US20140234435A1 - Setting of hardenable bone substitute - Google Patents

Setting of hardenable bone substitute Download PDF

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US20140234435A1
US20140234435A1 US14/185,668 US201414185668A US2014234435A1 US 20140234435 A1 US20140234435 A1 US 20140234435A1 US 201414185668 A US201414185668 A US 201414185668A US 2014234435 A1 US2014234435 A1 US 2014234435A1
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composition
hydroxyapatite
passivated
bone substitute
raw
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Kristina C.V. EHRENBORG
Veronica R. Sandell
Eva C. Lidén
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Bone Support AB
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Bone Support AB
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Assigned to BONE SUPPORT AB reassignment BONE SUPPORT AB ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: EHRENBORG, KRISTINA CAROLINE V., LIDEN, EVA C., SANDELL, VERONICA R.
Publication of US20140234435A1 publication Critical patent/US20140234435A1/en
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    • C01B—NON-METALLIC ELEMENTS; COMPOUNDS THEREOF; METALLOIDS OR COMPOUNDS THEREOF NOT COVERED BY SUBCLASS C01C
    • C01B25/00—Phosphorus; Compounds thereof
    • C01B25/16—Oxyacids of phosphorus; Salts thereof
    • C01B25/26—Phosphates
    • C01B25/32—Phosphates of magnesium, calcium, strontium, or barium
    • C01B25/327—After-treatment
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    • A61K31/7034—Compounds having saccharide radicals attached to non-saccharide compounds by glycosidic linkages attached to a carbocyclic compound, e.g. phloridzin
    • A61K31/7036—Compounds having saccharide radicals attached to non-saccharide compounds by glycosidic linkages attached to a carbocyclic compound, e.g. phloridzin having at least one amino group directly attached to the carbocyclic ring, e.g. streptomycin, gentamycin, amikacin, validamycin, fortimicins
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Definitions

  • the present invention relates to hardenable ceramic bone substitute compositions having improved setting, powders for such compositions and methods for their manufacture and use in medical treatment. More specifically, the invention relates to hardenable bone substitute powder and hardenable bone substitute paste with improved setting properties, comprising calcium sulfate and heat-treated hydroxyapatite (passivated HA), which bone substitute is suitable for treatment of disorders of supportive tissue such as bone loss, bone fracture, bone trauma, and osteomyelitis.
  • HA hydroxyapatite
  • Bone is the second most common tissue to be transplanted after blood.
  • the most reliable method to repair bone defects is to use autogenous bone, i.e. bone taken from another site in the body.
  • problems may occur at the second surgical site from where the graft is taken.
  • allografts can be used, i.e. bone graft between individuals of the same species. Allografts have a lower osteogenic capacity than autografts and the rate of new bone formation might be lower. They also have a higher resorption rate, a larger immunogenic response and less revascularisation of the recipient. Allografts must also be controlled for viruses since they can transfer, for example, HIV and hepatitis.
  • Ceramic based synthetic bones substitutes can be divided into two main types. One type is based on calcium phosphate as the setting component and these are referred to as calcium phosphate cements. Another type is based on calcium sulfate as the setting component. The most important advantage with calcium sulfate is its excellent biocompatibility. The drawbacks with pure calcium sulfate bone substitutes are the rapid resorption and low strength, which make them less useful in larger or non-contained defects and when the fracture healing exceeds 4-6 weeks.
  • Bone Support AB has developed hardenable and injectable calcium sulfate based bone substitutes with the powder phase comprising approximately 40 wt % sintered hydroxyapatite (HA) (Ca 10 (PO 4 ) 6 (OH) 2 ) and approximately 60 wt % calcium sulfate hemihydrate, CSH, (CaSO 4 .1 ⁇ 2H 2 O). Of the two components, only CSH will set during the setting process. The HA powder will remain un-dissolved.
  • the liquid phase of the injectable paste consists of an aqueous solution that for some of the products contain iohexol molecules to enhance the radiopacity of the material (WO2003/053488).
  • the setting time of the hardened bone substitute from the paste is an important parameter for determining their applicability as bone substitutes.
  • Gillmore needles ASTM 0266
  • IST initial setting time
  • FST final setting time
  • IST times around 5-25 min typically allows sufficient time for the cement to be injected or molded
  • FST times around 10-40 minutes are usually acceptable for clinical use. It is preferred to have IST times around 5-15 minutes, such as less than 10 minutes. Different products have different specifications since they will be used for different applications.
  • Other ways of determining the applicability of a hardenable bone substitute are known in the art.
  • Bone substitutes comprising an additive such as, for example an antibiotic, would be desirable to have in order to be able to treat or prevent different disorders, e.g. osteomyelitis (bone infections).
  • an additive such as, for example an antibiotic
  • the addition of some bioactive agents, such as antibiotics retard the setting of the bone substitute in such a manner that the setting time exceeds clinically acceptable values.
  • not only additives, but also basic components of the bone substitute, such as HA may have a negative effect on the setting properties. It has surprisingly turned out, that the rate of the CSH hydration necessary for setting of the calcium sulfate in a HA containing calcium sulfate based bone substitute is highly dependent on the properties of the HA.
  • the present invention was made in view of the problems observed in connection with the prior art described above, and the object of the present invention has been to provide a solution to the problem which solution is the provision of a HA that does not, alone or together with different additives such as antibiotics, give clinically poor and/or unacceptable setting times for hardenable bone substitutes based on calcium sulfate (CSH) and hydroxyapatite (HA).
  • CSH calcium sulfate
  • HA hydroxyapatite
  • the induction period starts immediately after the CSH powder is mixed with water.
  • the CSH dissolves and the solution becomes supersaturated with respect to calcium and sulfate ions. This leads to precipitation of the less soluble calcium sulfate dihydrate (CSD).
  • CSD less soluble calcium sulfate dihydrate
  • initially formed CSD nucleuses need to have a radius that is larger than a “critical radius” (to be determined for each specific system).
  • the induction period is critical for the hydration reaction and any disturbances in the solubility of CSH or growth of CSD crystals in this phase will delay the further hydration reaction to a higher degree than if the same disturbances took place in a later phase of the process.
  • the acceleration or growth period starts when a sufficient number of CSD crystals have reached the critical size for acting as nucleating embryos.
  • the CSD nucleus formed will then grow and form large crystals.
  • the crystals will eventually be sufficiently large to interlock with each other and the friction between crystals contributes to the strength of the formed solidified material.
  • the third phase is relatively slow and consists of the completion of the hydration of the CSH as illustrated in FIG. 1 in the form of a schematic view showing the fraction of hydrated calcium sulfate as a function of time.
  • the inventors of the present invention have surprisingly found that the unpredictable setting properties of hardenable bone substitutes comprising CSH and HA (Example 1), which most often lead to clinically unacceptable setting times, can be overcome by making the HA practically inert to the CSH hydration reaction by exposing sintered and micronized HA powder (“raw HA powder”), normally used in hardenable bone substitutes, to a heat-treatment step of for example 500° C. for two hours, where temperature and time are inversely related, to obtain “passivated HA powder” (pHA).
  • raw HA powder sintered and micronized raw HA powder
  • pHA passivated HA powder
  • passivating HA Another advantage of passivating HA is that the setting of a hardenable bone substitute will become more reliable and kept under control without changing the composition of the bone substitute by adding further chemicals, such as accelerants.
  • additives such as for example antibiotics
  • the passivated HA is also shown to be more resistant to storage over time and to changing temperatures and relative humidity in the surroundings of stored hardenable bone substitute products (see Example 12).
  • setting time for hardenable bone substitutes containing different lots of passivated HA but with the same CSH/HA ratio have become much more uniform than when using non-passivated raw HA, and thus much more predictable.
  • the minimized spread in setting times is surprisingly also independent of the degree of retardation induced by the same raw HA lots before passivation.
  • Raw HA can be produced in several ways.
  • the most common way to synthesize HA is by wet precipitation methods using orthophosphoric acid and calcium hydroxide as raw materials followed by drying and heating,
  • HA can also be produced with a solid state reaction where the Ca 2+ and PO 4 3 ⁇ are mixed dry and then heated to a high temperature.
  • a solid state reaction where the Ca 2+ and PO 4 3 ⁇ are mixed dry and then heated to a high temperature.
  • several combinations of salts can be mixed. By using different salt combinations, a lot of different precipitation/solid state reaction can be performed.
  • Ca 2+ is mixed with PO 4 3 ⁇ in a ratio of 1.67. If HA is to be precipitated, the Ca 2+ and the PO 4 3 ⁇ are added to a water solution and the pH and temperature is controlled while the HA is precipitated.
  • FIG. 4 illustrates the different steps in one way of producing raw HA.
  • FIG. 1 shows the fraction of CSH hydrated as a function of time. Taken from N. B. Singh and B. Middendorf, Calcium sulfate hemihydrate hydration leading to gypsum crystallization , Progress in Crystal Growth and Characterization of Materials 53 (2007) 57-77.
  • FIG. 2 shows change in buffering capacity after passivation of the HA.
  • the dotted lines (and unfilled symbols) represents the pH/buffering results of the HA lot before passivation (raw HA).
  • the full line (and filled symbols) represent the results of the same HA lot after passivation.
  • FIG. 3 shows buffering capabilities in the presence of vancomycin.
  • HA A is before passivation (raw HA) and HA B is after passivation.
  • the up arrow indicates when HA was added and the down arrow indicates when the addition of HCl started.
  • FIG. 4 shows a schematic figure of the procedure for manufacturing hydroxyapatite by wet precipitation method.
  • HA hydroxyapatite
  • CSH calcium sulfate hemihydrate
  • Example 3 The critical role of HA for the setting times of calcium sulfate containing bone substitute is surprising since the calcium sulfate, and not the HA, is the setting component. Previously, the HA had been considered to be “inert” and therefore not involved in any steps of the CSH hydration reaction described above.
  • the present invention relates to hardenable bone substitutes comprising as the two major components passivated crystalline HA and CSH, where the bone substitute shows a faster setting time after passivation of the crystalline HA.
  • HA present in the powders of the present invention have a slow resorption rate inside the body.
  • the solubility of the HA should be as low as possible.
  • the solubility is mainly determined by the stoichiometry and the crystal size.
  • the sintered HA powder should contain >90% crystalline HA, preferably 95% or more, such as 99%.
  • crystalline hydroxyapatite when used in the present context thus means that the sintered HA consists of >90% crystalline HA, preferably 95% or more, such as 99% crystalline HA.
  • a method for preparing passivated sintered crystalline hydroxyapatite (pHA) powder as well as the products obtainable by such method comprising providing a first sintered crystalline raw HA powder (for example a commercial available HA powder) and heating said powder at a temperature up to about 900° C. for at least 5 minutes to obtain said passivated HA powder.
  • the temperature is from 100° C. to 900° C. for between 10 minutes and 2 weeks, from 300° C. to 900° C. for between 10 minutes and 10 hours, from 300° C. to 600° C. for between 1 and 4 hours.
  • the heat-treatment is from 450° C. to 550° C. for between 11 ⁇ 2 and 21 ⁇ 2 hours, such as 500° C. for 2 hours.
  • the HA powder, raw or passivated has a crystalline content of >90%, preferably >95%, such as >99% after the sintering process, which takes place at a temperature above 900° C., for example between 900 and 1350° C.
  • the powder has a particle size of D(v,0.99) ⁇ 1000 ⁇ m, such as ⁇ 200 ⁇ m, preferably ⁇ 100 ⁇ m and more preferably ⁇ 50 ⁇ m, such as less than 35 ⁇ m.
  • the specific surface area of the powder should preferably be below 20 m 2 /g, and more preferably below 10 m 2 /g, when measured according to the BET (Brunauer, Emmett and Teller) method, which is a method for the determination of the total surface area of a powder expressed in units of area per mass of sample (m 2 /g) by measurement of the volume of gas (usually N 2 ) adsorbed on the surface of a known weight of the powder sample.
  • BET Brunauer, Emmett and Teller
  • the temperature and duration of the heating step necessary for passivation may be influenced by several parameters including, but not limited to, the previous sintering conditions, how extensive the mechanical treatment has been, the type and means for micronization, the crucible used during passivation heating, how much powder to be passivated and how fast the oven reaches its passivation temperature and cools off. For example, in some cases the duration and/or temperature may be reduced if the mechanical treatment has not been extensive.
  • the minimum duration of the heating step in the passivation can be experimentally determined and depends on many factors, such as the temperature during passivation, the heating temperature during sintering and extent of mechanical treatment.
  • the duration of the passivation heat-treatment is at least 5 minutes, such as at least 10 minutes, and preferably at least 1 hour.
  • the heating time is between 1 and 4 hours.
  • the heat-treatment step is performed above 100° C., such as above 200° C., above 300° C. above 400° C., or above 500° C.
  • the passivation heat-treatment preferably is below 900° C., such as below 800° C. or below 700° C.
  • Example 8 shows the effect of the heating temperature in passivation and the risk of having a too high temperature on the pH/buffering properties.
  • the passivation temperature is between 300 and 600° C.
  • Example 6 It has also been found that the HA powder is less buffering after the passivation than before. Two examples that show this, with and without additives, are shown in Example 6. This effect may be used to monitor the passivation effect of the heat treatment.
  • the heating step is e.g. from 100° C. to 900° C. for between 10 min and 2 weeks, e.g. from 200° C. to 800° C. for between 10 min and 1 week, e.g. from 300° C. to 700° C. for between 10 min and 1 week, e.g. from 400° C. to 600° C. for between 10 min and 1 week, e.g. from 450° C. to 550° C. for between 10 min and 1 week.
  • the heating step is e.g. from 100° C. to 900° C. for between 10 min and 1 week, e.g. for between 1 h and 24 h. In some embodiments the heating step is e.g. from 300° C. to 600° C. for between 1 h and 4 h, e.g. from 400° C. to 600° C. for between 1 h and 4 h, e.g. from 450° C. to 550° C. for between 11 ⁇ 2 h and 21 ⁇ 2 h, e.g. 500° C. ⁇ 10° C. for 2 h ⁇ 15 min
  • the passivated HA is further characterized by a method where the pH/buffering capacity is investigated by studying how the pH of the HA/water solution is changed when 100 it 1 M HCl is added every 10 th second to the suspension.
  • two hardenable bone substitute pastes comprising at least CSH, HA and an aqueous phase, wherein the only difference is the HA, which in one hardenable bone substitute is a first raw HA and in the other hardenable bone substitute it is the same raw HA, however after being passivated, for example after 2 hours at 500° C.
  • the comparison should be performed under identical conditions.
  • a reduction in setting time of at least 3 minutes should preferably be obtained by use of passivated HA compared to non-passivated raw HA.
  • One way of determine the setting time may be by use of Gillmore needles, where both the initial setting time (IST) and final setting time (FST) are determined.
  • Reduction in setting time of less than 3 minutes may be the result of an inadequate passivation treatment of the raw HA lot or because the raw HA lot remains practically inert without any setting retarding properties being introduced during the sintering and micronization process.
  • passivation of the lot may reduce the setting time by more than 3 minutes, such as by 5 minutes or more, or by 10 minutes or more, compared to the use of the raw HA lot without passivation.
  • the passivation of said first (raw) HA powder causes the setting time (both initial setting time (IST) and final setting time (FST), measured with e.g. Gillmore needles) for a hardenable bone substitute paste consisting of said passivated hydroxyapatite (pHA) powder, calcium sulfate powder and an aqueous liquid to be reduced, under identical conditions, by at least 3 minutes, such as 5 minutes or more, for example 10 minutes or more, compared to the setting time for the same paste, however comprising said first raw HA powder instead of said passivated HA powder.
  • IST initial setting time
  • FST final setting time
  • the passivated HA can be used in powders for hardenable bone substitutes, and consequently it is an aspect of the present invention to provide a powder, which is ready to use in a hardenable bone substitute, comprising as the two major components passivated crystalline HA (pHA) as described herein and CSH.
  • the expression “ready-to-use” means that the powder includes passivated HA (in contrast to raw un-passivated HA, and therefore prepared for use with a high chance of leading to acceptable setting times), such that only an aqueous liquid, e.g. water, needs to be added before use in a clinical treatment, such as in treatment of a disease in supportive tissue, typically involving surgery.
  • the ready-to-use powder does not comprise an aqueous phase and is a dry powder.
  • the CSH can exist in an alfa-CSH and a beta-CSH form.
  • the CSH is alfa-CSH, as this crystal form often forms a stronger superstructure when mixed with an aqueous phase.
  • CSH is the only component present in the powder that hardens by hydration.
  • CSH and passivated crystalline HA is present as the major components in the ready-to-use powder, which means that these components are the two largest components when measured by weight percent (wt %). Accordingly, in one embodiment, the passivated crystalline HA (pHA) is present in the range of 20-80 wt % of the total weight of the powder components and the CSH is present in the range of 80-20 wt % of the total weight of the powder components.
  • one or more accelerators are present in the ready-to-use powder, such as, e.g. in an amount of up to 10 wt % of the total weight of the powder components, which accelerator(s) will speed up the setting reaction of CSH by their presence and thus shorten the setting time.
  • One such accelerator is calcium sulfate dihydrate (CSD).
  • suitable salts for example inorganic salts, such as chloride and sulfate salts, for example sodium chloride.
  • calcium sulfate dihydrate may constitutes up to 10 wt %, such as up to 5 wt %, 2 wt %, or 1 wt % of the total weight of the powder components.
  • the powder components consists of 59.6 wt % alfa-CSH, 40.0 wt % passivated crystalline HA and 0.4 wt % calcium sulfate dihydrate.
  • the ready-to-use powder consists of passivated HA in the range of 35-45 wt % of the total weight of the powder components, CSH in the range of 55-65 wt % of the total weight of the powder components, and calcium sulfate dihydrate in the range of 0-5 wt %, preferably 0-2 wt % of the total weight of the powder components and optionally up to 10 wt % of other components/additives.
  • Such other components/additives may include, but are not limited to bioactive agents, organic and inorganic viscosity modifiers, such as starches, alginates, cellulose derivatives, and the like, and/or additives to accelerate/retard the setting of the calcium sulfate.
  • methods for preparing hardenable bone substitutes using the passivated crystalline HA according to the present invention are provided as well as the use of passivated crystalline HA according to the present invention in the preparation of a hardenable bone substitute.
  • the passivated crystalline HA according to the present invention and powders of the present invention comprising the passivated HA can be used in hardenable bone substitute pastes, such as for the manufacture of beads or any tailor-made forms for use in treatment of disorders of supportive tissue, or in the use as an injectable hardenable bone substitute paste for application to, e.g. injection at, the place of treatment of disorders of supportive tissue in a human or non-human patient.
  • a hardenable bone substitute paste such as a hardenable bone substitute paste comprising the ready-to-use powder according to the present invention admixed with an aqueous liquid.
  • the paste according to the present invention is made by mixing an aqueous liquid, which in its simplest form is water, together with the ready-to-use powder to prepare the paste.
  • the final paste is made by adding one or more additives at different stages, such as dissolving the additive in the liquid prior to mixing with the powder and/or by delayed mixing as described in WO2011/098438, which is hereby incorporated by reference.
  • the mixing ratio for the powder and the aqueous phase is called the liquid-to-powder ratio (LIP).
  • the LIP is in the range of 0.2-0.6 ml/g, such as between 0.3 and 0.5 ml/g. In a specific embodiment, the LIP ratio is 0.43 ml/g or 0.5 ml/g.
  • a lower L/P ratio, such as between 0.2 and 0.4 ml/g can be employed to further reduce the IST and FST, however a lower LIP ratio may also reduce the injectability of the paste, something that is negative for several clinical applications.
  • the aqueous liquid is water, and in other embodiments the aqueous phase comprises one or more suitable salt(s), such as a chloride or a sulfate salt, for example sodium chloride, a water soluble non-ionic X-ray contrast agent, and/or one or more bioactive agents.
  • suitable salt(s) such as a chloride or a sulfate salt, for example sodium chloride, a water soluble non-ionic X-ray contrast agent, and/or one or more bioactive agents.
  • sodium chloride acts as an accelerant of the calcium sulfate hydration, thereby contributing to a reduction in the IST/FST.
  • water soluble non-ionic X-ray contrast agent is advantageous as it offers the possibility of monitoring the paste by X-ray during and right after the surgical procedure.
  • suitable x-ray contrast agents are Iohexol compounds as described in WO 03/05388.
  • Further suitable water soluble non-ionic X-ray contrast agents as well as their concentrations are given in WO 03/05388, which is hereby incorporated by reference.
  • X-ray contrast agent is dissolved in pure water alone or together with suitable additives in the form of e.g. buffers and/or chelating agents.
  • the liquid comprises Tris (tris(hydroxymethyl)aminomethane), HCl and calcium EDTA in addition to the X-ray agent, such as iohexol.
  • X-ray agent such as iohexol.
  • kits for forming a hardenable bone substitute paste according to the present invention may comprise, in addition to the ready-to-use powder, a liquid solution, e.g. water comprising an X-ray agent and suitable additives, in a separate container or the agent and optionally additives may be in a container for being dissolved in the liquid prior to use.
  • Suitable water soluble non-ionic X-ray contrast agent may be selected from iohexol, iodixanol, ioversol, iopamidol, iotrolane, metrizamid, iodecimol, ioglucol, ioglucamide, ioglunide, iogulamide, iomeprol, iopentol, iopromide, iosarcol, iosimide, iotusal, ioxilane, iofrotal, and iodecol.
  • biodegradable particles comprising biocompatible and biodegradable X-ray contrast agent, as disclosed in WO 2009/081169, may be used to provide radiopacity in the bone substitute of the present invention. These particle are added to the ceramic powder prior to addition of the liquid.
  • Biodegradable X-ray contrast agent particles may be cleavable, preferably enzymatically-cleavable, derivatives of a physiologically tolerable organoiodine X-ray contrast agent, or the biodegradable X-ray particles may be prepared from biodegradable polymers comprising biocompatible, organoiodine X-ray compounds.
  • the biodegradable X-ray contrast agents can be considered to be water insoluble derivatives of the corresponding organoiodine compounds in the sense that cleavage (for example by the body's esterases) releases physiologically tolerable organoiodine compounds.
  • biodegradable particles comprising biocompatible and biodegradable X-ray contrast agent
  • the new biodegradable X-ray contrast agent will remain as intact particles in the cement matrix. Thereafter degradation of the contrast agent particles to water-soluble biocompatible organoiodine compounds will contribute to a beneficial osteoconductive, osteoinductive and resorbable macroporous structure of the bone substitute material.
  • physiologically tolerable organoiodine compounds for use according to the invention include analogues of known ionic, non-ionic, monomeric or dimeric organoiodine X-ray contrast agents in which solubilising carboxylic groups are esterified with alcohols, hydroxyl groups are acylated (e.g. acetylated) or formed into 2,4-dioxacyclopentan-1-yl groups.
  • Biodegradable X-ray particles may be selected from the group comprising cleavable derivatives of diatrizoic acid, iobenguane, iobenzamic acid, iobitriol, iocarmic acid, iocetamic acid, iodamide, iodipamide, iodixanol, iodized oil, iodoalphionic acid, p-iodianiline, o-iodobenzoic acid, iodochlorhydroxyquin, o-iodohippurate sodium, o-iodophenol, p-iodophenol, iodophthalein sodium, iodopsin, iodpyracet, iodopyrrole, iodoquinol, ioglycamic acid, iohexol, iomeglarnic acid, iomeprol, iopamidol, iopano
  • biodegradable polymers for inclusion of x-ray agent are poly(lactic acid) (PLA), poly( ⁇ -caprolactone) (PCL), poly(glycolic acid) (PGA), poly(lactide-co-glycolide) (PLGA), poly(dioxanone), poly(glycolide-co-trimethylene carbonate), poly(vinyl alcohol) (PVA), poly(vinylpyrrolidine), poly(hydroxybutarates), poly(hydroxyvalerate), poly(sebaic acid-co-hexadecandioic acid anhydride), poly(trimethylene carbonate), poly(orthoester), poly(caprolactams), poly(acrylamides), poly(terphthalate), polyether block amides (PEBA), poly(urethane), polysaccarides like cellulose polymers, methylcellulose, carboxymethylcellulose, ethylcellulose, hydroxyethylcellulose, hydroxypropylmethylcellulose, natural polymers like alginates,
  • bioactive agents to the powder or aqueous phase will be able to give the hardenable bone substitutes further beneficial properties.
  • one or more bioactive agent(s) is/are added to the aqueous phase, and in some embodiments these bioactive agents are selected from the group consisting of: antibiotics (including antifungal drugs), chemotherapeutics, vitamins, hormones, cytostatics, bisphosphonates, growth factors, proteins, peptides, bone marrow aspirate, platelet rich plasma and demineralized bone.
  • antibiotics including antifungal drugs
  • chemotherapeutics include chemotherapeutics, vitamins, hormones, cytostatics, bisphosphonates, growth factors, proteins, peptides, bone marrow aspirate, platelet rich plasma and demineralized bone.
  • Silica, zirconium, strontium, and the like may be added to promote bone healing.
  • a kit for forming a hardenable bone substitute paste according to the present invention may comprise, in addition to the ready-to-use powder, one or more containers containing the bioactive agent(s) to be added to the liquid solution prior to use or to the paste during use.
  • the hardenable bone substitute may be effective in preventing or treating osteomyelitis.
  • the bioactive agent is an antibiotic
  • the hardenable bone substitute may be effective in preventing or treating osteomyelitis.
  • antibiotics there is a great interest for adding antibiotics to bone substitutes in order to prevent bone infections in treated patients.
  • previous tests in the laboratory have however shown that the addition of antibiotics affects the properties of the paste significantly, mainly by a prolonged setting time.
  • the use of passivated crystalline HA according to the present invention has proven to be effective.
  • antibiotic agent(s) belonging to the following groups may advantageously be part of the hardenable bone substitute according to the present invention: the group consisting of aminoglycoside antibiotics, the group consisting of penicillins, the group consisting of cephalosporins, rifampicin, clindamycin, and the group consisting of antifungal drugs.
  • the antibiotic agent(s) is/are selected from the list consisting of: gentamicin, vancomycin, tobramycin, cefazolin, rifampicin, clindamycin, nystatin, griseofulvin, amphotericin B, ketoconazole and miconazole.
  • the aqueous phase comprises the antibiotic agent gentamicin sulfate, vancomycin hydrochloride and/or cefazolin.
  • the hardenable bone substitutes according to the present invention ie with passivated HA
  • passivated HA have been shown to give a reduction in the IST and FST (see Examples 9, 10 and 11) compared to applying these antibiotic agents in a hardenable bone substitute without passivated HA according to the present invention.
  • the passivated HA according to the present invention is comprised in a ready-to-use hardenable bone substitute powder according to the present invention, which powder, after being mixed with a liquid is ready for use in clinical treatment, e.g. as part of a surgical treatment, in order to treat disorders of supportive tissue in a human or non-human subject by regenerating lost bone tissue and/or treating bone infections.
  • disorders may be bone loss, bone fracture, bone trauma and/or osteomyelitis.
  • the ready-to-use bone substitute powders according to the present invention as well as the one or more aqueous liquids for use in the preparation of the bone substitute paste can advantageously be provided as a kit, which is ready for use and requires a minimum of handling of the various components so as to obtain an optimal time and viscosity window for applying the hardenable bone substitute in form of an injectable paste to the patient and in order to minimize the introduction of bacteria from the surroundings.
  • the present invention provides in another aspect of the invention a kit for preparing a hardenable bone substitute, comprising a ready-to-use powder according to the present invention placed in a combined mixing and injection device.
  • a combined mixing and injection device Such combined mixing and injection devices (CMI devices) are known in the prior art, e.g. from WO 2005/122971.
  • the kit additionally comprises in one or more separate container(s), one or more aqueous solution(s) optionally comprising one or more accelerants and/or one or more bioactive agent(s) and/or one or more non-ionic X-ray contrast agent(s); and optionally instructions for use of said mixing and injection device.
  • the accelerant(s), bioactive agent(s) and/or non-ionic X-ray contrast agent(s) or biodegradable X-ray particles may be included in the kit in separate containers.
  • the kit may also comprise a combined mixing and injection device.
  • the iohexol solutions used consist of water for injection (WFI), lohexol, the buffer Trometamol (Tris: tris(hydroxymethyl)aminomethane), the chelating agent Edetate Calcium Disodium (calcium EDTA) and Hydrochloric acid (HCl).
  • WFI water for injection
  • lohexol the buffer Trometamol (Tris: tris(hydroxymethyl)aminomethane)
  • the chelating agent Edetate Calcium Disodium calcium EDTA
  • Hydrochloric acid HCl
  • the iohexol solutions meet the requirements stated in the US Pharmacopoeia for lohexol Injection.
  • the content of iohexol, trometamol and sodium calcium edetate meets each specific requirement according to standards.
  • the saline solution consists of 0.9 wt % NaCl in water for injection (WFI).
  • WFI water for injection
  • the reason for having a solution comprising iohexol or similar X-ray agents as the liquid phase is to increase the radiopacity of the bone substitute material (see WO 03/053488).
  • the powder for the hardenable bone substitute used in the presented examples consisted of 59.6 wt % ⁇ -CSH, 0.4 wt % CSD and 40.0 wt % HA, but the UP ratio and type of liquid used to mix the samples varied.
  • the method used to investigate the buffering capacity of the HA powders was based on that a slurry with 3.2 g HA powder in 32 g water was prepared. After the HA was mixed with water, 100 ⁇ l 1 M HCl was added every 10 seconds under continuously stirring. The pH was measured and noted during the whole procedure, and the pH value right before the HCl additions started was denoted as the pH of the HA. If the HCl was to be added in pure water, a rapid decrease in pH could be expected, but the presence of HA powder will delay the decrease to different extents.
  • a mixture of 59.6 wt % of synthetically produced CSH (particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt % raw HA (different lots from same producer, see above) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m) were mixed with a liquid phase containing iohexol (180 mg l/mL).
  • 30 g of the ceramic powder mixture was mixed with 15 mL iohexol solution (i.e. a liquid-to-powder ratio of 0.5 mL/g). The mixing was conducted for 30 seconds using a specially designed mixing and injection device (WO 2005/122971).
  • the setting behavior of the obtained paste was evaluated using Gillmore needles (ASTM 0266).
  • the goal with the study was to evaluate the effect on the setting time of the CSH/HA bone substitute, containing different HA lots, when the antibiotic vancomycin was added to the system.
  • 500 mg vancomycin (as vancomycin hydrochloride) was dissolved in the liquid phase prior to mixing with the ceramic powders.
  • a mixture of 59.6 wt % synthetically produced CSH (particle size distribution: 0.1-80 urn and mean particle size ⁇ 9 ⁇ m), 40.0 wt % raw HA (different lots from the same producer, see above) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m) were mixed with a liquid phase containing iohexol (180 mg l/mL), 18.5 g of the ceramic powder mixture was mixed with 8 mL liquid (either pure iohexol solution or iohexol solution premixed with vancomycin, see above), which gave a liquid-to-powder ratio of 0.43 mL/g).
  • the mixing was conducted for 30 seconds using a specially designed mixing and injection device (WO 2005/122971).
  • the setting behavior of the obtained paste was evaluated using Gillmore needles ASTM 0266.
  • the first type of ceramic bone substitute consisted only of a mixture of 99.3 wt synthetically produced CSH (particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 7 ⁇ m) and 0.67 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m).
  • CSH particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 7 ⁇ m
  • accelerator CSD synthetic: particle size distribution: 0.1-55 ⁇ m
  • the second type of bone substitute raw HA was also present (59.6 wt % CSH, 40 wt % HA and 0.4 wt are CSD).
  • the raw HA powder was commercial and had been sintered at 1275 ⁇ 50° C. for 4 hours and thereafter micronized.
  • the particle size distribution was 0.1-40 ⁇ m with a mean particle size of ⁇ 7 ⁇ m.
  • the liquid phase contained either only the iohexol solution or iohexol solutions with 1 g of the antibiotic (either vancomycin or gentamicin sulfate) dissolved.
  • the mixing of the ceramic powders (either containing HA or not) and the iohexol solution (either containing the antibiotic or not) was conducted for 30 seconds using a specially designed mixing and injection device (WO 2005/122971).
  • the setting behavior of the obtained paste was evaluated using Gillmore needles.
  • HA powders were either raw HA or raw HA that had been additionally heat treated at 500° C. for 2 hours (pHA).
  • the ceramic powder mixture consisted of 59.6 wt % synthetically produced CSH (particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt % HA (either raw or passivated) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m).
  • the ceramic powder was mixed with a liquid phase containing iohexol (180 mg l/mL). 18.5 g of the ceramic powder mixture was mixed with 8 mL iohexol solution (ie a liquid-to-powder ratio of 0.43 mL/g). The mixing was conducted for 30 s using a specially designed mixing and injection device (WO 2005/122971). The setting behavior of the obtained paste was evaluated using Gillmore needles.
  • the setting times of bone substitutes containing different HA lots before and after passivation are presented.
  • the setting times of the CSH/HA pastes containing the three lots of HA gave initial setting times in the range of 27-39 min when the HA powders has not been passivated and therefore exceed clinical relevant values.
  • the initial setting time decreased to approximately 10 minutes, i.e. approximately 1 ⁇ 3 of the initial values. All three lots of HA gave after the passivation the same (clinical relevant) performance of the bone substitute paste.
  • the ceramic powder mixture consisted of 59.6 wt % synthetically produced CSH (particle size distribution: 0.1 to 80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt raw HA (of any of the types described above) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m).
  • the ceramic powder was mixed with a liquid phase containing iohexol (300 mg l/mL). 3.0 g of the ceramic powder mixture was mixed with 1.5 mL iohexol solution (i.e. a liquid-to-powder ratio of 0.5 mL/g). The mixing of these small samples was conducted for 60 seconds using a spoon in a beaker. The setting behavior of the obtained paste was evaluated using Gillmore needles ASTM C266.
  • the HA that had been milled after the sintering and the HA that had been milled after sintering and heat-treatment step retarded the calcium sulfate setting much more than the unmilled HA, and the HA that had undergone a heat-treatment after the ball milling.
  • the results show that the ball milling step of HA causes its retarding effect on the CSH/HA bone substitute. This supports the theory that the mechanical forces applied to the HA during the milling is responsible for the retardation of the calcium sulfate.
  • the sample with the HA before passivation has a greater resistance to a change in pH when adding HCl than the sample with the passivated HA has.
  • the same HA lot was used in both measurements presented, but in the first, the HA powder was passivated in 500° C. for 1 hour and in the second in 500° C. for two hours.
  • a commercial, sintered (1275° C. for 4 h) and micronized raw HA powder (particle size distribution: 0.1-20 ⁇ m, mean particle size ⁇ 3 ⁇ m) was heat treated at different temperatures (400-600° C.) and times (1-3 hours) and then mixed in the ceramic powder mixture in order to evaluate the effect on the setting of the CSH based paste.
  • a ceramic powder mixture consisted of 59.6 wt % synthetically produced CSH (particle size distribution from 0.1-80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt % HA (passivated by heating as described above) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m).
  • 18.5 g of the ceramic powder mixture was mixed with 8 mL iohexol solution (180 mg l/mL), i.e. a liquid-to-powder ratio of 0.43 mL/g.
  • the mixing was conducted for 30 seconds using a specially designed mixing and injection device (WO 2005/122971).
  • the setting behavior of the obtained paste was evaluated using Gillmore needles.
  • results in the table below show how the setting times of a calcium sulfate based bone substitute varied when the same lot of HA, but with different heat-treatments, was used.
  • the retardering effect of the HA powder on the CSH setting time decreases when the temperature as well as the duration time of the heat treatment is increased.
  • a commercial, sintered (1275° C. for 4 hours) and micronized raw HA powder (particle size distribution: 0.1-20 ⁇ m, mean particle size ⁇ 5 ⁇ m) was heat treated at different temperatures (between 120-900° C. for 10 hours). The lot was identified to have too long setting time properties in a test according to Example 1.
  • the pH/buffering test showed that the heat treatment up to 360° C. did not affect the pH/buffering performance for this tested lot, but when the temperature was increased up to 900° C. (for 10 h), it had an effect on the powder.
  • the HA powder which had been heat treated at 900° C. for 10 h had an increase in pH and also a higher buffering capacity (more acid had to be added to decrease the pH).
  • a mixture of 59.6 wt % of synthetically produced SCH (particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt % HA (prepared as described above) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m) were mixed with a liquid phase containing iohexol (300 mg l/mL), 3.0 g of the ceramic powder mixture was mixed with 1.5 mL iohexol solution (i.e. a liquid-to-powder ratio of 0.5 mL/g). The mixing of these small samples was conducted for 60 seconds using a spoon in a beaker. The setting behavior of the obtained paste was evaluated using Gillmore needles.
  • the table below shows how the pH and buffering capacity was affected by the heat-treatment of the same HA lot from 120 to 900° C.
  • the variation in the setting time of CSH/HA bone substitutes with a HA lot treated at the different temperatures is also shown in the table.
  • the results showed that the retarding effect the raw HA powder has on the calcium sulfate setting time is decreased when the temperature used in the heat treatment step of the raw HA is increased.
  • a too high temperature (and too long time) could result in undesired properties of the HA regarding its pH/buffering properties.
  • the ceramic powder mixture consisted of 59.6 wt % synthetically produced SCH (particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt % HA (either raw or passivated as described above) and 0.4 wt % of the accelerator calcium sulfate dihydrate (synthetic: particle size distribution: 0.1-55 ⁇ m).
  • the ceramic powder was mixed with a liquid phase containing iohexol (180 mg l/mL) and 1 g of cefazolin (corresponding to 5.4 wt % of the ceramic powder phase).
  • 18.5 g of the ceramic powder mixture was mixed with 8 mL iohexol/cefazolin solution (i.e. a liquid-to-powder ratio of 0.43 mL/g).
  • the mixing was conducted for 30 seconds using a specially designed mixing and injection device (WO 2005/122971).
  • the setting behavior of the obtained paste was evaluated using Gillmore
  • the table below shows the effect of the antibiotic cefazolin on the same bone substitute system depending on whether the HA had been passivated or not.
  • the results show that passivation of the raw HA has a large impact on the setting performance when the antibiotic cefazolin is present. Without passivation, the initial setting time was close to one hour, but decreased to ⁇ 10 minutes when the raw HA powder had been passivated at 500° C. for 2 hours.
  • the ceramic powder mixture consisted of 59.6 wt % synthetically produced SCH (particle size distribution: 0.1-40 ⁇ m and mean particle size ⁇ 5 ⁇ m), 40.0 wt % hydroxyapatite (either raw or passivated as described above) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m).
  • the ceramic powder was mixed with a liquid phase consisting of gentamicin sulfate dissolved in saline. 6.3 g of the ceramic powder mixture was mixed with 2.7 mL of the saline/gentamicin solution (i.e. a liquid-to-powder ratio of 0.43 mL/g). 128 mg gentamicin sulfate (1.4 wt % based on the paste and 2.0 wt % based on the ceramic powder) was present in each sample.
  • the mixing of the small samples was conducted for 30 seconds using a spoon in the beaker.
  • the setting behavior of the obtained paste was evaluated using Gillmore needles.
  • the table below shows the setting times for compositions containing the same lots and proportions of calcium sulfate, liquid and gentamicin sulfate, but different HA lots before and after passivation at 500° C. for 2 hours. Almost all compositions gave clinically irrelevant setting times when HA without passivation was used, but after passivation, the setting times were decreased to relevant values and there were only small differences in the results no matter which lot of HA had been used.
  • the example shows that without passivation only one of 9 lots of HA gave acceptable setting properties of this specific system with gentamicin added (acceptance criteria of initial setting ⁇ 15 min), whereas after the passivation all 9 of the HA samples could be used. The results showed that without the use of a passivated HA the spread in setting performance is large between the CSH/HA samples containing gentamicin, but if instead a passivated HA was used the results were nearly identical and all of clinical relevance.
  • the ceramic powder mixture consisted of 59.6 wt % of synthetically produced CSH (particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt % hydroxyapatite (either raw or passivated as described above) and 0.4 wt % of the accelerator CSD (synthetic: particle size distribution: 0.1-55 ⁇ m).
  • the ceramic powder was mixed with a liquid phase consisting of iohexol solution (180 mg l/mL) with the antibiotic vancomycin predissolved (500 mg vancomycin corresponding to 2.7 wt % of the powder weight).
  • the table below shows the setting times for compositions containing the same lots and proportions of CSH, CSD, liquid and vancomycin hydrochloride, but different HA lots before and after passivation at 500° C. for 2 hours. All compositions gave clinically irrelevant setting times when the raw HA was used before the passivation, but after passivation, the setting times were decreased to relevant values. The results show that if the HA is used without heat-treatment (raw HA), the setting is strongly retarded, whereas if the raw HA powder is heat treated, the setting of the CSH/HA paste is significantly shorter.
  • compositions with Before Passivated Vancomycin and HA passivation (500° C. 2 h) lot IST/min FST/min IST/min FST/min A >60 >60 18.0 ⁇ 0 31.0 ⁇ 0 B >60 >60 12.0 ⁇ 0 23.3 ⁇ 0.6 C >60 >60 11.0 ⁇ 0 18.0 ⁇ 0
  • a commercial, sintered (1275° C. for 4 hours) and micronized raw HA powder (particle size distribution: 0.1-40 ⁇ m, mean particle size ⁇ 7 ⁇ m) was investigated in the study.
  • the powder was either used as raw HA or after additional heat treatment at 500° C. for 2 hours (i.e. passivated).
  • the raw HA lot was selected after an initial pre-test as described in Example 1, since the resulting CSH/HA bone substitute gave acceptable setting results.
  • the two types of HA powders were placed in a humid environment (95-100% RH) at room temperature for two weeks in order to investigate the stability against moisture. Thereafter they were used in the CSH/HA bone substitute and the setting performance of the different pastes were evaluated.
  • the ceramic powder mixture consisted of 59.6 wt % synthetically produced CSH (particle size distribution: 0.1-80 ⁇ m and mean particle size ⁇ 9 ⁇ m), 40.0 wt % hydroxyapatite (either raw or passivated as described above) and 0.4 wt % of the accelerator CSD (synthetic: particle size 0.1-55 ⁇ m).
  • the ceramic powder was mixed with a liquid phase consisting of an iohexol solution. 11.6 g of the ceramic powder mixture was mixed with 5 mL iohexol solution (180 mg l/mL), i.e. a liquid-to-powder ratio of 0.43 mL/g.
  • the mixing was conducted for 30 seconds using a specially designed mixing and injection device (WO 2005/122971). The setting behavior of the obtained paste was evaluated using Gillmore needles.
  • the table below shows the setting times achieved for the hardenable bone substitutes before and after the HA had been stored in the humid environment. As can be seen, storage of the raw HA in a humid environment resulted in more prolonged setting times when used in the hardenable CSH/HA bone substitute compared to when passivated HA was stored and used. If the HA has not been passivated, the setting of the CS/HA paste is retarded. These results indicate that the passivated HA is more resistant towards storage.

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