Surgical Techniques
Antibiotic Beads
Thomas A. DeCoster, MD
Shahram Bozorgnia, MD
The video that accompanies
this article is “Preparation and
Use of Antibiotic-Impregnated
Beads for Orthopaedic Infec-
tions,” available on the Orthopaedic Knowl-
edge Online Website, at http://www5.
aaos.org/oko/jaaos/surgical.cfm
Dr. DeCoster is Professor and Vice
Chair, Department of Orthopaedics and
Rehabilitation, University of New Mexico
School of Medicine, Albuquerque, NM.
Dr. Bozorgnia is Trauma Fellow,
Department of Orthopaedics and
Rehabilitation, University of New Mexico
School of Medicine.
Dr. DeCoster or a member of his
immediate family has received research
or institutional support from Biomet, EBI,
Orthofix, Smith & Nephew, Stryker, and
Zimmer; has stock or stock options held
in Merck and Wyeth; and has received
royalties from Innomed. Neither
Dr. Bozorgnia nor a member of his
immediate family has received anything
of value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
Reprint requests: Dr. DeCoster,
Department of Orthopaedics and
Rehabilitation, University of New Mexico
School of Medicine, 1127 University
Boulevard NE, Albuquerque, NM
87131.
J Am Acad Orthop Surg 2008;16:674-
678
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.
674
B one infection, or osteomyelitis,
can be one of the most difficult
problems confronted by the ortho-
paedic surgeon. Common causes of
osteomyelitis include open frac-
tures, hematogenous spread of bacte-
ria to bone, and orthopaedic surgical
procedures complicated by infec-
tion. Assessment involves identifi-
cation of the offending organism by
tissue culture and sensitivity to an-
tibiotics; radiographic assessment of
the extent of the infection; clinical
evaluation of the patient’s general
health and ability to fight infection;
and determination of the local ana-
tomic condition of the bone and soft
tissue.
Treatment is individualized but
generally involves prolonged use of
systemic antibiotics, surgical dé-
bridement, and support of the pa-
tient’s overall health.1,2 Results are
generally good but are not universal-
ly successful. Difficulties include
recurrence or lack of control of in-
fection, systemic toxicity to antibi-
otics, scar formation, and persistent
nonunion of fractures.2 Other prob-
lems include expense and practical
difficulties for the patient and the
surgeon, including multiple surgical
treatments, lengthy and frequent
hospitalizations, and prolonged limb
dysfunction. Control of infection
eventually may be obtained, but pa-
tient function still may be limited
by scar, stiffness, and weakness, as
well as nonunion or malunion of the
fracture. Late recurrence of infection
is also a problem.
To deliver therapeutic tissue lev-
els of parenteral antibiotics to the
target area, high serum levels of an-
tibiotics must be achieved.3 These
high serum levels, however, may
result in an increased incidence of
systemic side effects such as nephro-
toxicity and ototoxicity.4 As an alter-
Journal of the American Academy of Orthopaedic Surgeons
native, the use of antibiotic-
impregnated beads as an adjunct to
other treatment offers advantages
compared with systemic aminogly-
cosides. With the bead pouch tech-
nique, the systemic levels are low,
and the systemic complications are
virtually eliminated, while the local
concentration, where it is needed, is
extremely high.3 Antibiotic beads
also offer the benefit of management
of dead space. They are relatively in-
expensive and are easy for the sur-
geon to insert and the patient to tol-
erate.5
Indications and
Contraindications
Antibiotic beads can be used in mul-
tiple different applications. Typical
indications include prevention of in-
fection (eg, open fracture antibiotic
bead pouch prophylaxis), treatment
of established bone infection (ie,
acute and chronic osteomyelitis),
treatment of infected joint arthro-
plasties, dead space management in
patients with large soft-tissue inju-
ries, and chronic infected non-
unions.
Contraindications to the use of
antibiotic bead pouches in the treat-
ment of open fractures include pa-
tient hypersensitivity to specific an-
tibiotics, small wounds (for which
beads are not necessary), and unsal-
vageable limbs (because beads do not
overcome massive tissue injuries).
Contraindication to the use of anti-
biotic beads in the treatment of os-
teomyelitis include patient hyper-
sensitivity to a specific antibiotic
and the presence of resistant and
slime-forming organisms such as
Enterococcus. The foreign-body sur-
face of the methacrylate beads them-
selves is conductive to slime-
producing organisms, and the slime

barrier severely limits the efficacy of
the antibiotics in controlling the in-
fection.6,7
Specific Characteristics
of Antibiotic Beads
Antibiotic-impregnated polymethyl-
methacrylate (PMMA) cement beads
are a popular modality used in con-
junction with surgical débridement
and intravenous antibiotic therapy
for the treatment or prophylaxis of
orthopaedic infections. The beads
vary in size, type and amount of an-
tibiotic used, and type of bone ce-
ment used. The beads can be pre-
pared in advance by molding or by
rolling by hand in the operating
room.
Nonbiodegradable PMMA ce-
ment is the most common carrier
used. To incorporate antibiotics, an-
tibiotic powder is mixed with the
powdered cement polymer before
adding the methylmethacrylate liq-
uid monomer. The antibiotic must
be water soluble, available as pow-
der, able to remain stable despite the
heat generated during the polymer-
ization reaction, and hypoallergenic,
as well as have a broad spectrum of
activity. Antibiotic release is highest
in the first 4 days following implan-
tation; the remaining elution at ther-
apeutic concentration persists for
weeks to months.8 Wahlig et al3
showed that, if gentamicin-PMMA
chains are implanted and the wound
is closed, then the local concen-
trations of antibiotic achieved are
200 times the levels achieved with
systemic antibiotic administration.
However, the use of the beads in an
open system or in combination with
suction irrigation rapidly lowers lo-
cal antibiotic concentrations, and
the therapeutic advantage is dimin-
ished. Therefore, this technique is
not recommended.
Aminoglycosides are the most
commonly used antibiotics in this
context. They are effective against
aerobic gram-negative bacilli and
staphylococci as well as streptococ-
Volume 16, Number 11, November 2008
Thomas A. DeCoster, MD, and Shahram Bozorgnia, MD
Figure 1
A string of antibiotic beads is placed
into the wound for dead space
management and to provide a high
concentration of local antibiotic to the
wound.
ci, enterococci, and anaerobes.9
Among the aminoglycosides are to-
bramycin and gentamicin. Tobramy-
cin has been substituted for genta-
micin in the United States because it
is available as a pharmaceutical-
grade powder, whereas gentamicin is
not. There is extensive information
on the elution patterns of aminogly-
cosides from beads in a variety of
clinical scenarios.4,10
Vancomycin should be consid-
ered when there is a risk of resistant
staphylococcal organisms, that is,
methicillin-resistant Staphylococ-
cus aureus. Vancomycin is available
in powder form and is not neutral-
ized by the heat of methacrylate po-
lymerization. Effective elution of
vancomycin has also been report-
ed.11
Bead molds are available in a va-
riety of sizes. A diameter of 8 mm is
the largest and 2 mm, the smallest.
Small-diameter beads are used in
wounds of the hand and in other
small wounds to maximize the sur-
face area and antibiotic elution.
Consistency in size and shape of the
beads also facilitates their passage
into tight spaces, including the med-
ullary canal.
Surgical Technique
The technique of application of anti-
biotic beads involves the production
Figure 2
In open fractures with significant soft-
tissue injuries, antibiotic beads can be
placed in the open wound. The soft-
tissue defect will be covered with an
adhesive, porous, polyethylene wound
film.
of beads, followed by surgical place-
ment within the débrided wound
and in place of débrided bone (Fig-
ures 1 and 2). Following bead im-
plantation, the soft tissue is closed.
The beads allow for very high levels
of antibiotic bathing of the wound
and also assist in fighting infection.
The beads occupy space, preventing
the accumulation of hematoma that
otherwise would be a potential site
for infection. Antibiotic beads also
provide management of dead space
by preventing the formation of scar
tissue in the bone-defect site. If in-
fection persists, a repeat débride-
ment, culture, and antibiotic bead
exchange may be performed after
several days or weeks. Once the in-
fection is well controlled, the beads
are surgically removed. For non-
union or a large bone void, bone graft
may be placed in the area that the
beads occupied.
Although the antibiotic within
the beads produces a high local con-
centration in the surrounding tis-
sues, the systemic level of antibiot-
ic resulting from beads is low, which
minimizes complications, including
renal toxicity and ototoxicity. The
high local concentration of antibiot-
ic reduces and often eliminates the
need for intravenous antibiotics;
therefore, intravenous access and
compliance are not required. Osteo-
myelitis typically involves seques-
675
Antibiotic Beads
Figure 3
The liquid cement mixture is pressed
forcefully with a tongue depressor into
the bead mold.
tration of dead infected bone with
little to no blood supply. Many sys-
temic antibiotics exhibit poor pene-
tration of bone, even when the bone
is vascularized. Hence, systemic an-
tibiotics and blood-borne antimicro-
bial cells may not reach the area
of greatest need. Antibiotic beads,
however, provide high local concen-
trations of antibiotic not dependent
on blood supply to the bone. Neither
are the antibiotics dependent on
bone penetration.5
Antibiotic Bead
Preparation Technique
Bead Preparation
The bead preparation technique
described here results in spherical,
uniform tobramycin-impregnated
PMMA beads ( video, “Ingredi-
ents”). These beads can be made in
advance, sterilely packaged, and
stored in the operating room ready
for use. Alternatively, beads can be
prepared in the operating room at
the time of implantation, with or
without the use of bead molds.
When this technique is used, suffi-
cient time (at least 30 minutes) must
be allowed for full curing of the ce-
ment to minimize toxic monomers.
Materials
The materials needed for the pro-
duction of tobramycin-impregnated
PMMA beads are the following:
• One package (40 g) of PMMA
676
Figure 4
The liquid cement mixture is pressed
forcefully with a cement-filled syringe
into the bead mold.
bone cement
• 20 mL of liquid monomer
• Two 1.2-g vials of tobramycin
powder
• Two twisted strands of 26-gauge
wire
• A cast-metal, Teflon-coated bead
mold
• One medium-size (approximate-
ly 200 mL) plastic bowl
• Tongue depressors
• Two 10-mL syringes
• Tweezers from a suture-removal
kit
• Gloves
Technique
Twist together two strands of 26-
gauge wire (50 turns using a hand
drill) ( video, “Wire-Twisting Pro-
cedure”). Carefully place the wire
into the grooves of the bead mold
and tighten the mold ( video,
“Preparation Technique A [Spatu-
la]”). A cool working environment
and precooling of the mold and
PMMA prolong the polymerization
time. In a medium-size plastic bowl,
mix most of one package of bone ce-
ment (ie, 35 of 40 g) with two 1.2-g
vials of tobramycin powder. This al-
lows a prolonged liquid phase, which
facilitates better bead production.
Stir thoroughly to ensure homogene-
ity of the mixture. Pour 20 mL of liq-
uid monomer into the powder and
stir vigorously for about 30 seconds
until the mixture liquefies. Contin-
ue to stir the cement mixture, mov-
Journal of the American Academy of Orthopaedic Surgeons
ing the cement away from the bot-
tom and edges of the bowl to prevent
hardening.
With a tongue depressor, forceful-
ly press the liquid cement mixture
into the bead mold (Figure 3). Quick-
ly and carefully fill all of the holes
until the entire mold is filled with
the cement mixture. It is imperative
that this step is done in less than 8
minutes, before the mixture hard-
ens. Smooth the surface of the mold
by scraping off the remaining ce-
ment with a tongue depressor. Place
the mold on its side and let it sit for
15 minutes as the cement hardens.
An alternative technique for plac-
ing the cement into the mold holes
is to pour 3 mL of the liquid cement
mixture into a 10-mL syringe with
the plunger removed and the tip
capped, then replace the plunger and
remove the syringe cap ( video,
“Preparation Technique B [Sy-
ringe]”). While applying pressure,
use the syringe to fill each hole in
the mold with the cement mixture.
Keep the syringe at a 90° angle as
each hole is filled and apply pressure
to maintain a tight seal between the
mold and the syringe (Figure 4). Ce-
ment should bulge into the adjacent
hole. Proceed rapidly because the sy-
ringe technique requires the cement
to be in the liquid state. Four sy-
ringes typically are needed for two
20-bead chains. The tip of each sy-
ringe is cut off so that the lumen
matches the diameter of the mold.
Smooth the surface of the mold by
scraping off the remaining cement
with a tongue depressor. Place the
mold on its side and let it sit for 15
minutes until the cement is com-
pletely hardened.
After 15 minutes, take the mold
apart and gently remove the beads
by pulling the wire (Figure 5). Re-
move the excess cement (ie, flash-
ing) between the beads using the
tweezers from the suture kit. Excess
cement in the mold also should be
removed to facilitate the next use
of the mold. A pair of scissors from
a suture-removal set is the exact
 Thomas A. DeCoster, MD, and Shahram Bozorgnia, MD

Pearls
• Remove all avascular, necrotic, and contaminated tissue before applying antibiotic beads. Infection re-
sulting from inadequate débridement will not be overcome by the use of antibiotic beads.
• Beads can be made in advance and stored in the operating room.
• Thoroughly mix the bone cement with the antibiotic powder before adding the liquid monomer.
• Fill all of the holes of the mold as quickly as possible before the mixture hardens.
• An assistant is helpful.

Pitfalls
• Do not use the beads in an open system or in combination with suction irrigation because doing so pre-
vents development of effective antibiotic levels in the wound.
• Do not use the beads as an initial measure in inflamed and suppurating wounds.
• Do not use the beads in the treatment of osteomyelitis in the presence of resistant organisms or slime-
forming organisms (eg, Enterococcus) because effective elution of antibiotic is not achieved.
• Do not substitute antibiotic beads for thorough wound débridement.
• Do not insert handmade beads that are too large to fit into the medullary canal or too big to completely
fill the wound.
• Use care to produce bead chains in a timely fashion during the short available working time (8 minutes)
as the methacrylate polymerizes. Failure to do so results in wasted material and surgeon frustration. These
can be avoided by planning and relying on an assistant.
• Do not leave beads in the patient so long (>3 weeks) that removal is difficult.

width of the slots in the mold and subjected to excessive or chronic

thus can be used to remove residual
cement from the mold.
Transfer the beads into gas-
sterilization packages (Figure 6) and
have them sterilized. Wash your
hands and all work surfaces thor-
oughly after working with the ce-
ment. This same process can be per-
formed in the operating room, using
sterile technique, for immediate
use.
Complications
Complications caused by the use of
antibiotic beads are uncommon;
however, difficulty with bead re-
moval can occur when the beads are
left in place too long, especially in
the medullary canal of long bones.
Antibiotic beads reduce the rate of
infection in open fractures, but they
do not eliminate the risk. Beads help
to control established infections, but
not all infections will completely re-
solve. A major complication is persis-
tent or recurrent infection. Also, spac-
ers can fragment or dislodge when
Figure 5
loads. Infection resulting from inad-
equate débridement will not be over-
come by the use of antibiotic beads.
Knowledge of the effectiveness of
antibiotic beads is limited. The opti-
mal dose, duration of treatment, and
relative efficacy of various antibiotic
classes are not known. Differential
elution of antibiotics from various
forms of PMMA has been report-
ed,12,13 but the ideal carrier medium After 15 minutes, the mold is taken
is still a matter of debate. The role apart, and the beads are gently
and efficacy of absorbable beads is not removed by pulling the wire.
yet known. Local antibiotic delivery
by pump or other mechanism is an al-
Figure 6
ternative route of local antibiotic
therapy. In addition, the efficacy of
beads compared with the efficacy of
other delivery methods is not yet
known.
Summary
Antibiotic beads are an attractive
method of treatment in the manage-
ment and prevention of osteomyeli-
tis. Antibiotic beads provide high lo- The beads are transferred into gas-
cal concentrations of antibiotic at sterilization packages.

Volume 16, Number 11, November 2008 677

Antibiotic Beads
the site of infection without signifi-
cant systemic toxicity. A variety of
techniques to provide local antibiot-
ics has been reported, including ab-
sorbable beads with various types of
antibiotics, antibiotic sticks, coated
nails, and coated joint spacers. Beads
can be prepared in the operating
room or in advance. Antibiotic beads
assist in dead space management
and help facilitate the filling of bone
voids and healing of infected non-
unions. Results demonstrate im-
proved efficacy in the control of in-
fection and enhanced outcomes,
with financial and practical sav-
ings.14
References
Citation numbers printed in bold
type indicate references published
within the past 5 years.
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of infection in the treatment of one
thousand and twenty-five open frac-
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prospective analyses. J Bone Joint
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678
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3. Wahlig H, Dingeldein E, Bergmann R,
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