Abstract
OBJECTIVE: Surgical site infections (SSIs) particularly periprosthetic joint infection (PJI, a deep/organ-space infection) remain devastating after total hip arthroplasty (THA). Because routine systemic perioperative antibiotics are standard of care, we focused on the added value of intrawound (local) prophylaxis. We evaluated whether intrawound antibiotics, used in addition to standard systemic prophylaxis, reduce infection after THA and explored effects across surgery type (primary vs. revision). METHODS: We searched PubMed, Cochrane Library, ScienceDirect, EMBASE, CNKI, VIP, Wanfang, and CBM (January 2010 to final search) for cohort studies comparing intrawound antibiotic prophylaxis + standard systemic prophylaxis versus standard systemic prophylaxis alone. We systematically searched studies published since 2010 to include the most recent and relevant data, ensuring that the research included reflects modern surgical techniques, standardized reporting, and advancements in the use of intrawound antibiotics. Two reviewers independently screened, extracted data, and assessed risk of bias; meta-analysis used RevMan 5.3. RESULTS: Eight cohort studies (n = 16,939) met criteria. Heterogeneity for PJI was low (Chi² = 7.57, df = 7, P = 0.37; I² = 8%). Intrawound prophylaxis plus systemic prophylaxis was associated with lower PJI risk than systemic prophylaxis alone (OR = 0.42, 95% CI: 0.30-0.58, P < 0.00001). Subgroup analysis showed consistent benefit in both primary and revision THA (OR = 0.30, 95% CI: 0.20-0.47, P < 0.00001; I² = 0%). Superficial incisional SSI (skin/subcutaneous) showed no significant difference (OR = 0.41, 95% CI: 0.10-1.66, P = 0.92), and adverse events did not differ significantly (OR = 0.89, 95% CI: 0.45-1.78, P = 0.75). Funnel plots suggested possible publication bias. CONCLUSION: There is limited evidence, with a possible risk of publication bias, suggesting that intrawound (local) antibiotic prophylaxis, when added to standard systemic antibiotics, may be associated with reduced postoperative PJI after THA across primary and revision procedures. Evidence for superficial SSI and safety remains limited by few contributing studies. Standardized, head-to-head randomized trials are needed to define optimal regimens (agent, dose, timing) and long-term safety (including antimicrobial resistance).