Osteoinduction and -conduction through absorbable bone substitute materials based on calcium sulfate: in vivo biological behavior in a rabbit model

  • D. Pförringer
  • N. Harrasser
  • H. Mühlhofer
  • M. Kiokekli
  • A. Stemberger
  • M. van Griensven
  • M. Lucke
  • R. Burgkart
  • A. Obermeier
Clinical Applications of Biomaterials Original Research
Part of the following topical collections:
  1. Clinical Applications of Biomaterials


Calcium sulfate (CS) can be used as an antibiotically impregnated bone substitute in a variety of clinical constellations. Antibiotically loaded bone substitutes find specific application in orthopedic and trauma surgery to prevent or treat bone infections especially in relation to open bone defects. However, its use as a structural bone graft reveals some concerns due to its fast biodegradation. The addition of calcium carbonate and tripalmitin makes CS formulations more resistant to resorption leaving bone time to form during a prolonged degradation process. The aim of the present study was the evaluation of biocompatibility and degradation properties of newly formulated antibiotically impregnated CS preparations. Three different types of CS bone substitute beads were implanted into the tibial metaphysis of rabbits (CS dihydrate with tripalmitin, containing gentamicin (Group A) or vancomycin (Group B); Group C: tobramycin-loaded CS hemihydrate). Examinations were performed by means of x-ray, micro-computed tomography (micro-CT) and histology after 4, 6, 8 and 12 weeks. Regarding biocompatibility of the formulations, no adverse reactions were observed. Histology showed formation of vital bone cells attached directly to the implanted materials, while no cytotoxic effect in the surrounding of the beads was detected. All CS preparations showed osteogenesis associated to implanted material. Osteoblasts attached directly to the implant surface and revealed osteoid production, osteocytes were found in newly mineralized bone. Group C implants (Osteoset®) were subject to quick degradation within 4 weeks, after 6–8 weeks there were only minor remnants with little osteogenesis demonstrated by histological investigations. Group A implants (Herafill®-G) revealed similar degradation within atleast 12 weeks. In contrast, group B implants (CaSO4-V) were still detectable after 12 weeks with the presence of implant-associated osteogenesis atlatest follow-up. In all of these preparations, giant cells were found during implant degradation on surface and inside of resorption lacunae. None of the analyzed CS preparations triggered contact activation. All implants demonstrated excellent biocompatibility, with implants of Group A and B showing excellent features as osteoconductive and -inductive scaffolds able to improve mechanical stability.

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At first, we would like to thank Mr. Dr. H. Büchner and Mr. Dr. S. Vogt (Heraeus Medical GmbH, Werheim, Germany) for their kind supply of bone substitute materials (Herafill®-G, as well as CaSO4-V). Second, many thanks to the central pre-clinical research division (ZPF) of the Klinikum rechts der Isar at the Technical University of Munich for their excellent support in performing the animal study. Especially, many thanks to Mrs. Dr. M. Rößner and Prof. Dr. H. Gollwitzer for their guidance in surgical procedure. Also, many thanks to Mrs. Dr. S. Kerschbaumer for generating and interpreting histological slices. Moreover, special thanks to Prof. Dr. P. Augat (Department of Biomechanics at the Unfallklinik Murnau) for his kind support in micro-CT investigations. Finally, many thanks to Mr. F. Seidl (M.A. Interpreting and Translating, MBA) for his kind support due to his perfect command of scientific English.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest


  1. 1.
    Lalidou F, Kolios G, Drosos GI. Bone infections and bone graft substitutes for local antibiotic therapy. Surg Technol Int. 2014;24:353–62.Google Scholar
  2. 2.
    Cortez PP, Silva MA, Santos M, et al. A glass-reinforced hydroxyapatite and surgical-grade calcium sulfate for bone regeneration: In vivo biological behavior in a sheep model. J Biomater Appl. 2012;27:201–17. CrossRefGoogle Scholar
  3. 3.
    Peltier LF. The use of plaster of paris to fill large defects in bone. Am J Surg. 1959;97:311–5.CrossRefGoogle Scholar
  4. 4.
    Helgeson MD, Potter BK, Tucker CJ, Frisch HM, Shawen SB. Antibiotic-impregnated calcium sulfate use in combat-related open fractures. Orthopedics. 2009;32:323.CrossRefGoogle Scholar
  5. 5.
    Beuerlein MJ, McKee MD. Calcium sulfates: what is the evidence? J Orthop Trauma. 2010;24(Suppl 1):S46–51. CrossRefGoogle Scholar
  6. 6.
    Thomas MV, Puleo DA. Calcium sulfate: Properties and clinical applications. J Biomed Mater Res B Appl Biomater. 2009;88:597–610. CrossRefGoogle Scholar
  7. 7.
    Slater N, Dasmah A, Sennerby L, Hallman M, Piattelli A, Sammons R. Back-scattered electron imaging and elemental microanalysis of retrieved bone tissue following maxillary sinus floor augmentation with calcium sulphate. Clin Oral Implant Res. 2008;19:814–22. CrossRefGoogle Scholar
  8. 8.
    Parsons JR, Ricci JL, Alexander H, Bajpai PK. Osteoconductive composite grouts for orthopedic use. Ann N Y Acad Sci. 1988;523:190–207.CrossRefGoogle Scholar
  9. 9.
    Stubbs D, Deakin M, Chapman-Sheath P, et al. In vivo evaluation of resorbable bone graft substitutes in a rabbit tibial defect model. Biomaterials. 2004;25:5037–44. CrossRefGoogle Scholar
  10. 10.
    Fan X, Ren H, Luo X, et al. Mechanics, degradability, bioactivity, in vitro, and in vivo biocompatibility evaluation of poly(amino acid)/hydroxyapatite/calcium sulfate composite for potential load-bearing bone repair. J Biomater Appl. 2016;30:1261–72. CrossRefGoogle Scholar
  11. 11.
    Chen X, Zhou XC, Liu S, Wu RF, Aparicio C, Wu JY. In vivo osseointegration of dental implants with an antimicrobial peptide coating. J Mater Sci Mater Med. 2017;28:76 CrossRefGoogle Scholar
  12. 12.
    Frost HM. Tetracycline-based histological analysis of bone remodeling. Calcif Tissue Res. 1969;3:211–37.CrossRefGoogle Scholar
  13. 13.
    Pforringer D, Obermeier A, Kiokekli M, et al. Antimicrobial Formulations of Absorbable Bone Substitute Materials as Drug Carriers Based on Calcium Sulfate. Antimicrob Agents Chemother. 2016;60:3897–905. CrossRefGoogle Scholar
  14. 14.
    J Borrelli, Jr., Prickett WD, Ricci WM. Treatment of nonunions and osseous defects with bone graft and calcium sulfate. Clin Orthop Relat Res. 2003:245–54.
  15. 15.
    Evaniew N, Tan V, Parasu N, et al. Use of a calcium sulfate-calcium phosphate synthetic bone graft composite in the surgical management of primary bone tumors. Orthopedics. 2013;36:e216–22. CrossRefGoogle Scholar
  16. 16.
    Glazer PA, Spencer UM, Alkalay RN, Schwardt J. In vivo evaluation of calcium sulfate as a bone graft substitute for lumbar spinal fusion. Spine J. 2001;1:395–401.CrossRefGoogle Scholar
  17. 17.
    Coetzee AS. Regeneration of bone in the presence of calcium sulfate. Arch Otolaryngol. 1980;106:405–9.CrossRefGoogle Scholar
  18. 18.
    Coraca-Huber D, Hausdorfer J, Fille M, Nogler M, Kuhn KD. Calcium carbonate powder containing gentamicin for mixing with bone grafts. Orthopedics. 2014;37:e669–72. CrossRefGoogle Scholar
  19. 19.
    Coraca-Huber DC, Putzer D, Fille M, Hausdorfer J, Nogler M, Kuhn KD. Gentamicin palmitate as a new antibiotic formulation for mixing with bone tissue and local release. Cell Tissue Bank. 2014;15:139–44. CrossRefGoogle Scholar
  20. 20.
    Obermeier A, Matl FD, Schwabe J, et al. Novel fatty acid gentamicin salts as slow-release drug carrier systems for anti-infective protection of vascular biomaterials. J Mater Sci Mater Med. 2012;23:1675–83. CrossRefGoogle Scholar
  21. 21.
    Lebourg L, Biou. C. [The imbedding of plaster of paris in surgical cavities of the maxilla]. Sem Med Prof Med Soc. 1961;37:1195–7.Google Scholar
  22. 22.
    Geldmacher J. [Therapy of enchondroma with a plaster implant--renaissance of a treatment principle]. Handchir Mikrochir Plast Chir. 1986;18:336–8.Google Scholar
  23. 23.
    Petruskevicius J, Nielsen S, Kaalund S, Knudsen PR, Overgaard S. No effect of Osteoset, a bone graft substitute, on bone healing in humans: a prospective randomized double-blind study. Acta Orthop Scand. 2002;73:575–8. CrossRefGoogle Scholar
  24. 24.
    Bell WH. Resorption Characteristics of Bone and Bone Substitutes. Oral Surg Oral Med Oral Pathol. 1964;17:650–7.CrossRefGoogle Scholar
  25. 25.
    Lillo R, Peltier LF. The substitution of plaster of Paris rods for portions of the diaphysis of the radius in dogs. Surg Forum. 1956;6:556–8.Google Scholar
  26. 26.
    Tay BK, Patel VV, Bradford DS. Calcium sulfate- and calcium phosphate-based bone substitutes. Mimicry Mineral phase bone Orthop Clin North Am. 1999;30:615–23.CrossRefGoogle Scholar
  27. 27.
    Kelly CM, Wilkins RM, Gitelis S, Hartjen C, Watson JT, Kim PT. The use of a surgical grade calcium sulfate as a bone graft substitute: results of a multicenter trial. Clin Orthop Relat Res. 2001:42–50.
  28. 28.
    Blaha JD. Calcium sulfate bone-void filler. Orthopedics. 1998;21:1017–9.Google Scholar
  29. 29.
    Calhoun NR, Greene GW Jr., Blackledge GT. Plaster: a bone substitute in the mandible of dogs. J Dent Res. 1965;44:940–6. Scholar
  30. 30.
    McKee JC, Bailey BJ. Calcium sulfate as a mandibular implant. Otolaryngol Head Neck Surg. 1984;92:277–86.CrossRefGoogle Scholar
  31. 31.
    Walsh WR, Morberg P, Yu Y, et al. Response of a calcium sulfate bone graft substitute in a confined cancellous defect. Clin Orthop Relat Res. 2003;228–36.
  32. 32.
    Sidqui M, Collin P, Vitte C, Forest N. Osteoblast adherence and resorption activity of isolated osteoclasts on calcium sulphate hemihydrate. Biomaterials. 1995;16:1327–32.CrossRefGoogle Scholar
  33. 33.
    Orsini G, Ricci J, Scarano A, et al. Bone-defect healing with calcium-sulfate particles and cement: an experimental study in rabbit. J Biomed Mater Res B Appl Biomater. 2004;68:199–208. CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2017

Authors and Affiliations

  • D. Pförringer
    • 1
  • N. Harrasser
    • 2
  • H. Mühlhofer
    • 2
  • M. Kiokekli
    • 2
  • A. Stemberger
    • 2
  • M. van Griensven
    • 1
  • M. Lucke
    • 3
  • R. Burgkart
    • 2
  • A. Obermeier
    • 2
  1. 1.Klinikum rechts der Isar der Technischen Universität München, Klinik und Poliklinik für UnfallchirurgieMünchenGermany
  2. 2.Klinikum rechts der Isar der Technischen Universität München, Klinik für Orthopädie und SportorthopädieMünchenGermany
  3. 3.Chirurgisches Klinikum München SüdMünchenGermany

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