Vancomycin Powder May Curb Wound Infection After Knee and Ankle Fracture Surgery

By David Douglas

April 06, 2021

NEW YORK (Reuters Health) - Intra-wound vancomycin powder reduces gram-positive infection in operatively treated high-risk tibia fractures, according to an open-label randomized clinical trial.

"Patients with a fracture around the knee or ankle face a high risk of debilitating infections that require additional surgical treatment," Dr. Robert V. O'Toole of the University of Maryland School of Medicine, in Baltimore, told Reuters Health by email.

"The VANCO trial," he said, "coordinated by the Major Extremity Trauma Research Consortium (, provides strong evidence that vancomycin powder placed in the surgical wound at the initial fracture treatment is a promising, low-cost intervention to reduce the risk of post-operative infections."

The study included 980 patients at 36 trauma centers in the U.S. All met the criteria for a high risk of infection associated with operatively treated tibial plateau or pilon fracture.

In addition to a standard infection-prevention protocol, including prophylactic perioperative antibiotics administered intravenously, about half the patients received 1,000 mg of intra-wound vancomycin powder, while the other half didn't. The powder was placed directly over metal implants in the surgical wound at the time of definitive fracture fixation. Placebo powder was not employed because of concerns that it might be harmful.

A deep surgical-site infection was observed in 29 of 481 patients in the treatment group within 182 days of wound closure and in 46 of 499 control patients. At 224 days, the corresponding numbers were 30 and 46. A number of patients in both groups with insufficient follow-up were excluded in the complete case analysis.

The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (P=0.06). A post hoc analysis of the effect demonstrated that this was a result of its reduction in gram-positive infections (P=0.02).

As Dr. O'Toole pointed out, "Vancomycin powder was particularly effective against gram-positive infections, such as those from staph aureus, and our results suggest this simple intervention reduced the infection risk from these gram-positive bacteria by approximately 50%. Orthopedic surgeons should, therefore, consider adopting this method when surgically treating their patients with fractures."

The study had no commercial funding.

SOURCE: JAMA Surgery, online March 24, 2021.