Efficacy of topical vancomycin in preventing surgical site infection following fracture surgery

Aims Fracture-related infection (FRI) is a major cause of morbidity following limb fracture surgery. Topical vancomycin has gained popularity as an adjunct to systemic prophylaxis; however, concerns regarding nephrotoxicity, impaired bone healing, and wound complications remain. This review aims to evaluate the efficacy and safety of intraoperative topical vancomycin powder in preventing FRI in patients undergoing surgical management of upper or lower limb fractures. Methods A systematic review of randomized controlled trials (RCTs) was conducted in February 2026. Comprehensive searches of Medline, EMBASE, and Cochrane CENTRAL were performed. Trials were included if they randomized patients with limb fractures between intraoperative topical vancomycin powder and no vancomycin, placebo, or standard care. The primary outcome was FRI or deep surgical site infection (SSI). Secondary outcomes included time to FRI, organism profile, antimicrobial resistance, superficial SSI, nonunion, revision surgery, wound healing problems, renal impairment, and other reported complications. Results Five studies involving 1,373 patients were included. Topical vancomycin significantly reduced FRI rates compared with controls (risk ratio (RR) 0.64 (95% CI 0.43 to 0.96); p = 0.030). A significant reduction in FRIs caused by gram-positive organisms was identified in patients given topical vancomycin (RR 0.41 (95% CI 0.24 to 0.71); p = 0.001). No differences in FRIs caused by gram-negative or resistant organisms were identified. There were no significant differences in superficial SSI, nonunion rates, wound healing, or other complications. Topical vancomycin was not associated with a significant risk of nephrotoxicity. Conclusion Topical vancomycin powder may be a safe and effective adjunct to standard systemic prophylaxis for preventing FRI, particularly in reducing gram-positive infections. However, current evidence is limited by a lack of high-quality RCTs and small sample sizes. A large, definitive RCT is needed to determine the efficacy, safety, and cost-effectiveness of topical vancomycin in limb fracture surgery. Cite this article: Bone Jt Open 2026;7(10):1253–1260.