete regeneration with mature trabecular bone formation 8weeks after implantation. [Copyright &y& Elsevier]

Abstract: Dicalcium phosphate cements were developed two decades ago and ever since there has been a substantial growth in research into improving their properties in order to satisfy the requirements needed for several clinical applications. The present paper presents an overview of the rapidly expanding research field of the two main dicalcium phosphate bioceramics: brushite and monetite. This review begins with a summary of all the different formulae developed to prepare dicalcium phosphate cements, and their setting reaction, in order to set the scene for the key cement physical and chemical properties, such as compressive and tensile strength, cohesion, injectability and shelf-life. We address the issue of brushite conversion into either monetite or apatite. Moreover, we discuss the in vivo behavior of the cements, including their ability to promote bone formation, biodegradation and potential clinical applications in drug delivery, orthopedics, craniofacial surgery, cancer therapy and biosensors. [Copyright &y& Elsevier]

Abstract: There is a current need for the localised delivery of antibiotics in order to treat implant-based bacterial infections. Existing treatments use non-resorbable materials such as poly(methyl methacrylate) beads loaded with antibiotics; unfortunately, as they are not resorbable, these beads require secondary surgery for removal. Calcium phosphate cements have considerable potential for the localised delivery of drugs since they can be resorbed to some extent within the body, eliminating the need for a secondary surgical procedure. Therefore, in this study, the efficacy of both hydroxyapatite and brushite cements in the delivery of silver ions has been investigated. The activity of the Ag+ released from the cements was assessed against the growth of both Staphylococcus aureus and Staphylococcus epidermidis; the brushite cement exhibited excellent antibacterial properties and also showed an increase in compressive strength of over 30%. In this study we have found that with a few changes in Ag+ concentration it should be possible to produce a fully resorbable bone replacement material that is combined with an antibacterial scaffold with controlled release over a period of time, which is likely to inhibit bacterial infections associated with implantation procedures. [Copyright &y& Elsevier]

Abstract: Bone replacement using synthetic and degradable materials is desirable in various clinical conditions. Most applied commercial materials are based on hydroxyapatite, which is not chemically degradable under physiological conditions. Here we report the effect of a long-term intramuscular implantation regime on the dissolution of various low temperature calcium and magnesium phosphate ceramics in vivo. The specimens were analysed by consecutive radiographs, micro-computed tomography scans, compressive strength testing, scanning electron microscopy and X-ray diffractometry. After 15months in vivo, the investigated materials brushite (CaHPO4·2H2O), newberyite (MgHPO4·3H2O), struvite (MgNH4PO4·6H2O) and hydroxyapatite (Ca9(PO4)5HPO4OH) showed significant differences regarding changes of their characteristics. Struvite presented the highest loss of mechanical performance (95%), followed by newberyite (67%) and brushite (41%). This was accompanied by both a distinct extent of cement dissolution as well as changes of the phase composition of the retrieved cement implants. While the secondary phosphate phases (brushite, newberyite, struvite) completely dissolved, re-precipitates of whitlockite and octacalcium phosphate were formed in either particulate or whisker-like morphology. Furthermore, for the first time the possibility of a macropore-free volume degradation mechanism of bioceramics was demonstrated. [Copyright &y& Elsevier]

Abstract: The main objective of this study was to investigate calcium phosphate (CaP) coatings on Ti6Al4V substrates by using the biomimetic technique. To this purpose, a new solution was developed to coat CaP on Ti6Al4V alloy substrates. The newly formulated body fluid (Lac-SBF) contained appropriate amounts of sodium lactate (NaL) and lactic acid (HL), as well as all the other ionic constituents of the human blood plasma. The inorganic ion concentrations of the Lac-SBF solutions were identical with those of human blood plasma. The new Lac-SBF solution of this study eliminated the need for using Tris/HCl or Hepes/NaOH buffers. Prior to coating, Ti6Al4V substrates were chemically treated in NaOH and/or NaOH+H2O2 solutions as an alternative route and then heated at 600°C for 1h in air. In the previous applications, the Cl− ion concentration was found to be higher than blood plasma 103mM, which exists in human blood plasma as a result of Tris/HCl which are used to prevent precipitation and to keep the pH level at certain values. In this study, instead of using Tris/HCl, HL/NaL which are generated by human body and do not show any toxic behavior, are used and Cl− concentration was kept at 103mM value for the first time. The prepared Lac-SBF was shown to have similar concentration to human blood plasma in terms of all inorganic ions for the first time. Solution properties were evaluated by using turbidimeter, pH meter and rheometer. The coatings were characterized using Fourier-transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), scanning electron microscopy (SEM), and a scratch tester. The obtained results are presented and discussed. [Copyright &y& Elsevier]

Abstract: New bone cements made of Sr-substituted brushite-forming α-tricalcium phosphate (α-TCP) were prepared and characterized in the present work. The quantitative phase analysis and structural refinement of the starting powders and of hardened cements were performed by X-ray powder diffraction and the Rietveld refinement technique. Isothermal calorimetry along with setting time analysis allowed a precise tracing of the setting process of the pastes. The pastes showed exothermic reactions within the first 10–15min after mixing and further release of heat after about 1h. An apatitic phase formed upon immersion of the hardened cements in simulated body fluid for 15 and 30days due to the conversion of brushite into apatite confirming their in vitro mineralization capability. The compressive strength of the wet cement specimens decreased with increasing curing time, being higher in the case of Sr-substituted CPC. The results suggest that the newly developed Sr-substituted brushite-forming α-TCP cements show promise for uses in orthopaedic and trauma surgery such as in filling bone defects. [Copyright &y& Elsevier]

Abstract: The cohesion of calcium phosphate cements can be improved by the addition of substances to either the solid or liquid phase during the setting reaction. This study reports the effect of silica gel on brushite cement cohesion. The cement was prepared using a mixture of β-tricalcium phosphate (β-TCP) and monocalcium phosphate monohydrate as the solid phase, while the liquid phase comprised carboxylic acids silica gel. This cement presents a shorter final setting time (FST), better cohesion and higher amount of unreacted β-TCP than the cement prepared without silica gel. Furthermore, in vivo experiments using rabbits as an animal model showed that after 8weeks of implantation cements modified with silica gel showed a similar new bone formation volume and more remaining graft in comparison with unmodified cements. Thus, the silica gel could be efficiently applied to reduce cement disintegration and to decrease the resorption rate of brushite cements. [Copyright &y& Elsevier]

Abstract: The improvement of calcium phosphate cement (CPC) cohesion is essential for its application in highly blood perfused regions. This study reports the effectiveness of hyaluronic acids of different molecular weights in the enhancement of brushite cement cohesion. The cement was prepared using a powder phase composed of a mixture of β-tricalcium phosphate and monocalcium phosphate monohydrate, whereas the liquid phase was formed by 0.5M citric acid solution modified by the addition of hyaluronic acid of different molecular weights. It was found that medium and high molecular weight hyaluronic acid enhances the cement cohesion and scarcely affects the cement mechanical properties. However, concentrations >0.5% (w/v) were less efficient to prevent the cement disintegration. It is concluded that hyaluronic acid could be applied efficiently to reduce brushite cement disintegration. [Copyright &y& Elsevier]

Abstract: In the present work a macroporous brushite bone cement for use either as an injected or mouldable paste, or in the shape of preformed grafts, has been investigated. Macropores have been introduced by adding to the powder single crystals of mannitol which worked as a porogen. The size of the crystals was in the range of 250–500μm in diameter, suitable for cell infiltration, with a shape ratio between 3 and 6. From compression tests on cylindrical samples an elastic modulus in the range 2.5–4.2GPa and a compressive strength in the range 17.5–32.6MPa were obtained for a volume fraction of macropores varying between 15 and 0%. Thus the compressive strength exceeded in all tests the maximum value currently attributed to cancellous bone. [Copyright &y& Elsevier]

Abstract: An experimental, light-curable, degradable polyester-based bone adhesive reinforced with phosphate glass particles ((P2O5)0.45(CaO) x (Na2O)0.55− , x =0.3 or 0.4mol) or calcium phosphate (monocalcium phosphate/β-tricalcium phosphate (MCPM/β-TCP)) has been characterized. Early water sorption (8wt.% at 1week) by the unfilled set adhesive catalysed subsequent bulk degradation (4wt.% at 2weeks) and substantial decline in both elastic and storage moduli. Addition of phosphate glass fillers substantially enhanced this water sorption, catalysed greater bulk mass loss (40–50 and 52–55wt.%, respectively) but enabled generation of a microporous scaffold within 2weeks. The high levels of acidic polymer degradation products (38–50wt.% of original polymer) were advantageously buffered by the filler, which initially released primarily sodium trimetaphosphate (). Calcium phosphate addition raised polymer water sorption to a lesser extent (16wt.%) and promoted intermediate early bulk mass loss (12wt.%) but simultaneous anomalous increase in modulus. This was attributed to MCPM reacting with absorbed water and β-TCP to form more homogeneously dispersed brushite (CaHPOx , x =0.3 or 0.4mol) or calcium phosphate (monocalcium phosphate/β-tricalcium phosphate (MCPM/β-TCP)) has been characterized. Early water sorption (8wt.% at 1week) by the unfilled set adhesive catalysed subsequent bulk degradation (4wt.% at 2weeks) and substantial decline in both elastic and storage moduli. Addition of phosphate glass fillers substantially enhanced this water sorption, catalysed greater bulk mass loss (40–50 and 52–55wt.%, respectively) but enabled generation of a microporous scaffold within 2weeks. The high levels of acidic polymer degradation products (38–50wt.% of original polymer) were advantageously buffered by the filler, which initially released primarily sodium trimetaphosphate (). Calcium phosphate addition raised polymer water sorption to a lesser extent (16wt.%) and promoted intermediate early bulk mass loss (12wt.%) but simultaneous anomalous increase in modulus. This was attributed to MCPM reacting with absorbed water and β-TCP to form more homogeneously dispersed brushite (CaHPO4) throughout the polymer. Between 2 and 10weeks, linear erosion of both polymer (0.5wt.%week−1) and composites (0.7–1.2wt.%week−1) occurred, with all fillers providing long-term buffer action through calcium and orthophosphate () release. In conclusion, both fillers can raise degradation of bone adhesives whilst simultaneously providing the buffering action and ions required for new bone formation. Through control of water sorption catalysed filler reactions, porous structures for cell support or substantially stiffer materials may be generated. [Copyright &y& Elsevier]

Abstract: Bioactive composite bone cements were obtained by incorporation of tricalcium silicate (Ca3SiO5, C3S) into a brushite bone cement composed of β-tricalcium phosphate [β-Ca3(PO4)2, β-TCP] and monocalcium phosphate monohydrate [Ca(H2PO4)2·H2O, MCPM], and the properties of the new cements were studied and compared with pure brushite cement. The results indicated that the injectability, setting time and short- and long-term mechanical strength of the material are higher than those of pure brushite cement, and the compressive strength of the TCP/MCPM/C3S composite paste increased with increasing aging time. Moreover, the TCP/MCPM/C3S specimens showed significantly improved in vitro bioactivity in simulated body fluid and similar degradability in phosphate-buffered saline as compared with brushite cement. Additionally, the reacted TCP/MCPM/C3S paste possesses the ability to stimulate osteoblast proliferation and promote osteoblastic differentiation of the bone marrow stromal cells. The results indicated that the TCP/MCPM/C3S cements may be used as a bioactive material for bone regeneration, and might have significant clinical advantage over the traditional β-TCP/MCPM brushite cement. [Copyright &y& Elsevier]

Abstract: This study investigated the cytocompatibility of low-temperature direct 3-D printed calcium phosphate scaffolds in vitro. The fabrication of the scaffolds was performed with a commercial 3-D powder printing system. Diluted phosphoric acid was printed into tricalcium phosphate powder, leading to the formation of dicalcium phosphate dihydrate (brushite). Hydrothermal conversion of the brushite matrices led to the formation of dicalcium phosphate anhydrous (monetite). The biocompatibility was investigated using the osteoblastic cell line MC3T3-E1. Cell viability and the expression of alkaline phosphatase served as parameters. The culture medium was analyzed for pH value, concentration of free calcium and phosphate ions and osteocalcin. Both types of scaffolds showed a considerable increase of cell proliferation and viability; the monetite matrices were a little inferior compared with the brushite ones. The activity of alkaline phosphatase showed a similar pattern. Optical and electron microscopy revealed an obvious cell growth on the surface of both materials. Analysis of the culture medium showed minor alterations of pH value within the physiological range. The concentrations of free calcium and phosphate ions were obviously different among brushite and monetite cultures, due to their different solubility. The content of osteocalcin of the culture medium was reduced by the printed scaffolds due to adsorption. We conclude that the powder printed brushite and monetite matrices have a suitable biocompatibility for their use as cell culture scaffolds. Both materials enable osteoblastic cells in vitro to proliferate and differentiate due to the expression of typical osteoblastic markers. [Copyright &y& Elsevier]

Abstract: Brushite cements differ from apatite-forming compositions by consuming a lot of water in their setting reaction whereas apatite-forming cements consume little or no water at all. Only such cement systems that consume water during setting can theoretically produce near-zero porosity ceramics. This study aimed to produce such a brushite ceramic and investigated whether near elimination of porosity would prevent a burst release profile of incorporated antibiotics that is common to prior calcium phosphate cement delivery matrices. Through adjustment of the powder technological properties of the powder reactants, that is particle size and particle size distribution, and by adjusting citric acid concentration of the liquid phase to 800mM, a relative porosity of as low as 11% of the brushite cement matrix could be achieved (a 60% reduction compared to previous studies), resulting in a wet unprecompacted compressive strength of 52MPa (representing a more than 100% increase to previously reported results) with a workable setting time of 4.5min of the cement paste. Up to 2wt.% of vancomycin and ciprofloxacin could be incorporated into the cement system without loss of wet compressive strength. It was found that drug release rates could be controlled by the adjustable relative porosity of the cement system and burst release could be minimized and an almost linear release achieved, but the solubility of the antibiotic (vancomycin>ciprofloxacin) appeared also to be a crucial factor. [Copyright &y& Elsevier]

Abstract: Calcium phosphate cements typically harden following the combination of a calcium phosphate powder component with an aqueous solution to form a matrix consisting of hydroxyapatite or brushite. The mixing process can be very important to the mechanical properties exhibited by cement materials and consequently when used clinically, since they are usually hand-mixed their mechanical properties are prone to operator-induced variability. It is possible to reduce this variability by pre-mixing the cement, e.g. by replacing the aqueous liquid component with non-reactive glycerol. Here, for the first time, we report the formation of three different pre-mixed brushite cement formulations formed by freezing the cement pastes following combination of the powder and liquid components. When frozen and stored at −80°C or less, significant degradation in compression strength did not occur for the duration of the study (28 days). Interestingly, in the case of the brushite cement formed from the combination of β-tricalcium phosphate with 2M orthophosphoric acid solution, freezing the cement paste had the effect of increasing mean compressive strength fivefold (from 4 to 20MPa). The increase in compression strength was accompanied by a reduction in the setting rate of the cement. As no differences in porosity or degree of reaction were observed, strength improvement was attributed to a modification of crystal morphology and a reduction in damage caused to the cement matrix during manipulation. [Copyright &y& Elsevier]

Abstract: Brushite-based biomaterials are of special interest in bone regeneration due to their biocompatibility and biodegradability; on the other hand, collagen is a well-known osteoconductive biomaterial. In the present study a new brushite–collagen composite biomaterial is reported. This new biomaterial was prepared by combining citric acid/collagen type I solutions with a brushite cement powder. The obtained biomaterial was a cement paste, with improved handling properties. The effect of collagen on the setting reaction of brushite cement was studied, and was found to speed up the cement setting reaction. The cement paste set into a hard ceramic material within 18.5±2.1min and had compressive strength similar to that of spongeous bone (48.9±5.9MPa in dry conditions and 12.7±1.5MPa in humid conditions). The combination of collagen with citric acid revealed an interesting synergistic effect on the compressive strength of the composite material. Moreover, this new biomaterial had excellent cohesion properties (ninefold better than brushite cement), and high cellular adhesion capacity (threefold higher than brushite cement). The composite biomaterial described in this study combines good handling properties, compressive strength, cohesion and cell adhesion capacity, along with the osteoconductive and biodegradable properties inherent in brushite and in collagen-based biomaterials. [Copyright &y& Elsevier]

Abstract: The effect of antibacterial chlorhexidine diacetate powder (CHX) on the setting kinetics of a brushite-forming β-tricalcium phosphate/monocalcium phosphate monohydrate (β-TCP/MCPM) cement was monitored using attenuated total reflection Fourier transform infrared spectroscopy. The final composition of the set cement with up to 12wt.% CHX content before and after submersion in water for 24h, the kinetics of chlorhexidine release and the total sample mass change in water over four weeks was monitored using Raman mapping, UV spectroscopy and gravimetry, respectively. Below 9wt.%, CHX content had no significant effect on brushite formation rate at 37°C, but at 12wt.% the half-life of the reaction decreased by one-third. Raman mapping confirmed that brushite was the main inorganic component of the set cements irrespective of CHX content, both before and after submersion in water. The CHX could be detected largely as discrete solid particles but could also be observed partially dispersed throughout the pores of the set cement. The percentage of CHX release was found to follow Fick’s law of diffusion, being independent of its initial concentration, proportional to the square root of time and, with 1mm thick specimens, 60% was released at 24h. Total set cement mass loss rate was not significantly affected by CHX content. On average, cements exhibited a loss of 7wt.% assigned largely to surface phosphate particle loss within the initial 8h followed by 0.36wt.% per day. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]