Intrawound Vancomycin Powder Reduces Deep Surgical Site Infection in Tibial Plateau and Pilon Fractures: A Systematic Review and Meta-Analysis.

Deep surgical site infection (SSI) after operative fixation of tibial plateau and pilon fractures remains a common complication despite modern surgical protocols. A systematic review and meta-analysis was performed to determine whether intrawound vancomycin powder reduces deep SSI in these fractures. PubMed, Cochrane CENTRAL, and Scopus were searched from inception to February 20, 2026. Our study identified that vancomycin powder was associated with reduced deep SSI (odds ratio (OR) 0.53; 95% confidence interval (CI) 0.35-0.80; p = 0.002; I² = 0%), with an infection rate of 4.9% versus 9.7%. The effect was driven by gram-positive deep infections (OR 0.32; 95% CI 0.14-0.73; p = 0.007). No effect was observed on superficial SSI (OR 1.17; p = 0.66). Results were robust across all sensitivity analyses including leave-one-out, fixed-effect, Peto, and subgroup analyses by study design and fracture risk level. The certainty of evidence was moderate for deep SSI and high for gram-positive deep SSI (Grading of Recommendations, Assessment, Development and Evaluations (GRADE)). Intrawound vancomycin powder appears to be a safe, low-cost intervention that may be considered for routine use in operative fixation of tibial plateau and pilon fractures.