The Use of Calcium Sulphate beads in Periprosthetic Joint Infection, a systematic review

Purpose: To assess the use of calcium sulphate (CS) beads in the management of knee and hip periprosthetic joint infections (PJI) in terms of outcomes, complications and re-infection rates. Methods: A search of NICE healthcare database advanced search (HDAS) was conducted from its year of inception to October 2019 with the keywords: "Calcium Sulphate Beads" or "Calcium Sulfate Beads" or "Antibiotics beads" or "Stimulan" and "Arthroplasty" or "Hip Replacement" or "Knee Replacement" and "Periprothetic joint infection" or "Debridement, Antibiotics and implant retention" or "Revision". A quality assessment was performed using the NIH study Quality Assessment Tool for case series. Results: Out of relevant 74 articles, 5 articles met the inclusion criteria. Variable outcomes and success rates have been reported in most of the patients. A small number of wound discharges and heterotrophic ossification (HO) were reported, which are occasionally symptomatic. Hypercalcemia is identified as a potential risk with the use of CS beads especially with doses over 40 cc per operation. The influence of CS beads on reinfection rate is reported in 4 out of 5 articles. Due to the case-mix and heterogenicity of the patients involved and the causative microorganism reported as well as varied procedures are undertaken including one and two stages revision and Debridement, Antibiotics and implant retention (DAIR), the influence of CS beads varied from high success to poor outcome. The poor outcome is higher if the primary procedure for the management of hip and knee PJI is DAIR rather than full revision. Conclusions: The use of CS beads in the treatment of PJI is a useful technique in delivering high doses of antibiotics locally. A favourable outcome is reported when antibiotics loaded CS is used as an adjuvant to revision procedure for PJI in hip and knee arthroplasty compared to its use as an adjuvant to DAIR procedure. There has been an increase in complications when higher volumes of beads are used, especially in subcutaneous structures and in high-risk patients. Another possible theoretical and unreported complication of CS beads is accelerating the wear rate in the artificial joint due to the possibility of causing abrasion to the bearing surfaces. The current evidence is not enough to indicate the superiority of antibiotic-loaded CS beads as an adjuvant for the treatment of PJI in Hip and Knee arthroplasty.