Effect of Vancomycin Powder in Reducing Infection after Primary and Revision Hip and Knee Arthroplasty and Its Complications: An Umbrella Review and Meta-Analysis.

Abstract

Periprosthetic joint infection (PJI) after hip or knee arthroplasty greatly increases morbidity and costs. Local antibiotic powders may help curb infections while minimizing systemic toxicity. We assessed their efficacy and safety in preventing PJI. We systematically searched PubMed, Scopus, CENTRAL, Web of Science, Embase, and CINAHL for studies published from January 1990 to January 2024. Eligible trials compared intraoperative antibiotic powder with no powder in primary or revision arthroplasty. Risk ratios (RR) with 95% confidence intervals (CI) were pooled. Methodologic quality was assessed using AMSTAR-2, ROB 2, and ROBINS-I; evidence certainty was rated with GRADE. Stratified analyses examined dose, surgical type, and administration technique. There were 10 secondary studies (comprising 22 primary studies with 137,651 patients) - all evaluating vancomycin powder (VP) - that met the inclusion criteria. Pooled data showed no significant reduction with VP in total infections (RR 0.86, 95% CI, 0.62 to 1.18), superficial infections, or PJI specifically. High-quality, randomized, and prospective studies have likewise demonstrated no prophylactic benefit. Retrospective studies suggested benefit, but their certainty was low to very low. The application of VP did not increase local wound complications or systemic adverse events. Robust evidence from randomized and prospective research does not support the routine use of vancomycin powder to prevent infection in hip or knee arthroplasty. Favorable findings from retrospective analyses are insufficient to outweigh the lack of benefit in higher-quality trials. Routine intraoperative VP application cannot be recommended until stronger evidence emerges.