Calcium sulphate beads in the management of periprosthetic knee joint infection: a systematic review and single-arm meta-analysis

Abstract Background Periprosthetic joint infection (PJI) following total knee arthroplasty remains a devastating complication associated with substantial morbidity and mortality. Antibiotic-impregnated calcium sulphate (AICS) beads have been increasingly used to enhance local antimicrobial delivery; however, their clinical outcomes and complication profile in periprosthetic knee infection remain unclear. This systematic review and meta-analysis aimed to evaluate the clinical outcomes and complications associated with AICS bead use in patients undergoing debridement, antibiotics, and implant retention (DAIR) or two-stage revision (2SR) for periprosthetic knee infections. Methods Embase, Cochrane Library, and PubMed were searched from inception to November 2025 for studies reporting outcomes of AICS bead use in periprosthetic knee infections managed with DAIR or 2SR. Outcomes assessed included infection eradication, re-operation rates, and AICS bead-related complications, specifically wound drainage, hypercalcaemia, and heterotopic ossification. Data extraction and quality assessment were performed, and a random-effects meta-analysis of single proportions was conducted, with DAIR and 2SR analysed separately. Results Nine studies comprising 242 patients undergoing DAIR were included. The failed infection eradication rate was 18% (95% CI 10.7–28.6%, n = 205), and the re-operation rate was 19.8% (95% CI 10.5–34.2%, n = 142). Wound drainage was the most common complication, with an estimated rate of 6.4% (95% CI 2.2–17%, n = 118). Five studies comprising 205 patients undergoing 2SR were included. The failed infection eradication rate was 6.4% (95% CI 2.8–14%, n = 205), and the re-operation rate was 5.9% (95% CI 1.2–24.2%, n = 190). Wound drainage was the most common complication with an estimated rate of 10.6% (95% CI 3.1–30.6%, n = 143). Conclusion This single-arm meta-analysis summarises the reported outcomes and complications associated with AICS bead use in periprosthetic knee infection treated with DAIR or 2SR. Pooled rates of failed infection eradication were reported, without direct comparisons between DAIR and 2SR, while wound drainage was the most frequently reported AICS bead-related complication. However, these findings should be interpreted cautiously given the low quality and heterogeneity of the included studies. Further prospective studies are warranted. Level of Evidence Therapeutic level III.