A systematic review on bioactive glass as a treatment for limb osteomyelitis and infected nonunion.

Aims: Osteomyelitis and infected nonunion cause devastating morbidity and are difficult to treat. Antimicrobial resistance further complicates musculoskeletal infection and is a significant global problem, including in low- and middle-income countries. Extensively drug-resistant bacteria and high rates of musculoskeletal infection have been identified during the Russian-Ukrainian war. Biomaterials with antimicrobial properties unrelated to antibiotics represent a potential solution. Bioactive glass, for example, has shown promise as a bone void filler. It binds to bone, stimulates bone formation, causes no harmful immune response, and has antimicrobial properties. This systematic review appraises the evidence for bioactive glass as a treatment for osteomyelitis and infected nonunion. Methods: A comprehensive search of MEDLINE and EMBASE was performed with research librarian guidance. Articles were screened and assessed for risk of bias by two blinded authors. No date limitations were used. Methodology was guided by the Cochrane Handbook and the PRISMA statement. Data were compiled and narratively synthesized. Results: We included 24 observational studies on 957 patients. Reported outcomes were heterogeneous, with patient-reported outcome measures available in only one study. Most studies were small and at considerable risk of bias. Studies supported bioactive glass use with high rates of bone healing and infection resolution. Comparative studies found non-inferiority with established treatments such as antibiotic-containing calcium sulphate and polymethylmethacrylate cement spacers. Few significant bioactive glass-related complications were reported. Conclusion: This review demonstrates the potential of bioactive glass as a treatment for osteomyelitis and infected nonunion. Widespread uptake over established treatments is likely to require further supporting evidence, such as high-quality randomized controlled trials, to understand the role of biomaterials in treating these challenging conditions. Future work should examine 3D-printed bioactive glass hybrids, which may have biomechanical advantages for large bone defects.