Use of topical vancomycin powder in total joint arthroplasty: Why the current literature is inconsistent?

Table 1 Serum and local levels of vancomycin at different post-wound closure collection times

Procedure	Serum levels after wound closure of VP intrawound administration (g/mL)
	1.5 h (mean ± SD; max)	3 h (mean ± SD; max)	12 h (mean ± SD; max)	24 h (mean ± SD; max)	Highest level observed across the 24-h period
THA (n = 15)	3.8 ± 3.9; 9.5	4.9 ± 4.5; 12.7	5.1 ± 3.3; 8.4	3.5 ± 3.5; 8.0	6.6 ± 3.8; 12.7
TKA (n = 19)	1.0 ± 2.5; 8.7	1.8 ± 3.2; 9.8	4.4 ± 3.1; 7.3	3.5 ± 3.6; 10.4	5.2 ± 3.4; 10.4
THA + TKA (n = 34)	2.2 ± 3.4; 9.5	3.2 ± 4.1; 12.7	4.7 ± 3.2; 8.4	3.5 ± 3.5; 10.4	5.8 ± 3.6; 12.7
	Local levels after wound closure of VP intrawound administration, n (g/mL)
	-	3 h (mean ± SD)	12 h (mean ± SD)	24 h (mean ± SD)	-
THA	-	988 ± 628 (12)	769 ± 1059 (11)	280 ± 436 (11)	-
TKA	-	877 ± 455 (18)	288 ± 203 (16)	163 ± 220 (18)	-
THA + TKA	-	922 ± 523 (30)	484 ± 716 (27)	207 ± 317 (29)	-

VP: Vancomycin powder; THA: Total hip arthroplasty; TKA: Total knee arthroplasty. Adapted from: Johnson JD, Nessler JM, Horazdovsky RD, Vang S, Thomas AJ, Marston SB. Serum and Wound Vancomycin Levels After Intrawound Administration in Primary Total Joint Arthroplasty. J Arthroplasty 2017 Mar; 32(3): 924-928. Copyright © 2015 Elsevier Inc. All rights reserved.

Table 2 Main characteristics and results of the recent literature on the topic vancomycin powder

Ref.	Type of study	No. of studies	No. of cases (control/intervention)	PJI Rate/RR (control vs intervention)	SSI/Aseptic wound complications (control vs intervention)	Authors’ conclusions
Martin et al[36], 2022	Systematic review and meta-analysis	7/7	144724/8029	RR 0.39 (95%CI 0.27-0.56, P < 0.001)	6.48% vs 3.79%	VP ± PI lavage reduced PJI rate in primary and revision THA/TKA. Associated with reduced aseptic wound complications
Liao et al[35], 2022	Systematic review and meta-analysis	14	7720/1292	RR 0.41 (95%CI 0.29-0.58, P < 0.001)	-	VP recommended in primary TKA
Movassaghi et al[30], 2022	Systematic review and meta-analysis	16	3731/17164	1.65% vs 0.87% (P < 0.05)	-	Local VP may reduce the risk of PJI in primary and revision TJA
Wong et al[31], 2021	Systematic review	9	6255/3371	-	No difference	Recommend the surgeons not to use VP in routine THA and TKA
Peng et al[32], 2021	Systematic review and meta-analysis	9	4512/2354	RR 0.37 (95%CI 0.23- 0.60, P < 0.001)	RR = 0.40, 95%CI 0.27-0.61 (P < 0.001)	Local VP could significantly decrease the rate of SSI and PJI in primary TJA
Saidahmed et al[33], 2021	Systematic review and meta-analysis	9	3714/1985	3.5% vs 1.6%, RR 0.53 (95%CI 0.35-0.79, P = 0.002, I2 = 0.0%)	No difference 1.6% vs 0.7%, RR = 0.61, 95%CI 0.17-2.12, (P = 0.43, I2 = 0.0%)	Local antibiotic application results in a moderate reduction in deep infection rates in primary TJA, with no significant impact on SSI rate
Xu et al[34], 2020	Systematic review and meta-analysis	9	4607/2497	2.75% vs 1.20% (OR 0.44, 95%CI 0.28-0.69, I2 = 0.0%)	No difference 1.60% vs 0.67% (OR 0.60, 95%CI 0.17-2.12, I2 = 0.0%)	VP used in primary hip and knee arthroplasty may reduce the incidence of PJI but it may increase the risk of aseptic wound complications

RR: Relative risk; SSI: Superficial site infection; VP: Vancomycin powder; PI: Povidone iodine; PJI: Periprosthetic joint infection; THA: Total hip arthroplasty; TKA: Total knee arthroplasty; TJA: Total joint arthroplasty; OR: Odds ratio.