The Risk of Iatrogenic Hypercalcemia in Patients Undergoing Calcium Sulphate Beads Implantation in Prosthetic Joint Surgery: A Systematic Review

Calcium sulphate beads are increasingly being used in the management of prosthetic joint infections (PJI). Traditionally their use was limited to a void or dead space-filling combined with other additives such as Hydroxyapatite. Over the last decade, they have been developed to act more frequently as an antibiotics delivery system. Stimulan, a bio-absorbable form of Calcium sulfate, theoretically has an increased risk of hypercalcemia. Over the last few years, there have been published case reports which report it as an isolated cause of iatrogenic hypercalcemia. The sparsity of literature on this topic makes it difficult for surgeons to decide on the use of Calcium sulphate beads in patients with hypercalcemia predisposition in conditions like autoimmune disorders, sarcoidosis, malignancy, granulomatous diseases, heterotopic ossification, and hyperparathyroidism. The study was performed to assess the risk of hypercalcemia in patients after Calcium sulphate beads implantation in PJI. Two reviewers searched relevant literature in 3 online databases using cochrane methodology for systematic reviews. Studies reporting complications with the use of calcium sulphate beads in prosthetic joints were included. Studies reporting on less than five patients and studies reporting use in any other surgeries were excluded. The search of databases resulted in a total of 96 articles. After screening, a total of four articles were deemed suitable to be included in the analysis. A total of 1049 patients underwent calcium sulfate beads implantation, out of which 44 (4.2%) reported hypercalcemia with 41 (3.91%) transient in nature and 3 (0.28%) required management, including one with ICU admission. The result of this systematic review shows that calcium sulphate beads are safe and effective against PJI. There is a significant risk of transient hypercalcemia in susceptible patients and a low risk of symptomatic hypercalcemia.