Efficacy and Safety of Intraosseous Versus Intravenous Antibiotic in Primary and Revision Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

Background and Objectives: Periprosthetic joint infection (PJI) is one of the most serious complications following total joint arthroplasty (TJA), leading to poor functional outcomes and increased healthcare burden. Intraosseous (IO) regional antibiotic prophylaxis has emerged as a promising method for infection prevention, offering potential advantages over conventional intravenous (IV) systemic administration. This study aimed to systematically evaluate the clinical evidence on the efficacy and safety of IO prophylaxis in TJA. Materials and Methods: A comprehensive literature search was conducted in PubMed, Embase, Scopus, Web of Science, and the Cochrane Library up to 23 June 2025. Eligible studies included randomized controlled trials and observational studies reporting outcomes of IO antibiotic administration in TJA. Primary endpoints were systemic and local antibiotic concentrations (bone and fat tissue), the incidence of PJI, and complication profiles. Risk of bias was assessed using the ROB-2 and ROBINS-I tools, and meta-analyses were conducted using RevMan v 7.2.0. Results: Fifteen studies (eight RCTs, one prospective study, and six retrospective studies) were included for qualitative synthesis, of which ten were included in the meta-analysis. As compared with IV, IO administration resulted in significantly higher local antibiotic concentrations in bone (MD: 15.52 μg/g; 95% CI: 8.60–22.45; p < 0.0001) and fat tissue (MD: 18.15 μg/g; 95% CI: 12.86–23.45; p < 0.0001). IO prophylaxis was associated with a significantly lower PJI rate (OR: 0.26; 95% CI: 0.12–0.57; p = 0.008) without a significant difference in the incidence of complications (p = 0.66). Conclusions: IO antibiotic prophylaxis is an effective and safe strategy for infection prevention in total joint arthroplasty. By achieving superior local antibiotic concentrations and reducing PJI rates without increasing complications, this approach holds promise for broader clinical application.