SLR - August 2020 - Geoffrey R. Linn

The Use of Calcium Sulphate Beads in Periprosthetic Joint Infection, A Systematic Review

Reference: Abosala A, Ali M. The Use of Calcium Sulphate Beads in Periprosthetic Joint Infection, A Systematic Review. Journal of Bone and Joint Infection. 2020 Jan 14; 5(1), 43-49.

Scientific Literature Review

Reviewed By: Geoffrey R. Linn, DPM
Residency Program: DVA Puget Sound Healthcare System – Seattle, WA

Podiatric Relevance: Joint arthritis is treated in several ways by foot and ankle surgeons. One option is joint replacement surgery utilizing a prosthetic joint. This is commonly performed for the ankle joint and, to a lesser extent, the first metatarsophalangeal joint. Prosthetic joint infections remain a significant peri-operative and post-operative complication with inherent morbidity and mortality. This study reviews literature on the use of antibiotic eluting beads which are resorbable and thus, can be left implanted in a surgical site. The study focuses on total hip and knee replacements, but can easily be applied to the foot and ankle. 

Methods: A level I evidence systematic review was performed via a search of the MEDLINE, EMBASE, CINAHL, EMCARE, and PUBMED databases. Studies were included if they discussed the use of calcium sulfate (CS) beads in hip and knee arthroplasty surgery as an adjunct in revision and debridement, antibiotics and implant retention (DAIR) procedures for the management of periprosthetic joint infections. Case reports, reviews, conference abstracts, studies on animals and technical notes were excluded. Papers regarding the management of osteomyelitis of bone non-union were also excluded. Data was extracted using a standardized form including author, year of publication, study design, level of evidence, number of joints, inclusion criteria, type of joints, beads characteristics, antibiotics, follow ups and complications specific to CS beads including wound discharge, heterotrophic ossification and hypercalcemia in addition to reinfection. A meta-analysis was not performed due to the heterogeneity of data and all data was reported descriptively. 

Results: Of 76 articles, five papers met inclusion criteria. Two cited articles reported hypercalcemia for a total of 44 out of 770 (5.7 percent) with a mean level of 11.7 mg/dl. Two patients developed symptoms and were treated with one intravenous dose of bisphosphonate and 0.9 percent saline. There was an increased risk of hypercalcemia with the use of higher volume of CS beads. Postoperative wound discharge was reported in four articles, for a total of 41 out of 1076 joints (3.8 percent). There was a potential association of wound discharge with a volume of CS beads at 30cc or more. Heterotrophic ossification was reported in four articles at 18 of 1077 joints (1.7 percent), also associated with large volumes of CS beads (average of 33cc). The majority did not require surgical intervention. Reinfection rates were highly varied among articles, ranging from 2.4-48 percent with poorer outcomes associated with the DAIR procedure. 

Conclusions: In terms of hypercalcemia, postoperative wound discharge, and heterotrophic ossification, complications were relatively mild with a low incidence and seemed to be ameliorated by using smaller volumes of CS beads. There were more favorable outcomes when CS beads were used as an adjuvant to revision procedures compared to DAIR, making the product a reasonable choice to deliver highly concentrated antibiotics to a focal site. This study investigated joints outside of the foot and ankle. Similar comparison studies with use of CS beads versus non-absorbable antibiotic cement versus no bioceramic adjunct would be the next logical step. 

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