Alpha-Tricalcium Phosphate Bone Cement in the Surgical Treatment of Open Mastoid Cavity

Hypothesis: This study aimed to evaluate the biocompatibility of alpha-tricalcium phosphate bone cement in the obliteration of the mastoid cavity in guinea pigs. Background: Treatment with open cavity mastoidectomy can present poor functional results in chronic otitis media with cholesteatoma, especially if the cavity is large. Partial or total obliteration of the cavity can overcome these problems. Alpha-tricalcium phosphate bone cement has physicochemical characteristics that suggest its potential in mastoid cavity obliteration. Materials and Methods: Twenty guinea pigs were studied. All animals underwent surgery involving the dorsal tympanic bulla. In the study group animals (n = 10), mastoid cavity obliteration was performed with alpha-tricalcium phosphate bone cement. In the control group animals (n = 10), the cavity was left unfilled. On postoperative day 60, the animals were sacrificed and studied for signs of rejection of the material and other complications. Temporal bones were removed for histopathological study, in which the type and degree of inflammatory response, as well as the degree of ossification, were analyzed. Results: The mortality rate was the same in both groups. Deaths were attributed to anesthetic complications in the initial postoperative period. In the animals that survived, there were no complications, and there was good healing of the incision in both groups. There were no clinical signs of rejection of the material, and the histopathological analysis of the cement group revealed no signs of foreign body reaction (inflammatory response). Conclusion: Alpha-tricalcium phosphate bone cement is biocompatible in the mastoid cavity of guinea pigs.

BONE CEMENT AND GENTAMICIN IN THE TREATMENT OF BONE INFECTION. BACKGROUND AND IN VITRO STUDY

Objective: To determine the elution characteristics of the antibiotic (gentamicin) mixed with bone cement. Methods: 480mg of gentamicin was added to 40g of bone cement. Ten specimens were immersed in buffered saline solution for 28 days. Samples of days 1, 2, 7, 14, 21 and 28 were analyzed by the fluorescence polarization immunoassay method, Results: Most of the gentamicin was eluted from the cement in the first 24 hours. A gradual downslide occurred between days 2 and 14. By the 28th day, there was no trace of the antibiotic. Conclusion: The mixture released high amounts of the antibiotic in a predictable (therapeutic) manner during at least fourteen days.

Postmortem findings in bone cement implantation syndrome-related deaths.

Several mechanisms have been postulated as potentially involved in life-threatening complications during cemented surgery. In this study, we evaluated the role of anaphylaxis and pulmonary fat embolism in the pathophysiology of bone cement implantation syndrome in a series of fatal cases that underwent medicolegal investigations. Postmortem findings in these cases were compared with those obtained from individuals who died after other injuries and/or interventions and in which activated mast cells and pulmonary fat embolism were involved in the pathogenesis of death. Fifty subjects were selected including 6 individuals who had undergone cemented total hip arthroplasty and died intraoperatively, 32 subjects who died shortly after being involved in traffic accidents, 8 individuals who died shortly after the injection of contrast material, and 4 subjects who had undergone orthopedic surgery and died postoperatively. Massive pulmonary fat embolism was determined to be the cause of death in all the 6 subjects who died intraoperatively as well as the main cause of death in traffic-road victims with rapid respiratory function deterioration. Mast cell activation was identified exclusively in the group of subjects who died shortly after contrast material administration. Massive pulmonary fat embolism appears to be the most important factor responsible for severe cardiorespiratory function deterioration during cemented arthroplasty. Cardiac comorbidities can also significantly influence the severity of intraoperative complications, thus corroborating the hypothesis of a multifactorial model in the pathogenesis of bone cement implantation syndrome.

Activity of polymethylmethacrylate (PMMA) bone cement loaded with daptomycin, vancomycin and gentamicin against Staphylococcus epidermidis biofilms

Background: Local antibiotics may significantly improve the treatmentoutcome in bone infection without systemic toxicity. For impregnationof polymethylmethacrylate (PMMA), gentamicin, vancomycin and/orclindamycin are currently used. A new lipopeptid antibiotic,daptomycin, is a promising candidate for local treatment due to itsspectrum against staphylococci and enterococci (including multiresistantstrains), and concentration-dependent rapid bactericidalactivity. We investigated activity of antibiotic-loaded PMMA againstStaphylococcus epidermidis biofilms using an ultra-sensitive bacterialheat detection method (microcalorimetry).Methods: Staphylococcus epidermidis (strain RP62A, susceptibleto daptomycin, vancomycin and gentamicin) at concentration 106bacteria/ml was incubated with 2 g-PMMA block (Palacos, HeraeusMedical, Hanau, Germany) in 25 ml tryptic soy broth (TSB)supplemented with calcium. PMMA blocks were preloaded withdaptomycin, vancomycin and gentamicin each at 2 g/40 mg (= 100 mg/block) PMMA. After 72 h-incubation at 35 °C under static conditions,PMMA blocks were rinsed in phosphate-buffered solution (PBS) 5times and transferred in 4 ml-microcalorimetry ampoule filled with 1 mlTSB. Bacterial heat production, which is proportional to the quantityof biofilm on PMMA surface, was measured by isothermalmicrocalorimetry. The detection time was calculated as the time untilthe heat flow reached 20 microwatt.Results: Biomechanical properties did not differ between antibioticloadedand non-loaded PMMA blocks. The mean detection time (±standard deviation) of bacterial heat was 6.5 ± 0.4 h for PMMA withoutantibiotics (negative control), 13.5 ± 4.6 h for PMMA with daptomycin,14.0 ± 4.1 h for PMMA with vancomycin and 5.0 ± 0.4 h for PMMAwith gentamicin.Conclusion: Our data indicates that antibiotics at 2 g/40 mg PMMAdid not change the biomechanical properties of bone cement. Daptomycinand vancomycin were more active than gentamicin against S.epidermidis biofilms when all tested at 2 g/40 mg PMMA. In the nextstep, higher concentrations of daptomycin and their elution kineticneeds to be determined to optimize its antibiofilm activity before usingin the clinical setting.

Activity of bone cement loaded with daptomycin alone or in combination with gentamicin or PEG600 against Staphylococcus epidermidis biofilms.

Daptomycin is a promising candidate for local treatment of bone infection due to its activity against multi-resistant staphylococci. We investigated the activity of antibiotic-loaded PMMA against Staphylococcus epidermidis biofilms using an ultra-sensitive method bacterial heat detection method (microcalorimetry). PMMA cylinders loaded with daptomycin alone or in combination with gentamicin or PEG600, vancomycin and gentamicin were incubated with S. epidermidis-RP62A in tryptic soy broth (TSB) for 72h. Cylinders were thereafter washed and transferred in microcalorimetry ampoules pre-filled with TSB. Bacterial heat production, proportional to the quantity of biofilm on the PMMA, was measured by isothermal microcalorimetry at 37°C. Heat detection time was considered time to reach 20μW. Experiments were performed in duplicate. The heat detection time was 5.7-7.0h for PMMA without antibiotics. When loaded with 5% of daptomycin, vancomycin or gentamicin, detection times were 5.6-16.4h, 16.8-35.7h and 4.7-6.2h, respectively. No heat was detected when 5% gentamicin or 0.5% PEG600 was added to the daptomycin-loaded PMMA. The study showed that vancomycin was superior to daptomycin and gentamicin in inhbiting staphylococcal adherence in vitro. However, PMMA loaded with daptomycin combined with gentamicin or PEG600 completely inhibited S. epidermidis-biofilm formation. PMMA loaded with these combinations may represent effective strategies for local treatment in the presence of multi-resistant staphylococci.

Iliac osteosynthesis with nylon clamp associated to polymethylmethacrylate bone cement - experimental study in dogs cadavers

Fractures of iliac body are generally consequences of traumas of great impact. These fractures lead to a lack of locomotor response and in specific cases, surgery is needed. Among the possible therapeutic lines, implants become a good option. In this paper, the authors used dog corpses to develop a surgery technique of iliac osteosynthesis, employing nylon clamps and bone cement of polymethylmethacrylate (PMMA). Sixteen hemi pelvises of eight dog corpses, which had its iliac bodies totally fractured previously, were utilized. The osteosynthesis was reached through the implantation of six nylon clamps, distributed equally between the bone fragments. With the use of the nylon clamps there were bone realignment and a contact surface to fixation of the biomaterial. The technique developed in corpses was easily executed, effective in reduction, alignment and stabilization of the fracture. The authors suggest more studies in vitro to evaluate immobilization resistance and functionality in dogs with this condition.

Multiscale Characterization of Acrylic Bone Cement Modified with Functionalized Mesoporous Silica Nanoparticles

Acrylic bone cement is widely used to anchor orthopedic implants to bone and mechanical failure of the cement mantle surrounding an implant can contribute to aseptic loosening. In an effort to enhance the mechanical properties of bone cement, a variety of nanoparticles and fibers can be incorporated into the cement matrix. Mesoporous silica nanoparticles (MSNs) are a class of particles that display high potential for use as reinforcement within bone cement. Therefore, the purpose of this study was to quantify the impact of modifying an acrylic cement with various low-loadings of mesoporous silica. Three types of MSNs (one plain variety and two modified with functional groups) at two loading ratios (0.1 and 0.2 wt/wt) were incorporated into a commercially available bone cement. The mechanical properties were characterized using four-point bending, microindentation and nanoindentation (static, stress relaxation, and creep) while material properties were assessed through dynamic mechanical analysis, differential scanning calorimetry, thermogravimetric analysis, FTIR spectroscopy, and scanning electron microscopy. Four-point flexural testing and nanoindentation revealed minimal impact on the properties of the cements, except for several changes in the nano-level static mechanical properties. Conversely, microindentation testing demonstrated that the addition of MSNs significantly increased the microhardness. The stress relaxation and creep properties of the cements measured with nanoindentation displayed no effect resulting from the addition of MSNs. The measured material properties were consistent among all cements. Analysis of scanning electron micrographs images revealed that surface functionalization enhanced particle dispersion within the cement matrix and resulted in fewer particle agglomerates. These results suggest that the loading ratios of mesoporous silica used in this study were not an effective reinforcement material. Future work should be conducted to determine the impact of higher MSN loading ratios and alternative functional groups. (C) 2014 Elsevier Ltd. All rights reserved.

The effect of pulsed jet lavage in vertebroplasty on injection forces of polymethylmethacrylate bone cement, material distribution, and potential fat embolism: a cadaver study

STUDY DESIGN: In vitro testing of vertebroplasty techniques including pulsed jet-lavage for fat and marrow removal in human cadaveric lumbar and thoracic vertebrae. OBJECTIVE: To develop jet-lavage techniques for vertebroplasty and investigate their effect on cement distribution, injection forces, and fat embolism. SUMMARY OF BACKGROUND DATA: The main complications of cement vertebroplasty are cement leakage and pulmonary fat embolism, which can have fatal consequences and are difficult to prevent reliably by current vertebroplasty techniques. METHODS: Twenty-four vertebrae (Th8-L04) from 5 osteoporotic cadaver spines were grouped in triplets depending on bone mineral density (BMD). Before polymethylmethacrylate (PMMA) vertebroplasty, a pulsatile jet-lavage for removal of intertrabecular fat and bone marrow was performed in 2 groups with 8 specimens each, performing radial and axial irrigation from the biopsy needles. One hundred mL of Ringer solution were injected through 1 pedicle and regained by low vacuum via the contralateral pedicle. Eight control vertebrae were not irrigated. All specimens underwent standardized PMMA cement augmentation injecting 20% of the vertebral volume. Injection forces, cement distribution, and extravasations were quantified. RESULTS: All irrigation solution could be retrieved with the vacuum applied. A Kruskal-Wallis test revealed significantly higher injection forces of the control group as compared with the irrigated groups (P = 0.021). Dilatation of the syringe at forces above 300 N occurred in 75% of the untreated compared with 12.5% of the lavaged specimens. CT distribution analysis showed more homogenous cement distribution of the cement and significantly less extravasation in the irrigated specimens. CONCLUSION: The developed lavage technique for vertebroplasty showed to be feasible and reproducible. The reduction of injection forces would allow the use of more viscous PMMA cement lowering the risk for cement embolization and results in a safer procedure. The wash-out of bone marrow and the possible reduction of pulmonary fat embolism have to be verified with in vivo models.

Long-term reaction to bone cement in osteoporotic bone: new bone formation in vertebral bodies after vertebroplasty

Elderly patients frequently suffer from osteoporotic vertebral fractures resulting in the need of vertebroplasty or kyphoplasty. Nevertheless, no data are available about the long-term consequences of cement injection into osteoporotic bone. Therefore, the aim of the present study was to evaluate the long-term tissue reaction on bone cement injected to osteoporotic bone during vertebroplasty. The thoracic spine of an 80-year-old female was explanted 3.5 years after vertebroplasty with polymethylmethacrylate. The treatment had been performed due to painful osteoporotic compression fractures. Individual vertebral bodies were cut in axial or sagittal sections after embedding. The sections were analysed using contact radiography and staining with toluidine blue. Furthermore, selected samples were evaluated with scanning electron microscopy and micro-compted tomography (in-plane resolution 6 microm). Large amounts of newly formed callus surrounding the injected polymethylmethacrylate were detected with all imaging techniques. The callus formation almost completely filled the spaces between the vertebral endplate, the cancellous bone, and the injected polymethylmethacrylate. In trabecular bone microfractures and osteoclast lacuna were bridged or filled with newly formed bone. Nevertheless, the majority of the callus formation was found in the immediate vicinity of the polymethylmethacrylate without any obvious relationship to trabecular fractures. The results indicate for the first time that, contrary to established knowledge, even in osteoporosis the formation of large amounts of new bone is possible.

Properties of an injectable low modulus PMMA bone cement for osteoporotic bone

The use of polymethylmethacrylate (PMMA) cement to reinforce fragile or broken vertebral bodies (vertebroplasty) leads to extensive bone stiffening. Fractures in the adjacent vertebrae may be the consequence of this procedure. PMMA with a reduced Young's modulus may be more suitable. The goal of this study was to produce and characterize stiffness adapted PMMA bone cements. Porous PMMA bone cements were produced by combining PMMA with various volume fractions of an aqueous sodium hyaluronate solution. Porosity, Young's modulus, yield strength, polymerization temperature, setting time, viscosity, injectability, and monomer release of those porous cements were investigated. Samples presented pores with diameters in the range of 25-260 microm and porosity up to 56%. Young's modulus and yield strength decreased from 930 to 50 MPa and from 39 to 1.3 MPa between 0 and 56% porosity, respectively. The polymerization temperature decreased from 68 degrees C (0%, regular cement) to 41 degrees C for cement having 30% aqueous fraction. Setting time decreased from 1020 s (0%, regular cement) to 720 s for the 30% composition. Viscosity of the 30% composition (145 Pa s) was higher than the ones received from regular cement and the 45% composition (100-125 Pa s). The monomer release was in the range of 4-10 mg/mL for all porosities; showing no higher release for the porous materials. The generation of pores using an aqueous gel seems to be a promising method to make the PMMA cement more compliant and lower its mechanical properties to values close to those of cancellous bone.