Repair of segmental bone defects using bioactive bone cement: comparison with PMMA bone cement.

We developed a bioactive bone cement (BABC) that consists of apatite and wollastonite containing glass ceramic (AW-GC) powder and bisphenol-A-glycidyl dimethacrylate (Bis-GMA) based resin. In the present study, the effectiveness of the BABC for repair of segmental bone defects under load-bearing conditions was examined using a rabbit tibia model. Polymethylmethacrylate (PMMA) bone cement was used as a control. A 15-mm length of bone was resected from the middle of the shaft of the tibia, and the tibia was fixed by two Kirschner wires. The defects were replaced by cement. Each cement was used in 12 rabbits; six rabbits were sacrificed at 12 and 25 weeks after surgery, and the tibia containing the bone cement was excised and tension tested. At both the intervals studied, the failure loads of the BABC were significantly higher than those of the PMMA cement. The BABC was in direct contact with bone, whereas soft tissue was observed between the cement and bone in all PMMA cement specimens. Results indicated that the BABC was useful as a bone substitute under load-bearing conditions.     

In vivo aging test for a bioactive bone cement consisting of glass bead filler and PMMA matrix

The degradation of a new bioactive bone cement (GBC), comprised of an inorganic filler (bioactive MgO-CaO-SiO(2)-P(2)O(5)-CaF(2) glass beads) and an organic matrix [high-molecular-weight polymethyl methacrylate (PMMA)], was evaluated in an in vivo aging test. Hardened rectangular specimens (20 x 4 x 3 mm) were prepared from two GBC formulations (containing 50% w/w [GBC50] or 60% w/w [GBC60] bioactive beads) and a conventional PMMA bone cement control (CMW-1). Initial bending strengths were measured with the use of the three-point bending method. Specimens of all three cements were then implanted into the dorsal subcutaneous tissue of rats, removed after 3, 6, or 12 months, and tested for bending strength. The bending strengths (MPa) of GBC50 at baseline (0 months), 3, 6, and 12 months were 136 +/- 1, 119 +/- 3, 106 +/- 5 and 104 +/- 5, respectively. Corresponding values were 138 +/- 3, 120 +/- 3, 110 +/- 2 and 109 +/- 5 for GBC60, and 106 +/- 5, 97 +/- 5, 92 +/- 4 and 88 +/- 4 for CMW-1. Although the bending strengths of all three cements decreased significantly from 0 to 6 months, those of GBC50 and GBC60 did not change significantly thereafter, whereas that of CMW-1 declined significantly between 6 and 12 months. Thus, degradation of GBC50 and GBC60 does not appear to continue after 6 months, whereas CMW-1 degrades progressively over 12 months. Moreover, the bending strengths of GBC50 and GBC60 (especially GBC60) were significantly higher than that of CMW-1 throughout. It is believed that GBC60 is strong enough for use under weight-bearing conditions and that its mechanical strength is retained in vivo; however, its dynamic fatigue behavior will need assessment before application in the clinical setting.     

Bone bonding ability and handling properties of a titania-polymethylmethacrylate (PMMA) composite bioactive bone cement modified with a unique PMMA powder

One of the challenges of using bioactive bone cements is adjusting their handling properties for clinical application. To resolve the poorer handling properties of bioactive bone cements we developed a novel bioactive bone cement containing a unique polymethylmethacrylate (PMMA) powder, termed SPD-PMMA (40 μm in diameter), composed of cohered minute particles of PMMA (0.5 μm). The present study aimed to examine the mechanical and handling properties and the in vivo bone bonding strength of this cement. The titania content of the cement varied from 10 to 30 wt.% (Ts10, Ts20, and Ts30). The mechanical and thermal properties of Ts10 and Ts20 exceeded those of commercially available PMMA cements (PMMAc). The setting properties of Ts20, including a shorter dough time and a working time that was comparable with that of PMMAc, were adequate for clinical application. Hardened cylindrical cement specimens were inserted into rabbit femurs and the interfacial shear strengths were measured by a push-out test at 6, 12, and 26 weeks after the operation. The interfacial shear strength values (in Newtons per square millimeter) of Ts10, Ts20, and Ts30 at 12 weeks and those of Ts20 and Ts30 at 26 weeks were significantly higher than that of PMMAc (P < 0.05). These results show that a bioactive titania–PMMA composite bone cement modified by SPD-PMMA particles possesses adequate mechanical and handling properties, as well as osteoconductivity and in vivo bone bonding ability, and can be used for prosthesis fixation.     

Pressurization of bioactive bone cement in vitro

We have developed a bioactive bone cement consisting of MgO-CaO-SiO2-P2O5-CaF2 glass-ceramic powder (AW glass-ceramic powder), silica glass powder as an inorganic filler, and bisphenol-a-glycidyl methacrylate (bis-GMA) based resin as an organic matrix. The efficacy of this bioactive bone cement was investigated by evaluating its pressurization in a 5-mm hole and small pores using a simulated acetabular cavity. Two types of acetabular components were used (flanged and unflanged sockets) and a commercially available polymethylmethacrylate (PMMA) bone cement (CMW 1 Radiopaque Bone Cement) was selected as a comparative control. Bioactive bone cement exerted greater intrusion volume in 5-mm holes than PMMA bone cement in both the flanged and unflanged sockets 10 minutes after pressurization (p < 0.05). In the small pores the bioactive and PMMA bone cements exerted almost identical intrusion volumes in flanged and unflanged sockets 10 min after pressurization. The intrusion volume in the flanged socket 10 minutes after pressurization was greater than that in the unflanged socket in all groups (p < 0.05). These results show that bioactive bone cement intrudes deeper into anchor holes than PMMA bone cement.     

Free radical decay kinetics in PMMA bone cement

Electron-spin resonance has been used to measure the decay of the concentration of polymerization radicals in polymethyl methacrylate (PMMA) bone cement and the kinetics of the decay determined. Thermal annealing at various temperatures has shown that the logarithm of the concentration of radicals varies linearly with time, but with a nonzero intercept. These results have been analyzed by including both first- and second-order decay processes. The first-order process has an activation energy of 39 +/- 2 kcal/mol and is probably due to a diffusion-limited termination. The second-order process has an activation energy of 36 +/- 5 kcal/mol and is probably due to bimolecular termination.     

Attachment of PMMA cement to bone: force measurements in rats

The attachment of an implant material to bone relates to surface roughness and surface chemistry. There is a relatively low chemical bonding strength of so-called bioactive surfaces. Hydroxyapatite interfaces typically have an interfacial tensile strength of 0.15-1.5 MPa. An attachment force similar to that of bioactive surfaces might also be reached through mechanical interlock with ordinary bone cement. This study measured bone cement interfacial tensile strength for polished (R(a) 0.5 microm) and regular (R(a) 4.8 microm) vacuum mixed PMMA bone cement. Bone bonding was evaluated by a detachment test. We used unloaded cement surfaces, which could be detached from the bone. Titanium plates were developed such that a cement fill was contained within a plate, which was contained within a titanium holder. The cement surface came into contact with traumatized bone only, and the rest of the plate had no contact with tissue. The cement surface was either polished or left untreated after conventional preparation. Four weeks later, the plates were detached from the bone by a perpendicular force. The detaching load of the polished cement surface never exceeded 0.07 MPa, whereas for unpolished cement there was a load up to 0.9 MPa. The results suggest that surface irregularities and microinterlock enable an attachment that can resist tension between bone and a cement surface.     

Hydroxyapatite/PMMA composites as bone cements

Currently PMMA is the polymer most commonly used as a bone cement for the fixation of total hip prostheses. Ideally, a bone cement material should be easy to handle, biologically compatible, nonsupporting of oral microbial growth, available in the particulate and molded forms, easy to obtain, nonallergenic, adaptable to a broad range of dental and medical applications, in possession of high compressive strength, and effective in guided tissue regenerative procedures. One of the problems associated with the conventional types of bone cement used is their unsatisfactory mechanical and exothermic reaction properties. The purpose of this in vitro study was to investigate and compare the mechanical properties (three-point bending strength, energy-to-break, and modulus of elasticity) and physical properties (setting time, water sorption, and exothermic heat) of HA/PMMA (HA group) and bovine-bone originated HA/PMMA (BB group) composites. Composites samples were fabricated by admixing method. It was found that the addition of HA and BB particles increased the water sorption. Generally 10 v/o 20 v/o HA and 0 v/o to 10 v/o BB ratio combinations had significant beneficial effects on the mechanical properties. The heat generated during polymerization was influenced by the different admixtures. More than 40 v/o HA and 40 v/o BB should be mixed into PMMA to reduce the peak temperature. Overall evaluation indicated that the BB group had better properties than the HA group.     

Transmission electron microscopic study of interface between bioactive bone cement and bone: comparison of apatite and wollastonite containing glass-ceramic filler with hydroxyapatite and beta-tricalcium phosphate fillers.

We developed a bioactive bone cement that consists of apatite and wollastonite containing glass-ceramic (AW-GC) powder and bisphenol-a-glycidyl methacrylate (Bis-GMA) based resin. In this study, we made three types of cement (designated AWC, HAC, and TCPC) consisting of either AW-GC, hydroxyapatite (HA), or beta-tricalcium phosphate (beta-TCP) powder as the inorganic filler and Bis-GMA based resin as the organic matrix. These cements were implanted into rat tibiae and cured in situ. Specimens were prepared 1, 2, 4, and 8 weeks after the operation and observed using transmission electron microscopy. Each of the bone cements was in direct contact with the bone. In AWC-implanted tibiae, the uncured surface layer of Bis-GMA based resin was completely filled with newly formed bone-like tissue 2 weeks after implantation. The AW-GC particles were surrounded by bone and were in contact with bone through an apatite layer. No intervening soft tissue was seen. In HAC-implanted tibiae, it took 4 weeks for the uncured layer to completely fill with newly formed bonelike tissue. The HA particles were also in contact with bone through an apatite layer. In TCPC-implanted tibiae, it took 8 weeks for the uncured layer to fill with newly formed bone-like tissue. The new bone that formed on the TCPC was not as dense as that on the AWC or HAC, and an intervening apatite layer was not evident. Results indicated that AWC had higher bioactivity than either HAC or TCPC.     

Leaching of tobramycin from PMMA bone cement beads

The in vitro leaching characteristics of tobramycin from acrylic resin (PMMA) bone cement beads have been determined by a radioimmune assay. Tobramycin was incorporated at two concentrations into bone cement beads fabricated from three commercial brands of acrylic resin. Antibiotic leaching followed a curvilinear relationship of the form X . Y = A . X + B . Y. All beads showed similar tobramycin leaching rates over time but the initial amount of leached material differed with the amount of tobramycin incorporated in the bead and the source of the PMMA bone cement. The data indicate that tobramycin-impregnated PMMA beads permit antibiotic leaching at a controlled rate compatible with possible clinical application.     

Low-modulus PMMA bone cement modified with castor oil

Some of the current clinical and biomechanical data suggest that vertebroplasty causes the development of adjacent vertebral fractures shortly after augmentation. These findings have been attributed to high injection volumes as well as high Young's moduli of PMMA bone cements compared to that of the osteoporotic cancellous bone. The aim of this study was to evaluate the use of castor oil as a plasticizer for PMMA bone cements. The Young's modulus, yield strength, maximum polymerization temperature, doughing time, setting time and the complex viscosity curves during curing, were determined. The cytotoxicity of the materials extracts was assessed on cells of an osteoblast-like cell line. The addition of up to 12 wt% castor oil decreased yield strength from 88 to 15 MPa, Young's modulus from 1500 to 446 MPa and maximum polymerization temperature from 41.3 to 25.6°C, without affecting the setting time. However, castor oil seemed to interfere with the polymerization reaction, giving a negative effect on cell viability in a worst-case scenario.     

Nano-mechanics of bone and bioactive bone cement interfaces in a load-bearing model

Many bioactive bone cements were developed for total hip replacement and found to bond with bone directly. However, the mechanical properties at the bone/bone cement interface under load bearing are not fully understood. In this study, a bioactive bone cement, which consists of strontium-containing hydroxyapatite (Sr-HA) powder and bisphenol-alpha-glycidyl dimethacrylate (Bis-GMA)-based resin, was evaluated in rabbit hip replacement for 6 months, and the mechanical properties of interfaces of cancellous bone/Sr-HA cement and cortical bone/Sr-HA cement were investigated by nanoindentation. The results showed that Young's modulus (17.6+/-4.2 GPa) and hardness (987.6+/-329.2 MPa) at interface between cancellous bone and Sr-HA cement were significantly higher than those at the cancellous bone (12.7+/-1.7 GPa; 632.7+/-108.4 MPa) and Sr-HA cement (5.2+/-0.5 GPa; 265.5+/-39.2 MPa); whereas Young's modulus (6.3+/-2.8 GPa) and hardness (417.4+/-164.5 MPa) at interface between cortical bone and Sr-HA cement were significantly lower than those at cortical bone (12.9+/-2.2 GPa; 887.9+/-162.0 MPa), but significantly higher than Sr-HA cement (3.6+/-0.3 GPa; 239.1+/-30.4 MPa). The results of the mechanical properties of the interfaces were supported by the histological observation and chemical composition. Osseointegration of Sr-HA cement with cancellous bone was observed. An apatite layer with high content of calcium and phosphorus was found between cancellous bone and Sr-HA cement. However, no such apatite layer was observed at the interface between cortical bone and Sr-HA cement. And the contents of calcium and phosphorus of the interface were lower than those of cortical bone. The mechanical properties indicated that these two interfaces were diffused interfaces, and cancellous bone or cortical bone was grown into Sr-HA cement 6 months after the implantation.     

Strontium-containing hydroxyapatite bioactive bone cement in revision hip arthroplasty

Clinical outcome of cemented implants to revision total hip replacement (THR) is not as satisfactory as primary THR, due to the loss of bone stock and normal trabecular pattern. This study evaluated a bioactive bone cement, strontium-containing hydroxyapatite (Sr-HA) bone cement, in a goat revision hip hemi-arthroplasty model, and compared outcomes with polymethylmethacrylate (PMMA) bone cement. Nine months after operation, significantly higher bonding strength was found in the Sr-HA group (3.36+/-1.84 MPa) than in the PMMA bone cement group (1.23+/-0.73 MPa). After detached from the femoral component, the surface of PMMA bone cement mantle was shown relatively smooth, whereas the surface of the Sr-HA bioactive bone cement mantle was uneven, by SEM observation. EDX analysis detected little calcium and no phosphorus on the surface of PMMA bone cement mantle, while high content of calcium (14.03%) and phosphorus (10.37%) was found on the surface of the Sr-HA bone cement mantle. Even higher content of calcium (17.37%) and phosphorus (10.84%) were detected in the concave area. Intimate contact between Sr-HA bioactive bone cement and bone was demonstrated by histological and SEM observation. New bone bonded to the surface of Sr-HA cement and grew along its surface. However, fibrous tissue was observed between PMMA bone cement and bone. The results showed good bioactivity of Sr-HA bioactive bone cement in this revision hip replacement model using goats. This in vivo study also suggested that Sr-HA bioactive bone cement was superior to PMMA bone cement in terms of bone-bonding strength. Use of bioactive bone cement may be a possible solution overcoming problems associated with the use of PMMA bone cement in revision hip replacement.     

Fabrication of bioactive glass-ceramic foams mimicking human bone portions for regenerative medicine

A technique for the preparation of bioglass foams for bone tissue engineering is presented. The process is based on the in situ foaming of a bioglass-loaded polyurethane foam as the intermediate step for obtaining a bioglass porous monolith, starting from sol-gel synthesized bioglass powders. The obtained foams were characterized using X-ray diffraction analysis, Fourier transform infrared spectroscopy, and field emission scanning electron microscopy observations. The material was assessed by soaking samples in simulated body fluid and observing apatite layer formation. Diagnostic imaging taken from human patients was used to reconstruct a human bone portion, which was used to mould a tailored scaffold fabricated using the in situ foaming technique. The results confirmed that the obtained bioactive materials prepared with three-dimensional processing are promising for applications in reconstructive surgery tailored to each single patient.     

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.     

Evaluation of bioactive bone cement in canine total hip arthroplasty

Total hip arthroplasties (THAs) were performed in beagle dogs using a bioactive bone cement (BABC) consisting of a silane-treated apatite- and wollastonite-containing glass-ceramic (AW glass-ceramic) powder and a silica glass powder as the filling particles and a bisphenol-A-glycidyl dimethacrylate-based resin (Bis-GMA-based resin) as the organic matrix. The outcomes were compared with the results of polymethylmethacrylate (PMMA) bone cement. The mechanical properties of the BABC were stronger than those of PMMA bone cement. The bonding strength of the BABC to bone in the dogs' femora increased with time and reached 3.7 MPa at 24 months after implantation whereas that of PMMA bone cement was 2.0 MPa (p < 0.05). Histological examination showed direct bonding between the BABC and the femoral bone for up to 24 months after implantation. However, with PMMA bone cement an intervening soft-tissue layer consistently was observed at the bone-cement interface. Direct bonding at the interface between the BABC and the bone through a calcium phosphorous layer 30 microm-thick was revealed by scanning electron microscopy. Femoral bone resorption was observed at 24 months after implantation in the BABC group, but it was not observed in the PMMA bone cement group. Direct bonding between BABC and the bone may have accelerated femoral bone resorption. Cement fractures of the BABC were observed on the acetabular side 24 months after implantation. Weak bonding between the BABC and an acetabular component made of ultrahigh molecular weight polyethylene (UHMWPE), relatively high elastic characteristics of BABC, and weakness of the calcium phosphorous layer formed on the surface of this cement seemed to lead to failure at 24 months on the acetabular side.     

Comprehensive biocompatibility testing of a new PMMA-hA bone cement versus conventional PMMA cement in vitro

For more than 50 years PMMA bone cements have been used in orthopaedic surgery. In this study attempts were made to show whether cultured human bone marrow cells (HBMC) show an osteogenetic response resulting in new bone formation, production of extracellular matrix (ECM) and cell differentiation when they were cultured onto polymerized polymethylmethacrylate (PMMA)-hydroxyapatite (HA), conventional PMMA bone cement being taken as reference. Biocompatibility parameters were collagen-I and -II synthesis, the detection of the osteoblast markers alkaline phosphatase (ALP) and osteocalcin, the number of adherent cells and the cytodifferentiation of immunocompetent cells. Cement surface structure, HA stability in culture medium and chemical element analysis of specimens were considered. Fresh marrow cells were obtained from the human femora during hip replacement. Incubation time was up to ten weeks. We used atomic forced microscopy (AFM) and scanning electron microscopy (SEM) for cement specimen analysis. Fluorescent activated cell sorter (FACS), immunohistochemical staining. SEM and light microscopy (LM) served us to judge the cellular morphology. Products of the extracellular matrix were analyzed by protein dot blot analysis, SEM energy dispersive X-ray analysis (SEM-EDX) and Ca2+/PO(4)3- detection. HA particles increased the osteogenetic potential of PMMA bone cement regarding the cellular production of collagen, alkaline phosphatase (AP), the number of osteoblasts and the cellular differentiation pattern in vitro. Both tested cements showed good biocompatibility in a human long-term bone marrow cell-culture system.     

Comprehensive biocompatibility testing of a new PMMA-HA bone cement versus conventional PMMA cement in vitro

For more than 50 years PMMA bone cements have been used in orthopaedic surgery. In this study attempts were made to show whether cultured human bone marrow cells (HBMC) show an osteogenetic response resulting in new bone formation, production of extracellular matrix (ECM) and cell differentiation when they were cultured onto polymerized polymethylmethacrylate (PMMA)-hydroxyapatite (HA), conventional PMMA bone cement being taken as reference. Biocompatibility parameters were collagen-I and -III synthesis, the detection of the osteoblast markers alkaline phosphatase (ALP) and osteocalcin, the number of adherent cells and the cytodifferentiation of immunocompetent cells. Cement surface structure, HA stability in culture medium and chemical element analysis of specimens were considered. Fresh marrow cells were obtained from the human femora during hip replacement. Incubation time was up to ten weeks. We used atomic forced microscopy (AFM) and scanning electron microscopy (SEM) for cement specimen analysis. Fluorescent activated cell sorter (FACS), immunohistochemical staining, SEM and light microscopy (LM) served us to judge the cellular morphology. Products of the extracellular matrix were analyzed by protein dot blot analysis, SEM energy dispersive X-ray analysis (SEM-EDX) and Ca²⁺/PO₄ ^3- detection. HA particles increased the osteogenetic potential of PMMA bone cement regarding the cellular production of collagen, alkaline phosphatase (AP), the number of osteoblasts and the cellular differentiation pattern in vitro. Both tested cements showed good biocompatibility in a human long-term bone marrow cell-culture system.     

Preliminary study of interfacial shear strength between PMMA precoated UHMWPE acetabular cup and PMMA bone cement

Followed by successful demonstration of high interfacial tensile strength in a new design of cemented all-polyethylene acetabular cup, interfacial shear strength was investigated in this study, with the use of canine-size prototypes of polymethylmethacrylate (PMMA) precoated UHMWPE acetabular cups. In addition to the PMMA precoated prototypes, three different types of controls were also prepared and tested: grooved UHMWPE cups, PMMA (bone cement) cups, and noncoated, plain UHMWPE cups. The interfacial shear strength of the precoated prototypes was 10.1 +/- 0.69 MPa (n = 6), whereas it was 24.3 +/- 0.78 MPa (n = 2) for the PMMA cup, 6.95 +/- 0.21 MPa (n = 2) for the grooved UHMWPE cup, and 0.34 +/- 0.47 MPa (n = 2) for the UHMWPE cup. These results indicate benefits of the PMMA precoating to stabilize the polyethylene acetabular cup securely when applied with bone cement in simulated clinical applications. Analysis of the failed PMMA precoated UHMWPE prototype cups suggested that the chemically induced bonds between precoated PMMA layer and bone cement played a key role in developing high shear strength. After the interfacial shear test of the PMMA precoated prototypes, major disruptions at the interface between treated UHMWPE and precoated PMMA layer were observed by scanning electron microscopy (SEM), which was a unique failure pattern, not found with other prototypes.     

Effect of vacuum-treatment on deformation properties of PMMA bone cement

Deformation behavior of polymethyl methacrylate (PMMA) bone cement is explored using microindentation. Two types of PMMA bone cement were prepared. Vacuum treated samples were subjected to the degassing of the material under vacuum of 270 mbar for 35 s, followed by the second degassing under vacuum of 255 mbar for 35 s. Air-cured samples were left in ambient air to cool down and harden. All samples were left to age for 6 months before the test. The samples were then subjected to the indentation fatigue test mode, using sharp Vickers indenter. First, loading segment rise time was varied in order to establish time-dependent behavior of the samples. Experimental data showed that viscous part of the deformation can be neglected under the observed test conditions. The second series of microindentation tests were realized with variation of number of cycles and indentation hardness and modulus were obtained. Approximate hardness was also calculated using analysis of residual impression area. Porosity characteristics were analyzed using CellC software. Scanning electron microscopy (SEM) analysis showed that air-cured bone cement exhibited significant number of large voids made of aggregated PMMA beads accompanied by particles of the radiopaque agent, while vacuum treated samples had homogeneous structure. Air-cured samples exhibited variable hardness and elasticity modulus throughout the material. They also had lower hardness values (approximately 65-100 MPa) than the vacuum treated cement (approximately 170 MPa). Porosity of 5.1% was obtained for vacuum treated cement and 16.8% for air-cured cement. Extensive plastic deformation, microcracks and craze whitening were produced during indentation of air-cured bone cement, whereas vacuum treated cement exhibited no cracks and no plastic deformation.