Intrawound vancomycin powder reduces postoperative infection risk (OR 0.59) in high-risk fracture fixation casesVancomycin Powder May Reduce Infections After High Risk Fractures

OBJECTIVES: 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. METHODS: 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. STUDY SELECTION: 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. DATA EXTRACTION: 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. DATA SYNTHESIS: Random-effects models were used to estimate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I statistic. RESULTS: 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; I = 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; I = 0%). CONCLUSIONS: 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. LEVEL OF EVIDENCE: II.