Impact of Silver Coating on Periprosthetic Joint Infection Risk in Modular Endoprostheses Used in Primary and Revision Arthroplasty: A Systematic Review and Meta-Analysis.

Abstract

Periprosthetic joint infection (PJI) remains a devastating complication in endoprosthetic reconstruction. Silver coatings have emerged as a potential solution due to their inherent antimicrobial properties, yet their comparative effectiveness against traditional titanium implants remains under debate. We conducted a systematic review and meta-analysis following with prior PROSPERO registration (CRD420250651012). The PubMed and Embase databases were searched from inception to February 2025. Studies comparing silver-coated and uncoated titanium endoprostheses were included. Primary outcomes included PJI after primary oncologic reconstruction and PJI reinfection after revision arthroplasty for failed total joint arthroplasty. There were 13 studies comprising 1,517 patients (707 silver-coated, 810 uncoated) included. Silver-coated endoprostheses showed a 14% reduction in PJI risk after primary oncologic reconstruction (risk ratio [RR] 0.86, 95% confidence interval [CI] 0.59 to 1.24, P = 0.41). Similar reductions were observed for proximal femoral (RR 0.67, P = 0.29) and proximal tibial replacements (RR 0.80, P = 0.46). Silver coating showed reductions in both acute (RR 0.71, P = 0.59) and chronic PJI (RR 0.95, P = 0.85). Patients who had silver-coated implants developing PJI were more likely to undergo debridement, antibiotics, and implant retention (DAIR) plus procedures (RR 4.08, 95% CI 1.14 to 14.55, P = 0.03) and showed a 40% reduction in amputation risk (RR 0.60, 95% CI 0.28 to 1.19, P = 0.20). In revision cases, silver coating demonstrated a 19% reduction in reinfection risk (RR 0.81, 95% CI 0.48 to 1.12, P = 0.21). Confidence intervals encompassed both meaningful benefit and potential harm across all outcomes, but the selection of DAIR plus treatment. Silver-coated endoprostheses demonstrated consistent reductions in infection and amputation rates, but confidence intervals encompassed both meaningful benefit and potential harm. Current evidence lacks sufficient precision to support routine use. Adequately powered trials are needed to establish definitive recommendations.