Use of Antibiotic Eluting Calcium Sulfate Beads in High-Risk Primary Total Knee Arthroplasty

 

 Buy Article Permissions and Reprints

Abstract

Local delivery of high-dose antibiotics via absorbable calcium sulfate beads has been investigated as a treatment of prosthetic joint infection (PJI). We investigate this strategy as a prophylactic measure for high-risk patients undergoing primary total knee arthroplasty (TKA). A retrospective review of a single-surgeon consecutive series of primary TKA patients with identified risk factors for PJI development was performed. These patients were treated with calcium sulfate beads containing 1 g of vancomycin and 1.2 g of tobramycin per 10 cc, with 10 cc placed intraarticularly. Outcomes included PJI, wound complications, revision surgery, and medical complications. There were 114 knees in 103 patients, with 76 women (66.7%), a mean age of 66.8 years (range: 21–91), and a mean follow-up of 16 months (range: 3–55). The mean preoperative lifetime PJI risk based on the 2018 International Consensus Meeting on the PJI calculator was 11.3% (standard deviation: 16.3%, range: 0.9–94.3%). Risk factors included medical comorbidities, homelessness, chronic urinary tract infection, other PJI or septic arthritis history, or prior ipsilateral knee surgeries. One delayed PJI occurred 1 year postoperatively from presumed hematogenous seeding following dialysis. There were no other known deep infections. There were nine patients who had delayed wound healing with marginal skin necrosis—six resolved with wound care and three underwent superficial extraarticular surgical debridement. There was one patient who underwent aseptic revision for patellar instability and nine patients required manipulation under anesthesia for stiffness. There was one patient who died after readmission for cardiac arrhythmia and one patient had bilateral DVT. No cases of chronic PJI, persistent wound drainage, or postoperative hypercalcemia were identified. Prophylactic use of antibiotic-eluting calcium sulfate beads in primary TKA has resulted in low rates of early PJI in a high-risk cohort, warranting further prospective studies and investigation.

Ethics Approval

This study utilizes de-identified retrospective data from a medical record system and underwent institutional review board approval (IRB #23–001791).

Publication History

Received: 05 April 2025

Accepted: 17 June 2025

Article published online:
03 July 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

• References

• 1 Xu Y, Huang TB, Schuetz MA, Choong PFM. Mortality, patient-reported outcome measures, and the health economic burden of prosthetic joint infection. EFORT Open Rev 2023; 8 (09) 690-697
  Search in Google Scholar
• 2 Premkumar A, Kolin DA, Farley KX. et al. Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty 2021; 36 (05) 1484-1489.e3
  Search in Google Scholar
• 3 Kurtz SM, Lau EC, Son MS, Chang ET, Zimmerli W, Parvizi J. Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the medicare population. J Arthroplasty 2018; 33 (10) 3238-3245
  Search in Google Scholar
• 4 Weinstein EJ, Stephens-Shields AJ, Newcomb CW. et al. Incidence, microbiological studies, and factors associated with prosthetic joint infection after total knee arthroplasty. JAMA Netw Open 2023; 6 (10) e2340457
  Search in Google Scholar
• 5 Son MS, Lau E, Parvizi J, Mont MA, Bozic KJ, Kurtz S. What are the frequency, associated factors, and mortality of amputation and arthrodesis after a failed infected TKA?. Clin Orthop Relat Res 2017; 475 (12) 2905-2913
  Search in Google Scholar
• 6 Hasenauer MD, Ho H, Engh III CA, Engh Jr CA. Factors associated with the incidence and timing of total knee arthroplasty infection. J Arthroplasty 2022; 37 (6S): S276 , 280.e3
  Search in Google Scholar
• 7 Crowe B, Payne A, Evangelista PJ. et al. Risk factors for infection following total knee arthroplasty: a series of 3836 cases from one institution. J Arthroplasty 2015; 30 (12) 2275-2278
  Search in Google Scholar
• 8 Tayton ER, Frampton C, Hooper GJ, Young SW. The impact of patient and surgical factors on the rate of infection after primary total knee arthroplasty: an analysis of 64,566 joints from the New Zealand joint registry. Bone Joint J 2016; 98-B (03) 334-340
  Search in Google Scholar
• 9 Tan TL, Maltenfort MG, Chen AF. et al. Development and evaluation of a preoperative risk calculator for periprosthetic joint infection following total joint arthroplasty. J Bone Joint Surg Am 2018; 100 (09) 777-785
  Search in Google Scholar
• 10 Bourget-Murray J, Azad M, Gofton W, Abdelbary H, Garceau S, Grammatopoulos G. Is the routine use of local antibiotics in the management of periprosthetic joint infections justified?. Hip Int 2023; 33 (01) 4-16
  Search in Google Scholar
• 11 Moore K, Os RW, Dusane DH. et al. Elution kinetics from antibiotic-loaded calcium sulfate beads, antibiotic-loaded polymethacrylate spacers, and a powdered antibiotic bolus for surgical site infections in a novel in vitro draining knee model. Antibiotics (Basel) 2021; 10 (03) 270
  Search in Google Scholar
• 12 McConoughey SJ, Howlin RP, Wiseman J, Stoodley P, Calhoun JH. Comparing PMMA and calcium sulfate as carriers for the local delivery of antibiotics to infected surgical sites. J Biomed Mater Res B Appl Biomater 2015; 103 (04) 870-877
  Search in Google Scholar
• 13 Tarar MY, Toe KKZ, Javed K, Shah N, Khalid A. The risk of iatrogenic hypercalcemia in patients undergoing calcium sulphate beads implantation in prosthetic joint surgery: a systematic review. Cureus 2021; 13 (10) e18777
  Search in Google Scholar
• 14 Myers TG, Lipof JS, Chen AF, Ricciardi BF. Antibiotic stewardship for total joint arthroplasty in 2020. J Am Acad Orthop Surg 2020; 28 (18) e793-e802
  Search in Google Scholar
• 15 Cowie RM, Aiken SS, Cooper JJ, Jennings LM. The influence of a calcium sulphate bone void filler on the third-body damage and polyethylene wear of total knee arthroplasty. Bone Joint Res 2019; 8 (02) 65-72
  Search in Google Scholar
• 16 Kallala R, Harris WE, Ibrahim M, Dipane M, McPherson E. Use of stimulan absorbable calcium sulphate beads in revision lower limb arthroplasty: safety profile and complication rates. Bone Joint Res 2018; 7 (10) 570-579
  Search in Google Scholar
• 17 Mcpherson EJ, Dipane MV, Sherif M. Dissolvable Antibiotic Beads in Treatment of Periprosthetic Joint Infection and Revision Arthroplasty the Use of Synthetic Pure Calcium Sulfate (Stimulan) Impregnated with Vancomycin and Tobramycin. Reconstr Rev 2013; 3 (01) 32-43
  Search in Google Scholar
• 18 Abosala A, Ali M. The use of calcium sulphate beads in periprosthetic joint infection, a systematic review. J Bone Jt Infect 2020; 5 (01) 43-49
  Search in Google Scholar
• 19 Lum ZC, Pereira GC. Local bio-absorbable antibiotic delivery in calcium sulfate beads in hip and knee arthroplasty. J Orthop 2018; 15 (02) 676-678
  Search in Google Scholar
• 20 Agarwal S, Healey B. The use of antibiotic impregnated absorbable calcium sulphate beads in management of infected joint replacement prostheses. J Arthrosc Jt Surg 2014; 1 (02) 72-75
  Search in Google Scholar
• 21 Howlin RP, Brayford MJ, Webb JS, Cooper JJ, Aiken SS, Stoodley P. Antibiotic-loaded synthetic calcium sulfate beads for prevention of bacterial colonization and biofilm formation in periprosthetic infections. Antimicrob Agents Chemother 2015; 59 (01) 111-120
  Search in Google Scholar
• 22 de Lachica JCV, Reyes SSS, Ureña JAP, Fragoso MAR. Decrease in acute periprosthetic joint infections incidence with vancomycin-loaded calcium sulfate beads in patients with non-modifiable risk factors. A randomized clinical trial. J ISAKOS 2022; 7 (06) 201-205
  Search in Google Scholar
• 23 McPherson EJ, Jennings JA, Yunis O. et al. Simulated large joint fluid model for evaluating intra-articular antibiotic delivery systems: initial evaluation using antibiotic-loaded calcium sulfate beads. J Bone Jt Infect 2022; 7 (03) 117-125
  Search in Google Scholar
• 24 Randelli P, Evola FR, Cabitza P, Polli L, Denti M, Vaienti L. Prophylactic use of antibiotic-loaded bone cement in primary total knee replacement. Knee Surg Sports Traumatol Arthrosc 2010; 18 (02) 181-186
  Search in Google Scholar
• 25 Leta TH, Fenstad AM, Lygre SHL. et al. The use of antibiotic-loaded bone cement and systemic antibiotic prophylactic use in 2,971,357 primary total knee arthroplasties from 2010 to 2020: an international register-based observational study among countries in Africa, Europe, North America, and Oceania. Acta Orthop 2023; 94: 416-425
  Search in Google Scholar
• 26 Kheir MM, Dilley JE, Ziemba-Davis M, Meneghini RM. The AAHKS clinical research award: extended oral antibiotics prevent periprosthetic joint infection in high-risk cases: 3855 patients with 1-year follow-up. J Arthroplasty 2021; 36 (7S): S18-S25
  Search in Google Scholar
• 27 Kelly MP, Gililland JM, Blackburn BE, Anderson LA, Pelt CE, Certain LK. Extended oral antibiotics increase bacterial resistance in patients who fail 2-stage exchange for periprosthetic joint infection. J Arthroplasty 2022; 37 (8S): S989-S996
  Search in Google Scholar
• 28 Lewicki K, Prioreschi B, Koenig K. et al. The effect of absorbable calcium sulfate on wear rates in ultra-high-molecular-weight polyethylene: potential implications for its use in treating arthroplasty infections. J Am Acad Orthop Surg 2017; 25 (06) e114-e120
  Search in Google Scholar
• 29 Kallala R, Haddad FS. Hypercalcaemia following the use of antibiotic-eluting absorbable calcium sulphate beads in revision arthroplasty for infection. Bone Joint J 2015; 97-B (09) 1237-1241
  Search in Google Scholar