Intrawound vancomycin powder for infection prophylaxis in definitive fixation of complex fractures: a systematic review and meta-analysis of efficacy and safety.

Abstract

To evaluate the effectiveness and safety of intrawound vancomycin powder in the definitive surgical management of high-risk fractures, with particular attention to postoperative infection, microbiological profile, and adverse events. Data Sources: A systematic search of PubMed, EMBASE, Web of Science, Cochrane Library and Scopus was conducted in February 2025, with a search cut-off date of January 31, 2025 following PRISMA framework. Randomized and observational comparative studies evaluating intrawound vancomycin powder in patients undergoing definitive fracture fixation were included if they reported postoperative infection, microbiological outcomes, or adverse events. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Cochrane Risk of Bias 2 (RoB 2) tool for randomized trials and ROBINS-I for non-randomized studies. Random-effects models were used to estimate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. Eight studies involving 3185 patients were included, of whom 1149 received topical vancomycin powder. Vancomycin use was associated with a significant reduction in postoperative infection following fracture fixation (OR 0.59, 95% CI 0.42-0.82; p = 0.002; I² = 0%). Microbiological data were limited; however, one study reported a lower proportion of gram-positive infections in the vancomycin group, with no corresponding reduction in gram-negative infections. Two studies contributed to an exploratory pooled safety analysis, which showed no statistically significant difference in adverse events between groups (OR 1.39, 95% CI 0.95-2.02; p = 0.38; I² = 0%). The certainty of evidence was limited by risk of bias, outcome indirectness, and the inclusion of non-randomized studies. Intrawound vancomycin powder was associated with a reduced risk of postoperative infection in high-risk fracture fixation without a statistically significant increase in reported adverse events. Microbiological findings remain sparse and should be interpreted cautiously. These results suggest that intrawound vancomycin powder may represent a useful prophylactic adjunct in selected orthopaedic trauma cases, although further high-quality studies are required to clarify its safety profile and microbiological consequences. II.