Evolving Role of Synthetic Bone Graft Substitutes with Local Antibiotic Elution in High-Energy Trauma
6 affiliations
- 1Trauma and Orthopaedic Registrar, Wye Valley, National Health Service Trust, Hereford, United Kingdom.
- 2Department of Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, Tamil Nadu, India.
- 3Department of Regenerative Medicine, Agathisha Institute of Stemcell and Regenerative Medicine, Chennai, Tamil Nadu, India.
- 4Department of Orthopaedics, Orthopaedic Research Group, Coimbatore, Tamil Nadu, India.
- 5Department of Emergency Medicine, NHS England, United Kingdom.
- 6Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Karaikal, Puducherry, India.
Abstract
Introduction: The risk of fracture-related infection (FRI) is between 5% and 30% depending on the Gustilo grade, and FRI leads to an 8-fold longer hospital stay and 2.8-fold greater hospitalization costs. Synthetic bone graft substitutes in combination with systemic antibiotic treatment (calcium sulfate, biphasic CS/hydroxyapatite composites (CERAMENT G/V), bioactive glass S53P4) have proven to be important adjuncts to systemic antibiotic therapy in Gustilo-Anderson IIIB injuries, FRI management, and reconstruction of segmental defects. The objective of the review is to critically evaluate the evidence, pharmacokinetics, adverse events, and clinical outcomes of synthetic bone graft substitutes with local antibiotic elution in high-energy open fractures and FRIs, with the aim of defining their role in prevention and treatment strategies. Materials and Methods: PubMed/MEDLINE, Embase, Cochrane Library, and Scopus databases were searched for literature that was compliant with the Scale for the Assessment of Narrative Review Articles guidelines (January 2019 to September 2026), with landmark pre-2019 literature added to perform a narrative review. The search terms used were bone graft substitute, calcium sulfate, CERAMENT, bioactive glass S53P4, local antibiotic delivery, open fracture, FRI, and Masquelet. Only peer-reviewed studies and meta-analyses were included; pre-prints were excluded. Results: 5.1% of CERAMENT G had osteomyelitis at a mean of 88.7 months compared to a historical reference of 14.5%, and primary union was 83.3%. A 2025 meta-analysis of S53P4 (28 studies, n = 1,122) demonstrated pooled infection eradication of 88.1% (95% confidence interval 85.4–90.4%; I2 = 0%). The trend in this group for protection was not statistically significant (deep infection respiratory rate = 0.17). CS resorption is followed by wound drainage in 20-58% of cases. There are no well-powered randomized controlled trials (RCTs) available for most local antibiotic carrier indications. Conclusion: Local antibiotic-eluting bone graft substitutes decrease the risk of FRI in Gustilo IIIB injuries and have shown to have high efficacy in eradicating infections in osteomyelitis, but there is not enough RCT evidence to support their use. Wound grade, defect size, and local microbiology should influence the use.
Related
- Solvent-Dependent Monomer Leaching From Two Commercial Dental Resin Composites: A Time-Dependent Elution Behaviour
- The Bridge-or-Trap Model of Companion AI: When Emotional Support Connects or Substitutes.
- Ethical Challenges of Bioprinted and Lab-Grown Skin Substitutes in Burn Care
- Milk-lupin mixes and fermentation as levers for improving the nutritional and environmental performance of plant-based yoghurt substitutes
- BEYOND THE BLOOD GROUP O MOTHERS: EVALUATION OF THE ANTIBODIES IGG ANTI-A AND ANTI-B EXTRACTED BY ELUTION TECHNIQUES IN ABO NEWBORN INCOMPATIBILITIES
BibTeX
@article{bharadwaj2026evolving,
title = {{Evolving Role of Synthetic Bone Graft Substitutes with Local Antibiotic Elution in High-Energy Trauma}},
author = {Sanjeevi Bharadwaj and Naveen Jeyaraman and Subasri Balasubramanian and Arunagiri Gunasekar and Arulkumar Nallakumarasamy and Madhan Jeyaraman},
journal = {Journal of Orthopaedic Case Reports},
year = {2026},
month = nov,
doi = {10.13107/jocr.2026.v16.i11.8540},
url = {https://doi.org/10.13107/jocr.2026.v16.i11.8540},
note = {CC BY-NC},
}
RIS
TY - JOUR
TI - Evolving Role of Synthetic Bone Graft Substitutes with Local Antibiotic Elution in High-Energy Trauma
AU - Sanjeevi Bharadwaj
AU - Naveen Jeyaraman
AU - Subasri Balasubramanian
AU - Arunagiri Gunasekar
AU - Arulkumar Nallakumarasamy
AU - Madhan Jeyaraman
PY - 2026
DA - 2026/11/01
JO - Journal of Orthopaedic Case Reports
DO - 10.13107/jocr.2026.v16.i11.8540
UR - https://doi.org/10.13107/jocr.2026.v16.i11.8540
AB - Introduction: The risk of fracture-related infection (FRI) is between 5% and 30% depending on the Gustilo grade, and FRI leads to an 8-fold longer hospital stay and 2.8-fold greater hospitalization costs. Synthetic bone graft substitutes in combination with systemic antibiotic treatment (calcium sulfate, biphasic CS/hydroxyapatite composites (CERAMENT G/V), bioactive glass S53P4) have proven to be important adjuncts to systemic antibiotic therapy in Gustilo-Anderson IIIB injuries, FRI management, and reconstruction of segmental defects. The objective of the review is to critically evaluate the evidence, pharmacokinetics, adverse events, and clinical outcomes of synthetic bone graft substitutes with local antibiotic elution in high-energy open fractures and FRIs, with the aim of defining their role in prevention and treatment strategies. Materials and Methods: PubMed/MEDLINE, Embase, Cochrane Library, and Scopus databases were searched for literature that was compliant with the Scale for the Assessment of Narrative Review Articles guidelines (January 2019 to September 2026), with landmark pre-2019 literature added to perform a narrative review. The search terms used were bone graft substitute, calcium sulfate, CERAMENT, bioactive glass S53P4, local antibiotic delivery, open fracture, FRI, and Masquelet. Only peer-reviewed studies and meta-analyses were included; pre-prints were excluded. Results: 5.1% of CERAMENT G had osteomyelitis at a mean of 88.7 months compared to a historical reference of 14.5%, and primary union was 83.3%. A 2025 meta-analysis of S53P4 (28 studies, n = 1,122) demonstrated pooled infection eradication of 88.1% (95% confidence interval 85.4–90.4%; I2 = 0%). The trend in this group for protection was not statistically significant (deep infection respiratory rate = 0.17). CS resorption is followed by wound drainage in 20-58% of cases. There are no well-powered randomized controlled trials (RCTs) available for most local antibiotic carrier indications. Conclusion: Local antibiotic-eluting bone graft substitutes decrease the risk of FRI in Gustilo IIIB injuries and have shown to have high efficacy in eradicating infections in osteomyelitis, but there is not enough RCT evidence to support their use. Wound grade, defect size, and local microbiology should influence the use.
SN - 2250-0685
SN - 2321-3817
ER -