Effectiveness of Local Antibiotics for Infection Prevention in Primary Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background/Objectives: To evaluate the effectiveness of local antibiotic prophylaxis (e.g., powder, bone cement, intraosseous injection) in reducing periprosthetic joint infections (PJI) and deep wound infections in adults undergoing primary joint replacement surgery. Methods: A comprehensive search of PubMed, EMBASE, and the Cochrane Library was conducted from inception to 7 September 2024, including randomized controlled trials (RCTs) and cohort studies without language restrictions. Quality assessment was performed using the Cochrane Risk of Bias (RoB) 2.0 for RCTs and the Newcastle-Ottawa Scale (NOS) for cohort studies. Infection rates were extracted and analyzed using risk ratios (RR) or odds ratios (OR) in a random-effects model with Review Manager (RevMan) 5.4. Sensitivity analysis and meta-regression were also performed to validate the study results and possible risk factors. Results: Twelve RCTs and 21 cohort studies were included in the review. Vancomycin powder in the cohort studies demonstrated statistical significance (OR = 0.47, 95% confidence interval (CI): 0.36-0.61, I2 = 0%), in contrast to the results in the RCTs (RR = 0.37, 95% CI: 0.06-2.47, I2 = 49%). Sensitivity analyses confirmed the robustness and statistical significance of these findings. Both the control and treatment groups primarily cultured Gram-positive pathogens, including in the overall data and specifically for vancomycin powder. The evidence for the use of intraosseous injection (RR of RCTs not estimable, I2 not applicable; OR of cohorts = 0.12, 95% CI: 0.02-0.63, I2 = 0%) and bone cement (RR of RCTs = 0.40, 95% CI: 0.14-1.17, I2 = 56%; OR of cohorts = 1.88, 95% CI: 1.25-2.82, I2 not applicable) was inconclusive. Smoking was identified as an important risk factor for post-operative infection. Further research, including more robust trials and cohort studies, is needed to confirm these findings. Conclusions: Local administration of vancomycin powder appears effective in preventing deep wound infection after arthroplasty.