Loading compliance of static load bearing exercises performed by transfemoral amputees fitted with an osseointegrated implant

Background To date bone-anchored prostheses are used to alleviate the concerns caused by socket suspended prostheses and to improve the quality of life of transfemoral amputees (TFA). Currently, two implants are commercially available (i.e., OPRA (Integrum AB, Sweden), ILP (Orthodynamics GmbH, Germany)). [1-17]The success of the OPRA technique is codetermined by the rehabilitation program. TFA fitted with an osseointegrated implant perform progressive mechanical loading (i.e. static load bearing exercises (LBE)) to facilitate bone remodelling around the implant.[18, 19] Aim This study investigated the trustworthiness of monitoring the load prescribed (LP) during experimental static LBEs using the vertical force provided by a mechanical bathroom scale that is considered a surrogate of the actual load applied. Method Eleven unilateral TFAs fitted with an OPRA implant performed five trials in four loading conditions. The forces and moments on the three axes of the implant were measured directly with an instrumented pylon including a six-channel transducer. The “axial” and “vectorial” comparisons corresponding to the difference between the force applied on the long axis of the fixation and LP as well as the resultant of the three components of the load applied and LP, respectively were analysed Results For each loading condition, Wilcoxon One-Sample Signed Rank Tests were used to investigate if significant differences (p<0.05) could be demonstrated between the force applied on the long axis and LP, and between the resultant of the force and LP. The results demonstrated that the raw axial and vectorial differences were significantly different from zero in all conditions (p<0.05), except for the vectorial difference for the 40 kg loading condition (p=0.182). The raw axial difference was negative for all the participants in every loading condition, except for TFA03 in the 10 kg condition (11.17 N). Discussion & Conclusion This study showed a significant lack of axial compliance. The load applied on the long axis was significantly smaller than LP in every loading condition. This led to a systematic underloading of the long axis of the implant during the proposed experimental LBE. Monitoring the vertical force might be only partially reflective of the actual load applied, particularly on the long axis of the implant.

Bone-anchored prosthesis: Current developments worldwide and challenges

Background Individuals with limb amputation fitted with conventional socket-suspended prostheses often experience socket related discomfort leading to a significant decrease in quality of life. Most of these concerns can be overcome by surgical techniques enabling bone-anchored prostheses. In this case, the prosthesis is attached directly to the residual skeleton through a percutaneous implant (e.g., screw type fixation, press-fit implant).[46, 48, 51, 52, 77, 78] The aim of this study is to present the current advances in these surgical techniques worldwide with a strong focus on the current challenges. Methods The current advances will be extracted from a systematic literature review including approximately 40 articles. The outcomes measured will include the estimation of the population worldwide as well as the complications (e.g., infection, loosening, fractures, and breakage) and the benefits (e.g., functional outcomes, health-related quality of life).[5-19, 51-53, 55, 57, 58, 62, 73, 79] Results The population of individuals fitted with a bone-anchored prosthesis is approximately 550 worldwide. Publications focusing on infection are sparse. However, the rate of superficial infection is estimated at 20%. Deep infection occurs rarely. Loosening and peri-prosthetic fractures are fairly uncommon. Breakage of implant parts occurs regularly mainly due to fall. All studies reported a significant improvement in functional level and overall quality of life. Conclusions Several commercial implants are in developments in Europe and US. The number of procedures is consistently growing worldwide. This technique might be primary way to fit a prosthesis to young and active amputees by 2025.

Bone-anchored prosthesis: Current developments worldwide and challenges

Background Individuals with limb amputation fitted with conventional socket-suspended prostheses often experience socket related discomfort leading to a significant decrease in quality of life. Most of these concerns can be overcome by surgical techniques enabling bone-anchored prostheses. In this case, the prosthesis is attached directly to the residual skeleton through a percutaneous implant (e.g., screw type fixation, press-fit implant).[46, 48, 51, 52, 77, 78] The aim of this study is to present the current advances in these surgical techniques worldwide with a strong focus on the current challenges. Methods The current advances will be extracted from a systematic literature review including approximately 40 articles. The outcomes measured will include the estimation of the population worldwide as well as the complications (e.g., infection, loosening, fractures, and breakage) and the benefits (e.g., functional outcomes, health-related quality of life).[5-19, 51-53, 55, 57, 58, 62, 73, 79] Results The population of individuals fitted with a bone-anchored prosthesis is approximately 550 worldwide. Publications focusing on infection are sparse. However, the rate of superficial infection is estimated at 20%. Deep infection occurs rarely. Loosening and peri-prosthetic fractures are fairly uncommon. Breakage of implant parts occurs regularly mainly due to fall. All studies reported a significant improvement in functional level and overall quality of life. Conclusions Several commercial implants are in developments in Europe and US. The number of procedures is consistently growing worldwide. This technique might be primary way to fit a prosthesis to young and active amputees by 2025.

Can the direct measurement of the load applied on the residuum of individuals with transfemoral amputation fitted with bone-anchored prosthesis help to improve the rehabilitation program?

To strive to improve the rehabilitation program of individuals with transfemoral amputation fitted with bone-anchored prosthesis based on data from direct measurements of the load applied on the residuum we first of all need to understand the load applied on the fixation. Therefore the load applied on the residuum was first directly measured during standardized activities of daily living such as straight line level walking, ascending and descending stairs and a ramp and walking around a circle. From measuring the load in standardized activities of daily living the load was also measured during different phases of the rehabilitation program such as during walking with walking aids and during load bearing exercises.[1-15] The rehabilitation program for individuals with a transfemoral amputation fitted with an OPRA implant relies on a combination of dynamic and static load bearing exercises.[16-20] This presentation will focus on the study of a set of experimental static load bearing exercises. [1] A group of eleven individuals with unilateral transfemoral amputation fitted with an OPRA implant participated in this study. The load on the implant during the static load bearing exercises was measured using a portable system including a commercial transducer embedded in a short pylon, a laptop and a customized software package. This apparatus was previously shown effective in a proof-of-concept study published by Prof. Frossard. [1-9] The analysis of the static load bearing exercises included an analysis of the reliability as well as the loading compliance. The analysis of the loading reliability showed a high reliability between the loading sessions indicating a correct repetition of the LBE by the participants. [1, 5] The analysis of the loading compliance showed a significant lack of axial compliance leading to a systematic underloading of the long axis of the implant during the proposed experimental static LBE.

Can we safely deform a plate to fit every bone? Population-based fit assessment and finite element deformation of a distal tibial plate

Anatomically precontoured plates are commonly used to treat periarticular fractures. A well-fitting plate can be used as a tool for anatomical reduction of the fractured bone. Recent studies highlighted that some plates fit poorly for many patients due to considerable shape variations between bones of the same anatomical site. While it is impossible to design one shape that fits all, it is also burdensome for the manufacturers and hospitals to produce, store and manage multiple plate shapes without the certainty of utilization by a patient population. In this study, we investigated the number of shapes required for maximum fit within a given dataset, and if they could be obtained by manually deforming the original plate. A distal medial tibial plate was automatically positioned on 45 individual tibiae, and the optimal deformation was determined iteratively using finite element analysis simulation. Within the studied dataset, we found that: (i) 89% fit could be achieved with four shapes, (ii) 100% fit was impossible through mechanical deformation, and (iii) the deformations required to obtain the four plate shapes were safe for the stainless steel plate for further clinical use. The proposed framework is easily transferable to other orthopaedic plates.

ADAMs, Osteoclastogenesis and Bone Destruction in the Loosening of the Totally Replaced Hip

Total hip replacement is the golden standard treatment for severe osteoarthritis refractory for conservative treatment. Aseptic loosening and osteolysis are the major long-term complications after total hip replacement. Foreign body giant cells and osteoclasts are locally formed around aseptically loosening implants from precursor cells by cell fusion. When the foreign body response is fully developed, it mediates inflammatory and destructive host responses, such as collagen degradation. In the present study, it was hypothesized that the wear debris and foreign body inflammation are the forces driving local osteoclast formation, peri-implant bone resorption and enhanced tissue remodeling. Therefore the object was to characterize the eventual expression and the role of fusion molecules, ADAMs (an abbreviation for A Disintegrin And Metalloproteinase, ADAM9 and ADAM12) in the fusion of progenitor cells into multinuclear giant cells. For generation of such cells, activated macrophages trying to respond to foreign debris play an important role. Matured osteoclasts together with activated macrophages mediate bone destruction by secreting protons and proteinases, including matrix metalloproteinases (MMPs) and cathepsin K. Thus this study also assessed collagen degradation and its relationship to some of the key collagenolytic proteinases in the aggressive synovial membrane-like interface tissue around aseptically loosened hip replacement implants. ADAMs were found in the interface tissues of revision total hip replacement patients. Increased expression of ADAMs at both transcriptional and translational levels was found in synovial membrane-like interface tissue of revision total hip replacement (THR) samples compared with that in primary THR samples. These studies also demonstrate that multinucleate cell formation from monocytes by stimulation with macrophage-colony stimiulating factor (M-CSF) and receptor activator of nuclear factor kappa B ligand (RANKL) is characterized by time dependent changes of the proportion of ADAMs positive cells. This was observed both in the interface membrane in patients and in two different in vitro models. In addition to an already established MCS-F and RANKL driven model, a new virally (parainfluenza 2) driven model (of human salivary adenocarcinoma (HSY) cells or green monkey kidney (GMK) cells) was developed to study various fusion molecules and their role in cell fusion in general. In interface membranes, collagen was highly degraded and collagen degradation significantly correlated with the number of local cells containing collagenolytic enzymes, particularly cathepsin K. As a conclusion, fusion molecules ADAM9 and ADAM12 seem to be dynamically involved in cell-cell fusion processes and multinucleate cell formation. The highly significant correlation between collagen degradation and collagenolytic enzymes, particularly cathepsin K, indicates that the local acidity of the interface membrane in the pathologic bone and soft tissue destruction. This study provides profound knowledge about cell fusion and mechanism responsible for aseptic loosening as well as increases knowledge helpful for prevention and treatment.

Novel surgical and imaging methods of the middle ear and temporal bone

Välikorvaleikkauksiin usein liittyvän välikorvan ja kuuloluuketjun kirurgisen rekonstruktion tavoitteena on luoda olosuhteet, jotka mahdollistavat hyvän kuulon sekä välikorvan säilymisen tulehduksettomana ja ilmapitoisena. Välikorvan rekonstruktiossa on käytetty implanttimateriaaleina perinteisesti potilaan omia kudoksia sekä tarvittaessa erilaisia hajoamattomia biomateriaaleja, mm. titaania ja silikonia. Ongelmana biomateriaalien käytössä voi olla bakteerien adherenssi eli tarttuminen vieraan materiaalin pintaan, mikä saattaa johtaa biofilmin muodostumiseen. Tämä voi aiheuttaa kroonisen, huonosti antibiootteihin reagoivan infektion kudoksessa, mikä usein käytännössä johtaa uusintaleikkaukseen ja implantin poistoon. Maitohappo- ja glykolihappopohjaiset biologisesti hajoavat polymeerit ovat olleet kliinisessä käytössä jo vuosikymmeniä. Niitä on käytetty erityisesti tukimateriaaleina mm. ortopediassa sekä kasvo- ja leukakirurgiassa. Niitä ei ole toistaiseksi käytetty välikorvakirurgiassa. Korvan kuvantamiseen käytetään ensisijaisesti tietokonetomografiaa (TT). TT-tutkimuksen ongelmana on potilaan altistuminen suhteellisen korkealle sädeannokselle, joka kasvaa kumulatiivisesti, jos kuvaus joudutaan toistamaan. Väitöskirjatyö selvittää uuden, aiemmin kliinisessä työssä rutiinisti lähinnä hampaiston ja kasvojen alueen kuvantamiseen käytetyn rajoitetun kartiokeila-TT:n soveltuvuutta korvan alueen kuvantamiseen. Väitöskirjan kahdessa ensimmäisessä osatyössä tutkittiin ja verrattiin kahden kroonisia ja postoperatiivisia korvainfektioita aiheuttavan bakteerin, Staphylococcus aureuksen ja Pseudomonas aeruginosan, in vitro adherenssia titaanin, silikonin ja kahden eri biohajoavan polymeerin (PLGA) pintaan. Lisäksi tutkittiin materiaalien albumiinipinnoituksen vaikutusta adherenssiin. Kolmannessa osatyössä tutkittiin eläinmallissa PLGA:n biokompatibiliteettia eli kudosyhteensopivuutta kokeellisessa välikorvakirurgiassa. Chinchillojen välikorviin istutettiin PLGA-materiaalia, eläimiä seurattiin, ja ne lopetettiin 6 kk:n kuluttua operaatiosta. Biokompatibiliteetin arviointi perustui kliinisiin havaintoihin sekä kudosnäytteisiin. Neljännessä osatyössä tutkittiin kartiokeila-TT:n soveltuvuutta korvan alueen kuvantamiseen vertaamalla sen tarkkuutta perinteisen spiraali-TT:n tarkkuuteen. Molemmilla laitteilla kuvattiin ohimo- eli temporaaliluita korvan alueen kliinisesti ja kirurgisesti tärkeiden rakenteiden kuvantumisen tarkkuuden arvioimiseksi. Viidennessä osatyössä arvioitiin myös operoitujen temporaaliluiden kuvantumista kartiokeila-TT:ssa. Bakteeritutkimuksissa PLGA-materiaalin pintaan tarttui keskimäärin korkeintaan saman verran tai vähemmän bakteereita kuin silikonin tai titaanin. Albumiinipinnoitus vähensi bakteeriadherenssia merkitsevästi kaikilla materiaaleilla. Eläinkokeiden perusteella PLGA todettiin hyvin siedetyksi välikorvassa. Korvakäytävissä tai välikorvissa ei todettu infektioita, tärykalvon perforaatioita tai materiaalin esiin työntymistä. Kudosnäytteissä näkyi lievää tulehdusreaktiota ja fibroosia implantin ympärillä. Temporaaliluutöissä rajoitettu kartiokeila-TT todettiin vähintään yhtä tarkaksi menetelmäksi kuin spiraali-TT välikorvan ja sisäkorvan rakenteiden kuvantamisessa, ja sen aiheuttama kertasäderasitus todettiin spiraali-TT:n vastaavaa huomattavasti vähäisemmäksi. Kartiokeila-TT soveltui hyvin välikorvaimplanttien ja postoperatiivisen korvan kuvantamiseen. Tulokset osoittavat, että PLGA on välikorvakirurgiaan soveltuva, turvallinen ja kudosyhteensopiva biomateriaali. Biomateriaalien pinnoittaminen albumiinilla vähentää merkittävästi bakteeriadherenssia niihin, mikä puoltaa pinnoituksen soveltamista implanttikirurgiassa. Kartiokeila-TT soveltuu korvan alueen kuvantamiseen. Sen tarkkuus kliinisesti tärkeiden rakenteiden osoittamisessa on vähintään yhtä hyvä ja sen potilaalle aiheuttama sädeannos pienempi kuin nykyisen korva-spiraali-TT:n. Tämä tekee menetelmästä spiraali-TT:aa potilasturvallisemman vaihtoehdon erityisesti, jos potilaan tilanne vaatii seurantaa ja useampia kuvauksia, ja jos halutaan kuvata rajoitettuja alueita uni- tai bilateraalisesti.

Multifunctional Properties of Multistage Spark Plasma Sintered HA-BaTiO3-Based Piezobiocomposites for Bone Replacement Applications

This work reports the processing-microstructure-property correlation of novel HA-BaTiO3-based piezobiocomposites, which demonstrated the bone-mimicking functional properties. A series of composites of hydroxyapatite (HA) with varying amounts of piezoelectric BaTiO3 (BT) were optimally processed using uniquely designed multistage spark plasma sintering (SPS) route. Transmission electron microscopy imaging during in situ heating provides complementary information on the real-time observation of sintering behavior. Ultrafine grains (0.50m) of HA and BT phases were predominantly retained in the SPSed samples. The experimental results revealed that dielectric constant, AC conductivity, piezoelectric strain coefficient, compressive strength, and modulus values of HA-40wt% BT closely resembles with that of the natural bone. The addition of 40wt% BT enhances the long-crack fracture toughness, compressive strength, and modulus by 132%, 200%, and 165%, respectively, with respect to HA. The above-mentioned exceptional combination of functional properties potentially establishes HA-40wt% BT piezocomposite as a new-generation composite for orthopedic implant applications.

Incorporation of chitosan in acrylic bone cement: Effect on antibiotic release, bacterial biofilm formation and mechanical properties

Bacterial infection remains a significant problem following total joint replacement. Efforts to prevent recurrent implant infection, including the use of antibiotic-loaded bone cement for implant fixation at the time of revision surgery, are not always successful. In this in vitro study, we investigated whether the addition of chitosan to gentamicin-loaded Palacos® R bone cement increased antibiotic release and prevented bacterial adherence and biofilm formation by Staphylococcus spp. clinical isolates. Furthermore, mechanical tests were performed as a function of time post-polymerisation in pseudo-physiological conditions. The addition of chitosan to gentamicin-loaded Palacos® R bone cement significantly decreased gentamicin release and did not increase the efficacy of the bone cement at preventing bacterial colonisation and biofilm formation. Moreover, the mechanical performance of cement containing chitosan was significantly reduced after 28 days of saline degradation with the compressive and bending strengths not in compliance with the minimum requirements as stipulated by the ISO standard for PMMA bone cement. Therefore, incorporating chitosan into gentamicin-loaded Palacos® R bone cement for use in revision surgery has no clinical antimicrobial benefit and the detrimental effect on mechanical properties could adversely affect the longevity of the prosthetic joint.

In vitro study of the efficacy of acrylic bone cement loaded with supplementary amounts of gentamicin: Effect on mechanical properties, antibiotic release, and biofilm formation

Background: Infection remains a severe complication following a total hip replacement. If infection is suspected when revision surgery is being performed, additional gentamicin is often added to the cement on an ad hoc basis in an attempt to reduce the risk of recurrent infection.

Methods and results: In this in vitro study, we determined the effect of incorporating additional gentamicin on the mechanical properties of cement. We also determined the degree of gentamicin release from cement, and also the extent to which biofilms of clinical Staphylococcus spp. isolates form on cement in vitro. When gentamicin was added to unloaded cement (1–4 g), there was a significant reduction in the mechanical performance of the loaded cements compared to unloaded cement. A significant increase in gentamicin release from the cement over 72 h was apparent, with the amount of gentamicin released increasing significantly with each additional 1 g of gentamicin added. When overt infection was modeled, the incorporation of additional gentamicin did result in an initial reduction in bacterial colonization, but this beneficial effect was no longer apparent by 72 h, with the clinical strains forming biofilms on the cements despite the release of high levels of gentamicin.

Interpretation: Our findings indicate that the addition of large amounts of gentamicin to cement is unlikely to eradicate bacteria present as a result of an overt infection of an existing implant, and could result in failure of the prosthetic joint because of a reduction in mechanical performance of the bone cement.

The relationship between cement fatigue damage and implant surface finish in proximal femoral prostheses

The majority of cemented femoral hip replacements fail as a consequence of loosening. One design feature that may affect loosening rates is implant surface finish. To determine whether or not surface finish effects fatigue damage accumulation in a bone cement mantle, we developed an experimental model of the implanted proximal femur that allows visualisation of damage growth in the cement layer. Five matt surface and five polished surface stems were tested. Pre-load damage and damage after two million cycles was measured. Levels of pre-load (shrinkage) damage were the same for both matt and polished stems; furthermore damage for matt vs. polished stems was not significantly different after two million cycles. This was due to the large variability in damage accumulation rates. Finite element analysis showed that the stress is higher for the polished (assumed debonded) stem, and therefore we must conclude that either the magnitude of the stress increase is not enough to appreciably increase the damage accumulation rate or, alternatively, the polished stem does not debond immediately from the cement. Significantly (P = 0.05) more damage was initiated in the lateral cement compared to the medial cement for both kinds of surface finish. It was concluded that, despite the higher cement stresses with debonded stems, polished prostheses do not provoke the damage accumulation failure scenario. (C) 2003 IPEM. Published by Elsevier Ltd. All rights reserved.

Computer simulating a trial of a load-bearing implant: example of an intramedullary prosthesis

Computational modelling is becoming ever more important for obtaining regulatory approval for new medical devices. An accepted approach is to infer performance in a population from an analysis conducted for an idealised or ‘average’ patient; we present here a method for predicting the performance of an orthopaedic implant when released into a population—effectively simulating a clinical trial. Specifically we hypothesise that an analysis based on a method for predicting the performance in a population will lead to different conclusions than an analysis based on an idealised or ‘average’ patient. To test this hypothesis we use a finite element model of an intramedullary implant in a bone whose size and remodelling activity is different for each individual in the population. We compare the performance of a low Young’s modulus implant (View the MathML source) to one with a higher Young’s modulus (200 GPa). Cyclic loading is applied and failure is assumed when the migration of the implant relative to the bone exceeds a threshold magnitude. The analysis for an idealised of ‘average’ patient predicts that the lower modulus device survives longer whereas the analysis simulating a clinical trial predicts no statistically-significant tendency (p=0.77) for the low modulus device to perform better. It is concluded that population-based simulations of implant performance–simulating a clinical trial–present a very valuable opportunity for more realistic computational pre-clinical testing of medical devices.

Modelling fatigue of bone cement

Accurate models of cement and interface fatigue are essential if computationally assessing risk of aseptic loosening of cemented joint replacements is to become clinically relevant. A series of approaches will be presented that attempt to model several aspects of bone cement fatigue relevant to predicting cemented joint replacement failure. Failure models for homogeneous (bulk) bone cement and its interface with implant and host tissue are reviewed. Variability introduced by porosity and interaction between fatigue and creep are also considered. Finally, some current and potential future developments are discussed.

Implant-retained overdentures did not have a significant improvement in dietary intake

DESIGN: Randomised controlled trial.

INTERVENTION: Patients aged 65 or above edentate for a minimum of five years, with sufficient bone for two implants in the anterior mandible, were recruited. Those with systemic disease that contraindicated implants or had a low mini-mental state evaluation score were excluded. Patients in both groups had a standard maxillary complete denture fabricated. Patients randomised to the treatment group received a two-implant mandibular overdenture while those in the control group received a standard mandibular complete denture. Three 24-hour dietary recalls were collected by telephone interviews at baseline and at 12 months.

RESULTS: 255 patients were randomised: 128 received a standard complete denture (CD) and 127 a two-implant mandibular overdenture (IOD). 127 patients were available at 12-month follow up, 114 in the CD group and 103 in the IOD group. No significant between-group differences were found.

CONCLUSIONS: Although there is much evidence supporting the adoption of two-implant mandibular overdenture (IOD) treatment as the standard of care for edentate patients, this evidence does not include an improvement in dietary intake at one year for medically healthy independent edentate elders when given no specific dietary counselling.

Acrylic bone cements modified with bioactive and biodegradable fillers

O cimento ósseo acrílico é o único material utilizado para a fixação de próteses em cirurgias ortopédicas, surgindo como uma alternativa às técnicas não cimentadas. Cerca de um milhão de pacientes são anualmente tratados para a substituição total da articulação do quadril e do joelho. Com a maior expectativa de vida da população e o aumento do número de cirurgias realizadas por ano espera-se que o uso do cimento ósseo aumente substancialmente. A fraca ligação do cimento ao osso é um problema comum que pode causar perda asséptica da prótese. Assim, torna-se necessário investir no desenvolvimento de cimentos ósseos alternativos que permitam promover maior estabilidade e melhor desempenho do implante. O principal objetivo desta tese foi desenvolver um cimento ósseo bioativo, capaz de ligar-se ao osso, com propriedades melhoradas relativamente aos sistemas convencionais. A preparação dos materiais foi realizada por dois processos diferentes, a polimerização por via térmica e a polimerização por via química. Inicialmente, utilizando o processo térmico, foram desenvolvidos compósitos de PMMA-co-EHA reforçados com vidro de sílica (CSi) e vidro de boro (CB) e comparados em termos do seu comportamento in vitro em meio acelular e celular. A formação de precipitados de fosfato de cálcio foi observada sobre a superfície de todos os compósitos indicando que estes materiais são potencialmente bioativos. Em relação à avaliação biológica o CSi demonstrou um efeito indutor da proliferação das células. As células apresentaram uma morfologia normal e alta taxa de crescimento quando comparadas com o padrão de cultura. Por outro lado ocorreu inibição da proliferação celular para o CB provavelmente devido à sua elevada taxa de degradação, levando a uma elevada concentraçao de iões de B e de Mg no meio de cultura. O efeito do vidro nos cimentos curados por via química, incorporando um activador de baixa toxicidade, também foi avaliado. Os resultados sugerem que as novas formulações podem diminuir o efeito exotérmico na cura do cimento e melhorar as propriedades mecânicas (flexão e compressão). Outro estudo conduzido neste trabalho explorou a possibilidade de incorporar ibuprofeno (fármaco anti-inflamatório) no cimento, dando origem a um material capaz de ser simultaneamente, bioativo e promotor da libertação controlada de fármacos. Neste contexto foi evidenciado que o desempenho do cimento desenvolvido pode contribuir para minimizar o processo inflamatório associado a uma cirurgia ortopédica. Finalmente, a fase sólida do cimento ósseo bioativo foi modificada por diferentes polímeros biodegradáveis. A adição deste enchimento deu origem a um cimento parcialmente biodegradável que pode permitir a formação de poros e o crescimento ósseo para o interior do cimento, resultando numa melhor fixação da prótese.