Bone Vol. 25, No.

2, Supplement
August 1999:31S34S

Effects of Various Adjuvants (Lactic Acid, Glycerol, and

Chitosan) on the Injectability of a Calcium
Phosphate Cement
L. LEROUX, Z. HATIM, M. FRE`CHE, and J. L. LACOUT
Laboratoire Interfaces et Materiaux, Physico-Chimie des Phosphates, CNRS UPRESA 5071, ENSCT-INPT, Toulouse, France

phosphocalcium hydroxyapatite, which is the main compound in

the mineral phase of bone.6,9 The evolution to hydroxyapatite is
the result of acid-basic reactions between basic phosphates (solid
phase) and acidic phosphates (liquid phase). After mixing of the
phases, brushite is immediately formed, then octocalcicium
phosphate, which finally evolves into hydroxyapatite.4 These
cements are principally used for bone filling operations, which
require heavy surgical operations. In some cases, it can be
interesting to place the cement at the surgical site by catheterization, which does not require such heavy operations. That is
why it is very important to make the cement injectable.2,4 We
used a phosphocalcium cement prepared in the laboratory and
marketed by Teknimed. Various adjuvants were studied to make
the cement more injectable while keeping the physico-chemical
properties suitable for surgical use: setting time convenient for
surgery, disintegration of the cement in biological fluids as little
as possible, and mechanical properties suited to the kind
of operation.

Calcium phosphate cements are well-known orthopedic materials for filling bone. Various formulations are proposed.
The current challenge is to place the material in the surgical
site by methods as least invasive as possible. One approach
consists of making the cement injectable by incorporation of
various adjuvants. However, the requirement properties of
the cement must be preserved: setting times suited to a
convenient delay with surgical intervention, limited disintegration in aqueous medium, and sufficient mechanical resistance. Various additives were studied: in particular, lactic
acid, glycerol, chitosan, and sodium glycerophosphate. Injectability, setting time, disintegration, and toughness after
10 days were followed in vitro. Glycerol greatly improved
injectability and increased setting time, but decreased mechanical properties. Lactic acid reduced setting time, increased toughness of the material, but limited the dissolution
rate. After injection, the cement did not present any disintegration. The effects lactic acid were correlated with the
formation of calcium complex. Its association with sodium
glycerophosphate is particularly interesting. Chitosan alone
improved injectability, increased setting time, and limited the
evolution of the cement by maintaining the OCP phase. Only
slight disintegration was observed. These first results show
that is possible to transform the cement into an injectable
paste by addition of adjuvants without fundamentally modifying the chemical reactions occurring during setting and
hardening. (Bone 25:31S34S; 1999) 1999 by Elsevier
Science Inc. All rights reserved.

Materials and Methods

The initial cement was Cementek, which was obtained by mixing
a solid phase (-TCP, TTCP, NaGP, i.e., respectively: -tricalcium phosphate [Ca3(PO4)3], tetracalcium phosphate
[Ca4(PO4)2O], and sodium glycerophosphate) with a liquid phase
[Ca(OH)2, H3PO4, and H2O]. The effects of the following
adjuvants: sodium glycerophosphate (Prolabo), lactic acid (Prolabo), chitosan (Aepeichem), and glycerol (Prolabo) were studied. Setting time was determined qualitatively, and cements were
characterized by X-ray diffraction (CPS 120 INEL), infrared
spectroscopy (Perkin-Elmer FTIR), and electron microscopy
(S.E.M.: Leo 435 VPS). The mechanical properties were measured by compression testing on four cylindrical samples (diameter 6 mm, height 6 mm) with a Hounsfiel Series S device. The
measurements were made after maturation for 10 days in moist
air. Injectability was measured with an apparatus designed in the
laboratory (Figure 1). It consisted of a syringe with a catheter
(diameter 3 mm), and a tee connector leading to a manometer.
The injection pressure was indicated by the manometer when the
cement column moved.

Key Words: Injectability; Cement; Phosphocalcium; Adjuvants;

Filling; Hydroxyapatite.
Introduction
Phosphocalcium cements are materials that have been developed
for about 10 years in France but also in Japan and in the
U.S.1,5,8,10 These new biocompatible materials are bioresorbable,
which means they can be replaced in time by new bone, and also
are osteoconductors, favoring new bone formation. The main
characteristic of the studied cement is to evolve in situ into a

Results and Discussion

Address for correspondence and reprints: L. Leroux, Laboratoire Interfaces et Materiaux, Physico-Chimie des Phosphates, CNRS UPRESA
5071, ENSCT-INPT, 38, rue des 36 Ponts, 31400 Toulouse, France.
E-mail: leroux@cict.fr
1999 by Elsevier Science Inc.
All rights reserved.

Role of Sodium Glycerophosphate on Injectability

NaGP [CH2OH-CH(O-Na2PO3)-CH2OH] is a hygroscopic compound that acts as a regulator. Its action is attributed to the fact
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L. Leroux et al.
Adjuvants and calcium phosphate cement

Bone Vol. 25, No. 2, Supplement

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Figure 1. Device for the evaluation of the injectability.

that it quickly absorbs water in the solid phase, then slowly

releases it in the whole medium. The influence of NaGP was
studied for two liquid/solid (L/S) ratios (0.43 and 0.48). The
NaGP content in the solid phase was in the range of 10%20%
weight. The variation of the injection pressure vs. the NaGP
weight percentage in the solid phase is reported in Figure 2. For
L/S 0.43, NaGP addition favors injectability. Minimum injection pressure (Pinj 1 bar) was obtained with 18% weight NaGP.
Over this value, the injection pressure increased. When the
amount of the NaGP in the cement was lower than 18%, it acted
as a homogenizer entrancing injectability. Above 18%, however,
it absorbed too much water and the paste became too dry to move
in the catheter. For L/S 0.48, this phenomenon was not
observed. The quantity of water in the cement being higher, the
quantity of NaGP required to dry the paste was over 18%. We
can assume that injection pressure increases for over 18% NaGP.
It was observed that NaGP addition to the cement did not cause
any disintegration but slightly increased the setting time. The
mature cements were mainly composed of hydroxyapatite.
Influence of Lactic Acid on Injectability
Lactic acid (CH3-CHOH-COOH) is a viscous compound used in
medicine. It was introduced in the liquid phase; the solid phase
contained 18% weight NaGP and the L/S ratio was 0.43. The
lactic acid content was in the range 0% to 4% weight. The
variation of the injection pressure vs. the lactic acid percent

Figure 3. Injection pressure vs. weight percent of lactic acid.

weight is reported in Figure 3. Addition of lactic acid reduced

the injection pressure. Just after mixing, the paste was injectable
due to the viscous character of lactic acid. But, the setting time
decreased. This decrease is attributed to the resulting decrease in
pH. This pH decrease promotes brushite development. Lactic
acid contents over 4% cannot be studied because precipitation
occurs in the liquid phase caused by formation of a complex
between calcium ions and lactic acid. No disintegration was
observed with this adjuvant.
Influence of Chitosan on Injectability
The solid phase for making these cements contained 13% weight
NaGP and the L/S ratio was 0.43. The chitosan contents studied
in the liquid phase ranged from 0.02% to 1.64% weight. The
cement pastes with low chitosan contents (0.5%) presented
both good fluidity and good injectability. Also, a slight increase
in setting time was observed. It can be explained by chitosan
adsorption on the surface of the brushite crystals, which inhibits
brushite crystal growth. A high chitosan content (0.5%) decreased both the setting time and injectability. This is the consequence of an agglomeration of particles. Chitosan acts as a
glue.3 Here, it is not faster brushite formation that is responsible
for the setting time decrease, but a better cohesion between the
grains that increases the paste viscosity. It is important to note
that the presence of chitosan inhibits maturation toward hydroxyapatite and leads to one main phase: octocalcium phosphate
(Figure 4). This phenomenon is the consequence of chitosan
adsorption on the crystal surface, which reduces cement
maturation.
Influence of Glycerol on Injectability

Figure 2. Injection pressure vs. weight percent of NaGP.

Glycerol (CH2OH-CHOH-CH2OH) is a very viscous and hygroscopic compound that is an ingredient of ointments. That is why
glycerol was used without NaGP. The L/S ratio used was 0.43.
Glycerol was introduced in the solid phase at proportions from
0% to 10% weight. The variation of the injection pressure vs.
weight percent of glycerol is reported in Figure 5. Glycerol
addition decreases the injection pressure. Glycerol, being a very
viscous compound, certainly allows brushite plates to slide over
each other, making the paste easy to move. No disintegration was
observed but the setting time increased. When the cements
contained over 7% weight glycerol, overlapping of brushite
plates was largely disturbed: the setting time exceeded 24 h.

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L. Leroux et al.
Adjuvants and calcium phosphate cement

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Figure 4. Octocalcium phosphate in cement with chitosan.

Mechanical Properties

Conclusions

Compression tests were carried out on the cements with the best
injectability: a) 7% weight glycerol cement, b) 4% weight lactic
acid and 18% weight NaGP cement, and c) cements with chitosan. The ultimate compressive stress of cements a), b), and c)
was respectively, 29, 33, and 35 MPa. The ultimate compressive
stress of Cementek was about 30 MPa. The resistance of the
cements was not greatly modified by adjuvant additions. Just a
slight increase was observed with chitosan cements.

Calcium phosphate cements, without adjuvant or with glycerol,

lactic acid, or NaGP, mature to hydroxyapatite and, with chitosan, to octocalcium phosphate. The setting time was always
suitable for surgical operations if the adjuvant content was not
too high. Injectability was improved by addition of NaGP, acid
lactic, and glycerol. Chitosan slightly improved injectability and
the strength of the cement. The NaGP addition appears to be
necessary for a better homogenization of the cement paste. It is
possible to improve injectability with the simultaneous addition
of several adjuvants in the same cement. But, in this case, it
would be necessary to take care that their effects on the injectability are additive.
These preliminary results should be completed by studying
their stability over time, their behavior during sterilization,
and also by in vivo testing. The use of new adjuvants is also
planned.
References

Figure 5. Injection pressure vs. weight percent of glycerol.

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