SLR - October 2021 - Taylor R. Tendrich

Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection

Reference: Qadir R, Costales T, Coale M, Mulliken A, Zerhusen T Jr, Joshi M, Castillo RC, Carlini AR, O'Toole RV. Vancomycin Powder Use in Fractures at High Risk of Surgical Site Infection. J Orthop Trauma. 2021 Jan 1;35(1):23-28. doi: 10.1097/BOT.0000000000001863. PMID: 32898082.

Scientific Literature Review 

Level of Evidence: III

Reviewed By: Taylor R. Tendrich, DPM 
Residency Program: Northwest Medical Center – Margate, FL 

Podiatric Relevance: There is a high incidence of deep infection after high energy fractures. Certain high risk injury patterns such as pilon fractures and calcaneal fractures have been reported to have infection rates higher than 50 percent. Recently, intrawound application of vancomycin powder has been shown to be effective in decreasing post-operative infection by multiple retrospective studies. Limited data exists examining the use of intrawound vancomycin powder to reduce infection after ORIF of tibial plateau, tibial pilon and calcaneal fractures. The purpose of this study was to explore whether vancomycin powder decreases the incidence of deep surgical site infection in these high risk treated fractures. 

Methods: This was a retrospective cohort review of all fractures which were operatively treated from 2011 to 2015. A total of 583 high risk fractures were included, of which 35 received topical vancomycin powder. High risk fractures were defined as those requiring planned surgical delay and staged fracture fixation because of soft tissue concerns and risk for infection. All closed and open injuries were included, including those requiring soft tissue coverage and/or fasciotomies for compartment syndrome. During the study period, patients received IV Ancef preoperatively and for 24 hours postoperatively for both open and closed fractures. One gram of vancomycin powder was applied topically to the surgical site directly in contact with the fixation device at the time of wound closure. The powder was applied directly as powder at the time of wound closure. The primary outcome measure was deep surgical site infection, which was defined as a post-operative infection requiring operative debridement with infection that was deep to the subcutaneous layer.

Results: In the 208 operatively treated tibial pilon fractures without vancomycin powder, 14 percent had deep infections. In the 126 calcaneus fractures without vancomycin powder, 4 percent suffered from a deep infection. The overall deep infection rate without vancomycin powder was 10.6 percent. No infections occurred in 35 high risk fractures treated with vancomycin powder compared with the retrospective control group. Compared with their previously published infection rate of 13 percent for these injuries, vancomycin powder was also associated with significantly decreased deep surgical site infection. 

Conclusions: Traumatic wounds consist of local tissue necrosis and hematoma which have a high potential for surgical site infection. Systemic antibiotic delivery might be inadequate because these injuries contain local areas of tissue ischemia. Local antibiotic delivery, such as vancomycin powder, would be useful in these settings. Vancomycin powder is inexpensive, readily available in the operating room and takes no additional operative time to apply. This is important in podiatric surgery because it shows how vancomycin powder might play a role in lowering the rate of surgical site infection after fracture fixation surgery. Vancomycin powder should be considered in cases where surgical site infection rates can be considered high. 

Educational Opportunities