The VANCO trial (METRC) is the first RCT of intrawound vancomycin powder in fracture surgery. It randomized 980 adults with high-risk tibial plateau or pilon fractures to 1000 mg intrawound vancomycin powder versus standard prophylaxis at definitive plate fixation. The primary outcome was deep surgical site infection within 182 days.
Intrawound vancomycin powder was already widely used in spine surgery based on retrospective data before this trial. What was missing was RCT-level evidence in fracture surgery — and crucially, any understanding of which organisms it actually protects against.
This trial answers both questions. When you close a high-risk tibial plateau or pilon fracture, 1000 mg of vancomycin powder over the implants cuts gram-positive deep SSI by half. That's the intervention. That's the effect.
Know the limitation: it does nothing for gram-negative organisms. In open fractures with contamination and gram-negative exposure, vancomycin powder alone is insufficient. The authors explicitly state that combining it with a topical aminoglycoside is the logical next step for broader coverage.
The safety profile is clean. Zero allergic reactions, no increase in nonunion or wound dehiscence. This is a low-cost, low-risk adjunct that belongs in your closure protocol for tibial plateau and pilon fractures meeting high-risk criteria.
The VANCO trial (METRC) is the first RCT of intrawound vancomycin powder in fracture surgery. It randomized 980 adults with high-risk tibial plateau or pilon fractures to 1000 mg intrawound vancomycin powder versus standard prophylaxis at definitive plate fixation. The primary outcome was deep surgical site infection within 182 days.
Intrawound vancomycin powder was already widely used in spine surgery based on retrospective data before this trial. What was missing was RCT-level evidence in fracture surgery — and crucially, any understanding of which organisms it actually protects against.
This trial answers both questions. When you close a high-risk tibial plateau or pilon fracture, 1000 mg of vancomycin powder over the implants cuts gram-positive deep SSI by half. That's the intervention. That's the effect.
Know the limitation: it does nothing for gram-negative organisms. In open fractures with contamination and gram-negative exposure, vancomycin powder alone is insufficient. The authors explicitly state that combining it with a topical aminoglycoside is the logical next step for broader coverage.
The safety profile is clean. Zero allergic reactions, no increase in nonunion or wound dehiscence. This is a low-cost, low-risk adjunct that belongs in your closure protocol for tibial plateau and pilon fractures meeting high-risk criteria.