Intrawound Vancomycin Powder for Infection Prophylaxis in Definitive Fixation of Complex Fractures: A Systematic Review and Meta-analysis of Efficacy and Safety

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, and Scopus was conducted in February 2025, with a search cut-off date of January 31, 2025. Study Selection: Randomized and observational comparative studies were included if they evaluated intrawound vancomycin powder in patients undergoing definitive fracture fixation and reported outcomes related to postoperative infection, microbiology, 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). Heterogeneity was assessed using the I² statistic. Results Eight studies involving 3185 patients were included; 1149 received topical vancomycin powder. Vancomycin use was associated with a significant reduction in postoperative infection after fracture fixation (OR 0.59, 95% CI 0.42–0.82; p = 0.002; I² = 0%). Microbiological data were limited, but one study reported a lower proportion of gram-positive infections in the vancomycin group, with no similar pattern for gram-negative organisms. 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%). Conclusions The certainty of evidence was limited by risk of bias, indirectness, and the inclusion of non-randomized studies. Intrawound vancomycin powder was associated with reduced 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 support selective consideration of intrawound vancomycin powder in orthopedic trauma surgery, while further high-quality studies are needed to clarify safety and microbiological consequences.