The Use of Calcium Sulphate Beads in the Management of Osteomyelitis of Femur and Tibia: A Systematic Review



1 ja Krkovic PhD FRCS1 1 Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Hills Road, Cambridge, United Kingdom

2 School of Clinical Medicine, University of Cambridge, Hills Road, Cambridge, United Kingdom

3 Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Hills Road, Cambridge, United Kingdom


Background: Calcium sulphate is a recent alternative for delayed antibiotic elution in infected bones and joints. The 
purpose of this study is to evaluate the use of antibiotic impregnated calcium sulphate (AICS) beads in the management 
of infected tibia and femur, with regards to patient outcomes and complication rates (including reinfection rate, remission 
rate and union rate).
Methods: Searches of AMED, CINAHL, EMBASE, EMCARE, Medline, PubMed and Google Scholar were conducted 
in June 2020, with the mesh terms: “Calcium sulphate beads” or “Calcium sulfate beads” or “antibiotic beads” or 
“Stimulan” AND “Bone infection” or “Osteomyelitis” or “Debridement” AND “Tibia” or “Femur”. Risk of bias was assessed 
using the Risk of Bias in Non-randomised Studies of interventions (ROBINS-i) tool, and quality assessed via the 
Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria.
Results: Out of 104 relevant papers, 10 met the inclusion criteria for data extraction. Total infection remission was 
6.8%, which was greater than that of polymethylmethacrylate (PMMA, 21.2%). Complication rates varied. The main 
issue regarding AICS use was wound drainage, which was considerably higher in studies involving treatment of tibia 
alone. Studies using PMMA did not experience this issue, but there were a few incidences of superficial pin tract 
infection following surgery.
Conclusion: Where AICS was used, it was consistently effective at infection eradication, despite variation in causative 
organism and location of bead placement. Wound drainage varied and was higher in papers regarding tibial cases alone.
Level of evidence: III


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