Systematic Review and Meta-Analysis of Intrawound Vancomycin in Total Hip and Total Knee Arthroplasty: A Continued Call for a Prospective Randomized Trial

Periprosthetic joint injection (PJI) is a rare, but life-altering complication of total joint arthroplasty (TJA). Though intrawound vancomycin powder (IVP) has been studied in other orthopedic subspecialties, its efficacy and safety in TJA has not been established.PubMed and MEDLINE databases were used to identify studies utilizing IVP in primary and revision total hip (THA) and knee arthroplasty (TKA). Postoperative PJI data were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Studies were weighted by the inverse variance of their effect estimates.Overall, 16 of the 1871 studies identified were pooled for final analysis, yielding 33,731 patients totally. Of these, 17 164 received IVP. In aggregate, patients who received IVP had a decreased rate of PJI (OR 0.46, P.05). Separately, TKA and THA patients who received IVP had lower rates of PJI (OR 0.41, P.05 and OR 0.45, P.05, respectively). Aggregate analysis of primary TKA and THA patients also revealed a decreased PJI rate (OR 0.44, P.05). Pooled revision TKA and THA patients had a similar decrease in PJI rates (OR 0.30, P.05). Although no publication bias was appreciated, these findings are limited by the low-quality evidence available.While IVP may reduce the risk of PJI in primary and revision TJA, its widespread use cannot be recommended until higher-quality data, such as that obtained from randomized control trials, are available. This study underscores the continued need for more rigorous studies before general adoption of this practice by arthroplasty surgeons.