JOURNAL ARTICLE
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Biological and mechanical performance and degradation characteristics of calcium phosphate cements in large animals and humans.

Acta Biomaterialia 2020 September 24
Calcium phosphate cements (CPCs) have been used to treat bone defects and support bone regeneration because of their good biocompatibility and osteointegrative behavior. Since their introduction in the 1980s, remarkable clinical success has been achieved with these biomaterials, because they offer the unique feature of being moldable and even injectable into implant sites, where they harden through a low-temperature setting reaction. However, despite decades of research efforts, two major limitations concerning their biological and mechanical performance hamper a broader clinical use. Firstly, achieving a degradation rate that is well adjusted to the dynamics of bone formation remains a challenging issue. While apatite-forming CPCs frequently remain for years at the implant site without major signs of degradation, brushite-forming CPCs are considered to degrade to a greater extent. However, the latter tend to convert into lower soluble phases under physiological conditions, which makes their degradation behavior rather unpredictable. Secondly, CPCs exhibit insufficient mechanical properties for load bearing applications because of their inherent brittleness. This review places an emphasis on these limitations and provides an overview of studies that have investigated the biological and biomechanical performance as well as the degradation characteristics of different CPCs after implantation into trabecular bone. We reviewed studies performed in large animals, because they mimic human bone physiology more closely in terms of bone metabolism and mechanical loading conditions compared with small laboratory animals. We compared the results of these studies with clinical trials that have dealt with the degradation behavior of CPCs after vertebroplasty and kyphoplasty. Statement of significance Ideally, a bone substitute is replaced within a suitable time period by newly formed bone without a temporary decline in mechanical competence. The biological and mechanical performance and degradation characteristics of CPCs vary widely depending on their composition. This review presents an overview of the different CPCs and their functionality in large animals studies, which more closely resemble human bone physiology compared to small animal studies. This allows a more accurate extrapolation of the results to clinical applications, which are also discussed in this review. It is anticipated that this overview will lead to a better understanding of the advantages and current limitations of different CPCs for both basic and clinical scientists.

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