Outcomes and safety of antibiotic-loaded calcium sulfate beads in orthopaedics: A systematic review and meta-analysis.

INTRODUCTION

Calcium sulfate (CS) has emerged as a local antibiotic delivery system, offering biodegradability, osteoconductive properties and sustained antibiotic release. The aim was to evaluate the clinical outcomes and safety of antibiotic-loaded CS beads as an adjunct in the management and prevention of orthopaedic infections.

METHODS

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting outcomes on the use of antibiotic-loaded CS beads in orthopaedics were considered eligible. Risk of bias assessment was performed using the methodological index for non-randomized studies (MINORS) criteria. Evaluated outcomes included rates of infection eradication or incidence, bone union, CS resorption, complications and reinterventions. Exploratory meta-analyses used a random-effects model, with heterogeneity assessed via the I2 statistic.

RESULTS

The systematic search included 41 studies. No randomized controlled trials were identified. Twenty-three studies examined patients with osteomyelitis, yielding a pooled infection eradication rate of 88% (95% CI: 85 to 90%; I2 = 19%). Among patients with infected nonunion, the pooled bone union rate was 93% (95% CI: 85 to 97%; I2 = 36%). In patients with periprosthetic joint infections (PJI), the pooled infection eradication rate reached 88% (95% CI: 76 to 95%; I2 = 87%). Wound-related complications were documented in 17% (189/1086) of osteomyelitis cases, compared to 8% (23/277) of PJI cases. PJI treatment was associated with minimal complications, including 12 cases of hypercalcemia (12/277, 4%) and nine cases of heterotopic ossification (9/262, 3%).

CONCLUSION

Current evidence describes favorable infection eradication rates when antibiotic-loaded CS beads are used as an adjunct in orthopaedic infection management and prevention, but the absence of comparative trials precludes conclusions regarding independent efficacy. All studies showed complete CS resorption. Wound-related complications were substantial in osteomyelitis cases, while other adverse events were rare. Higher-quality comparative studies are required before routine adoption.