# Prevention of surgical site infections in lower limb fracture fixation and elective arthroplasty: a systematic review and meta-analysis of decolonization and skin antisepsis strategies

## TL;DR

This study reviews how pre-surgery decolonization strategies can reduce infections in joint replacements and fractures, finding they work well for joint surgeries but not enough evidence for fracture cases.

## Contribution

The study provides a systematic review and meta-analysis of decolonization strategies for preventing SSIs in lower limb surgeries.

## Key findings

- Nasal and skin decolonization protocols reduce SSIs in elective hip and knee arthroplasty.
- Combined decolonization strategies show moderate effectiveness in trauma surgery, but evidence is insufficient and inconsistent.
- High-quality randomized trials are needed to evaluate decolonization in lower extremity trauma surgery.

## Abstract

Surgical site infections (SSIs) account for up to 20% of healthcare-associated infections and significantly increase morbidity, mortality, and healthcare costs. Preoperative decolonization strategies—targeting nasal and/or skin colonization—are variably recommended across surgical disciplines. While benefits have been reported in elective arthroplasty, their efficacy in trauma surgery remains unclear.

We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines and the Cochrane Handbook for systematic reviews and Meta-Analyses. The study protocol was registered in PROSPERO (CRD420250642382). MEDLINE, Cochrane Library, ClinicalTrials.gov, and Google Deep Research were searched up to 26 February 2025. Eligible studies reported on patients undergoing elective lower extremity joint arthroplasty or fracture surgery and compared nasal, skin, or combined decolonization protocols to standard care. Primary outcome was the incidence of SSIs. Risk of bias was assessed using RoB 2 for RCTs and ROBINS-I for observational studies.

Nineteen studies (n = 64,796 patients) met inclusion criteria. Of those, five were RCTs and 14 were observational, retrospective or pre-post studies. 17 focused on elective arthroplasty; two addressed fracture surgery. Among orthopedic patients, nasal decolonization reduced SSIs with an OR of 0.65 (95% CI, 0.34–1.22), skin decolonization with an OR of 0.43 (95% CI, 0.29–0.64), and combined strategies with an OR of 0.48 (95% CI, 0.33–0.69). Trauma surgery data were limited and heterogeneous (I² = 81%); the pooled OR for combined decolonization was 0.59 (95% CI, 0.08–4.32), but with conflicting individual study results.

Nasal and skin decolonization protocols seem to reduce the incidence of SSIs in elective hip and knee arthroplasty. Thereby, skin, nasal and combined decolonization strategies may be used. However, current evidence in fracture surgery remains insufficient and inconsistent. High-quality randomized trials are urgently needed to evaluate decolonization efficacy in lower extremity trauma surgery.

The online version contains supplementary material available at 10.1186/s13756-026-01713-y.